Harvard Pilgrim Health Care Prescription Drug List

Harvard Pilgrim Health Care Prescription Drug List VALUE FORMULARY FIVE-TIER DRUG LIST (2017) BY CATEGORY This list is subject to change at any time....
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Harvard Pilgrim Health Care Prescription Drug List VALUE FORMULARY FIVE-TIER DRUG LIST (2017) BY CATEGORY

This list is subject to change at any time.

Harvard Pilgrim Health Care includes Harvard Pilgrim Health Care, Harvard Pilgrim Health Care of Connecticut, Harvard Pilgrim Health Care of New England and HPHC Insurance Company.

VALUE FORMULARY FIVE-TIER DRUG LIST

Last Updated: 01/17/2017

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About Harvard Pilgrim's formulary Harvard Pilgrim's formulary is a list of therapeutically safe and effective medications for treating most common medical conditions. The list is continually updated to incorporate the most recent decisions of Harvard Pilgrim's Pharmacy Services Department and our Pharmacy &Therapeutics Committee.

Harvard Pilgrim's 5-Tier Prescription Drug Program Covered medications are categorized in one of the five tiers described below. Our tiered benefit structure encourages patients and physicians to discuss pharmaceutical treatment options and choose the drug that is therapeutically appropriate. This kind of patient/physician dialogue is an important component in promoting quality, cost-effective care.

How to use this five-tier prescription drug list The following list is by drug category and class, with the tier indicated to the right of the drug name. Follow these simple steps to find out what tier a covered medication you are currently taking is on: 1. Under "Drug," look up the name of your medication. 2. Once you find the medication, check the tier number to the right of the drug name. $0 indicates that the drug may be covered at $0 copayment for some benefit plans. Tier 1 is primarily made up of lower cost generic drugs that have been selected by HPHC. These drugs contain the same active ingredients as their brand-name counterparts. Tier 2 is primarily made up of higher cost generic drugs that have been selected by HPHC. These drugs contain the same active ingredients as their brand-name counterparts. Tier 3 is primarily made up of preferred brand name drugs for which there are no generic equivalents available. These drugs have been selected because of their overall high value based on a review of the relative safety, effectiveness and cost of the many brand name drugs on the market. Tier 3 may also include some generic drugs that have lower-cost or over-the-counter alternatives available. Tier 4 is primarily made up of preferred specialty drugs and non-preferred brand name drugs. Tier 4 may also include some generic drugs that have lower-cost or over-thecounter alternatives available. Tier 5 is primarily made up of non-preferred specialty drugs. Tier 5 may also include selected brand and generic drugs. N/C: Drug is not covered. ●













Please note: Some plans may require you to pay a deductible for prescription medications before copayments and/or coinsurance apply. Refer to your Prescription Drug Brochure for details.

VALUE FORMULARY FIVE-TIER DRUG LIST

Last Updated: 01/17/2017

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DRUG NAME

TIER

LIMITATIONS/ * NOTES

4 4 4 4 4 4 1 2 1 1 2 NC NC NC NC NC NC 2 NC NC NC 2 2 2 NC NC NC NC NC NC NC NC NC NC NC NC NC 2 2 NC 2 2 2 2 2 2 2 2 2 2 2 2 2

Prior Authorization required;Max. 120 per 30 days Prior Authorization required;Max. 120 per 30 days Prior Authorization required;Max. 120 per 30 days Prior Authorization required;Max. 120 per 30 days Prior Authorization required;Max. 120 per 30 days Prior Authorization required;Max. 120 per 30 days

ANALGESICS ANALGESICS, MISCELLANEOUS ABSTRAL 100 MCG TAB SUBLINGUAL ABSTRAL 200 MCG TAB SUBLINGUAL ABSTRAL 300 MCG TAB SUBLINGUAL ABSTRAL 400 MCG TAB SUBLINGUAL ABSTRAL 600 MCG TAB SUBLINGUAL ABSTRAL 800 MCG TAB SUBLINGUAL ACETAMINOP-CODEINE 120-12 MG/5 ACETAMINOPH-CAFF-DIHYDROCODEIN ACETAMINOPHEN-COD #2 TABLET ACETAMINOPHEN-COD #3 TABLET ACETAMINOPHEN-COD #4 TABLET ACTIQ 1,200 MCG LOZENGE ACTIQ 1,600 MCG LOZENGE ACTIQ 200 MCG LOZENGE ACTIQ 400 MCG LOZENGE ACTIQ 600 MCG LOZENGE ACTIQ 800 MCG LOZENGE ALAGESIC LQ ORAL SOLUTION ALFENTANIL 500 MCG/ML AMPUL ALFENTANIL 500 MCG/ML AMPULE ALLZITAL 25-325 MG TABLET ASCOMP WITH CODEINE CAPSULE ASPIRIN-CAFF-DIHYDROCODEIN CAP ASTRAMORPH-PF 10 MG/10 ML VIAL AVINZA 120 MG CAPSULE AVINZA 30 MG CAPSULE AVINZA 45 MG CAPSULE AVINZA 60 MG CAPSULE AVINZA 75 MG CAPSULE AVINZA 90 MG CAPSULE BELBUCA 150 MCG FILM BELBUCA 300 MCG FILM BELBUCA 450 MCG FILM BELBUCA 600 MCG FILM BELBUCA 75 MCG FILM BELBUCA 750 MCG FILM BELBUCA 900 MCG FILM BELLADONNA-OPIUM 16.2-30 SUPP BELLADONNA-OPIUM 16.2-60 SUPP BUPAP 50 MG-300 MG TABLET BUPAP TABLET BUPRENORPHINE 0.3 MG/ML SYRN BUPRENORPHINE 0.3 MG/ML VIAL BUTALB-ACETAMIN-CAFF 50-300-40 BUTALB-ACETAMIN-CAFF 50-325-40 BUTALB-ACETAMIN-CAFF 50-500-40 BUTALB-ACETAMINOPH-CAFF-CODEIN BUTALB-CAFF-ACETAMINOPH-CODEIN BUTALBIT-ACETAMINOPHEN-CAFF CP BUTALBITAL COMP-CODEINE #3 CAP BUTALBITAL-ACETAMINOPHN 50-325 BUTALBITAL-ASA-CAFFEINE CAP BUTALBITAL-ASA-CAFFEINE TABLET

VALUE FORMULARY FIVE-TIER DRUG LIST

Last Updated: 01/17/2017

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DRUG NAME

TIER

BUTORPHANOL 10 MG/ML SPRAY BUTRANS 10 MCG/HR PATCH BUTRANS 15 MCG/HR PATCH BUTRANS 20 MCG/HR PATCH BUTRANS 5 MCG/HR PATCH BUTRANS 7.5 MCG/HR PATCH CAPACET CAPSULE CAPITAL WITH CODEINE SUSP CO-GESIC 5-500 TABLET CODEINE SULFATE 15 MG TABLET CODEINE SULFATE 30 MG TABLET CODEINE SULFATE 30 MG/5 ML SOL CODEINE SULFATE 60 MG TABLET CONZIP 100 MG CAPSULE CONZIP 200 MG CAPSULE CONZIP 300 MG CAPSULE DEMEROL 100 MG TABLET DEMEROL 50 MG TABLET DEMEROL 75 MG/ML SYRINGE DIHYDROCODEIN-ACETAMINOPH-CAFF DILAUDID 1 MG/ML LIQUID DILAUDID 2 MG TABLET DILAUDID 4 MG TABLET DILAUDID 8 MG TABLET DISKETS 40 MG TABLET DISPR DOLOPHINE HCL 10 MG TABLET DOLOPHINE HCL 5 MG TABLET DURAGESIC 100 MCG/HR PATCH DURAGESIC 12 MCG/HR PATCH DURAGESIC 25 MCG/HR PATCH DURAGESIC 50 MCG/HR PATCH DURAGESIC 75 MCG/HR PATCH EMBEDA ER 100-4 MG CAPSULE EMBEDA ER 20-0.8 MG CAPSULE EMBEDA ER 30-1.2 MG CAPSULE EMBEDA ER 50-2 MG CAPSULE EMBEDA ER 60-2.4 MG CAPSULE EMBEDA ER 80-3.2 MG CAPSULE ENDOCET 10-325 MG TABLET ENDOCET 10-650 MG TABLET ENDOCET 2.5-325 MG TABLET ENDOCET 5-325 TABLET ENDOCET 7.5-325 MG TABLET ENDOCET 7.5-500 MG TABLET ENDODAN 4.8355-325 MG TABLET ESGIC 50-325-40 MG TABLET ESGIC CAPSULE ESGIC PLUS CAPSULE ESGIC-PLUS 50-500-40 MG TABLET EXALGO ER 12 MG TABLET EXALGO ER 16 MG TABLET EXALGO ER 32 MG TABLET EXALGO ER 8 MG TABLET FENTANYL 100 MCG/HR PATCH FENTANYL 12 MCG/HR PATCH FENTANYL 25 MCG/HR PATCH FENTANYL 2MCG-BUPIV 0.0625%-NS FENTANYL 37.5 MCG/HR PATCH FENTANYL 50 MCG/HR PATCH

2 3 3 3 3 3 2 NC 2 2 2 NC 2 NC NC NC NC NC 4 2 NC NC NC NC 2 NC NC NC NC NC NC NC 3 3 3 3 3 3 2 2 2 2 2 2 2 NC NC NC NC NC NC NC NC 2 2 2 NC 2 2

VALUE FORMULARY FIVE-TIER DRUG LIST

LIMITATIONS/ * NOTES Max. 4 per 28 days Max. 4 per 28 days Max. 4 per 28 days Max. 4 per 28 days Max. 4 per 28 days

Max. 3 per day Max. 3 per day Max. 3 per day Max. 3 per day Max. 3 per day Max. 3 per day

Max. 15 per 30 days Max. 15 per 30 days Max. 15 per 30 days Max. 15 per 30 days Max. 15 per 30 days

Last Updated: 01/17/2017

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DRUG NAME

TIER

LIMITATIONS/ * NOTES

FENTANYL 62.5 MCG/HR PATCH FENTANYL 75 MCG/HR PATCH FENTANYL 87.5 MCG/HR PATCH FENTANYL CIT OTFC 1,200 MCG FENTANYL CIT OTFC 1,600 MCG FENTANYL CITRATE OTFC 200 MCG FENTANYL CITRATE OTFC 400 MCG FENTANYL CITRATE OTFC 600 MCG FENTANYL CITRATE OTFC 800 MCG FENTANYL-ROPIV-NS 2 MCG-0.1% FENTORA 100 MCG BUCCAL TABLET FENTORA 200 MCG BUCCAL TABLET FENTORA 400 MCG BUCCAL TABLET FENTORA 600 MCG BUCCAL TABLET FENTORA 800 MCG BUCCAL TABLET FIORICET 50-300-40 MG CAPSULE FIORICET 50-325-40 MG TABLET FIORICET-COD 30-50-325-40 CAP FIORICET-COD 50-300-40-30 CAP FIORINAL 50-325-40 MG CAPSULE FIORINAL-COD 30-50-325-40 CAP HYCET 7.5 MG-325 MG/15 ML SOLN HYDROCODON-ACETAMIN 7.5-325/15 HYDROCODON-ACETAMINOPH 2.5-325 HYDROCODON-ACETAMINOPH 2.5-500 HYDROCODON-ACETAMINOPH 7.5-300 HYDROCODON-ACETAMINOPH 7.5-325 HYDROCODON-ACETAMINOPH 7.5-500 HYDROCODON-ACETAMINOPH 7.5-650 HYDROCODON-ACETAMINOPH 7.5-750 HYDROCODON-ACETAMINOPHEN 5-300 HYDROCODON-ACETAMINOPHEN 5-325 HYDROCODON-ACETAMINOPHEN 5-500 HYDROCODON-ACETAMINOPHN 10-300 HYDROCODON-ACETAMINOPHN 10-325 HYDROCODON-ACETAMINOPHN 10-500 HYDROCODON-ACETAMINOPHN 10-650 HYDROCODON-ACETAMINOPHN 10-660 HYDROCODON-ACETAMINOPHN 10-750 HYDROCODONE-ACETAMIN 10-325/15 HYDROCODONE-ACETAMIN 2.5-167/5 HYDROCODONE-IBUPROFEN 10-200 HYDROCODONE-IBUPROFEN 2.5-200 HYDROCODONE-IBUPROFEN 5-200 MG HYDROCODONE-IBUPROFEN 7.5-200 HYDROMORPHONE 2 MG TABLET HYDROMORPHONE 3 MG SUPPOS HYDROMORPHONE 4 MG TABLET HYDROMORPHONE 5 MG/5 ML SOLN HYDROMORPHONE 8 MG TABLET HYDROMORPHONE HCL ER 12 MG TAB HYDROMORPHONE HCL ER 16 MG TAB HYDROMORPHONE HCL ER 32 MG TAB HYDROMORPHONE HCL ER 8 MG TAB HYSINGLA ER 100 MG TABLET HYSINGLA ER 120 MG TABLET HYSINGLA ER 20 MG TABLET HYSINGLA ER 30 MG TABLET HYSINGLA ER 40 MG TABLET

2 2 2 4 4 4 4 4 4 2 5 5 5 5 5 NC NC NC NC NC NC NC 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 3 3 3 3 3

Max. 15 per 30 days Max. 15 per 30 days Max. 15 per 30 days Prior Authorization required;Max. 120 per 30 days Prior Authorization required;Max. 120 per 30 days Prior Authorization required;Max. 120 per 30 days Prior Authorization required;Max. 120 per 30 days Prior Authorization required;Max. 120 per 30 days Prior Authorization required;Max. 120 per 30 days

VALUE FORMULARY FIVE-TIER DRUG LIST

Prior Authorization required;Max. 120 per 30 days Prior Authorization required;Max. 120 per 30 days Prior Authorization required;Max. 120 per 30 days Prior Authorization required;Max. 120 per 30 days Prior Authorization required;Max. 120 per 30 days

Max. 2 per day Max. 2 per day Max. 2 per day Max. 2 per day Max. 30 Days Supply;Max. 1 per day Max. 30 Days Supply;Max. 1 per day Max. 30 Days Supply;Max. 2 per day Max. 30 Days Supply;Max. 2 per day Max. 30 Days Supply;Max. 1 per day

Last Updated: 01/17/2017

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DRUG NAME

TIER

LIMITATIONS/ * NOTES

HYSINGLA ER 60 MG TABLET HYSINGLA ER 80 MG TABLET IBUDONE 10-200 MG TABLET IBUDONE 5-200 MG TABLET KADIAN ER 10 MG CAPSULE KADIAN ER 100 MG CAPSULE KADIAN ER 130 MG CAPSULE KADIAN ER 150 MG CAPSULE KADIAN ER 20 MG CAPSULE KADIAN ER 200 MG CAPSULE KADIAN ER 30 MG CAPSULE KADIAN ER 40 MG CAPSULE KADIAN ER 50 MG CAPSULE KADIAN ER 60 MG CAPSULE KADIAN ER 70 MG CAPSULE KADIAN ER 80 MG CAPSULE LAZANDA 100 MCG NASAL SPRAY LAZANDA 300 MCG NASAL SPRAY LAZANDA 400 MCG NASAL SPRAY LEVORPHANOL 2 MG TABLET LORCET 10-650 TABLET LORCET 5-325 MG TABLET LORCET HD 10-325 MG TABLET LORCET PLUS 7.5-325 MG TABLET LORCET PLUS TABLET LORTAB 10 MG-300 MG/15 ML ELXR LORTAB 10-325 MG TABLET LORTAB 10-500 TABLET LORTAB 5-325 MG TABLET LORTAB 5-500 TABLET LORTAB 7.5-325 MG TABLET LORTAB 7.5-500 MG/15 ML ELIXIR LORTAB 7.5-500 TABLET MAGNACET 10 MG-400 MG TABLET MAGNACET 5 MG-400 MG TABLET MAGNACET 7.5 MG-400 MG TABLET MARGESIC CAPSULE MARTEN-TAB 325-50 TABLET MAXIDONE 10-750 MG TABLET MEPERIDINE 100 MG TABLET MEPERIDINE 50 MG TABLET MEPERIDINE 50 MG/5 ML SOLUTION MEPERIDINE 550 MG/55 ML-NS SYR METHADONE 10 MG/5 ML SOLUTION METHADONE 5 MG/5 ML SOLUTION METHADONE HCL 10 MG TABLET METHADONE HCL 10 MG/ML VIAL METHADONE HCL 5 MG TABLET METHADONE INTENSOL 10 MG/ML METHADOSE 10 MG/ML ORAL CONC METHADOSE 40 MG TABLET DISPR MORPHINE 0.5 MG/ML VIAL MORPHINE 1 MG/ML VIAL P-F MORPHINE 2 MG/ML CARPUJECT MORPHINE 50 MG/50 ML-0.9% NACL MORPHINE SULF 10 MG SUPPOS MORPHINE SULF 10 MG/5 ML SOLN MORPHINE SULF 100 MG/5 ML SOLN MORPHINE SULF 20 MG SUPPOS

3 3 NC NC NC NC 3 3 NC 3 NC 3 NC NC 3 NC 5 5 5 4 NC 2 2 2 NC NC NC NC NC NC NC NC NC NC NC NC 2 2 NC 2 2 2 2 2 2 2 2 2 2 NC 2 MD MD NC 2 2 2 2 2

Max. 30 Days Supply;Max. 1 per day Max. 30 Days Supply;Max. 1 per day

VALUE FORMULARY FIVE-TIER DRUG LIST

Max. 2 per day Max. 2 per day Max. 2 per day Max. 2 per day

Max. 2 per day Prior Authorization required;Max. 1 per 2 days Prior Authorization required;Max. 1 per 2 days Prior Authorization required;Max. 1 per 2 days

Last Updated: 01/17/2017

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DRUG NAME

TIER

MORPHINE SULF 20 MG/5 ML SOLN MORPHINE SULF 30 MG SUPPOS MORPHINE SULF 5 MG SUPPOS MORPHINE SULF ER 100 MG TABLET MORPHINE SULF ER 15 MG TABLET MORPHINE SULF ER 200 MG TABLET MORPHINE SULF ER 30 MG TABLET MORPHINE SULF ER 60 MG TABLET MORPHINE SULFATE ER 10 MG CAP MORPHINE SULFATE ER 100 MG CAP MORPHINE SULFATE ER 120 MG CAP MORPHINE SULFATE ER 20 MG CAP MORPHINE SULFATE ER 30 MG CAP MORPHINE SULFATE ER 45 MG CAP MORPHINE SULFATE ER 50 MG CAP MORPHINE SULFATE ER 60 MG CAP MORPHINE SULFATE ER 75 MG CAP MORPHINE SULFATE ER 80 MG CAP MORPHINE SULFATE ER 90 MG CAP MORPHINE SULFATE IR 15 MG TAB MORPHINE SULFATE IR 30 MG TAB MS CONTIN 100 MG TABLET MS CONTIN 15 MG TABLET MS CONTIN 200 MG TABLET MS CONTIN 60 MG TABLET MS CONTIN CR 30 MG TABLET NORCO 10-325 TABLET NORCO 5-325 TABLET NORCO 7.5-325 TABLET NUCYNTA 100 MG TABLET NUCYNTA 50 MG TABLET NUCYNTA 75 MG TABLET NUCYNTA ER 100 MG TABLET NUCYNTA ER 150 MG TABLET NUCYNTA ER 200 MG TABLET NUCYNTA ER 250 MG TABLET NUCYNTA ER 50 MG TABLET ONSOLIS 1,200 MCG SOLUBLE FILM ONSOLIS 200 MCG SOLUBLE FILM ONSOLIS 400 MCG SOLUBLE FILM ONSOLIS 600 MCG SOLUBLE FILM ONSOLIS 800 MCG SOLUBLE FILM OPANA 10 MG TABLET OPANA 5 MG TABLET OPANA ER 10 MG TABLET OPANA ER 15 MG TABLET OPANA ER 20 MG TABLET OPANA ER 30 MG TABLET OPANA ER 40 MG TABLET OPANA ER 5 MG TABLET OPANA ER 7.5 MG TABLET ORBIVAN CAPSULE ORBIVAN CF TABLET OXAYDO 5 MG TABLET OXAYDO 7.5 MG TABLET OXECTA 5 MG TABLET OXECTA 7.5 MG TABLET OXYCODON-ACETAMINOPHEN 2.5-325 OXYCODON-ACETAMINOPHEN 7.5-325

2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 4 4 NC NC NC NC NC NC NC NC 3 3 3 3 3 3 3 3 5 5 5 5 5 NC NC NC NC NC NC NC NC NC NC NC 4 4 4 4 2 2

VALUE FORMULARY FIVE-TIER DRUG LIST

LIMITATIONS/ * NOTES

Max. 90 per 30 days Max. 90 per 30 days Max. 90 per 30 days Max. 90 per 30 days Max. 90 per 30 days Max. 2 per day Max. 2 per day Max. 2 per day Max. 2 per day Max. 2 per day Max. 2 per day Max. 2 per day Max. 2 per day Max. 2 per day Max. 2 per day Max. 2 per day

Max. 2 per day Max. 2 per day Max. 2 per day Max. 2 per day Max. 2 per day Max. 120 in 30 days Max. 120 in 30 days Max. 120 in 30 days Max. 120 in 30 days Max. 120 in 30 days

Last Updated: 01/17/2017

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DRUG NAME

TIER

OXYCODON-ACETAMINOPHEN 7.5-500 OXYCODONE HCL 10 MG TABLET OXYCODONE HCL 100 MG/5 ML SOLN OXYCODONE HCL 15 MG TABLET OXYCODONE HCL 20 MG TABLET OXYCODONE HCL 30 MG TABLET OXYCODONE HCL 5 MG CAPSULE OXYCODONE HCL 5 MG TABLET OXYCODONE HCL 5 MG/5 ML SOLN OXYCODONE HCL ER 10 MG TABLET OXYCODONE HCL ER 15 MG TABLET OXYCODONE HCL ER 20 MG TABLET OXYCODONE HCL ER 30 MG TABLET OXYCODONE HCL ER 40 MG TABLET OXYCODONE HCL ER 60 MG TABLET OXYCODONE HCL ER 80 MG TABLET OXYCODONE-ACETAMINOPHEN 10-325 OXYCODONE-ACETAMINOPHEN 10-650 OXYCODONE-ACETAMINOPHEN 5-325 OXYCODONE-ACETAMINOPHEN 5-500 OXYCODONE-ACETAMINOPHN 5-325/5 OXYCODONE-ASPIRIN 4.8355-325 OXYCODONE-IBUPROFEN 5-400 TAB OXYCONTIN 10 MG TABLET OXYCONTIN 15 MG TABLET OXYCONTIN 20 MG TABLET OXYCONTIN 30 MG TABLET OXYCONTIN 40 MG TABLET OXYCONTIN 60 MG TABLET OXYCONTIN 80 MG TABLET OXYMORPHONE HCL 10 MG TABLET OXYMORPHONE HCL 5 MG TABLET OXYMORPHONE HCL ER 10 MG TAB OXYMORPHONE HCL ER 15 MG TAB OXYMORPHONE HCL ER 20 MG TAB OXYMORPHONE HCL ER 30 MG TAB OXYMORPHONE HCL ER 40 MG TAB OXYMORPHONE HCL ER 5 MG TABLET OXYMORPHONE HCL ER 7.5 MG TAB PENTAZOCIN-ACETAMINOPHN 25-650 PENTAZOCINE-NALOXONE TABLET PERCOCET 10-325 MG TABLET PERCOCET 10-650 MG TABLET PERCOCET 2.5-325 MG TABLET PERCOCET 5-325 MG TABLET PERCOCET 7.5-325 MG TABLET PERCOCET 7.5-500 MG TABLET PERCODAN 4.8355-325 MG TABLET PHRENILIN FORTE CAPSULE PRIMLEV 10-300 MG TABLET PRIMLEV 5-300 MG TABLET PRIMLEV 7.5-300 MG TABLET PROMACET 50-650 MG TABLET RELAGESIC 650-50 MG TABLET REPREXAIN 10-200 MG TABLET REPREXAIN 2.5-200 MG TABLET REPREXAIN 5-200 MG TABLET RHINOFLEX-650 TABLET ROXICET 5-325 ORAL SOLUTION

2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 3 3 3 3 3 3 3 2 2 2 2 2 2 2 2 2 2 2 NC NC NC NC NC NC NC NC NC NC NC 2 NC 2 2 2 2 2

VALUE FORMULARY FIVE-TIER DRUG LIST

LIMITATIONS/ * NOTES

Max. 4 per day;Max. 180 in 30 days Max. 4 per day;Max. 180 in 30 days Max. 4 per day;Max. 180 in 30 days Max. 4 per day;Max. 180 in 30 days Max. 4 per day;Max. 180 in 30 days Max. 4 per day;Max. 180 in 30 days Max. 4 per day;Max. 180 in 30 days

Max. 4 per day;Max. 180 in 30 days Max. 4 per day;Max. 180 in 30 days Max. 4 per day;Max. 180 in 30 days Max. 4 per day;Max. 180 in 30 days Max. 4 per day;Max. 180 in 30 days Max. 4 per day;Max. 180 in 30 days Max. 4 per day;Max. 180 in 30 days

Max. 3 per day Max. 3 per day Max. 3 per day Max. 3 per day Max. 3 per day Max. 3 per day Max. 3 per day

Last Updated: 01/17/2017

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DRUG NAME

TIER

ROXICET 5-325 TABLET ROXICODONE 15 MG TABLET ROXICODONE 30 MG TABLET ROXICODONE 5 MG TABLET RYBIX ODT 50 MG TABLET STAGESIC 5-500 CAPSULE SUBSYS 1,200 MCG SPRAY SUBSYS 1,600 MCG SPRAY SUBSYS 100 MCG SPRAY SUBSYS 200 MCG SPRAY SUBSYS 400 MCG SPRAY SUBSYS 600 MCG SPRAY SUBSYS 800 MCG SPRAY SYNALGOS-DC CAPSULE TENCON 50-325 MG TABLET TENCON TABLET TRAMADOL HCL 50 MG TABLET TRAMADOL HCL ER 100 MG CAPSULE TRAMADOL HCL ER 100 MG TABLET TRAMADOL HCL ER 150 MG CAPSULE TRAMADOL HCL ER 200 MG CAPSULE TRAMADOL HCL ER 200 MG TABLET TRAMADOL HCL ER 300 MG CAPSULE TRAMADOL HCL ER 300 MG TABLET TRAMADOL-ACETAMINOPHN 37.5-325 TREZIX 16-320.5-30 MG CAPSULE TREZIX CAPSULE TYLENOL WITH CODEINE #3 TABLET TYLENOL WITH CODEINE #4 TABLET ULTRACET TABLET ULTRAM 50 MG TABLET ULTRAM ER 100 MG TABLET ULTRAM ER 200 MG TABLET ULTRAM ER 300 MG TABLET VANATOL LQ ORAL SOLUTION VERDROCET 2.5-325 MG TABLET VICODIN 5-300 MG TABLET VICODIN ES 7.5-300 MG TABLET VICODIN HP 10-300 MG TABLET VICOPROFEN 7.5-200 MG TABLET XARTEMIS XR 7.5-325 MG TABLET XODOL 10-300 TABLET XODOL 5-300 TABLET XODOL 7.5-300 MG TABLET XOLOX 10-500 MG TABLET XTAMPZA ER 13.5 MG CAPSULE XTAMPZA ER 18 MG CAPSULE XTAMPZA ER 27 MG CAPSULE XTAMPZA ER 36 MG CAPSULE XTAMPZA ER 9 MG CAPSULE XYLON 10-200 MG TABLET ZAMICET 10-325 MG/15 ML SOLN ZEBUTAL 50-325-40 MG CAPSULE ZEBUTAL CAPSULE ZFLEX TABLET ZGESIC TABLET ZOHYDRO ER 10 MG CAPSULE ZOHYDRO ER 15 MG CAPSULE ZOHYDRO ER 20 MG CAPSULE

2 NC NC NC NC 2 5 5 5 5 5 5 5 NC 2 NC 1 2 2 2 2 2 2 2 2 NC NC NC NC NC NC NC NC NC NC NC 2 2 2 NC 5 NC NC NC NC NC NC NC NC NC 2 NC 2 NC 2 NC NC NC NC

VALUE FORMULARY FIVE-TIER DRUG LIST

LIMITATIONS/ * NOTES

Prior Authorization required;Max. 120 per 30 days Prior Authorization required;Max. 120 per 30 days Prior Authorization required;Max. 120 per 30 days Prior Authorization required;Max. 120 per 30 days Prior Authorization required;Max. 120 per 30 days Prior Authorization required;Max. 120 per 30 days Prior Authorization required;Max. 120 per 30 days

Max. 120 per 30 days

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DRUG NAME

TIER

ZOHYDRO ER 30 MG CAPSULE ZOHYDRO ER 40 MG CAPSULE ZOHYDRO ER 50 MG CAPSULE ZOLVIT 10 MG-300 MG/15 ML SOLN ZYDONE 10-400 MG TABLET ZYDONE 5-400 MG TABLET ZYDONE 7.5-400 MG TABLET

NC NC NC 2 NC NC NC

LIMITATIONS/ * NOTES

NONSTEROIDAL ANTI-INFLAMMATORY AGENTS ANAPROX 275 MG TABLET ANAPROX DS 550 MG TABLET ARTHROTEC 50 MG-200 MCG TAB ARTHROTEC 75 MG-200 MCG TAB ASPIR-LOW EC 81 MG TABLET ASPIRIN 300 MG SUPPOSITORY ASPIRIN 325 MG TABLET ASPIRIN 600 MG SUPPOSITORY ASPIRIN 81 MG CHEWABLE TABLET ASPIRIN EC 325 MG TABLET ASPIRIN EC 500 MG TABLET ASPIRIN EC 650 MG TABLET ASPIRIN EC 81 MG TABLET ASPIRIN EC 975 MG TABLET BAYER ADVANCED 500 MG TABLET BAYER ASPIRIN 81 MG CHEW TAB CAMBIA 50 MG POWDER PACKET CATAFLAM 50 MG TABLET CELEBREX 100 MG CAPSULE CELEBREX 200 MG CAPSULE CELEBREX 400 MG CAPSULE CELEBREX 50 MG CAPSULE CELECOXIB 100 MG CAPSULE CELECOXIB 200 MG CAPSULE CELECOXIB 400 MG CAPSULE CELECOXIB 50 MG CAPSULE CHOLINE MAG TRISAL LIQUID COMFORT PAC-IBUPROFEN KIT COMFORT PAC-NAPROXEN KIT DAYPRO 600 MG CAPLET DERMACINRX LEXITRAL PHARMAPAK DICLOFENAC 1.5% TOPICAL SOLN DICLOFENAC POT 50 MG TABLET DICLOFENAC SOD EC 25 MG TAB DICLOFENAC SOD EC 50 MG TAB DICLOFENAC SOD EC 75 MG TAB DICLOFENAC SOD ER 100 MG TAB DICLOFENAC SODIUM 1% GEL DICLOFENAC-MISOPROST 50-200 TB DICLOFENAC-MISOPROST 75-200 TB DICLOTRAL PAK DIFLUNISAL 500 MG TABLET DISALCID 500 MG TABLET DISALCID 750 MG TABLET DUEXIS 800-26.6 MG TABLET DURLAZA ER 162.5 MG CAPSULE EC-NAPROSYN EC 375 MG TABLET ECOTRIN EC 325 MG TABLET

VALUE FORMULARY FIVE-TIER DRUG LIST

NC NC NC NC 0 0 0 0 0 0 0 0 0 0 NC NC NC NC NC NC NC NC 2 2 2 2 2 NC NC NC NC 2 2 2 2 2 2 2 2 2 NC 2 NC NC NC NC NC 0

ACA* ACA* ACA* ACA* ACA* ACA* ACA* ACA* ACA* ACA*

ACA*

Last Updated: 01/17/2017

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DRUG NAME

TIER

ECOTRIN EC 81 MG TABLET ECPIRIN EC 325 MG TABLET ETODOLAC 200 MG CAPSULE ETODOLAC 300 MG CAPSULE ETODOLAC 400 MG TABLET ETODOLAC 500 MG TABLET ETODOLAC ER 400 MG TABLET ETODOLAC ER 500 MG TABLET ETODOLAC ER 600 MG TABLET FELDENE 10 MG CAPSULE FELDENE 20 MG CAPSULE FENOPROFEN 200 MG CAPSULE FENOPROFEN 400 MG CAPSULE FENOPROFEN 600 MG TABLET FENORTHO 200 MG CAPSULE FENORTHO 400 MG CAPSULE FLECTOR 1.3% PATCH FLURBIPROFEN 100 MG TABLET FLURBIPROFEN 50 MG TABLET HALFPRIN EC 81 MG TABLET IBUPROFEN 100 MG/5 ML SUSP IBUPROFEN 400 MG TABLET IBUPROFEN 600 MG TABLET IBUPROFEN 800 MG TABLET INDOCIN 25 MG/5 ML SUSPENSION INDOCIN 50 MG SUPPOSITORY INDOMETHACIN 25 MG CAPSULE INDOMETHACIN 50 MG CAPSULE INDOMETHACIN ER 75 MG CAPSULE KETOPROFEN 50 MG CAPSULE KETOPROFEN 75 MG CAPSULE KETOPROFEN ER 200 MG CAPSULE KETOROLAC 10 MG TABLET LEVACET CAPLET LODINE 400 MG TABLET MECLOFENAMATE 100 MG CAPSULE MECLOFENAMATE 50 MG CAPSULE MEFENAMIC ACID 250 MG CAPSULE MELOXICAM 15 MG TABLET MELOXICAM 7.5 MG TABLET MELOXICAM 7.5 MG/5 ML SUSP MINIPRIN EC 81 MG TABLET MOBIC 15 MG TABLET MOBIC 7.5 MG TABLET MOBIC 7.5 MG/5 ML SUSPENSION NABUMETONE 500 MG TABLET NABUMETONE 750 MG TABLET NALFON 400 MG CAPSULE NAPRELAN CR 375 MG TABLET NAPRELAN CR 500 MG TABLET NAPRELAN CR 750 MG TABLET NAPROSYN 125 MG/5 ML SUSPEN NAPROSYN 250 MG TABLET NAPROSYN 375 MG TABLET NAPROSYN 500 MG TABLET NAPROSYN EC 500 MG TABLET NAPROXEN 125 MG/5 ML SUSPEN NAPROXEN 250 MG TABLET NAPROXEN 375 MG TABLET

NC 0 2 2 2 2 2 2 2 NC NC 2 4 2 NC NC 3 2 2 0 2 1 1 1 4 4 2 2 2 1 2 2 2 NC NC 2 2 2 1 1 2 0 NC NC NC 2 2 NC NC NC NC NC NC NC NC NC 2 1 1

VALUE FORMULARY FIVE-TIER DRUG LIST

LIMITATIONS/ * NOTES ACA*

ACA*

Max. 5 Days Supply;Max. quantity of 20 per fill

ACA*

Last Updated: 01/17/2017

Page 11

DRUG NAME

TIER

NAPROXEN 500 MG TABLET NAPROXEN DR 375 MG TABLET NAPROXEN DR 500 MG TABLET NAPROXEN SOD CR 375 MG TABLET NAPROXEN SOD CR 500 MG TABLET NAPROXEN SODIUM 275 MG TAB NAPROXEN SODIUM 550 MG TAB OXAPROZIN 600 MG CAPLET PAIN RELIEF COLLECTION KIT PENNSAID 1.5% SOLUTION PENNSAID 2% PUMP PIROXICAM 10 MG CAPSULE PIROXICAM 20 MG CAPSULE PONSTEL 250 MG KAPSEALS SALSALATE 500 MG TABLET SALSALATE 750 MG TABLET SPRIX 15.75 MG NASAL SPRAY ST. JOSEPH ASPIRIN 81 MG CHEW ST. JOSEPH ASPIRIN EC 81 MG TB SULINDAC 150 MG TABLET SULINDAC 200 MG TABLET SURE RESULT DSS PREMIUM PACK TIVORBEX 20 MG CAPSULE TIVORBEX 40 MG CAPSULE TOLMETIN SODIUM 200 MG TAB TOLMETIN SODIUM 400 MG CAP TOLMETIN SODIUM 600 MG TAB VIMOVO DR 375-20 MG TABLET VIMOVO DR 500-20 MG TABLET VIVLODEX 10 MG CAPSULE VIVLODEX 5 MG CAPSULE VOLTAREN 1% GEL VOLTAREN-XR 100 MG TABLET XRYLIX 1.5% KIT ZIPSOR 25 MG CAPSULE ZORVOLEX 18 MG CAPSULE ZORVOLEX 35 MG CAPSULE

1 2 2 4 4 2 2 2 NC NC NC 2 2 NC 2 2 4 0 0 2 2 NC NC NC 2 2 2 NC NC NC NC NC NC NC NC 3 3

LIMITATIONS/ * NOTES

Max. quantity of 5 per fill ACA* ACA*

ANESTHETICS LOCAL ANESTHETICS ALTAFLUOR EYE DROPS BUCALSEP SOLUTION DERMACINRX PRIZOPAK KIT EMLA CREAM FLUORESCEIN-BENOXINATE EYE DRP FLURESS EYE DROPS FLUROX EYE DROPS GLYDO 2% JELLY SYRINGE LIDOCAINE 2% VISCOUS SOLN LIDOCAINE 3% CREAM LIDOCAINE 5% OINTMENT LIDOCAINE 5% PATCH LIDOCAINE HCL 2% JELLY LIDOCAINE HCL 4% SOLUTION LIDOCAINE-HC 3-0.5% CREAM LIDOCAINE-HC 3-1% CREAM KIT

VALUE FORMULARY FIVE-TIER DRUG LIST

NC NC NC NC NC NC NC 2 1 2 1 2 2 2 2 2

Last Updated: 01/17/2017

Page 12

DRUG NAME

TIER

LIDOCAINE-HC 3-2.5% GEL KIT LIDOCAINE-PRILOCAINE CREAM LIDODERM 5% PATCH LIPROZONEPAK 2.5-2.5% CRM-DRSS LORENZA 4%-1% PATCH PINNACAINE 20% OTIC DROPS PONTOCAINE 2% SOLUTION PRE-ATTACHED LTA KIT RELADOR PAK 2.5-2.5% CRM-DRESS SYNERA PATCH VEXA PATCH XYLOCAINE 4% SOLUTION

NC 2 NC NC NC 2 NC NC NC 4 NC NC

LIMITATIONS/ * NOTES

ANTI-ADDICTION/SUBSTANCE ABUSE TREATMENT AGENTS ANTI-ADDICTION/SUBSTANCE ABUSE TREATMENT AGENTS ACAMPROSATE CALC DR 333 MG TAB ANTABUSE 250 MG TABLET ANTABUSE 500 MG TABLET BUNAVAIL 2.1-0.3 MG FILM BUNAVAIL 4.2-0.7 MG FILM BUNAVAIL 6.3-1 MG FILM BUPRENORPHIN-NALOXON 8-2 MG SL BUPRENORPHINE 2 MG TABLET SL BUPRENORPHINE 8 MG TABLET SL BUPRENORPHN-NALOXN 2-0.5 MG SL BUPROBAN 150 MG TABLET

2 NC NC 4 4 4 2 2 2 2 2

BUPROPION HCL SR 150 MG TABLET

0

BUPROPION HCL SR 150 MG TABLET CAMPRAL DR 333 MG TABLET CHANTIX 0.5 MG TABLET

2 4 0

CHANTIX 1 MG CONT MONTH BOX

0

CHANTIX 1 MG TABLET

0

CHANTIX STARTING MONTH BOX

0

DISULFIRAM 250 MG TABLET DISULFIRAM 500 MG TABLET EVZIO 0.4 MG AUTO-INJECTOR EVZIO 2 MG AUTO-INJECTOR NALOXONE 0.4 MG/ML SYRINGE NALOXONE 0.4 MG/ML VIAL NALOXONE 2 MG/2 ML SYRINGE NALTREXONE 50 MG TABLET NARCAN 4 MG NASAL SPRAY

2 2 NC NC MD MD MD 2 MD

NICODERM CQ 14 MG/24HR PATCH NICODERM CQ 21 MG/24HR PATCH NICODERM CQ 7 MG/24HR PATCH NICORELIEF 2 MG GUM

NC NC NC 0

NICORELIEF 2 MG LOZENGE

0

NICORELIEF 4 MG GUM

0

VALUE FORMULARY FIVE-TIER DRUG LIST

Max. 3 per day Max. 3 per day Max. 2 per day

Max. 180 Days Supply ACA* Max. 180 Days Supply;Max. 180 in 365 days ACA*

Max. 182 Days Supply ACA* Max. 182 Days Supply ACA* Max. 182 Days Supply ACA* Max. 182 Days Supply ACA*

Max. 2 ML(s) per 15 days Max. 2 ML(s) per 15 days Max. 2 ML(s) per 15 days Max. 2 per 15 days MQC*: 2 inhalers (1 package)/copay, Max. 4 inhalers (2 packages)/30-day supply

Max. 180 Days Supply;Max. 480 in 30 days ACA* Max. 180 Days Supply;Max. 480 in 30 days ACA* Max. 180 Days Supply;Max. 480 in 30 days ACA*

Last Updated: 01/17/2017

Page 13

DRUG NAME

TIER

LIMITATIONS/ * NOTES

NICORELIEF 4 MG LOZENGE

0

NICORETTE 2 MG CHEWING GUM

0

Max. 180 Days Supply;Max. 480 in 30 days ACA* Max. 180 Days Supply;Max. 480 in 30 days ACA*

NICORETTE 2 MG MINI LOZENGE NICORETTE 4 MG CHEWING GUM NICORETTE 4 MG MINI LOZENGE NICOTINE 14 MG/24HR PATCH

NC NC NC 0

NICOTINE 2 MG CHEWING GUM

0

NICOTINE 2 MG LOZENGE

0

NICOTINE 21 MG/24HR PATCH

0

NICOTINE 22 MG/24HR PATCH

0

NICOTINE 4 MG CHEWING GUM

0

NICOTINE 4 MG LOZENGE

0

NICOTINE 7 MG/24HR PATCH

0

NICOTINE TRANSDERMAL SYSTEM

0

NICOTROL CARTRIDGE INHALER

0

NICOTROL NS 10 MG/ML SPRAY

0

REVIA 50 MG TABLET SUBOXONE 12 MG-3 MG SL FILM SUBOXONE 2 MG-0.5 MG SL FILM SUBOXONE 2 MG-0.5 MG TABLET SL SUBOXONE 4 MG-1 MG SL FILM SUBOXONE 8 MG-2 MG SL FILM SUBOXONE 8 MG-2 MG TABLET SL VIVITROL 380 MG VIAL + DILUENT ZUBSOLV 0.7-0.18 MG TABLET SL ZUBSOLV 1.4-0.36 MG TABLET SL ZUBSOLV 11.4-2.9 MG TABLET SL ZUBSOLV 2.9-0.71 MG TABLET SL ZUBSOLV 5.7-1.4 MG TABLET SL ZUBSOLV 8.6-2.1 MG TABLET SL ZYBAN SR 150 MG TABLET

NC 3 3 NC 3 3 NC MD 4 4 4 4 4 4 0

Max. 180 Days Supply;Max. 1 per day ACA* Max. 180 Days Supply;Max. 480 in 30 days ACA* Max. 180 Days Supply;Max. 480 in 30 days ACA* Max. 180 Days Supply;Max. 1 per day ACA* Max. 180 Days Supply;Max. 1 per day ACA* Max. 180 Days Supply;Max. 480 in 30 days ACA* Max. 180 Days Supply;Max. 480 in 30 days ACA* Max. 180 Days Supply;Max. 1 per day ACA* Max. 180 Days Supply;Max. 1 per day ACA* Max. 180 Days Supply;Max. quantity of 168 per fill ACA* Max. 180 Days Supply;Max. quantity of 40 per fill;Max. 180 ML(s) in 365 days ACA*; Max 4 units/fill; Limit 180 days supply per year

SPP*: Must use Accredo

Max. 180 Days Supply;Max. 180 in 365 days ACA*

ANTI-INFECTIVES (SKIN AND MUCOUS MEMBRANE) ANTI-INFECTIVES (SKIN AND MUCOUS MEMBRANE) AVC 15% CREAM CLEOCIN 100 MG VAGINAL OVULE CLEOCIN 2% VAGINAL CREAM CLINDAMYCIN 2% VAGINAL CREAM CLINDESSE 2% VAGINAL CREAM FEM PH VAGINAL JELLY GYNAZOLE 1 2% CREAM METROGEL-VAGINAL 0.75% GEL METRONIDAZOLE VAGINAL 0.75% GL NUVESSA VAGINAL 1.3% GEL RELAGARD VAGINAL GEL TERAZOL 3 80 MG SUPPOSITORY

VALUE FORMULARY FIVE-TIER DRUG LIST

NC 4 NC 2 4 NC 4 NC 2 NC NC NC

Last Updated: 01/17/2017

Page 14

DRUG NAME

TIER

TERAZOL 3 CREAM TERAZOL 7 CREAM TERCONAZOLE 0.4% CREAM TERCONAZOLE 0.8% CREAM TERCONAZOLE 80 MG SUPPOSITORY VANDAZOLE VAGINAL 0.75% GEL

NC NC 2 2 2 4

LIMITATIONS/ * NOTES

ANTIANXIETY AGENTS BENZODIAZEPINES ALPRAZOLAM 0.25 MG TABLET ALPRAZOLAM 0.5 MG TABLET ALPRAZOLAM 1 MG TABLET ALPRAZOLAM 1 MG/ML ORAL CONC ALPRAZOLAM 2 MG TABLET ALPRAZOLAM ER 0.5 MG TABLET ALPRAZOLAM ER 1 MG TABLET ALPRAZOLAM ER 2 MG TABLET ALPRAZOLAM ER 3 MG TABLET ALPRAZOLAM ODT 0.25 MG TAB ALPRAZOLAM ODT 0.5 MG TAB ALPRAZOLAM ODT 1 MG TAB ALPRAZOLAM ODT 2 MG TAB ATIVAN 0.5 MG TABLET ATIVAN 1 MG TABLET ATIVAN 2 MG TABLET CHLORDIAZEPOXIDE 10 MG CAPSULE CHLORDIAZEPOXIDE 25 MG CAPSULE CHLORDIAZEPOXIDE 5 MG CAPSULE CLONAZEPAM 0.125 MG DIS TAB CLONAZEPAM 0.25 MG ODT CLONAZEPAM 0.5 MG DIS TABLET CLONAZEPAM 0.5 MG TABLET CLONAZEPAM 1 MG DIS TABLET CLONAZEPAM 1 MG TABLET CLONAZEPAM 2 MG ODT CLONAZEPAM 2 MG TABLET CLORAZEPATE 15 MG TABLET CLORAZEPATE 3.75 MG TABLET CLORAZEPATE 7.5 MG TABLET DIASTAT 2.5 MG PEDI SYSTEM DIASTAT ACUDIAL 12.5-15-20 MG DIASTAT ACUDIAL 5-7.5-10 MG KT DIAZEPAM 10 MG RECTAL GEL SYST DIAZEPAM 10 MG TABLET DIAZEPAM 2 MG TABLET DIAZEPAM 2.5 MG RECTAL GEL SYS DIAZEPAM 20 MG RECTAL GEL SYST DIAZEPAM 5 MG TABLET DIAZEPAM 5 MG/5 ML SOLUTION DIAZEPAM 5 MG/ML ORAL CONC DIAZEPAM 5 MG/ML VIAL DORAL 15 MG TABLET ESTAZOLAM 1 MG TABLET ESTAZOLAM 2 MG TABLET FLURAZEPAM 15 MG CAPSULE FLURAZEPAM 30 MG CAPSULE

VALUE FORMULARY FIVE-TIER DRUG LIST

1 1 1 NC 1 2 2 2 2 2 2 2 2 NC NC NC 1 1 2 2 2 2 1 2 1 2 1 2 2 2 NC NC NC 2 1 1 2 2 1 2 2 2 NC 2 2 2 1

Last Updated: 01/17/2017

Page 15

DRUG NAME

TIER

HALCION 0.25 MG TABLET KLONOPIN 0.5 MG TABLET KLONOPIN 1 MG TABLET KLONOPIN 2 MG TABLET LORAZEPAM 0.5 MG TABLET LORAZEPAM 1 MG TABLET LORAZEPAM 2 MG TABLET LORAZEPAM 2 MG/ML ORAL CONCENT MIDAZOLAM HCL 2 MG/ML SYRUP NIRAVAM 0.25 MG ODT NIRAVAM 0.5 MG ODT NIRAVAM 1 MG ODT NIRAVAM 2 MG ODT ONFI 10 MG TABLET ONFI 2.5 MG/ML SUSPENSION ONFI 20 MG TABLET ONFI 5 MG TABLET OXAZEPAM 10 MG CAPSULE OXAZEPAM 15 MG CAPSULE OXAZEPAM 30 MG CAPSULE QUAZEPAM 15 MG TABLET RESTORIL 15 MG CAPSULE RESTORIL 22.5 MG CAPSULE RESTORIL 30 MG CAPSULE RESTORIL 7.5 MG CAPSULE TEMAZEPAM 15 MG CAPSULE TEMAZEPAM 22.5 MG CAPSULE TEMAZEPAM 30 MG CAPSULE TEMAZEPAM 7.5 MG CAPSULE TRANXENE T-TAB 15 MG TRANXENE T-TAB 3.75 MG TRANXENE T-TAB 7.5 MG TRIAZOLAM 0.125 MG TABLET TRIAZOLAM 0.25 MG TABLET VALIUM 10 MG TABLET VALIUM 2 MG TABLET VALIUM 5 MG TABLET XANAX 0.25 MG TABLET XANAX 0.5 MG TABLET XANAX 1 MG TABLET XANAX 2 MG TABLET XANAX XR 0.5 MG TABLET XANAX XR 1 MG TABLET XANAX XR 2 MG TABLET XANAX XR 3 MG TABLET

NC NC NC NC 1 1 1 2 1 NC NC NC NC 3 3 3 3 2 2 2 2 NC NC NC NC 1 2 1 2 NC NC NC 2 2 NC NC NC NC NC NC NC NC NC NC NC

LIMITATIONS/ * NOTES

Prior Authorization required for members 18 and older Prior Authorization required for members 18 and older Prior Authorization required for members 18 and older

ANTIBACTERIALS AMINOGLYCOSIDES BETHKIS 300 MG/4 ML AMPULE NEOMYCIN 500 MG TABLET TOBI 300 MG/5 ML SOLUTION TOBI PODHALER 28 MG INHALE CAP TOBRAMYCIN 300 MG/5 ML AMPULE

4 2 NC 4 4

SPP*: Must use Accredo

SPP*: Accredo SPP*: Must use Accredo

ANTIBACTERIALS, MISCELLANEOUS VALUE FORMULARY FIVE-TIER DRUG LIST

Last Updated: 01/17/2017

Page 16

DRUG NAME

TIER

CLEOCIN 75 MG/5 ML GRANULES CLEOCIN HCL 150 MG CAPSULE CLEOCIN HCL 300 MG CAPSULE CLEOCIN HCL 75 MG CAPSULE CLINDAMYCIN 75 MG/5 ML SOLN CLINDAMYCIN HCL 150 MG CAPSULE CLINDAMYCIN HCL 300 MG CAPSULE CLINDAMYCIN HCL 75 MG CAPSULE FLAGYL 250 MG TABLET FLAGYL 375 CAPSULE FLAGYL 500 MG TABLET FLAGYL ER 750 MG TABLET FURADANTIN 25 MG/5 ML SUSP HIPREX 1 GM TABLET LINEZOLID 100 MG/5 ML SUSP LINEZOLID 600 MG TABLET MACROBID 100 MG CAPSULE MACRODANTIN 100 MG CAPSULE MACRODANTIN 25 MG CAPSULE MACRODANTIN 50 MG CAPSULE METHENAMINE HIPP 1 GM TABLET METHENAMINE MD 1 GM TABLET METHENAMINE MD 500 MG TABLET METRONIDAZOLE 250 MG TABLET METRONIDAZOLE 375 MG CAPSULE METRONIDAZOLE 500 MG TABLET MONUROL 3 GM SACHET NITROFURANTOIN 25 MG/5 ML SUSP NITROFURANTOIN MCR 100 MG CAP NITROFURANTOIN MCR 25 MG CAP NITROFURANTOIN MCR 50 MG CAP NITROFURANTOIN MONO-MCR 100 MG POLYMYXIN B 100 MILLION UNIT PRIMSOL 50 MG/5 ML ORAL SOLN SIVEXTRO 200 MG TABLET

NC NC NC NC 2 1 2 2 NC NC NC 4 NC NC 2 4 NC NC NC NC 2 2 2 2 2 2 4 2 2 2 2 2 NC 4 5

TRIMETHOPRIM 100 MG TABLET UROQID-ACID NO.2 500-500 TB VANCOCIN HCL 125 MG CAPSULE VANCOCIN HCL 250 MG CAPSULE VANCOMYCIN HCL 10 GM VIAL VANCOMYCIN HCL 125 MG CAPSULE VANCOMYCIN HCL 250 MG CAPSULE VANCOMYCIN HCL 5 GM VIAL VIBATIV 250 MG VIAL XIFAXAN 200 MG TABLET

2 NC NC NC 2 4 4 2 NC 4

XIFAXAN 550 MG TABLET ZYVOX 100 MG/5 ML SUSPENSION ZYVOX 600 MG TABLET

3 NC NC

LIMITATIONS/ * NOTES

Max. quantity of 6 per fill MQC*: 6 tabs/copay

Not covered for members 18 and older

Not covered for members 18 and older Max. quantity of 9 per fill MQC*: 9 tabs/copay

CEPHALOSPORINS CEDAX 180 MG/5 ML SUSPENSION CEDAX 400 MG CAPSULE CEFACLOR 125 MG/5 ML SUSP CEFACLOR 250 MG CAPSULE

VALUE FORMULARY FIVE-TIER DRUG LIST

NC NC 2 2

Last Updated: 01/17/2017

Page 17

DRUG NAME

TIER

CEFACLOR 250 MG/5 ML SUSP CEFACLOR 375 MG/5 ML SUSPEN CEFACLOR 500 MG CAPSULE CEFACLOR ER 500 MG TABLET CEFADROXIL 1 GM TABLET CEFADROXIL 250 MG/5 ML SUSP CEFADROXIL 500 MG CAPSULE CEFADROXIL 500 MG/5 ML SUSP CEFDINIR 125 MG/5 ML SUSP CEFDINIR 250 MG/5 ML SUSP CEFDINIR 300 MG CAPSULE CEFDITOREN PIVOXIL 200 MG TAB CEFDITOREN PIVOXIL 400 MG TAB CEFIXIME 100 MG/5 ML SUSP CEFIXIME 200 MG/5 ML SUSP CEFPODOXIME 100 MG TABLET CEFPODOXIME 100 MG/5 ML SUSP CEFPODOXIME 200 MG TABLET CEFPODOXIME 50 MG/5 ML SUSP CEFPROZIL 125 MG/5 ML SUSP CEFPROZIL 250 MG TABLET CEFPROZIL 250 MG/5 ML SUSP CEFPROZIL 500 MG TABLET CEFTIBUTEN 180 MG/5 ML SUSP CEFTIBUTEN 400 MG CAPSULE CEFTIN 125 MG/5 ML ORAL SUSP CEFTIN 250 MG TABLET CEFTIN 250 MG/5 ML ORAL SUSP CEFTIN 500 MG TABLET CEFUROXIME AXETIL 250 MG TAB CEFUROXIME AXETIL 500 MG TAB CEPHALEXIN 125 MG/5 ML SUSP CEPHALEXIN 250 MG CAPSULE CEPHALEXIN 250 MG TABLET CEPHALEXIN 250 MG/5 ML SUSP CEPHALEXIN 500 MG CAPSULE CEPHALEXIN 500 MG TABLET CEPHALEXIN 750 MG CAPSULE KEFLEX 250 MG CAPSULE KEFLEX 500 MG CAPSULE KEFLEX 750 MG CAPSULE SPECTRACEF 200 MG DOSE PACK TB SPECTRACEF 400 MG DOSE PACK TB SUPRAX 100 MG TABLET CHEWABLE SUPRAX 100 MG/5 ML SUSPENSION SUPRAX 200 MG TABLET CHEWABLE SUPRAX 200 MG/5 ML SUSPENSION SUPRAX 400 MG CAPSULE SUPRAX 400 MG TABLET SUPRAX 500 MG/5 ML SUSPENSION

2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 4 NC 4 NC 2 2 2 1 1 2 1 2 2 NC NC NC NC NC 4 4 4 4 4 4 4

LIMITATIONS/ * NOTES

MACROLIDES AZITHROMYCIN 1 GM PWD PACKET AZITHROMYCIN 100 MG/5 ML SUSP AZITHROMYCIN 200 MG/5 ML SUSP AZITHROMYCIN 250 MG TABLET AZITHROMYCIN 500 MG TABLET

VALUE FORMULARY FIVE-TIER DRUG LIST

2 2 2 1 2

Last Updated: 01/17/2017

Page 18

DRUG NAME

TIER

AZITHROMYCIN 600 MG TABLET BIAXIN 250 MG TABLET BIAXIN 250 MG/5 ML SUSPENSION BIAXIN 500 MG TABLET BIAXIN XL 500 MG TABLET CLARITHROMYCIN 125 MG/5 ML SUS CLARITHROMYCIN 250 MG TABLET CLARITHROMYCIN 250 MG/5 ML SUS CLARITHROMYCIN 500 MG TABLET CLARITHROMYCIN ER 500 MG TAB DIFICID 200 MG TABLET E.E.S. 200 MG/5 ML GRANULES E.E.S. 400 FILMTAB ERY-TAB EC 250 MG TABLET ERY-TAB EC 333 MG TABLET ERY-TAB EC 500 MG TABLET ERYPED 200 MG/5 ML SUSPENSION ERYPED 400 MG/5 ML SUSPENSION ERYTHROCIN 250 MG FILMTAB ERYTHROMYCIN 200 MG/5 ML GRAN ERYTHROMYCIN 250 MG FILMTAB ERYTHROMYCIN 500 MG FILMTAB ERYTHROMYCIN DR 250 MG CAP ERYTHROMYCIN ES 400 MG TAB ERYTHROMYCIN-SULFISOX SUSP KETEK 300 MG TABLET KETEK 400 MG TABLET PCE 333 MG TABLET PCE 500 MG TABLET ZITHROMAX 1 GM POWDER PACKET ZITHROMAX 100 MG/5 ML SUSP ZITHROMAX 200 MG/5 ML SUSP ZITHROMAX 250 MG TABLET ZITHROMAX 250 MG Z-PAK TABLET ZITHROMAX 500 MG TABLET ZITHROMAX 600 MG TABLET ZITHROMAX TRI-PAK 500 MG TAB ZMAX 2 G/60 ML ORAL SUSPENSION

2 NC NC NC NC 2 2 2 2 2 3 2 2 2 4 2 NC 4 2 2 2 2 2 2 2 4 4 4 4 NC NC NC NC NC NC NC NC 4

LIMITATIONS/ * NOTES

Limit fills to 1 in 30 days;Max. 20 per 10 days

MISCELLANEOUS B-LACTAM ANTIBIOTICS CAYSTON 75 MG INHAL SOLUTION

5

LDD*: IV Solutions. 1-800-658-6046.

PENICILLINS AMOX-CLAV 200-28.5 MG TAB CHEW AMOX-CLAV 200-28.5 MG/5 ML SUS AMOX-CLAV 250-125 MG TABLET AMOX-CLAV 250-62.5 MG/5 ML SUS AMOX-CLAV 400-57 MG TAB CHEW AMOX-CLAV 400-57 MG/5 ML SUSP AMOX-CLAV 500-125 MG TABLET AMOX-CLAV 600-42.9 MG/5 ML SUS AMOX-CLAV 875-125 MG TABLET AMOX-CLAV ER 1,000-62.5 MG TAB AMOXICILLIN 125 MG TAB CHEW AMOXICILLIN 125 MG/5 ML SUSP

VALUE FORMULARY FIVE-TIER DRUG LIST

2 2 2 2 2 2 2 2 2 2 2 1

Last Updated: 01/17/2017

Page 19

DRUG NAME

TIER

AMOXICILLIN 200 MG/5 ML SUSP AMOXICILLIN 250 MG CAPSULE AMOXICILLIN 250 MG TAB CHEW AMOXICILLIN 250 MG/5 ML SUSP AMOXICILLIN 400 MG/5 ML SUSP AMOXICILLIN 500 MG CAPSULE AMOXICILLIN 500 MG TABLET AMOXICILLIN 875 MG TABLET AMOXICILLIN ER 775 MG TABLET AMPICILLIN 125 MG/5 ML SUSP AMPICILLIN 250 MG CAPSULE AMPICILLIN 250 MG/5 ML SUSP AMPICILLIN 500 MG CAPSULE AUGMENTIN 125-31.25 MG/5 ML AUGMENTIN 250-62.5 MG/5 ML AUGMENTIN 500-125 TABLET AUGMENTIN 875-125 TABLET AUGMENTIN ES-600 SUSPENSION AUGMENTIN XR 1,000-62.5 TAB DICLOXACILLIN 250 MG CAPSULE DICLOXACILLIN 500 MG CAPSULE MOXATAG ER 775 MG TABLET PENICILLIN VK 125 MG/5 ML SOLN PENICILLIN VK 250 MG TABLET PENICILLIN VK 250 MG/5 ML SOLN PENICILLIN VK 500 MG TABLET

2 1 2 2 2 1 2 1 NC 2 1 2 2 4 NC NC NC NC NC 2 2 NC 1 1 2 2

LIMITATIONS/ * NOTES

QUINOLONES AVELOX 400 MG TABLET AVELOX ABC PACK 400 MG TAB CIPRO 10% SUSPENSION CIPRO 250 MG TABLET CIPRO 5% SUSPENSION CIPRO 500 MG TABLET CIPRO XR 1,000 MG TABLET CIPRO XR 500 MG TABLET CIPROFLOXACIN 250 MG/5 ML SUSP CIPROFLOXACIN 500 MG/5 ML SUSP CIPROFLOXACIN ER 1,000 MG TAB CIPROFLOXACIN ER 500 MG TABLET CIPROFLOXACIN HCL 100 MG TAB CIPROFLOXACIN HCL 250 MG TAB CIPROFLOXACIN HCL 500 MG TAB CIPROFLOXACIN HCL 750 MG TAB FACTIVE 320 MG TABLET LEVAQUIN 25 MG/ML SOLUTION LEVAQUIN 250 MG TABLET LEVAQUIN 500 MG TABLET LEVAQUIN 750 MG TABLET LEVOFLOXACIN 25 MG/ML SOLUTION LEVOFLOXACIN 250 MG TABLET LEVOFLOXACIN 500 MG TABLET LEVOFLOXACIN 750 MG TABLET MOXIFLOXACIN HCL 400 MG TABLET NOROXIN 400 MG TABLET OFLOXACIN 200 MG TABLET OFLOXACIN 300 MG TABLET

VALUE FORMULARY FIVE-TIER DRUG LIST

NC NC NC NC NC NC NC NC 2 2 2 2 2 1 1 1 5 NC NC NC NC 2 1 1 1 2 4 2 2

Last Updated: 01/17/2017

Page 20

DRUG NAME

TIER

OFLOXACIN 400 MG TABLET

2

LIMITATIONS/ * NOTES

SULFONAMIDES AZULFIDINE 500 MG TABLET AZULFIDINE ENTAB 500 MG BACTRIM 400-80 MG TABLET BACTRIM DS TABLET SULFADIAZINE 500 MG TABLET SULFAMETHOXAZOLE-TMP DS TABLET SULFAMETHOXAZOLE-TMP SS TABLET SULFAMETHOXAZOLE-TMP SUSP SULFASALAZINE 500 MG TABLET SULFASALAZINE DR 500 MG TAB SULFATRIM PEDIATRIC SUSPENSION

NC NC NC NC 2 1 1 2 2 2 2

TETRACYCLINES ACTICLATE 150 MG TABLET ACTICLATE 75 MG TABLET ADOXA 150 MG CAPSULE ALODOX CONVENIENCE KIT AVIDOXY 100 MG TABLET BENZODOX 30 KIT BENZODOX 60 KIT DEMECLOCYCLINE 150 MG TABLET DEMECLOCYCLINE 300 MG TABLET DORYX DR 150 MG TABLET DORYX DR 200 MG TABLET DORYX DR 50 MG TABLET DORYX MPC DR 120 MG TABLET DOXYCYCLINE 25 MG/5 ML SUSP DOXYCYCLINE HYC DR 100 MG TAB DOXYCYCLINE HYC DR 150 MG TAB DOXYCYCLINE HYC DR 200 MG TAB DOXYCYCLINE HYC DR 50 MG TAB DOXYCYCLINE HYC DR 75 MG TAB DOXYCYCLINE HYCLATE 100 MG CAP DOXYCYCLINE HYCLATE 100 MG TAB DOXYCYCLINE HYCLATE 20 MG TAB DOXYCYCLINE HYCLATE 50 MG CAP DOXYCYCLINE IR-DR 40 MG CAP DOXYCYCLINE MONO 100 MG CAP DOXYCYCLINE MONO 100 MG TABLET DOXYCYCLINE MONO 150 MG CAP DOXYCYCLINE MONO 150 MG TABLET DOXYCYCLINE MONO 50 MG CAP DOXYCYCLINE MONO 50 MG TABLET DOXYCYCLINE MONO 75 MG CAPSULE DOXYCYCLINE MONO 75 MG TABLET DYNACIN 100 MG TABLET DYNACIN 50 MG TABLET DYNACIN 75 MG TABLET MINOCIN 100 MG PELLETIZED CAP MINOCIN 50 MG PELLETIZED CAP MINOCIN 75 MG PELLETIZED CAP MINOCIN KIT 100 MG COMBO

VALUE FORMULARY FIVE-TIER DRUG LIST

NC NC NC 4 NC NC NC 2 2 NC NC NC 2 2 4 4 4 4 4 2 2 2 2 NC 2 4 4 2 2 4 4 2 NC NC NC NC NC NC NC

Last Updated: 01/17/2017

Page 21

DRUG NAME

TIER

MINOCIN KIT 50 MG COMBO MINOCYCLINE 100 MG CAPSULE MINOCYCLINE 50 MG CAPSULE MINOCYCLINE 75 MG CAPSULE MINOCYCLINE ER 135 MG TABLET MINOCYCLINE ER 45 MG TABLET MINOCYCLINE ER 90 MG TABLET MINOCYCLINE HCL 100 MG TABLET MINOCYCLINE HCL 50 MG TABLET MINOCYCLINE HCL 75 MG TABLET MONDOXYNE NL 100 MG CAPSULE MONDOXYNE NL 50 MG CAPSULE MONDOXYNE NL 75 MG CAPSULE MONODOX 100 MG CAPSULE MONODOX 50 MG CAPSULE MONODOX 75 MG CAPSULE MORGIDOX 100 MG CAPSULE MORGIDOX 1X100 MG KIT OCUDOX CONVENIENCE KIT ORACEA 40 MG CAPSULE SOLODYN ER 105 MG TABLET SOLODYN ER 115 MG TABLET SOLODYN ER 135 MG TABLET SOLODYN ER 45 MG TABLET SOLODYN ER 55 MG TABLET SOLODYN ER 65 MG TABLET SOLODYN ER 80 MG TABLET SOLODYN ER 90 MG TABLET TARGADOX 50 MG TABLET TETRACYCLINE 250 MG CAPSULE TETRACYCLINE 500 MG CAPSULE VIBRAMYCIN 100 MG CAPSULE VIBRAMYCIN 25 MG/5 ML SUSP VIBRAMYCIN 50 MG/5 ML SYRUP

NC 2 2 2 2 2 2 2 2 2 NC NC NC NC NC NC NC NC NC NC 5 NC NC NC 5 NC 5 NC NC 2 2 NC NC 4

LIMITATIONS/ * NOTES

Prior Authorization required Prior Authorization required Prior Authorization required

Prior Authorization required

Prior Authorization required Prior Authorization required

ANTICANCER AGENTS ANTICANCER AGENTS AFINITOR 10 MG TABLET AFINITOR 2.5 MG TABLET AFINITOR 5 MG TABLET AFINITOR 7.5 MG TABLET AFINITOR DISPERZ 2 MG TABLET AFINITOR DISPERZ 3 MG TABLET AFINITOR DISPERZ 5 MG TABLET ALECENSA 150 MG CAPSULE ALKERAN 2 MG TABLET ANASTROZOLE 1 MG TABLET ARIMIDEX 1 MG TABLET AROMASIN 25 MG TABLET BEXAROTENE 75 MG CAPSULE BICALUTAMIDE 50 MG TABLET BOSULIF 100 MG TABLET BOSULIF 500 MG TABLET CABOMETYX 20 MG TABLET

VALUE FORMULARY FIVE-TIER DRUG LIST

4 4 4 4 4 4 4 5 3 2 NC NC 2 2 4 4 5

CH*; SPP*: Accredo CH*; SPP*: Accredo CH*; SPP*: Accredo CH*; SPP*: Accredo CH*; SPP*: Accredo CH*; SPP*: Accredo CH*; SPP*: Accredo CH*; SPP*: Accredo CH* CH*; HSA*

CH* CH* CH*; SPP*: Accredo CH*; SPP*: Accredo Max. 1 per day CH*

Last Updated: 01/17/2017

Page 22

DRUG NAME

TIER

LIMITATIONS/ * NOTES

CABOMETYX 40 MG TABLET

5

CABOMETYX 60 MG TABLET

5

CAPECITABINE 150 MG TABLET CAPECITABINE 500 MG TABLET CAPRELSA 100 MG TABLET CAPRELSA 300 MG TABLET CASODEX 50 MG TABLET CEENU 10 MG CAPSULE CEENU 100 MG CAPSULE CEENU 40 MG CAPSULE COMETRIQ 100 MG DAILY-DOSE PK COMETRIQ 140 MG DAILY-DOSE PK COMETRIQ 60 MG DAILY-DOSE PACK COTELLIC 20 MG TABLET CYCLOPHOSPHAMIDE 25 MG CAPSULE CYCLOPHOSPHAMIDE 25 MG TAB CYCLOPHOSPHAMIDE 50 MG CAPSULE CYCLOPHOSPHAMIDE 50 MG TABLET DROXIA 200 MG CAPSULE DROXIA 300 MG CAPSULE DROXIA 400 MG CAPSULE ELIGARD 22.5 MG SYRINGE KIT ELIGARD 30 MG SYRINGE KIT ELIGARD 45 MG SYRINGE KIT ELIGARD 7.5 MG SYRINGE KIT EMCYT 140 MG CAPSULE ERIVEDGE 150 MG CAPSULE ETOPOSIDE 50 MG CAPSULE EXEMESTANE 25 MG TABLET FARESTON 60 MG TABLET FARYDAK 10 MG CAPSULE FARYDAK 15 MG CAPSULE FARYDAK 20 MG CAPSULE FEMARA 2.5 MG TABLET FLUTAMIDE 125 MG CAPSULE GILOTRIF 20 MG TABLET GILOTRIF 30 MG TABLET GILOTRIF 40 MG TABLET GLEEVEC 100 MG TABLET

2 2 5 5 NC 4 NC 4 4 4 4 4 3 2 3 2 4 4 4 5 5 5 5 3 5 2 2 3 5 5 5 NC 2 4 4 4 5

Max. 1 per day CH* Max. 1 per day CH* CH*; SPP*: Accredo CH*; SPP*: Accredo CH* CH*

GLEEVEC 400 MG TABLET

5

GLEOSTINE 10 MG CAPSULE GLEOSTINE 100 MG CAPSULE GLEOSTINE 40 MG CAPSULE GLEOSTINE 5 MG CAPSULE HEXALEN 50 MG CAPSULE HYCAMTIN 0.25 MG CAPSULE HYCAMTIN 1 MG CAPSULE HYCAMTIN 4 MG VIAL HYDREA 500 MG CAPSULE HYDROXYUREA 500 MG CAPSULE IBRANCE 100 MG CAPSULE IBRANCE 125 MG CAPSULE IBRANCE 75 MG CAPSULE ICLUSIG 15 MG TABLET ICLUSIG 45 MG TABLET IMATINIB MESYLATE 100 MG TAB

4 3 4 4 5 4 4 NC NC 2 5 5 5 5 5 3

VALUE FORMULARY FIVE-TIER DRUG LIST

CH* CH* CH*; LDD*: Diplomat Pharmacy. 1-877-977-9118. CH*; LDD*: Diplomat Pharmacy. 1-877-977-9118. CH*; LDD*: Diplomat Pharmacy. 1-877-977-9118. CH*; SPP*: Accredo CH* CH* CH* CH*

SPP*: Must use Magellan Rx SPP*: Must use Magellan Rx SPP*: Must use Magellan Rx SPP*: Must use Magellan Rx CH* CH*; SPP*: Accredo CH* CH*; HSA* CH*; HSA* CH*; SPP*: Accredo CH*; SPP*: Accredo CH*; SPP*: Accredo

CH*; SPP*: Must use Accredo CH*; SPP*: Must use Accredo CH*; SPP*: Must use Accredo Max. 30 Days Supply CH*; SPP*: Accredo Max. 30 Days Supply CH*; SPP*: Accredo CH* CH* CH* CH* CH* CH*; SPP*: Accredo CH*; SPP*: Accredo

CH* CH*; SPP*: Must use Accredo CH*; SPP*: Must use Accredo CH*; SPP*: Must use Accredo CH* CH* Max. 30 Days Supply CH*; SPP*: Accredo

Last Updated: 01/17/2017

Page 23

DRUG NAME

TIER

LIMITATIONS/ * NOTES

IMATINIB MESYLATE 400 MG TAB

3

IMBRUVICA 140 MG CAPSULE INLYTA 1 MG TABLET INLYTA 5 MG TABLET IRESSA 250 MG TABLET JAKAFI 10 MG TABLET JAKAFI 15 MG TABLET JAKAFI 20 MG TABLET JAKAFI 25 MG TABLET JAKAFI 5 MG TABLET LENVIMA 10 MG DAILY DOSE LENVIMA 14 MG DAILY DOSE LENVIMA 18 MG DAILY DOSE LENVIMA 20 MG DAILY DOSE LENVIMA 24 MG DAILY DOSE LENVIMA 8 MG DAILY DOSE LETROZOLE 2.5 MG TABLET LEUKERAN 2 MG TABLET LEUPROLIDE 2WK 14 MG/2.8 ML KT

5 5 5 4 5 5 5 5 5 5 5 5 5 5 5 2 3 2

LOMUSTINE 10 MG CAPSULE LOMUSTINE 100 MG CAPSULE LOMUSTINE 40 MG CAPSULE LONSURF 15 MG-6.14 MG TABLET LONSURF 20 MG-8.19 MG TABLET LUPRON DEPOT 11.25 MG 3MO KIT LUPRON DEPOT 22.5 MG 3MO KIT LUPRON DEPOT 3.75 MG KIT LUPRON DEPOT 45 MG 6MO KIT LUPRON DEPOT 7.5 MG KIT LUPRON DEPOT-4 MONTH KIT LYNPARZA 50 MG CAPSULE LYSODREN 500 MG TABLET MATULANE 50 MG CAPSULE MEGESTROL 20 MG TABLET MEGESTROL 40 MG TABLET MEKINIST 0.5 MG TABLET MEKINIST 2 MG TABLET MERCAPTOPURINE 50 MG TABLET METHOTREXATE 1 GM VIAL METHOTREXATE 2.5 MG TABLET METHOTREXATE 50 MG/2 ML VIAL METHOTREXATE 50 MG/2 ML VIAL MYLERAN 2 MG TABLET NEXAVAR 200 MG TABLET NILANDRON 150 MG TABLET NILUTAMIDE 150 MG TABLET NINLARO 2.3 MG CAPSULE NINLARO 3 MG CAPSULE NINLARO 4 MG CAPSULE ODOMZO 200 MG CAPSULE ONIVYDE 43 MG/10 ML VIAL POMALYST 1 MG CAPSULE POMALYST 2 MG CAPSULE POMALYST 3 MG CAPSULE POMALYST 4 MG CAPSULE PURINETHOL 50 MG TABLET PURIXAN 20 MG/ML ORAL SUSP REVLIMID 10 MG CAPSULE

2 2 2 4 4 MD MD MD MD MD MD NC 3 3 2 2 5 5 2 MD 2 MD MD 3 5 4 3 5 5 5 4 NC 5 5 5 5 NC 4 5

Max. 30 Days Supply CH*; SPP*: Accredo CH*; LDD*: Diplomat Pharmacy. 1-877-977-9118. CH*; SPP*: Accredo CH*; SPP*: Accredo CH*; SPP*: Accredo CH*; SPP*: Must use Accredo CH*; SPP*: Must use Accredo CH*; SPP*: Must use Accredo CH*; SPP*: Must use Accredo CH*; SPP*: Must use Accredo CH*; SPP*: Accredo CH*; SPP*: Accredo CH*; SPP*: Accredo CH*; SPP*: Accredo CH*; SPP*: Accredo CH*; SPP*: Accredo CH*; HSA* CH* Max. 30 Days Supply IVF* CH* CH* CH* CH*; SPP*: Accredo CH*; SPP*: Accredo SPP*: Must use Magellan Rx SPP*: Must use Magellan Rx SPP*: Must use Magellan Rx SPP*: Must use Magellan Rx SPP*: Must use Magellan Rx SPP*: Must use Magellan Rx

VALUE FORMULARY FIVE-TIER DRUG LIST

CH* CH*; LDD*: Walgreens Specialty CH* CH* CH*; SPP*: Accredo CH*; SPP*: Accredo CH*

CH* CH*; SPP*: Must use Accredo CH* CH* CH*; SPP*: Accredo CH*; SPP*: Accredo CH*; SPP*: Accredo CH*; SPP*: Accredo CH*; SPP*: Must use Accredo CH*; SPP*: Must use Accredo CH*; SPP*: Must use Accredo CH*; SPP*: Must use Accredo CH* CH*; SPP*: Must use Accredo

Last Updated: 01/17/2017

Page 24

DRUG NAME

TIER

LIMITATIONS/ * NOTES

REVLIMID 15 MG CAPSULE REVLIMID 2.5 MG CAPSULE REVLIMID 20 MG CAPSULE REVLIMID 25 MG CAPSULE REVLIMID 5 MG CAPSULE RHEUMATREX 2.5 MG TABLET RUBRACA 200 MG TABLET RUBRACA 300 MG TABLET SOLTAMOX 10 MG/5 ML SOLN SPRYCEL 100 MG TABLET SPRYCEL 140 MG TABLET SPRYCEL 20 MG TABLET SPRYCEL 50 MG TABLET SPRYCEL 70 MG TABLET SPRYCEL 80 MG TABLET STIVARGA 40 MG TABLET SUTENT 12.5 MG CAPSULE SUTENT 25 MG CAPSULE SUTENT 37.5 MG CAPSULE SUTENT 50 MG CAPSULE SYNRIBO 3.5 MG/ML VIAL TABLOID 40 MG TABLET TAFINLAR 50 MG CAPSULE TAFINLAR 75 MG CAPSULE TAGRISSO 40 MG TABLET TAGRISSO 80 MG TABLET TAMOXIFEN 10 MG TABLET TAMOXIFEN 20 MG TABLET TARCEVA 100 MG TABLET TARCEVA 150 MG TABLET TARCEVA 25 MG TABLET TARGRETIN 1% GEL TARGRETIN 75 MG CAPSULE TASIGNA 150 MG CAPSULE TASIGNA 200 MG CAPSULE TEMODAR 100 MG CAPSULE TEMODAR 140 MG CAPSULE TEMODAR 180 MG CAPSULE TEMODAR 20 MG CAPSULE TEMODAR 250 MG CAPSULE TEMODAR 5 MG CAPSULE TEMOZOLOMIDE 100 MG CAPSULE TEMOZOLOMIDE 140 MG CAPSULE TEMOZOLOMIDE 180 MG CAPSULE TEMOZOLOMIDE 20 MG CAPSULE TEMOZOLOMIDE 250 MG CAPSULE TEMOZOLOMIDE 5 MG CAPSULE TOPOTECAN HCL 4 MG VIAL TRETINOIN 10 MG CAPSULE TREXALL 10 MG TABLET TREXALL 15 MG TABLET TREXALL 5 MG TABLET TREXALL 7.5 MG TABLET TYKERB 250 MG TABLET VENCLEXTA 10 MG TABLET VENCLEXTA 100 MG TABLET VENCLEXTA 50 MG TABLET VENCLEXTA STARTING PACK VOTRIENT 200 MG TABLET

5 5 5 5 5 NC 4 4 4 4 4 4 4 4 4 4 4 4 4 4 MD 3 5 5 5 5 2 2 4 4 4 5 NC 4 4 NC NC NC NC NC NC 2 2 2 2 2 2 NC 4 NC NC NC NC 4 4 4 4 4 4

CH*; SPP*: Must use Accredo CH*; SPP*: Must use Accredo CH*; SPP*: Must use Accredo CH*; SPP*: Must use Accredo CH*; SPP*: Must use Accredo

VALUE FORMULARY FIVE-TIER DRUG LIST

CH*; HSA* CH*; SPP*: Accredo CH*; SPP*: Accredo CH*; SPP*: Accredo CH*; SPP*: Accredo CH*; SPP*: Accredo CH*; SPP*: Accredo CH*; SPP*: Accredo CH*; SPP*: Accredo CH*; SPP*: Accredo CH*; SPP*: Accredo CH*; SPP*: Accredo CH* CH*; SPP*: Accredo CH*; SPP*: Accredo CH*; SPP*: Accredo CH*; SPP*: Accredo CH*; HSA* CH*; HSA* CH*; SPP*: Accredo CH*; SPP*: Accredo CH*; SPP*: Accredo

CH*; SPP*: Accredo CH*; SPP*: Accredo

CH*; SPP*: Accredo CH*; SPP*: Accredo CH*; SPP*: Accredo CH*; SPP*: Accredo CH*; SPP*: Accredo CH*; SPP*: Accredo CH*

CH*; SPP*: Accredo CH*; LDD*: Diplomat Pharmacy. 1-877-977-9118. CH*; LDD*: Diplomat Pharmacy. 1-877-977-9118. CH*; LDD*: Diplomat Pharmacy. 1-877-977-9118. CH*; LDD*: Diplomat Pharmacy. 1-877-977-9118. CH*; SPP*: Accredo

Last Updated: 01/17/2017

Page 25

DRUG NAME

TIER

LIMITATIONS/ * NOTES

XALKORI 200 MG CAPSULE

5

XALKORI 250 MG CAPSULE

5

Max. 2 per day CH*; SPP*: Accredo Max. 2 per day CH*; SPP*: Accredo

XELODA 150 MG TABLET XELODA 500 MG TABLET XTANDI 40 MG CAPSULE ZELBORAF 240 MG TABLET ZOLINZA 100 MG CAPSULE ZYDELIG 100 MG TABLET ZYDELIG 150 MG TABLET ZYKADIA 150 MG CAPSULE ZYTIGA 250 MG TABLET

NC NC 4 5 5 5 5 5 4

CH*; SPP*: Accredo CH*; SPP*: Accredo CH*; SPP*: Must use Accredo CH* CH* CH*; SPP*: Must use Accredo CH*; SPP*: Accredo

ANTICHOLINERGIC AGENTS ANTIMUSCARINICS/ANTISPASMODICS CHLORDIAZEPOXIDE-CLIDINIUM CAP LIBRAX CAPSULE PROPANTHELINE 15 MG TABLET

2 NC 2

ANTICONVULSANTS ANTICONVULSANTS APTIOM 200 MG TABLET APTIOM 400 MG TABLET APTIOM 600 MG TABLET APTIOM 800 MG TABLET BANZEL 200 MG TABLET BANZEL 40 MG/ML SUSPENSION BANZEL 400 MG TABLET BRIVIACT 10 MG TABLET BRIVIACT 10 MG/ML ORAL SOLN BRIVIACT 100 MG TABLET BRIVIACT 25 MG TABLET BRIVIACT 50 MG TABLET BRIVIACT 75 MG TABLET CARBAMAZEPINE 100 MG TAB CHEW CARBAMAZEPINE 100 MG/5 ML SUSP CARBAMAZEPINE 200 MG TABLET CARBAMAZEPINE ER 100 MG CAP CARBAMAZEPINE ER 100 MG TABLET CARBAMAZEPINE ER 200 MG CAP CARBAMAZEPINE ER 200 MG TABLET CARBAMAZEPINE ER 300 MG CAP CARBAMAZEPINE ER 400 MG TABLET CARBATROL ER 100 MG CAPSULE CARBATROL ER 200 MG CAPSULE CARBATROL ER 300 MG CAPSULE CELONTIN 300 MG KAPSEAL DEPAKENE 250 MG CAPSULE DEPAKENE 250 MG/5 ML SOLUTION DEPAKOTE 125 MG SPRINKLE CAP DEPAKOTE DR 125 MG TABLET DEPAKOTE DR 250 MG TABLET

VALUE FORMULARY FIVE-TIER DRUG LIST

4 4 4 4 3 3 3 NC NC NC NC NC NC 2 2 2 2 2 2 2 2 2 NC NC NC 4 NC NC NC NC NC

Last Updated: 01/17/2017

Page 26

DRUG NAME

TIER

DEPAKOTE DR 500 MG TABLET DEPAKOTE ER 250 MG TABLET DEPAKOTE ER 500 MG TABLET DILANTIN 100 MG CAPSULE DILANTIN 125 MG/5 ML SUSP DILANTIN 30 MG CAPSULE DILANTIN 50 MG INFATAB DIVALPROEX SOD DR 125 MG TAB DIVALPROEX SOD DR 250 MG TAB DIVALPROEX SOD DR 500 MG TAB DIVALPROEX SOD ER 250 MG TAB DIVALPROEX SOD ER 500 MG TAB DIVALPROEX SODIUM 125 MG CAP EPITOL 200 MG TABLET EQUETRO 100 MG CAPSULE EQUETRO 200 MG CAPSULE EQUETRO 300 MG CAPSULE ETHOSUXIMIDE 250 MG CAPSULE ETHOSUXIMIDE 250 MG/5 ML SOLN FANATREX ORAL SUSPENSION FELBAMATE 400 MG TABLET FELBAMATE 600 MG TABLET FELBAMATE 600 MG/5 ML SUSP FELBATOL 400 MG TABLET FELBATOL 600 MG TABLET FELBATOL 600 MG/5 ML SUSP FYCOMPA 0.5 MG/ML ORAL SUSP FYCOMPA 10 MG TABLET FYCOMPA 12 MG TABLET FYCOMPA 2 MG TABLET FYCOMPA 4 MG TABLET FYCOMPA 6 MG TABLET FYCOMPA 8 MG TABLET GABAPENTIN 100 MG CAPSULE GABAPENTIN 250 MG/5 ML SOLN GABAPENTIN 300 MG CAPSULE GABAPENTIN 400 MG CAPSULE GABAPENTIN 600 MG TABLET GABAPENTIN 800 MG TABLET GABITRIL 12 MG TABLET GABITRIL 16 MG TABLET GABITRIL 2 MG TABLET GABITRIL 4 MG TABLET GRALISE 30-DAY STARTER PACK GRALISE ER 300 MG TABLET GRALISE ER 600 MG TABLET HORIZANT ER 300 MG TABLET HORIZANT ER 600 MG TABLET KEPPRA 1,000 MG TABLET KEPPRA 100 MG/ML ORAL SOLN KEPPRA 250 MG TABLET KEPPRA 500 MG TABLET KEPPRA 750 MG TABLET KEPPRA XR 500 MG TABLET KEPPRA XR 750 MG TABLET LAMICTAL 100 MG TABLET LAMICTAL 150 MG TABLET LAMICTAL 2 MG DISPER TABLET LAMICTAL 200 MG TABLET

NC NC NC 4 4 4 4 2 2 2 2 2 2 2 4 4 4 2 2 NC 2 2 2 NC NC NC 4 4 4 4 4 4 4 2 2 2 2 2 2 NC NC NC NC 4 4 4 NC NC NC NC NC NC NC NC NC NC NC 4 NC

VALUE FORMULARY FIVE-TIER DRUG LIST

LIMITATIONS/ * NOTES

Last Updated: 01/17/2017

Page 27

DRUG NAME

TIER

LAMICTAL 25 MG DISPER TABLET LAMICTAL 25 MG TABLET LAMICTAL 5 MG DISPER TABLET LAMICTAL ODT 100 MG TABLET LAMICTAL ODT 200 MG TABLET LAMICTAL ODT 25 MG TABLET LAMICTAL ODT 50 MG TABLET LAMICTAL ODT START KIT (BLUE) LAMICTAL ODT START KIT (GREEN) LAMICTAL ODT START KT (ORANGE) LAMICTAL TAB START KIT (BLUE) LAMICTAL TAB START KIT (GREEN) LAMICTAL TB START KIT (ORANGE) LAMICTAL XR 100 MG TABLET LAMICTAL XR 200 MG TABLET LAMICTAL XR 25 MG TABLET LAMICTAL XR 250 MG TABLET LAMICTAL XR 300 MG TABLET LAMICTAL XR 50 MG TABLET LAMICTAL XR START KIT (BLUE) LAMICTAL XR START KIT (GREEN) LAMICTAL XR START KIT (ORANGE) LAMOTRIGINE 100 MG TABLET LAMOTRIGINE 150 MG TABLET LAMOTRIGINE 200 MG TABLET LAMOTRIGINE 25 MG DISPER TAB LAMOTRIGINE 25 MG TABLET LAMOTRIGINE 25 MG TB START KIT LAMOTRIGINE 5 MG DISPER TABLET LAMOTRIGINE ER 100 MG TABLET LAMOTRIGINE ER 200 MG TABLET LAMOTRIGINE ER 25 MG TABLET LAMOTRIGINE ER 250 MG TABLET LAMOTRIGINE ER 300 MG TABLET LAMOTRIGINE ER 50 MG TABLET LAMOTRIGINE ODT 100 MG TABLET LAMOTRIGINE ODT 200 MG TABLET LAMOTRIGINE ODT 25 MG TABLET LAMOTRIGINE ODT 50 MG TABLET LAMOTRIGINE ODT KIT (BLUE) LAMOTRIGINE ODT KIT (GREEN) LAMOTRIGINE ODT KIT (ORANGE) LEVETIRACETAM 1,000 MG TABLET LEVETIRACETAM 100 MG/ML SOLN LEVETIRACETAM 250 MG TABLET LEVETIRACETAM 500 MG TABLET LEVETIRACETAM 750 MG TABLET LEVETIRACETAM ER 500 MG TABLET LEVETIRACETAM ER 750 MG TABLET LYRICA 100 MG CAPSULE

NC NC NC 4 4 4 4 4 4 4 NC NC 4 4 4 4 4 4 4 4 4 4 1 1 1 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 4

LYRICA 150 MG CAPSULE

4

LYRICA 20 MG/ML ORAL SOLUTION

4

LYRICA 200 MG CAPSULE

4

VALUE FORMULARY FIVE-TIER DRUG LIST

LIMITATIONS/ * NOTES

Not covered for members 18 and older;Step Therapy required STA*: 18 and older Not covered for members 18 and older;Step Therapy required STA*: 18 and older Not covered for members 18 and older;Step Therapy required STA*: 18 and older Not covered for members 18 and older;Step Therapy required STA*: 18 and older

Last Updated: 01/17/2017

Page 28

DRUG NAME

TIER

LIMITATIONS/ * NOTES

LYRICA 225 MG CAPSULE

4

LYRICA 25 MG CAPSULE

4

LYRICA 300 MG CAPSULE

4

LYRICA 50 MG CAPSULE

4

LYRICA 75 MG CAPSULE

4

Not covered for members 18 and older;Step Therapy required STA*: 18 and older Not covered for members 18 and older;Step Therapy required STA*: 18 and older Not covered for members 18 and older;Step Therapy required STA*: 18 and older Not covered for members 18 and older;Step Therapy required STA*: 18 and older Not covered for members 18 and older;Step Therapy required STA*: 18 and older

MYSOLINE 250 MG TABLET MYSOLINE 50 MG TABLET NEURONTIN 100 MG CAPSULE NEURONTIN 250 MG/5 ML SOLN NEURONTIN 300 MG CAPSULE NEURONTIN 400 MG CAPSULE NEURONTIN 600 MG TABLET NEURONTIN 800 MG TABLET OXCARBAZEPINE 150 MG TABLET OXCARBAZEPINE 300 MG TABLET OXCARBAZEPINE 300 MG/5 ML SUSP OXCARBAZEPINE 600 MG TABLET OXTELLAR XR 150 MG TABLET OXTELLAR XR 300 MG TABLET OXTELLAR XR 600 MG TABLET PEGANONE 250 MG TABLET PHENOBARBITAL 100 MG TABLET PHENOBARBITAL 15 MG TABLET PHENOBARBITAL 16.2 MG TABLET PHENOBARBITAL 20 MG/5 ML ELIX PHENOBARBITAL 30 MG TABLET PHENOBARBITAL 32.4 MG TABLET PHENOBARBITAL 60 MG TABLET PHENOBARBITAL 64.8 MG TABLET PHENOBARBITAL 97.2 MG TABLET PHENYTEK 200 MG CAPSULE PHENYTEK 300 MG CAPSULE PHENYTOIN 125 MG/5 ML SUSP PHENYTOIN 50 MG INFATAB PHENYTOIN SOD EXT 100 MG CAP PHENYTOIN SOD EXT 200 MG CAP PHENYTOIN SOD EXT 300 MG CAP POTIGA 200 MG TABLET POTIGA 300 MG TABLET POTIGA 400 MG TABLET POTIGA 50 MG TABLET PRIMIDONE 250 MG TABLET PRIMIDONE 50 MG TABLET QUDEXY XR 100 MG CAPSULE QUDEXY XR 150 MG CAPSULE QUDEXY XR 200 MG CAPSULE QUDEXY XR 25 MG CAPSULE QUDEXY XR 50 MG CAPSULE ROWEEPRA 500 MG TABLET SABRIL 500 MG POWDER PACKET SABRIL 500 MG TABLET SMARTRX GABA-V KIT

NC NC NC NC NC NC NC NC 2 2 2 2 NC NC NC 4 1 1 1 2 2 2 2 2 1 4 4 2 2 2 2 2 4 4 4 4 2 2 NC NC NC NC NC NC 3 3 NC

VALUE FORMULARY FIVE-TIER DRUG LIST

SPP*: Must use Accredo SPP*: Must use Accredo

Last Updated: 01/17/2017

Page 29

DRUG NAME

TIER

SPRITAM 1,000 MG TABLET SPRITAM 250 MG TABLET SPRITAM 500 MG TABLET SPRITAM 750 MG TABLET STAVZOR DR 125 MG CAPSULE STAVZOR DR 250 MG CAPSULE STAVZOR DR 500 MG CAPSULE TEGRETOL 100 MG/5 ML SUSP TEGRETOL 200 MG TABLET TEGRETOL XR 100 MG TABLET TEGRETOL XR 200 MG TABLET TEGRETOL XR 400 MG TABLET TIAGABINE HCL 2 MG TABLET TIAGABINE HCL 4 MG TABLET TOPAMAX 100 MG TABLET TOPAMAX 15 MG SPRINKLE CAP TOPAMAX 200 MG TABLET TOPAMAX 25 MG SPRINKLE CAP TOPAMAX 25 MG TABLET TOPAMAX 50 MG TABLET TOPIRAGEN 100 MG TABLET TOPIRAGEN 200 MG TABLET TOPIRAGEN 25 MG TABLET TOPIRAGEN 50 MG TABLET TOPIRAMATE 100 MG TABLET TOPIRAMATE 15 MG SPRINKLE CAP TOPIRAMATE 200 MG TABLET TOPIRAMATE 25 MG SPRINKLE CAP TOPIRAMATE 25 MG TABLET TOPIRAMATE 50 MG TABLET TOPIRAMATE ER 100 MG CAPSULE TOPIRAMATE ER 150 MG CAPSULE TOPIRAMATE ER 200 MG CAPSULE TOPIRAMATE ER 25 MG CAPSULE TOPIRAMATE ER 50 MG CAPSULE TRILEPTAL 150 MG TABLET TRILEPTAL 300 MG TABLET TRILEPTAL 300 MG/5 ML SUSP TRILEPTAL 600 MG TABLET TROKENDI XR 100 MG CAPSULE TROKENDI XR 200 MG CAPSULE TROKENDI XR 25 MG CAPSULE TROKENDI XR 50 MG CAPSULE VALPROIC ACID 250 MG CAPSULE VALPROIC ACID 250 MG/5 ML SOLN VIMPAT 10 MG/ML SOLUTION VIMPAT 100 MG TABLET VIMPAT 150 MG TABLET VIMPAT 200 MG TABLET VIMPAT 50 MG TABLET ZARONTIN 250 MG CAPSULE ZARONTIN 250 MG/5 ML SOLUTION ZONEGRAN 100 MG CAPSULE ZONEGRAN 25 MG CAPSULE ZONISAMIDE 100 MG CAPSULE ZONISAMIDE 25 MG CAPSULE ZONISAMIDE 50 MG CAPSULE

NC NC NC NC 4 4 4 NC NC 4 4 4 2 2 NC NC NC NC NC NC 1 2 1 1 1 2 2 2 1 1 2 2 2 2 2 NC NC 4 NC 4 4 4 4 2 2 3 3 3 3 3 NC NC NC NC 2 2 2

LIMITATIONS/ * NOTES

ANTIDEMENTIA AGENTS VALUE FORMULARY FIVE-TIER DRUG LIST

Last Updated: 01/17/2017

Page 30

DRUG NAME

TIER

LIMITATIONS/ * NOTES

ANTIDEMENTIA AGENTS ARICEPT 10 MG TABLET ARICEPT 23 MG TABLET ARICEPT 5 MG TABLET ARICEPT ODT 10 MG TABLET ARICEPT ODT 5 MG TABLET DONEPEZIL HCL 10 MG TABLET DONEPEZIL HCL 23 MG TABLET DONEPEZIL HCL 5 MG TABLET DONEPEZIL HCL ODT 10 MG TABLET DONEPEZIL HCL ODT 5 MG TABLET EXELON 1.5 MG CAPSULE EXELON 13.3 MG/24HR PATCH EXELON 2 MG/ML ORAL SOLUTION EXELON 3 MG CAPSULE EXELON 4.5 MG CAPSULE EXELON 4.6 MG/24HR PATCH EXELON 6 MG CAPSULE EXELON 9.5 MG/24HR PATCH GALANTAMINE 4 MG/ML ORAL SOLN GALANTAMINE ER 16 MG CAPSULE GALANTAMINE ER 24 MG CAPSULE GALANTAMINE ER 8 MG CAPSULE GALANTAMINE HBR 12 MG TABLET GALANTAMINE HBR 4 MG TABLET GALANTAMINE HBR 8 MG TABLET MEMANTINE 5-10 MG TITRATION PK MEMANTINE HCL 10 MG TABLET MEMANTINE HCL 2 MG/ML SOLUTION MEMANTINE HCL 5 MG TABLET NAMENDA 10 MG TABLET NAMENDA 2 MG/ML SOLUTION NAMENDA 5 MG TABLET NAMENDA 5-10 MG TITRATION PK NAMENDA XR 14 MG CAPSULE NAMENDA XR 21 MG CAPSULE NAMENDA XR 28 MG CAPSULE NAMENDA XR 7 MG CAPSULE NAMENDA XR TITRATION PACK NAMZARIC 14 MG-10 MG CAPSULE NAMZARIC 21 MG-10 MG CAPSULE NAMZARIC 28 MG-10 MG CAPSULE NAMZARIC 7 MG-10 MG CAPSULE NAMZARIC TITRATION PACK RAZADYNE 12 MG TABLET RAZADYNE 4 MG TABLET RAZADYNE 4 MG/ML ORAL SOLUTION RAZADYNE 8 MG TABLET RAZADYNE ER 16 MG CAPSULE RAZADYNE ER 24 MG CAPSULE RAZADYNE ER 8 MG CAPSULE RIVASTIGMINE 1.5 MG CAPSULE RIVASTIGMINE 13.3 MG/24HR PTCH RIVASTIGMINE 3 MG CAPSULE RIVASTIGMINE 4.5 MG CAPSULE RIVASTIGMINE 4.6 MG/24HR PATCH

VALUE FORMULARY FIVE-TIER DRUG LIST

NC NC NC NC NC 1 2 1 2 2 NC NC 4 NC NC NC NC NC 2 2 2 2 2 2 2 2 2 2 2 NC NC NC NC 4 4 4 4 4 NC NC NC NC NC NC NC NC NC NC NC NC 2 2 2 2 2

Last Updated: 01/17/2017

Page 31

DRUG NAME

TIER

RIVASTIGMINE 6 MG CAPSULE RIVASTIGMINE 9.5 MG/24HR PATCH

2 2

LIMITATIONS/ * NOTES

ANTIDEPRESSANTS ANTIDEPRESSANTS AMITRIPTYLINE HCL 10 MG TAB AMITRIPTYLINE HCL 100 MG TAB AMITRIPTYLINE HCL 150 MG TAB AMITRIPTYLINE HCL 25 MG TAB AMITRIPTYLINE HCL 50 MG TAB AMITRIPTYLINE HCL 75 MG TAB AMOXAPINE 100 MG TABLET AMOXAPINE 150 MG TABLET AMOXAPINE 25 MG TABLET AMOXAPINE 50 MG TABLET ANAFRANIL 25 MG CAPSULE ANAFRANIL 50 MG CAPSULE ANAFRANIL 75 MG CAPSULE APLENZIN ER 174 MG TABLET APLENZIN ER 348 MG TABLET APLENZIN ER 522 MG TABLET BRINTELLIX 10 MG TABLET

2 2 2 2 2 2 2 2 2 2 NC NC NC NC NC NC 4

BRINTELLIX 20 MG TABLET

4

BRINTELLIX 5 MG TABLET

4

BRISDELLE 7.5 MG CAPSULE

4

BUDEPRION SR 100 MG TABLET BUDEPRION SR 150 MG TABLET BUPROPION HCL 100 MG TABLET BUPROPION HCL 75 MG TABLET BUPROPION HCL SR 100 MG TABLET BUPROPION HCL SR 150 MG TABLET BUPROPION HCL SR 200 MG TABLET BUPROPION HCL XL 150 MG TABLET BUPROPION HCL XL 300 MG TABLET CELEXA 10 MG TABLET CELEXA 20 MG TABLET CELEXA 40 MG TABLET CHLORDIAZEPO-AMITRIPTYL 5-12.5 CHLORDIAZEPOX-AMITRIPTYL 10-25 CITALOPRAM HBR 10 MG TABLET CITALOPRAM HBR 10 MG/5 ML SOLN CITALOPRAM HBR 20 MG TABLET CITALOPRAM HBR 40 MG TABLET CLOMIPRAMINE 25 MG CAPSULE CLOMIPRAMINE 50 MG CAPSULE CLOMIPRAMINE 75 MG CAPSULE CYMBALTA 20 MG CAPSULE CYMBALTA 30 MG CAPSULE CYMBALTA 60 MG CAPSULE DESIPRAMINE 10 MG TABLET DESIPRAMINE 100 MG TABLET

2 2 2 2 2 2 2 2 2 NC NC NC 2 2 1 2 1 1 2 2 2 NC NC NC 2 2

VALUE FORMULARY FIVE-TIER DRUG LIST

Not covered for members 18 and older;Step Therapy required STA*: 18 and older Not covered for members 18 and older;Step Therapy required STA*: 18 and older Not covered for members 18 and older;Step Therapy required STA*: 18 and older Not covered for members 18 and older;Step Therapy required

Last Updated: 01/17/2017

Page 32

DRUG NAME

TIER

DESIPRAMINE 150 MG TABLET DESIPRAMINE 25 MG TABLET DESIPRAMINE 50 MG TABLET DESIPRAMINE 75 MG TABLET DESVENLAFAXINE ER 100 MG TAB DESVENLAFAXINE ER 100 MG TAB DESVENLAFAXINE ER 50 MG TAB DESVENLAFAXINE ER 50 MG TABLET DESVENLAFAXINE FUM ER 100 MG DESVENLAFAXINE FUM ER 50 MG DOXEPIN 10 MG CAPSULE DOXEPIN 10 MG/ML ORAL CONC DOXEPIN 100 MG CAPSULE DOXEPIN 150 MG CAPSULE DOXEPIN 25 MG CAPSULE DOXEPIN 50 MG CAPSULE DOXEPIN 75 MG CAPSULE DULOXETINE HCL DR 20 MG CAP DULOXETINE HCL DR 30 MG CAP DULOXETINE HCL DR 40 MG CAP DULOXETINE HCL DR 60 MG CAP EFFEXOR XR 150 MG CAPSULE EFFEXOR XR 37.5 MG CAPSULE EFFEXOR XR 75 MG CAPSULE EMSAM 12 MG/24 HOURS PATCH EMSAM 6 MG/24 HOURS PATCH EMSAM 9 MG/24 HOURS PATCH ESCITALOPRAM 10 MG TABLET ESCITALOPRAM 20 MG TABLET ESCITALOPRAM 5 MG TABLET ESCITALOPRAM OXALATE 5 MG/5 ML FETZIMA 20-40 MG TITRATION PAK

2 2 2 2 2 3 3 2 NC NC 2 2 2 2 2 2 2 2 2 2 2 NC NC NC 4 4 4 1 1 1 2 5

FETZIMA ER 120 MG CAPSULE

5

FETZIMA ER 20 MG CAPSULE

5

FETZIMA ER 40 MG CAPSULE

5

FETZIMA ER 80 MG CAPSULE

5

FLUOXETINE 20 MG/5 ML SOLUTION FLUOXETINE DR 90 MG CAPSULE FLUOXETINE HCL 10 MG CAPSULE FLUOXETINE HCL 10 MG TABLET FLUOXETINE HCL 20 MG CAPSULE FLUOXETINE HCL 20 MG TABLET FLUOXETINE HCL 40 MG CAPSULE FLUOXETINE HCL 60 MG TABLET FLUVOXAMINE ER 100 MG CAPSULE FLUVOXAMINE ER 150 MG CAPSULE FLUVOXAMINE MALEATE 100 MG TAB FLUVOXAMINE MALEATE 25 MG TAB FLUVOXAMINE MALEATE 50 MG TAB FORFIVO XL 450 MG TABLET

2 2 1 2 1 2 2 NC 2 2 2 2 2 3

IMIPRAMINE HCL 10 MG TABLET IMIPRAMINE HCL 25 MG TABLET IMIPRAMINE HCL 50 MG TABLET IMIPRAMINE PAMOATE 100 MG CAP

2 2 2 2

VALUE FORMULARY FIVE-TIER DRUG LIST

LIMITATIONS/ * NOTES

(generic) (Brand); STA: 18 and over (Brand); STA: 18 and over (generic)

Not covered for members 18 and older;Prior Authorization required Not covered for members 18 and older;Prior Authorization required Not covered for members 18 and older;Prior Authorization required Not covered for members 18 and older;Prior Authorization required Not covered for members 18 and older;Prior Authorization required

Not covered for members 18 and older;Step Therapy required STA*: 18 and older

Last Updated: 01/17/2017

Page 33

DRUG NAME

TIER

IMIPRAMINE PAMOATE 125 MG CAP IMIPRAMINE PAMOATE 150 MG CAP IMIPRAMINE PAMOATE 75 MG CAP IRENKA DR 40 MG CAPSULE KHEDEZLA ER 100 MG TABLET KHEDEZLA ER 50 MG TABLET LEXAPRO 10 MG TABLET LEXAPRO 20 MG TABLET LEXAPRO 5 MG TABLET LEXAPRO 5 MG/5 ML SOLUTION LUVOX CR 100 MG CAPSULE LUVOX CR 150 MG CAPSULE MAPROTILINE 25 MG TABLET MAPROTILINE 50 MG TABLET MAPROTILINE 75 MG TABLET MARPLAN 10 MG TABLET MIRTAZAPINE 15 MG ODT MIRTAZAPINE 15 MG TABLET MIRTAZAPINE 30 MG ODT MIRTAZAPINE 30 MG TABLET MIRTAZAPINE 45 MG ODT MIRTAZAPINE 45 MG TABLET MIRTAZAPINE 7.5 MG TABLET NARDIL 15 MG TABLET NEFAZODONE HCL 100 MG TABLET NEFAZODONE HCL 150 MG TABLET NEFAZODONE HCL 200 MG TABLET NEFAZODONE HCL 250 MG TABLET NEFAZODONE HCL 50 MG TABLET NORPRAMIN 10 MG TABLET NORPRAMIN 100 MG TABLET NORPRAMIN 150 MG TABLET NORPRAMIN 25 MG TABLET NORPRAMIN 50 MG TABLET NORPRAMIN 75 MG TABLET NORTRIPTYLINE 10 MG/5 ML SOL NORTRIPTYLINE HCL 10 MG CAP NORTRIPTYLINE HCL 25 MG CAP NORTRIPTYLINE HCL 50 MG CAP NORTRIPTYLINE HCL 75 MG CAP OLANZAPINE-FLUOXETINE 12-25 MG OLANZAPINE-FLUOXETINE 12-50 MG OLANZAPINE-FLUOXETINE 3-25 MG OLANZAPINE-FLUOXETINE 6-25 MG OLANZAPINE-FLUOXETINE 6-50 MG OLEPTRO ER 150 MG TABLET OLEPTRO ER 300 MG TABLET PAMELOR 10 MG CAPSULE PAMELOR 25 MG CAPSULE PAMELOR 50 MG CAPSULE PAMELOR 75 MG CAPSULE PARNATE 10 MG TABLET PAROXETINE ER 12.5 MG TABLET PAROXETINE ER 25 MG TABLET PAROXETINE ER 37.5 MG TABLET PAROXETINE HCL 10 MG TABLET PAROXETINE HCL 20 MG TABLET PAROXETINE HCL 30 MG TABLET PAROXETINE HCL 40 MG TABLET

2 2 2 NC NC NC NC NC NC NC NC NC 2 2 2 4 2 1 2 2 2 2 2 NC 2 2 2 2 2 NC NC NC NC NC NC 2 2 2 2 2 2 2 2 2 2 4 4 NC NC NC NC NC 2 2 2 1 1 1 1

VALUE FORMULARY FIVE-TIER DRUG LIST

LIMITATIONS/ * NOTES

Last Updated: 01/17/2017

Page 34

DRUG NAME

TIER

PAXIL 10 MG TABLET PAXIL 10 MG/5 ML SUSPENSION

NC 3

PAXIL 20 MG TABLET PAXIL 30 MG TABLET PAXIL 40 MG TABLET PAXIL CR 12.5 MG TABLET PAXIL CR 25 MG TABLET PAXIL CR 37.5 MG TABLET PERPHEN-AMITRIP 2 MG-10 MG TAB PERPHEN-AMITRIP 2 MG-25 MG TAB PERPHEN-AMITRIP 4 MG-10 MG TAB PERPHEN-AMITRIP 4 MG-25 MG TAB PERPHEN-AMITRIP 4 MG-50 MG TAB PEXEVA 10 MG TABLET PEXEVA 20 MG TABLET PEXEVA 30 MG TABLET PEXEVA 40 MG TABLET PHENELZINE SULFATE 15 MG TAB PRISTIQ ER 100 MG TABLET

NC NC NC NC NC NC 2 2 2 2 2 NC NC NC NC 2 4

PRISTIQ ER 25 MG TABLET

4

PRISTIQ ER 50 MG TABLET

4

PROTRIPTYLINE HCL 10 MG TABLET PROTRIPTYLINE HCL 5 MG TABLET PROZAC 10 MG PULVULE PROZAC 20 MG PULVULE PROZAC 40 MG PULVULE PROZAC WEEKLY 90 MG CAPSULE REMERON 15 MG SOLTAB REMERON 15 MG TABLET REMERON 30 MG SOLTAB REMERON 30 MG TABLET REMERON 45 MG SOLTAB REMERON 45 MG TABLET SARAFEM 10 MG TABLET SARAFEM 20 MG TABLET SERTRALINE 20 MG/ML ORAL CONC SERTRALINE HCL 100 MG TABLET SERTRALINE HCL 25 MG TABLET SERTRALINE HCL 50 MG TABLET SURMONTIL 100 MG CAPSULE SURMONTIL 25 MG CAPSULE SURMONTIL 50 MG CAPSULE SYMBYAX 12-25 MG CAPSULE SYMBYAX 12-50 MG CAPSULE SYMBYAX 3-25 MG CAPSULE SYMBYAX 6-25 MG CAPSULE SYMBYAX 6-50 MG CAPSULE TOFRANIL 10 MG TABLET TOFRANIL 25 MG TABLET TOFRANIL 50 MG TABLET TOFRANIL-PM 100 MG CAPSULE TOFRANIL-PM 125 MG CAPSULE TOFRANIL-PM 150 MG CAPSULE TOFRANIL-PM 75 MG CAPSULE

2 2 NC NC NC NC NC NC NC NC NC NC NC NC 2 1 1 1 4 4 4 NC NC NC NC NC NC NC NC NC NC NC NC

VALUE FORMULARY FIVE-TIER DRUG LIST

LIMITATIONS/ * NOTES Not covered for members 18 and older;Step Therapy required

Not covered for members 18 and older;Step Therapy required STA*: 18 and older Not covered for members 18 and older;Step Therapy required STA*: 18 and older Not covered for members 18 and older;Step Therapy required STA*: 18 and older

Last Updated: 01/17/2017

Page 35

DRUG NAME

TIER

TRANYLCYPROMINE SULF 10 MG TAB TRAZODONE 100 MG TABLET TRAZODONE 150 MG TABLET TRAZODONE 300 MG TABLET TRAZODONE 50 MG TABLET TRIMIPRAMINE MALEATE 100 MG CP TRIMIPRAMINE MALEATE 25 MG CAP TRIMIPRAMINE MALEATE 50 MG CAP TRINTELLIX 10 MG TABLET

2 1 1 2 1 2 2 2 4

TRINTELLIX 20 MG TABLET

4

TRINTELLIX 5 MG TABLET

4

VENLAFAXINE HCL 100 MG TABLET VENLAFAXINE HCL 25 MG TABLET VENLAFAXINE HCL 37.5 MG TABLET VENLAFAXINE HCL 50 MG TABLET VENLAFAXINE HCL 75 MG TABLET VENLAFAXINE HCL ER 150 MG CAP VENLAFAXINE HCL ER 150 MG TAB VENLAFAXINE HCL ER 225 MG TAB VENLAFAXINE HCL ER 37.5 MG CAP VENLAFAXINE HCL ER 37.5 MG TAB VENLAFAXINE HCL ER 75 MG CAP VENLAFAXINE HCL ER 75 MG TAB VIIBRYD 10 MG TABLET

2 2 2 2 2 2 NC 4 2 NC 2 NC 4

VIIBRYD 10-20 MG STARTER PACK

4

VIIBRYD 10-20-40 MG STARTER PK

4

VIIBRYD 20 MG TABLET

4

VIIBRYD 40 MG TABLET

4

VIVACTIL 10 MG TABLET VIVACTIL 5 MG TABLET WELLBUTRIN 100 MG TABLET WELLBUTRIN 75 MG TABLET WELLBUTRIN SR 100 MG TABLET WELLBUTRIN SR 150 MG TABLET WELLBUTRIN SR 200 MG TABLET WELLBUTRIN XL 150 MG TABLET WELLBUTRIN XL 300 MG TABLET ZOLOFT 100 MG TABLET ZOLOFT 20 MG/ML ORAL CONC ZOLOFT 25 MG TABLET ZOLOFT 50 MG TABLET

NC NC NC NC NC NC NC NC NC NC NC NC NC

LIMITATIONS/ * NOTES

Not covered for members 18 and older;Step Therapy required STA*: 18 and older Not covered for members 18 and older;Step Therapy required STA*: 18 and older Not covered for members 18 and older;Step Therapy required STA*: 18 and older

Not covered for members 18 and older;Step Therapy required STA*: 18 and older Not covered for members 18 and older;Step Therapy required STA*: 18 and older Not covered for members 18 and older;Step Therapy required STA*: 18 and older Not covered for members 18 and older;Step Therapy required STA*: 18 and older Not covered for members 18 and older;Step Therapy required STA*: 18 and older

ANTIDIABETIC AGENTS ANTIDIABETIC AGENTS, MISCELLANEOUS ACARBOSE 100 MG TABLET

VALUE FORMULARY FIVE-TIER DRUG LIST

2

HSA*

Last Updated: 01/17/2017

Page 36

DRUG NAME

TIER

LIMITATIONS/ * NOTES

ACARBOSE 25 MG TABLET ACARBOSE 50 MG TABLET ACTOPLUS MET 15 MG-500 MG TAB ACTOPLUS MET 15 MG-850 MG TAB ACTOPLUS MET XR 15-1,000 MG TB ACTOPLUS MET XR 30-1,000 MG TB ACTOS 15 MG TABLET ACTOS 30 MG TABLET ACTOS 45 MG TABLET ADLYXIN 10-20 MCG STARTER PACK ADLYXIN 20 MCG MAINTENANCE PK ALOGLIPTIN 12.5 MG TABLET

2 2 NC NC NC NC NC NC NC NC NC 5

HSA* HSA*

ALOGLIPTIN 25 MG TABLET

5

ALOGLIPTIN 6.25 MG TABLET

5

ALOGLIPTIN-METFORMIN 12.5-1000 ALOGLIPTIN-METFORMIN 12.5-500 ALOGLIPTIN-PIOGLIT 12.5-15 MG ALOGLIPTIN-PIOGLIT 12.5-30 MG ALOGLIPTIN-PIOGLIT 12.5-45 MG ALOGLIPTIN-PIOGLIT 25-15 MG TB ALOGLIPTIN-PIOGLIT 25-30 MG TB ALOGLIPTIN-PIOGLIT 25-45 MG TB AVANDAMET 2 MG-1,000 MG TAB AVANDAMET 2 MG-500 MG TABLET AVANDAMET 4 MG-1,000 MG TABLET AVANDAMET 4 MG-500 MG TABLET AVANDARYL 4 MG-1 MG TABLET AVANDARYL 4 MG-2 MG TABLET AVANDARYL 4 MG-4 MG TABLET AVANDARYL 8 MG-2 MG TABLET AVANDARYL 8 MG-4 MG TABLET AVANDIA 2 MG TABLET AVANDIA 4 MG TABLET AVANDIA 8 MG TABLET BYDUREON 2 MG PEN INJECT

NC NC NC NC NC NC NC NC NC NC NC NC NC NC NC NC NC 4 4 4 3

BYDUREON 2 MG VIAL

3

BYETTA 10 MCG DOSE PEN INJ

3

BYETTA 5 MCG DOSE PEN INJ

3

CYCLOSET 0.8 MG TABLET DUETACT 30-2 MG TABLET DUETACT 30-4 MG TABLET FARXIGA 10 MG TABLET

3 NC NC 5

FARXIGA 5 MG TABLET

5

FORTAMET ER 1,000 MG TABLET FORTAMET ER 500 MG TABLET GLUCOPHAGE 1,000 MG TABLET GLUCOPHAGE 500 MG TABLET GLUCOPHAGE 850 MG TABLET GLUCOPHAGE XR 500 MG TAB GLUCOPHAGE XR 750 MG TAB GLUMETZA ER 1,000 MG TABLET GLUMETZA ER 500 MG TABLET GLYSET 100 MG TABLET

NC NC NC NC NC NC NC NC NC NC

VALUE FORMULARY FIVE-TIER DRUG LIST

Step Therapy required HSA* Step Therapy required HSA* Step Therapy required HSA*

HSA* HSA* HSA* Max. 4 per 28 days;Step Therapy required HSA* Max. 4 per 28 days;Step Therapy required HSA* Step Therapy required HSA* Step Therapy required HSA* HSA*

Prior Authorization required HSA* Prior Authorization required HSA*

Last Updated: 01/17/2017

Page 37

DRUG NAME

TIER

GLYSET 25 MG TABLET GLYSET 50 MG TABLET GLYXAMBI 10 MG-5 MG TABLET GLYXAMBI 25 MG-5 MG TABLET INVOKAMET 150-1,000 MG TABLET INVOKAMET 150-500 MG TABLET INVOKAMET 50-1,000 MG TABLET INVOKAMET 50-500 MG TABLET INVOKAMET XR 150-1,000 MG TAB INVOKAMET XR 150-500 MG TABLET INVOKAMET XR 50-1,000 MG TAB INVOKAMET XR 50-500 MG TABLET INVOKANA 100 MG TABLET INVOKANA 300 MG TABLET JANUMET 50-1,000 MG TABLET JANUMET 50-500 MG TABLET JANUMET XR 100-1,000 MG TABLET JANUMET XR 50-1,000 MG TABLET JANUMET XR 50-500 MG TABLET JANUVIA 100 MG TABLET JANUVIA 25 MG TABLET JANUVIA 50 MG TABLET JARDIANCE 10 MG TABLET JARDIANCE 25 MG TABLET JENTADUETO 2.5 MG-1000 MG TAB JENTADUETO 2.5 MG-500 MG TAB JENTADUETO 2.5 MG-850 MG TAB JENTADUETO XR 2.5 MG-1,000 MG JENTADUETO XR 5 MG-1,000 MG TB JUVISYNC 100-10 MG TABLET JUVISYNC 100-20 MG TABLET JUVISYNC 100-40 MG TABLET JUVISYNC 50-10 MG TABLET JUVISYNC 50-20 MG TABLET JUVISYNC 50-40 MG TABLET KAZANO 12.5-1,000 MG TABLET KAZANO 12.5-500 MG TABLET KOMBIGLYZE XR 2.5-1,000 MG TAB KOMBIGLYZE XR 5-1,000 MG TAB KOMBIGLYZE XR 5-500 MG TABLET KORLYM 300 MG TABLET METFORMIN ER 1,000 MG OSM-TAB METFORMIN HCL 1,000 MG TABLET METFORMIN HCL 500 MG TABLET METFORMIN HCL 850 MG TABLET METFORMIN HCL ER 1,000 MG TAB

NC NC NC NC 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 NC NC NC NC NC NC NC NC NC NC NC 5 4 1 1 1 4

METFORMIN HCL ER 500 MG OSM-TB METFORMIN HCL ER 500 MG TABLET METFORMIN HCL ER 500 MG TABLET

2 1 4

METFORMIN HCL ER 750 MG TABLET MIFEPREX 200 MG TABLET MIGLITOL 100 MG TABLET MIGLITOL 25 MG TABLET MIGLITOL 50 MG TABLET NATEGLINIDE 120 MG TABLET NATEGLINIDE 60 MG TABLET NESINA 12.5 MG TABLET NESINA 25 MG TABLET

2 NC 2 2 2 2 2 NC NC

VALUE FORMULARY FIVE-TIER DRUG LIST

LIMITATIONS/ * NOTES

HSA* HSA* HSA* HSA* HSA* HSA* HSA* HSA* HSA* HSA* HSA* HSA* HSA* HSA* HSA* HSA* HSA* HSA* HSA* HSA* HSA* HSA* HSA* HSA* HSA*

SPP*: Must use Dohmen Life Sciences. 1-800-305-7881. HSA*; (generic Fortamet) HSA* HSA* HSA* Prior Authorization required HSA*; (generic Glumetza) HSA*; (generic Fortamet) HSA* Prior Authorization required HSA*; (generic Glumetza) HSA* HSA* HSA* HSA* HSA* HSA*

Last Updated: 01/17/2017

Page 38

DRUG NAME

TIER

NESINA 6.25 MG TABLET ONGLYZA 2.5 MG TABLET

NC 5

ONGLYZA 5 MG TABLET

5

OSENI 12.5-15 MG TABLET OSENI 12.5-30 MG TABLET OSENI 12.5-45 MG TABLET OSENI 25-15 MG TABLET OSENI 25-30 MG TABLET OSENI 25-45 MG TABLET PIOGLITAZONE HCL 15 MG TABLET PIOGLITAZONE HCL 30 MG TABLET PIOGLITAZONE HCL 45 MG TABLET PIOGLITAZONE-GLIMEPIRIDE 30-2 PIOGLITAZONE-GLIMEPIRIDE 30-4 PIOGLITAZONE-METFORMIN 15-500 PIOGLITAZONE-METFORMIN 15-850 PRANDIMET 1 MG-500 MG TABLET PRANDIMET 2 MG-500 MG TABLET PRANDIN 0.5 MG TABLET PRANDIN 1 MG TABLET PRANDIN 2 MG TABLET PRECOSE 100 MG TABLET PRECOSE 25 MG TABLET PRECOSE 50 MG TABLET REPAGLINIDE 0.5 MG TABLET REPAGLINIDE 1 MG TABLET REPAGLINIDE 2 MG TABLET REPAGLINIDE-METFORMIN 1-500 MG REPAGLINIDE-METFORMIN 2-500 MG RIOMET 500 MG/5 ML SOLUTION STARLIX 120 MG TABLET STARLIX 60 MG TABLET SYMLINPEN 120 PEN INJECTOR SYMLINPEN 60 PEN INJECTOR SYNJARDY 12.5-1,000 MG TABLET SYNJARDY 12.5-500 MG TABLET SYNJARDY 5-1,000 MG TABLET SYNJARDY 5-500 MG TABLET TANZEUM 30 MG PEN INJECT TANZEUM 50 MG PEN INJECT TRADJENTA 5 MG TABLET TRULICITY 0.75 MG/0.5 ML PEN

NC NC NC NC NC NC 2 2 2 2 2 2 2 NC NC NC NC NC NC NC NC 2 2 2 2 2 4 NC NC 3 3 NC NC NC NC NC NC 3 3

TRULICITY 1.5 MG/0.5 ML PEN

3

VICTOZA 3-PAK 18 MG/3 ML PEN

3

XIGDUO XR 10 MG-1,000 MG TAB

5

XIGDUO XR 10 MG-500 MG TABLET

5

XIGDUO XR 5 MG-1,000 MG TABLET

5

XIGDUO XR 5 MG-500 MG TABLET

5

LIMITATIONS/ * NOTES Prior Authorization required HSA* Prior Authorization required HSA*

HSA* HSA* HSA* HSA* HSA* HSA* HSA*

HSA* HSA* HSA* HSA* HSA* HSA*

HSA* HSA*

HSA* Max. 0.5 ML(s) per 7 days;Step Therapy required HSA* Max. 0.5 ML(s) per 7 days;Step Therapy required HSA* Step Therapy required HSA* Prior Authorization required HSA* Prior Authorization required HSA* Prior Authorization required HSA* Prior Authorization required HSA*

INSULINS AFREZZA 30-4 UNIT / 60-8 UNIT

VALUE FORMULARY FIVE-TIER DRUG LIST

NC

Last Updated: 01/17/2017

Page 39

DRUG NAME

TIER

AFREZZA 4 UNIT CARTRIDGE AFREZZA 60-4 UNIT / 30-8 UNIT AFREZZA 60-8 UNIT / 30-12 UNIT APIDRA 100 UNITS/ML VIAL APIDRA SOLOSTAR 100 UNITS/ML BASAGLAR 100 UNIT/ML KWIKPEN

NC NC NC NC NC 4

HUMALOG 100 UNITS/ML CARTRIDGE HUMALOG 100 UNITS/ML KWIKPEN HUMALOG 100 UNITS/ML VIAL HUMALOG 200 UNITS/ML KWIKPEN HUMALOG MIX 50-50 KWIKPEN HUMALOG MIX 50-50 VIAL HUMALOG MIX 75-25 KWIKPEN HUMALOG MIX 75-25 VIAL HUMULIN 70-30 VIAL HUMULIN 70/30 KWIKPEN HUMULIN N 100 UNITS/ML KWIKPEN HUMULIN N 100 UNITS/ML VIAL HUMULIN R 100 UNITS/ML VIAL HUMULIN R 500 UNITS/ML KWIKPEN HUMULIN R 500 UNITS/ML VIAL LANTUS 100 UNITS/ML VIAL LANTUS SOLOSTAR 100 UNITS/ML LEVEMIR 100 UNITS/ML VIAL LEVEMIR FLEXTOUCH 100 UNITS/ML NOVOLIN 70-30 100 UNIT/ML VIAL

3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 4

NOVOLIN N 100 UNITS/ML VIAL

4

NOVOLIN R 100 UNITS/ML VIAL

4

NOVOLOG 100 UNIT/ML CARTRIDGE

4

NOVOLOG 100 UNIT/ML VIAL

4

NOVOLOG 100 UNITS/ML FLEXPEN

4

NOVOLOG MIX 70-30 FLEXPEN SYRN

4

NOVOLOG MIX 70-30 VIAL

4

SOLIQUA 100 UNIT-33 MCG/ML PEN TOUJEO SOLOSTAR 300 UNITS/ML TRESIBA FLEXTOUCH 100 UNITS/ML

NC 3 5

TRESIBA FLEXTOUCH 200 UNITS/ML

5

XULTOPHY 100 UNIT-3.6MG/ML PEN

NC

LIMITATIONS/ * NOTES

Prior Authorization required HSA* HSA* HSA* HSA* HSA* HSA* HSA* HSA* HSA* HSA* HSA* HSA* HSA* HSA* HSA* HSA* HSA* HSA* HSA* HSA* Prior Authorization required HSA* Prior Authorization required HSA* Prior Authorization required HSA* Prior Authorization required HSA* Prior Authorization required HSA* Prior Authorization required HSA* Prior Authorization required HSA* Prior Authorization required HSA* HSA* Prior Authorization required HSA* Prior Authorization required HSA*

SULFONYLUREAS AMARYL 1 MG TABLET AMARYL 2 MG TABLET AMARYL 4 MG TABLET CHLORPROPAMIDE 100 MG TABLET CHLORPROPAMIDE 250 MG TABLET DIABETA 1.25 MG TABLET DIABETA 2.5 MG TABLET DIABETA 5 MG TABLET GLIMEPIRIDE 1 MG TABLET GLIMEPIRIDE 2 MG TABLET

VALUE FORMULARY FIVE-TIER DRUG LIST

NC NC NC 2 2 NC NC NC 1 1

HSA* HSA*

HSA* HSA*

Last Updated: 01/17/2017

Page 40

DRUG NAME

TIER

LIMITATIONS/ * NOTES

GLIMEPIRIDE 4 MG TABLET GLIPIZIDE 10 MG TABLET GLIPIZIDE 5 MG TABLET GLIPIZIDE ER 10 MG TABLET GLIPIZIDE ER 2.5 MG TABLET GLIPIZIDE ER 5 MG TABLET GLIPIZIDE-METFORMIN 2.5-250 MG GLIPIZIDE-METFORMIN 2.5-500 MG GLIPIZIDE-METFORMIN 5-500 MG GLUCOTROL 10 MG TABLET GLUCOTROL 5 MG TABLET GLUCOTROL XL 10 MG TABLET GLUCOTROL XL 2.5 MG TABLET GLUCOTROL XL 5 MG TABLET GLUCOVANCE 2.5-500 MG TABLET GLUCOVANCE 5-500 MG TABLET GLYBURID-METFORMIN 1.25-250 MG GLYBURIDE 1.25 MG TABLET GLYBURIDE 2.5 MG TABLET GLYBURIDE 5 MG TABLET GLYBURIDE MICRO 1.5 MG TAB GLYBURIDE MICRO 3 MG TABLET GLYBURIDE MICRO 6 MG TABLET GLYBURIDE-METFORMIN 2.5-500 MG GLYBURIDE-METFORMIN 5-500 MG GLYNASE 1.5 MG PRESTAB GLYNASE 3 MG PRESTAB GLYNASE 6 MG PRESTAB TOLAZAMIDE 250 MG TABLET TOLAZAMIDE 500 MG TABLET TOLBUTAMIDE 500 MG TABLET

2 1 1 2 2 2 2 2 2 NC NC NC NC NC NC NC 2 2 2 2 1 2 2 2 2 NC NC NC 2 2 2

HSA* HSA* HSA* HSA* HSA* HSA* HSA* HSA* HSA*

HSA* HSA* HSA* HSA* HSA* HSA* HSA* HSA* HSA*

HSA* HSA* HSA*

ANTIFUNGALS ANTIFUNGALS ALA-QUIN 3-0.5% CREAM ANCOBON 250 MG CAPSULE ANCOBON 500 MG CAPSULE CICLODAN 0.77% CREAM CICLODAN 0.77% CREAM KIT CICLODAN 8% KIT CICLODAN 8% SOLUTION CICLOPIROX 0.77% CREAM CICLOPIROX 0.77% GEL CICLOPIROX 0.77% TOPICAL SUSP CICLOPIROX 1% SHAMPOO CICLOPIROX 8% SOLUTION CICLOPIROX 8% TREATMENT KIT CLOTRIMAZOLE 1% CREAM CLOTRIMAZOLE 1% SOLUTION CLOTRIMAZOLE 10 MG TROCHE CLOTRIMAZOLE-BETAMETHASONE CRM CLOTRIMAZOLE-BETAMETHASONE LOT CRESEMBA 186 MG CAPSULE DIFLUCAN 10 MG/ML SUSPENSION DIFLUCAN 100 MG TABLET DIFLUCAN 150 MG TABLET

VALUE FORMULARY FIVE-TIER DRUG LIST

NC NC NC NC NC NC NC 2 2 2 2 2 NC NC NC 2 2 2 5 NC NC NC

Prior Authorization required

Last Updated: 01/17/2017

Page 41

DRUG NAME

TIER

DIFLUCAN 200 MG TABLET DIFLUCAN 40 MG/ML SUSPENSION DIFLUCAN 50 MG TABLET ECONAZOLE NITRATE 1% CREAM ECOZA 1% FOAM ERTACZO 2% CREAM EXELDERM 1% CREAM EXELDERM 1% SOLUTION EXTINA 2% FOAM FIRST-DUKE'S MOUTHWASH FIRST-MARY'S MOUTHWASH FLUCONAZOLE 10 MG/ML SUSP FLUCONAZOLE 100 MG TABLET FLUCONAZOLE 150 MG TABLET FLUCONAZOLE 200 MG TABLET FLUCONAZOLE 40 MG/ML SUSP FLUCONAZOLE 50 MG TABLET FLUCYTOSINE 250 MG CAPSULE FLUCYTOSINE 500 MG CAPSULE GRIFULVIN V 500 MG TABLET GRIS-PEG 125 MG TABLET GRIS-PEG 250 MG TABLET GRISEOFULVIN 125 MG/5 ML SUSP GRISEOFULVIN MICRO 500 MG TAB GRISEOFULVIN ULTRA 125 MG TAB GRISEOFULVIN ULTRA 250 MG TAB ITRACONAZOLE 100 MG CAPSULE

NC NC NC 2 NC 5 4 4 NC NC NC 2 2 1 2 2 1 2 2 NC NC NC 2 2 2 2 2

JUBLIA 10% TOPICAL SOLUTION KERYDIN 5% TOPICAL SOLUTION KETOCONAZOLE 2% CREAM KETOCONAZOLE 2% FOAM KETOCONAZOLE 2% SHAMPOO KETOCONAZOLE 200 MG TABLET KETODAN 2% FOAM KETODAN 2% FOAM KIT LAMISIL 125 MG GRANULES PACKET LAMISIL 187.5 MG GRANULES PACK LAMISIL 250 MG TABLET LOPROX 0.77% CREAM LOPROX 0.77% GEL LOPROX 0.77% TOPICAL SUSP LOPROX 1% SHAMPOO LOTRISONE CREAM LUZU 1% CREAM MENTAX 1% CREAM MICONAZOLE 3 200 MG VAG SUPP NAFTIFINE HCL 1% CREAM NAFTIFINE HCL 2% CREAM NAFTIN 1% CREAM NAFTIN 1% GEL NAFTIN 2% CREAM NAFTIN 2% GEL NIZORAL 2% SHAMPOO NOXAFIL 40 MG/ML SUSPENSION NOXAFIL DR 100 MG TABLET NYAMYC 100,000 UNITS/GM POWDER NYATA 100,000 UNIT/GM POWDER NYSTATIN 100,000 UNIT/GM CREAM

NC 5 2 2 2 2 2 NC NC NC NC NC NC NC NC NC 5 5 NC 2 2 NC 4 NC 4 NC 5 NC 2 2 2

VALUE FORMULARY FIVE-TIER DRUG LIST

LIMITATIONS/ * NOTES

Prior Authorization required

Max. 84 Days Supply;Prior Authorization required;Max. 168 in 365 days Prior Authorization required

Prior Authorization required Prior Authorization required

Last Updated: 01/17/2017

Page 42

NYSTATIN 100,000 UNIT/GM POWD NYSTATIN 100,000 UNIT/ML SUSP NYSTATIN 100,000 UNITS/GM OINT NYSTATIN 500,000 UNIT ORAL TAB NYSTATIN-TRIAMCINOLONE CREAM NYSTATIN-TRIAMCINOLONE OINTM NYSTOP 100,000 UNITS/GM POWDER ONMEL 200 MG TABLET ORAVIG 50 MG BUCCAL TABLET OXICONAZOLE NITRATE 1% CREAM OXISTAT 1% CREAM OXISTAT 1% LOTION PEDI-DRI TOPICAL POWDER PEDIADERM AF KIT PEDIPIROX-4 NAIL KIT PENLAC 8% SOLUTION SPORANOX 10 MG/ML SOLUTION SPORANOX 100 MG CAPSULE TERBINAFINE HCL 250 MG TABLET TRIPLE DYE SWAB UNDECYLENIC ACID LIQUID VFEND 200 MG TABLET VFEND 40 MG/ML SUSPENSION VFEND 50 MG TABLET VORICONAZOLE 200 MG TABLET VORICONAZOLE 40 MG/ML SUSP VORICONAZOLE 50 MG TABLET VUSION OINTMENT XOLEGEL 2% GEL

2 2 2 2 2 2 2 NC 4 2 NC 4 2 NC NC NC 4 NC 2 NC NC NC NC NC 4 4 4 NC 4

Max. quantity of 28 per fill;Max. 84 in 365 days

ANTIGOUT AGENTS ANTIGOUT AGENTS, OTHER ALLOPURINOL 100 MG TABLET ALLOPURINOL 300 MG TABLET COLCHICINE 0.6 MG CAPSULE COLCHICINE 0.6 MG TABLET COLCRYS 0.6 MG TABLET MITIGARE 0.6 MG CAPSULE PROBENECID 500 MG TABLET PROBENECID-COLCHICINE TABS ULORIC 40 MG TABLET ULORIC 80 MG TABLET ZURAMPIC 200 MG TABLET ZYLOPRIM 100 MG TABLET ZYLOPRIM 300 MG TABLET

2 2 2 2 NC NC 2 2 3 3 NC NC NC

ANTIHISTAMINES ANTIHISTAMINES ALLEGRA ODT 30 MG TABLET ALLEGRA-D 24 HOUR TABLET ARBINOXA 4 MG TABLET ARBINOXA 4 MG/5 ML LIQUID CARBINOXAMINE 4 MG/5 ML LIQUID CARBINOXAMINE MALEATE 4 MG TAB CETIRIZINE HCL 1 MG/ML SOLN

VALUE FORMULARY FIVE-TIER DRUG LIST

NC NC 2 2 2 2 NC

Last Updated: 01/17/2017

Page 43

DRUG NAME

TIER

CLARINEX 0.5 MG/ML (2.5 MG/5) CLARINEX 2.5 MG REDITABS CLARINEX 5 MG REDITABS CLARINEX 5 MG TABLET CLARINEX-D 12 HOUR TABLET CLARINEX-D 24 HOUR TABLET CLEMASTINE 0.5 MG/5 ML SYRUP CLEMASTINE FUM 2.68 MG TAB CYPROHEPTADINE 2 MG/5 ML SYRUP CYPROHEPTADINE 4 MG TABLET DESLORATADINE 2.5 MG ODT DESLORATADINE 5 MG ODT DESLORATADINE 5 MG TABLET DICOPANOL ORAL SUSPENSION DIPHENHYDRAMINE 50 MG CAPSULE FEXOFENADINE-PSE ER 180-240 TB HYDROXYZINE 10 MG/5 ML SOLN HYDROXYZINE HCL 10 MG TABLET HYDROXYZINE HCL 25 MG TABLET HYDROXYZINE HCL 50 MG TABLET KARBINAL ER 4 MG/ 5 ML SUSP LEVOCETIRIZINE 2.5 MG/5 ML SOL LEVOCETIRIZINE 5 MG TABLET PALGIC 4 MG TABLET PALGIC 4 MG/5 ML LIQUID PROMETHAZINE 6.25 MG/5 ML SYRP PROMETHAZINE VC SYRUP RESPA A.R. TABLET SA SEMPREX-D 8 MG-60 MG CAPSULE XYZAL 2.5 MG/5 ML SOLUTION XYZAL 5 MG TABLET

4 NC NC NC NC NC 2 2 2 2 NC NC NC NC 1 NC 2 2 2 2 NC 2 2 NC 2 1 2 NC NC NC NC

LIMITATIONS/ * NOTES

ANTIMIGRAINE AGENTS ANTIMIGRAINE AGENTS ALMOTRIPTAN MALATE 12.5 MG TAB

2

ALMOTRIPTAN MALATE 6.25 MG TAB

2

ALSUMA 6 MG/0.5 ML AUTO-INJECT AMERGE 1 MG TABLET AMERGE 2.5 MG TABLET AXERT 12.5 MG TABLET AXERT 6.25 MG TABLET CAFERGOT TABLET D.H.E.45 1 MG/ML AMPUL DIHYDROERGOTAMINE 1 MG/ML AM DIHYDROERGOTAMINE 4 MG/ML SPRY ERGOMAR 2 MG TABLET SL ERGOTAMINE-CAFFEINE 1-100MG TB FROVA 2.5 MG TABLET FROVATRIPTAN SUCC 2.5 MG TAB

NC NC NC NC NC NC NC 2 4 3 2 NC 2

IMITREX 100 MG TABLET IMITREX 20 MG NASAL SPRAY IMITREX 25 MG TABLET IMITREX 4 MG/0.5 ML PEN INJECT IMITREX 5 MG NASAL SPRAY

NC NC NC NC NC

VALUE FORMULARY FIVE-TIER DRUG LIST

Max. quantity of 6 per fill MQC*: 6 tabs/copay Max. quantity of 12 per fill MQC*: 12 tabs/copay

Max. quantity of 9 per fill;Step Therapy required MQC*: 9 tabs/copay

Last Updated: 01/17/2017

Page 44

IMITREX 50 MG TABLET IMITREX 6 MG/0.5 ML CARTRIDGES IMITREX 6 MG/0.5 ML VIAL ISOMETHEPT-DICHLORALP-ACETAMIN MAXALT 10 MG TABLET MAXALT 5 MG TABLET MAXALT MLT 10 MG TABLET MAXALT MLT 5 MG TABLET MIGERGOT SUPPOSITORY MIGRANAL NASAL SPRAY NARATRIPTAN HCL 1 MG TABLET

NC NC NC 2 NC NC NC NC NC NC 2

NARATRIPTAN HCL 2.5 MG TABLET

2

NODOLOR CAPSULE ONZETRA XSAIL 11 MG RELPAX 20 MG TABLET

2 NC 3

RELPAX 40 MG TABLET

3

RIZATRIPTAN 10 MG ODT

2

RIZATRIPTAN 10 MG TABLET

2

RIZATRIPTAN 5 MG ODT

2

RIZATRIPTAN 5 MG TABLET

2

SUMATRIPTAN 20 MG NASAL SPRAY

2

SUMATRIPTAN 4 MG/0.5 ML INJECT

2

SUMATRIPTAN 5 MG NASAL SPRAY

2

SUMATRIPTAN 6 MG/0.5 ML INJECT

2

SUMATRIPTAN 6 MG/0.5 ML REFILL

2

SUMATRIPTAN 6 MG/0.5 ML SYRNG

2

SUMATRIPTAN 6 MG/0.5 ML VIAL

2

SUMATRIPTAN SUCC 100 MG TABLET

2

SUMATRIPTAN SUCC 25 MG TABLET

2

SUMATRIPTAN SUCC 50 MG TABLET

2

SUMAVEL DOSEPRO 4 MG/0.5 ML SUMAVEL DOSEPRO 6 MG/0.5 ML TREXIMET 10-60 MG TABLET TREXIMET 85-500 MG TABLET ZEMBRACE SYMTOUCH 3 MG/0.5 ML ZOLMITRIPTAN 2.5 MG ODT

NC NC NC NC NC 2

ZOLMITRIPTAN 2.5 MG TABLET

2

ZOLMITRIPTAN 5 MG ODT

2

ZOLMITRIPTAN 5 MG TABLET

2

ZOMIG 2.5 MG NASAL SPRAY

4

ZOMIG 2.5 MG TABLET ZOMIG 5 MG NASAL SPRAY

NC 4

ZOMIG 5 MG TABLET ZOMIG ZMT 2.5 MG TABLET ZOMIG ZMT 5 MG TABLET

NC NC NC

VALUE FORMULARY FIVE-TIER DRUG LIST

Max. quantity of 15 per fill MQC*: 15 tabs/copay Max. quantity of 6 per fill MQC*: 6 tabs/copay

Max. quantity of 12 per fill MQC*: 12 tabs per copay Max. quantity of 6 per fill MQC*: 6 tabs/copay Max. quantity of 9 per fill MQC*: 9 tabs/copay Max. quantity of 9 per fill MQC*: 9 tabs/copay Max. quantity of 18 per fill MQC*: 4 patches/copay Max. quantity of 18 per fill MQC*: 18 tabs/copay Max. quantity of 6 per fill MQC*: 6 sprays/copay Max. quantity of 3 per fill MQC*: 3 boxes (6 inj)/copay Max. quantity of 6 per fill MQC*: 6 sprays/copay Max. quantity of 3 per fill MQC*: 3 boxes (6 inj)/copay Max. quantity of 3 per fill MQC*: 3 boxes (6 inj)/copay Max. quantity of 3 per fill MQC*: 3 boxes (6 inj)/copay Max. quantity of 3 per fill MQC*: 3 boxes (6 inj)/copay Max. quantity of 6 per fill MQC*: 6 tabs/copay Max. quantity of 24 per fill MQC*: 24 tabs/copay Max. quantity of 12 per fill MQC*: 12 tabs/copay

Max. quantity of 12 per fill MQC*: 12 tabs/copay Max. quantity of 12 per fill MQC*: 12 tabs/copay Max. quantity of 6 per fill MQC*: 6 tabs/copay Max. quantity of 6 per fill MQC*: 6 tabs/copay Max. quantity of 12 per fill MQC*: 6 sprays/copay Max. quantity of 6 per fill MQC*: 6 sprays/copay

Last Updated: 01/17/2017

Page 45

DRUG NAME

TIER

LIMITATIONS/ * NOTES

ANTIMYCOBACTERIALS ANTIMYCOBACTERIALS CYCLOSERINE 250 MG CAPSULE DAPSONE 100 MG TABLET DAPSONE 25 MG TABLET ETHAMBUTOL HCL 100 MG TABLET ETHAMBUTOL HCL 400 MG TABLET ISONIAZID 100 MG TABLET ISONIAZID 300 MG TABLET ISONIAZID 50 MG/5 ML SOLUTION MYAMBUTOL 400 MG TABLET MYCOBUTIN 150 MG CAPSULE PASER GRANULES 4 GM PACKET PRIFTIN 150 MG TABLET PYRAZINAMIDE 500 MG TABLET RIFABUTIN 150 MG CAPSULE RIFADIN 150 MG CAPSULE RIFADIN 300 MG CAPSULE RIFAMATE CAPSULE RIFAMPIN 150 MG CAPSULE RIFAMPIN 300 MG CAPSULE RIFATER TABLET SEROMYCIN 250 MG CAPSULE SIRTURO 100 MG TABLET TRECATOR 250 MG TABLET

2 2 2 2 2 2 1 2 NC NC 4 4 2 2 NC NC 4 2 2 4 NC 5 4

Prior Authorization required;Max. quantity of 32 per fill

ANTINAUSEA AGENTS ANTINAUSEA AGENTS AKYNZEO 300-0.5 MG CAPSULE

5

ANZEMET 100 MG TABLET

4

ANZEMET 50 MG TABLET

4

APREPITANT 125 MG CAPSULE

3

APREPITANT 125-80-80 MG PACK

3

APREPITANT 40 MG CAPSULE

3

APREPITANT 80 MG CAPSULE

3

CESAMET 1 MG CAPSULE

4

COMPAZINE 10 MG TABLET COMPAZINE 25 MG SUPPOSITORY COMPAZINE 5 MG TABLET COMPRO 25 MG SUPPOSITORY DICLEGIS DR 10-10 MG TABLET DRONABINOL 10 MG CAPSULE DRONABINOL 2.5 MG CAPSULE DRONABINOL 5 MG CAPSULE EMEND 125 MG CAPSULE

NC NC NC 2 4 2 2 2 4

VALUE FORMULARY FIVE-TIER DRUG LIST

Prior Authorization required;Max. quantity of 1 per fill;Max. 3 in 30 days MQC*: 1 cap/copay, Max. 3 caps/28 day-supply Max. quantity of 6 per fill MQC*: 3 tabs/copay Max. quantity of 6 per fill MQC*: 6 tabs/copay Max. 30 Days Supply;Max. quantity of 1 per fill MQC*: 1 cap/copay Max. 30 Days Supply;Max. quantity of 3 per fill MQC*: 1 pack/copay Max. 30 Days Supply;Max. quantity of 4 per fill MQC*: 4 caps/copay Max. 30 Days Supply;Max. quantity of 2 per fill MQC*: 2 caps/copay Max. quantity of 18 per fill MQC*: 18 tabs/copay

Max. 30 Days Supply;Max. quantity of 1 per fill MQC*: 1 cap/copay

Last Updated: 01/17/2017

Page 46

DRUG NAME

TIER

LIMITATIONS/ * NOTES

EMEND 125 MG POWDER PACKET

4

EMEND 40 MG CAPSULE

4

EMEND 80 MG CAPSULE

4

EMEND TRIPACK

4

GRANISETRON HCL 1 MG TABLET

2

GRANISOL 2 MG/10 ML SOLUTION

2

Max. 30 Days Supply;Max. quantity of 1 per fill MQC*: 1 packet/copay Max. 30 Days Supply;Max. quantity of 4 per fill MQC*: 4 caps/copay Max. 30 Days Supply;Max. quantity of 2 per fill MQC*: 2 caps/copay Max. 30 Days Supply;Max. quantity of 3 per fill MQC*: 1 pack/copay Max. quantity of 6 per fill MQC*: 6 tabs/copay Max. quantity of 30 per fill MQC*: 30mL/copay

MARINOL 10 MG CAPSULE MARINOL 2.5 MG CAPSULE MARINOL 5 MG CAPSULE MECLIZINE 12.5 MG TABLET MECLIZINE 25 MG TABLET ONDANSETRON 4 MG/5 ML SOLUTION

NC NC NC 2 2 2

ONDANSETRON HCL 24 MG TABLET

2

ONDANSETRON HCL 4 MG TABLET

1

ONDANSETRON HCL 8 MG TABLET

2

ONDANSETRON ODT 4 MG TABLET

2

ONDANSETRON ODT 8 MG TABLET

2

PHENADOZ 12.5 MG SUPPOSITORY PHENADOZ 25 MG SUPPOSITORY PHENERGAN 12.5 MG SUPPOSITORY PHENERGAN 25 MG SUPPOSITORY PHENERGAN 50 MG SUPPOSITORY PROCHLORPERAZINE 10 MG TAB PROCHLORPERAZINE 25 MG SUPP PROCHLORPERAZINE 5 MG TABLET PROMETHAZINE 12.5 MG SUPPOS PROMETHAZINE 12.5 MG TABLET PROMETHAZINE 25 MG SUPPOSITORY PROMETHAZINE 25 MG TABLET PROMETHAZINE 50 MG SUPPOSITORY PROMETHAZINE 50 MG TABLET PROMETHEGAN 12.5 MG SUPPOS PROMETHEGAN 25 MG SUPPOSITORY PROMETHEGAN 50 MG SUPPOSITORY SANCUSO 3.1 MG/24 HR PATCH

2 2 NC NC NC 1 2 1 2 1 2 1 2 2 2 2 2 4

TIGAN 300 MG CAPSULE TRANSDERM-SCOP 1.5 MG/3 DAY

NC 3

TRIMETHOBENZAMIDE 300 MG CAP VARUBI 90 MG TABLET ZOFRAN 4 MG TABLET ZOFRAN 4 MG/5 ML ORAL SOLN ZOFRAN 8 MG TABLET ZOFRAN ODT 4 MG TABLET ZOFRAN ODT 8 MG TABLET ZUPLENZ 4 MG SOLUBLE FILM ZUPLENZ 8 MG SOLUBLE FILM

2 NC NC NC NC NC NC NC NC

Max. quantity of 100 per fill MQC*: 100mL (2 bottles)/copay Max. quantity of 3 per fill MQC*: 3 tabs/copay Max. quantity of 18 per fill MQC*: 18 tabs/copay Max. quantity of 9 per fill MQC*: 9 tabs/copay Max. quantity of 18 per fill MQC*: 18 tabs/copay Max. quantity of 9 per fill MQC*: 9 tabs/copay

Max. quantity of 4 per fill MQC*: 4 patches/copay Max. quantity of 4 per fill MQC*: 1 box (4 patches)/copay

ANTIPARASITE AGENTS

VALUE FORMULARY FIVE-TIER DRUG LIST

Last Updated: 01/17/2017

Page 47

DRUG NAME

TIER

LIMITATIONS/ * NOTES

ANTIPARASITE AGENTS ALBENZA 200 MG TABLET ALINIA 100 MG/5 ML SUSPENSION ALINIA 500 MG TABLET ATOVAQUONE 750 MG/5 ML SUSP ATOVAQUONE-PROGUANIL 250-100 ATOVAQUONE-PROGUANIL 62.5-25 BILTRICIDE 600 MG TABLET CHLOROQUINE PH 250 MG TABLET CHLOROQUINE PH 500 MG TABLET COARTEM TABLETS

4 4 4 2 2 2 4 2 2 4

DARAPRIM 25 MG TABLET EMVERM 100 MG TABLET CHEW HYDROXYCHLOROQUINE 200 MG TAB IMPAVIDO 50 MG CAPSULE IVERMECTIN 3 MG TABLET MALARONE 250-100 MG TABLET MALARONE 62.5-25 MG PED TAB MEFLOQUINE HCL 250 MG TABLET MEPRON 750 MG/5 ML SUSPENSION NEBUPENT 300 MG INHAL POWDER PAROMOMYCIN 250 MG CAPSULE PLAQUENIL 200 MG TABLET PRIMAQUINE 26.3 MG TABLET QUALAQUIN 324 MG CAPSULE QUININE SULFATE 324 MG CAPSULE STROMECTOL 3 MG TABLET TINDAMAX 250 MG TABLET TINDAMAX 500 MG TABLET TINIDAZOLE 250 MG TABLET TINIDAZOLE 500 MG TABLET YODOXIN 210 MG TABLET YODOXIN 650 MG TABLET

5 NC 2 NC 2 NC NC 2 NC 4 2 NC 3 NC 2 NC NC NC 2 2 NC NC

Max. 121 per day;Max. quantity of 24 per fill MQC*: 24 tabs/copay Prior Authorization required

ANTIPARKINSONIAN AGENTS ANTIPARKINSONIAN AGENTS AMANTADINE 100 MG CAPSULE AMANTADINE 100 MG TABLET AMANTADINE 50 MG/5 ML SOLUTION APOKYN 30 MG/3 ML CARTRIDGE AZILECT 0.5 MG TABLET AZILECT 1 MG TABLET BENZTROPINE MES 0.5 MG TAB BENZTROPINE MES 1 MG TABLET BENZTROPINE MES 2 MG TABLET BROMOCRIPTINE 2.5 MG TABLET BROMOCRIPTINE 5 MG CAPSULE CABERGOLINE 0.5 MG TABLET CARBIDOPA 25 MG TABLET CARBIDOPA-LEVO 10-100 MG ODT CARBIDOPA-LEVO 25-100 MG ODT CARBIDOPA-LEVO 25-250 MG ODT CARBIDOPA-LEVO ER 25-100 TAB

VALUE FORMULARY FIVE-TIER DRUG LIST

2 2 2 5 4 4 1 1 2 2 2 2 2 2 2 2 2

Last Updated: 01/17/2017

Page 48

DRUG NAME

TIER

CARBIDOPA-LEVO ER 50-200 TAB CARBIDOPA-LEVODOPA 10-100 TAB CARBIDOPA-LEVODOPA 25-100 TAB CARBIDOPA-LEVODOPA 25-250 TAB CARBIDOPA-LEVODOPA-ENTA 100 MG CARBIDOPA-LEVODOPA-ENTA 125 MG CARBIDOPA-LEVODOPA-ENTA 150 MG CARBIDOPA-LEVODOPA-ENTA 200 MG CARBIDOPA-LEVODOPA-ENTA 50 MG CARBIDOPA-LEVODOPA-ENTA 75 MG COMTAN 200 MG TABLET DUOPA 4.63 MG-20 MG/ML SUSPENS ELDEPRYL 5 MG CAPSULE ENTACAPONE 200 MG TABLET LODOSYN 25 MG TABLET MIRAPEX 0.125 MG TABLET MIRAPEX 0.25 MG TABLET MIRAPEX 0.5 MG TABLET MIRAPEX 0.75 MG TABLET MIRAPEX 1 MG TABLET MIRAPEX 1.5 MG TABLET MIRAPEX ER 0.375 MG TABLET MIRAPEX ER 0.75 MG TABLET MIRAPEX ER 1.5 MG TABLET MIRAPEX ER 2.25 MG TABLET MIRAPEX ER 3 MG TABLET MIRAPEX ER 3.75 MG TABLET MIRAPEX ER 4.5 MG TABLET NEUPRO 1 MG/24 HR PATCH NEUPRO 2 MG/24 HR PATCH NEUPRO 3 MG/24 HR PATCH NEUPRO 4 MG/24 HR PATCH NEUPRO 6 MG/24 HR PATCH NEUPRO 8 MG/24 HR PATCH PARCOPA 10 MG-100 MG ODT PARCOPA 25 MG-100 MG ODT PARCOPA 25 MG-250 MG ODT PARLODEL 2.5 MG TABLET PARLODEL 5 MG CAPSULE PRAMIPEXOLE 0.125 MG TABLET PRAMIPEXOLE 0.25 MG TABLET PRAMIPEXOLE 0.5 MG TABLET PRAMIPEXOLE 0.75 MG TABLET PRAMIPEXOLE 1 MG TABLET PRAMIPEXOLE 1.5 MG TABLET PRAMIPEXOLE ER 0.375 MG TABLET PRAMIPEXOLE ER 0.75 MG TABLET PRAMIPEXOLE ER 1.5 MG TABLET PRAMIPEXOLE ER 2.25 MG TABLET PRAMIPEXOLE ER 3 MG TABLET PRAMIPEXOLE ER 3.75 MG TABLET PRAMIPEXOLE ER 4.5 MG TABLET RASAGILINE MESYLATE 0.5 MG TAB RASAGILINE MESYLATE 1 MG TAB REQUIP 0.25 MG TABLET REQUIP 0.5 MG TABLET REQUIP 1 MG TABLET REQUIP 2 MG TABLET REQUIP 3 MG TABLET

2 2 2 2 2 2 2 2 2 2 NC NC NC 2 NC NC NC NC NC NC NC NC NC NC NC NC NC NC NC NC NC NC NC NC NC NC NC NC NC 2 2 2 2 2 2 2 2 2 2 2 2 2 3 3 NC NC NC NC NC

VALUE FORMULARY FIVE-TIER DRUG LIST

LIMITATIONS/ * NOTES

Last Updated: 01/17/2017

Page 49

DRUG NAME

TIER

REQUIP 4 MG TABLET REQUIP 5 MG TABLET REQUIP XL 12 MG TABLET REQUIP XL 2 MG TABLET REQUIP XL 4 MG TABLET REQUIP XL 6 MG TABLET REQUIP XL 8 MG TABLET ROPINIROLE HCL 0.25 MG TABLET ROPINIROLE HCL 0.5 MG TABLET ROPINIROLE HCL 1 MG TABLET ROPINIROLE HCL 2 MG TABLET ROPINIROLE HCL 3 MG TABLET ROPINIROLE HCL 4 MG TABLET ROPINIROLE HCL 5 MG TABLET ROPINIROLE HCL ER 12 MG TABLET ROPINIROLE HCL ER 2 MG TABLET ROPINIROLE HCL ER 4 MG TABLET ROPINIROLE HCL ER 6 MG TABLET ROPINIROLE HCL ER 8 MG TABLET RYTARY ER 23.75 MG-95 MG CAP RYTARY ER 36.25 MG-145 MG CAP RYTARY ER 48.75 MG-195 MG CAP RYTARY ER 61.25 MG-245 MG CAP SELEGILINE HCL 5 MG CAPSULE SELEGILINE HCL 5 MG TABLET SINEMET 10-100 MG TABLET SINEMET 25-100 MG TABLET SINEMET 25-250 MG TABLET SINEMET CR 25-100 TABLET SINEMET CR 50-200 TABLET STALEVO 100 TABLET STALEVO 125 TABLET STALEVO 150 TABLET STALEVO 200 TABLET STALEVO 50 TABLET STALEVO 75 TABLET TASMAR 100 MG TABLET TOLCAPONE 100 MG TABLET TRIHEXYPHENIDYL 2 MG TABLET TRIHEXYPHENIDYL 2 MG/5 ML ELX TRIHEXYPHENIDYL 5 MG TABLET ZELAPAR 1.25 MG ODT TABLET

NC NC NC NC NC NC NC 2 2 2 2 2 2 2 2 2 2 2 2 NC NC NC NC 2 2 NC NC NC NC NC NC NC NC NC NC NC NC 2 2 2 2 NC

LIMITATIONS/ * NOTES

ANTIPSYCHOTIC AGENTS ANTIPSYCHOTIC AGENTS ABILIFY 1 MG/ML SOLUTION ABILIFY 10 MG TABLET ABILIFY 15 MG TABLET ABILIFY 2 MG TABLET ABILIFY 20 MG TABLET ABILIFY 30 MG TABLET ABILIFY 5 MG TABLET ABILIFY DISCMELT 10 MG TABLET ABILIFY DISCMELT 15 MG TABLET ARIPIPRAZOLE 1 MG/ML SOLUTION ARIPIPRAZOLE 10 MG TABLET

VALUE FORMULARY FIVE-TIER DRUG LIST

NC NC NC NC NC NC NC NC NC 2 2

Last Updated: 01/17/2017

Page 50

DRUG NAME

TIER

ARIPIPRAZOLE 15 MG TABLET ARIPIPRAZOLE 2 MG TABLET ARIPIPRAZOLE 20 MG TABLET ARIPIPRAZOLE 30 MG TABLET ARIPIPRAZOLE 5 MG TABLET ARIPIPRAZOLE ODT 10 MG TABLET ARIPIPRAZOLE ODT 15 MG TABLET CHLORPROMAZINE 10 MG TABLET CHLORPROMAZINE 100 MG TABLET CHLORPROMAZINE 200 MG TABLET CHLORPROMAZINE 25 MG TABLET CHLORPROMAZINE 50 MG TABLET CLOZAPINE 100 MG TABLET CLOZAPINE 200 MG TABLET CLOZAPINE 25 MG TABLET CLOZAPINE 50 MG TABLET CLOZAPINE ODT 100 MG TABLET CLOZAPINE ODT 12.5 MG TABLET CLOZAPINE ODT 150 MG TABLET CLOZAPINE ODT 200 MG TABLET CLOZAPINE ODT 25 MG TABLET CLOZARIL 100 MG TABLET CLOZARIL 25 MG TABLET FANAPT 1 MG TABLET FANAPT 10 MG TABLET FANAPT 12 MG TABLET FANAPT 2 MG TABLET FANAPT 4 MG TABLET FANAPT 6 MG TABLET FANAPT 8 MG TABLET FANAPT TITRATION PACK FAZACLO 100 MG ODT FAZACLO 12.5 MG ODT FAZACLO 150 MG ODT FAZACLO 200 MG ODT FAZACLO 25 MG ODT FLUPHENAZINE 1 MG TABLET FLUPHENAZINE 10 MG TABLET FLUPHENAZINE 2.5 MG TABLET FLUPHENAZINE 2.5 MG/5 ML ELIX FLUPHENAZINE 5 MG TABLET FLUPHENAZINE 5 MG/ML CONC GEODON 20 MG CAPSULE GEODON 40 MG CAPSULE GEODON 60 MG CAPSULE GEODON 80 MG CAPSULE HALOPERIDOL 0.5 MG TABLET HALOPERIDOL 1 MG TABLET HALOPERIDOL 10 MG TABLET HALOPERIDOL 2 MG TABLET HALOPERIDOL 20 MG TABLET HALOPERIDOL 5 MG TABLET HALOPERIDOL LAC 2 MG/ML CONC INVEGA ER 1.5 MG TABLET INVEGA ER 3 MG TABLET INVEGA ER 6 MG TABLET INVEGA ER 9 MG TABLET INVEGA SUSTENNA 117 MG/0.75 ML INVEGA SUSTENNA 156 MG/ML SYRG

2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 NC NC 4 4 4 4 4 4 4 4 NC NC NC NC NC 1 2 2 2 2 2 NC NC NC NC 1 1 2 2 2 2 1 NC NC NC NC MD MD

VALUE FORMULARY FIVE-TIER DRUG LIST

LIMITATIONS/ * NOTES

Max. 28 Days Supply Max. 28 Days Supply Max. 28 Days Supply Max. 28 Days Supply Max. 28 Days Supply Max. 28 Days Supply Max. 28 Days Supply Max. 28 Days Supply Max. 28 Days Supply

SPP*: Must use Accredo SPP*: Must use Accredo

Last Updated: 01/17/2017

Page 51

DRUG NAME

TIER

LIMITATIONS/ * NOTES

INVEGA SUSTENNA 234 MG/1.5 ML INVEGA SUSTENNA 39 MG/0.25 ML INVEGA SUSTENNA 78 MG/0.5 ML LATUDA 120 MG TABLET LATUDA 20 MG TABLET LATUDA 40 MG TABLET LATUDA 60 MG TABLET LATUDA 80 MG TABLET LOXAPINE 10 MG CAPSULE LOXAPINE 25 MG CAPSULE LOXAPINE 5 MG CAPSULE LOXAPINE 50 MG CAPSULE LOXITANE 10 MG CAPSULE LOXITANE 25 MG CAPSULE LOXITANE 5 MG CAPSULE MOLINDONE HCL 10 MG TABLET MOLINDONE HCL 25 MG TABLET MOLINDONE HCL 5 MG TABLET NUPLAZID 17 MG TABLET OLANZAPINE 10 MG TABLET OLANZAPINE 10 MG VIAL OLANZAPINE 15 MG TABLET OLANZAPINE 2.5 MG TABLET OLANZAPINE 20 MG TABLET OLANZAPINE 5 MG TABLET OLANZAPINE 7.5 MG TABLET OLANZAPINE ODT 10 MG TABLET OLANZAPINE ODT 15 MG TABLET OLANZAPINE ODT 20 MG TABLET OLANZAPINE ODT 5 MG TABLET ORAP 1 MG TABLET ORAP 2 MG TABLET PALIPERIDONE ER 1.5 MG TABLET PALIPERIDONE ER 3 MG TABLET PALIPERIDONE ER 6 MG TABLET PALIPERIDONE ER 9 MG TABLET PERPHENAZINE 16 MG TABLET PERPHENAZINE 2 MG TABLET PERPHENAZINE 4 MG TABLET PERPHENAZINE 8 MG TABLET PIMOZIDE 1 MG TABLET PIMOZIDE 2 MG TABLET QUETIAPINE ER 150 MG TABLET QUETIAPINE ER 200 MG TABLET QUETIAPINE ER 300 MG TABLET QUETIAPINE ER 400 MG TABLET QUETIAPINE ER 50 MG TABLET QUETIAPINE FUMARATE 100 MG TAB QUETIAPINE FUMARATE 200 MG TAB QUETIAPINE FUMARATE 25 MG TAB QUETIAPINE FUMARATE 300 MG TAB QUETIAPINE FUMARATE 400 MG TAB QUETIAPINE FUMARATE 50 MG TAB REXULTI 0.25 MG TABLET REXULTI 0.5 MG TABLET REXULTI 1 MG TABLET REXULTI 2 MG TABLET REXULTI 3 MG TABLET REXULTI 4 MG TABLET

MD MD MD 3 3 3 3 3 2 2 2 2 NC NC NC 2 2 2 NC 2 MD 2 2 2 2 2 2 2 2 2 NC NC 2 2 2 2 2 2 2 2 2 2 3 3 3 3 3 2 2 2 2 2 2 NC NC NC NC NC NC

SPP*: Must use Accredo SPP*: Must use Accredo SPP*: Must use Accredo

VALUE FORMULARY FIVE-TIER DRUG LIST

Last Updated: 01/17/2017

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DRUG NAME

TIER

RISPERDAL 0.25 MG TABLET RISPERDAL 0.5 MG TABLET RISPERDAL 1 MG TABLET RISPERDAL 1 MG/ML SOLUTION RISPERDAL 2 MG TABLET RISPERDAL 3 MG TABLET RISPERDAL 4 MG TABLET RISPERDAL CONSTA 12.5 MG SYR RISPERDAL CONSTA 25 MG SYR RISPERDAL CONSTA 37.5 MG SYR RISPERDAL CONSTA 50 MG SYR RISPERDAL M-TAB 0.5 MG ODT RISPERDAL M-TAB 1 MG ODT RISPERDAL M-TAB 2 MG ODT RISPERDAL M-TAB 3 MG ODT RISPERDAL M-TAB 4 MG ODT RISPERIDONE 0.25 MG ODT RISPERIDONE 0.25 MG TABLET RISPERIDONE 0.5 MG ODT RISPERIDONE 0.5 MG TABLET RISPERIDONE 1 MG ODT RISPERIDONE 1 MG TABLET RISPERIDONE 1 MG/ML SOLUTION RISPERIDONE 2 MG ODT RISPERIDONE 2 MG TABLET RISPERIDONE 3 MG ODT RISPERIDONE 3 MG TABLET RISPERIDONE 4 MG ODT RISPERIDONE 4 MG TABLET SAPHRIS 10 MG TAB SL BLK CHERY SAPHRIS 2.5 MG TAB SL BLK CHRY SAPHRIS 5 MG TAB SL BLK CHERRY SEROQUEL 100 MG TABLET SEROQUEL 200 MG TABLET SEROQUEL 25 MG TABLET SEROQUEL 300 MG TABLET SEROQUEL 400 MG TABLET SEROQUEL 50 MG TABLET SEROQUEL XR 150 MG TABLET SEROQUEL XR 200 MG TABLET SEROQUEL XR 300 MG TABLET SEROQUEL XR 400 MG TABLET SEROQUEL XR 50 MG TABLET SEROQUEL XR SAMPLE KIT THIORIDAZINE 10 MG TABLET THIORIDAZINE 100 MG TABLET THIORIDAZINE 25 MG TABLET THIORIDAZINE 50 MG TABLET THIOTHIXENE 1 MG CAPSULE THIOTHIXENE 10 MG CAPSULE THIOTHIXENE 2 MG CAPSULE THIOTHIXENE 5 MG CAPSULE TRIFLUOPERAZINE 1 MG TABLET TRIFLUOPERAZINE 10 MG TABLET TRIFLUOPERAZINE 2 MG TABLET TRIFLUOPERAZINE 5 MG TABLET VERSACLOZ 50 MG/ML SUSPENSION VRAYLAR 1.5 MG CAPSULE VRAYLAR 1.5 MG-3 MG PACK

NC NC NC NC NC NC NC MD MD MD MD NC NC NC NC NC 2 2 2 1 2 1 2 2 2 2 2 2 2 4 4 4 NC NC NC NC NC NC 4 4 4 4 4 NC 2 2 2 2 2 2 2 2 2 2 2 2 4 NC NC

VALUE FORMULARY FIVE-TIER DRUG LIST

LIMITATIONS/ * NOTES

SPP*: Must use Accredo SPP*: Must use Accredo SPP*: Must use Accredo SPP*: Must use Accredo

Max. 28 Days Supply

Last Updated: 01/17/2017

Page 53

DRUG NAME

TIER

VRAYLAR 3 MG CAPSULE VRAYLAR 4.5 MG CAPSULE VRAYLAR 6 MG CAPSULE ZIPRASIDONE HCL 20 MG CAPSULE ZIPRASIDONE HCL 40 MG CAPSULE ZIPRASIDONE HCL 60 MG CAPSULE ZIPRASIDONE HCL 80 MG CAPSULE ZYPREXA 10 MG TABLET ZYPREXA 10 MG VIAL ZYPREXA 15 MG TABLET ZYPREXA 2.5 MG TABLET ZYPREXA 20 MG TABLET ZYPREXA 5 MG TABLET ZYPREXA 7.5 MG TABLET ZYPREXA ZYDIS 10 MG TABLET ZYPREXA ZYDIS 15 MG TABLET ZYPREXA ZYDIS 20 MG TABLET ZYPREXA ZYDIS 5 MG TABLET

NC NC NC 2 2 2 2 NC MD NC NC NC NC NC NC NC NC NC

LIMITATIONS/ * NOTES

SPP*: Must use Accredo

ANTIVIRALS (SYSTEMIC) ANTIRETROVIRALS ABACAVIR 300 MG TABLET ABACAVIR-LAMIVUDINE 600-300 MG ABACAVIR-LAMIVUDINE-ZIDOV TAB APTIVUS 100 MG/ML SOLUTION APTIVUS 250 MG CAPSULE ATRIPLA TABLET COMBIVIR TABLET COMPLERA TABLET CRIXIVAN 200 MG CAPSULE CRIXIVAN 400 MG CAPSULE DESCOVY 200-25 MG TABLET DIDANOSINE DR 125 MG CAPSULE DIDANOSINE DR 200 MG CAPSULE DIDANOSINE DR 250 MG CAPSULE DIDANOSINE DR 400 MG CAPSULE EDURANT 25 MG TABLET EMTRIVA 10 MG/ML SOLUTION EMTRIVA 200 MG CAPSULE EPIVIR 10 MG/ML ORAL SOLN EPIVIR 150 MG TABLET EPIVIR 300 MG TABLET EPIVIR HBV 100 MG TABLET EPIVIR HBV 25 MG/5 ML SOLN EPZICOM TABLET EVOTAZ 300 MG-150 MG TABLET FUZEON 90 MG VIAL GENVOYA TABLET INTELENCE 100 MG TABLET INTELENCE 200 MG TABLET INTELENCE 25 MG TABLET INVIRASE 200 MG CAPSULE INVIRASE 500 MG TABLET ISENTRESS 100 MG POWDER PACKET ISENTRESS 100 MG TABLET CHEW ISENTRESS 25 MG TABLET CHEW

VALUE FORMULARY FIVE-TIER DRUG LIST

2 3 2 4 4 3 NC 4 3 3 4 2 2 2 2 4 4 4 NC NC NC NC 3 4 4 5 4 4 4 4 3 3 3 3 3

SPP*: Must use Accredo

Last Updated: 01/17/2017

Page 54

DRUG NAME

TIER

ISENTRESS 400 MG TABLET KALETRA 100-25 MG TABLET KALETRA 200-50 MG TABLET KALETRA 400-100/5 ML ORAL SOLU LAMIVUDINE 10 MG/ML ORAL SOLN LAMIVUDINE 150 MG TABLET LAMIVUDINE 300 MG TABLET LAMIVUDINE HBV 100 MG TABLET LAMIVUDINE-ZIDOVUDINE TABLET LEXIVA 50 MG/ML SUSPENSION LEXIVA 700 MG TABLET NEVIRAPINE 200 MG TABLET NEVIRAPINE 50 MG/5 ML SUSP NEVIRAPINE ER 100 MG TABLET NEVIRAPINE ER 400 MG TABLET NORVIR 100 MG SOFTGEL CAP NORVIR 100 MG TABLET NORVIR 80 MG/ML SOLUTION ODEFSEY TABLET PREZCOBIX 800 MG-150 MG TABLET PREZISTA 100 MG/ML SUSPENSION PREZISTA 150 MG TABLET PREZISTA 400 MG TABLET PREZISTA 600 MG TABLET PREZISTA 75 MG TABLET PREZISTA 800 MG TABLET RESCRIPTOR 100 MG TABLET RESCRIPTOR 200 MG TABLET RETROVIR 10 MG/ML SYRUP RETROVIR 100 MG CAPSULE REYATAZ 100 MG CAPSULE REYATAZ 150 MG CAPSULE REYATAZ 200 MG CAPSULE REYATAZ 300 MG CAPSULE REYATAZ 50 MG POWDER PACKET SELZENTRY 150 MG TABLET SELZENTRY 300 MG TABLET STAVUDINE 1 MG/ML SOLUTION STAVUDINE 15 MG CAPSULE STAVUDINE 20 MG CAPSULE STAVUDINE 30 MG CAPSULE STAVUDINE 40 MG CAPSULE STRIBILD TABLET SUSTIVA 200 MG CAPSULE SUSTIVA 50 MG CAPSULE SUSTIVA 600 MG TABLET TIVICAY 10 MG TABLET TIVICAY 25 MG TABLET TIVICAY 50 MG TABLET TRIUMEQ TABLET TRIZIVIR TABLET TRUVADA 100 MG-150 MG TABLET TRUVADA 133 MG-200 MG TABLET TRUVADA 167 MG-250 MG TABLET TRUVADA 200 MG-300 MG TABLET VIDEX 2 GM PEDIATRIC SOLN VIDEX EC 125 MG CAPSULE VIDEX EC 200 MG CAPSULE VIDEX EC 250 MG CAPSULE

3 3 3 3 2 2 2 2 2 4 4 2 2 2 2 4 4 4 5 4 3 3 3 3 3 3 3 3 NC NC 3 3 3 3 3 3 3 2 2 2 2 2 4 3 3 3 4 4 4 4 NC 3 3 3 3 3 NC NC NC

VALUE FORMULARY FIVE-TIER DRUG LIST

LIMITATIONS/ * NOTES

Last Updated: 01/17/2017

Page 55

DRUG NAME

TIER

VIDEX EC 400 MG CAPSULE VIRACEPT 250 MG TABLET VIRACEPT 625 MG TABLET VIRAMUNE 200 MG TABLET VIRAMUNE 50 MG/5 ML SUSP VIRAMUNE XR 100 MG TABLET VIRAMUNE XR 400 MG TABLET VIREAD 150 MG TABLET VIREAD 200 MG TABLET VIREAD 250 MG TABLET VIREAD 300 MG TABLET VIREAD POWDER VITEKTA 150 MG TABLET VITEKTA 85 MG TABLET ZERIT 1 MG/ML SOLUTION ZERIT 15 MG CAPSULE ZERIT 20 MG CAPSULE ZERIT 30 MG CAPSULE ZERIT 40 MG CAPSULE ZIAGEN 20 MG/ML SOLUTION ZIAGEN 300 MG TABLET ZIDOVUDINE 100 MG CAPSULE ZIDOVUDINE 300 MG TABLET ZIDOVUDINE 50 MG/5 ML SYRUP

NC 3 3 NC NC NC NC 3 3 3 3 3 4 4 NC NC NC NC NC 4 NC 2 2 2

LIMITATIONS/ * NOTES

ANTIVIRALS, MISCELLANEOUS FLUMADINE 100 MG TABLET OSELTAMIVIR PHOS 30 MG CAPSULE OSELTAMIVIR PHOS 45 MG CAPSULE OSELTAMIVIR PHOS 75 MG CAPSULE RELENZA 5 MG DISKHALER RIMANTADINE HCL 100 MG TABLET SYNAGIS 100 MG/1 ML VIAL

NC 3 3 3 4 2 MD

SYNAGIS 50 MG/0.5 ML VIAL

MD

TAMIFLU 30 MG CAPSULE TAMIFLU 45 MG CAPSULE TAMIFLU 6 MG/ML SUSPENSION TAMIFLU 75 MG CAPSULE

4 4 3 4

Max. 10 Days Supply;Max. 20 in 180 days Max. 10 Days Supply;Max. 20 in 180 days Max. 10 Days Supply;Max. 10 in 180 days Max. quantity of 20 per fill Prior Authorization required SPP*: Must use Magellan Rx Prior Authorization required SPP: Must use Magellan Rx Max. 10 Days Supply;Max. 20 in 180 days Max. 10 Days Supply;Max. 20 in 180 days Max. 240 ML(s) in 180 days Max. 10 Days Supply;Max. 10 in 180 days

HCV ANTIVIRALS DAKLINZA 30 MG TABLET

4

DAKLINZA 60 MG TABLET

4

DAKLINZA 90 MG TABLET

4

EPCLUSA 400 MG-100 MG TABLET

4

HARVONI 90-400 MG TABLET

4

INCIVEK 375 MG TABLET OLYSIO 150 MG CAPSULE SOVALDI 400 MG TABLET

NC NC 4

TECHNIVIE DOSE PACK

5

VALUE FORMULARY FIVE-TIER DRUG LIST

Prior Authorization required;Max. 28 per 28 days SPP*: Must use Accredo Prior Authorization required;Max. 28 per 28 days SPP*: Must use Accredo Prior Authorization required;Max. 28 per 28 days SPP*: Must use Accredo Prior Authorization required;Max. 28 per 28 days SPP*: Must use Accredo Prior Authorization required;Max. 28 per 28 days SPP*: Must use Accredo

Prior Authorization required;Max. 1 per day SPP*: Must use Accredo Prior Authorization required;Max. 56 per 28 days Max 56 tabs/28 days supply; SPP*: Must use Accredo

Last Updated: 01/17/2017

Page 56

DRUG NAME

TIER

LIMITATIONS/ * NOTES

VICTRELIS 200 MG CAPSULE VIEKIRA PAK VIEKIRA XR TABLET ZEPATIER 50-100 MG TABLET

5 NC NC 4

Prior Authorization required;Max. 12 per day

Prior Authorization required;Max. 28 per 28 days SPP*: Must use Accredo

INTERFERONS INFERGEN 15 MCG/0.5 ML VIAL INFERGEN 9 MCG/0.3 ML VIAL INTRON A 10 MILLION UNITS VIAL INTRON A 18 MILLION UNIT/3 ML INTRON A 18 MILLION UNITS VIAL INTRON A 25 MILLION UNIT/2.5ML INTRON A 50 MILLION UNITS VIAL PEGASYS 180 MCG/0.5 ML SYRINGE PEGASYS 180 MCG/ML VIAL PEGASYS PROCLICK 135 MCG/0.5 PEGASYS PROCLICK 180 MCG/0.5 PEGINTRON 120 MCG KIT PEGINTRON 150 MCG KIT PEGINTRON 50 MCG KIT PEGINTRON 80 MCG KIT PEGINTRON REDIPEN 120 MCG PEGINTRON REDIPEN 150 MCG PEGINTRON REDIPEN 50 MCG PEGINTRON REDIPEN 80 MCG SYLATRON 200 MCG KIT SYLATRON 300 MCG KIT SYLATRON 600 MCG KIT

5 5 5 5 5 5 5 4 4 4 4 5 5 5 5 5 5 5 5 4 4 4

SPP*: Accredo SPP*: Accredo SPP*: Accredo SPP*: Accredo SPP*: Accredo SPP*: Accredo SPP*: Accredo

SPP*: Accredo SPP*: Accredo SPP*: Accredo SPP*: Accredo

SPP*: Must use Accredo SPP*: Must use Accredo SPP*: Must use Accredo

NUCLEOSIDES AND NUCLEOTIDES ACYCLOVIR 200 MG CAPSULE ACYCLOVIR 200 MG/5 ML SUSP ACYCLOVIR 400 MG TABLET ACYCLOVIR 800 MG TABLET ADEFOVIR DIPIVOXIL 10 MG TAB BARACLUDE 0.05 MG/ML SOLUTION BARACLUDE 0.5 MG TABLET BARACLUDE 1 MG TABLET COPEGUS 200 MG TABLET ENTECAVIR 0.5 MG TABLET ENTECAVIR 1 MG TABLET FAMCICLOVIR 125 MG TABLET FAMCICLOVIR 250 MG TABLET FAMCICLOVIR 500 MG TABLET FAMVIR 125 MG TABLET FAMVIR 250 MG TABLET FAMVIR 500 MG TABLET HEPSERA 10 MG TABLET MODERIBA 200 MG TABLET MODERIBA 200-400 MG DOSEPACK MODERIBA 400-400 MG DOSEPACK MODERIBA 600-400 MG DOSEPACK MODERIBA 600-600 MG DOSEPACK REBETOL 200 MG CAPSULE REBETOL 40 MG/ML SOLUTION

VALUE FORMULARY FIVE-TIER DRUG LIST

2 2 2 2 2 3 NC NC NC 2 2 2 2 2 NC NC NC NC NC NC NC NC NC NC 4

SPP*: Accredo

Last Updated: 01/17/2017

Page 57

DRUG NAME

TIER

LIMITATIONS/ * NOTES

RIBASPHERE 200 MG CAPSULE RIBASPHERE 200 MG TABLET RIBASPHERE 400 MG TABLET RIBASPHERE 600 MG TABLET RIBASPHERE RIBAPAK 200-400 MG RIBASPHERE RIBAPAK 400-400 MG RIBASPHERE RIBAPAK 600-400 MG RIBASPHERE RIBAPAK 600-600 MG RIBATAB 400-400 MG DOSEPACK RIBATAB 400-600 MG DOSEPACK RIBAVIRIN 200 MG CAPSULE RIBAVIRIN 200 MG TABLET SITAVIG 50 MG BUCCAL TABLET TYZEKA 600 MG TABLET VALACYCLOVIR HCL 1 GRAM TABLET VALACYCLOVIR HCL 500 MG TABLET VALCYTE 450 MG TABLET VALCYTE 50 MG/ML SOLUTION VALGANCICLOVIR 450 MG TABLET VALGANCICLOVIR HCL 50 MG/ML VALTREX 1 GM CAPLET VALTREX 500 MG CAPLET VEMLIDY 25 MG TABLET VIRAZOLE 6 GM VIAL ZOVIRAX 200 MG CAPSULE ZOVIRAX 200 MG/5 ML SUSP ZOVIRAX 400 MG TABLET ZOVIRAX 800 MG TABLET

2 2 2 2 2 2 2 2 NC NC 2 2 NC 5 2 2 NC 4 2 2 NC NC NC 4 NC NC NC NC

SPP*: Must use Accredo SPP*: Must use Accredo SPP*: Must use Accredo SPP*: Must use Accredo

SPP*: Accredo SPP*: Accredo

BLOOD PRODUCTS/MODIFIERS/VOLUME EXPANDERS ANTICOAGULANTS ARGATROBN-0.9% NACL 250 MG/250 ARIXTRA 10 MG/0.8 ML SYRINGE ARIXTRA 2.5 MG/0.5 ML SYRINGE ARIXTRA 5 MG/0.4 ML SYRINGE ARIXTRA 7.5 MG/0.6 ML SYRINGE COUMADIN 1 MG TABLET COUMADIN 10 MG TABLET COUMADIN 2 MG TABLET COUMADIN 2.5 MG TABLET COUMADIN 3 MG TABLET COUMADIN 4 MG TABLET COUMADIN 5 MG TABLET COUMADIN 6 MG TABLET COUMADIN 7.5 MG TABLET ELIQUIS 2.5 MG TABLET ELIQUIS 5 MG TABLET ENOXAPARIN 100 MG/ML SYRINGE ENOXAPARIN 120 MG/0.8 ML SYR ENOXAPARIN 150 MG/ML SYRINGE ENOXAPARIN 30 MG/0.3 ML SYR ENOXAPARIN 300 MG/3 ML VIAL ENOXAPARIN 40 MG/0.4 ML SYR ENOXAPARIN 60 MG/0.6 ML SYR ENOXAPARIN 80 MG/0.8 ML SYR FONDAPARINUX 10 MG/0.8 ML SYR

VALUE FORMULARY FIVE-TIER DRUG LIST

NC NC NC NC NC NC NC NC NC NC NC NC NC NC 3 3 2 2 2 2 2 2 2 2 4

HSA* HSA* HSA*; SPP*: Accredo HSA*; SPP*: Accredo HSA*; SPP*: Accredo HSA*; SPP*: Accredo HSA*; SPP*: Accredo HSA*; SPP*: Accredo HSA*; SPP*: Accredo HSA*; SPP*: Accredo HSA*; SPP*: Accredo

Last Updated: 01/17/2017

Page 58

DRUG NAME

TIER

LIMITATIONS/ * NOTES

FONDAPARINUX 2.5 MG/0.5 ML SYR FONDAPARINUX 5 MG/0.4 ML SYR FONDAPARINUX 7.5 MG/0.6 ML SYR FRAGMIN 10,000 UNITS/ML SYRING FRAGMIN 12,500 UNITS/0.5 ML FRAGMIN 15,000 UNITS/0.6 ML FRAGMIN 18,000 UNITS/0.72 ML FRAGMIN 2,500 UNITS/0.2 ML SYR FRAGMIN 5,000 UNITS/0.2 ML SYR FRAGMIN 7,500 UNITS/0.3 ML SYR FRAGMIN 95,000 UNITS/3.8 ML VL HEPARIN SOD 10,000 UNIT/ML VL HEPARIN SOD 100,000 UNITS PWDE HEPARIN SOD 20,000 UNIT/ML VL HEPARIN SOD 25,000 UNIT POWDER HEPARIN SOD 5,000 UNIT/ML VIAL IPRIVASK 15 MG VIAL JANTOVEN 1 MG TABLET JANTOVEN 10 MG TABLET JANTOVEN 2 MG TABLET JANTOVEN 2.5 MG TABLET JANTOVEN 3 MG TABLET JANTOVEN 4 MG TABLET JANTOVEN 5 MG TABLET JANTOVEN 6 MG TABLET JANTOVEN 7.5 MG TABLET LOVENOX 100 MG/ML SYRINGE LOVENOX 120 MG/0.8 ML SYRINGE LOVENOX 150 MG/ML SYRINGE LOVENOX 30 MG/0.3 ML SYRINGE LOVENOX 300 MG/3 ML VIAL LOVENOX 40 MG/0.4 ML SYRINGE LOVENOX 60 MG/0.6 ML SYRINGE LOVENOX 80 MG/0.8 ML SYRINGE PRADAXA 110 MG CAPSULE PRADAXA 150 MG CAPSULE PRADAXA 75 MG CAPSULE SAVAYSA 15 MG TABLET SAVAYSA 30 MG TABLET SAVAYSA 60 MG TABLET SODIUM CITRATE 4% SOLN WARFARIN SODIUM 1 MG TABLET WARFARIN SODIUM 10 MG TABLET WARFARIN SODIUM 2 MG TABLET WARFARIN SODIUM 2.5 MG TABLET WARFARIN SODIUM 3 MG TABLET WARFARIN SODIUM 4 MG TABLET WARFARIN SODIUM 5 MG TABLET WARFARIN SODIUM 6 MG TABLET WARFARIN SODIUM 7.5 MG TABLET XARELTO 10 MG TABLET XARELTO 15 MG TABLET XARELTO 20 MG TABLET XARELTO STARTER PACK

4 4 4 5 5 5 5 5 5 5 5 2 NC 2 NC 2 NC 2 1 2 2 1 1 2 1 1 NC NC NC NC NC NC NC NC 4 4 4 NC NC NC NC 2 1 2 2 1 1 2 1 1 3 3 3 3

HSA*; SPP*: Accredo HSA*; SPP*: Accredo HSA*; SPP*: Accredo HSA*; SPP*: Accredo HSA*; SPP*: Accredo HSA*; SPP*: Accredo HSA*; SPP*: Accredo HSA*; SPP*: Accredo HSA*; SPP*: Accredo HSA*; SPP*: Accredo HSA*; SPP*: Accredo

HSA* HSA* HSA* HSA* HSA* HSA* HSA* HSA* HSA*

HSA* HSA* HSA*

HSA* HSA* HSA* HSA* HSA* HSA* HSA* HSA* HSA* HSA* HSA* HSA* HSA*

BLOOD FORMATION MODIFIERS

VALUE FORMULARY FIVE-TIER DRUG LIST

Last Updated: 01/17/2017

Page 59

DRUG NAME

TIER

LIMITATIONS/ * NOTES

ARANESP 10 MCG/0.4 ML SYRINGE

5

ARANESP 100 MCG/0.5 ML SYRINGE

5

ARANESP 100 MCG/ML VIAL

5

ARANESP 150 MCG/0.3 ML SYRINGE

5

ARANESP 150 MCG/0.75 ML VIAL

5

ARANESP 200 MCG/0.4 ML SYRINGE

5

ARANESP 200 MCG/ML VIAL

5

ARANESP 25 MCG/0.42 ML SYRING

5

ARANESP 25 MCG/ML VIAL

5

ARANESP 300 MCG/0.6 ML SYRINGE

5

ARANESP 300 MCG/ML VIAL

5

ARANESP 40 MCG/0.4 ML SYRINGE

5

ARANESP 40 MCG/ML VIAL

5

ARANESP 500 MCG/1 ML SYRINGE

5

ARANESP 60 MCG/0.3 ML SYRINGE

5

ARANESP 60 MCG/ML VIAL

5

BERINERT 500 UNIT KIT CINRYZE 500 UNIT VIAL

MD MD

EPOGEN 10,000 UNITS/ML VIAL

4

EPOGEN 2,000 UNITS/ML VIAL

4

EPOGEN 20,000 UNITS/ML VIAL

4

EPOGEN 3,000 UNITS/ML VIAL

4

EPOGEN 4,000 UNITS/ML VIAL

4

GRANIX 300 MCG/0.5 ML SAFE SYR GRANIX 480 MCG/0.8 ML SAFE SYR MIRCERA 100 MCG/0.3 ML SYRINGE MIRCERA 150 MCG/0.3 ML SYRINGE MIRCERA 200 MCG/0.3 ML SYRINGE MIRCERA 30 MCG/0.3 ML SYRINGE MIRCERA 50 MCG/0.3 ML SYRINGE MIRCERA 75 MCG/0.3 ML SYRINGE MOZOBIL 24 MG/1.2 ML VIAL

4 4 NC NC NC NC NC NC 5

Prior Authorization required;Max. quantity of 1.6 per fill SPP*: Accredo or Magellan Rx Prior Authorization required;Max. quantity of 2 per fill SPP*: Accredo or Magellan Rx Prior Authorization required;Max. quantity of 4 per fill SPP*: Accredo or Magellan Rx Prior Authorization required SPP*: Accredo or Magellan Rx Prior Authorization required;Max. quantity of 4 per fill SPP: Accredo or Magellan Rx Prior Authorization required;Max. quantity of 1.6 per fill SPP*: Accredo or Magellan Rx Prior Authorization required;Max. quantity of 4 per fill SPP*: Accredo or Magellan Rx Prior Authorization required;Max. quantity of 1.68 per fill SPP*: Accredo or Magellan Rx Prior Authorization required;Max. quantity of 4 per fill SPP*: Accredo or Magellan Rx Prior Authorization required;Max. quantity of 2.4 per fill SPP*: Accredo or Magellan Rx Prior Authorization required;Max. quantity of 4 per fill SPP*: Accredo or Magellan Rx Prior Authorization required;Max. quantity of 1.6 per fill SPP*: Accredo or Magellan Rx Prior Authorization required;Max. quantity of 4 per fill SPP*: Accredo or Magellan Rx Prior Authorization required;Max. quantity of 4 per fill SPP*: Accredo or Magellan Rx Prior Authorization required SPP*: Accredo or Magellan Rx Prior Authorization required;Max. quantity of 4 per fill SPP*: Accredo or Magellan Rx SPP*: Must use Accredo or Magellan Rx Prior Authorization required;Max. 2 per 3 days SPP*: Must use Accredo Prior Authorization required;Max. quantity of 12 per fill SPP*: Accredo Prior Authorization required;Max. quantity of 12 per fill SPP*: Accredo Prior Authorization required;Max. quantity of 4 per fill SPP*: Accredo Prior Authorization required;Max. quantity of 12 per fill SPP*: Accredo Prior Authorization required;Max. quantity of 12 per fill SPP*: Accredo SPP*: Accredo SPP*: Accredo

NEULASTA 6 MG/0.6 ML SYRINGE NEULASTA ONPRO 6 MG/0.6 ML KIT NEUMEGA 5 MG VIAL NEUPOGEN 300 MCG/0.5 ML SYR NEUPOGEN 300 MCG/ML VIAL NEUPOGEN 480 MCG/0.8 ML SYR NEUPOGEN 480 MCG/1.6 ML VIAL PROCRIT 10,000 UNITS/ML VIAL

5 5 4 5 5 5 5 4

PROCRIT 10,000 UNITS/ML VIAL

4

PROCRIT 2,000 UNITS/ML VIAL

4

VALUE FORMULARY FIVE-TIER DRUG LIST

Max. quantity of 4 per fill SPP*: Must use Accredo; MQC*: 4 vials per copay SPP*: Accredo or Magellan Rx SPP*: Accredo or Magellan Rx SPP*: Must use Accredo SPP*: Must use Accredo or Magellan Rx SPP*: Must use Accredo or Magellan Rx SPP*: Must use Accredo or Magellan Rx SPP*: Must use Accredo or Magellan Rx Prior Authorization required;Max. quantity of 12 per fill SPP: Accredo or Magellan Rx Prior Authorization required;Max. quantity of 12 per fill SPP*: Accredo or Magellan Rx Prior Authorization required;Max. quantity of 12 per fill SPP*: Accredo or Magellan Rx

Last Updated: 01/17/2017

Page 60

DRUG NAME

TIER

LIMITATIONS/ * NOTES

PROCRIT 20,000 UNITS/ML VIAL

4

PROCRIT 3,000 UNITS/ML VIAL

4

PROCRIT 4,000 UNITS/ML VIAL

4

PROCRIT 40,000 UNITS/ML VIAL

4

PROMACTA 12.5 MG TABLET PROMACTA 25 MG TABLET PROMACTA 50 MG TABLET PROMACTA 75 MG TABLET ZARXIO 300 MCG/0.5 ML SYRINGE ZARXIO 480 MCG/0.8 ML SYRINGE

5 5 5 5 NC NC

Prior Authorization required;Max. quantity of 4 per fill SPP*: Accredo or Magellan Rx Prior Authorization required;Max. quantity of 12 per fill SPP*: Accredo or Magellan Rx Prior Authorization required;Max. quantity of 12 per fill SPP*: Accredo or Magellan Rx Prior Authorization required;Max. quantity of 4 per fill SPP*: Accredo or Magellan Rx SPP*: Must use Accredo SPP*: Must use Accredo SPP*: Must use Accredo SPP*: Must use Accredo

HEMATOLOGIC AGENTS, MISCELLANEOUS ADVATE 2,401-3,600 UNITS VIAL ADYNOVATE 401-800 UNIT VIAL AGRYLIN 0.5 MG CAPSULE ALPHANATE 500-200 UNIT VIAL ALPHANINE SD 1,500 UNITS VIAL ALPROLIX 3,000 UNIT NOMINAL AMICAR 0.25 GRAM/ML ORAL SOLN AMICAR 1,000 MG TABLET AMICAR 500 MG TABLET AMINOCAPROIC ACID 1,000 MG TAB AMINOCAPROIC ACID 25% SOLUTION AMINOCAPROIC ACID 500 MG TAB ANAGRELIDE HCL 0.5 MG CAPSULE ANAGRELIDE HCL 1 MG CAPSULE AVITENE FLOUR AVITENE SHEET 35MMX35MM AVITENE SHEET 70MMX35MM AVITENE SHEET 70MMX70MM BEBULIN 200-1,200 UNITS VIAL BENEFIX 2,000 UNIT KIT CORIFACT KIT ELOCTATE 1,000 UNIT NOMINAL FEIBA NF 2,500 UNIT (NOMINAL) GELFOAM POWDER HELIXATE FS 2,000 UNIT VIAL

MD MD NC MD MD MD 4 4 4 2 2 2 2 2 NC NC NC NC MD MD MD MD MD NC MD

HEMOFIL M 1,700 UNIT NOMINAL HUMATE-P 2,400 UNIT VWF:RCO IXINITY 500 UNIT VIAL KOATE-DVI 250 UNITS VIAL KOGENATE FS 2,000 UNIT VIAL LYSTEDA 650 MG TABLET MONOCLATE-P 1,000 UNIT KIT

MD MD MD MD MD NC 4

MONONINE 1,000 UNITS KIT NOVOEIGHT 1,500 UNIT VIAL NOVOSEVEN RT 2 MG VIAL NUWIQ 250 UNIT VIAL PACK PROFILNINE 500 UNITS VIAL RECOMBINATE 1,801-2,400 UNIT V RECOTHROM 5,000 UNITS VIAL RIASTAP VIAL RIXUBIS 1,000 UNIT NOMINAL

MD MD MD MD MD MD NC MD MD

VALUE FORMULARY FIVE-TIER DRUG LIST

SPP*: Must use Accredo or Caremark SPP*: Must use Accredo or Caremark SPP*: Must use Accredo or Caremark SPP*: Must use Accredo or Caremark SPP*: Must use Accredo or Caremark

HSA* HSA*

SPP*: Must use Accredo or Caremark SPP*: Must use Accredo or Caremark SPP*: Must use Caremark SPP*: Must use Magellan Rx SPP*: Must use Accredo or Caremark SPP*: Must use Accredo or Caremark; Kogenate Preferred SPP*: Must use Accredo or Caremark SPP*: Must use Accredo or Caremark SPP*: Must use Accredo or Caremark SPP*: Must use Accredo or Caremark Prior Authorization required SPP*: Must use Accredo or Caremark SPP*: Must use Accredo or Caremark SPP*: Must use Accredo or Caremark SPP*: Must use Accredo or Caremark SPP*: Must use Accredo or Caremark SPP*: Must use Accredo or Caremark SPP*: Must use Caremark SPP*: Must use Accredo

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DRUG NAME

TIER

THROMBIN-JMI 20,000 UNITS PUMP THROMBIN-JMI 5,000 UNITS VIAL TISSEEL VHSD 2 ML KIT TRANEXAMIC ACID 650 MG TABLET TRETTEN 2,500 UNIT VIAL ULTRAFOAM 2X6.25X7CM SPONGE WILATE 450-450 UNIT VIAL XYNTHA 500 UNIT KIT XYNTHA SOLOFUSE 1,000 UNIT KIT

NC NC NC 2 MD NC MD MD MD

LIMITATIONS/ * NOTES

Max. 30 in 30 days SPP*: Must use Accredo or Caremark SPP*: Must use Caremark SPP*: Must use Accredo or Caremark SPP*: Must use Accredo or Caremark

PLATELET-AGGREGATION INHIBITORS AGGRENOX 25 MG-200 MG CAPSULE ASPIRIN-DIPYRIDAM ER 25-200 MG BRILINTA 60 MG TABLET BRILINTA 90 MG TABLET CILOSTAZOL 100 MG TABLET CILOSTAZOL 50 MG TABLET CLOPIDOGREL 300 MG TABLET CLOPIDOGREL 75 MG TABLET DIPYRIDAMOLE 25 MG TABLET DIPYRIDAMOLE 50 MG TABLET DIPYRIDAMOLE 75 MG TABLET EFFIENT 10 MG TABLET EFFIENT 5 MG TABLET PENTOXIFYLLINE ER 400 MG TAB PERSANTINE 25 MG TABLET PERSANTINE 50 MG TABLET PERSANTINE 75 MG TABLET PLAVIX 300 MG TABLET PLAVIX 75 MG TABLET PLETAL 100 MG TABLET PLETAL 50 MG TABLET TICLOPIDINE 250 MG TABLET TRENTAL ER 400 MG TABLET ZONTIVITY 2.08 MG TABLET

NC 2 3 3 2 2 2 1 2 2 2 3 3 2 NC NC NC NC NC NC NC 2 NC 5

HSA* HSA* HSA* HSA* HSA* HSA* HSA* HSA* HSA* HSA* HSA* HSA* HSA*

HSA* Prior Authorization required HSA*

CALORIC AGENTS CALORIC AGENTS PROTECT PLUS LIQUID

NC

CARDIOVASCULAR AGENTS ALPHA-ADRENERGIC AGENTS CARDURA 1 MG TABLET CARDURA 2 MG TABLET CARDURA 4 MG TABLET CARDURA 8 MG TABLET CARDURA XL 4 MG TABLET CARDURA XL 8 MG TABLET CATAPRES 0.1 MG TABLET CATAPRES 0.2 MG TABLET

VALUE FORMULARY FIVE-TIER DRUG LIST

NC NC NC NC 4 4 NC NC

HSA* HSA*

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DRUG NAME

TIER

CATAPRES 0.3 MG TABLET CATAPRES-TTS 1 PATCH CATAPRES-TTS 2 PATCH CATAPRES-TTS 3 PATCH CLONIDINE 0.1 MG/DAY PATCH CLONIDINE 0.2 MG/DAY PATCH CLONIDINE 0.3 MG/DAY PATCH CLONIDINE HCL 0.1 MG TABLET CLONIDINE HCL 0.2 MG TABLET CLONIDINE HCL 0.3 MG TABLET CLORPRES 0.1-15 TABLET CLORPRES 0.2-15 TABLET CLORPRES 0.3-15 TABLET DIBENZYLINE 10 MG CAPSULE DOXAZOSIN MESYLATE 1 MG TAB DOXAZOSIN MESYLATE 2 MG TAB DOXAZOSIN MESYLATE 4 MG TAB DOXAZOSIN MESYLATE 8 MG TAB GUANFACINE 1 MG TABLET GUANFACINE 2 MG TABLET METHYLDOPA 250 MG TABLET METHYLDOPA 500 MG TABLET METHYLDOPA-HCTZ 250-15 MG TAB METHYLDOPA-HCTZ 250-25 MG TAB MIDODRINE HCL 10 MG TABLET MIDODRINE HCL 2.5 MG TABLET MIDODRINE HCL 5 MG TABLET MINIPRESS 1 MG CAPSULE MINIPRESS 2 MG CAPSULE MINIPRESS 5 MG CAPSULE NORTHERA 100 MG CAPSULE NORTHERA 200 MG CAPSULE NORTHERA 300 MG CAPSULE PHENOXYBENZAMINE HCL 10 MG CAP PHENTOLAMINE 5 MG VIAL PRAZOSIN 1 MG CAPSULE PRAZOSIN 2 MG CAPSULE PRAZOSIN 5 MG CAPSULE TENEX 1 MG TABLET TENEX 2 MG TABLET

NC NC NC NC 2 2 2 1 1 1 2 2 2 NC 2 2 2 2 1 2 2 2 2 1 2 2 2 NC NC NC NC NC NC 2 NC 2 2 2 NC NC

LIMITATIONS/ * NOTES

HSA* HSA* HSA* HSA* HSA* HSA* HSA* HSA* HSA* HSA* HSA* HSA* HSA* HSA* HSA* HSA* HSA* HSA* HSA* HSA* HSA* HSA*

HSA* HSA* HSA* HSA*

ANGIOTENSIN II RECEPTOR ANTAGONISTS ATACAND 16 MG TABLET ATACAND 32 MG TABLET ATACAND 4 MG TABLET ATACAND 8 MG TABLET ATACAND HCT 16-12.5 MG TAB ATACAND HCT 32-12.5 MG TAB ATACAND HCT 32-25 MG TABLET AVALIDE 150-12.5 MG TABLET AVALIDE 300-12.5 MG TABLET AVAPRO 150 MG TABLET AVAPRO 300 MG TABLET AVAPRO 75 MG TABLET BENICAR 20 MG TABLET BENICAR 40 MG TABLET BENICAR 5 MG TABLET

VALUE FORMULARY FIVE-TIER DRUG LIST

NC NC NC NC NC NC NC NC NC NC NC NC 4 4 4

HSA* HSA* HSA*

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DRUG NAME

TIER

BENICAR HCT 20-12.5 MG TABLET BENICAR HCT 40-12.5 MG TABLET BENICAR HCT 40-25 MG TABLET CANDESARTAN CILEXETIL 16 MG TB CANDESARTAN CILEXETIL 32 MG TB CANDESARTAN CILEXETIL 4 MG TAB CANDESARTAN CILEXETIL 8 MG TAB CANDESARTAN-HCTZ 16-12.5 MG TB CANDESARTAN-HCTZ 32-12.5 MG TB CANDESARTAN-HCTZ 32-25 MG TAB COZAAR 100 MG TABLET COZAAR 25 MG TABLET COZAAR 50 MG TABLET DIOVAN 160 MG TABLET DIOVAN 320 MG TABLET DIOVAN 40 MG TABLET DIOVAN 80 MG TABLET DIOVAN HCT 160-12.5 MG TAB DIOVAN HCT 160-25 MG TABLET DIOVAN HCT 320-12.5 MG TAB DIOVAN HCT 320-25 MG TABLET DIOVAN HCT 80-12.5 MG TABLET EDARBI 40 MG TABLET EDARBI 80 MG TABLET EDARBYCLOR 40-12.5 MG TABLET EDARBYCLOR 40-25 MG TABLET ENTRESTO 24 MG-26 MG TABLET

NC NC NC 2 2 2 2 2 2 2 NC NC NC NC NC NC NC NC NC NC NC NC 4 4 NC NC 3

ENTRESTO 49 MG-51 MG TABLET

3

ENTRESTO 97 MG-103 MG TABLET

3

EPROSARTAN MESYLATE 600 MG TAB HYZAAR 100-12.5 TABLET HYZAAR 100-25 TABLET HYZAAR 50-12.5 TABLET IRBESARTAN 150 MG TABLET IRBESARTAN 300 MG TABLET IRBESARTAN 75 MG TABLET IRBESARTAN-HCTZ 150-12.5 MG TB IRBESARTAN-HCTZ 300-12.5 MG TB LOSARTAN POTASSIUM 100 MG TAB LOSARTAN POTASSIUM 25 MG TAB LOSARTAN POTASSIUM 50 MG TAB LOSARTAN-HCTZ 100-12.5 MG TAB LOSARTAN-HCTZ 100-25 MG TAB LOSARTAN-HCTZ 50-12.5 MG TAB MICARDIS 20 MG TABLET MICARDIS 40 MG TABLET MICARDIS 80 MG TABLET MICARDIS HCT 40-12.5 MG TABLET MICARDIS HCT 80-12.5 MG TABLET MICARDIS HCT 80-25 MG TABLET OLMESARTAN MEDOXOMIL 20 MG TAB OLMESARTAN MEDOXOMIL 40 MG TAB OLMESARTAN MEDOXOMIL 5 MG TAB OLMESARTAN-HCTZ 20-12.5 MG TAB OLMESARTAN-HCTZ 40-12.5 MG TAB OLMESARTAN-HCTZ 40-25 MG TAB OLMSRTN-AMLDPN-HCTZ 20-5-12.5

2 NC NC NC 2 2 2 2 2 1 1 1 1 1 1 NC NC NC NC NC NC 3 3 3 3 3 3 3

VALUE FORMULARY FIVE-TIER DRUG LIST

LIMITATIONS/ * NOTES

HSA* HSA* HSA* HSA* HSA* HSA* HSA*

HSA* HSA*

Prior Authorization required;Max. 2 per day HSA* Prior Authorization required;Max. 2 per day HSA* Prior Authorization required;Max. 2 per day HSA* HSA*

HSA* HSA* HSA* HSA* HSA* HSA* HSA* HSA* HSA* HSA* HSA*

HSA* HSA* HSA* HSA* HSA* HSA* HSA*

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DRUG NAME

TIER

LIMITATIONS/ * NOTES

OLMSRTN-AMLDPN-HCTZ 40-10-12.5 OLMSRTN-AMLDPN-HCTZ 40-10-25MG OLMSRTN-AMLDPN-HCTZ 40-5-12.5 OLMSRTN-AMLDPN-HCTZ 40-5-25 MG TELMISARTAN 20 MG TABLET TELMISARTAN 40 MG TABLET TELMISARTAN 80 MG TABLET TELMISARTAN-AMLODIPINE 40-10

3 3 3 3 2 2 2 2

TELMISARTAN-AMLODIPINE 40-5 MG

2

TELMISARTAN-AMLODIPINE 80-10

2

TELMISARTAN-AMLODIPINE 80-5 MG

2

TELMISARTAN-HCTZ 40-12.5 MG TB TELMISARTAN-HCTZ 80-12.5 MG TB TELMISARTAN-HCTZ 80-25 MG TAB TEVETEN 400 MG TABLET TEVETEN 600 MG TABLET TEVETEN HCT 600-12.5 MG TAB TEVETEN HCT 600-25 MG TAB TRIBENZOR 20-5-12.5 MG TABLET TRIBENZOR 40-10-12.5 MG TABLET TRIBENZOR 40-10-25 MG TABLET TRIBENZOR 40-5-12.5 MG TABLET TRIBENZOR 40-5-25 MG TABLET TWYNSTA 40-10 MG TABLET TWYNSTA 40-5 MG TABLET TWYNSTA 80-10 MG TABLET TWYNSTA 80-5 MG TABLET VALSARTAN 160 MG TABLET VALSARTAN 320 MG TABLET VALSARTAN 40 MG TABLET VALSARTAN 80 MG TABLET VALSARTAN-HCTZ 160-12.5 MG TAB VALSARTAN-HCTZ 160-25 MG TAB VALSARTAN-HCTZ 320-12.5 MG TAB VALSARTAN-HCTZ 320-25 MG TAB VALSARTAN-HCTZ 80-12.5 MG TAB

2 2 2 4 NC NC NC NC NC NC NC NC NC NC NC NC 2 2 2 2 2 2 2 2 2

HSA* HSA* HSA* HSA* HSA* HSA* HSA* Max. 30 in 30 days HSA* Max. 30 in 30 days HSA* Max. 30 in 30 days HSA* Max. 30 in 30 days HSA* HSA* HSA* HSA* HSA*

HSA* HSA* HSA* HSA* HSA* HSA* HSA* HSA* HSA*

ANGIOTENSIN-CONVERTING ENZYME INHIBITORS ACCUPRIL 10 MG TABLET ACCUPRIL 20 MG TABLET ACCUPRIL 40 MG TABLET ACCUPRIL 5 MG TABLET ACCURETIC 10-12.5 MG TABLET ACCURETIC 20-12.5 MG TABLET ACCURETIC 20-25 MG TABLET ACEON 4 MG TABLET ACEON 8 MG TABLET ALTACE 1.25 MG CAPSULE ALTACE 10 MG CAPSULE ALTACE 2.5 MG CAPSULE ALTACE 5 MG CAPSULE BENAZEPRIL HCL 10 MG TABLET BENAZEPRIL HCL 20 MG TABLET BENAZEPRIL HCL 40 MG TABLET

VALUE FORMULARY FIVE-TIER DRUG LIST

NC NC NC NC NC NC NC NC NC NC NC NC NC 1 1 1

HSA* HSA* HSA*

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DRUG NAME

TIER

LIMITATIONS/ * NOTES

BENAZEPRIL HCL 5 MG TABLET BENAZEPRIL-HCTZ 10-12.5 MG TAB BENAZEPRIL-HCTZ 20-12.5 MG TAB BENAZEPRIL-HCTZ 20-25 MG TAB BENAZEPRIL-HCTZ 5-6.25 MG TAB CAPTOPRIL 100 MG TABLET CAPTOPRIL 12.5 MG TABLET CAPTOPRIL 25 MG TABLET CAPTOPRIL 50 MG TABLET CAPTOPRIL-HCTZ 25-15 MG TABLET CAPTOPRIL-HCTZ 25-25 MG TABLET CAPTOPRIL-HCTZ 50-15 MG TABLET CAPTOPRIL-HCTZ 50-25 MG TABLET ENALAPRIL MALEATE 10 MG TAB ENALAPRIL MALEATE 2.5 MG TAB ENALAPRIL MALEATE 20 MG TAB ENALAPRIL MALEATE 5 MG TABLET ENALAPRIL-HCTZ 10-25 MG TABLET ENALAPRIL-HCTZ 5-12.5 MG TAB EPANED 1 MG/ML SOLUTION FOSINOPRIL SODIUM 10 MG TAB FOSINOPRIL SODIUM 20 MG TAB FOSINOPRIL SODIUM 40 MG TAB FOSINOPRIL-HCTZ 10-12.5 MG TAB FOSINOPRIL-HCTZ 20-12.5 MG TAB LISINOPRIL 10 MG TABLET LISINOPRIL 2.5 MG TABLET LISINOPRIL 20 MG TABLET LISINOPRIL 30 MG TABLET LISINOPRIL 40 MG TABLET LISINOPRIL 5 MG TABLET LISINOPRIL-HCTZ 10-12.5 MG TAB LISINOPRIL-HCTZ 20-12.5 MG TAB LISINOPRIL-HCTZ 20-25 MG TAB LOTENSIN 20 MG TABLET LOTENSIN 40 MG TABLET LOTENSIN HCT 10-12.5 MG TABLET LOTENSIN HCT 20-12.5 MG TABLET LOTENSIN HCT 20-25 MG TABLET MAVIK 1 MG TABLET MAVIK 2 MG TABLET MAVIK 4 MG TABLET MOEXIPRIL HCL 15 MG TABLET MOEXIPRIL HCL 7.5 MG TABLET MOEXIPRIL-HCTZ 15-12.5 MG TAB MOEXIPRIL-HCTZ 15-25 MG TABLET MOEXIPRIL-HCTZ 7.5-12.5 MG TAB PERINDOPRIL ERBUMINE 2 MG TAB PERINDOPRIL ERBUMINE 4 MG TAB PERINDOPRIL ERBUMINE 8 MG TAB PRINIVIL 10 MG TABLET PRINIVIL 20 MG TABLET PRINIVIL 5 MG TABLET QBRELIS 1MG/ML SOLUTION QUINAPRIL 10 MG TABLET QUINAPRIL 20 MG TABLET QUINAPRIL 40 MG TABLET QUINAPRIL 5 MG TABLET QUINAPRIL-HCTZ 10-12.5 MG TAB

1 2 2 2 2 2 2 2 1 2 2 2 2 2 2 2 2 1 1 NC 2 2 2 2 2 1 1 1 1 1 1 1 1 1 NC NC NC NC NC NC NC NC 2 2 2 2 2 2 2 2 NC NC NC NC 2 2 2 2 2

HSA* HSA* HSA* HSA* HSA* HSA* HSA* HSA* HSA* HSA* HSA* HSA* HSA* HSA* HSA* HSA* HSA* HSA* HSA*

VALUE FORMULARY FIVE-TIER DRUG LIST

HSA* HSA* HSA* HSA* HSA* HSA* HSA* HSA* HSA* HSA* HSA* HSA* HSA* HSA*

HSA* HSA* HSA* HSA* HSA* HSA* HSA* HSA*

HSA* HSA* HSA* HSA* HSA*

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DRUG NAME

TIER

LIMITATIONS/ * NOTES

QUINAPRIL-HCTZ 20-12.5 MG TAB QUINAPRIL-HCTZ 20-25 MG TAB RAMIPRIL 1.25 MG CAPSULE RAMIPRIL 10 MG CAPSULE RAMIPRIL 2.5 MG CAPSULE RAMIPRIL 5 MG CAPSULE TARKA ER 1-240 MG TABLET TARKA ER 2-180 MG TABLET TARKA ER 2-240 MG TABLET TARKA ER 4-240 MG TABLET TRANDOLAPR-VERAPAM ER 1-240 MG TRANDOLAPR-VERAPAM ER 2-180 MG TRANDOLAPR-VERAPAM ER 2-240 MG TRANDOLAPR-VERAPAM ER 4-240 MG TRANDOLAPRIL 1 MG TABLET TRANDOLAPRIL 2 MG TABLET TRANDOLAPRIL 4 MG TABLET UNIRETIC 15-12.5 TABLET UNIRETIC 15-25 MG TABLET UNIRETIC 7.5-12.5 MG TABLET UNIVASC 15 MG TABLET UNIVASC 7.5 MG TABLET VASERETIC 10-25 MG TABLET VASOTEC 10 MG TABLET VASOTEC 2.5 MG TABLET VASOTEC 20 MG TABLET VASOTEC 5 MG TABLET ZESTORETIC 10-12.5 MG TABLET ZESTORETIC 20-12.5 MG TABLET ZESTORETIC 20-25 MG TABLET ZESTRIL 10 MG TABLET ZESTRIL 2.5 MG TABLET ZESTRIL 20 MG TABLET ZESTRIL 30 MG TABLET ZESTRIL 40 MG TABLET ZESTRIL 5 MG TABLET

2 2 2 1 1 1 NC NC NC NC 2 2 2 2 2 2 2 NC NC NC NC NC NC NC NC NC NC NC NC NC NC NC NC NC NC NC

HSA* HSA* HSA* HSA* HSA* HSA*

HSA* HSA* HSA* HSA* HSA* HSA* HSA*

ANTIARRHYTHMIC AGENTS AMIODARONE HCL 100 MG TABLET AMIODARONE HCL 200 MG TABLET AMIODARONE HCL 400 MG TABLET CORDARONE 200 MG TABLET DISOPYRAMIDE 100 MG CAPSULE DISOPYRAMIDE 150 MG CAPSULE DOFETILIDE 125 MCG CAPSULE DOFETILIDE 250 MCG CAPSULE DOFETILIDE 500 MCG CAPSULE FLECAINIDE ACETATE 100 MG TAB FLECAINIDE ACETATE 150 MG TAB FLECAINIDE ACETATE 50 MG TAB MEXILETINE 150 MG CAPSULE MEXILETINE 200 MG CAPSULE MEXILETINE 250 MG CAPSULE MULTAQ 400 MG TABLET NORPACE 100 MG CAPSULE NORPACE 150 MG CAPSULE NORPACE CR 100 MG CAPSULE

VALUE FORMULARY FIVE-TIER DRUG LIST

2 2 2 NC 2 2 3 3 3 2 2 2 2 2 2 3 NC NC 4

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DRUG NAME

TIER

NORPACE CR 150 MG CAPSULE PACERONE 100 MG TABLET PACERONE 200 MG TABLET PACERONE 400 MG TABLET PROPAFENONE HCL 150 MG TABLET PROPAFENONE HCL 225 MG TAB PROPAFENONE HCL 300 MG TAB PROPAFENONE HCL ER 225 MG CAP PROPAFENONE HCL ER 325 MG CAP PROPAFENONE HCL ER 425 MG CAP QUINIDINE GLUC ER 324 MG TAB QUINIDINE SULF ER 300 MG TAB QUINIDINE SULFATE 200 MG TAB QUINIDINE SULFATE 300 MG TAB RYTHMOL 150 MG TABLET RYTHMOL 225 MG TABLET RYTHMOL SR 225 MG CAPSULE RYTHMOL SR 325 MG CAPSULE RYTHMOL SR 425 MG CAPSULE TAMBOCOR 100 MG TABLET TAMBOCOR 150 MG TABLET TAMBOCOR 50 MG TABLET TIKOSYN 125 MCG CAPSULE TIKOSYN 250 MCG CAPSULE TIKOSYN 500 MCG CAPSULE

4 2 2 2 2 2 2 2 2 2 2 2 2 2 NC NC NC NC NC NC NC NC NC NC NC

LIMITATIONS/ * NOTES

BETA-ADRENERGIC BLOCKING AGENTS ACEBUTOLOL 200 MG CAPSULE ACEBUTOLOL 400 MG CAPSULE ATENOLOL 100 MG TABLET ATENOLOL 25 MG TABLET ATENOLOL 50 MG TABLET ATENOLOL-CHLORTHALIDONE 100-25 ATENOLOL-CHLORTHALIDONE 50-25 BETAPACE 120 MG TABLET BETAPACE 160 MG TABLET BETAPACE 240 MG TABLET BETAPACE AF 80 MG TABLET BETAXOLOL 10 MG TABLET BETAXOLOL 20 MG TABLET BISOPROLOL FUMARATE 10 MG TAB BISOPROLOL FUMARATE 5 MG TAB BISOPROLOL-HCTZ 10-6.25 MG TAB BISOPROLOL-HCTZ 2.5-6.25 MG TB BISOPROLOL-HCTZ 5-6.25 MG TAB BYSTOLIC 10 MG TABLET BYSTOLIC 2.5 MG TABLET BYSTOLIC 20 MG TABLET BYSTOLIC 5 MG TABLET BYVALSON 5 MG-80 MG TABLET CARVEDILOL 12.5 MG TABLET CARVEDILOL 25 MG TABLET CARVEDILOL 3.125 MG TABLET CARVEDILOL 6.25 MG TABLET COREG 12.5 MG TABLET COREG 25 MG TABLET COREG 3.125 MG TABLET

VALUE FORMULARY FIVE-TIER DRUG LIST

2 2 1 1 1 2 2 NC NC NC NC 2 2 2 2 1 2 1 3 3 3 3 3 1 1 1 1 NC NC NC

HSA* HSA* HSA* HSA* HSA* HSA* HSA*

HSA* HSA* HSA* HSA* HSA* HSA* HSA* HSA* HSA* HSA* HSA* HSA* HSA* HSA* HSA* HSA*

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Page 68

DRUG NAME

TIER

COREG 6.25 MG TABLET COREG CR 10 MG CAPSULE COREG CR 20 MG CAPSULE COREG CR 40 MG CAPSULE COREG CR 80 MG CAPSULE CORGARD 20 MG TABLET CORGARD 40 MG TABLET CORGARD 80 MG TABLET CORZIDE 40-5 TABLET CORZIDE 80-5 TABLET DUTOPROL 100-12.5 MG TABLET DUTOPROL 25-12.5 MG TABLET DUTOPROL 50-12.5 MG TABLET HEMANGEOL 4.28 MG/ML ORAL SOLN

NC 3 3 3 3 NC NC NC NC NC NC NC NC 5

INDERAL LA 120 MG CAPSULE INDERAL LA 160 MG CAPSULE INDERAL LA 60 MG CAPSULE INDERAL LA 80 MG CAPSULE INNOPRAN XL 120 MG CAPSULE INNOPRAN XL 80 MG CAPSULE LABETALOL HCL 100 MG TABLET LABETALOL HCL 200 MG TABLET LABETALOL HCL 300 MG TABLET LEVATOL 20 MG TABLET LOPRESSOR 100 MG TABLET LOPRESSOR 50 MG TABLET LOPRESSOR HCT 50-25 TABLET METOPROLOL ER-HCTZ 100-12.5 MG METOPROLOL ER-HCTZ 25-12.5 MG METOPROLOL ER-HCTZ 50-12.5 MG METOPROLOL SUCC ER 100 MG TAB METOPROLOL SUCC ER 200 MG TAB METOPROLOL SUCC ER 25 MG TAB METOPROLOL SUCC ER 50 MG TAB METOPROLOL TARTRATE 100 MG TAB METOPROLOL TARTRATE 25 MG TAB METOPROLOL TARTRATE 37.5 MG TB METOPROLOL TARTRATE 50 MG TAB METOPROLOL TARTRATE 75 MG TAB METOPROLOL-HCTZ 100-25 MG TAB METOPROLOL-HCTZ 100-50 MG TAB METOPROLOL-HCTZ 50-25 MG TAB NADOLOL 20 MG TABLET NADOLOL 40 MG TABLET NADOLOL 80 MG TABLET NADOLOL-BENDROFLU 40-5 MG TAB NADOLOL-BENDROFLU 80-5 MG TAB PINDOLOL 10 MG TABLET PINDOLOL 5 MG TABLET PROPRANOLOL 10 MG TABLET PROPRANOLOL 20 MG TABLET PROPRANOLOL 20 MG/5 ML SOLN PROPRANOLOL 40 MG TABLET PROPRANOLOL 40 MG/5 ML SOLN PROPRANOLOL 60 MG TABLET PROPRANOLOL 80 MG TABLET PROPRANOLOL ER 120 MG CAPSULE PROPRANOLOL ER 160 MG CAPSULE

NC NC NC NC NC NC 2 2 2 4 NC NC NC 3 3 3 2 2 2 2 1 1 2 1 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2

VALUE FORMULARY FIVE-TIER DRUG LIST

LIMITATIONS/ * NOTES HSA* HSA* HSA* HSA*

Prior Authorization required HSA*

HSA* HSA* HSA* HSA*

HSA* HSA* HSA* HSA* HSA* HSA* HSA* HSA* HSA* HSA* HSA* HSA* HSA* HSA* HSA* HSA* HSA* HSA* HSA* HSA* HSA* HSA* HSA* HSA* HSA* HSA* HSA* HSA* HSA* HSA*

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DRUG NAME

TIER

LIMITATIONS/ * NOTES

PROPRANOLOL ER 60 MG CAPSULE PROPRANOLOL ER 80 MG CAPSULE PROPRANOLOL-HCTZ 40-25 MG TAB PROPRANOLOL-HCTZ 80-25 MG TAB SECTRAL 200 MG CAPSULE SECTRAL 400 MG CAPSULE SORINE 120 MG TABLET SORINE 160 MG TABLET SORINE 240 MG TABLET SORINE 80 MG TABLET SOTALOL 120 MG TABLET SOTALOL 160 MG TABLET SOTALOL 240 MG TABLET SOTALOL 80 MG TABLET SOTYLIZE 5 MG/ML ORAL SOLUTION TENORETIC 100 TABLET TENORETIC 50 TABLET TENORMIN 100 MG TABLET TENORMIN 25 MG TABLET TENORMIN 50 MG TABLET TIMOLOL MALEATE 10 MG TABLET TIMOLOL MALEATE 20 MG TABLET TIMOLOL MALEATE 5 MG TABLET TOPROL XL 100 MG TABLET TOPROL XL 200 MG TABLET TOPROL XL 25 MG TABLET TOPROL XL 50 MG TABLET TRANDATE 100 MG TABLET TRANDATE 200 MG TABLET TRANDATE 300 MG TABLET ZEBETA 10 MG TABLET ZEBETA 5 MG TABLET ZIAC 10-6.25 MG TABLET ZIAC 2.5-6.25 MG TABLET ZIAC 5-6.25 MG TABLET

2 2 2 2 NC NC 2 2 2 2 2 2 2 2 NC NC NC NC NC NC 2 2 2 NC NC NC NC NC NC NC NC NC NC NC NC

HSA* HSA* HSA* HSA*

HSA* HSA* HSA* HSA* HSA* HSA* HSA* HSA*

HSA* HSA* HSA*

CALCIUM-CHANNEL BLOCKING AGENTS CALAN 120 MG TABLET CALAN 80 MG TABLET CALAN SR 120 MG CAPLET CALAN SR 180 MG CAPLET CALAN SR 240 MG CAPLET CARDIZEM 120 MG TABLET CARDIZEM 30 MG TABLET CARDIZEM 60 MG TABLET CARDIZEM 90 MG TABLET CARDIZEM CD 120 MG CAPSULE CARDIZEM CD 180 MG CAPSULE CARDIZEM CD 240 MG CAPSULE CARDIZEM CD 300 MG CAPSULE CARDIZEM CD 360 MG CAPSULE CARDIZEM LA 120 MG TABLET CARDIZEM LA 180 MG TABLET CARDIZEM LA 240 MG TABLET CARDIZEM LA 300 MG TABLET CARDIZEM LA 360 MG TABLET CARDIZEM LA 420 MG TABLET

VALUE FORMULARY FIVE-TIER DRUG LIST

NC NC NC NC NC NC NC NC NC NC NC NC NC NC 4 NC NC NC NC NC

Last Updated: 01/17/2017

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DRUG NAME

TIER

LIMITATIONS/ * NOTES

CARTIA XT 120 MG CAPSULE CARTIA XT 180 MG CAPSULE CARTIA XT 240 MG CAPSULE CARTIA XT 300 MG CAPSULE DILACOR XR 240 MG CAPSULE DILT XR 120 MG CAPSULE DILT XR 180 MG CAPSULE DILT XR 240 MG CAPSULE DILT-CD ER 300 MG CAPSULE DILTIA XT 120 MG CAPSULE DILTIA XT 180 MG CAPSULE DILTIA XT 240 MG CAPSULE DILTIAZEM 120 MG TABLET DILTIAZEM 12HR ER 120 MG CAP DILTIAZEM 12HR ER 60 MG CAP DILTIAZEM 12HR ER 90 MG CAP DILTIAZEM 24HR ER 120 MG CAP DILTIAZEM 24HR ER 180 MG CAP DILTIAZEM 24HR ER 240 MG CAP DILTIAZEM 24HR ER 300 MG CAP DILTIAZEM 24HR ER 360 MG CAP DILTIAZEM 30 MG TABLET DILTIAZEM 60 MG TABLET DILTIAZEM 90 MG TABLET DILTIAZEM ER 180 MG TABLET DILTIAZEM ER 240 MG TABLET DILTIAZEM ER 300 MG TABLET DILTIAZEM ER 360 MG TABLET DILTIAZEM ER 420 MG TABLET DILTIAZEM HCL ER 420 MG CAP DILTZAC ER 120 MG CAPSULE DILTZAC ER 180 MG CAPSULE DILTZAC ER 240 MG CAPSULE DILTZAC ER 300 MG CAPSULE DILTZAC ER 360 MG CAPSULE MATZIM LA 180 MG TABLET MATZIM LA 240 MG TABLET MATZIM LA 300 MG TABLET MATZIM LA 360 MG TABLET MATZIM LA 420 MG TABLET TAZTIA XT 120 MG CAPSULE TAZTIA XT 180 MG CAPSULE TAZTIA XT 240 MG CAPSULE TAZTIA XT 300 MG CAPSULE TAZTIA XT 360 MG CAPSULE TIAZAC ER 120 MG CAPSULE TIAZAC ER 180 MG CAPSULE TIAZAC ER 240 MG CAPSULE TIAZAC ER 300 MG CAPSULE TIAZAC ER 360 MG CAPSULE TIAZAC ER 420 MG CAPSULE VERAPAMIL 120 MG TABLET VERAPAMIL 360 MG CAP PELLET VERAPAMIL 40 MG TABLET VERAPAMIL 80 MG TABLET VERAPAMIL ER 120 MG CAPSULE VERAPAMIL ER 120 MG TABLET VERAPAMIL ER 180 MG CAPSULE VERAPAMIL ER 180 MG TABLET

2 2 2 2 NC 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 NC NC NC NC NC NC 1 2 2 1 2 2 2 2

HSA* HSA* HSA* HSA*

VALUE FORMULARY FIVE-TIER DRUG LIST

HSA* HSA* HSA* HSA* HSA* HSA* HSA* HSA* HSA* HSA* HSA* HSA* HSA* HSA* HSA* HSA* HSA* HSA* HSA* HSA* HSA* HSA* HSA* HSA* HSA* HSA* HSA* HSA* HSA* HSA* HSA* HSA* HSA* HSA* HSA* HSA* HSA* HSA* HSA* HSA*

HSA* HSA* HSA* HSA* HSA* HSA* HSA*

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DRUG NAME

TIER

VERAPAMIL ER 240 MG CAPSULE VERAPAMIL ER 240 MG TABLET VERAPAMIL ER PM 100 MG CAPSULE VERAPAMIL ER PM 200 MG CAPSULE VERAPAMIL ER PM 300 MG CAPSULE VERELAN 120 MG CAP PELLET VERELAN 180 MG CAP PELLET VERELAN 240 MG CAP PELLET VERELAN 360 MG CAP PELLET VERELAN PM 100 MG CAP PELLET VERELAN PM 200 MG CAP PELLET VERELAN PM 300 MG CAP PELLET

2 2 2 2 2 NC NC NC NC NC NC NC

LIMITATIONS/ * NOTES HSA* HSA* HSA* HSA*

CARDIOVASCULAR AGENTS, MISCELLANEOUS ADRENACLICK 0.15 MG AUTO-INJCT ADRENACLICK 0.3 MG AUTO-INJECT ADYPHREN KIT AUVI-Q 0.15 MG AUTO-INJECTOR

NC NC NC 5

AUVI-Q 0.3 MG AUTO-INJECTOR

5

CORLANOR 5 MG TABLET

3

CORLANOR 7.5 MG TABLET

3

DEMSER 250 MG CAPSULE DIGITEK 125 MCG TABLET DIGITEK 250 MCG TABLET DIGOX 125 MCG TABLET DIGOXIN 0.05 MG/ML SOLUTION DIGOXIN 250 MCG TABLET EPINEPHRINE 0.15 MG AUTO-INJCT

NC 2 2 2 3 2 2

EPINEPHRINE 0.3 MG AUTO-INJECT

2

EPIPEN 0.3 MG AUTO-INJECTOR

4

EPIPEN 2-PAK 0.3 MG AUTO-INJCT

4

EPIPEN JR 2-PAK 0.15 MG INJCTR

4

FIRAZYR 30 MG/3 ML SYRINGE HYDRALAZINE 10 MG TABLET HYDRALAZINE 100 MG TABLET HYDRALAZINE 25 MG TABLET HYDRALAZINE 50 MG TABLET ISOXSUPRINE 10 MG TABLET ISOXSUPRINE 20 MG TABLET LANOXIN 125 MCG TABLET LANOXIN 187.5 MCG TABLET LANOXIN 250 MCG TABLET LANOXIN 62.5 MCG TABLET PAPAVERINE 150 MG CAPSULE SA PAPAVRN 30 MG-PHENTO 1 MG/ML RANEXA ER 1,000 MG TABLET RANEXA ER 500 MG TABLET RESERPINE 0.1 MG TABLET RESERPINE 0.25 MG TABLET VECAMYL 2.5 MG TABLET YOSPRALA DR 325-40 MG TABLET

5 2 2 2 2 2 2 NC NC NC NC 2 2 3 3 2 2 NC NC

VALUE FORMULARY FIVE-TIER DRUG LIST

Max. quantity of 2 per fill HSA*; MQC*: 2 units/copay Max. quantity of 2 per fill HSA*; MQC*: 2 units/copay Prior Authorization required;Max. 2 per day HSA* Prior Authorization required;Max. 2 per day HSA* HSA* HSA* HSA* HSA* Max. quantity of 2 per fill HSA*; MQC*: 2 units/copay Max. quantity of 2 per fill HSA*; MQC*: 2 units/copay Max. quantity of 2 per fill HSA*; MQC*: 2 units/copay Max. quantity of 2 per fill HSA*; MQC*: 2 units/copay Max. quantity of 2 per fill HSA*; MQC*: 2 units/copay SPP*: Must use Accredo HSA* HSA* HSA* HSA*

HSA* HSA* HSA* HSA*

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DRUG NAME

TIER

YOSPRALA DR 81-40 MG TABLET

NC

LIMITATIONS/ * NOTES

DIHYDROPYRIDINES ADALAT CC 30 MG TABLET ADALAT CC 60 MG TABLET ADALAT CC 90 MG TABLET AFEDITAB CR 30 MG TABLET AFEDITAB CR 60 MG TABLET AMLOD-VALSA-HCTZ 10-160-12.5MG AMLOD-VALSA-HCTZ 10-160-25 MG AMLOD-VALSA-HCTZ 10-320-25 MG AMLOD-VALSA-HCTZ 5-160-12.5 MG AMLOD-VALSA-HCTZ 5-160-25 MG AMLODIPINE BESYLATE 10 MG TAB AMLODIPINE BESYLATE 2.5 MG TAB AMLODIPINE BESYLATE 5 MG TAB AMLODIPINE-BENAZEPRIL 10-20 MG AMLODIPINE-BENAZEPRIL 10-40 MG AMLODIPINE-BENAZEPRIL 2.5-10 AMLODIPINE-BENAZEPRIL 5-10 MG AMLODIPINE-BENAZEPRIL 5-20 MG AMLODIPINE-BENAZEPRIL 5-40 MG AMLODIPINE-OLMESARTAN 10-20 MG AMLODIPINE-OLMESARTAN 10-40 MG AMLODIPINE-OLMESARTAN 5-20 MG AMLODIPINE-OLMESARTAN 5-40 MG AMLODIPINE-VALSARTAN 10-160 MG AMLODIPINE-VALSARTAN 10-320 MG AMLODIPINE-VALSARTAN 5-160 MG AMLODIPINE-VALSARTAN 5-320 MG AZOR 10-20 MG TABLET AZOR 10-40 MG TABLET AZOR 5-20 MG TABLET AZOR 5-40 MG TABLET CARDENE SR 30 MG CAPSULE CARDENE SR 60 MG CAPSULE EXFORGE 10-160 MG TABLET EXFORGE 10-320 MG TABLET EXFORGE 5-160 MG TABLET EXFORGE 5-320 MG TABLET EXFORGE HCT 10-160-12.5 MG TAB EXFORGE HCT 10-160-25 MG TAB EXFORGE HCT 10-320-25 MG TAB EXFORGE HCT 5-160-12.5 MG TAB EXFORGE HCT 5-160-25 MG TAB FELODIPINE ER 10 MG TABLET FELODIPINE ER 2.5 MG TABLET FELODIPINE ER 5 MG TABLET ISRADIPINE 2.5 MG CAPSULE ISRADIPINE 5 MG CAPSULE LOTREL 10-20 MG CAPSULE LOTREL 10-40 MG CAPSULE LOTREL 2.5-10 MG CAPSULE LOTREL 5-10 MG CAPSULE LOTREL 5-20 MG CAPSULE LOTREL 5-40 MG CAPSULE NICARDIPINE 20 MG CAPSULE

VALUE FORMULARY FIVE-TIER DRUG LIST

NC NC NC 2 2 2 2 2 2 2 1 1 1 2 2 2 2 2 2 3 3 3 3 2 2 2 2 NC NC NC NC NC NC NC NC NC NC NC NC NC NC NC 2 2 2 2 2 NC NC NC NC NC NC 2

HSA* HSA* HSA* HSA* HSA* HSA* HSA* HSA* HSA* HSA* HSA* HSA* HSA* HSA* HSA* HSA* HSA* HSA* HSA* HSA* HSA* HSA* HSA* HSA*

HSA* HSA* HSA* HSA* HSA*

HSA*

Last Updated: 01/17/2017

Page 73

DRUG NAME

TIER

LIMITATIONS/ * NOTES

NICARDIPINE 30 MG CAPSULE NIFEDIAC CC 90 MG TABLET NIFEDICAL XL 30 MG TABLET NIFEDICAL XL 60 MG TABLET NIFEDIPINE 10 MG CAPSULE NIFEDIPINE 20 MG CAPSULE NIFEDIPINE ER 30 MG TABLET NIFEDIPINE ER 60 MG TABLET NIFEDIPINE ER 90 MG TABLET NIMODIPINE 30 MG CAPSULE NISOLDIPINE ER 17 MG TABLET NISOLDIPINE ER 20 MG TABLET NISOLDIPINE ER 25.5 MG TABLET NISOLDIPINE ER 30 MG TABLET NISOLDIPINE ER 34 MG TABLET NISOLDIPINE ER 40 MG TABLET NISOLDIPINE ER 8.5 MG TABLET NORVASC 10 MG TABLET NORVASC 2.5 MG TABLET NORVASC 5 MG TABLET NYMALIZE 60 MG/20 ML SOLUTION PROCARDIA 10 MG CAPSULE PROCARDIA XL 30 MG TABLET PROCARDIA XL 60 MG TABLET PROCARDIA XL 90 MG TABLET SULAR ER 17 MG TABLET SULAR ER 34 MG TABLET SULAR ER 8.5 MG TABLET

2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 NC NC NC 5 NC NC NC NC NC NC NC

HSA* HSA* HSA* HSA* HSA* HSA* HSA* HSA* HSA* HSA* HSA* HSA* HSA* HSA* HSA* HSA* HSA*

HSA*

DIURETICS ALDACTAZIDE 25-25 TABLET ALDACTAZIDE 50-50 TABLET ALDACTONE 100 MG TABLET ALDACTONE 25 MG TABLET ALDACTONE 50 MG TABLET AMILORIDE HCL 5 MG TABLET AMILORIDE HCL-HCTZ 5-50 MG TAB BUMETANIDE 0.5 MG TABLET BUMETANIDE 1 MG TABLET BUMETANIDE 2 MG TABLET CHLOROTHIAZIDE 250 MG TABLET CHLOROTHIAZIDE 500 MG TABLET CHLORTHALIDONE 25 MG TABLET CHLORTHALIDONE 50 MG TABLET DEMADEX 10 MG TABLET DEMADEX 100 MG TABLET DEMADEX 20 MG TABLET DEMADEX 5 MG TABLET DIURIL 250 MG/5 ML ORAL SUSP DYAZIDE 37.5-25 CAPSULE DYRENIUM 100 MG CAPSULE DYRENIUM 50 MG CAPSULE EDECRIN 25 MG TABLET ETHACRYNIC ACID 25 MG TABLET FUROSEMIDE 10 MG/ML SOLUTION FUROSEMIDE 20 MG TABLET FUROSEMIDE 40 MG TABLET

VALUE FORMULARY FIVE-TIER DRUG LIST

NC NC NC NC NC 2 2 1 2 2 1 2 2 2 NC NC NC NC 4 NC 4 4 NC 3 2 1 1

HSA* HSA* HSA* HSA* HSA* HSA* HSA* HSA* HSA*

HSA* HSA* HSA* HSA* HSA* HSA* HSA*

Last Updated: 01/17/2017

Page 74

DRUG NAME

TIER

LIMITATIONS/ * NOTES

FUROSEMIDE 40 MG/5 ML SOLN FUROSEMIDE 80 MG TABLET HYDROCHLOROTHIAZIDE 12.5 MG CP HYDROCHLOROTHIAZIDE 12.5 MG TB HYDROCHLOROTHIAZIDE 25 MG TAB HYDROCHLOROTHIAZIDE 50 MG TAB INDAPAMIDE 1.25 MG TABLET INDAPAMIDE 2.5 MG TABLET LASIX 20 MG TABLET LASIX 40 MG TABLET LASIX 80 MG TABLET MAXZIDE 37.5 MG-25 MG TABLET MAXZIDE 75 MG-50 MG TABLET METHYCLOTHIAZIDE 5 MG TABLET METOLAZONE 10 MG TABLET METOLAZONE 2.5 MG TABLET METOLAZONE 5 MG TABLET MICROZIDE 12.5 MG CAPSULE SAMSCA 15 MG TABLET SAMSCA 30 MG TABLET SPIRONOLACTONE 100 MG TABLET SPIRONOLACTONE 25 MG TABLET SPIRONOLACTONE 50 MG TABLET SPIRONOLACTONE-HCTZ 25-25 TAB TORSEMIDE 10 MG TABLET TORSEMIDE 100 MG TABLET TORSEMIDE 20 MG TABLET TORSEMIDE 5 MG TABLET TRIAMTERENE-HCTZ 37.5-25 MG CP TRIAMTERENE-HCTZ 37.5-25 MG TB TRIAMTERENE-HCTZ 50-25 MG CAP TRIAMTERENE-HCTZ 75-50 MG TAB ZAROXOLYN 2.5 MG TABLET ZAROXOLYN 5 MG TABLET

2 1 1 1 1 1 1 1 NC NC NC NC NC 2 2 2 2 NC 5 5 2 1 2 2 2 2 2 2 2 1 2 2 NC NC

HSA* HSA* HSA* HSA* HSA* HSA* HSA* HSA*

HSA* HSA* HSA* HSA*

HSA* HSA* HSA* HSA* HSA* HSA* HSA* HSA* HSA* HSA* HSA* HSA*

DYSLIPIDEMICS ADVICOR 1,000 MG-20 MG TABLET ADVICOR 1,000 MG-40 MG TABLET ADVICOR 500 MG-20 MG TABLET ADVICOR 750 MG-20 MG TABLET ALTOPREV 20 MG TABLET ALTOPREV 40 MG TABLET ALTOPREV 60 MG TABLET AMLODIPINE-ATORVAST 10-10 MG AMLODIPINE-ATORVAST 10-20 MG AMLODIPINE-ATORVAST 10-40 MG AMLODIPINE-ATORVAST 10-80 MG AMLODIPINE-ATORVAST 2.5-10 MG AMLODIPINE-ATORVAST 2.5-20 MG AMLODIPINE-ATORVAST 2.5-40 MG AMLODIPINE-ATORVAST 5-10 MG AMLODIPINE-ATORVAST 5-20 MG AMLODIPINE-ATORVAST 5-40 MG AMLODIPINE-ATORVAST 5-80 MG ANTARA 130 MG CAPSULE ANTARA 30 MG CAPSULE ANTARA 43 MG CAPSULE

VALUE FORMULARY FIVE-TIER DRUG LIST

NC NC NC NC 4 4 4 2 2 2 2 2 2 2 2 2 2 2 NC NC NC

HSA* HSA* HSA HSA* HSA* HSA* HSA* HSA* HSA* HSA* HSA* HSA* HSA* HSA*

Last Updated: 01/17/2017

Page 75

DRUG NAME

TIER

ANTARA 90 MG CAPSULE ATORVASTATIN 10 MG TABLET ATORVASTATIN 20 MG TABLET ATORVASTATIN 40 MG TABLET ATORVASTATIN 80 MG TABLET CADUET 10 MG-10 MG TABLET CADUET 10 MG-20 MG TABLET CADUET 10 MG-40 MG TABLET CADUET 10 MG-80 MG TABLET CADUET 2.5 MG-10 MG TABLET CADUET 2.5 MG-20 MG TABLET CADUET 2.5 MG-40 MG TABLET CADUET 5 MG-10 MG TABLET CADUET 5 MG-20 MG TABLET CADUET 5 MG-40 MG TABLET CADUET 5 MG-80 MG TABLET CHOLESTYRAMINE LIGHT PACKET CHOLESTYRAMINE PACKET COLESTID 1 GM TABLET COLESTID FLAVORED GRANULES COLESTIPOL HCL GRANULES PACKET COLESTIPOL MICRONIZED 1 GM TAB CRESTOR 10 MG TABLET CRESTOR 20 MG TABLET CRESTOR 40 MG TABLET CRESTOR 5 MG TABLET EZETIMIBE 10 MG TABLET

NC 1 1 1 1 NC NC NC NC NC NC NC NC NC NC NC 2 2 NC NC 2 2 NC NC NC NC 3

FENOFIBRATE 120 MG TABLET FENOFIBRATE 130 MG CAPSULE FENOFIBRATE 134 MG CAPSULE FENOFIBRATE 145 MG TABLET FENOFIBRATE 150 MG CAPSULE FENOFIBRATE 160 MG TABLET FENOFIBRATE 200 MG CAPSULE FENOFIBRATE 40 MG TABLET FENOFIBRATE 43 MG CAPSULE FENOFIBRATE 48 MG TABLET FENOFIBRATE 50 MG CAPSULE FENOFIBRATE 54 MG TABLET FENOFIBRATE 67 MG CAPSULE FENOFIBRIC ACID 105 MG TABLET FENOFIBRIC ACID 35 MG TABLET FENOFIBRIC ACID DR 135 MG CAP FENOFIBRIC ACID DR 45 MG CAP FENOGLIDE 120 MG TABLET FENOGLIDE 40 MG TABLET FIBRICOR 105 MG TABLET FIBRICOR 35 MG TABLET FLUVASTATIN ER 80 MG TABLET FLUVASTATIN SODIUM 20 MG CAP FLUVASTATIN SODIUM 40 MG CAP GEMFIBROZIL 600 MG TABLET JUXTAPID 10 MG CAPSULE JUXTAPID 20 MG CAPSULE JUXTAPID 30 MG CAPSULE JUXTAPID 40 MG CAPSULE JUXTAPID 5 MG CAPSULE JUXTAPID 60 MG CAPSULE

2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 NC NC NC NC 2 2 2 2 NC NC NC NC NC NC

VALUE FORMULARY FIVE-TIER DRUG LIST

LIMITATIONS/ * NOTES HSA* HSA* HSA* HSA*

HSA*

HSA* HSA*

Max. 1 per day HSA* HSA* HSA* HSA* HSA* HSA* HSA* HSA* HSA* HSA* HSA* HSA* HSA* HSA* HSA* HSA* HSA* HSA*

HSA* HSA* HSA* HSA*

Last Updated: 01/17/2017

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DRUG NAME

TIER

KYNAMRO 200 MG/ML SYRINGE LESCOL 20 MG CAPSULE LESCOL 40 MG CAPSULE LESCOL XL 80 MG TABLET LIPITOR 10 MG TABLET LIPITOR 20 MG TABLET LIPITOR 40 MG TABLET LIPITOR 80 MG TABLET LIPOFEN 150 MG CAPSULE LIPOFEN 50 MG CAPSULE LIPTRUZET 10-20 MG TABLET LIPTRUZET 10-40 MG TABLET LIPTRUZET 10-80 MG TABLET LIVALO 1 MG TABLET LIVALO 2 MG TABLET LIVALO 4 MG TABLET LOFIBRA 134 MG CAPSULE LOFIBRA 160 MG TABLET LOFIBRA 200 MG CAPSULE LOFIBRA 54 MG TABLET LOFIBRA 67 MG CAPSULE LOPID 600 MG TABLET LOVASTATIN 10 MG TABLET LOVASTATIN 20 MG TABLET LOVASTATIN 40 MG TABLET LOVAZA 1 GM CAPSULE MEVACOR 20 MG TABLET MEVACOR 40 MG TABLET NIACIN ER 1,000 MG TABLET NIACIN ER 500 MG TABLET NIACIN ER 750 MG TABLET NIACOR 500 MG TABLET NIASPAN ER 1,000 MG TABLET NIASPAN ER 500 MG TABLET NIASPAN ER 750 MG TABLET OMEGA-3 ETHYL ESTERS 1 GM CAP PRALUENT 150 MG/ML PEN

NC NC NC NC NC NC NC NC NC NC NC NC NC 4 4 4 NC NC NC NC NC NC 1 1 1 NC NC NC 2 2 2 2 NC NC NC 2 5

PRALUENT 150 MG/ML SYRINGE

5

PRALUENT 75 MG/ML PEN

5

PRALUENT 75 MG/ML SYRINGE

5

PRAVACHOL 20 MG TABLET PRAVACHOL 40 MG TABLET PRAVACHOL 80 MG TABLET PRAVASTATIN SODIUM 10 MG TAB PRAVASTATIN SODIUM 20 MG TAB PRAVASTATIN SODIUM 40 MG TAB PRAVASTATIN SODIUM 80 MG TAB PREVALITE PACKET QUESTRAN LIGHT POWDER QUESTRAN PACKET REPATHA 140 MG/ML SURECLICK

NC NC NC 2 2 2 2 2 NC NC 4

REPATHA 140 MG/ML SYRINGE

4

REPATHA 420 MG/3.5ML PUSHTRONX

4

ROSUVASTATIN CALCIUM 10 MG TAB

3

VALUE FORMULARY FIVE-TIER DRUG LIST

LIMITATIONS/ * NOTES

HSA* HSA* HSA*

HSA* HSA* HSA*

HSA* HSA* HSA* HSA*

HSA* Prior Authorization required;Max. 2 ML(s) per 28 days SPP*: Must use Walgreens Specialty Prior Authorization required;Max. 2 ML(s) per 28 days SPP*: Must use Walgreens Specialty Prior Authorization required;Max. 2 ML(s) per 28 days SPP*: Must use Walgreens Specialty Prior Authorization required;Max. 2 ML(s) per 28 days SPP*: Must use Walgreens Specialty

HSA* HSA* HSA* HSA* HSA*

Prior Authorization required;Max. 2 ML(s) per 28 days SPP*: Must use Walgreens Specialty Prior Authorization required;Max. 2 ML(s) per 28 days SPP*: Must use Walgreens Specialty Prior Authorization required;Max. 3.5 ML(s) per 30 days SPP*: Must use Walgreens Specialty HSA*

Last Updated: 01/17/2017

Page 77

ROSUVASTATIN CALCIUM 20 MG TAB ROSUVASTATIN CALCIUM 40 MG TAB ROSUVASTATIN CALCIUM 5 MG TAB SIMCOR 1,000-20 MG TABLET SIMCOR 1,000-40 MG TABLET SIMCOR 500-20 MG TABLET SIMCOR 500-40 MG TABLET SIMCOR 750-20 MG TABLET SIMVASTATIN 10 MG TABLET SIMVASTATIN 20 MG TABLET SIMVASTATIN 40 MG TABLET SIMVASTATIN 5 MG TABLET SIMVASTATIN 80 MG TABLET TRICOR 145 MG TABLET TRICOR 48 MG TABLET TRIGLIDE 160 MG TABLET TRIGLIDE 50 MG TABLET TRILIPIX DR 135 MG CAPSULE TRILIPIX DR 45 MG CAPSULE VASCAZEN CAPSULE VASCEPA 0.5 GM CAPSULE VASCEPA 1 GM CAPSULE VYTORIN 10-10 MG TABLET

3 3 3 3 3 3 3 3 1 1 1 1 1 NC NC 4 4 NC NC NC 3 3 4

VYTORIN 10-20 MG TABLET

4

VYTORIN 10-40 MG TABLET

4

VYTORIN 10-80 MG TABLET

4

WELCHOL 3.75G PACKET WELCHOL 625 MG TABLET ZETIA 10 MG TABLET

3 3 4

ZOCOR 10 MG TABLET ZOCOR 20 MG TABLET ZOCOR 40 MG TABLET ZOCOR 5 MG TABLET ZOCOR 80 MG TABLET

NC NC NC NC NC

HSA* HSA* HSA* HSA* HSA* HSA* HSA* HSA* HSA* HSA* HSA* HSA* HSA*

HSA* HSA*

HSA* HSA* Max. 1 per day HSA* Max. 1 per day HSA* Max. 1 per day HSA* Max. 1 per day HSA* HSA* HSA* Max. 1 per day HSA*

RENIN-ANGIOTENSIN-ALDOSTERONE SYSTEM INHIBITORS AMTURNIDE 150-5-12.5 MG TAB AMTURNIDE 300-10-12.5 MG TAB AMTURNIDE 300-10-25 MG TAB AMTURNIDE 300-5-12.5 MG TAB AMTURNIDE 300-5-25 MG TAB EPLERENONE 25 MG TABLET EPLERENONE 50 MG TABLET INSPRA 25 MG TABLET INSPRA 50 MG TABLET TEKAMLO 150 MG-10 MG TABLET

NC NC NC NC NC 2 2 NC NC 4

TEKAMLO 150 MG-5 MG TABLET

4

TEKAMLO 300 MG-10 MG TABLET

4

TEKAMLO 300 MG-5 MG TABLET

4

TEKTURNA 150 MG TABLET

4

TEKTURNA 300 MG TABLET

4

VALUE FORMULARY FIVE-TIER DRUG LIST

HSA* HSA*

Max. 1.5 per day HSA* Max. 1.5 per day HSA* Max. 1 per day HSA* Max. 1 per day HSA* Max. 1.5 per day HSA* Max. 1 per day HSA*

Last Updated: 01/17/2017

Page 78

DRUG NAME

TIER

LIMITATIONS/ * NOTES

TEKTURNA HCT 150-12.5 MG TAB

4

TEKTURNA HCT 150-25 MG TABLET

4

TEKTURNA HCT 300-12.5 MG TAB

4

TEKTURNA HCT 300-25 MG TABLET

4

Max. 30 in 30 days HSA* Max. 30 in 30 days HSA* Max. 30 in 30 days HSA* Max. 30 in 30 days HSA*

VASODILATORS AMYL NITRITE AMPUL BIDIL TABLET DILATRATE-SR 40 MG CAPSULE GONITRO 0.4 MG SUBLINGUAL PWD IMDUR ER 120 MG TABLET IMDUR ER 30 MG TABLET IMDUR ER 60 MG TABLET ISOCHRON 40 MG TABLET SA ISORDIL 40 MG TABLET ISORDIL TITRADOSE 5 MG TAB ISOSORBIDE DN 10 MG TABLET ISOSORBIDE DN 2.5 MG TAB SL ISOSORBIDE DN 20 MG TABLET ISOSORBIDE DN 30 MG TABLET ISOSORBIDE DN 5 MG TABLET ISOSORBIDE DN 5 MG TABLET SL ISOSORBIDE DN ER 40 MG TABLET ISOSORBIDE MN 10 MG TABLET ISOSORBIDE MN 20 MG TABLET ISOSORBIDE MN ER 120 MG TAB ISOSORBIDE MN ER 30 MG TABLET ISOSORBIDE MN ER 60 MG TABLET MINITRAN 0.1 MG/HR PATCH

2 3 4 NC NC NC NC NC 4 NC 2 2 2 2 2 1 2 2 2 2 2 2 4

MINITRAN 0.2 MG/HR PATCH

4

MINITRAN 0.4 MG/HR PATCH

4

MINITRAN 0.6 MG/HR PATCH

4

MINOXIDIL 10 MG TABLET MINOXIDIL 2.5 MG TABLET NITRO-BID 2% OINTMENT NITRO-DUR 0.1 MG/HR PATCH NITRO-DUR 0.2 MG/HR PATCH NITRO-DUR 0.3 MG/HR PATCH NITRO-DUR 0.4 MG/HR PATCH NITRO-DUR 0.6 MG/HR PATCH NITRO-DUR 0.8 MG/HR PATCH NITROGLYCERIN 0.1 MG/HR PATCH NITROGLYCERIN 0.2 MG/HR PATCH NITROGLYCERIN 0.3 MG TABLET SL NITROGLYCERIN 0.4 MG TABLET SL NITROGLYCERIN 0.4 MG/HR PATCH NITROGLYCERIN 0.6 MG TABLET SL NITROGLYCERIN 0.6 MG/HR PATCH NITROGLYCERIN ER 2.5 MG CAP NITROGLYCERIN ER 6.5 MG CAP NITROGLYCERIN ER 9 MG CAPSULE NITROGLYCERIN LINGUAL 0.4 MG

2 2 3 NC NC 4 NC NC 4 2 2 3 3 2 3 2 2 2 2 2

VALUE FORMULARY FIVE-TIER DRUG LIST

Prior Authorization required HSA* Prior Authorization required HSA* Prior Authorization required HSA* Prior Authorization required HSA* HSA* HSA* HSA*

HSA*

HSA* HSA* HSA* HSA* HSA* HSA* HSA* HSA* HSA* HSA* HSA* HSA*

Last Updated: 01/17/2017

Page 79

DRUG NAME

TIER

NITROLINGUAL 0.4 MG SPRAY NITROMIST 400 MCG SPRAY NITROSTAT 0.3 MG TABLET SL NITROSTAT 0.4 MG TABLET SL NITROSTAT 0.6 MG TABLET SL NYLIDRIN HCL POWDER PRESTALIA 14 MG-10 MG TABLET PRESTALIA 3.5 MG-2.5 MG TABLET PRESTALIA 7 MG-5 MG TABLET PROGLYCEM 50 MG/ML ORAL SUSP

NC NC 4 4 4 NC NC NC NC 4

LIMITATIONS/ * NOTES HSA* HSA* HSA*

HSA*

CENTRAL NERVOUS SYSTEM AGENTS CENTRAL NERVOUS SYSTEM AGENTS ADDERALL 10 MG TABLET ADDERALL 12.5 MG TABLET ADDERALL 15 MG TABLET ADDERALL 20 MG TABLET ADDERALL 30 MG TABLET ADDERALL 5 MG TABLET ADDERALL 7.5 MG TABLET ADDERALL XR 10 MG CAPSULE ADDERALL XR 15 MG CAPSULE ADDERALL XR 20 MG CAPSULE ADDERALL XR 25 MG CAPSULE ADDERALL XR 30 MG CAPSULE ADDERALL XR 5 MG CAPSULE ADDYI 100 MG TABLET ADZENYS XR-ODT 12.5 MG TABLET ADZENYS XR-ODT 15.7 MG TABLET ADZENYS XR-ODT 18.8 MG TABLET ADZENYS XR-ODT 3.1 MG TABLET ADZENYS XR-ODT 6.3 MG TABLET ADZENYS XR-ODT 9.4 MG TABLET AMPYRA ER 10 MG TABLET

NC NC NC NC NC NC NC NC NC NC NC NC NC NC NC NC NC NC NC NC 5

APTENSIO XR 10 MG CAPSULE APTENSIO XR 15 MG CAPSULE APTENSIO XR 20 MG CAPSULE APTENSIO XR 30 MG CAPSULE APTENSIO XR 40 MG CAPSULE APTENSIO XR 50 MG CAPSULE APTENSIO XR 60 MG CAPSULE AUBAGIO 14 MG TABLET

NC NC NC NC NC NC NC 5

AUBAGIO 7 MG TABLET

5

AVONEX 30 MCG VIAL KIT

4

AVONEX PEN 30 MCG/0.5 ML KIT AVONEX PREFILLED SYR 30 MCG KT

4 4

BETASERON 0.3 MG KIT

5

CAFCIT 20 MG/ML ORAL SOLN CAFFEINE CIT 60 MG/3 ML ORAL CLONIDINE HCL ER 0.1 MG TABLET CONCERTA ER 18 MG TABLET CONCERTA ER 27 MG TABLET

NC 2 2 NC NC

VALUE FORMULARY FIVE-TIER DRUG LIST

Max. 2 per day SPP*: Must use Accredo

Max. 1 per day SPP*: Must use Accredo Max. 1 per day SPP*: Must use Accredo Max. 30 Days Supply SPP*: Accredo Max. 30 Days Supply Max. 30 Days Supply SPP*: Accredo Max. 30 Days Supply SPP*: Accredo

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DRUG NAME

TIER

CONCERTA ER 36 MG TABLET CONCERTA ER 54 MG TABLET COPAXONE 20 MG/ML SYRINGE

NC NC 4

COPAXONE 40 MG/ML SYRINGE

4

D-AMPHETAMINE ER 10 MG CAPSULE D-AMPHETAMINE ER 15 MG CAPSULE D-AMPHETAMINE ER 5 MG CAPSULE DAYTRANA 10 MG/9 HR PATCH DAYTRANA 15 MG/9 HR PATCH DAYTRANA 20 MG/9 HOUR PATCH DAYTRANA 30 MG/9 HOUR PATCH DESOXYN 5 MG TABLET DEXEDRINE 10 MG TABLET DEXEDRINE 5 MG TABLET DEXEDRINE SPANSULE 10 MG DEXEDRINE SPANSULE 15 MG DEXEDRINE SPANSULE 5 MG DEXMETHYLPHENIDATE 10 MG TAB DEXMETHYLPHENIDATE 2.5 MG TAB DEXMETHYLPHENIDATE 5 MG TAB DEXMETHYLPHENIDATE ER 10 MG CP DEXMETHYLPHENIDATE ER 15 MG CP DEXMETHYLPHENIDATE ER 20 MG CP DEXMETHYLPHENIDATE ER 25 MG CP DEXMETHYLPHENIDATE ER 30 MG CP DEXMETHYLPHENIDATE ER 35 MG CP DEXMETHYLPHENIDATE ER 40 MG CP DEXMETHYLPHENIDATE ER 5 MG CAP DEXTROAMP-AMPHET ER 10 MG CAP DEXTROAMP-AMPHET ER 15 MG CAP DEXTROAMP-AMPHET ER 20 MG CAP DEXTROAMP-AMPHET ER 25 MG CAP DEXTROAMP-AMPHET ER 30 MG CAP DEXTROAMP-AMPHET ER 5 MG CAP DEXTROAMP-AMPHETAM 12.5 MG TAB DEXTROAMP-AMPHETAM 7.5 MG TAB DEXTROAMP-AMPHETAMIN 10 MG TAB DEXTROAMP-AMPHETAMIN 15 MG TAB DEXTROAMP-AMPHETAMIN 20 MG TAB DEXTROAMP-AMPHETAMIN 30 MG TAB DEXTROAMP-AMPHETAMINE 5 MG TAB DEXTROAMPHETAMINE 10 MG TAB DEXTROAMPHETAMINE 5 MG TAB DEXTROAMPHETAMINE 5 MG/5 ML DYANAVEL XR 2.5 MG/ML SUSP EVEKEO 10 MG TABLET EVEKEO 5 MG TABLET EXTAVIA 0.3 MG KIT FOCALIN 10 MG TABLET FOCALIN 2.5 MG TABLET FOCALIN 5 MG TABLET FOCALIN XR 10 MG CAPSULE FOCALIN XR 15 MG CAPSULE FOCALIN XR 20 MG CAPSULE FOCALIN XR 25 MG CAPSULE FOCALIN XR 30 MG CAPSULE FOCALIN XR 35 MG CAPSULE FOCALIN XR 40 MG CAPSULE

2 2 2 4 4 4 4 NC NC NC NC NC NC 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 NC 4 NC NC NC NC NC NC NC NC 4 NC 4 NC

VALUE FORMULARY FIVE-TIER DRUG LIST

LIMITATIONS/ * NOTES Max. 30 Days Supply SPP*: Accredo Max. 30 Days Supply SPP*: Accredo Max. 60 Days Supply Max. 60 Days Supply Max. 60 Days Supply Max. 60 Days Supply Max. 60 Days Supply Max. 60 Days Supply Max. 60 Days Supply

Max. 60 Days Supply Max. 60 Days Supply Max. 60 Days Supply Max. 60 Days Supply Max. 60 Days Supply Max. 60 Days Supply Max. 60 Days Supply Max. 60 Days Supply Max. 60 Days Supply Max. 60 Days Supply Max. 60 Days Supply Max. 60 Days Supply Max. 60 Days Supply Max. 60 Days Supply Max. 60 Days Supply Max. 60 Days Supply Max. 60 Days Supply Max. 60 Days Supply Max. 60 Days Supply Max. 60 Days Supply Max. 60 Days Supply Max. 60 Days Supply Max. 60 Days Supply Max. 60 Days Supply Max. 60 Days Supply Max. 60 Days Supply Max. 60 Days Supply Max. 60 Days Supply

Max. 60 Days Supply Max. 60 Days Supply

Last Updated: 01/17/2017

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DRUG NAME

TIER

FOCALIN XR 5 MG CAPSULE GILENYA 0.5 MG CAPSULE

NC 4

GLATOPA 20 MG/ML SYRINGE

4

GUANFACINE HCL ER 1 MG TABLET GUANFACINE HCL ER 2 MG TABLET GUANFACINE HCL ER 3 MG TABLET GUANFACINE HCL ER 4 MG TABLET INTUNIV ER 1 MG TABLET INTUNIV ER 2 MG TABLET INTUNIV ER 3 MG TABLET INTUNIV ER 4 MG TABLET KAPVAY 0.1-0.2 MG DOSEPACK KAPVAY ER 0.1 MG TABLET LITHIUM 8 MEQ/5 ML SOLUTION LITHIUM CARBONATE 150 MG CAP LITHIUM CARBONATE 300 MG CAP LITHIUM CARBONATE 300 MG TAB LITHIUM CARBONATE 600 MG CAP LITHIUM CARBONATE ER 300 MG TB LITHIUM CARBONATE ER 450 MG TB LITHOBID ER 300 MG TABLET METADATE CD 10 MG CAPSULE METADATE CD 20 MG CAPSULE METADATE CD 30 MG CAPSULE METADATE CD 40 MG CAPSULE METADATE CD 50 MG CAPSULE METADATE CD 60 MG CAPSULE METADATE ER 20 MG TABLET METHAMPHETAMINE 5 MG TABLET METHYLIN 10 MG CHEWABLE TABLET METHYLIN 10 MG/5 ML SOLUTION METHYLIN 2.5 MG CHEWABLE TAB METHYLIN 5 MG CHEWABLE TABLET METHYLIN 5 MG/5 ML SOLUTION METHYLPHENIDATE 10 MG CHEW TAB METHYLPHENIDATE 10 MG TABLET METHYLPHENIDATE 10 MG/5 ML SOL METHYLPHENIDATE 2.5 MG CHEW TB METHYLPHENIDATE 20 MG TABLET METHYLPHENIDATE 5 MG CHEW TAB METHYLPHENIDATE 5 MG TABLET METHYLPHENIDATE 5 MG/5 ML SOLN METHYLPHENIDATE CD 10 MG CAP METHYLPHENIDATE CD 20 MG CAP METHYLPHENIDATE CD 30 MG CAP METHYLPHENIDATE CD 40 MG CAP METHYLPHENIDATE CD 50 MG CAP METHYLPHENIDATE CD 60 MG CAP METHYLPHENIDATE ER 10 MG TAB METHYLPHENIDATE ER 18 MG TAB METHYLPHENIDATE ER 20 MG TAB METHYLPHENIDATE ER 27 MG TAB METHYLPHENIDATE ER 36 MG TAB METHYLPHENIDATE ER 54 MG TAB NUEDEXTA 20-10 MG CAPSULE PLEGRIDY 125 MCG/0.5 ML PEN

2 2 2 2 NC NC NC NC NC NC 2 1 1 2 2 2 2 NC NC NC NC NC NC NC 2 2 NC NC NC NC NC 2 2 1 2 2 2 2 1 2 2 2 2 2 2 2 2 2 2 2 2 4 5

VALUE FORMULARY FIVE-TIER DRUG LIST

LIMITATIONS/ * NOTES Max. 1 per day SPP*: Must use Accredo Max. 30 Days Supply SPP*: Accredo

Max. 60 Days Supply Max. 60 Days Supply

Max. 60 Days Supply Max. 60 Days Supply Max. 60 Days Supply Max. 60 Days Supply Max. 60 Days Supply Max. 60 Days Supply Max. 60 Days Supply Max. 60 Days Supply Max. 60 Days Supply Max. 60 Days Supply Max. 60 Days Supply Max. 60 Days Supply Max. 60 Days Supply Max. 60 Days Supply Max. 60 Days Supply Max. 60 Days Supply Max. 60 Days Supply Max. 60 Days Supply Max. 60 Days Supply Max. 60 Days Supply Prior Authorization required;Max. 2 ML(s) per 28 days SPP*: Must use Accredo

Last Updated: 01/17/2017

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DRUG NAME

TIER

LIMITATIONS/ * NOTES

PLEGRIDY 125 MCG/0.5 ML SYRING

5

PLEGRIDY PEN INJ STARTER PACK

5

PLEGRIDY SYRINGE STARTER PACK

5

Prior Authorization required;Max. 2 ML(s) per 28 days SPP*: Must use Accredo Prior Authorization required;Max. 2 ML(s) per 28 days SPP*: Must use Accredo Prior Authorization required;Max. 2 ML(s) per 28 days SPP*: Must use Accredo

PROCENTRA 5 MG/5 ML SOLUTION QUILLICHEW ER 20 MG CHEW TAB QUILLICHEW ER 30 MG CHEW TAB QUILLICHEW ER 40 MG CHEW TAB QUILLIVANT XR 25 MG/5 ML SUSP REBIF 22 MCG/0.5 ML SYRINGE

NC NC NC NC 4 5

REBIF 44 MCG/0.5 ML SYRINGE

5

REBIF REBIDOSE 22 MCG/0.5 ML

5

REBIF REBIDOSE 44 MCG/0.5 ML

5

REBIF REBIDOSE TITRATION PACK

5

REBIF TITRATION PACK

5

RILUTEK 50 MG TABLET RILUZOLE 50 MG TABLET RITALIN 10 MG TABLET RITALIN 20 MG TABLET RITALIN 5 MG TABLET RITALIN LA 10 MG CAPSULE RITALIN LA 20 MG CAPSULE RITALIN LA 30 MG CAPSULE RITALIN LA 40 MG CAPSULE RITALIN LA 60 MG CAPSULE RITALIN SR 20 MG TABLET SAVELLA 100 MG TABLET

NC 2 NC NC NC 4 NC NC NC 4 4 3

SAVELLA 12.5 MG TABLET

3

SAVELLA 25 MG TABLET

3

SAVELLA 50 MG TABLET

3

SAVELLA TITRATION PACK

3

STRATTERA 10 MG CAPSULE STRATTERA 100 MG CAPSULE STRATTERA 18 MG CAPSULE STRATTERA 25 MG CAPSULE STRATTERA 40 MG CAPSULE STRATTERA 60 MG CAPSULE STRATTERA 80 MG CAPSULE TECFIDERA DR 120 MG CAPSULE TECFIDERA DR 240 MG CAPSULE TECFIDERA STARTER PACK TETRABENAZINE 12.5 MG TABLET TETRABENAZINE 25 MG TABLET VYVANSE 10 MG CAPSULE VYVANSE 20 MG CAPSULE VYVANSE 30 MG CAPSULE VYVANSE 40 MG CAPSULE

3 3 3 3 3 3 3 4 4 4 2 2 3 3 3 3

VALUE FORMULARY FIVE-TIER DRUG LIST

Max. 60 Days Supply Max. 30 Days Supply SPP*: Accredo Max. 30 Days Supply SPP*: Accredo Max. 30 Days Supply SPP*: Accredo Max. 30 Days Supply SPP*: Accredo Max. 30 Days Supply SPP*: Accredo Max. 30 Days Supply SPP*: Accredo

Max. 60 Days Supply

Max. 60 Days Supply Max. 60 Days Supply Not covered for members 18 and older;Step Therapy required STA*: 18 and older Not covered for members 18 and older;Step Therapy required STA*: 18 and older Not covered for members 18 and older;Step Therapy required STA*: 18 and older Not covered for members 18 and older;Step Therapy required STA*: 18 and older Not covered for members 18 and older;Step Therapy required STA*: 18 and older Max. 60 Days Supply Max. 60 Days Supply Max. 60 Days Supply Max. 60 Days Supply Max. 60 Days Supply Max. 60 Days Supply Max. 60 Days Supply SPP*: Must use Accredo SPP*: Must use Accredo SPP*: Must use Accredo SPP*: Accredo SPP*: Accredo Max. 60 Days Supply Max. 60 Days Supply Max. 60 Days Supply Max. 60 Days Supply

Last Updated: 01/17/2017

Page 83

DRUG NAME

TIER

LIMITATIONS/ * NOTES

VYVANSE 50 MG CAPSULE VYVANSE 60 MG CAPSULE VYVANSE 70 MG CAPSULE XENAZINE 12.5 MG TABLET XENAZINE 25 MG TABLET ZENZEDI 10 MG TABLET ZENZEDI 15 MG TABLET ZENZEDI 2.5 MG TABLET ZENZEDI 20 MG TABLET ZENZEDI 30 MG TABLET ZENZEDI 5 MG TABLET ZENZEDI 7.5 MG TABLET ZINBRYTA 150 MG/ML SYRINGE

3 3 3 NC NC 2 4 4 4 4 2 4 NC

Max. 60 Days Supply Max. 60 Days Supply Max. 60 Days Supply

Max. 60 Days Supply Max. 60 Days Supply Max. 60 Days Supply Max. 60 Days Supply Max. 60 Days Supply Max. 60 Days Supply Max. 60 Days Supply

CONTRACEPTIVES CONTRACEPTIVES AFTERA 1.5 MG TABLET ALTAVERA-28 TABLET ALYACEN 1-35-28 TABLET ALYACEN 7-7-7-28 TABLET AMETHIA 0.15-0.03-0.01 MG TAB

NC 0 0 0 0

AMETHIA LO TABLET

0

AMETHYST 90-20 MCG TABLET APRI 28 DAY TABLET ARANELLE 28 TABLET ASHLYNA 0.15-0.03-0.01 MG TAB

NC 0 0 0

AUBRA-28 TABLET AVIANE-28 TABLET AZURETTE 28 DAY TABLET BALZIVA 28 TABLET BEKYREE 28 DAY TABLET BEYAZ 28 TABLET BLISOVI 24 FE TABLET BLISOVI FE 1-20 TABLET BLISOVI FE 1.5-30 TABLET BREVICON 28 TABLET BRIELLYN TABLET CAMILA 0.35 MG TABLET CAMRESE 0.15-0.03-0.01 MG TAB

0 0 0 0 0 4 0 0 0 0 0 0 0

CAMRESE LO TABLET

0

CAYA CONTOURED DIAPHRAGM CAZIANT 28 DAY TABLET CHATEAL-28 TABLET CONCEPTROL GEL CRYSELLE-28 TABLET CYCLAFEM 1-35-28 TABLET CYCLAFEM 7-7-7-28 TABLET CYCLESSA 28 DAY TABLET CYRED 28 DAY TABLET DASETTA 1-35-28 TABLET DASETTA 7/7/7-28 TABLET DAYSEE 0.15-0.03-0.01 MG TAB

0 0 0 0 0 0 0 NC 0 0 0 0

VALUE FORMULARY FIVE-TIER DRUG LIST

ACA* ACA* ACA* Max. 91 Days Supply;Max. 1 per day ACA* Max. 91 Days Supply;Max. 1 per day ACA* ACA* ACA* Max. 91 Days Supply;Max. 1 per day ACA* ACA* ACA* ACA* ACA* ACA* ACA* ACA* ACA* ACA* ACA* ACA* Max. 91 Days Supply;Max. 1 per day ACA* Max. 91 Days Supply;Max. 1 per day ACA* ACA* ACA* ACA* ACA* ACA* ACA* ACA* ACA* ACA* ACA* Max. 91 Days Supply;Max. 1 per day ACA*

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DRUG NAME

TIER

LIMITATIONS/ * NOTES

DEBLITANE 0.35 MG TABLET DELYLA-28 TABLET DEMULEN 1-50-21 TABLET DESOGEN 28 DAY TABLET DESOGESTR-ETH ESTRAD ETH ESTRA DESOGESTREL-ETHINYL ESTRAD TAB DROSP-EE-LEVOMEF 3-0.02-0.451 DROSPIRENONE-EE 3-0.02 MG TAB DROSPIRENONE-EE 3-0.03 MG TAB ECONTRA EZ 1.5 MG TABLET

0 0 NC NC 0 0 0 0 0 0

ACA* ACA*

ELINEST-28 TABLET ELLA 30 MG TABLET

0 0

EMOQUETTE 28 DAY TABLET ENPRESSE-28 TABLET ENSKYCE 28 TABLET ERRIN 0.35 MG TABLET ESTARYLLA 0.25-0.035 MG TABLET ESTROSTEP FE-28 TABLET ETHYNODIOL-ETH ESTRA 1MG-50MCG FALLBACK SOLO 1.5 MG TABLET

0 0 0 0 0 NC 0 0

FALMINA-28 TABLET FC2 FEMALE CONDOM FEMCAP 22 MM CERVICAL CAP FEMCAP 26 MM CERVICAL CAP FEMCAP 30 MM CERVICAL CAP FEMCON FE CHEWABLE TABLET FEMYNOR 28 TABLET GENERESS FE CHEWABLE TABLET GIANVI 3 MG-0.02 MG TABLET GILDAGIA 0.4 MG-0.035 MG TAB GILDESS 1 MG-20 MCG TABLET GILDESS 1.5 MG-30 MCG TABLET GILDESS 24 FE 1-0.02 MG TABLET GILDESS FE 1-20 TABLET GILDESS FE 1.5-30 TABLET GYNOL II 3% GEL HEATHER TABLET IMPLANON 68 MG IMPLANT INTROVALE 0.15-0.03 MG TABLET

0 0 0 0 0 NC 0 NC 0 0 0 0 0 0 0 0 0 MD 0

JENCYCLA 0.35 MG TABLET JOLESSA 0.15 MG-0.03 MG TABLET

0 0

JOLIVETTE TABLET JULEBER 28 DAY TABLET JUNEL 1 MG-20 MCG TABLET JUNEL 1.5 MG-30 MCG TABLET JUNEL FE 1 MG-20 MCG TABLET JUNEL FE 1.5 MG-30 MCG TABLET JUNEL FE 24 TABLET KAITLIB FE CHEWABLE TABLET KARIVA 28 DAY TABLET KELNOR 1-35 28 TABLET KIMIDESS 28 DAY TABLET KURVELO TABLET LARIN 1.5 MG-30 MCG TABLET LARIN 21 1-20 TABLET LARIN 24 FE 1 MG-20 MCG TABLET

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

VALUE FORMULARY FIVE-TIER DRUG LIST

ACA* ACA* ACA* ACA* ACA* Max. quantity of 1 per fill ACA* ACA* Max. quantity of 1 per fill ACA* ACA* ACA* ACA* ACA* ACA*

Max. quantity of 1 per fill ACA* ACA* ACA* ACA* ACA* ACA* ACA* ACA* ACA* ACA* ACA* ACA* ACA* ACA* ACA* ACA* SPP*: Must use Accredo Max. 91 Days Supply;Max. 1 per day ACA* ACA* Max. 91 Days Supply;Max. 1 per day ACA* ACA* ACA* ACA* ACA* ACA* ACA* ACA* ACA* ACA* ACA* ACA* ACA* ACA* ACA* ACA*

Last Updated: 01/17/2017

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DRUG NAME

TIER

LIMITATIONS/ * NOTES

LARIN FE 1-20 TABLET LARIN FE 1.5-30 TABLET LARISSIA-28 TABLET LAYOLIS FE CHEWABLE TABLET LEENA 28 TABLET LESSINA-28 TABLET LEVONEST-28 TABLET LEVONO-E ESTRAD 0.10-0.02-0.01

0 0 0 0 0 0 0 0

LEVONO-E ESTRAD 0.15-0.03-0.01

0

LEVONOR-ETH ESTRA 0.09-0.02 MG LEVONOR-ETH ESTRAD 0.1-0.02 MG LEVONOR-ETH ESTRAD 0.15-0.03

0 0 0

LEVONOR-ETH ESTRAD TRIPHASIC

0

LEVONORGESTREL 0.75 MG TABLET

0

LEVONORGESTREL 1.5 MG TABLET

0

LEVORA-28 TABLET LO LOESTRIN FE 1-10 TABLET LOESTRIN 21 1-20 TABLET LOESTRIN 21 1.5-30 TABLET LOESTRIN 24 FE TABLET LOESTRIN FE 1-20 TABLET LOESTRIN FE 1.5-30 TABLET LOMEDIA 24 FE 1 MG-20 MCG TAB LORYNA 3 MG-0.02 MG TABLET LOSEASONIQUE TABLET LOW-OGESTREL-28 TABLET LUTERA-28 TABLET LYZA 0.35 MG TABLET MARLISSA-28 TABLET MICROGESTIN 21 1-20 TABLET MICROGESTIN 21 1.5-30 TAB MICROGESTIN 24 FE 1 MG-20 MCG MICROGESTIN FE 1-20 TABLET MICROGESTIN FE 1.5-30 TAB MINASTRIN 24 FE CHEWABLE TAB MIRCETTE 28 DAY TABLET MODICON 28 TABLET MONO-LINYAH 28 TABLET MONONESSA 28 TABLET MY WAY 1.5 MG TABLET

0 0 NC NC NC NC NC 0 0 NC 0 0 0 0 0 0 NC 0 0 NC NC NC 0 0 0

ACA* ACA* ACA* ACA* ACA* ACA* ACA* Max. 91 Days Supply;Max. 1 per day ACA* Max. 91 Days Supply;Max. 1 per day ACA* ACA* ACA* Max. 91 Days Supply;Max. 1 per day ACA* Max. 91 Days Supply ACA* Max. quantity of 1 per fill ACA* Max. quantity of 1 per fill ACA* ACA* ACA*

MYZILRA-28 TABLET NATAZIA 28 TABLET NECON 0.5-35-28 TABLET NECON 1-35-28 TABLET NECON 1-50-28 TABLET NECON 10-11-28 TABLET NECON 7-7-7-28 TABLET NEXPLANON 68 MG IMPLANT NEXT CHOICE 0.75 MG TABLET

0 0 0 0 0 0 0 MD 0

NEXT CHOICE ONE DOSE 1.5 MG TB

0

NIKKI 3 MG-0.02 MG TABLET NOR-Q-D TABLET NORA-BE TABLET

0 NC 0

VALUE FORMULARY FIVE-TIER DRUG LIST

ACA* ACA* ACA* ACA* ACA* ACA* ACA* ACA* ACA* ACA*

ACA* ACA* Max. quantity of 1 per fill ACA* ACA* ACA* ACA* ACA* ACA* ACA* ACA* SPP*: Must use Accredo Max. quantity of 1 per fill ACA* Max. quantity of 1 per fill ACA* ACA* ACA*

Last Updated: 01/17/2017

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DRUG NAME

TIER

NORDETTE-28 TABLET NORET-ESTR-FE 0.4-0.035(21)-75 NORETH-ESTRAD-FE 1-0.02(24)-75 NORETHIN-ESTRA-FE 0.8-0.025 MG NORETHIND-ETH ESTRAD 1-0.02 MG NORETHINDRONE 0.35 MG TABLET NORG-EE 0.18-0.215-0.25/0.035 NORG-ETHIN ESTRA 0.25-0.035 MG NORINYL 1+35-28 TABLET NORINYL 1+50-28 TABLET NORLYROC 0.35 MG TABLET NORTREL 0.5-35 TABLET NORTREL 1-35 TABLET NORTREL 7-7-7-28 TABLET NUVARING VAGINAL RING OCELLA 3 MG-0.03 MG TABLET OGESTREL TABLET OPCICON ONE-STEP 1.5 MG TABLET

NC 0 0 0 0 0 0 0 0 NC 0 0 0 0 0 0 0 0

ORSYTHIA-28 TABLET ORTHO ALL-FLEX DIAPHRAGM 65MM ORTHO ALL-FLEX DIAPHRAGM 70MM ORTHO ALL-FLEX DIAPHRAGM 75MM ORTHO ALL-FLEX DIAPHRAGM 80MM ORTHO EVRA PATCH ORTHO MICRONOR 0.35 MG TABLET ORTHO TRI-CYCLEN 28 TABLET ORTHO TRI-CYCLEN LO TABLET ORTHO-CEPT 28 DAY TABLET ORTHO-CYCLEN 28 TABLET ORTHO-NOVUM 1-35-28 TABLET ORTHO-NOVUM 7-7-7-28 TABLET OVCON-35 28 TABLET PHILITH 0.4-0.035 MG TABLET PIMTREA 28 DAY TABLET PIRMELLA 1-35-28 TABLET PIRMELLA 7-7-7-28 TABLET PLAN B ONE-STEP 1.5 MG TABLET PORTIA-28 TABLET PREVIFEM TABLET QUARTETTE TABLET

0 0 0 0 0 NC NC NC NC NC NC NC NC NC 0 0 0 0 NC 0 0 0

QUASENSE 0.15-0.03 MG TABLET

0

RAJANI 28 TABLET RECLIPSEN 28 DAY TABLET SAFYRAL TABLET SEASONIQUE 0.15-0.03-0.01 TAB SETLAKIN 0.15 MG-0.03 MG TAB

0 0 0 NC 0

SHAROBEL 0.35 MG TABLET SPRINTEC 28 DAY TABLET SRONYX 0.10-0.02 MG TABLET SYEDA 28 TABLET TAKE ACTION 1.5 MG TABLET TARINA FE 1-20 TABLET TAYTULLA 1 MG-20 MCG CAPSULE TILIA FE 28 TABLET TODAY CONTRACEPTIVE SPONGE TRI-ESTARYLLA TABLET

0 0 0 0 NC 0 0 0 0 0

VALUE FORMULARY FIVE-TIER DRUG LIST

LIMITATIONS/ * NOTES ACA* ACA* ACA* ACA* ACA* ACA* ACA* ACA* ACA* ACA* ACA* ACA* ACA* ACA* ACA* Max. quantity of 1 per fill ACA* ACA* ACA* ACA* ACA* ACA*

ACA* ACA* ACA* ACA* ACA* ACA* Max. 91 Days Supply;Max. 1 per day ACA* Max. 91 Days Supply;Max. 1 per day ACA* ACA* ACA* ACA* Max. 91 Days Supply;Max. 1 per day ACA* ACA* ACA* ACA* ACA* ACA* ACA* ACA* ACA* ACA*

Last Updated: 01/17/2017

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DRUG NAME

TIER

LIMITATIONS/ * NOTES

TRI-LEGEST FE-28 DAY TABLET TRI-LINYAH TABLET TRI-LO-ESTARYLLA TABLET TRI-LO-MARZIA TABLET TRI-LO-SPRINTEC TABLET TRI-NORINYL 28 TABLET TRI-PREVIFEM TABLET TRI-SPRINTEC TABLET TRINESSA LO TABLET TRINESSA TABLET TRIVORA-28 TABLET VCF CONTRACEPTIVE FILM VCF CONTRACEPTIVE FOAM VCF CONTRACEPTIVE GEL VELIVET 28 DAY TABLET VESTURA 3 MG-0.02 MG TABLET VIENVA-28 TABLET VIORELE 28 DAY TABLET VYFEMLA 28 TABLET WERA 0.5/0.035 MG 28 TABLET WIDE SEAL DIAPHRAGM 65MM WYMZYA FE CHEWABLE TABLET XULANE PATCH YASMIN 28 TABLET YAZ 28 TABLET ZARAH TABLET ZENCHENT 0.4 MG-35 MCG TABLET ZENCHENT FE TABLET CHEWABLE ZEOSA CHEWABLE TABLET ZOVIA 1-35E TABLET ZOVIA 1-50E TABLET

0 0 0 0 0 NC 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 NC NC 0 0 0 0 0 0

ACA* ACA* ACA* ACA* ACA* ACA* ACA* ACA* ACA* ACA* ACA* ACA* ACA* ACA* ACA* ACA* ACA* ACA* ACA* ACA* ACA* ACA*

ACA* ACA* ACA* ACA* ACA* ACA*

COUGH AND COLD PRODUCTS COUGH AND COLD PRODUCTS BENZONATATE 100 MG CAPSULE BENZONATATE 150 MG CAPSULE BENZONATATE 200 MG CAPSULE BROMFED DM COUGH SYRUP BROMPHENIR-PSEUDOEPHED-DM SYR CHERATUSSIN AC SYRUP CHERATUSSIN DAC SYRUP COTABFLU TABLET FLOWTUSS 2.5-200 MG/5 ML SOLN G TUSSIN AC LIQUID HYCOFENIX 2.5-30-200 MG/5 ML HYDROCOD-CPM-PSEUDOEP 5-4-60/5 HYDROCOD-HOMATROP 5-1.5 MG TAB HYDROCODONE-CHLORPHEN ER SUSP HYDROCODONE-HOMATROPINE SYRUP HYDROMET SYRUP J-COF DHC LIQUID J-MAX DHC LIQUID LORTUSS EX LIQUID MAXIFLU CD TABLET MAXIFLU CDX TABLET MYTUSSIN DAC SYRUP

VALUE FORMULARY FIVE-TIER DRUG LIST

2 2 2 NC NC 2 NC NC NC 2 NC 2 2 2 2 2 2 2 NC NC NC NC

Last Updated: 01/17/2017

Page 88

DRUG NAME

TIER

OBREDON 2.5-200 MG/5 ML SOLN PHENFLU CD TABLET PHENFLU CDX TABLET PHENYLHISTINE DH LIQUID POLY-TUSSIN AC LIQUID PROMETHAZINE VC-CODEINE SYRUP PROMETHAZINE-CODEINE SYRUP PROMETHAZINE-DM SYRUP REZIRA SOLUTION TESSALON PERLE 100 MG CAP TUSNEL C SYRUP TUSNEL PEDIATRIC LIQUID TUSSICAPS 10 MG-8 MG CAPSULE TUSSICAPS 5 MG-4 MG CAPSULE TUSSIGON 5-1.5 MG TABLET TUSSIONEX PENNKINETIC SUSP TUZISTRA XR 14.7-2.8 MG/5 ML VIRTUSSIN AC LIQUID VIRTUSSIN DAC LIQUID VITUZ SOLUTION ZODRYL AC 25 SUSPENSION ZODRYL AC 30 SUSPENSION ZODRYL AC 35 SUSPENSION ZODRYL AC 40 SUSPENSION ZODRYL AC 50 SUSPENSION ZODRYL AC 60 SUSPENSION ZODRYL AC 80 SUSPENSION ZODRYL DAC 25 SUSPENSION ZODRYL DAC 30 SUSPENSION ZODRYL DAC 35 SUSPENSION ZODRYL DAC 40 SUSPENSION ZODRYL DAC 50 SUSPENSION ZODRYL DAC 60 SUSPENSION ZODRYL DAC 80 SUSPENSION ZODRYL DEC 25 SUSPENSION ZODRYL DEC 30 SUSPENSION ZODRYL DEC 35 SUSPENSION ZODRYL DEC 40 SUSPENSION ZODRYL DEC 50 SUSPENSION ZODRYL DEC 60 SUSPENSION ZODRYL DEC 80 SUSPENSION ZONATUSS 150 MG CAPSULE ZUTRIPRO SOLUTION

NC NC NC NC NC 2 2 1 NC NC NC NC NC NC NC NC 5 2 NC NC NC NC NC NC NC NC NC NC NC NC NC NC NC NC NC NC NC NC NC NC NC NC NC

LIMITATIONS/ * NOTES

Prior Authorization required

DENTAL AND ORAL AGENTS DENTAL AND ORAL AGENTS CAPHOSOL SOLUTION CEVIMELINE HCL 30 MG CAPSULE CHLORHEXIDINE 0.12% RINSE CLINPRO 5000 1.1% TOOTHPASTE DEBACTEROL SWABSTICK DENTA 5000 PLUS CREAM DENTAGEL 1.1% GEL EVOXAC 30 MG CAPSULE FIRST-MOUTHWASH BLM SUSPENSION FLUORIDEX DEFENSE 1.1% GEL

VALUE FORMULARY FIVE-TIER DRUG LIST

4 2 2 NC 4 1 1 NC 3 2

SPP*: Accredo

Last Updated: 01/17/2017

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DRUG NAME

TIER

FLUORIDEX SENSITIVITY RLF GEL GELCLAIR ORAL GEL PACKET GELX ORAL GEL NAFRINSE DAILY-NEUTRAL RINSE NEUTRAL SODIUM FLUORIDE NEUTRASAL 538 MG POWDER PACKET ORALONE 0.1% PASTE PERIDEX 0.12% ORAL RINSE PERIOGARD 0.12% ORAL RINSE PHOS-FLUR 1.1% GEL PILOCARPINE HCL 5 MG TABLET PILOCARPINE HCL 7.5 MG TABLET PREVIDENT 5000 BOOSTER PLUS PREVIDENT 5000 SENSITIVE PASTE PREVIDENT DENTAL RINSE SALAGEN 5 MG TABLET SALAGEN 7.5 MG TABLET SALIVAMAX POWDER PACKET SF 5000 PLUS CREAM STANNOUS FLUOR 0.63% RINSE TRIAMCINOLONE 0.1% PASTE

NC NC NC NC 2 NC 2 NC 1 NC 2 2 NC NC NC NC NC NC 1 2 2

LIMITATIONS/ * NOTES

ACA*: Children through age 5; HSA

DERMATOLOGICAL AGENTS DERMATOLOGICAL AGENTS, OTHER 8-MOP 10 MG CAPSULE ABSORICA 10 MG CAPSULE ABSORICA 20 MG CAPSULE ABSORICA 25 MG CAPSULE ABSORICA 30 MG CAPSULE ABSORICA 35 MG CAPSULE ABSORICA 40 MG CAPSULE ACITRETIN 10 MG CAPSULE ACITRETIN 17.5 MG CAPSULE ACITRETIN 25 MG CAPSULE ACYCLOVIR 5% OINTMENT ACZONE 5% GEL ACZONE 7.5% GEL PUMP ALDARA 5% CREAM ALEVICYN ANTIPRURITIC SG GEL ALUMINUM MONOSTEARATE POWD ALUVEA 39% CREAM AMMONIUM LACTATE 12% CREAM AMMONIUM LACTATE 12% LOTION AMNESTEEM 10 MG CAPSULE AMNESTEEM 20 MG CAPSULE AMNESTEEM 40 MG CAPSULE ANACAINE OINTMENT ATOPICLAIR CREAM AVAR CLEANSER AVAR LS 10%-2% FOAM AVAR LS CLEANSER AVAR-E EMOLLIENT CREAM AVAR-E LS CREAM AZELEX 20% CREAM BENSAL HP 3% OINTMENT BENZAC AC 5% GEL

VALUE FORMULARY FIVE-TIER DRUG LIST

4 NC NC NC NC NC NC 2 2 2 2 4 4 NC NC NC NC 2 2 2 2 2 NC NC NC NC NC NC NC 4 NC NC

Max. 15 GM(s) in 30 days

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BENZAC AC WASH 10% LIQUID BENZOIN TINCTURE BP CLEANSING WASH BP-50% UREA EMULSION BPO 4% GEL BPO 8% GEL CALCIPOTRIENE 0.005% CREAM CALCIPOTRIENE 0.005% OINTMENT CALCIPOTRIENE 0.005% SOLUTION CALCIPOTRIENE-BETAMETH DP OINT CALCITRENE 0.005% OINTMENT CALCITRIOL 3 MCG/G OINTMENT CARAC 0.5% CREAM CELACYN GEL CETACAINE ANESTHETIC LIQUID CETACAINE SPRAY CHLORHEXIDINE GLUC 20% SOLN CLARAVIS 10 MG CAPSULE CLARAVIS 20 MG CAPSULE CLARAVIS 30 MG CAPSULE CLARAVIS 40 MG CAPSULE CLARIS CLARIFYING WASH CONDYLOX 0.5% GEL CONDYLOX 0.5% TOPICAL SOLN COSENTYX 300 MG DOSE-2 PENS

NC NC 4 NC 2 2 4 4 4 4 4 2 NC NC NC NC NC 2 2 2 2 NC 3 NC 5

COSENTYX 300 MG DOSE-2 SYRINGE

5

DENAVIR 1% CREAM DICLOFENAC SODIUM 3% GEL DOVONEX 0.005% CREAM DOXEPIN 5% CREAM DRITHOCREME HP 1% CREAM DRYSOL DAB-O-MATIC SOLUTION EFUDEX 5% CREAM ENSTILAR 0.005%-0.064% FOAM ETHYL CHLORIDE SPRAY EXODERM LOTION FINACEA 15% FOAM FINACEA 15% GEL FLUOROPLEX 1% CREAM FLUOROURACIL 0.5% CREAM FLUOROURACIL 2% TOPICAL SOLN FLUOROURACIL 5% CREAM FLUOROURACIL 5% TOP SOLUTION FORMADON 10% SOLUTION GORDO-UREA 22% OINTMENT GORDO-UREA 40% OINTMENT GRANULEX SPRAY GUAIACOL LIQUID PURIFIED HYPERCARE 20% SOLUTION IMIQUIMOD 5% CREAM PACKET INOVA 4% EASY PAD INOVA 4-1 EASY PAD INOVA 8% EASY PAD INOVA 8-2 EASY PAD IODOFLEX PAD IODOSORB GEL IV INFUSION CPI KIT KERAFOAM 30% FOAM

4 2 NC 2 3 4 NC NC 2 2 3 3 4 2 2 2 2 NC NC NC 2 NC 2 2 NC NC NC NC NC NC NC NC

VALUE FORMULARY FIVE-TIER DRUG LIST

LIMITATIONS/ * NOTES

Prior Authorization required;Max. 1 ML(s) per 28 days SPP*: Must use Accredo Prior Authorization required;Max. 1 ML(s) per 28 days SPP*: Must use Accredo Max. 5 GM(s) in 30 days Step Therapy required

Step Therapy required Step Therapy required

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KERALYT 6% GEL KERALYT SCALP COMPLETE KIT KEROL 50% SUSPENSION LAC-HYDRIN 12% CREAM LAC-HYDRIN 12% LOTION LACTIC ACID 10% E CREAM LACTIC ACID 10% LOTION LEVULAN KERASTICK MAFENIDE ACETATE 50 GM POWD PK METHOXSALEN 10 MG SOFTGEL MIRVASO 0.33% GEL MYORISAN 10 MG CAPSULE MYORISAN 20 MG CAPSULE MYORISAN 30 MG CAPSULE MYORISAN 40 MG CAPSULE NIVATOPIC PLUS CREAM NORMLGEL AG 0.11% WOUND GEL OVACE PLUS 10% SHAMPOO OVACE PLUS WASH 10% CLNSNG GEL OXALIS OINTMENT OXSORALEN 1% LOTION OXSORALEN-ULTRA 10 MG CAP PAIN EASE SPRAY PANRETIN 0.1% GEL PICATO 0.015% GEL PICATO 0.05% GEL PLEXION 9.8-4.8% CLEANSER PODOCON-25 LIQUID PODOFILOX 0.5% TOPICAL SOLN POTASSIUM HYDROXIDE 5% SOLN PR CREAM KIT PRASCION RA CREAM PRUCLAIR NONSTEROIDAL CREAM PRUDOXIN 5% CREAM PYROGALLIC ACID 25% OINTMENT RADIAPLEXRX GEL REA LO 39 CREAM REA LO 40 CREAM REA LO 40 LOTION REGENECARE 2% WOUND GEL REGRANEX 0.01% GEL REMEVEN 50% CREAM RESTIZAN GEL ROSANIL CLEANSER LOTION ROSULA 10%-5% CLOTHS SALACYN 6% CREAM SALACYN 6% LOTION SALEX 6% CREAM KIT SALEX 6% LOTION KIT SALEX 6% SHAMPOO SALICYLIC ACID 26% LIQUID SALICYLIC ACID 27.5% LIQUID SALICYLIC ACID 6% CREAM SALICYLIC ACID 6% CREAM KIT SALICYLIC ACID 6% GEL SALICYLIC ACID 6% SHAMPOO SANTYL OINTMENT SEB-PREV 10% WASH SILVRSTAT DRESSING GEL

NC NC NC NC NC 2 2 NC 2 2 5 2 2 2 2 4 NC NC NC NC 5 NC NC 4 4 4 NC 2 2 2 2 2 2 4 NC NC NC NC NC NC 5 2 NC NC NC NC 2 NC NC NC 2 2 2 NC 2 2 4 2 NC

VALUE FORMULARY FIVE-TIER DRUG LIST

LIMITATIONS/ * NOTES

Prior Authorization required

Max. 30 Days Supply;Step Therapy required Max. 30 Days Supply;Step Therapy required

Limit fills to 3 in 365 days;Max. 15 GM(s) in 30 days

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SOD SULFACE-SULF 9.8-4.8% CLSR SOD SULFACE-SULFUR 10-5% CLOTH SOD SULFACET-SULFUR 10-2% CLSR SOD SULFACETAMIDE 10% SHAMPOO SOD SULFACETAMIDE-SULFUR LOTN SODIUM LAURYL SULFATE CRYST SODIUM SULF-SULFUR CLEANSER SODIUM SULFACETAMIDE 10% WASH SODIUM SULFACETAMIDE MED PADS SOLARAZE 3% GEL SORIATANE 10 MG CAPSULE SORIATANE 17.5 MG CAPSULE SORIATANE 25 MG CAPSULE SORILUX 0.005% FOAM SPRAY AND STRETCH SPRAY SULFACETAMIDE-SULFUR 10-2% CRM SULFACETAMIDE-SULFUR 10-5% CRM SULFAMYLON 8.5% CREAM SULFAMYLON POWDER PACKET SULFUR SUBLIMED POWDER SULFUR SUBLIMED POWDER TACLONEX 0.005%-0.064% SUSPENS TACLONEX OINTMENT TALTZ 80 MG/ML AUTOINJECTOR

2 2 2 2 NC NC 2 2 2 NC NC NC NC NC NC 2 2 4 NC NC NC NC NC 5

TALTZ 80 MG/ML SYRINGE

5

TETRIX CREAM TOLAK 4% CREAM TRI-CHLOR 80% SOLUTION UMECTA 40% EMULSION UMECTA PD 40% EMULSION UREA 39% CREAM UREA 40% CREAM UREA 40% GEL UREA 40% LOTION UREA 50% CREAM VALCHLOR 0.016% GEL

NC NC 2 NC NC 2 2 2 2 2 5

VANOXIDE-HC LOTION VASELINE WHITE PETROLEUM JELLY VASOLEX OINTMENT VECTICAL 3 MCG/G OINTMENT VENELEX OINTMENT VEREGEN 15% OINTMENT VIRASAL ANTIVIRAL WART REMOVER X-VIATE 40% CREAM X-VIATE 40% GEL X-VIATE 40% LOTION XENADERM OINTMENT XERESE 5%-1% CREAM ZENATANE 10 MG CAPSULE ZENATANE 20 MG CAPSULE ZENATANE 30 MG CAPSULE ZENATANE 40 MG CAPSULE ZINC STEARATE POWDER ZONALON 5% CREAM ZOVIRAX 5% CREAM ZOVIRAX 5% OINTMENT ZYCLARA 2.5% CREAM PUMP

NC 2 2 NC NC 3 NC 2 NC 2 NC NC 4 4 4 4 NC NC 4 NC 4

VALUE FORMULARY FIVE-TIER DRUG LIST

LIMITATIONS/ * NOTES

Prior Authorization required;Max. 1 ML(s) per 28 days SPP*: Must use Accredo Prior Authorization required;Max. 1 ML(s) per 28 days SPP*: Must use Accredo

Max. 60 GM(s) in 30 days SPP*: Must use Accredo

Max. 5 GM(s) in 30 days

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ZYCLARA 3.75% CREAM PUMP

4

LIMITATIONS/ * NOTES

DERMATOLOGICAL ANTI-INFLAMMATORY AGENTS ALA-CORT 1% CREAM ALA-CORT 2.5% CREAM ALA-SCALP 2% LOTION ALCLOMETASONE DIPR 0.05% OINT ALCLOMETASONE DIPRO 0.05% CRM AMCINONIDE 0.1% CREAM AMCINONIDE 0.1% LOTION AMCINONIDE 0.1% OINTMENT ANALPRAM HC 1% CREAM ANALPRAM HC 2.5%-1% CREAM ANALPRAM HC 2.5%-1% LOTION ANUCORT-HC 25 MG SUPPOSITORY ANUSOL-HC 2.5% CREAM ANUSOL-HC 25 MG SUPPOSITORY APEXICON E 0.05% CREAM AQUA GLYCOLIC HC 2% KIT BETAMETHASONE DP 0.05% CRM BETAMETHASONE DP 0.05% LOT BETAMETHASONE DP 0.05% OINT BETAMETHASONE DP AUG 0.05% CRM BETAMETHASONE DP AUG 0.05% GEL BETAMETHASONE DP AUG 0.05% LOT BETAMETHASONE DP AUG 0.05% OIN BETAMETHASONE VA 0.1% CREAM BETAMETHASONE VA 0.1% LOTION BETAMETHASONE VALER 0.1% OINTM BETAMETHASONE VALER 0.12% FOAM CAPEX SHAMPOO CLOBETASOL 0.05% CREAM CLOBETASOL 0.05% GEL CLOBETASOL 0.05% OINTMENT CLOBETASOL 0.05% SHAMPOO CLOBETASOL 0.05% SOLUTION CLOBETASOL 0.05% TOPICAL LOTN CLOBETASOL PROP 0.05% FOAM CLOBETASOL PROP 0.05% SPRAY CLOBEX 0.05% SHAMPOO CLOBEX 0.05% SPRAY CLOBEX 0.05% TOPICAL LOTION CLOCORTOLONE PIVALATE 0.1% CRM CLODAN 0.05% KIT CLODAN 0.05% SHAMPOO CLODERM 0.1% CREAM CORDRAN 0.05% CREAM CORDRAN 0.05% LOTION CORDRAN 0.05% OINTMENT CORDRAN 4 MCG/SQ CM TAPE LARGE CORMAX 0.05% SOLUTION CORTIFOAM 10% AEROSOL CUTIVATE 0.05% CREAM CUTIVATE 0.05% LOTION DERMA-SMOOTHE-FS SCALP OIL DERMASORB HC 2% COMPLETE KIT DERMASORB TA 0.1% COMPLETE KIT

VALUE FORMULARY FIVE-TIER DRUG LIST

1 1 2 2 2 2 2 2 NC NC 3 2 NC NC 4 NC 2 2 2 2 2 2 2 2 2 2 2 4 2 2 2 2 2 2 2 2 NC NC NC 2 NC NC NC NC 4 4 4 2 NC NC NC NC NC NC

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DERMATOP 0.1% OINTMENT DERMATOP EMOLLIENT 0.1% CREAM DERMAZENE CREAM DESONATE 0.05% GEL DESONIDE 0.05% CREAM DESONIDE 0.05% LOTION DESONIDE 0.05% OINTMENT DESOWEN 0.05% CREAM DESOWEN 0.05% LOTION DESOXIMETASONE 0.05% CREAM DESOXIMETASONE 0.05% GEL DESOXIMETASONE 0.05% OINTMENT DESOXIMETASONE 0.25% CREAM DESOXIMETASONE 0.25% OINTMENT DIFLORASONE 0.05% CREAM DIFLORASONE 0.05% OINTMENT DIPROLENE 0.05% LOTION DIPROLENE 0.05% OINTMENT DIPROLENE AF 0.05% CREAM ELIDEL 1% CREAM ELOCON 0.1% CREAM ELOCON 0.1% LOTION ELOCON 0.1% OINTMENT EPIFOAM FOAM FIRST HYDROCORT 10% GEL FLUOCINOLONE 0.01% BODY OIL FLUOCINOLONE 0.01% CREAM FLUOCINOLONE 0.01% SOLUTION FLUOCINOLONE 0.025% CREAM FLUOCINOLONE 0.025% OINTMENT FLUOCINONIDE 0.05% CREAM FLUOCINONIDE 0.05% GEL FLUOCINONIDE 0.05% OINTMENT FLUOCINONIDE 0.05% SOLUTION FLUOCINONIDE 0.1% CREAM FLURANDRENOLIDE 0.05% CREAM FLURANDRENOLIDE 0.05% LOTION FLUTICASONE PROP 0.005% OINT FLUTICASONE PROP 0.05% CREAM FLUTICASONE PROP 0.05% LOTION HALOBETASOL PROP 0.05% CREAM HALOBETASOL PROP 0.05% OINTMNT HALOG 0.1% CREAM HALOG 0.1% OINTMENT HALONATE COMBO PACK HALONATE PAC COMBO PACK HEMMOREX-HC 25 MG SUPPOSITORY HEMMOREX-HC 30 MG SUPPOSITORY HEMRIL-30 30 MG SUPPOSITORY HYDROCORT-PRAMOXINE 1%-1% CRM HYDROCORT-PRAMOXINE 2.5-1% CRM HYDROCORTISONE 1% CREAM HYDROCORTISONE 1% OINTMENT HYDROCORTISONE 2.5% CREAM HYDROCORTISONE 2.5% LOTION HYDROCORTISONE 2.5% OINTMENT HYDROCORTISONE 30 MG SUPP HYDROCORTISONE AC 25 MG SUPP HYDROCORTISONE ACETATE 2% GEL

NC NC 2 4 2 2 2 NC NC 2 2 2 2 2 2 2 NC NC NC 4 NC NC NC NC NC 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 4 4 NC NC NC NC 2 2 2 1 2 1 2 1 2 2 2

VALUE FORMULARY FIVE-TIER DRUG LIST

LIMITATIONS/ * NOTES

Prior Authorization required

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HYDROCORTISONE BUTY 0.1% CREAM HYDROCORTISONE BUTYR 0.1% OINT HYDROCORTISONE BUTYR 0.1% SOLN HYDROCORTISONE VAL 0.2% CREAM HYDROCORTISONE VAL 0.2% OINTMT HYDROCORTISONE-IODOQUINOL CRM HYDROCORTISONE-PRAMOXINE CREAM KENALOG 0.147 MG/GRAM SPRAY LOCOID 0.1% CREAM LOCOID 0.1% LOTION LOCOID 0.1% OINTMENT LOCOID 0.1% SOLUTION LUXIQ 0.12% FOAM MICORT HC 2.5% CREAM MOMETASONE FUROATE 0.1% CREAM MOMETASONE FUROATE 0.1% OINT MOMETASONE FUROATE 0.1% SOLN MOMEXIN COMBO PACK NUCORT LOTION OLUX 0.05% FOAM PANDEL 0.1% CREAM PEDIADERM TA 0.1% KIT PRAMCORT 1% CREAM PRAMOSONE 1% LOTION PRAMOSONE 1%-1% CREAM PRAMOSONE 1%-1% OINTMENT PRAMOSONE 2.5%-1% CREAM PRAMOSONE 2.5%-1% LOTION PRAMOSONE 2.5%-1% OINTMENT PRAMOSONE E 2.5%-1% CREAM PREDNICARBATE 0.1% CREAM PREDNICARBATE 0.1% OINTMENT PROCTO-MED HC 2.5% CREAM PROCTO-PAK 1% CREAM PROCTOCORT 1% CREAM PROCTOCORT 30 MG SUPPOSITORY PROCTOFOAM-HC 1%-1% FOAM PROCTOSOL-HC 2.5% CREAM PROCTOZONE-HC 2.5% CREAM PROCTOZONE-HC 2.5% CREAM PROTOPIC 0.03% OINTMENT PROTOPIC 0.1% OINTMENT PSORCON 0.05% CREAM RECTACORT-HC 25 MG SUPPOSITORY SCALACORT 2% LOTION SERNIVO 0.05% SPRAY SYNALAR 0.01% SOLUTION SYNALAR 0.025% CREAM SYNALAR 0.025% CREAM KIT SYNALAR 0.025% OINTMENT SYNALAR 0.025% OINTMENT KIT SYNALAR TS 0.01% KIT TACROLIMUS 0.03% OINTMENT TACROLIMUS 0.1% OINTMENT TEMOVATE 0.05% CREAM TEMOVATE 0.05% OINTMENT TEXACORT 2.5% SOLUTION TOPICORT 0.05% CREAM TOPICORT 0.05% GEL

2 2 2 2 2 2 2 NC NC NC NC NC NC NC 2 2 2 NC NC NC NC NC NC 3 NC 3 NC 3 NC NC 2 2 2 NC NC NC 3 2 NC 2 NC NC NC NC NC NC NC NC NC NC NC NC 2 2 NC NC 4 NC NC

VALUE FORMULARY FIVE-TIER DRUG LIST

LIMITATIONS/ * NOTES

Prior Authorization required Prior Authorization required

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TOPICORT 0.05% OINTMENT TOPICORT 0.25% CREAM TOPICORT 0.25% OINTMENT TOPICORT 0.25% SPRAY TRIAMCINOLONE 0.025% CREAM TRIAMCINOLONE 0.025% LOTION TRIAMCINOLONE 0.025% OINT TRIAMCINOLONE 0.1% CREAM TRIAMCINOLONE 0.1% LOTION TRIAMCINOLONE 0.1% OINTMENT TRIAMCINOLONE 0.147 MG/G SPRAY TRIAMCINOLONE 0.5% CREAM TRIAMCINOLONE 0.5% OINTMENT TRIANEX 0.05% OINTMENT TRIDERM 0.1% CREAM TRIDESILON 0.05% CREAM U-CORT 1% CREAM ULTRAVATE 0.05% CREAM ULTRAVATE 0.05% LOTION ULTRAVATE 0.05% OINTMENT ULTRAVATE PAC OINTMENT KIT ULTRAVATE X OINTMENT COMBO PAC VANOS 0.1% CREAM VERDESO 0.05% FOAM WESTCORT 0.2% OINTMENT

NC NC NC NC 2 2 2 2 2 2 2 2 2 4 2 2 2 NC NC NC NC NC NC 4 NC

LIMITATIONS/ * NOTES

DERMATOLOGICAL ANTIBACTERIALS ACANYA GEL PUMP AKNE-MYCIN 2% OINTMENT ALTABAX 1% OINTMENT BACTROBAN 2% CREAM BACTROBAN 2% OINTMENT BACTROBAN NASAL 2% OINTMENT BENOXYLDOXY 30 KIT BENOXYLDOXY 60 KIT BENZACLIN GEL 50G PUMP BENZAMYCIN GEL CENTANY 2% OINTMENT CENTANY AT 2% OINTMENT KIT CLEOCIN T 1% GEL CLEOCIN T 1% LOTION CLEOCIN T 1% PLEDGETS CLEOCIN T 1% SOLUTION CLIND PH-BENZOYL PEROX 1.2-5% CLINDA-DERM 1% SOLUTION CLINDA-TRETINOIN 1.2%-0.025% CLINDACIN ETZ 1% PLEDGET CLINDACIN ETZ KIT CLINDAGEL 1% GEL CLINDAMYCIN PH 1% GEL CLINDAMYCIN PH 1% SOLUTION CLINDAMYCIN PHOS 1% PLEDGET CLINDAMYCIN PHOSP 1% LOTION CLINDAMYCIN PHOSPHATE 1% FOAM CLINDAMYCIN-BENZOYL PEROX 1-5% CORTISPORIN CREAM CORTISPORIN OINTMENT

VALUE FORMULARY FIVE-TIER DRUG LIST

NC 4 4 NC NC 4 NC NC NC NC NC NC NC NC NC NC 2 2 NC NC NC NC 2 2 2 2 2 2 4 4

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DUAC 1.2-5% GEL ERY 2% PADS ERYGEL 2% GEL ERYTHROMYCIN 2% GEL ERYTHROMYCIN 2% PLEDGETS ERYTHROMYCIN 2% SOLUTION ERYTHROMYCIN-BENZOYL GEL EVOCLIN 1% FOAM GENTAMICIN 0.1% CREAM GENTAMICIN 0.1% OINTMENT KLARON 10% LOTION METROCREAM 0.75% CREAM METROGEL TOPICAL 1% GEL METROLOTION TOPICAL 0.75% METRONIDAZOLE 0.75% CREAM METRONIDAZOLE 0.75% LOTION METRONIDAZOLE TOPICAL 0.75% GL METRONIDAZOLE TOPICAL 1% GEL MUPIROCIN 2% CREAM MUPIROCIN 2% OINTMENT NEO-SYNALAR 0.5%-0.025% CREAM NEO-SYNALAR 0.5-0.025% CRM KIT NEUAC 1.2-5% KIT NEUAC GEL NORITATE 1% CREAM ONEXTON GEL PUMP PHISOHEX 3% CLEANSER ROSADAN 0.75% CREAM ROSADAN 0.75% CREAM KIT ROSADAN 0.75% GEL SELENIUM SULFIDE 2.25% SHAMPOO SELENIUM SULFIDE 2.5% LOTION SILVADENE 1% CREAM SILVER NITRATE 0.5% SOLN SILVER NITRATE 10% OINTMENT SILVER NITRATE 10% SOLUTION SILVER NITRATE 25% SOLUTION SILVER NITRATE 50% SOLUTION SILVER NITRATE APPLICATOR SILVER SULFADIAZINE 1% CREAM SSD 1% CREAM SULFACETAMIDE SOD 10% TOP SUSP TERSI 2.25% FOAM THERMAZENE 1% CREAM VELTIN 1.2%-0.025% GEL ZIANA GEL

NC 2 NC 2 2 2 2 NC 2 2 NC NC NC NC 2 2 2 2 2 2 5 NC NC 2 NC NC 3 2 NC NC 2 2 NC 2 2 2 2 2 2 2 2 2 NC NC 5 NC

LIMITATIONS/ * NOTES

Prior Authorization required

Prior Authorization required

DERMATOLOGICAL RETINOIDS ADAPALENE 0.1% CREAM ADAPALENE 0.1% GEL ADAPALENE 0.1% LOTION ADAPALENE 0.3% GEL ATRALIN 0.05% GEL AVITA 0.025% CREAM AVITA 0.025% GEL DIFFERIN 0.1% CREAM DIFFERIN 0.1% GEL

VALUE FORMULARY FIVE-TIER DRUG LIST

2 2 2 2 NC 2 2 NC NC

Prior Authorization required for members 30 and older Prior Authorization required for members 30 and older Prior Authorization required for members 30 and older Prior Authorization required for members 30 and older Prior Authorization required for members 30 and older Prior Authorization required for members 30 and older

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DIFFERIN 0.1% LOTION DIFFERIN 0.3% GEL PUMP EPIDUO 0.1-2.5% GEL PUMP EPIDUO FORTE 0.3-2.5% GEL PUMP FABIOR 0.1% FOAM RETIN-A 0.01% GEL RETIN-A 0.025% CREAM RETIN-A 0.025% GEL RETIN-A 0.05% CREAM RETIN-A 0.1% CREAM RETIN-A MICRO 0.04% GEL RETIN-A MICRO 0.1% GEL RETIN-A MICRO PUMP 0.08% GEL TAZORAC 0.05% CREAM TAZORAC 0.05% GEL TAZORAC 0.1% CREAM TAZORAC 0.1% GEL TRETIN-X 0.01% COMBO PACK TRETIN-X 0.025% CREAM COMB PCK TRETIN-X 0.025% GEL COMBO PACK TRETIN-X 0.0375% CREAM TRETIN-X 0.05% COMBO PACK TRETIN-X 0.075% CREAM TRETIN-X 0.1% COMBO PACK TRETINOIN 0.01% GEL TRETINOIN 0.025% CREAM TRETINOIN 0.025% GEL TRETINOIN 0.05% CREAM TRETINOIN 0.05% GEL TRETINOIN 0.1% CREAM TRETINOIN GEL MICRO 0.04% TUBE TRETINOIN GEL MICRO 0.1% TUBE

NC NC 4 4 4 NC NC NC NC NC NC NC NC 4 4 4 4 4 4 4 4 4 4 4 2 2 2 2 2 2 2 2

LIMITATIONS/ * NOTES Prior Authorization required Prior Authorization required Prior Authorization required for members 30 and older

Prior Authorization required for members 30 and older Prior Authorization required for members 30 and older Prior Authorization required for members 30 and older Prior Authorization required for members 30 and older Prior Authorization required for members 30 and older Prior Authorization required for members 30 and older Prior Authorization required for members 30 and older Prior Authorization required for members 30 and older Prior Authorization required for members 30 and older Prior Authorization required for members 30 and older Prior Authorization required for members 30 and older Prior Authorization required for members 30 and older Prior Authorization required for members 30 and older Prior Authorization required for members 30 and older Prior Authorization required for members 30 and older Prior Authorization required for members 30 and older Prior Authorization required for members 30 and older Prior Authorization required for members 30 and older Prior Authorization required for members 30 and older

SCABICIDES AND PEDICULICIDES ELIMITE 5% CREAM EURAX 10% CREAM EURAX 10% LOTION LINDANE 1% LOTION LINDANE 1% SHAMPOO MALATHION 0.5% LOTION NATROBA 0.9% TOPICAL SUSP OVIDE 0.5% LOTION PERMETHRIN 5% CREAM SKLICE 0.5% LOTION SOOLANTRA 1% CREAM SPINOSAD 0.9% TOPICAL SUSP

NC 4 4 2 2 2 NC NC 2 4 NC 2

DEVICES DEVICES 1ST CHOICE THIN LANCETS 1ST TIER COMFORTOUCH 28G LANCT 1ST TIER COMFORTOUCH 30G LANCT ACAPELLA DEVICE ACCU-CHEK ACTIVE TEST STRIP

VALUE FORMULARY FIVE-TIER DRUG LIST

3 3 3 NC NC

HSA* HSA* HSA*

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ACCU-CHEK AVIVA PLUS TEST STRP ACCU-CHEK AVIVA TEST STRIPS ACCU-CHEK CMFRT CURVE STRIP ACCU-CHEK COMPACT PLUS STRIPS ACCU-CHEK FASTCLIX LANCETS ACCU-CHEK MULTICLIX LANCETS ACCU-CHEK SAFE-T-PRO 23G LANCT ACCU-CHEK SAFE-T-PRO PLUS 23G ACCU-CHEK SMARTVIEW TEST STRIP ACCU-CHEK SOFTCLIX LANCETS ACCU-CHEK SPIRIT CLIP CASE ACCUTREND GLUCOSE TEST STRIP ACE AEROSOL CLOUD ENHANCER ACTI-LANCE LITE 28G LANCETS ACTI-LANCE SPECIAL 17G LANCETS ACTI-LANCE UNIVERS 23G LANCETS ACUICYN EYELID-EYELASH CLEANSR ACURA TEST STRIPS ADVANCED TRAVEL 28G LANCETS ADVANCED TRAVEL 30G LANCETS ADVOCATE 26G LANCETS ADVOCATE 26G LANCETS ADVOCATE 30G LANCETS ADVOCATE REDI-CODE TEST STRIP ADVOCATE REDI-CODE+ TEST STRIP ADVOCATE TEST STRIP AEROCHAMBER MINI AEROCHAMBER MV HOLD CHAMBER AEROCHAMBER PLUS FLOW-VU AEROCHAMBER PLUS FLOW-VU MED AEROCHAMBER PLUS W-FLOWSIGNAL AEROCHAMBER PLUS Z STAT MEDIUM AEROCHAMBER Z-STAT PLUS W-FLOW AEROGEAR ASTHMA ACTION KIT AEROTRACH HOLDING CHAMBER AEROVENT PLUS HOLDING CHAMBER AGAMATRIX AMP TEST STRIPS AIRZONE PEAK FLOW METER ALLERGIST PACK 26GX1/2" 1 ML ALLERGIST PACK 26GX3/8" 1 ML ALLERGIST PACK 27GX1/2" 1 ML ALLERGY SYRINGE 1 ML 27GX1/2" ALLERGY SYRINGE 1 ML 27GX3/8" ALTERNATE SITE 26G LANCETS ASEPTO BULB SYRINGES GLASS ASSESS PEAK FLOW METER ASSURE 4 TEST STRIPS ASSURE COMFORT 30G LANCETS ASSURE HAEMOLANCE PLUS 18G ASSURE HAEMOLANCE PLUS 21G ASSURE HAEMOLANCE PLUS 25G ASSURE HAEMOLANCE PLUS 28G ASSURE HAEMOLANCE PLUS BLADE ASSURE LANCE 25G LANCETS ASSURE LANCE 28G LANCETS ASSURE LANCE PLUS 21G LANCETS ASSURE LANCE PLUS 25G LANCETS ASSURE LANCE PLUS 30G LANCETS ASSURE PLATINUM TEST STRIPS

NC NC NC NC 3 3 3 3 NC 3 NC NC MD 3 3 3 NC NC 3 3 3 3 3 NC NC NC MD MD MD MD MD MD MD MD MD MD NC MD 3 3 3 3 3 3 3 MD NC 3 3 3 3 3 3 3 3 3 3 3 NC

VALUE FORMULARY FIVE-TIER DRUG LIST

LIMITATIONS/ * NOTES

HSA* HSA* HSA* HSA* HSA*

HSA* HSA* HSA*

HSA* HSA* HSA* HSA* HSA*

HSA*

HSA* HSA* HSA* HSA* HSA* HSA* HSA* HSA* HSA* HSA*

Last Updated: 01/17/2017

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DRUG NAME

TIER

ASSURE PRISM MULTI TEST STRIPS ASSURE PRO TEST STRIPS ASTHMA CHECK PEAK FLOW MTR ASTHMAMENTOR PEAK FLOW MTR ASTHMAPACK CHILDREN'S CARE KIT AURORA SUPER THIN 30G LANCETS AURSTAT ANTI-ITCH HYDROGEL KIT AURSTAT KIT AVENOVA LID-LASH SPRAY AVO CREAM TOPICAL EMULSION BD 1 ML SYRINGE WITH NEEDLE BD 1 ML SYRINGE-NEEDLE 25GX5/8 BD 10 ML SYRINGE BD 10 ML SYRINGE 20GX1" BD 10 ML SYRINGE 20GX1-1/2" BD 10 ML SYRINGE 21GX1" BD 10 ML SYRINGE 22GX1" BD 10 ML SYRINGE 22GX1-1/2" BD 10 ML SYRINGE WITH NEEDLE BD 20 ML SYRINGE BD 20 ML SYRINGE BULK BD 3 ML SYRINGE 18GX1-1/2" BD 3 ML SYRINGE 20GX1-1/2" BD 3 ML SYRINGE 25GX1" BD 3 ML SYRINGE 25GX1-1/2" BD 3 ML SYRINGE WITH NEEDLE BD 5 ML SYRINGE BD 5 ML SYRINGE 20GX1" BD 5 ML SYRINGE 20GX1-1/2" BD 5 ML SYRINGE 21GX1" BD 5 ML SYRINGE 21GX1-1/2" BD 5 ML SYRINGE 22GX1" BD 5 ML SYRINGE 22GX1-1/2" BD 5 ML SYRINGE WITH NEEDLE BD 60 ML SYRINGE BD ALLERGIST SYRINGE BD ALLERGIST TRAY BD ALLERGIST TRAY BD ALLERGY SYRINGE 1 ML 28G BD ALLERGY SYRINGE-NEEDLE 1 ML BD BULK SYRINGE 1 ML BD BULK SYRINGE 10 ML BD BULK SYRINGE 20 ML BD BULK SYRINGE 3 ML BD BULK SYRINGE 5 ML BD BULK SYRINGE 60 ML BD CATHETER TIP SYRINGE 60 ML BD ECLIPSE LUER-LOK SYR 3 ML BD ECLIPSE SYR 1 ML 25GX5/8 BD ECLIPSE SYRINGE 3 ML 21GX1" BD ECLIPSE SYRINGE 3 ML 22GX1" BD ECLIPSE SYRINGE 3 ML 25GX1" BD GLASPAK 1 ML SYRINGE BD GLASPAK 10 ML SYRINGE BD GLASPAK 2.5 ML SYRINGE BD GLASPAK 5 ML SYRINGE BD INSULIN SYR 0.3 ML 31GX5/16 BD INSULIN SYR 0.5 ML 6MMX31G BD INSULIN SYR 1 ML 31GX5/16"

NC NC MD MD MD 3 NC NC NC 2 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 4 4 3 3 3 3 3 3 3 3 3 3

VALUE FORMULARY FIVE-TIER DRUG LIST

LIMITATIONS/ * NOTES

HSA*

HSA* HSA* HSA*

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BD INTEGRA RETRA NEEDLE 23GX1" BD INTEGRA SYR 3 ML 21GX1 1/2" BD INTEGRA SYR 3 ML 22GX1 1/2" BD INTEGRA SYR 3 ML 25GX5/8" BD INTEGRA SYRINGE 1 ML 25GX1" BD INTEGRA SYRINGE 3 ML 21GX1" BD INTEGRA SYRINGE 3 ML 23GX1" BD INTEGRA SYRINGE 3 ML 25GX1" BD INTERLINK SYR 15G W-CANNULA BD INTERLINK SYR 17G W-CANNULA BD INTERLINK SYR 17G W-CANNULA BD LUER-LOK 5 ML SYRINGE BD LUER-LOK SYR 3 ML 25GX5/8" BD LUER-LOK SYRINGE 1ML 20GX1" BD LUER-LOK SYRINGE 20 ML BD LUER-LOK SYRINGE 3 ML BD LUER-LOK TIP SYRINGE 30 ML BD LUERSLIP SYRINGE 1 ML BD MEDSAVER 1 ML SYR-NEEDLE BD MEDSAVER SYRINGE BD MICROTAINER 21G LANCETS BD MICROTAINER 30G LANCETS BD MICROTAINER LANCETS BD NEEDLE 18GX1 1/2" BD NEEDLE 19GX1 1/2" BD NEEDLE 20GX1 1/2" BD NEEDLE 21GX1 1/2" BD NEEDLE 21GX1" BD NEEDLE 22GX1 1/2" BD NEEDLE 22GX1" BD NEEDLE 22GX3/4" BD NEEDLE 23GX1 1/2" BD NEEDLE 23GX1" BD NEEDLE 24GX1" BD NEEDLE 25GX1" BD NEEDLE 25GX5/8" BD NEEDLE 26GX0.625" BD NEEDLES 16GX1" BD NEEDLES 16GX1.5" BD NEEDLES 18GX1" BD NEEDLES 18GX1.5" BD NEEDLES 18GX1.5" BD NEEDLES 19GX1" BD NEEDLES 19GX1.5" BD NEEDLES 20GX1" BD NEEDLES 20GX1" BD NEEDLES 20GX1.5" BD NEEDLES 20GX1.5" BD NEEDLES 21GX1" BD NEEDLES 21GX1.5" BD NEEDLES 21GX2" BD NEEDLES 22GX1" BD NEEDLES 22GX1.5" BD NEEDLES 22GX1.5" BD NEEDLES 23GX0.75" BD NEEDLES 23GX1.25" BD NEEDLES 25GX0.625" BD NEEDLES 25GX0.875" BD NEEDLES 25GX1.5"

3 4 3 3 4 4 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3

VALUE FORMULARY FIVE-TIER DRUG LIST

LIMITATIONS/ * NOTES

HSA* HSA* HSA*

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BD NEEDLES 26GX0.375" BD NEEDLES 26GX0.5" BD NEEDLES 27GX0.5" BD NEEDLES 27GX1X1.25" BD NEEDLES 30GX0.5" BD NEEDLES 30GX1" BD NOKOR ADMIX NEEDLE 18GX1.5" BD PRECISIONGLIDE 3 ML 22GX3/4 BD PRECISIONGLIDE NEEDLE 25G BD SAFETYGLIDE 3 ML SYRINGE BD SAFETYGLIDE 3 ML SYRINGE BD SAFETYGLIDE ALLERGY 27G SYR BD SAFETYGLIDE ALLERGY SYRINGE BD SAFETYGLIDE SYR 22GX1.5" BD SAFETYGLIDE SYR 22GX1.5" BD SAFETYGLIDE TB 1 ML SYR BD SLIP TIP 5 ML SYRINGE BD SLIP TIP 60 ML SYRINGE BD SLIP-TIP SYRINGE 20 ML BD SYRINGE 10 ML BD SYRINGE 2 ML BD SYRINGE 20 ML BD SYRINGE 3 ML BD SYRINGE 3 ML BD SYRINGE 30 ML BD SYRINGE 30 ML BD SYRINGE 30 ML BD SYRINGE 5 ML BD SYRINGE 50 ML BD SYRINGE GLASS 3 ML BD SYRINGE WITH CANNULA BD SYRINGE-SAFETY GLIDE BD SYRINGE-SAFETY GLIDE BD TB SYRINGE 21GX1" BD TB SYRINGE 22GX1" BD TB SYRINGE 25GX5/8" BD TB SYRINGE 26GX3/8" BD TB SYRINGE 27GX1/2" BD TB SYRNGE 27GX1/2" BD TUBERCULIN 1 ML SYRINGE BD ULTRA-FINE 33G LANCETS BD ULTRA-FINE II 30G LANCETS BD ULTRA-FINE PEN NDL 4MMX32G BEAU RX SCAR CARE GEL BG-STAR GLUCOSE TEST STRIPS BIAFINE EMULSION BLOOD GLUCOSE TEST STRIP BLOOD GLUCOSE TEST STRIPS BLOOD LANCETS 30G BREATHERITE MDI SPACER BREATHRITE VALVED MDI CHAMBER BREEZE 2 DISC TEST STRIP BULLSEYE MINI SAFETY 21G BULLSEYE MINI SAFETY 25G LANCT CAREONE ULTRA THIN LANCET CARESENS N TEST STRIPS CARESENS ULTRA THIN 30G LANCET CERAMAX SKIN BARRIER CREAM CHOICEDM CLARUS TEST STRIPS

3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 4 3 3 3 3 3 3 4 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 NC NC NC NC NC 3 MD MD NC 3 3 3 NC 3 NC NC

VALUE FORMULARY FIVE-TIER DRUG LIST

LIMITATIONS/ * NOTES

HSA* HSA* HSA*

HSA*

HSA* HSA* HSA* HSA*

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DRUG NAME

TIER

CHOICEDM G20 TEST STRIPS CLEVER CHEK ULTRA THIN 30G CLEVER CHOICE MICRO TEST STRIP CLEVER CHOICE PRO TEST STRIP CLEVER CHOICE TALK TEST STRIPS CLEVER CHOICE TEST STRIPS CLEVER CHOICE VOICE+ TST STRIP COAGUCHEK LANCETS COMFORT EZ SAFETY 21G LANCETS COMFORT EZ SAFETY 23G LANCETS COMFORT EZ SAFETY 28G LANCETS COMFORT LANCETS COMPACT SPACE CHAMBER PLUS CONTOUR NEXT STRIPS CONTOUR TEST STRIPS CONTROL AST TEST STRIP CONTROL TEST STRIPS COOL GLUCOSE TEST STRIP CORNWALL SYRINGES LUER-LOK CORNWALL SYRINGES LUER-LOK CORNWALL SYRINGES LUER-LOK CVS ADVANCED GLUCOSE TEST STR CVS MICRO THIN 33G LANCETS CVS THIN 26G LANCETS CVS ULTRA THIN 30G LANCETS DIATRUE PLUS TEST STRIP DOVER BULB SYRINGE 60 ML DROPLET 30G LANCETS E-Z JECT LANCETS E-Z SPACER E-ZJECT COLOR 32G LANCETS E-ZJECT COLOR 33G LANCETS E-ZJECT SUPER THIN 30G LANCETS EASIVENT HOLDING CHAMBER EASIVENT MASK-LARGE EASIVENT MASK-MEDIUM EASIVENT MASK-SMALL EASY COMFORT 30G LANCETS EASY GLUCO G2 TEST STRIP EASY PLUS GLUCOSE TEST STRIP EASY PLUS II TEST STRIPS EASY STEP GLUCOSE TEST STRIPS EASY TALK GLUCOSE TEST STRIP EASY TOUCH 28G LANCETS EASY TOUCH FLIPLK 10ML 18GX1.5 EASY TOUCH FLIPLK 10ML 20GX1.5 EASY TOUCH FLIPLK 10ML 21GX1.5 EASY TOUCH FLIPLK 10ML 22GX1.5 EASY TOUCH FLIPLK 5 ML 20GX1.5 EASY TOUCH FLIPLK 5 ML 21GX1.5 EASY TOUCH FLIPLK 5 ML 22GX1.5 EASY TOUCH FLIPLK 5 ML 25GX5/8 EASY TOUCH FLIPLOCK 1 ML 25GX1 EASY TOUCH FLIPLOCK 10ML 21GX1 EASY TOUCH FLIPLOCK 3 ML 18GX1 EASY TOUCH FLIPLOCK 3 ML 19GX1 EASY TOUCH FLIPLOCK 3 ML 20GX1 EASY TOUCH FLIPLOCK 3 ML 21GX1 EASY TOUCH FLIPLOCK 3 ML 22GX1

NC 3 NC NC NC NC NC 3 3 3 3 3 MD NC NC NC NC NC 3 3 3 NC 3 3 3 NC 3 3 3 MD 3 3 3 MD MD MD MD 3 NC NC NC NC NC 3 4 3 3 4 3 3 3 4 3 4 4 4 3 3 3

VALUE FORMULARY FIVE-TIER DRUG LIST

LIMITATIONS/ * NOTES HSA*

HSA* HSA* HSA* HSA* HSA*

HSA* HSA* HSA*

HSA* HSA* HSA* HSA* HSA*

HSA*

HSA*

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EASY TOUCH FLIPLOCK 3 ML 23GX1 EASY TOUCH FLIPLOCK 3 ML 25GX1 EASY TOUCH FLIPLOCK 5 ML 18GX1 EASY TOUCH FLIPLOCK 5 ML 20GX1 EASY TOUCH FLIPLOCK 5 ML 21GX1 EASY TOUCH FLIPLOCK 5 ML 25GX1 EASY TOUCH FLIPLOK 10 ML 18GX1 EASY TOUCH FLIPLOK 10 ML 20GX1 EASY TOUCH FLIPLOK 10 ML 25GX1 EASY TOUCH FLIPLOK 1ML 26GX3/8 EASY TOUCH FLIPLOK 3ML 18GX1.5 EASY TOUCH FLIPLOK 3ML 19GX1.5 EASY TOUCH FLIPLOK 3ML 20GX1.5 EASY TOUCH FLIPLOK 3ML 21GX1.5 EASY TOUCH FLIPLOK 3ML 22GX1.5 EASY TOUCH FLIPLOK 3ML 23GX1.5 EASY TOUCH FLIPLOK 3ML 25GX5/8 EASY TOUCH FLURING 1ML 25GX5/8 EASY TOUCH FLURING 1ML 25GX5/8 EASY TOUCH FLURINGE 1 ML 25GX1 EASY TOUCH FLURINGE 1 ML 25GX1 EASY TOUCH FLURINGE 1 ML 25GX1 EASY TOUCH FLURINGE 25GX5/8" EASY TOUCH GLUCOSE TEST STRIP EASY TOUCH HYPODERMIC 16GX1" EASY TOUCH HYPODERMIC 16GX1.5" EASY TOUCH HYPODERMIC 18GX1" EASY TOUCH HYPODERMIC 18GX1.5" EASY TOUCH HYPODERMIC 19GX1" EASY TOUCH HYPODERMIC 19GX1.5" EASY TOUCH HYPODERMIC 20GX1" EASY TOUCH HYPODERMIC 20GX1.5" EASY TOUCH HYPODERMIC 21GX1" EASY TOUCH HYPODERMIC 21GX1.5" EASY TOUCH HYPODERMIC 22GX1" EASY TOUCH HYPODERMIC 22GX1.5" EASY TOUCH HYPODERMIC 23GX1" EASY TOUCH HYPODERMIC 23GX1.25 EASY TOUCH HYPODERMIC 23GX1.5" EASY TOUCH HYPODERMIC 23GX3/4" EASY TOUCH HYPODERMIC 24GX1" EASY TOUCH HYPODERMIC 25GX1" EASY TOUCH HYPODERMIC 25GX1.5" EASY TOUCH HYPODERMIC 25GX5/8" EASY TOUCH HYPODERMIC 26GX1/2" EASY TOUCH HYPODERMIC 26GX3/8" EASY TOUCH HYPODERMIC 26GX5/8" EASY TOUCH HYPODERMIC 27GX1.25 EASY TOUCH HYPODERMIC 27GX1.5" EASY TOUCH HYPODERMIC 27GX1/2" EASY TOUCH HYPODERMIC 30GX1" EASY TOUCH HYPODERMIC 30GX1/2" EASY TOUCH LUER LOCK 1 ML SYR EASY TOUCH LUER LOCK 10 ML SYR EASY TOUCH LUER LOCK 3 ML SYR EASY TOUCH LUER LOCK 5 ML SYR EASY TOUCH SAFETY 21G LANCETS EASY TOUCH SAFETY 23G LANCETS EASY TOUCH SAFETY 26G LANCETS

3 3 4 3 4 4 4 3 4 3 4 4 3 3 3 4 3 3 3 3 3 3 3 NC 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3

VALUE FORMULARY FIVE-TIER DRUG LIST

LIMITATIONS/ * NOTES

HSA* HSA* HSA*

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EASY TOUCH SHEATH 10 ML 25GX1" EASY TOUCH SHEATH 10ML 21GX1.5 EASY TOUCH SHEATH 10ML 22GX1.5 EASY TOUCH SHEATH 3 ML 21GX1" EASY TOUCH SHEATH 3 ML 21GX1.5 EASY TOUCH SHEATH 3 ML 22GX1" EASY TOUCH SHEATH 3 ML 22GX1.5 EASY TOUCH SHEATH 3 ML 23GX1" EASY TOUCH SHEATH 3 ML 25GX1" EASY TOUCH SHEATH 3 ML 25GX5/8 EASY TOUCH SHEATH 5 ML 21GX1.5 EASY TOUCH SHEATH 5 ML 22GX1.5 EASY TOUCH SHEATH 5 ML 25GX1" EASY TOUCH SHEATHLOCK 10ML SYR EASY TOUCH SHEATHLOCK 3 ML SYR EASY TOUCH SHEATHLOCK 5 ML SYR EASY TOUCH SYR 1 ML 25GX5/8" EASY TOUCH SYR 3 ML 22GX1-1/2" EASY TOUCH SYR 3 ML 25GX5/8" EASY TOUCH SYRINGE 1 ML 25GX1" EASY TOUCH SYRINGE 3 ML 20GX1" EASY TOUCH SYRINGE 3 ML 21GX1" EASY TOUCH SYRINGE 3 ML 22GX1" EASY TOUCH SYRINGE 3 ML 23GX1" EASY TOUCH SYRINGE 3 ML 25GX1" EASY TOUCH TB FLP 1 ML 26GX5/8 EASY TOUCH TB FLP 1 ML 27GX1/2 EASY TOUCH TB FLP 1 ML 28GX1/2 EASY TOUCH TB SHLK 1ML 25GX5/8 EASY TOUCH TB SHLK 1ML 26GX5/8 EASY TOUCH TB SHLK 1ML 27GX1/2 EASY TOUCH TB SHLK 1ML 28GX1/2 EASY TOUCH TWIST 28G LANCETS EASY TOUCH TWIST 30G LANCETS EASY TOUCH TWIST 32G LANCETS EASY TOUCH TWIST 33G LANCETS EASY TOUCH UNI-SLIP 10 ML SYR EASY TOUCH UNI-SLIP 3 ML SYR EASY TOUCH UNI-SLIP 5 ML SYR EASY TRAK GLUCOSE TEST STRIP EASY TWIST & CAP 28G LANCETS EASYGLUCO PLUS TEST STRIPS EASYGLUCO TEST STRIPS EASYMAX 15 GLUCOSE TEST STRIP EASYMAX GLUCOSE TEST STRIPS ECLIPSE TEST STRIPS ELEMENT COMPACT TEST STRIPS ELEMENT PLUS TEST STRIPS ELEMENT TEST STRIPS ELETONE CREAM ELETONE CREAM TWIN PACK EMBRACE 30G LANCETS EMBRACE EVO TEST STRIPS EMBRACE PRO TEST STRIPS EMBRACE TEST STRIPS EMULSION SB TOPICAL EMULSION ENVISION TEST STRIPS EPICERAM SKIN BARRIER EMULSION EPISIL LIQUID

4 3 4 3 3 3 3 3 3 3 3 3 4 4 3 4 3 3 3 3 3 3 3 3 3 4 4 4 3 4 4 3 3 3 3 3 4 4 4 NC 3 NC NC NC NC NC NC NC NC NC NC 3 NC NC NC 2 NC NC NC

VALUE FORMULARY FIVE-TIER DRUG LIST

LIMITATIONS/ * NOTES

HSA* HSA* HSA* HSA*

HSA*

HSA*

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EQUATE BLOOD GLUCOSE TEST STRP EVENCARE G2 TEST STRIP EVENCARE G3 TEST STRIP EVENCARE GLUCOSE TST STRIPS EVENCARE MINI GLUCOSE TEST STR EVOLUTION TEST STRIPS EXEL 3 ML SYRN 27G X 1 1/4" EXEL ALLERGY SYRINGE 27G-1 ML EXEL HYPO NEEDLE 16GX0.05" EXEL HYPO NEEDLE 16GX1" EXEL HYPO NEEDLE 18GX0.5" EXEL HYPO NEEDLE 18GX1" EXEL HYPO NEEDLE 19GX1" EXEL HYPO NEEDLE 19GX1.5" EXEL HYPO NEEDLE 20GX0.5" EXEL HYPO NEEDLE 20GX0.75" EXEL HYPO NEEDLE 20GX1" EXEL HYPO NEEDLE 21GX0.5" EXEL HYPO NEEDLE 21GX1" EXEL HYPO NEEDLE 21GX2" EXEL HYPO NEEDLE 22GX0.5" EXEL HYPO NEEDLE 22GX0.75" EXEL HYPO NEEDLE 22GX1" EXEL HYPO NEEDLE 23GX0.75" EXEL HYPO NEEDLE 23GX1" EXEL HYPO NEEDLE 23GX1.5" EXEL HYPO NEEDLE 25GX0.5" EXEL HYPO NEEDLE 25GX0.625" EXEL HYPO NEEDLE 25GX0.75" EXEL HYPO NEEDLE 25GX1" EXEL HYPO NEEDLE 26GX0.375" EXEL HYPO NEEDLE 26GX0.5" EXEL HYPO NEEDLE 26GX0.625" EXEL HYPO NEEDLE 26GX1.5" EXEL HYPO NEEDLE 27GX0.5" EXEL HYPO NEEDLE 30GX1.5" EXEL SYRINGE 10 ML EXEL SYRINGE 20 ML EXEL SYRINGE 20GX1" 3 ML EXEL SYRINGE 20GX1-1/2" 3 ML EXEL SYRINGE 21GX1" 3 ML EXEL SYRINGE 21GX1-1/2" 3 ML EXEL SYRINGE 22GX1" 3 ML EXEL SYRINGE 22GX1-1/2" 3 ML EXEL SYRINGE 22GX3/4" 3 ML EXEL SYRINGE 23GX1" 3 ML EXEL SYRINGE 23GX1-1/2" 3 ML EXEL SYRINGE 25GX1" 3 ML EXEL SYRINGE 25GX5/8" 3 ML EXEL SYRINGE 3 ML EXEL SYRINGE 30 ML EXEL SYRINGE 5 ML EXEL SYRINGE 50 ML EXEL TB WITH NEEDLE 25GX5/8" EXEL TB WITH NEEDLE 26GX3/8" EXEL TB WITH NEEDLE 26GX5/8" EXEL TB WITH NEEDLE 27GX1/2" EXEL TUBERCULIN SYRINGE 1 ML EZ SMART 28G LANCETS EZ SMART PLUS TEST STRIPS EZ SMART TEST STRIPS

VALUE FORMULARY FIVE-TIER DRUG LIST

NC NC NC NC NC NC 4 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 NC NC

HSA*

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DRUG NAME

TIER

FIFTY50 GLUCOSE TEST STRIP FIFTY50 SAFETY SEAL 30G LANCET FIFTY50 SAFETY SEAL 32G LANCET FINE 30 UNIVERSAL 30G LANCETS FINGERSTIX LANCETS FLEXICHAMBER FLOW-EZE VENTED NEEDLE FORA 30G LANCETS FORA BLOOD GLUCOSE TEST STRIP FORA D10 GLUCOSE TEST STRIPS FORA D15C GLUCOSE TEST STRIPS FORA D15G GLUCOSE TEST STRIPS FORA D15Z GLUCOSE TEST STRIPS FORA D20 GLUCOSE TEST STRIPS FORA D40-G31 TEST STRIPS FORA G20 GLUCOSE TEST STRIPS FORA G30A GLUCOSE TEST STRIP FORA G71A GLUCOSE TEST STRIP FORA G90 GLUCOSE TEST STRIP FORA GD50 TEST STRIPS FORA TEST N'GO TEST STRIPS FORA TN'G VOICE TEST STRIPS FORA V10 GLUCOSE TEST STRIP FORA V10-V12-D10-D20 STRIPS FORA V12 GLUCOSE TEST STRIP FORA V20 GLUCOSE TEST STRIPS FORA V22 GLUCOSE TEST STRIP FORA V30A GLUCOSE TEST STRIP FORACARE 30G LANCETS FORACARE GD20 TEST STRIPS FORACARE GD40 GLUCOSE STRIPS FORTISCARE GLUCOSE TEST STRIPS FREESTYLE 28G LANCETS FREESTYLE FREEDOM LITE METER

NC 3 3 3 3 MD 3 3 NC NC NC NC NC NC NC NC NC NC NC NC NC NC NC NC NC NC NC NC 3 NC NC NC 3 MD

FREESTYLE INSULINX GLUCOSE SYS

MD

FREESTYLE INSULINX TEST STRIP FREESTYLE INSULINX TEST STRIPS

3 3

FREESTYLE LITE METER FREESTYLE LITE TEST STRIP

MD 3

FREESTYLE LITE TEST STRIPS FREESTYLE TEST STRIPS

3 3

FREESTYLE UNISTIK 2 LANCETS G-4 TEST STRIPS GE100 BLOOD GLUCOSE TEST STRIP GENSTRIP GLUCOSE TEST STRIP GENULTIMATE TEST STRIP GENVISC 850 25 MG/2.5 ML SYR GLUCO NAVII GLUCOSE TEST STRIP GLUCOCARD 01 SENSOR PLUS STRIP GLUCOCARD EXPRESSION TEST STRP GLUCOCARD SHINE TEST STRIPS GLUCOCARD VITAL SENSOR STRIP GLUCOCARD VITAL TEST STRIPS GLUCOCOM 28G LANCETS GLUCOCOM 30G LANCETS GLUCOCOM 33G LANCETS

3 NC NC NC NC MD NC NC NC NC NC NC 3 3 3

VALUE FORMULARY FIVE-TIER DRUG LIST

LIMITATIONS/ * NOTES HSA* HSA* HSA* HSA*

HSA*

HSA*

HSA* Max. 1 in 365 days HSA* Max. 1 in 365 days HSA* Max. 204 per 30 days Max. 204 per 30 days HSA* Max. 1 in 365 days Max. 204 per 30 days HSA* Max. 204 per 30 days Max. 204 per 30 days HSA* HSA*

HSA* HSA* HSA*

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GLUCOCOM GLUCOSE TEST STRIP GLUCOLAB TEST STRIPS GLUCOSOURCE LANCETS GMATE 30G LANCETS GMATE TEST STRIPS GNP UNIVERSAL 1 STANDARD 21G GNP UNIVERSAL 1 SUPER THIN 30G GNP UNIVERSAL 1 THIN 26G LANCT HEALTHPRO GLUCOSE TEST STRIPS HEALTHY ACCENTS UNILET 30G HPR EMOLLIENT FOAM HPR PLUS CREAM HPR PLUS EMOLLIENT FOAM HPR PLUS HYDROGEL KIT HPR PLUS-MB HYDROGEL KIT HYLATOPIC EMOLLIENT FOAM HYLATOPICPLUS CREAM HYLATOPICPLUS EMOLLIENT FOAM HYPO NEEDLE,POLYPROPYL HUB HYPODERMIC NEEDLE,ALUM HUB HYPODERMIC NEEDLE,ALUM HUB IN-CHECK DIAL TRAINING DEVICE IN-CHECK NASAL WITH MASK IN-CHECK ORAL FLOW METER INCONTROL SUPER THIN 30G LANCT INCONTROL ULTRA THIN 28G LANCT INFINITY TEST STRIPS INJECT EASE 28G LANCETS INJECT EASE 30G LANCETS INSPIRACHAMBER INSPIRACHAMBER WITH MASK-MED INVACARE 30G LANCETS IRRIGATION SYRINGE KEYNOTE GLUCOSE TEST STRIPS KINNEY BRAND 23G LANCETS KITABIS PAK 300 MG/5 ML KRO PREMIUM BLOOD GLUCOSE TEST KROGER SUPER THIN LANCETS LANCETS 33G LANCETS THIN 23G LANCETS ULTRA THIN 26G LIBERTY TEST STRIPS LIFESHIELD BLUNT CANNULA LIFESHIELD BLUNT CANNULA LIFESHIELD BLUNT CANNULA LIFESHIELD BLUNT CANNULA LITE TOUCH 30G LANCETS LITE TOUCH 33G LANCETS LITEAIRE MDI CHAMBER LITETOUCH SMALL MASK LONGS THIN LANCETS 30G LUER LOCK SYRINGE 30 ML LUER SLIP TIP SYR TRAY 1 ML LUER-LOCK SYRINGE 60 ML LUXAMEND WOUND CREAM MAGELLAN TUBERCULIN SYR 1 ML MAJOR COMFORT LANCETS MAXIMA TEST STRIP MB HYDROGEL KIT

NC NC 3 3 NC 3 3 3 NC 3 NC 4 NC 2 NC NC NC NC 3 3 NC MD MD MD 3 3 NC 3 3 MD MD 3 3 NC 3 4 NC 3 3 3 3 NC 3 3 3 3 3 3 MD MD 3 3 4 4 NC 3 3 NC NC

VALUE FORMULARY FIVE-TIER DRUG LIST

LIMITATIONS/ * NOTES HSA* HSA* HSA* HSA* HSA* HSA*

HSA* HSA* HSA* HSA*

HSA*

HSA* SPP*: Must use Accredo HSA* HSA* HSA* HSA*

HSA* HSA*

HSA*

HSA*

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DRUG NAME

TIER

LIMITATIONS/ * NOTES

MEDI-LANCE LANCETS MEDISENSE THIN 28G LANCETS MEDLANCE PLUS 21G LANCETS MEDLANCE PLUS 30G LANCETS MEDLANCE PLUS LITE 25G LANCETS MEDLANCE PLUS SPECIAL BLADE MICROCHAMBER MICROCYN SKIN-WOUND HYDROGEL MICRODOT TEST STRIPS MICRODOT XTRA TEST STRIPS MICROLET LANCETS MICROLIFE PEAK FLOW METER MICROSPACER FOR AEROSOL DEVICE MINI WRIGHT PEAK FLOW METER MINIMED INFUSION SET MINIMED RESERVOIR 3 ML MISTASSIST IFCD MONAGHAN Z STAT CHAMBER-MD MSK MONOJECT 1 ML SYRN 28GX1/2" MONOJECT 12 ML SYRINGE 18GX1" MONOJECT 12 ML SYRN 20GX1.25 MONOJECT 12 ML SYRN 21GX1" MONOJECT 12 ML SYRN 21GX1.5" MONOJECT 3 ML SYRINGE 21GX1" MONOJECT 3 ML SYRINGE 23GX1" MONOJECT 3 ML SYRINGE 25GX1" MONOJECT 3 ML SYRN 21GX1-1/2" MONOJECT 3 ML SYRN 22GX1-1/2" MONOJECT 3 ML SYRN 25GX1" MONOJECT 3 ML SYRN 25GX1.25" MONOJECT 3 ML SYRN 25GX5/8" MONOJECT 3 ML SYRN 27GX1.25" MONOJECT 6 ML SYRINGE MONOJECT 6 ML SYRN 20GX11/2" MONOJECT 6 ML SYRN 21GX1" MONOJECT 6 ML SYRN 21GX11/2" MONOJECT 6 ML SYRN 22GX11/2" MONOJECT 6CC SAFETY SYRINGE MONOJECT CONTROL SYRINGE 12ML MONOJECT HYPO NEEDLE 19X1 MONOJECT HYPO NEEDLE 19X1-1/2 MONOJECT HYPO NEEDLE 20X1 MONOJECT HYPO NEEDLE 20X1-1/2 MONOJECT HYPO NEEDLE 21X1 MONOJECT HYPO NEEDLE 21X1-1/2 MONOJECT HYPO NEEDLE 22X1 MONOJECT HYPO NEEDLE 22X1.5 MONOJECT HYPO NEEDLE 23X0.5 MONOJECT HYPO NEEDLE 23X1 MONOJECT HYPO NEEDLE 25X1 MONOJECT HYPO NEEDLE 25X1.5 MONOJECT HYPO NEEDLE 25X5/8 MONOJECT HYPO NEEDLE 26X1.5 MONOJECT HYPO NEEDLE 27X0.5 MONOJECT HYPO NEEDLE 30X3/4 MONOJECT HYPODERMIC NEEDLE MONOJECT LUER LOCK TB SYR 1 ML MONOJECT MAGELLAN SYRINGE MONOJECT MAGELLAN SYRINGE 1 ML

3 3 3 3 3 3 MD NC NC NC 3 MD MD MD MD MD MD MD 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 NC NC NC NC NC NC 3 3 3 3 3 3 3 3 3 3 NC 3 3 3

HSA* HSA* HSA* HSA* HSA* HSA*

VALUE FORMULARY FIVE-TIER DRUG LIST

HSA*

HSA*

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MONOJECT MAGELLAN SYRINGE 3 ML MONOJECT MEGELLAN TB SYR 1 ML MONOJECT PHARMACY TRAY MONOJECT SAFETY SYRINGE MONOJECT SAFETY SYRINGE MONOJECT SAFETY SYRINGE MONOJECT SAFETY SYRINGE MONOJECT SAFETY SYRINGE MONOJECT SMARTIP CANNULA 12 ML MONOJECT SMARTIP CANNULA 3 ML MONOJECT SMARTIP CANNULA 6 ML MONOJECT SYR PHARM TRAY PK MONOJECT SYR PHARM TRAY PK MONOJECT SYRINGE 1 ML MONOJECT SYRINGE 12 ML MONOJECT SYRINGE 140 ML MONOJECT SYRINGE 20 ML MONOJECT SYRINGE 3 ML MONOJECT SYRINGE 3 ML 20GX1 MONOJECT SYRINGE 3 ML 22GX1" MONOJECT SYRINGE 35 ML MONOJECT SYRINGE 6 ML MONOJECT SYRINGE 60 ML MONOJECT SYRN 3 ML 20GX1-1/2" MONOJECT SYRN 3 ML 20GX3/4" MONOJECT TB 1 ML SYRN 26X3/8" MONOJECT TB 1 ML SYRN 28GX1/2 MONOJECT TB SAFETY SYRINGE MONOJECT TB SYRN 25GX5/8" MONOJECT TB SYRN 27GX1/2" MONOJECT TUBERCULIN SYR 1 ML MONOLET 21G LANCETS MONOLET THIN 28G LANCETS MUGARD ORAL WOUND RINSE MYGLUCOHEALTH 30G LANCETS MYGLUCOHEALTH TEST STRIPS NEOSALUS CP CREAM NEOSALUS CREAM NEOSALUS FOAM NEOSALUS LOTION NESSI SPACER NEUTEK 2TEK TEST STRIPS NEUTRASAL POWDER PACKET NORM-JECT 1 ML SYRINGE NOVA MAX GLUCOSE TEST STRIP NOVA SAFETY 23G LANCETS NOVA SAFETY 28G LANCETS NOVA SUREFLEX THIN LANCETS NOVAMAX PLUS KETONE TEST STRIP NUVAIL NAIL 16% SOLUTION ON CALL 30G LANCET ON CALL EXPRESS TEST STRIP ON CALL PLUS 30G LANCET ON CALL PLUS TEST STRIP ON CALL VIVID TEST STRIP ONE FLOW FVC KIT SPIROMETER ONE FLOW SPIROMETER PC CABLE ONE FLOW TESTER TYPE MOUTHPIEC ONE WAY VALVED MOUTHPIECE

4 4 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 NC 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 NC NC NC NC NC MD NC NC 3 NC 3 3 3 NC NC 3 NC 3 NC NC MD MD MD MD

VALUE FORMULARY FIVE-TIER DRUG LIST

LIMITATIONS/ * NOTES

HSA*

HSA* HSA* HSA*

HSA* HSA* HSA*

HSA* HSA*

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LIMITATIONS/ * NOTES

ONETOUCH DELICA 30G LANCETS ONETOUCH DELICA 33G LANCETS ONETOUCH FINEPOINT 25G LANCETS ONETOUCH SURESOFT LANCING DEV ONETOUCH ULTRA TEST STRIPS ONETOUCH ULTRASOFT LANCETS ONETOUCH VERIO TEST STRIP OPTICHAMBER ADULT MASK-LARGE OPTICHAMBER DIAMOND VHC OPTIUM EZ TEST STRIP OPTIUM TEST STRIP OPTUMRX TEST STRIP ORTHO ALL-FLEX FITTING SET PANDA MASK SMALL PARADIGM INFUSION 24" SET PARADIGM INSULIN PUMP PARADIGM RESERVOIR 1.8 ML PARADIGM RESERVOIR 3 ML PEAK-AIR PEAK FLOW METER PEDIATRIC MEDIUM MASK PEDIATRIC MOUTHPIECE PEDIATRIC PANDA MASK PERSONAL BEST PEAK FLOW MTR PFLEX INSPIRATORY TRAINER PHARMACIST CHOICE 30G LANCETS PHARMACIST CHOICE TEST STRIPS PHARMACIST CHOICE TEST STRIPS PIKO 1 FLOW METER POCKET CHAMBER POCKET PEAK FLOW METER POLYFIN QR INFUSION SET PRECISION XTR B-KETONE STRIP

3 3 3 NC NC 3 NC MD MD NC NC NC 0 MD MD MD MD MD MD MD MD MD MD MD 3 NC NC MD MD MD MD 3

HSA* HSA* HSA*

PRECISION XTRA MONITOR

MD

PRECISION XTRA TEST STRIPS PREMIUM V10 GLUCOSE TEST STRIP PRESERA FOAM PRESSURE ACTIVATED 21G LANCETS PRESSURE ACTIVATED 28G LANCETS PRIMEAIRE CHAMBER PROCHAMBER HOLDING CHAMBER PRODIGY NO CODING TEST STRIPS PRODIGY PRESSURE ACTIVATED 28G PRODIGY SAFETY 26G LANCETS PRODIGY TWIST TOP 28G LANCET PROMISEB COMPLETE KIT PROMISEB TOPICAL CREAM PRUMYX CREAM PUSH BUTTON SAFETY 21G LANCET PUSH BUTTON SAFETY 28G LANCET PV TRUETRACK SMART SYS STRIPS QC UNILET SUPER THIN 30G LANCT QUICK RELEASE TEFLN CANNULA QUINTET AC GLUCOSE TEST STRIPS QUINTET GLUCOSE TEST STRIPS RA E-ZJECT 26G LANCETS RA E-ZJECT 28G LANCETS REFUAH PLUS TEST STRIPS RELIAMED 30G LANCETS

3 NC NC 3 3 MD MD NC 3 3 3 NC NC 2 3 3 NC 3 MD NC NC 3 3 NC 3

VALUE FORMULARY FIVE-TIER DRUG LIST

HSA*

ACA*

HSA*

Max. 204 per 30 days HSA* Max. 1 in 365 days HSA* Max. 204 per 30 days

HSA* HSA*

HSA* HSA* HSA*

HSA* HSA* HSA*

HSA* HSA* HSA*

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LIMITATIONS/ * NOTES

RELIAMED SAFETY 23G LANCETS RELIAMED SAFETY 28G LANCETS RELIAMED SAFETY SEAL 28G LANCT RELIAMED SAFETY SEAL 30G LANCT RELION CONFIRM-MICRO TEST STRP RELION MICRO TEST STRIPS RELION PRIME TEST STRIPS RELION THIN 26G LANCETS RELION ULTIMA TEST STRIPS RELION ULTRA THIN PLUS 33G RELION ULTRA THIN PLUS LANCETS RENEW ADVANCED MICRO-LANCETS REVEAL TEST STRIP RIGHTEST GL300 30G LANCETS RIGHTEST GS100 TEST STRIPS RIGHTEST GS250S TEST STRIPS RIGHTEST GS260 TEST STRIPS RIGHTEST GS300 TEST STRIPS RIGHTEST GS550 TEST STRIPS RITEFLO SPACER SAFESNAP ALLERGY SYRINGE 1 ML SAFESNAP SYRINGE 10 ML SAFESNAP SYRINGE 3 ML SAFESNAP SYRINGE 3 ML SAFESNAP SYRINGE 5 ML SAFESNAP SYRINGE 5 ML SAFESNAP TUBERCULIN SYR 1 ML SAFETY 21G LANCETS SAFETY 28G LANCETS SAFETY LANCETS 26G SAFETY SEAL 28G LANCETS SAFETY SEAL 30G LANCETS SAFETY SYRINGE W-SHIELD 3 ML SAFETY-LET 30G LANCETS SAFETY-LOK 1 ML TB SYRINGE SAFETY-LOK 10 ML SYRINGE SAFETY-LOK 10 ML SYRINGE SAFETY-LOK 3 ML SYRINGE SAFETY-LOK 3 ML SYRINGE SAFETY-LOK 3 ML SYRINGE SAFETY-LOK 5 ML SYRINGE SAFETY-LOK 5 ML SYRINGE SB LANCETS THIN 28G SB LANCETS ULTRA THIN 30G SHOPKO ON-THE-GO 30G LANCETS SIDESTREAM PEDIATRIC FACE MASK SILHOUETTE INFUSION SET 43" SILICONE MASK-INFANT SILICONE MASK-PEDIATRIC SINGLE-LET LANCETS SM COLOR LANCETS 21G SM LANCETS 21G SM THIN LANCETS 26G SMART CARESENS N TEST STRIPS SMART SENSE COLOR 33G LANCETS SMART SENSE STANDARD 21G SMART SENSE TEST STRIPS SMART SENSE THIN 26G LANCETS SMARTDIABETES VANTAGE 30G

3 3 3 3 NC NC NC 3 NC 3 3 3 NC 3 NC NC NC NC NC MD 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 MD MD MD MD 3 3 3 3 NC 3 3 NC 3 3

HSA* HSA* HSA* HSA*

VALUE FORMULARY FIVE-TIER DRUG LIST

HSA* HSA* HSA* HSA* HSA*

HSA* HSA* HSA* HSA* HSA* HSA*

HSA* HSA* HSA*

HSA* HSA* HSA* HSA* HSA* HSA* HSA* HSA*

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DRUG NAME

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SMARTDIABETES XPRES TEST STRIP SMARTEST LANCET SMARTEST TEST STRIPS SOF-SET MICRO INFUSION SET SOF-SET ULTIMATE QR SET SOFT TOUCH LANCETS SOLUS V2 28G LANCETS SOLUS V2 30G TWIST LANCETS SOLUS V2 AUDIBLE TEST STRIPS SONAFINE TOPICAL EMULSION SPACE CHAMBER PLUS STERILANCE TL TWIST 30G LANCET STERILANCE TL TWIST 32G LANCET SUPER THIN 28G LANCETS SUPER THIN 33G LANCETS SURE COMFORT 28G LANCETS SURE COMFORT 30G LANCETS SURE EDGE TEST STRIPS SURE-LANCE 26G LANCETS SURE-LANCE FLAT LANCETS SURE-LANCE THIN 28G LANCETS SURE-LANCE ULTRA THIN 30G SURE-T PARADIGM 23" SET SURE-TEST EASYPLUS MINI STRIP SURE-TOUCH LANCET SURECHEK TEST STRIPS SURESTEP PRO TEST STRIPS SYRINGE 35 ML SYRINGE W-NEEDLE 1 ML 25X1" SYRINGE W-O NDL 12 ML-NON-STRL SYRINGE W-O NDL 20 ML-NON-STRL SYRINGE W-O NDL 3 ML NON-STRL SYRINGE W-O NDL 35 ML-NON-STRL SYRINGE W-O NEEDLE 140 ML SYRINGE W-O NEEDLE 60 ML SYRINGE W-O NEEDLE 60 ML TD GOLD TEST STRIP TECHLITE 28G LANCETS TECHLITE 30G LANCETS TELCARE TEST STRIPS TELCARE ULTRA THIN 30G LANCETS TERUMO ALLERGY 1 ML 27GX1/2" TERUMO HYPODERMIC NDL-SYRIN TERUMO SURGUARD2 SYR 20G-10 ML TERUMO SURGUARD2 SYR 20G-3 ML TERUMO SURGUARD2 SYR 20G-5 ML TERUMO SURGUARD2 SYR 21G 3 ML TERUMO SURGUARD2 SYR 21G-10 ML TERUMO SURGUARD2 SYR 21G-3 ML TERUMO SURGUARD2 SYR 21G-5 ML TERUMO SURGUARD2 SYR 22G 3 ML TERUMO SURGUARD2 SYR 23G 3 ML TERUMO SURGUARD2 SYR 25G 3 ML TERUMO SURGUARD2 SYR 25G-1 ML TERUMO SURGUARD2 SYR 26G-1 ML TERUMO SURGUARD2 SYR 27G-1 ML TERUMO SYRINGE 3 ML TERUMO SYRINGE 30 ML TEST N'GO GLUCOSE TEST STRIP

NC 3 NC MD MD 3 3 3 NC 2 MD 3 3 3 3 3 3 NC 3 3 3 3 MD NC 3 NC NC 3 3 3 3 3 3 3 3 3 NC 3 3 NC 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 NC

VALUE FORMULARY FIVE-TIER DRUG LIST

LIMITATIONS/ * NOTES HSA*

HSA* HSA* HSA*

HSA* HSA* HSA* HSA* HSA* HSA* HSA* HSA* HSA* HSA*

HSA*

HSA* HSA* HSA*

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DRUG NAME

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TETRIX CREAM KIT THIN LANCETS 28G THRESHOLD IMT TRAINER THRESHOLD PEP DEVICE TL-CERMIDE SKIN EMULSION TOOMEY SYRINGE 70 ML TOPCARE UNIVERSAL1 33G LANCETS TOPCARE UNIVERSAL1 THIN LANCET TROPAZONE LOTION TRUE METRIX GLUCOSE TEST STRIP TRUEPLUS 26G LANCETS TRUEPLUS 33G LANCETS TRUEPLUS SAFETY 28G LANCETS TRUEPLUS SUPER THIN 28G LANCET TRUEPLUS ULTRA THIN 30G LANCET TRUETEST GLUCOSE TEST STRIPS TRUETRACK GLUCOSE TEST STRIPS TRUZONE PEAK FLOW METER TUBERCULIN 1 ML SYRINGE TUBERCULIN SYRINGE TUBERCULIN SYRINGES ULTICARE SYR 1.5 ML 22GX1 1/2" ULTICARE TB SAFETY 1 ML 25GX1" ULTICARE TB SAFETY 1ML 25GX5/8 ULTICARE THIN 28G LANCETS ULTICARE THIN 30G LANCETS ULTILET 28G LANCETS ULTILET 30G LANCETS ULTILET 33G LANCETS ULTILET BASIC 30G LANCETS ULTILET CLASSIC 26G LANCETS ULTILET CLASSIC 28G LANCETS ULTILET CLASSIC 30G LANCETS ULTILET CLASSIC 33G LANCETS ULTILET SAFETY 23G LANCETS ULTIMA TEST STRIPS ULTRA THIN 28G LANCETS ULTRA THIN 30G LANCETS ULTRA THIN 31G LANCETS ULTRA THIN 33G LANCETS ULTRA-THIN II 26G LANCET ULTRA-THIN II 28G LANCETS ULTRA-THIN II 30G LANCETS ULTRALANCE 26G LANCETS ULTRALANCE 28G LANCETS ULTRATLC LANCETS ULTRATRAK TEST STRIP ULTRATRAK ULTIMATE TEST STRIPS UNILET COMFORTOUCH 26G LANCETS UNILET COMFORTOUCH LANCET UNILET EXCELITE II LANCET UNILET EXCELITE LANCET UNILET GP LANCET UNILET LANCET SUPERLITE UNILET MICRO THIN 33G LANCETS UNILET ULTRA THIN 28G LANCETS UNISTIK 3 COMFORT LANCET UNISTIK 3 EXTRA 21G LANCETS UNISTIK 3 GENTLE 30G LANCETS

NC 3 MD MD 2 3 3 3 NC NC 3 3 3 3 3 NC NC MD 3 3 3 NC 3 3 3 3 3 3 3 3 3 3 3 3 3 NC 3 3 3 3 3 3 3 3 3 3 NC NC 3 3 3 3 3 3 3 3 3 3 3

VALUE FORMULARY FIVE-TIER DRUG LIST

LIMITATIONS/ * NOTES HSA*

HSA* HSA*

HSA* HSA* HSA* HSA* HSA*

HSA* HSA* HSA* HSA* HSA* HSA* HSA* HSA* HSA* HSA* HSA* HSA* HSA* HSA* HSA* HSA* HSA* HSA* HSA* HSA* HSA*

HSA* HSA* HSA* HSA* HSA* HSA* HSA* HSA* HSA* HSA* HSA*

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DRUG NAME

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LIMITATIONS/ * NOTES

UNISTIK 3 NORMAL 23G LANCETS UNISTIK 3 SAFETY 21G LANCETS UNISTIK CZT COMFORT 28G LANCET UNISTIK CZT NORMAL 23G LANCETS UNISTIK SAFETY 28G LANCET UNISTIK SAFETY 30G LANCETS UNISTIK TOUCH 21G LANCETS UNISTIK TOUCH 23G LANCETS UNISTIK TOUCH 28G LANCETS UNISTIK TOUCH 30G LANCETS UNISTRIP1 GLUCOSE TEST STRIP UNIVERSAL 1 33G LANCETS VANISHPOINT 1 ML TB SYR 25X5/8 VANISHPOINT 1 ML TB SYR 27X1/2 VANISHPOINT 10 ML 21GX1-1/2" VANISHPOINT 20GX1" 3 ML SYRING VANISHPOINT 21GX1" 5 ML SYRING VANISHPOINT 21GX1.5" 3 ML SYR VANISHPOINT 22GX1" 3 ML SYR VANISHPOINT 22GX1-1/2" 5 ML SY VANISHPOINT 23GX1" 3 ML SYRING VANISHPOINT 23GX1-1/2 3 ML SYR VANISHPOINT 25GX1" 3 ML SYRING VANISHPOINT 25GX5/8" 3 ML SYR VANISHPOINT 3 ML 21GX1" SYRING VANISHPOINT 3 ML 22GX1.5" SYRG VANISHPOINT 5 ML 21GX1-1/2" VANISHPOINT SYRINGE 1 ML 25X1" VGO 40 DISPOSABLE DEVICE

3 3 3 3 3 3 3 3 3 3 NC 3 3 3 4 3 3 3 4 3 NC 4 3 4 4 4 4 3 3

HSA* HSA* HSA* HSA* HSA* HSA* HSA* HSA* HSA* HSA*

VICTORY GLUCOSE TEST STRIPS VOCAL POINT TEST STRIP VORTEX ADULT MASK VORTEX FROG CHILD MASK VORTEX HOLDING CHAMBER VORTEX LADYBUG TODDLER MASK VORTEX VHC FROG CHILD MASK WALGREENS ULTRA THIN LANCETS WATCHHALER SPACER WAVESENSE JAZZ TEST STRIPS WAVESENSE PRESTO TEST STRIPS WINDMILL TRAINER YALE GLASS TB SYR 0.25 ML YALE GLASS TB SYRINGE 1 ML YALE GLASS TB SYRINGE 2 ML YALE NEEDLES 21GX1" YALE NEEDLES 21GX1.25" YALE NEEDLES 21GX1.5" YALE NEEDLES 22GX1" YALE NEEDLES 22GX1.25" YALE NEEDLES 23GX1" YALE SYRINGE 10 ML YALE SYRINGE 100 ML YALE SYRINGE 20 ML YALE SYRINGE 3 ML YALE SYRINGE 30 ML YALE SYRINGE 5 ML YALE SYRINGE 50 ML

NC NC MD MD MD MD MD 3 MD NC NC MD 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3

VALUE FORMULARY FIVE-TIER DRUG LIST

HSA*

Max. 1 per day HSA*

HSA*

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DRUG NAME

TIER

LIMITATIONS/ * NOTES

ENZYME REPLACEMENT/MODIFIERS ENZYME REPLACEMENT/MODIFIERS ADAGEN 250 UNITS/ML VIAL ALDURAZYME 2.9 MG/5 ML VIAL CEREZYME 400 UNITS VIAL

MD MD MD

CHENODAL 250 MG TABLET CREON DR 12,000 UNITS CAPSULE CREON DR 24,000 UNITS CAPSULE CREON DR 3,000 UNITS CAPSULE CREON DR 36,000 UNITS CAPSULE CREON DR 6,000 UNITS CAPSULE CYSTAGON 150 MG CAPSULE CYSTAGON 50 MG CAPSULE ELAPRASE 6 MG/3 ML VIAL ELELYSO 200 UNITS VIAL

NC 3 3 3 3 3 5 5 MD MD

FABRAZYME 35 MG VIAL HYDROCHLORIC ACID 10% SOLN HYDROCHLORIC ACID LIQUID KRYSTEXXA 8 MG/ML VIAL KUVAN 100 MG POWDER PACKET KUVAN 100 MG TABLET KUVAN 500 MG POWDER PACKET LUMIZYME 50 MG VIAL

MD NC NC MD 4 4 4 MD

MYOZYME 50 MG VIAL

MD

NAGLAZYME 5 MG/5 ML VIAL ORFADIN 10 MG CAPSULE ORFADIN 2 MG CAPSULE ORFADIN 20 MG CAPSULE ORFADIN 4 MG/ML SUSPENSION ORFADIN 5 MG CAPSULE PANCREAZE DR 10,500 UNIT CAP PANCREAZE DR 16,800 UNIT CAP PANCREAZE DR 2,600 UNIT CAP PANCREAZE DR 21,000 UNIT CAP PANCREAZE DR 4,200 UNIT CAP PANCRELIPASE DR 5,000 UNIT CAP PERTZYE DR 16,000 UNITS CAPS PERTZYE DR 4,000 UNIT CAPSULE PERTZYE DR 8,000 UNITS CAPSULE PULMOZYME 1 MG/ML AMPUL STRENSIQ 18 MG/0.45 ML VIAL STRENSIQ 28 MG/0.7 ML VIAL STRENSIQ 40 MG/ML VIAL STRENSIQ 80 MG/0.8 ML VIAL SUCRAID 8,500 UNITS/ML SOLN ULTRESA DR 13,800 UNIT CAPSULE ULTRESA DR 20,700 UNIT CAPSULE ULTRESA DR 23,000 UNIT CAPSULE VIOKACE 10,440-39,150 UNITS TB VIOKACE 20,880-78,300 UNITS TB VPRIV 400 UNITS VIAL

MD 5 5 5 5 5 3 3 3 3 3 2 4 4 4 4 NC NC NC NC 5 4 4 4 4 4 MD

VALUE FORMULARY FIVE-TIER DRUG LIST

SPP*: Must use Accredo Prior Authorization required SPP*: Must use Accredo

SPP*: Must use Accredo Prior Authorization required LDD*: Dohmen Life Sciences. 1-800-305-7881. SPP*: Must use Accredo

SPP*: Must use Magellan Rx SPP*: Must use Accredo SPP*: Must use Magellan Rx SPP*: Must use Magellan Rx Prior Authorization required SPP*: Must use Accredo Prior Authorization required SPP*: Must use Accredo SPP*: Must use Accredo LDD*: Dohmen Life Sciences. 1-800-305-7881. LDD*: Dohmen Life Sciences. 1-800-305-7881. LDD*: Dohmen Life Sciences. 1-800-305-7881. LDD*: Dohmen Life Sciences. 1-800-305-7881.

SPP*: Accredo

Prior Authorization required SPP*: Must use Accredo

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DRUG NAME

TIER

LIMITATIONS/ * NOTES

XIAFLEX 0.9 MG VIAL

MD

ZAVESCA 100 MG CAPSULE ZENPEP DR 10,000 UNITS CAPSULE ZENPEP DR 15,000 UNITS CAPSULE ZENPEP DR 20,000 UNITS CAPSULE ZENPEP DR 25,000 UNITS CAPSULE ZENPEP DR 3,000 UNITS CAPSULE ZENPEP DR 40,000 UNITS CAPSULE ZENPEP DR 5,000 UNITS CAPSULE

5 3 3 3 3 3 3 3

SPP*: Must use Accredo; For the treatment of Peyronie's Disease call U.S. Bioservices at 1-888-518-7246 or go to www.usbioservices.com SPP*: Must use Accredo

EYE, EAR, NOSE, THROAT AGENTS EYE, EAR, NOSE, THROAT AGENTS, MISCELLANEOUS ADRENALIN 1 MG/ML NASAL SOLN ALCAINE 0.5% EYE DROPS ALOMIDE 0.1% EYE DROPS ALTACAINE 0.5% EYE DROPS APRACLONIDINE HCL 0.5% DROPS ASTELIN 137 MCG NASAL SPRAY ASTEPRO 0.15% NASAL SPRAY ATROPINE 1% EYE DROPS ATROPINE 1% EYE OINTMENT ATROPINE CARE 1% EYE DROPS ATROVENT 0.03% SPRAY ATROVENT 0.06% SPRAY AZELASTINE 0.1% (137 MCG) SPRY AZELASTINE 0.15% NASAL SPRAY AZELASTINE HCL 0.05% DROPS BEPREVE 1.5% EYE DROPS CARTEOLOL HCL 1% EYE DROPS CROMOLYN 4% EYE DROPS CYCLOGYL 0.5% EYE DROPS CYCLOGYL 1% EYE DROPS CYCLOGYL 2% EYE DROPS CYCLOMYDRIL EYE DROPS CYCLOPENTOLATE 0.5% EYE DROPS CYCLOPENTOLATE 1% EYE DROPS CYCLOPENTOLATE HCL 2% DROPS CYSTARAN 0.44% EYE DROPS

NC 2 4 2 2 NC NC 2 2 2 NC NC 2 NC 2 5 2 2 NC NC NC NC 2 2 2 5

DYMISTA NASAL SPRAY ELESTAT 0.05% EYE DROPS EMADINE 0.05% EYE DROPS EPINASTINE HCL 0.05% EYE DROPS EYLEA 2 MG/0.05 ML VIAL

3 NC 4 2 MD

FLUCAINE EYE DROPS GELFILM OPHTHALMIC 25X50MM HOMATROPAIRE 5% EYE DROPS HOMATROPINE 5% EYE DROPS IOPIDINE 0.5% EYE DROPS IOPIDINE 1% EYE DROPS IPRATROPIUM 0.03% SPRAY IPRATROPIUM 0.06% SPRAY ISOPTO ATROPINE 1% EYE DROPS ISOPTO HOMATROPINE 2% DROPS

NC NC 2 2 NC 4 2 2 NC NC

VALUE FORMULARY FIVE-TIER DRUG LIST

Prior Authorization required HSA*

LDD*: Walgreens Specialty. CYSTARAN Hotline: 1-877-534-9627.

Prior Authorization required SPP*: Must use Accredo

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DRUG NAME

TIER

ISOPTO HOMATROPINE 5% DROPS ISOPTO HYOSCINE 0.25% DROPS LACRISERT 5 MG EYE INSERT LASTACAFT 0.25% EYE DROPS MYDFRIN 2.5% EYE DROPS MYDRIACYL 1% EYE DROPS NAPHAZOLINE 0.1% EYE DROPS OLOPATADINE 665 MCG NASAL SPRY OLOPATADINE HCL 0.1% EYE DROPS OPTIVAR 0.05% DROPS OTICIN DROPS OTIPRIO 6% VIAL OTOVEL 0.3%-0.025% EAR DROPS OZURDEX 0.7 MG IMPLANT PARCAINE 0.5% EYE DROPS PAREMYD EYE DROPS PATADAY 0.2% EYE DROPS PATANASE 665 MCG NASAL SPRAY PATANOL 0.1% EYE DROPS PAZEO 0.7% EYE DROPS PHENYLEPHRINE 10% EYE DROPS PHENYLEPHRINE 2.5% EYE DROP PROPARACAINE 0.5% EYE DROPS TETRACAINE 0.5% EYE DROPS TETRAVISC FORTE 0.5% EYE DROPS TROPICAMIDE 0.5% EYE DROPS TROPICAMIDE 1% EYE DROPS TYZINE 0.1% NOSE DROPS TYZINE 0.1% NOSE SPRAY

NC NC 4 4 NC NC 1 2 2 NC 2 NC NC MD 2 NC 3 NC NC NC 2 2 2 2 NC 2 2 4 4

LIMITATIONS/ * NOTES

SPP*: Must use Accredo

EYE, EAR, NOSE, THROAT ANTI-INFECTIVES AGENTS ACETASOL HC EAR DROPS ACETIC ACID-ALUMINUM DROPS ANTIPYRINE-BENZOCAINE EAR DROP ANTIPYRINE-BENZOCAINE OTIC SOL AURAX OTIC SOLUTION AURODEX OTIC SOLUTION AZASITE 1% EYE DROPS BACITRACIN 500 UNIT/GM OPHTH BACITRACIN-POLYMYXIN EYE OINT BESIVANCE 0.6% SUSP BETADINE 5% EYE SOLUTION BLEPH-10 10% EYE DROPS BLEPHAMIDE EYE DROPS BLEPHAMIDE EYE OINTMENT CETRAXAL 0.2% EAR SOLUTION CILOXAN 0.3% EYE DROPS CILOXAN 0.3% OINTMENT CIPRO HC OTIC SUSPENSION CIPRODEX OTIC SUSPENSION CIPROFLOXACIN 0.2% OTIC SOLN CIPROFLOXACIN 0.3% EYE DROP COLY-MYCIN S OTIC SUSP DROP CORTISPORIN EAR SOLUTION CORTISPORIN-TC EAR SUSPENSION CRESYLATE EAR DROPS ERYTHROMYCIN 0.5% EYE OINTMENT

VALUE FORMULARY FIVE-TIER DRUG LIST

2 2 2 2 2 2 4 2 2 4 NC 2 NC NC NC NC 4 4 3 2 2 4 NC 4 2 2

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DRUG NAME

TIER

FLOXIN 0.3% EAR DROPS GARAMYCIN 0.3% EYE DROPS GARAMYCIN 3 MG/GM EYE OINTMENT GATIFLOXACIN 0.5% EYE DROPS GENTAK 0.3 % EYE OINTMENT GENTAMICIN 0.3% EYE OINTMENT GENTAMICIN 3 MG/ML EYE DROPS HYDROCORTISON-ACETIC ACID SOLN ILOTYCIN 0.5% EYE OINTMENT LEVOFLOXACIN 0.5% EYE DROPS MAXITROL EYE DROPS MAXITROL EYE OINTMENT MOXEZA 0.5% EYE DROPS NATACYN EYE DROPS NEO-BACIT-POLY-HC EYE OINTMENT NEO-POLYCIN EYE OINTMENT NEO-POLYCIN HC EYE OINTMENT NEOMYC-BACIT-POLYMIX EYE OINT NEOMYC-POLYM-DEXAMET EYE OINTM NEOMYC-POLYM-DEXAMETH EYE DROP NEOMYC-POLYM-GRAMICID EYE DROP NEOMYCIN-POLY-HC EYE DROPS NEOMYCIN-POLYMYXIN-HC EAR SOLN NEOMYCIN-POLYMYXIN-HC EAR SUSP NEOSPORIN EYE DROPS OCUFLOX 0.3% EYE DROPS OFLOXACIN 0.3% EAR DROPS OFLOXACIN 0.3% EYE DROPS POLYMYXIN B-TMP EYE DROPS POLYTRIM EYE DROPS PRED-G 1% EYE DROPS PRED-G S.O.P. EYE OINTMENT SULF-PRED 10-0.23% EYE DROPS SULFACETAMIDE 10% EYE DROPS SULFACETAMIDE 10% EYE OINTMENT TOBRADEX EYE DROPS TOBRADEX EYE OINTMENT TOBRADEX ST EYE DROPS TOBRAMYCIN 0.3% EYE DROPS TOBRAMYCIN-DEXAMETH OPHTH SUSP TOBREX 0.3% EYE DROPS TOBREX 0.3% EYE OINTMENT TRIFLURIDINE 1% EYE DROPS VIGAMOX 0.5% EYE DROPS VIROPTIC 1% EYE DROPS VOSOL HC EAR DROPS ZIRGAN 0.15% OPHTHALMIC GEL ZYLET EYE DROPS ZYMAXID 0.5% EYE DROPS

NC NC NC 2 2 2 2 2 NC 2 NC NC 4 4 2 2 2 2 2 2 2 2 2 2 NC NC 2 2 2 NC NC NC 2 2 2 NC 3 NC 2 2 NC 3 2 4 NC NC 4 NC NC

LIMITATIONS/ * NOTES

EYE, EAR, NOSE, THROAT ANTI-INFLAMMATORY AGENTS ACULAR 0.5% EYE DROPS ACULAR LS 0.4% OPHTH SOL ACUVAIL 0.45% OPHTH SOLUTION ALOCRIL 2% EYE DROPS ALREX 0.2% EYE DROPS BECONASE AQ 0.042% SPRAY

VALUE FORMULARY FIVE-TIER DRUG LIST

NC NC NC 4 NC NC

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BROMDAY 0.09% EYE DROPS BROMFENAC SODIUM 0.09% EYE DRP BROMSITE 0.075% EYE DROPS BUDESONIDE 32 MCG NASAL SPRAY CORTANE-B LOTION CORTANE-B OTIC DROPS DERMOTIC OIL 0.01% EAR DROPS DEXAMETHASONE 0.1% EYE DROP DICLOFENAC 0.1% EYE DROPS DUREZOL 0.05% EYE DROPS EXOTIC-HC EAR DROP FLAREX 0.1% EYE DROPS FLONASE 0.05% NASAL SPRAY FLUNISOLIDE 0.025% SPRAY FLUNISOLIDE 29 MCG-0.025% SPR FLUOCINOLONE OIL 0.01% EAR DRP FLUOROMETHOLONE 0.1% DROPS FLURBIPROFEN 0.03% EYE DROP FLUTICASONE PROP 50 MCG SPRAY FML FORTE 0.25% EYE DROPS FML LIQUIFILM 0.1% EYE DROP FML S.O.P. 0.1% OINTMENT ILEVRO 0.3% OPHTH DROPS KETOROLAC 0.4% OPHTH SOLUTION KETOROLAC 0.5% OPHTH SOLUTION LOTEMAX 0.5% EYE DROPS LOTEMAX 0.5% EYE OINTMENT LOTEMAX 0.5% OPHTHALMIC GEL MAXIDEX 0.1% EYE DROPS MOMETASONE FUROATE 50 MCG SPRY NASACORT AQ NASAL SPRAY NASONEX 50 MCG NASAL SPRAY NEVANAC 0.1% DROPTAINER OCUFEN 0.03% EYE DROPS OMNARIS 50 MCG NASAL SPRAY OMNIPRED 1% EYE DROPS OTICIN HC DROPS OTO-END 10 EAR DROPS OTOMAX-HC EAR DROPS PRED FORTE 1% EYE DROPS PRED MILD 0.12% EYE DROPS PREDNISOLONE AC 1% EYE DROP PREDNISOLONE SOD 1% EYE DROP PROLENSA 0.07% EYE DROPS QNASL 80 MCG NASAL SPRAY QNASL CHILDREN'S 40 MCG SPRAY RESTASIS 0.05% EYE EMULSION RESTASIS MULTIDOSE 0.05% EYE RHINOCORT AQUA NASAL SPRAY TRIAMCINOLONE 55 MCG NASAL SPR VERAMYST 27.5 MCG NASAL SPRAY VEXOL 1% EYE DROPS XIIDRA 5% EYE DROPS ZETONNA 37 MCG NASAL SPRAY

4 2 NC NC NC 2 NC 2 2 4 2 4 NC 2 2 2 2 2 1 4 NC 4 NC 2 2 3 3 3 4 2 NC NC 4 NC NC NC NC 2 2 NC 4 2 2 NC NC 4 3 3 NC 2 3 4 NC NC

LIMITATIONS/ * NOTES

Max. 2 per day Max. 2 ML(s) per day

GASTROINTESTINAL AGENTS ANTIULCER AGENTS AND ACID SUPPRESSANTS VALUE FORMULARY FIVE-TIER DRUG LIST

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DRUG NAME

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LIMITATIONS/ * NOTES

ACID REDUCER 20 MG TABLET ACIPHEX DR 20 MG TABLET ACIPHEX SPRINKLE DR 10 MG CAP ACIPHEX SPRINKLE DR 5 MG CAP AXID 15 MG/ML ORAL SOLUTION CARAFATE 1 GM TABLET CARAFATE 1 GM/10 ML SUSP CIMETIDINE 200 MG TABLET CIMETIDINE 300 MG TABLET CIMETIDINE 300 MG/5 ML SOLN CIMETIDINE 400 MG TABLET CIMETIDINE 800 MG TABLET CYTOTEC 100 MCG TABLET CYTOTEC 200 MCG TABLET DEPRIZINE ORAL SUSPENSION DEXILANT DR 30 MG CAPSULE DEXILANT DR 60 MG CAPSULE ESOMEPRAZOLE DR 24.65 MG CAP ESOMEPRAZOLE DR 49.3 MG CAP ESOMEPRAZOLE MAG DR 20 MG CAP ESOMEPRAZOLE MAG DR 40 MG CAP FAMOTIDINE 20 MG TABLET FAMOTIDINE 40 MG TABLET FAMOTIDINE 40 MG/5 ML SUSP FIRST-LANSOPRAZOLE 3 MG/ML FIRST-OMEPRAZOLE 2 MG/ML SUSP LANSOPRAZOL-AMOXICIL-CLARITHRO LANSOPRAZOLE DR 15 MG CAPSULE LANSOPRAZOLE DR 30 MG CAPSULE MISOPROSTOL 100 MCG TABLET MISOPROSTOL 200 MCG TABLET NEXIUM 24HR 20 MG TABLET NEXIUM 24HR 22.3 MG CAPSULE NEXIUM DR 10 MG PACKET NEXIUM DR 2.5 MG PACKET NEXIUM DR 20 MG CAPSULE NEXIUM DR 20 MG PACKET NEXIUM DR 40 MG CAPSULE NEXIUM DR 40 MG PACKET NEXIUM DR 5 MG PACKET NIZATIDINE 15 MG/ML SOLUTION NIZATIDINE 150 MG CAPSULE NIZATIDINE 300 MG CAPSULE OMECLAMOX-PAK COMBO PACK OMEPRAZOLE DR 10 MG CAPSULE OMEPRAZOLE DR 20 MG CAPSULE OMEPRAZOLE DR 40 MG CAPSULE OMEPRAZOLE+SYRSPEND SF ALKA KT OMEPRAZOLE-BICARB 20-1,100 CAP OMEPRAZOLE-BICARB 20-1,680 PKT OMEPRAZOLE-BICARB 40-1,100 CAP OMEPRAZOLE-BICARB 40-1,680 PKT PANTOPRAZOLE SOD DR 20 MG TAB PANTOPRAZOLE SOD DR 40 MG TAB PEPCID 20 MG TABLET PEPCID 40 MG TABLET PEPCID 40 MG/5 ML ORAL SUSP PREVACID 15 MG SOLUTAB

1 NC NC NC NC NC 4 1 1 2 1 2 NC NC NC 5 5 4 4 4 4 1 1 2 4 4 2 3 3 2 1 1 1 4 4 NC 4 NC 4 4 2 2 2 NC 2 1 2 4 NC NC NC NC 1 1 NC NC NC 3

Max. 180 Days Supply;Max. 1 per day

VALUE FORMULARY FIVE-TIER DRUG LIST

Prior Authorization required Prior Authorization required

Prior Authorization required

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DRUG NAME

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PREVACID 30 MG SOLUTAB PREVACID DR 15 MG CAPSULE PREVACID DR 30 MG CAPSULE PREVPAC PATIENT PACK PRILOSEC DR 10 MG CAPSULE PRILOSEC DR 10 MG SUSPENSION PRILOSEC DR 2.5 MG SUSPENSION PRILOSEC DR 20 MG CAPSULE PRILOSEC DR 40 MG CAPSULE PROTONIX 40 MG SUSPENSION PROTONIX DR 20 MG TABLET PROTONIX DR 40 MG TABLET RABEPRAZOLE SOD DR 20 MG TAB RANITIDINE 15 MG/ML SYRUP RANITIDINE 150 MG CAPSULE RANITIDINE 150 MG TABLET RANITIDINE 300 MG CAPSULE RANITIDINE 300 MG TABLET SUCRALFATE 1 GM TABLET ZANTAC 15 MG/ML SYRUP ZANTAC 150 MG TABLET ZANTAC 25 EFFERDOSE TABLET ZANTAC 300 MG TABLET ZEGERID 20 MG CAPSULE ZEGERID 20 MG PACKET ZEGERID 40 MG CAPSULE ZEGERID 40 MG PACKET

3 NC NC NC NC 4 4 NC NC 4 NC NC 3 2 2 1 2 1 2 NC NC NC NC NC NC NC NC

LIMITATIONS/ * NOTES

GASTROINTESTINAL AGENTS, OTHER ACTIGALL 300 MG CAPSULE AMITIZA 24 MCG CAPSULES AMITIZA 8 MCG CAPSULE BENTYL 10 MG CAPSULE BENTYL 20 MG TABLET BUPHENYL 500 MG TABLET BUPHENYL POWDER CANTIL 25 MG TABLET CARBAGLU 200 MG DISPER TABLET CHOLBAM 250 MG CAPSULE CHOLBAM 50 MG CAPSULE CONSTULOSE 10 GM/15 ML SOLN CROMOLYN 100 MG/5 ML ORAL CONC CUVPOSA 1 MG/5 ML SOLUTION DICYCLOMINE 10 MG CAPSULE DICYCLOMINE 10 MG/5 ML SOLN DICYCLOMINE 20 MG TABLET DIPHENOXYLAT-ATROP 2.5-0.025/5 DIPHENOXYLATE-ATROP 2.5-0.025 ENTEREG 12 MG CAPSULE ENULOSE 10 GM/15 ML SOLUTION FULYZAQ 125 MG DR TABLET GASTROCROM 100 MG/5 ML CONC GATTEX 5 MG 30-VIAL KIT GENERLAC 10 GM/15 ML SOLUTION GLYCATE 1.5 MG TABLET GLYCOPYRROLATE 1 MG TABLET GLYCOPYRROLATE 2 MG TABLET

VALUE FORMULARY FIVE-TIER DRUG LIST

NC 4 4 NC NC 4 NC 4 5 NC NC 2 2 4 2 2 2 2 2 NC 2 4 NC NC 2 NC 2 2

SPP*: Accredo

HSA* LDD*: Diplomat Pharmacy. 1-877-977-9118.

Step Therapy required

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DRUG NAME

TIER

HELIDAC THERAPY KAYEXALATE POWDER KIONEX 15 GM/60 ML SUSPENSION KRISTALOSE 10 GM PACKET KRISTALOSE 20 GM PACKET LACTULOSE 10 GM/15 ML SOLUTION LINZESS 145 MCG CAPSULE LINZESS 290 MCG CAPSULE LOMOTIL 2.5-0.025 MG TABLET LOPERAMIDE 2 MG CAPSULE METHSCOPOLAMINE BROM 2.5 MG TB METHSCOPOLAMINE BROM 5 MG TAB METOCLOPRAMIDE 10 MG TABLET METOCLOPRAMIDE 5 MG TABLET METOCLOPRAMIDE 5 MG/5 ML SOLN METOCLOPRAMIDE HCL ODT 10 MG METOCLOPRAMIDE HCL ODT 5 MG TB METOZOLV ODT 5 MG TABLET MOTOFEN TABLET MOVANTIK 12.5 MG TABLET MOVANTIK 25 MG TABLET MYTESI 125 MG DR TABLET NUTRESTORE POWDER PACKET OCALIVA 10 MG TABLET OCALIVA 5 MG TABLET OPIUM TINCTURE 10 MG/ML PAMINE 2.5 MG TABLET PAMINE FORTE 5 MG TABLET PAREGORIC LIQUID PYLERA CAPSULE RAVICTI 1.1 GRAM/ML LIQUID REGLAN 10 MG TABLET REGLAN 5 MG TABLET RELISTOR 12 MG/0.6 ML SYRINGE RELISTOR 12 MG/0.6 ML VIAL RELISTOR 150 MG TABLET RELISTOR 8 MG/0.4 ML SYRINGE ROBINUL 1 MG TABLET ROBINUL FORTE 2 MG TABLET SOD POLYSTYREN SULF 15 G/60 ML SODIUM PHENYLBUTYRATE POWDER SPS 15 GM/60 ML SUSPENSION SPS 30 GM/120 ML ENEMA URSO 250 MG TABLET URSO FORTE 500 MG TABLET URSODIOL 250 MG TABLET URSODIOL 300 MG CAPSULE URSODIOL 500 MG TABLET VELTASSA 16.8 GM POWDER PACKET VELTASSA 25.2 GM POWDER PACKET VELTASSA 8.4 GM POWDER PACKET VIBERZI 100 MG TABLET VIBERZI 75 MG TABLET

NC NC 2 3 3 2 3 3 NC NC 2 2 1 1 2 2 2 NC 4 3 3 4 NC NC NC 2 NC NC 2 NC NC NC NC 3 3 NC 3 NC NC 2 2 2 2 NC NC 2 2 2 4 4 4 3 3

LIMITATIONS/ * NOTES

Step Therapy required

LAXATIVES COLYTE WITH FLAVOR PACKETS GAVILYTE-C SOLUTION

VALUE FORMULARY FIVE-TIER DRUG LIST

NC 0

ACA*

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DRUG NAME

TIER

LIMITATIONS/ * NOTES

GAVILYTE-G SOLUTION GAVILYTE-H AND BISACODYL KIT GAVILYTE-N SOLUTION GOLYTELY PACKET GOLYTELY SOLUTION HALFLYTELY-BISACODYL BOWEL KIT MOVIPREP POWDER PACKET NULYTELY WITH FLAVOR PACKS SOL OSMOPREP TABLET PEG 3350 ELECTROLYTE SOLN PEG 3350-ELECTROLYTE SOLUTION PEG-3350 AND ELECTROLYTES SOLN PEG-PREP KIT POLYETHYLENE GLYCOL 3350 POWD PREPOPIK POWDER PACKET SORBITOL 70% SOLUTION SUCLEAR BOWEL PREP KIT SUPREP BOWEL PREP KIT TRILYTE WITH FLAVOR PACKETS

0 0 0 NC NC 4 3 NC 4 0 0 0 4 2 3 NC NC 4 0

ACA* ACA* ACA*

ACA* ACA* ACA*

ACA*

PHOSPHATE BINDERS AURYXIA 210 MG TABLET CALCIUM ACETATE 667 MG GELCAP CALCIUM ACETATE 667 MG TABLET ELIPHOS 667 MG TABLET FOSRENOL 1,000 MG POWDER PACK FOSRENOL 1,000 MG TABLET CHEW FOSRENOL 500 MG TABLET CHEW FOSRENOL 750 MG POWDER PACKET FOSRENOL 750 MG TABLET CHEW MAGNEBIND 400 RX TABLET PHOSLO 667 MG GELCAP PHOSLYRA 667 MG/5 ML SOLUTION RENAGEL 400 MG TABLET RENAGEL 800 MG TABLET RENVELA 0.8 GM POWDER PACKET RENVELA 2.4 GM POWDER PACKET RENVELA 800 MG TABLET SEVELAMER CARBONATE 800 MG TAB VELPHORO 500 MG CHEWABLE TAB

NC 2 2 2 5 5 5 5 5 2 NC 3 NC NC 3 3 3 2 5

Prior Authorization required

GENERAL ANESTHETICS GENERAL ANESTHETICS, MISCELLANEOUS KETALAR 200 MG/20 ML VIAL KETALAR 500 MG/10 ML VIAL KETALAR 500 MG/5 ML VIAL KETAMINE 100 MG/ML VIAL KETAMINE 200 MG/20 ML VIAL KETAMINE 500 MG/10 ML VIAL

NC NC NC NC NC NC

GENITOURINARY AGENTS ANTISPASMODICS, URINARY VALUE FORMULARY FIVE-TIER DRUG LIST

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DRUG NAME

TIER

BETHANECHOL 10 MG TABLET BETHANECHOL 25 MG TABLET BETHANECHOL 5 MG TABLET BETHANECHOL 50 MG TABLET DARIFENACIN ER 15 MG TABLET DARIFENACIN ER 7.5 MG TABLET DETROL 1 MG TABLET DETROL 2 MG TABLET DETROL LA 2 MG CAPSULE DETROL LA 4 MG CAPSULE DITROPAN XL 10 MG TABLET DITROPAN XL 15 MG TABLET DITROPAN XL 5 MG TABLET ENABLEX 15 MG TABLET ENABLEX 7.5 MG TABLET FLAVOXATE HCL 100 MG TABLET GELNIQUE 10% GEL SACHETS GELNIQUE 3% GEL MYRBETRIQ ER 25 MG TABLET MYRBETRIQ ER 50 MG TABLET OXYBUTYNIN 5 MG TABLET OXYBUTYNIN 5 MG/5 ML SYRUP OXYBUTYNIN CL ER 10 MG TABLET OXYBUTYNIN CL ER 15 MG TABLET OXYBUTYNIN CL ER 5 MG TABLET OXYTROL 3.9 MG/24HR PATCH SANCTURA 20 MG TABLET SANCTURA XR 60 MG CAPSULE TOLTERODINE TART ER 2 MG CAP TOLTERODINE TART ER 4 MG CAP TOLTERODINE TARTRATE 1 MG TAB TOLTERODINE TARTRATE 2 MG TAB TOVIAZ ER 4 MG TABLET TOVIAZ ER 8 MG TABLET TROSPIUM CHLORIDE 20 MG TABLET TROSPIUM CHLORIDE ER 60 MG CAP URECHOLINE 10 MG TABLET URECHOLINE 25 MG TABLET URECHOLINE 5 MG TABLET URECHOLINE 50 MG TABLET VESICARE 10 MG TABLET VESICARE 5 MG TABLET

2 2 2 2 2 2 NC NC NC NC NC NC NC 4 4 2 NC NC 3 3 2 2 2 2 2 NC NC NC 2 2 2 2 4 4 2 2 NC NC NC NC 3 3

LIMITATIONS/ * NOTES

GENITOURINARY AGENTS, MISCELLANEOUS ALFUZOSIN HCL ER 10 MG TABLET AVODART 0.5 MG SOFTGEL DUTASTERIDE 0.5 MG CAPSULE DUTASTERIDE-TAMSULOSIN 0.5-0.4 FINASTERIDE 5 MG TABLET FLOMAX 0.4 MG CAPSULE JALYN 0.5-0.4 MG CAPSULE PHENAZOPYRIDINE 100 MG TAB PHENAZOPYRIDINE 200 MG TAB PROSCAR 5 MG TABLET PYRIDIUM 100 MG TABLET PYRIDIUM 200 MG TABLET

VALUE FORMULARY FIVE-TIER DRUG LIST

2 NC 2 2 1 NC NC 2 2 NC NC NC

Max. 1 per day

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DRUG NAME

TIER

RAPAFLO 4 MG CAPSULE RAPAFLO 8 MG CAPSULE TAMSULOSIN HCL 0.4 MG CAPSULE TERAZOSIN 1 MG CAPSULE TERAZOSIN 10 MG CAPSULE TERAZOSIN 2 MG CAPSULE TERAZOSIN 5 MG CAPSULE UROXATRAL 10 MG TABLET

4 4 2 1 1 1 1 NC

LIMITATIONS/ * NOTES

HSA* HSA* HSA* HSA*

HEAVY METAL ANTAGONISTS HEAVY METAL ANTAGONISTS CHEMET 100 MG CAPSULE CUPRIMINE 250 MG CAPSULE DEPEN 250 MG TITRATAB EXJADE 125 MG TABLET EXJADE 250 MG TABLET EXJADE 500 MG TABLET FERRIPROX 100 MG/ML SOLUTION FERRIPROX 500 MG TABLET GALZIN 25 MG CAPSULE GALZIN 50 MG CAPSULE JADENU 180 MG TABLET JADENU 360 MG TABLET JADENU 90 MG TABLET SYPRINE 250 MG CAPSULE

4 3 3 5 5 5 4 4 NC NC NC NC NC 5

Prior Authorization required for new starts Prior Authorization required for new starts SPP*: Must use Accredo SPP*: Must use Accredo SPP*: Must use Accredo LDD*: Dohmen Life Sciences. 1-800-305-7881. LDD*: Dohmen Life Sciences. 1-800-305-7881.

Prior Authorization required for new starts

HORMONAL AGENTS, STIMULANT/REPLACEMENT/MODIFYING ANDROGENS ANADROL-50 TABLET ANDRODERM 2 MG/24HR PATCH

4 3

ANDRODERM 4 MG/24HR PATCH

3

ANDROGEL 1% GEL PUMP ANDROGEL 1%(2.5G) GEL PACKET ANDROGEL 1%(5G) GEL PACKET ANDROGEL 1.62% GEL PUMP

NC NC NC 3

ANDROGEL 1.62%(1.25G) GEL PCKT

3

ANDROGEL 1.62%(2.5G) GEL PCKT

3

ANDROID 10 MG CAPSULE ANDROXY 10 MG TABLET AXIRON 30 MG/ACTUATION SOLN

NC 2 4

COVARYX H.S. TABLET COVARYX TABLET DANAZOL 100 MG CAPSULE DANAZOL 200 MG CAPSULE DANAZOL 50 MG CAPSULE DEPO-TESTOSTERONE 100 MG/ML VL

2 2 2 2 2 4

DEPO-TESTOSTERONE 200 MG/ML

4

VALUE FORMULARY FIVE-TIER DRUG LIST

Max. 30 Days Supply Max. 30 Days Supply;Prior Authorization required for members 18 and older;Max. 2 per day Max. 30 Days Supply;Prior Authorization required for members 18 and older;Max. 1 per day

Max. 30 Days Supply;Prior Authorization required for members 18 and older;Max. 150 GM(s) in 30 days Max. 30 Days Supply;Prior Authorization required for members 18 and older;Max. 1.25 GM(s) per day Max. 30 Days Supply;Prior Authorization required for members 18 and older;Max. 5 GM(s) per day Max. 30 Days Supply Max. 30 Days Supply;Prior Authorization required for members 18 and older;Max. 180 ML(s) in 30 days Max. 30 Days Supply Max. 30 Days Supply

Max. 30 Days Supply;Prior Authorization required for members 18 and older;Max. 10 ML(s) in 30 days Max. 30 Days Supply;Prior Authorization required for members 18 and older;Max. 4 ML(s) in 30 days

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DRUG NAME

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LIMITATIONS/ * NOTES

ESTROGEN-METHYLTESTOS H.S. TAB ESTROGEN-METHYLTESTOSTERONE TB FIRST 2% TESTOSTERONE OINT FIRST-TESTOSTERONE MC 2% CR FORTESTA 10 MG GEL PUMP METHITEST 10 MG TABLET METHYLTESTOSTERONE 10 MG CAP NATESTO NASAL 5.5 MG/0.122 GM OXANDRIN 10 MG TABLET OXANDRIN 2.5 MG TABLET OXANDROLONE 10 MG TABLET OXANDROLONE 2.5 MG TABLET STRIANT 30 MG MUCOADHESIVE

2 2 NC NC NC 4 NC NC NC NC 2 2 4

Max. 30 Days Supply Max. 30 Days Supply

TESTIM 1% (50MG) GEL TESTONE CIK KIT TESTOSTERON CYP 1,000 MG/10 ML

NC NC 2

TESTOSTERON ENAN 1,000 MG/5 ML

2

TESTOSTERONE 10 MG GEL PUMP

2

TESTOSTERONE 12.5 MG/1.25 GRAM

2

TESTOSTERONE 25 MG/2.5 GM PKT

2

TESTOSTERONE 50 MG/5 GRAM GEL

2

TESTOSTERONE 50 MG/5 GRAM PKT

2

TESTOSTERONE CYP 200 MG/ML

2

TESTRED 10 MG CAPSULE VOGELXO 12.5 MG/1.25 GRAM PUMP VOGELXO 50 MG/5 GRAM GEL

NC NC NC

Max. 30 Days Supply;Prior Authorization required

Max. 30 Days Supply Max. 30 Days Supply Max. 30 Days Supply;Prior Authorization required for members 18 and older;Max. 2 per day

Max. 30 Days Supply;Prior Authorization required for members 18 and older;Max. 10 ML(s) in 30 days Max. 30 Days Supply;Prior Authorization required for members 18 and older;Max. 5 ML(s) in 30 days Max. 30 Days Supply;Prior Authorization required for members 18 and older;Max. 120 GM(s) in 30 days Max. 30 Days Supply;Prior Authorization required for members 18 and older;Max. 300 GM(s) in 30 days Max. 30 Days Supply;Prior Authorization required for members 18 and older;Max. 2.5 GM(s) per day Max. 30 Days Supply;Prior Authorization required for members 18 and older;Max. 10 GM(s) per day Max. 30 Days Supply;Prior Authorization required for members 18 and older;Max. 10 GM(s) per day Max. 30 Days Supply;Prior Authorization required for members 18 and older;Max. 4 ML(s) in 30 days

ESTROGENS AND ANTIESTROGENS ACTIVELLA 0.5-0.1 MG TABLET ACTIVELLA 1 MG-0.5 MG TABLET ALORA 0.025 MG PATCH ALORA 0.05 MG PATCH ALORA 0.075 MG PATCH ALORA 0.1 MG PATCH AMABELZ 0.5 MG-0.1 MG TABLET AMABELZ 1 MG-0.5 MG TABLET ANGELIQ 0.25 MG-0.5 MG TABLET ANGELIQ 0.5 MG-1 MG TABLET CENESTIN 0.3 MG TABLET CENESTIN 0.45 MG TABLET CENESTIN 0.625 MG TABLET CENESTIN 0.9 MG TABLET CENESTIN 1.25 MG TABLET CLIMARA 0.025 MG/DAY PATCH CLIMARA 0.0375 MG/DAY PATCH CLIMARA 0.05 MG/DAY PATCH CLIMARA 0.06 MG/DAY PATCH CLIMARA 0.075 MG/DAY PATCH CLIMARA 0.1 MG/DAY PATCH CLIMARA PRO PATCH CLOMIPHENE CITRATE 50 MG TAB

VALUE FORMULARY FIVE-TIER DRUG LIST

NC NC 4 4 4 4 2 2 NC NC 4 4 4 4 4 NC NC NC NC NC NC 3 2

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DRUG NAME

TIER

COMBIPATCH 0.05-0.14 MG PTCH COMBIPATCH 0.05-0.25 MG PTCH DIVIGEL 1 MG GEL PACKET DUAVEE 0.45-20 MG TABLET

3 3 3 5

ELESTRIN 0.06% GEL ENJUVIA 0.3 MG TABLET ENJUVIA 0.45 MG TABLET ENJUVIA 0.625 MG TABLET ENJUVIA 0.9 MG TABLET ENJUVIA 1.25 MG TABLET ESTRACE 0.01% CREAM ESTRACE 0.5 MG TABLET ESTRACE 1 MG TABLET ESTRACE 2 MG TABLET ESTRADIOL 0.025 MG PATCH ESTRADIOL 0.0375 MG PATCH ESTRADIOL 0.0375 MG/DAY PATCH ESTRADIOL 0.05 MG PATCH ESTRADIOL 0.05 MG/DAY PATCH ESTRADIOL 0.06 MG/DAY PATCH ESTRADIOL 0.075 MG PATCH ESTRADIOL 0.075 MG/DAY PATCH ESTRADIOL 0.1 MG PATCH ESTRADIOL 0.1 MG/DAY PATCH ESTRADIOL 0.5 MG TABLET ESTRADIOL 1 MG TABLET ESTRADIOL 2 MG TABLET ESTRADIOL TDS 0.025 MG/DAY ESTRADIOL-NORETH 0.5-0.1 MG TB ESTRADIOL-NORETH 1-0.5 MG TAB ESTRASORB PACKET ESTRING 2 MG VAGINAL RING ESTROGEL 0.06% GEL ESTROPIPATE 0.625(0.75 MG) TAB ESTROPIPATE 1.25(1.5 MG) TAB ESTROPIPATE 2.5(3 MG) TAB EVAMIST 1.53 MG/SPRAY EVISTA 60 MG TABLET FEMHRT 0.5 MG-2.5 MCG TABLET FEMRING 0.05 MG VAGINAL RING FEMRING 0.10 MG VAGINAL RING FYAVOLV 0.5 MG-2.5 MCG TABLET FYAVOLV 1 MG-5 MCG TABLET JEVANTIQUE LO 0.5 MG-2.5 MCG JINTELI 1 MG-5 MCG TABLET LOPREEZA 0.5 MG-0.1 MG TABLET LOPREEZA 1 MG-0.5 MG TABLET MENEST 0.3 MG TABLET MENEST 0.625 MG TABLET MENEST 1.25 MG TABLET MENEST 2.5 MG TABLET MENOSTAR 14 MCG/DAY PATCH MIMVEY 1-0.5 MG TABLET MIMVEY LO 0.5-0.1 MG TABLET MINIVELLE 0.025 MG PATCH MINIVELLE 0.0375 MG PATCH MINIVELLE 0.05 MG PATCH MINIVELLE 0.075 MG PATCH

NC 3 3 3 3 3 3 NC NC NC 2 2 2 2 2 2 2 2 2 2 1 2 2 2 2 2 3 3 4 2 2 2 NC NC NC 4 4 2 2 NC 2 2 2 4 4 4 4 NC 2 2 4 4 4 4

VALUE FORMULARY FIVE-TIER DRUG LIST

LIMITATIONS/ * NOTES

Prior Authorization required HSA*

Max. 90 Days Supply;Max. 1 in 90 days Max. 50 Days Supply

Max. 90 Days Supply;Max. 1 in 90 days Max. 90 Days Supply;Max. 1 in 90 days

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DRUG NAME

TIER

MINIVELLE 0.1 MG PATCH NORETHIN-ETH ESTRAD 1 MG-5 MCG NORETHIND-ETH ESTRAD 0.5-2.5 OSPHENA 60 MG TABLET PREFEST TABLET PREMARIN 0.3 MG TABLET PREMARIN 0.45 MG TABLET PREMARIN 0.625 MG TABLET PREMARIN 0.9 MG TABLET PREMARIN 1.25 MG TABLET PREMARIN VAGINAL CREAM-APPL PREMPHASE 0.625-5 MG TABLET PREMPRO 0.3 MG-1.5 MG TABLET PREMPRO 0.45-1.5 MG TABLET PREMPRO 0.625-2.5 MG TABLET PREMPRO 0.625-5 MG TABLET RALOXIFENE HCL 60 MG TABLET SEROPHENE 50 MG TABLET VAGIFEM 10 MCG VAGINAL TAB VIVELLE-DOT 0.025 MG PATCH VIVELLE-DOT 0.0375 MG PATCH VIVELLE-DOT 0.05 MG PATCH VIVELLE-DOT 0.075 MG PATCH VIVELLE-DOT 0.1 MG PATCH YUVAFEM 10 MCG VAGINAL INSERT

4 2 2 4 NC 3 3 3 3 3 3 3 3 3 3 3 2 NC 4 NC NC NC NC NC 3

LIMITATIONS/ * NOTES

HSA*; ACA*

GLUCOCORTICOIDS/MINERALOCORTICOIDS CELESTONE 0.6 MG/5 ML SOLUTION CORTEF 10 MG TABLET CORTEF 20 MG TABLET CORTEF 5 MG TABLET CORTISONE 25 MG TABLET DELTASONE 20 MG TABLET DEXAMETHASONE 0.5 MG TABLET DEXAMETHASONE 0.5 MG/5 ML ELX DEXAMETHASONE 0.75 MG TABLET DEXAMETHASONE 1 MG TABLET DEXAMETHASONE 1.5 MG TABLET DEXAMETHASONE 10 MG/ML VIAL DEXAMETHASONE 2 MG TABLET DEXAMETHASONE 4 MG TABLET DEXAMETHASONE 4 MG/ML VIAL DEXAMETHASONE 6 MG TABLET DEXAMETHASONE INTENSOL 1MG/1ML DEXPAK 10 DAY 1.5 MG TABLET DEXPAK 13 DAY 1.5 MG TABLET DEXPAK 6 DAY 1.5 MG TABLET FLO-PRED 16.7(15) MG/5 ML SUSP FLUDROCORTISONE 0.1 MG TABLET HYDROCORTISONE 10 MG TABLET HYDROCORTISONE 20 MG TABLET HYDROCORTISONE 5 MG TABLET MEDROL 16 MG TABLET MEDROL 2 MG TABLET MEDROL 32 MG TABLET MEDROL 4 MG DOSEPAK MEDROL 4 MG TABLET

VALUE FORMULARY FIVE-TIER DRUG LIST

NC NC NC NC 2 1 1 2 1 2 1 MD 2 1 MD 2 3 NC NC NC NC 2 2 2 2 NC NC NC NC NC

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DRUG NAME

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MEDROL 8 MG TABLET METHYLPREDNISOLONE 16 MG TAB METHYLPREDNISOLONE 32 MG TAB METHYLPREDNISOLONE 4 MG DOSEPK METHYLPREDNISOLONE 4 MG TABLET METHYLPREDNISOLONE 8 MG TAB MILLIPRED 10 MG/5 ML SOLUTION MILLIPRED 5 MG TABLET MILLIPRED DP 5 MG 12-DAY PACK MILLIPRED DP 5 MG 6-DAY PACK ORAPRED 15 MG/5 ML SOLUTION ORAPRED ODT 10 MG TABLET ORAPRED ODT 15 MG TABLET ORAPRED ODT 30 MG TABLET PEDIAPRED 5 MG/5 ML SOLN PREDNISOLONE 15 MG/5 ML SOLN PREDNISOLONE 5 MG/5 ML SOLN PREDNISOLONE ODT 10 MG TABLET PREDNISOLONE ODT 15 MG TABLET PREDNISOLONE ODT 30 MG TABLET PREDNISOLONE SOD PH 25 MG/5 ML PREDNISONE 1 MG TABLET PREDNISONE 10 MG TAB DOSE PACK PREDNISONE 10 MG TABLET PREDNISONE 2.5 MG TABLET PREDNISONE 20 MG TABLET PREDNISONE 5 MG TABLET PREDNISONE 5 MG/5 ML SOLUTION PREDNISONE 5 MG/ML SOLUTION PREDNISONE 50 MG TABLET PRELONE 15 MG/5 ML SYRUP RAYOS DR 1 MG TABLET RAYOS DR 2 MG TABLET RAYOS DR 5 MG TABLET VERIPRED 20 20 MG/5 ML SOLN

NC 2 2 2 2 2 NC NC NC NC NC NC NC NC NC 1 2 2 2 2 2 2 2 1 2 1 2 2 4 1 1 NC NC NC NC

LIMITATIONS/ * NOTES

PITUITARY BRAVELLE 75 UNIT VIAL

4

CETROTIDE 0.25 MG KIT

4

CETROTIDE 3 MG KIT

4

CHORIONIC GONAD 10,000 UNIT VL

3

DDAVP 0.01% NASAL SPRAY DDAVP 0.1 MG TABLET DDAVP 0.2 MG TABLET DDAVP 10 MCG/0.1 ML SOLUTION DDAVP 4 MCG/ML AMPUL DDAVP 4 MCG/ML VIAL DESMOPRESSIN 0.01% SOLUTION DESMOPRESSIN 0.1 MG/ML SOL DESMOPRESSIN AC 4 MCG/ML VIAL DESMOPRESSIN ACETATE 0.1 MG TB DESMOPRESSIN ACETATE 0.2 MG TB EGRIFTA 1 MG VIAL EGRIFTA 2 MG VIAL

NC NC NC NC NC NC 2 2 NC 2 2 NC NC

VALUE FORMULARY FIVE-TIER DRUG LIST

Max. 30 Days Supply IVF* Max. 30 Days Supply IVF* Max. 30 Days Supply IVF* Max. 30 Days Supply IVF*

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DRUG NAME

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FOLLISTIM AQ 150 UNIT VIAL FOLLISTIM AQ 300 UNIT CARTRIDG FOLLISTIM AQ 600 UNIT CARTRIDG FOLLISTIM AQ 75 UNIT VIAL FOLLISTIM AQ 900 UNIT CARTRIDG GENOTROPIN 12 MG CARTRIDGE GENOTROPIN 5 MG CARTRIDGE GENOTROPIN MINIQUICK 0.2 MG GENOTROPIN MINIQUICK 0.4 MG GENOTROPIN MINIQUICK 0.6 MG GENOTROPIN MINIQUICK 0.8 MG GENOTROPIN MINIQUICK 1 MG GENOTROPIN MINIQUICK 1.2 MG GENOTROPIN MINIQUICK 1.4 MG GENOTROPIN MINIQUICK 1.6 MG GENOTROPIN MINIQUICK 1.8 MG GENOTROPIN MINIQUICK 2 MG GONAL-F 450 UNITS VIAL

NC NC NC NC NC NC NC NC NC NC NC NC NC NC NC NC NC 4

GONAL-F RFF 300 UNITS PEN GONAL-F RFF 450 UNITS PEN GONAL-F RFF 75 UNITS VIAL GONAL-F RFF REDI-JECT 300 UNIT GONAL-F RFF REDI-JECT 450 UNIT GONAL-F RFF REDI-JECT 900 UNIT HUMATROPE 12 MG CARTRIDGE HUMATROPE 24 MG CARTRIDGE HUMATROPE 5 MG VIAL HUMATROPE 6 MG CARTRIDGE INCRELEX 40 MG/4 ML VIAL

4 4 4 4 4 4 NC NC NC NC 5

LUPRON DEPOT-PED 11.25 MG KIT LUPRON DEPOT-PED 15 MG KIT LUPRON DEPOT-PED 30 MG 3MO KIT LUPRON DEPOT-PED 7.5 MG KIT MENOPUR 75 UNIT VIAL

MD MD MD MD 4

METOPIRONE 250 MG CAPSULE NORDITROPIN FLEXPRO 10 MG/1.5 NORDITROPIN FLEXPRO 15 MG/1.5 NORDITROPIN FLEXPRO 30 MG/3 ML NORDITROPIN FLEXPRO 5 MG/1.5 NOVAREL 10,000 UNITS VIAL

4 NC NC NC NC 3

NUTROPIN 10 MG VIAL NUTROPIN AQ 20 MG/2ML PEN CART NUTROPIN AQ 5 MG/ML VIAL NUTROPIN AQ NUSPIN 10 INJECTOR NUTROPIN AQ NUSPIN 20 INJECTOR NUTROPIN AQ NUSPIN 5 INJECTOR NUTROPIN AQ PEN CARTRIDGE OCTREOTIDE 1,000 MCG/5 ML VIAL OCTREOTIDE 1,000 MCG/ML VIAL OCTREOTIDE ACET 100 MCG/ML SYR OCTREOTIDE ACET 50 MCG/ML SYR OCTREOTIDE ACET 500 MCG/ML VL OMNITROPE 10 MG/1.5 ML CRTG

NC NC NC NC NC NC NC MD MD MD MD MD 4

OMNITROPE 5 MG/1.5 ML CRTG

4

VALUE FORMULARY FIVE-TIER DRUG LIST

LIMITATIONS/ * NOTES

Max. 30 Days Supply IVF* Max. 30 Days Supply Max. 30 Days Supply Max. 30 Days Supply Max. 30 Days Supply Max. 30 Days Supply Max. 30 Days Supply

Prior Authorization required SPP*: Must use Accredo SPP*: Must use Magellan Rx SPP*: Must use Magellan Rx SPP*: Must use Magellan Rx SPP*: Must use Magellan Rx Max. 30 Days Supply IVF*

Max. 30 Days Supply IVF*

SPP*: Must use Magellan Rx SPP*: Must use Magellan Rx SPP*: Must use Magellan Rx SPP*: Must use Magellan Rx SPP*: Must use Magellan Rx Prior Authorization required SPP*: Must use Accredo Prior Authorization required SPP*: Must use Accredo

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DRUG NAME

TIER

LIMITATIONS/ * NOTES

OMNITROPE 5.8 MG VIAL

4

OVIDREL 250 MCG/0.5 ML SYRG

4

PREGNYL 10,000 UNITS VIAL

3

REPRONEX 75 UNIT VIAL

4

Prior Authorization required SPP*: Must use Accredo Max. 30 Days Supply IVF* Max. 30 Days Supply IVF* Max. 30 Days Supply IVF*

SAIZEN 5 MG VIAL SAIZEN 8.8 MG CLICK.EASY CARTG SAIZEN 8.8 MG VIAL SANDOSTATIN 0.05 MG/ML AMPUL SANDOSTATIN 0.1 MG/ML AMPUL SANDOSTATIN 0.2 MG/ML VIAL SANDOSTATIN 0.5 MG/ML AMPUL SANDOSTATIN 1 MG/ML VIAL SANDOSTATIN LAR DEPOT 10 MG KT SANDOSTATIN LAR DEPOT 20 MG VL SANDOSTATIN LAR DEPOT 30 MG VL SEROSTIM 4 MG VIAL

NC NC NC MD MD MD MD MD MD MD MD 4

SEROSTIM 5 MG VIAL

4

SEROSTIM 6 MG VIAL

4

SOMATULINE DEPOT 120 MG/0.5 ML SOMATULINE DEPOT 60 MG/0.2 ML SOMATULINE DEPOT 90 MG/0.3 ML SOMAVERT 10 MG VIAL SOMAVERT 15 MG VIAL SOMAVERT 20 MG VIAL SOMAVERT 25 MG VIAL SOMAVERT 30 MG VIAL STIMATE 1.5 MG/ML NASAL SPRAY SUPPRELIN LA 50 MG KIT TEV-TROPIN 5 MG VIAL VANTAS 50 MG KIT ZOMACTON 10 MG VIAL ZOMACTON 5 MG VIAL ZORBTIVE 8.8 MG VIAL

4 4 4 5 5 5 5 5 4 MD 4 MD NC NC NC

SPP*: Must use Magellan Rx SPP*: Must use Magellan Rx SPP*: Must use Magellan Rx SPP*: Must use Magellan Rx SPP*: Must use Magellan Rx SPP*: Must use Magellan Rx SPP*: Must use Magellan Rx SPP*: Must use Magellan Rx Prior Authorization required SPP*: Accredo Prior Authorization required SPP*: Accredo Prior Authorization required SPP*: Accredo SPP*: Must use Accredo SPP*: Must use Accredo SPP*: Must use Accredo SPP*: Accredo SPP*: Accredo SPP*: Accredo SPP*: Accredo SPP*: Accredo SPP*: Must use Magellan Rx Prior Authorization required SPP*: Must use Magellan Rx

PROGESTINS AYGESTIN 5 MG TABLET CRINONE 4% GEL

NC 3

CRINONE 8% GEL

3

DEPO-PROVERA 150 MG/ML SYRINGE DEPO-PROVERA 150 MG/ML VIAL

0 0

DEPO-PROVERA 400 MG/ML VIAL DEPO-SUBQ PROVERA 104 SYRINGE

MD 0

ENDOMETRIN 100 MG SUPPOSITORY

3

FIRST-PROGESTERONE VGS 100 SUP FIRST-PROGESTERONE VGS 200 SUP FIRST-PROGESTERONE VGS 25 SUPP FIRST-PROGESTERONE VGS 400 SUP FIRST-PROGESTERONE VGS 50 SUPP MAKENA 1,250 MG/5 ML VIAL

4 4 4 4 4 MD

VALUE FORMULARY FIVE-TIER DRUG LIST

Max. 30 Days Supply IVF* Max. 30 Days Supply IVF* Max. 90 Days Supply;Max. 1 ML(s) in 90 days Max. 90 Days Supply;Max. 1 ML(s) in 90 days ACA* Max. 1 ML(s) in 60 days ACA* Max. 30 Days Supply IVF* Max. 30 Days Supply Max. 30 Days Supply Max. 30 Days Supply Max. 30 Days Supply Max. 30 Days Supply IVF*; SPP*: Accredo

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DRUG NAME

TIER

MEDROXYPROGESTERONE 10 MG TAB MEDROXYPROGESTERONE 150 MG/ML

1 0

MEDROXYPROGESTERONE 150 MG/ML MEDROXYPROGESTERONE 2.5 MG TAB MEDROXYPROGESTERONE 5 MG TAB MEGACE 40 MG/ML ORAL SUSP MEGACE ES 625 MG/5 ML SUSP MEGESTROL 625 MG/5 ML SUSP MEGESTROL ACET 40 MG/ML SUSP NORETHINDRONE 5 MG TABLET PROGESTERONE 100 MG CAPSULE PROGESTERONE 200 MG CAPSULE PROGESTERONE OIL 50 MG/ML VL

0 1 1 NC NC 2 2 2 2 2 2

PROMETRIUM 100 MG CAPSULE PROMETRIUM 200 MG CAPSULE PROVERA 10 MG TABLET PROVERA 2.5 MG TABLET PROVERA 5 MG TABLET

NC NC NC NC NC

LIMITATIONS/ * NOTES Max. 90 Days Supply;Max. 1 ML(s) in 90 days ACA* Max. 90 Days Supply;Max. 1 ML(s) in 60 days

CH* CH* HSA* HSA* Max. 30 Days Supply IVF*

THYROID AND ANTITHYROID AGENTS ARMOUR THYROID 120 MG TABLET ARMOUR THYROID 15 MG TABLET ARMOUR THYROID 180 MG TABLET ARMOUR THYROID 240 MG TABLET ARMOUR THYROID 30 MG TABLET ARMOUR THYROID 300 MG TABLET ARMOUR THYROID 60 MG TABLET ARMOUR THYROID 90 MG TABLET CYTOMEL 25 MCG TABLET CYTOMEL 5 MCG TABLET CYTOMEL 50 MCG TABLET LEVO-T 100 MCG TABLET LEVO-T 112 MCG TABLET LEVO-T 125 MCG TABLET LEVO-T 137 MCG TABLET LEVO-T 150 MCG TABLET LEVO-T 175 MCG TABLET LEVO-T 200 MCG TABLET LEVO-T 25 MCG TABLET LEVO-T 300 MCG TABLET LEVO-T 50 MCG TABLET LEVO-T 75 MCG TABLET LEVO-T 88 MCG TABLET LEVOTHROID 100 MCG TABLET LEVOTHROID 112 MCG TABLET LEVOTHROID 125 MCG TABLET LEVOTHROID 137 MCG TABLET LEVOTHROID 150 MCG TABLET LEVOTHROID 175 MCG TABLET LEVOTHROID 200 MCG TABLET LEVOTHROID 25 MCG TABLET LEVOTHROID 300 MCG TABLET LEVOTHROID 50 MCG TABLET LEVOTHROID 75 MCG TABLET LEVOTHROID 88 MCG TABLET LEVOTHYROXINE 100 MCG TABLET

VALUE FORMULARY FIVE-TIER DRUG LIST

3 3 3 3 3 3 3 3 NC NC NC NC NC NC NC NC NC NC NC NC NC NC NC 2 2 2 2 2 2 2 2 2 2 2 2 2

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DRUG NAME

TIER

LEVOTHYROXINE 112 MCG TABLET LEVOTHYROXINE 125 MCG TABLET LEVOTHYROXINE 137 MCG TABLET LEVOTHYROXINE 150 MCG TABLET LEVOTHYROXINE 175 MCG TABLET LEVOTHYROXINE 200 MCG TABLET LEVOTHYROXINE 25 MCG TABLET LEVOTHYROXINE 300 MCG TABLET LEVOTHYROXINE 50 MCG TABLET LEVOTHYROXINE 75 MCG TABLET LEVOTHYROXINE 88 MCG TABLET LEVOXYL 100 MCG TABLET LEVOXYL 112 MCG TABLET LEVOXYL 125 MCG TABLET LEVOXYL 137 MCG TABLET LEVOXYL 150 MCG TABLET LEVOXYL 175 MCG TABLET LEVOXYL 200 MCG TABLET LEVOXYL 25 MCG TABLET LEVOXYL 50 MCG TABLET LEVOXYL 75 MCG TABLET LEVOXYL 88 MCG TABLET LIOTHYRONINE SOD 25 MCG TAB LIOTHYRONINE SOD 5 MCG TAB LIOTHYRONINE SOD 50 MCG TAB METHIMAZOLE 10 MG TABLET METHIMAZOLE 5 MG TABLET NATURE-THROID 113.75 MG TABLET NATURE-THROID 130 MG TABLET NATURE-THROID 146.25 MG TABLET NATURE-THROID 16.25 MG TABLET NATURE-THROID 162.5 MG TABLET NATURE-THROID 195 MG TABLET NATURE-THROID 260 MG TABLET NATURE-THROID 32.5 MG TABLET NATURE-THROID 325 MG TABLET NATURE-THROID 48.75 MG TABLET NATURE-THROID 65 MG TABLET NATURE-THROID 81.25 MG TABLET NATURE-THROID 97.5 MG TABLET NP THYROID 30 MG TABLET NP THYROID 60 MG TABLET NP THYROID 90 MG TABLET PROPYLTHIOURACIL 50 MG TABLET SSKI 1 GM/ML SOLUTION STRONG IODINE SOLUTION SYNTHROID 100 MCG TABLET SYNTHROID 112 MCG TABLET SYNTHROID 125 MCG TABLET SYNTHROID 137 MCG TABLET SYNTHROID 150 MCG TABLET SYNTHROID 175 MCG TABLET SYNTHROID 200 MCG TABLET SYNTHROID 25 MCG TABLET SYNTHROID 300 MCG TABLET SYNTHROID 50 MCG TABLET SYNTHROID 75 MCG TABLET SYNTHROID 88 MCG TABLET TAPAZOLE 10 MG TABLET

2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 4 4 4 4 4 4 4 4 4 4 4 4 NC

VALUE FORMULARY FIVE-TIER DRUG LIST

LIMITATIONS/ * NOTES

Last Updated: 01/17/2017

Page 135

DRUG NAME

TIER

TAPAZOLE 5 MG TABLET THYROGEN 1.1 MG VIAL THYROLAR-1 STRENGTH TABLET THYROLAR-1/2 STRENGTH TAB THYROLAR-1/4 STRENGTH TAB THYROLAR-2 STRENGTH TABLET THYROLAR-3 STRENGTH TABLET TIROSINT 100 MCG CAPSULE TIROSINT 112 MCG CAPSULE TIROSINT 125 MCG CAPSULE TIROSINT 13 MCG CAPSULE TIROSINT 137 MCG CAPSULE TIROSINT 150 MCG CAPSULE TIROSINT 25 MCG CAPSULE TIROSINT 50 MCG CAPSULE TIROSINT 75 MCG CAPSULE TIROSINT 88 MCG CAPSULE UNITHROID 100 MCG TABLET UNITHROID 112 MCG TABLET UNITHROID 125 MCG TABLET UNITHROID 137 MCG TABLET UNITHROID 150 MCG TABLET UNITHROID 175 MCG TABLET UNITHROID 200 MCG TABLET UNITHROID 25 MCG TABLET UNITHROID 300 MCG TABLET UNITHROID 50 MCG TABLET UNITHROID 75 MCG TABLET UNITHROID 88 MCG TABLET WESTHROID 113.75 MG TABLET WESTHROID 130 MG TABLET WESTHROID 146.25 MG TABLET WESTHROID 162.5 MG TABLET WESTHROID 195 MG TABLET WESTHROID 260 MG TABLET WESTHROID 32.5 MG TABLET WESTHROID 325 MG TABLET WESTHROID 65 MG TABLET WESTHROID 81.25 MG TABLET WESTHROID 97.5 MG TABLET WESTHROID-P 16.25 MG TABLET WESTHROID-P 48.75 MG TABLET WP THYROID 113.75 MG TABLET WP THYROID 130 MG TABLET WP THYROID 16.25 MG TABLET WP THYROID 32.5 MG TABLET WP THYROID 48.75 MG TABLET WP THYROID 65 MG TABLET WP THYROID 81.25 MG TABLET WP THYROID 97.5 MG TABLET

NC MD 4 4 4 4 4 NC NC NC NC NC NC NC NC NC NC 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2

LIMITATIONS/ * NOTES SPP*: Must use Magellan Rx

IMMUNOLOGICAL AGENTS IMMUNOLOGICAL AGENTS ACTEMRA 162 MG/0.9 ML SYRINGE

5

ARAVA 10 MG TABLET

NC

VALUE FORMULARY FIVE-TIER DRUG LIST

Prior Authorization required;Max. 3.6 ML(s) in 30 days SPP*: Must use Accredo

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DRUG NAME

TIER

ARAVA 20 MG TABLET ARCALYST 220 MG INJECTION ASTAGRAF XL 0.5 MG CAPSULE ASTAGRAF XL 1 MG CAPSULE ASTAGRAF XL 5 MG CAPSULE AZASAN 100 MG TABLET AZASAN 75 MG TABLET AZATHIOPRINE 50 MG TABLET BABYBIG 100 MG VIAL CELLCEPT 200 MG/ML ORAL SUSP CELLCEPT 250 MG CAPSULE CELLCEPT 500 MG TABLET CIMZIA 200 MG VIAL KIT

NC 4 NC NC NC 4 4 2 NC 4 NC NC 5

CIMZIA 200 MG/ML SYRINGE KIT

5

CYCLOSPORINE 100 MG CAPSULE CYCLOSPORINE 100 MG/ML SOLN CYCLOSPORINE 25 MG CAPSULE CYCLOSPORINE MODIFIED 100 MG CYCLOSPORINE MODIFIED 25 MG CYCLOSPORINE MODIFIED 50 MG ENBREL 25 MG KIT

2 2 2 2 2 2 4

ENBREL 25 MG/0.5 ML SYRINGE

4

ENBREL 50 MG/ML SURECLICK SYR

4

ENBREL 50 MG/ML SYRINGE

4

ENVARSUS XR 0.75 MG TABLET ENVARSUS XR 1 MG TABLET ENVARSUS XR 4 MG TABLET GENGRAF 100 MG CAPSULE GENGRAF 100 MG/ML SOLUTION GENGRAF 25 MG CAPSULE GENGRAF 50 MG CAPSULE HECORIA 0.5 MG CAPSULE HECORIA 1 MG CAPSULE HECORIA 5 MG CAPSULE HUMIRA 10 MG/0.2 ML SYRINGE

NC NC NC 2 2 2 2 NC NC NC 4

HUMIRA 20 MG/0.4 ML SYRINGE

4

HUMIRA 40 MG/0.8 ML PEN

4

HUMIRA 40 MG/0.8 ML SYRINGE

4

HUMIRA PEDIATRIC CROHN'S START

4

HUMIRA PEN CROHN-UC-HS STARTER

4

HUMIRA PEN PSORIASIS-UVEITIS

4

HYPERRAB S-D 150 UNITS/ML VIAL ILARIS 180 MG VIAL

MD MD

IMOGAM RABIES-HT 150 UNIT/ML IMURAN 50 MG TABLET KINERET 100 MG/0.67 ML SYRINGE

MD NC 5

LEFLUNOMIDE 10 MG TABLET LEFLUNOMIDE 20 MG TABLET MICRHOGAM ULTRA-FILTD PLUS SYR

2 2 MD

VALUE FORMULARY FIVE-TIER DRUG LIST

LIMITATIONS/ * NOTES SPP*: Must use Accredo

Prior Authorization required SPP*: Must use Accredo Prior Authorization required SPP*: Must use Accredo

Prior Authorization required SPP*: Accredo Prior Authorization required SPP*: Accredo Prior Authorization required SPP*: Accredo Prior Authorization required SPP*: Accredo

Prior Authorization required SPP*: Must use Accredo Prior Authorization required SPP*: Must use Accredo Prior Authorization required SPP*: Must use Accredo Prior Authorization required SPP*: Must use Accredo Prior Authorization required SPP*: Must use Accredo Prior Authorization required SPP*: Must use Accredo Prior Authorization required SPP*: Must use Accredo Prior Authorization required SPP*: Must use Accredo

Prior Authorization required LDD*: Omnicare/RX Crossroads. 866-547-0644.

SPP*: Must use Accredo

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DRUG NAME

TIER

MYCOPHENOLATE 200 MG/ML SUSP MYCOPHENOLATE 250 MG CAPSULE MYCOPHENOLATE 500 MG TABLET MYCOPHENOLIC ACID DR 180 MG TB MYCOPHENOLIC ACID DR 360 MG TB MYFORTIC 180 MG TABLET MYFORTIC 360 MG TABLET NEORAL 100 MG GELATIN CAPSULE NEORAL 100 MG/ML SOLUTION NEORAL 25 MG GELATIN CAPSULE NULOJIX 250 MG VIAL ORENCIA 125 MG/ML SYRINGE

2 2 2 2 2 NC NC NC NC NC MD 5

OTEZLA 28 DAY STARTER PACK

5

OTEZLA 30 MG TABLET OTEZLA STARTER PACK

5 5

OTREXUP 10 MG/0.4 ML AUTO-INJ OTREXUP 12.5 MG/0.4 ML AUTOINJ OTREXUP 15 MG/0.4 ML AUTO-INJ OTREXUP 17.5 MG/0.4 ML AUTOINJ OTREXUP 20 MG/0.4 ML AUTO-INJ OTREXUP 22.5 MG/0.4 ML AUTOINJ OTREXUP 25 MG/0.4 ML AUTO-INJ OTREXUP 7.5 MG/0.4 ML AUTO-INJ PROGRAF 0.5 MG CAPSULE PROGRAF 1 MG CAPSULE PROGRAF 5 MG CAPSULE RAPAMUNE 0.5 MG TABLET RAPAMUNE 1 MG TABLET RAPAMUNE 1 MG/ML ORAL SOLN RAPAMUNE 2 MG TABLET RASUVO 10 MG/0.2 ML AUTOINJ RASUVO 12.5 MG/0.25 ML AUTOINJ RASUVO 15 MG/0.3 ML AUTOINJ RASUVO 17.5 MG/0.35 ML AUTOINJ RASUVO 20 MG/0.4 ML AUTOINJ RASUVO 22.5 MG/0.45 ML AUTOINJ RASUVO 25 MG/0.5 ML AUTOINJ RASUVO 27.5 MG/0.55 ML AUTOINJ RASUVO 30 MG/0.6 ML AUTOINJ RASUVO 7.5 MG/0.15 ML AUTOINJ RHOGAM ULTRA-FILTERED PLUS SYR RIDAURA 3 MG CAPSULE SANDIMMUNE 100 MG CAPSULE SANDIMMUNE 100 MG/ML SOLN SANDIMMUNE 25 MG CAPSULE SIMPONI 100 MG/ML PEN INJECTOR

3 3 3 3 3 3 3 3 NC NC NC 4 4 4 4 3 3 3 3 3 3 3 3 3 3 MD 4 NC 3 NC 5

SIMPONI 100 MG/ML SYRINGE

5

SIMPONI 50 MG/0.5 ML PEN INJEC

5

SIMPONI 50 MG/0.5 ML SYRINGE

5

SIROLIMUS 0.5 MG TABLET SIROLIMUS 1 MG TABLET SIROLIMUS 2 MG TABLET STELARA 45 MG/0.5 ML SYRINGE

2 2 2 MD

VALUE FORMULARY FIVE-TIER DRUG LIST

LIMITATIONS/ * NOTES

SPP*: Must use Magellan Rx Prior Authorization required;Max. 1 ML(s) per 7 days SPP*: Must use Accredo Prior Authorization required SPP*: Must use Accredo Prior Authorization required Prior Authorization required SPP*: Must use Accredo

Max. 0.8 ML(s) in 30 days Max. 1 ML(s) in 30 days Max. 1.2 ML(s) in 30 days Max. 1.4 ML(s) in 30 days Max. 1.6 ML(s) in 30 days Max. 1.8 ML(s) in 30 days Max. 2 ML(s) in 30 days Max. 2.2 ML(s) in 30 days Max. 2.4 ML(s) in 30 days Max. 0.6 ML(s) in 30 days SPP*: Must use Accredo

Prior Authorization required;Max. 1 ML(s) per 30 days SPP*: Must use Accredo Prior Authorization required;Max. 1 ML(s) per 30 days SPP*: Must use Accredo Prior Authorization required;Max. 0.5 ML(s) per 30 days SPP*: Must use Accredo Prior Authorization required;Max. 0.5 ML(s) per 30 days SPP*: Must use Accredo

Prior Authorization required SPP*: Must use Accredo

Last Updated: 01/17/2017

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DRUG NAME

TIER

LIMITATIONS/ * NOTES

STELARA 90 MG/ML SYRINGE

MD

Prior Authorization required SPP*: Must use Accredo

TACROLIMUS 0.5 MG CAPSULE TACROLIMUS 1 MG CAPSULE TACROLIMUS 5 MG CAPSULE XELJANZ 5 MG TABLET

2 2 2 5

XELJANZ XR 11 MG TABLET

5

ZORTRESS 0.25 MG TABLET ZORTRESS 0.5 MG TABLET ZORTRESS 0.75 MG TABLET

4 4 4

Prior Authorization required;Max. 2 per day SPP*: Must use Accredo Prior Authorization required;Max. 1 per day SPP*: Must use Accredo

VACCINES ADENOVIRUS TYPE 4 & 7 EC TABS ADENOVIRUS TYPE 4 EC TABLET ADENOVIRUS TYPE 7 EC TABLET AFLURIA 2016-2017 SYRINGE AFLURIA 2016-2017 VIAL AFLURIA QUAD 2016-2017 SYRINGE AFLURIA QUAD 2016-2017 VIAL CERVARIX VACCINE SYRINGE

NC NC NC MD MD MD MD MD

ENGERIX-B 10 MCG/0.5 ML PED VL ENGERIX-B 20 MCG/ML SYRN ENGERIX-B 20 MCG/ML VIAL ENGERIX-B PEDI 10 MCG/0.5 SYRN EZ FLU 2016-17 (FLUVIRIN) KIT FLUAD 2016-2017 SYRINGE FLUARIX QUAD 2016-2017 SYRINGE FLUBLOK 2016-2017 VIAL FLUCELVAX QUAD 2016-2017 SYR FLULAVAL QUAD 2016-2017 SYR FLULAVAL QUAD 2016-2017 VIAL FLUVIRIN 2016-2017 SYRINGE FLUVIRIN 2016-2017 VIAL FLUZONE HIGH-DOSE 2016-17 SYR FLUZONE INTRADERM QUAD 2016-17 FLUZONE QUAD 2016-2017 SYRINGE FLUZONE QUAD 2016-2017 VIAL GARDASIL 9 SYRINGE GARDASIL 9 VIAL GARDASIL SYRINGE GARDASIL VIAL HAVRIX 1,440 UNITS/ML SYRINGE HAVRIX 1,440 UNITS/ML VIAL HAVRIX 720 UNIT/0.5 ML SYRINGE HAVRIX 720 UNITS/0.5 ML VIAL IMOVAX RABIES VACCINE+DILUENT MENACTRA VIAL MENOMUNE-A-C-Y-W-135 VIAL MENOMUNE-A-C-Y-W-135 W-DILUENT RABAVERT RABIES VACCINE VIAL RECOMBIVAX HB 10 MCG/ML SYR RECOMBIVAX HB 10 MCG/ML VIAL RECOMBIVAX HB 40 MCG/ML VIAL RECOMBIVAX HB 5 MCG/0.5 ML SYR TWINRIX VACCINE SYRINGE

MD MD MD MD MD MD MD MD MD MD MD MD MD MD MD MD MD MD MD MD MD MD MD MD MD MD MD MD MD MD MD MD MD MD MD

VALUE FORMULARY FIVE-TIER DRUG LIST

Not covered for members 18 and younger Not covered for members 18 and younger Not covered for members 18 and younger Not covered for members 18 and younger Covered for females only;Not covered for members 27 and older Not covered for members 17 and younger Not covered for members 17 and younger Not covered for members 17 and younger Not covered for members 17 and younger Not covered for members 18 and younger Not covered for members 64 and younger Not covered for members 18 and younger Not covered for members 18 and younger Not covered for members 18 and younger Not covered for members 18 and younger Not covered for members 18 and younger Not covered for members 18 and younger Not covered for members 18 and younger Not covered for members 64 and younger Not covered for members 18 and younger Not covered for members 18 and younger Not covered for members 18 and younger Not covered for members 27 and older Not covered for members 27 and older Not covered for members 27 and older Not covered for members 27 and older Not covered for members 17 and younger Not covered for members 17 and younger Not covered for members 17 and younger Not covered for members 17 and younger

Not covered for members 17 and younger Not covered for members 17 and younger Not covered for members 17 and younger Not covered for members 17 and younger

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LIMITATIONS/ * NOTES

TWINRIX VACCINE VIAL VAQTA 25 UNITS/0.5 ML VIAL VAQTA 50 UNITS/ML SYRINGE VAQTA 50 UNITS/ML VIAL VIVOTIF EC CAPSULE ZOSTAVAX VIAL

MD MD MD MD 4 MD

Not covered for members 17 and younger Not covered for members 17 and younger Not covered for members 17 and younger Not covered for members 17 and younger SPP*: Accredo

INFLAMMATORY BOWEL DISEASE AGENTS INFLAMMATORY BOWEL DISEASE AGENTS ALOSETRON HCL 0.5 MG TABLET ALOSETRON HCL 1 MG TABLET APRISO ER 0.375 GRAM CAPSULE ASACOL EC 400 MG TABLET ASACOL HD DR 800 MG TABLET BALSALAZIDE DISODIUM 750 MG CP BUDESONIDE EC 3 MG CAPSULE CANASA 1,000 MG SUPPOSITORY COLAZAL 750 MG CAPSULE COLOCORT 100 MG ENEMA CORTENEMA 100 MG/60 ML ENEMA DELZICOL DR 400 MG CAPSULE DIPENTUM 250 MG CAPSULE ENTOCORT EC 3 MG CAPSULE GIAZO 1.1 GM TABLET HYDROCORTISONE 100 MG/60 ML LIALDA DR 1.2 GM TABLET LOTRONEX 0.5 MG TABLET LOTRONEX 1 MG TABLET MESALAMINE 4 GM/60 ML ENEMA MESALAMINE 800 MG DR TABLET PENTASA 250 MG CAPSULE PENTASA 500 MG CAPSULE SFROWASA 4 GM/60 ML ENEMA UCERIS 2 MG RECTAL FOAM UCERIS 9 MG ER TABLET

2 2 3 4 4 2 2 4 NC 2 NC 3 4 NC 4 2 3 NC NC 2 3 3 3 NC NC NC

Covered for females only Covered for females only

IRRIGATING SOLUTIONS IRRIGATING SOLUTIONS GLYCINE 1.5% IRRIGATION RENACIDIN IRRIGATION SOLUTION SODIUM CHLORIDE 0.9% IRRIG.

NC NC 2

METABOLIC BONE DISEASE AGENTS METABOLIC BONE DISEASE AGENTS ACTONEL 150 MG TABLET ACTONEL 30 MG TABLET ACTONEL 35 MG TABLET ACTONEL 5 MG TABLET

VALUE FORMULARY FIVE-TIER DRUG LIST

NC NC NC NC

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LIMITATIONS/ * NOTES

ALENDRONATE SOD 70 MG/75 ML

2

ALENDRONATE SODIUM 10 MG TAB ALENDRONATE SODIUM 35 MG TAB

1 1

ALENDRONATE SODIUM 40 MG TAB ALENDRONATE SODIUM 5 MG TABLET ALENDRONATE SODIUM 70 MG TAB

2 2 1

Max. 75 ML(s) per 7 days HSA* HSA* Max. 28 Days Supply;Max. 4 per 28 days HSA* HSA* HSA* Max. 4 per 28 days HSA*

ATELVIA DR 35 MG TABLET BINOSTO 70 MG TABLET EFF

NC 4

BONIVA 150 MG TABLET BONIVA 3 MG/3 ML SYRINGE CALCITONIN-SALMON 200 UNITS SP CALCITRIOL 0.25 MCG CAPSULE CALCITRIOL 0.5 MCG CAPSULE CALCITRIOL 1 MCG/ML SOLUTION DIDRONEL 400 MG TABLET DOXERCALCIFEROL 0.5 MCG CAP DOXERCALCIFEROL 1 MCG CAPSULE DOXERCALCIFEROL 2.5 MCG CAP ETIDRONATE DISODIUM 200 MG TAB ETIDRONATE DISODIUM 400 MG TAB FORTEO 600 MCG/2.4 ML PEN INJ

NC MD 2 2 2 2 NC 2 2 2 2 2 4

FORTICAL 200 UNITS NASAL SPRAY FOSAMAX 70 MG TABLET FOSAMAX PLUS D 70 MG-2,800 IU FOSAMAX PLUS D 70 MG-5,600 IU HECTOROL 0.5 MCG CAPSULE HECTOROL 1 MCG CAPSULE HECTOROL 2.5 MCG CAPSULE IBANDRONATE 3 MG/3 ML SYRINGE IBANDRONATE SODIUM 150 MG TAB

NC NC NC NC NC NC NC MD 2

MIACALCIN 200 UNIT NASAL SPRAY NATPARA 100 MCG DOSE CARTRIDGE NATPARA 25 MCG DOSE CARTRIDGE NATPARA 50 MCG DOSE CARTRIDGE NATPARA 75 MCG DOSE CARTRIDGE PARICALCITOL 1 MCG CAPSULE PARICALCITOL 2 MCG CAPSULE PARICALCITOL 4 MCG CAPSULE PROLIA 60 MG/ML SYRINGE

NC NC NC NC NC 2 2 2 MD

RAYALDEE ER 30 MCG CAPSULE RECLAST 5 MG/100 ML SOLUTION RISEDRONATE SOD DR 35 MG TAB

NC MD 2

RISEDRONATE SODIUM 150 MG TAB

2

RISEDRONATE SODIUM 30 MG TAB

2

RISEDRONATE SODIUM 35 MG TAB

2

RISEDRONATE SODIUM 5 MG TABLET

2

ROCALTROL 0.25 MCG CAPSULE ROCALTROL 0.5 MCG CAPSULE ROCALTROL 1 MCG/ML ORAL SOLN XGEVA 120 MG/1.7 ML VIAL

NC NC NC MD

VALUE FORMULARY FIVE-TIER DRUG LIST

Max. 4 per 28 days HSA* HSA*; SPP*: Must use Magellan Rx

HSA* HSA* Prior Authorization required;Max. 2.4 ML(s) per 28 days HSA*; Max 1 syringe/28 days supply; SPP: Magellan Rx

SPP*: Must use Magellan Rx Max. 1 per 30 days HSA*

Prior Authorization required SPP*: Must use Magellan Rx

Max. 4 per 28 days HSA* Max. 1 in 30 days HSA* Max. 1 per day HSA* Max. 4 per 28 days HSA* Max. 1 per day HSA*

Prior Authorization required SPP*: Must use Magellan Rx

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ZEMPLAR 1 MCG CAPSULE ZEMPLAR 2 MCG CAPSULE ZEMPLAR 4 MCG CAPSULE ZOLEDRONIC ACID 5 MG/100 ML

NC NC NC MD

LIMITATIONS/ * NOTES

SPP*: Must use Magellan Rx

MISCELLANEOUS THERAPEUTIC AGENTS MISCELLANEOUS THERAPEUTIC AGENTS ACD-A SOLUTION ACTICOAT 16"X16" DRESSING ACTICOAT 2"X2" DRESSING ACTICOAT 4"X4" DRESSING ACTICOAT 4"X48" DRESSING ACTICOAT 4"X8" DRESSING ACTICOAT 5"X5" DRESSING ACTICOAT 8"X16" DRESSING ACTIMMUNE 100 MCG/0.5 ML VIAL

NC NC NC NC NC NC NC NC 4

ALEVICYN ANTIPRURITIC GEL ALEVICYN DERMAL SPRAY ATRAPRO DERMAL SPRAY ATRAPRO HYDROGEL BENLYSTA 120 MG VIAL BENLYSTA 400 MG VIAL BHT POWDER BIONECT 0.2% CREAM BIONECT 0.2% FOAM BIONECT 0.2% GEL BIONECT 0.2% SPRAY BOTOX 100 UNITS VIAL

NC NC NC NC MD MD NC NC NC NC NC MD

BOTOX 200 UNITS VIAL

MD

BUSPIRONE HCL 10 MG TABLET BUSPIRONE HCL 15 MG TABLET BUSPIRONE HCL 30 MG TABLET BUSPIRONE HCL 5 MG TABLET BUSPIRONE HCL 7.5 MG TABLET CARDIOVID PLUS SOFTGEL CARNITOR 330 MG TABLET CARNITOR SF 100 MG/ML ORAL SOL CERDELGA 84 MG CAPSULE CETYLEV 2.5 GM EFF TABLET CETYLEV 500 MG EFF TABLET CHOLESTEROL POWDER CITRIC ACID GRANULES CITRIC ACID POWDER CYSTADANE POWDER D-MANNOSE POWDER DIMETHYL SULFOXIDE LIQUID DYSPORT 300 UNIT VIAL

2 2 2 1 2 NC NC NC 4 4 4 NC NC NC 5 NC NC MD

DYSPORT 500 UNITS VIAL

MD

ELMIRON 100 MG CAPSULE ERGOLOID MESYLATES 1 MG TAB ETHYL ACETATE LIQUID ETHYL VANILLIN FLAKES

4 2 NC NC

VALUE FORMULARY FIVE-TIER DRUG LIST

Max. 30 Days Supply SPP*: Accredo

SPP*: Must use Magellan Rx SPP*: Must use Magellan Rx

Prior Authorization required SPP*: Must use Magellan Rx Prior Authorization required SPP*: Must use Magellan Rx

SPP*: Must use Accredo Max. quantity of 20 per fill Max. quantity of 20 per fill

Prior Authorization required SPP*: Must use Magellan Rx Prior Authorization required SPP*: Must use Magellan Rx

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FORMA-RAY 20% SOLUTION FORMALDEHYDE 10% SOLUTION FORMALDEHYDE 37% SOLUTION GANIRELIX ACET 250 MCG/0.5 ML

NC NC NC 5

GEL-ONE 30 MG/3 ML SYRINGE GLUCAGEN 1 MG HYPOKIT GLUCAGON 1 MG EMERGENCY KIT GLUTATHIONE-L POWDER GRASTEK 2,800 BAU SL TABLET GUANIDINE HCL 125 MG TABLET HP ACTHAR GEL 80 UNIT/ML VIAL

MD 3 3 NC NC 2 MD

HYALGAN 20 MG/2 ML SYRINGE HYDROGEN PEROXIDE ACS 30% SOLN HYDROXYETHYL METHACRYLATE LIQ HYDROXYZINE PAM 100 MG CAP HYDROXYZINE PAM 25 MG CAP HYDROXYZINE PAM 50 MG CAP HYGEL 2.5% GEL HYLASE WOUND GEL KALBITOR 10 MG/ML VIAL KEVEYIS 50 MG TABLET

NC NC NC 2 2 2 NC NC MD 5

L-GLUTATHIONE REDUCED POWDER LACTIC ACID LIQUID LEUCOVORIN CALCIUM 10 MG TAB LEUCOVORIN CALCIUM 15 MG TAB LEUCOVORIN CALCIUM 25 MG TAB LEUCOVORIN CALCIUM 5 MG TAB LEVOCARNITINE 100 MG/ML SOLN LEVOCARNITINE 330 MG TABLET LIPOCHOL PLUS TABLET LITHOSTAT 250 MG TABLET LUPANETA PK 11.25-5 MG 3MO KIT LUPANETA PK 3.75-5 MG 1MO KIT LYCELLE HEAD LICE REMOVAL KIT MEPROBAMATE 200 MG TABLET MEPROBAMATE 400 MG TABLET MESNEX 400 MG TABLET MESTINON 180 MG TIMESPAN MESTINON 60 MG TABLET MESTINON 60 MG/5 ML SYRUP METHERGINE 0.2 MG TABLET METHYLERGONOVINE 0.2 MG TABLET MICROCRYSTAL CELLULOSE POWDER MICROCYN SKIN-WOUND CARE SPRAY MYALEPT 11.3 MG (5 MG/ML) VIAL MYOBLOC 10,000 UNITS/2 ML VIAL

NC NC 2 2 2 2 2 2 NC NC NC NC NC 2 2 4 NC NC 4 NC 2 NC NC 5 MD

MYOBLOC 2,500 UNIT/0.5 ML VIAL

MD

MYOBLOC 5,000 UNITS/1 ML VIAL

MD

NPLATE 250 MCG VIAL

MD

NPLATE 500 MCG VIAL

MD

ORAFATE 1 GM/10 ML PASTE ORALAIR 100 IR STARTER PACK ORALAIR 300 IR SUBLINGUAL TAB ORENCIA CLICKJECT 125 MG/ML

NC NC NC NC

VALUE FORMULARY FIVE-TIER DRUG LIST

LIMITATIONS/ * NOTES

Max. 30 Days Supply IVF*

Prior Authorization required SPP*: Must use Accredo

SPP*: Must use Accredo Prior Authorization required SPP*: Diplomat

Prior Authorization required SPP*: Must use Magellan Rx Prior Authorization required SPP*: Must use Magellan Rx Prior Authorization required SPP*: Must use Magellan Rx Prior Authorization required SPP*: Must use Magellan Rx Prior Authorization required SPP*: Must use Magellan Rx

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POTABA 500 MG CAPSULE POTABA 500 MG TABLET PROCYSBI DR 25 MG CAPSULE PROCYSBI DR 75 MG CAPSULE PROPYLENE GLYCOL LIQUID PROSTIGMIN 15 MG TABLET PROTHELIAL 1 GM/10 ML PASTE PRUTECT TOPICAL EMULSION PYRIDOSTIGMINE BR 60 MG TABLET PYRIDOSTIGMINE ER 180 MG TAB RADIAGEL RAGWITEK SUBLINGUAL TABLET RECTIV 0.4% OINTMENT SENSIPAR 30 MG TABLET SENSIPAR 60 MG TABLET SENSIPAR 90 MG TABLET SIGNIFOR 0.3 MG/ML AMPULE SIGNIFOR 0.6 MG/ML AMPULE SIGNIFOR 0.9 MG/ML AMPULE SIGNIFOR LAR 20 MG VIAL SIGNIFOR LAR 40 MG KIT SIGNIFOR LAR 60 MG KIT SODIUM BISULFITE GRANULES SODIUM SUCCINATE POWDER SOLIRIS 300 MG/30 ML VIAL

NC NC NC NC NC NC NC 2 2 2 NC NC 4 4 4 4 4 4 4 MD MD MD NC NC MD

SORBITOL POWDER SUPARTZ 25 MG/2.5 ML SYRINGE SUPARTZ FX 25 MG/2.5 ML SYR SYNAREL 2 MG/ML NASAL SPRAY

NC MD MD 4

THALOMID 100 MG CAPSULE THALOMID 150 MG CAPSULE THALOMID 200 MG CAPSULE THALOMID 50 MG CAPSULE THIOLA 100 MG TABLET TOLU BALSAM MASS TRICHLOROACETIC ACID 25% TYBOST 150 MG TABLET ULESFIA 5% LOTION VANILLIN CRYSTALS VEHICLE-N MILD SOLUTION VEHICLE-N SOLUTION VISTARIL 25 MG CAPSULE VISTARIL 50 MG CAPSULE VISTOGARD 10 GRAM PACKET WATER FOR INJECTION VIAL XEOMIN 100 UNITS VIAL

4 4 4 4 NC NC NC NC 4 NC NC NC NC NC NC NC MD

XEOMIN 200 UNIT VIAL

MD

XEOMIN 50 UNITS VIAL

MD

XURIDEN GRANULE PACKET ZANABIN ANTIPRURITIC HYDROGEL

NC NC

LIMITATIONS/ * NOTES

SPP*: Must use Magellan Rx SPP*: Must use Magellan Rx SPP*: Must use Magellan Rx SPP*: Must use Accredo SPP*: Must use Accredo SPP*: Must use Accredo SPP*: Must use Accredo SPP*: Must use Accredo SPP*: Must use Accredo

Prior Authorization required SPP*: Must use Magellan Rx

Max. 30 Days Supply IVF* SPP*: Accredo SPP*: Accredo SPP*: Accredo SPP*: Accredo

Prior Authorization required SPP*: Must use Magellan Rx Prior Authorization required SPP: Must use Magellan RX Prior Authorization required SPP: Must use Magellan RX

MOUTHWASHES AND GARGLES MOUTHWASHES AND GARGLES

VALUE FORMULARY FIVE-TIER DRUG LIST

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ORAMAGICRX ORAL RINSE

NC

LIMITATIONS/ * NOTES

OPHTHALMIC AGENTS ANTIGLAUCOMA AGENTS ACETAZOLAMIDE 125 MG TABLET ACETAZOLAMIDE 250 MG TABLET ACETAZOLAMIDE ER 500 MG CAP ALPHAGAN P 0.1% DROPS ALPHAGAN P 0.15% EYE DROPS AZOPT 1% EYE DROPS BETAGAN 0.5% EYE DROPS BETAXOLOL HCL 0.5% EYE DROP BETIMOL 0.25% EYE DROPS BETIMOL 0.5% EYE DROPS BETOPTIC S 0.25% EYE DROPS BIMATOPROST 0.03% EYE DROPS BRIMONIDINE 0.2% EYE DROP BRIMONIDINE TARTRATE 0.15% DRP COMBIGAN 0.2%-0.5% EYE DROPS COSOPT EYE DROPS COSOPT PF EYE DROPS DIAMOX SEQUELS ER 500 MG CAP DORZOLAMIDE HCL 2% EYE DROPS DORZOLAMIDE-TIMOLOL EYE DROPS ISOPTO CARBACHOL 1.5% DROPS ISOPTO CARBACHOL 3% DROPS ISOPTO CARPINE 1% EYE DROPS ISOPTO CARPINE 2% EYE DROPS ISOPTO CARPINE 4% EYE DROPS ISTALOL 0.5% EYE DROPS LATANOPROST 0.005% EYE DROPS LEVOBUNOLOL 0.25% EYE DROPS LEVOBUNOLOL 0.5% EYE DROPS LUMIGAN 0.01% EYE DROPS METHAZOLAMIDE 25 MG TABLET METHAZOLAMIDE 50 MG TABLET METIPRANOLOL 0.3% EYE DROPS NEPTAZANE 25 MG TABLET NEPTAZANE 50 MG TABLET PHOSPHOLINE IODIDE 0.125% PILOCARPINE 1% EYE DROPS PILOCARPINE 2% EYE DROPS PILOCARPINE 4% EYE DROPS PILOPINE HS 4% EYE GEL RESCULA 0.15% EYE DROPS SIMBRINZA 1%-0.2% EYE DROPS TIMOLOL 0.25% EYE DROPS TIMOLOL 0.25% GEL-SOLUTION TIMOLOL 0.5% EYE DROPS TIMOLOL 0.5% GEL-SOLUTION TIMOPTIC 0.25% OCUDOSE DROP TIMOPTIC 0.5% OCUDOSE DROP TIMOPTIC-XE 0.25% EYE SOLN TIMOPTIC-XE 0.5% EYE SOLN

VALUE FORMULARY FIVE-TIER DRUG LIST

2 2 2 3 NC 3 NC 2 3 3 3 2 1 2 3 NC NC NC 2 2 NC NC NC NC NC NC 2 2 2 3 2 2 2 NC NC 4 2 2 2 3 5 3 1 2 1 2 NC NC NC NC

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TRAVATAN Z 0.004% EYE DROP TRAVOPROST 0.004% EYE DROP TRUSOPT 2% EYE DROPS XALATAN 0.005% EYE DROPS ZIOPTAN 0.0015% EYE DROPS

3 2 NC NC 4

LIMITATIONS/ * NOTES

REPLACEMENT PREPARATIONS REPLACEMENT PREPARATIONS CITRIC ACID GRANULES CITRIC ACID POWDER CYTRA-2 ORAL SOLUTION CYTRA-3 SYRUP CYTRA-K CRYSTALS PACKET CYTRA-K ORAL SOLUTION EFFER-K 10 MEQ TABLET EFF EFFER-K 20 MEQ TABLET EFF EFFER-K 25 MEQ TABLET EFF K EFFERVESCENT 25 MEQ TABLET K-PHOS #2 TABLET K-PHOS NEUTRAL TABLET K-PHOS ORIGINAL TABLET K-TAB ER 10 MEQ TABLET K-TAB ER 20 MEQ TABLET K-TAB ER 8 MEQ TABLET KAOCHLOR-EFF 20 MEQ TABLET KLOR-CON 10 MEQ TABLET KLOR-CON 20 MEQ PACKET KLOR-CON 8 MEQ TABLET KLOR-CON M10 TABLET KLOR-CON M15 TABLET KLOR-CON M20 TABLET KLOR-CON SPRINKLE ER 10 MEQ CP KLOR-CON SPRINKLE ER 8 MEQ CAP KLOR-CON-EF 25 MEQ TAB EFF ORACIT ORAL SOLUTION PHOSPHA 250 NEUTRAL TABLET POT CITRATE-CITRIC ACID PACKET POTASSIUM 25 MEQ TABLET EFF POTASSIUM CIT-CITRIC ACID SOLN POTASSIUM CITRATE ER 10 MEQ TB POTASSIUM CITRATE ER 15 MEQ TB POTASSIUM CITRATE ER 5 MEQ TAB POTASSIUM CL 10% (20 MEQ/15 ML POTASSIUM CL 20 MEQ PACKET POTASSIUM CL 20% (40 MEQ/15 ML POTASSIUM CL 25 MEQ TAB EFF POTASSIUM CL ER 10 MEQ CAPSULE POTASSIUM CL ER 10 MEQ TABLET POTASSIUM CL ER 20 MEQ TABLET POTASSIUM CL ER 8 MEQ CAPSULE POTASSIUM CL ER 8 MEQ TABLET SHOHL'S MODIFIED SOLUTION SOD CITRATE-CITRIC ACID SOLN TRICITRATES ORAL SOLUTION UROCIT-K ER 15 MEQ TABLET UROCIT-K SR 10 MEQ TABLET

VALUE FORMULARY FIVE-TIER DRUG LIST

NC NC 2 2 2 2 NC NC 2 2 NC NC NC NC NC NC NC 2 NC NC 2 2 2 2 2 NC 3 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 NC 2 2 NC NC

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DRUG NAME

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UROCIT-K SR 5 MEQ TABLET VIRT-PHOS 250 NEUTRAL TABLET ZINC SULFATE 220 MG CAPSULE

NC 2 NC

LIMITATIONS/ * NOTES

RESPIRATORY TRACT AGENTS ANTI-INFLAMMATORIES, INHALED CORTICOSTEROIDS ADVAIR 100-50 DISKUS

3

ADVAIR 250-50 DISKUS

3

ADVAIR 500-50 DISKUS

3

ADVAIR HFA 115-21 MCG INHALER

3

ADVAIR HFA 230-21 MCG INHALER

3

ADVAIR HFA 45-21 MCG INHALER

3

AEROSPAN 80 MCG INHALER ALVESCO 160 MCG INHALER ALVESCO 80 MCG INHALER ARNUITY ELLIPTA 100 MCG INH ARNUITY ELLIPTA 200 MCG INH ASMANEX HFA 100 MCG INHALER ASMANEX HFA 200 MCG INHALER ASMANEX TWISTHALER 110 MCG #30 ASMANEX TWISTHALER 110 MCG #7 ASMANEX TWISTHALER 220 MCG #14 ASMANEX TWISTHALER 220 MCG #30 ASMANEX TWISTHALER 220 MCG #60 ASMANEX TWISTHALR 220 MCG #120 BREO ELLIPTA 100-25 MCG INH

NC 4 4 NC NC 3 3 3 NC 3 3 3 3 3

BREO ELLIPTA 200-25 MCG INH

3

BUDESONIDE 0.25 MG/2 ML SUSP BUDESONIDE 0.5 MG/2 ML SUSP BUDESONIDE 1 MG/2 ML INH SUSP DULERA 100 MCG/5 MCG INHALER

2 2 2 3

DULERA 200 MCG/5 MCG INHALER

3

FLOVENT 100 MCG DISKUS FLOVENT 250 MCG DISKUS FLOVENT 50 MCG DISKUS FLOVENT HFA 110 MCG INHALER FLOVENT HFA 220 MCG INHALER FLOVENT HFA 44 MCG INHALER PULMICORT 0.25 MG/2 ML RESPUL PULMICORT 0.5 MG/2 ML RESPULE PULMICORT 1 MG/2 ML RESPULE PULMICORT 180 MCG FLEXHALER PULMICORT 90 MCG FLEXHALER QVAR 40 MCG ORAL INHALER QVAR 80 MCG ORAL INHALER SYMBICORT 160-4.5 MCG INHALER

3 3 3 3 3 3 NC NC NC 3 3 3 3 3

SYMBICORT 80-4.5 MCG INHALER

3

VALUE FORMULARY FIVE-TIER DRUG LIST

Max. 60 in 30 days HSA* Max. 60 in 30 days HSA* Max. 60 in 30 days HSA* Max. 12 GM(s) in 30 days HSA* Max. 12 GM(s) in 30 days HSA* Max. 12 GM(s) in 30 days HSA* HSA* HSA*

HSA* HSA* HSA* HSA* HSA* HSA* HSA* Max. 2 per day HSA* Max. 2 per day HSA* HSA* HSA* HSA* Max. 13 GM(s) in 30 days HSA* Max. 13 GM(s) in 30 days HSA* HSA* HSA* HSA* HSA* HSA* HSA*

HSA* HSA* HSA* HSA* Max. 1 GM(s) in 30 days HSA* Max. 1 GM(s) in 30 days HSA*

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LIMITATIONS/ * NOTES

ANTILEUKOTRIENES ACCOLATE 10 MG TABLET ACCOLATE 20 MG TABLET MONTELUKAST SOD 10 MG TABLET MONTELUKAST SOD 4 MG GRANULES MONTELUKAST SOD 4 MG TAB CHEW MONTELUKAST SOD 5 MG TAB CHEW SINGULAIR 10 MG TABLET SINGULAIR 4 MG GRANULES SINGULAIR 4 MG TABLET CHEW SINGULAIR 5 MG TABLET CHEW ZAFIRLUKAST 10 MG TABLET ZAFIRLUKAST 20 MG TABLET ZYFLO 600 MG FILMTAB ZYFLO CR 600 MG TABLET

NC NC 1 2 2 2 NC NC NC NC 2 2 NC 4

HSA* HSA* HSA* HSA*

HSA* HSA* HSA*

BRONCHODILATORS ACCUNEB 0.63 MG/3 ML INH SOLN ACCUNEB 1.25 MG/3 ML INH SOLN ALBUTEROL 5 MG/ML SOLUTION ALBUTEROL SUL 0.63 MG/3 ML SOL ALBUTEROL SUL 1.25 MG/3 ML SOL ALBUTEROL SUL 2.5 MG/3 ML SOLN ALBUTEROL SULF 2 MG/5 ML SYRUP ALBUTEROL SULFATE 2 MG TAB ALBUTEROL SULFATE 4 MG TAB ALBUTEROL SULFATE ER 4 MG TAB ALBUTEROL SULFATE ER 8 MG TAB ANORO ELLIPTA 62.5-25 MCG INH ARCAPTA NEOHALER 75 MCG CAP

NC NC 2 2 2 2 1 2 2 2 2 3 4

ATROVENT HFA INHALER BROVANA 15 MCG/2 ML SOLUTION COMBIVENT INHALER COMBIVENT RESPIMAT INHAL SPRAY DUONEB 0.5 MG-3 MG/3 ML SOLN ELIXOPHYLLIN 80 MG/15 ML ELIX FORADIL AEROLIZER 12 MCG CAP

4 4 NC 3 NC 2 3

INCRUSE ELLIPTA 62.5 MCG INH IPRAT-ALBUT 0.5-3(2.5) MG/3 ML IPRATROPIUM BR 0.02% SOLN LEVALBUTEROL 0.31 MG/3 ML SOL LEVALBUTEROL 0.63 MG/3 ML SOL LEVALBUTEROL 1.25 MG/3 ML SOL LEVALBUTEROL CONC 1.25 MG/0.5 LEVALBUTEROL TAR HFA 45MCG INH LUFYLLIN 200 MG TABLET LUFYLLIN-400 TABLET MAXAIR AUTOHALER 0.2 MG AERO METAPROTERENOL 10 MG TABLET METAPROTERENOL 10 MG/5 ML SYR METAPROTERENOL 20 MG TABLET PERFOROMIST 20 MCG/2 ML SOLN PROAIR HFA 90 MCG INHALER

3 2 2 2 2 2 2 3 4 4 4 2 2 2 3 3

VALUE FORMULARY FIVE-TIER DRUG LIST

HSA* HSA* HSA* HSA* HSA* HSA* HSA* HSA* HSA* Max. quantity of 60 per fill;Max. 60 in 30 days Max. 1 per day HSA* HSA* HSA* HSA* HSA* Max. 2 per day HSA* Max. quantity of 1 per fill;Max. 30 in 30 days HSA* HSA* HSA* HSA* HSA* HSA* HSA* HSA* HSA* HSA* HSA* HSA* HSA* HSA* HSA*

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DRUG NAME

TIER

LIMITATIONS/ * NOTES

PROAIR RESPICLICK INHAL POWDER PROVENTIL HFA 90 MCG INHALER SEEBRI NEOHALER 15.6 MCG INHAL SEREVENT DISKUS 50 MCG

3 NC NC 3

HSA*

SPIRIVA 18 MCG CP-HANDIHALER

3

SPIRIVA RESPIMAT 1.25 MCG INH

3

SPIRIVA RESPIMAT 2.5 MCG INH

3

STIOLTO RESPIMAT INHAL SPRAY STRIVERDI RESPIMAT INHAL SPRAY

NC 5

TERBUTALINE SULFATE 2.5 MG TAB TERBUTALINE SULFATE 5 MG TAB THEO-24 ER 100 MG CAPSULE THEO-24 ER 200 MG CAPSULE THEO-24 ER 300 MG CAPSULE THEO-24 ER 400 MG CAPSULE THEOCHRON ER 100 MG TABLET THEOCHRON ER 200 MG TABLET THEOCHRON ER 300 MG TABLET THEOPHYLLINE 80 MG/15 ML SOLN THEOPHYLLINE ER 100 MG TABLET THEOPHYLLINE ER 200 MG TABLET THEOPHYLLINE ER 300 MG TAB THEOPHYLLINE ER 400 MG TABLET THEOPHYLLINE ER 450 MG TAB THEOPHYLLINE ER 600 MG TABLET TUDORZA PRESSAIR 400 MCG INH

2 2 3 3 3 3 2 2 2 NC 2 2 2 2 2 2 3

UTIBRON NEOHALER 27.5-15.6 MCG VENTOLIN HFA 90 MCG INHALER VOSPIRE ER 4 MG TABLET VOSPIRE ER 8 MG TABLET XOPENEX 0.31 MG/3 ML SOLUTION XOPENEX 0.63 MG/3 ML SOLUTION XOPENEX 1.25 MG/3 ML SOLUTION XOPENEX CONC 1.25 MG/0.5 ML XOPENEX HFA 45 MCG INHALER

NC 3 NC NC NC NC NC NC 4

Max. 60 in 30 days HSA* Max. 1 per day HSA*; Max 1 inhaler/30 days supply Max. 4 GM(s) per 30 days HSA*; Max 1 inhaler/30 days supply Max. 4 GM(s) per 30 days HSA*; Max 1 inhaler/30 days supply Prior Authorization required;Max. 4 GM(s) per 30 days HSA*; Max 1 inhaler/30 days supply HSA* HSA* HSA* HSA* HSA* HSA* HSA* HSA* HSA* HSA* HSA* HSA* HSA* HSA* HSA* Max. 1 in 30 days HSA* HSA*

HSA*

RESPIRATORY TRACT AGENTS, OTHER ACETYLCYSTEINE 10% VIAL ACETYLCYSTEINE 20% VIAL ARALAST NP 1,000 MG VIAL

2 2 MD

BRONCOMAR-1 ELIXIR CROMOLYN 20 MG/2 ML NEB SOLN CUROSURF 120 MG/1.5 ML VIAL DALIRESP 500 MCG TABLET ESBRIET 267 MG CAPSULE

NC 2 NC 3 3

HYPER-SAL 3.5% VIAL HYPER-SAL 7% VIAL INFASURF 35 MG/ML VIAL KALYDECO 150 MG TABLET

4 NC NC 5

KALYDECO 50 MG GRANULES PACKET

5

VALUE FORMULARY FIVE-TIER DRUG LIST

Prior Authorization required SPP*: Must use Accredo HSA* HSA* Max. 9 per day SPP*: Must use Accredo

Prior Authorization required SPP*: Must use Accredo Prior Authorization required SPP*: Must use Accredo

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DRUG NAME

TIER

LIMITATIONS/ * NOTES

KALYDECO 75 MG GRANULES PACKET

5

Prior Authorization required SPP*: Must use Accredo

NEBUSAL 6% VIAL OFEV 100 MG CAPSULE

4 3

OFEV 150 MG CAPSULE

3

ORKAMBI 100 MG-125 MG TABLET

5

ORKAMBI 200 MG-125 MG TABLET

5

PROLASTIN C 1,000 MG VIAL

MD

PULMOSAL 7% VIAL SODIUM CHLORIDE 0.9% INHAL VL SODIUM CHLORIDE 10% VIAL SODIUM CHLORIDE 3% VIAL SODIUM CHLORIDE 7% VIAL SURVANTA 25 MG/ML VIAL XOLAIR 150 MG VIAL

NC 2 2 2 2 NC MD

ZEMAIRA 1,000 MG VIAL

MD

Max. 2 per day SPP*: Must use Accredo or Walgreens Specialty Max. 2 per day SPP*: Must use Accredo or Walgreens Specialty Prior Authorization required;Max. 112 per 28 days SPP*: Must use Accredo Prior Authorization required;Max. 112 per 28 days SPP*: Must use Accredo Prior Authorization required LDD*: Dohmen Life Sciences. 1-800-305-7881.

Prior Authorization required SPP*: Must use Magellan Rx Prior Authorization required SPP*: Must use Accredo

ROENTGENOGRAPHY ROENTGENOGRAPHY VARIBAR PUDDING 40% PASTE

NC

SALT AND SUGAR SUBSTITUTES SALT AND SUGAR SUBSTITUTES SACCHARIN POWDER

NC

SKELETAL MUSCLE RELAXANTS SKELETAL MUSCLE RELAXANTS AMRIX ER 15 MG CAPSULE AMRIX ER 30 MG CAPSULE BACLOFEN 10 MG TABLET BACLOFEN 20 MG TABLET CARISOPRODL-ASPIRIN 200-325 MG CARISOPRODOL 250 MG TABLET CARISOPRODOL 350 MG TABLET CARISOPRODOL CPD-CODEINE TAB CHLORZOXAZONE 500 MG TABLET COMFORT PAC-CYCLOBENZAPRINE KT CYCLOBENZAPRINE 10 MG TABLET CYCLOBENZAPRINE 5 MG TABLET CYCLOBENZAPRINE 7.5 MG TABLET DANTRIUM 100 MG CAPSULE DANTRIUM 25 MG CAPSULE DANTRIUM 50 MG CAPSULE DANTROLENE SODIUM 100 MG CAP

VALUE FORMULARY FIVE-TIER DRUG LIST

NC NC 2 2 2 2 2 2 2 NC 1 1 2 NC NC NC 2

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DRUG NAME

TIER

DANTROLENE SODIUM 25 MG CAP DANTROLENE SODIUM 50 MG CAP FEXMID 7.5 MG TABLET FLEXERIL 10 MG TABLET FLEXERIL 5 MG TABLET LORZONE 375 MG TABLET LORZONE 750 MG TABLET METAXALL 800 MG TABLET METAXALONE 400 MG TABLET METAXALONE 800 MG TABLET METHOCARBAMOL 500 MG TABLET METHOCARBAMOL 750 MG TABLET ORPHENADRINE COMP FORTE TAB ORPHENADRINE COMP TABLET ORPHENADRINE ER 100 MG TABLET PARAFON FORTE DSC 500 MG CAPLT ROBAXIN 500 MG TABLET ROBAXIN-750 TABLET SKELAXIN 800 MG TABLET SOMA 250 MG TABLET SOMA 350 MG TABLET TIZANIDINE HCL 2 MG CAPSULE TIZANIDINE HCL 2 MG TABLET TIZANIDINE HCL 4 MG CAPSULE TIZANIDINE HCL 4 MG TABLET TIZANIDINE HCL 6 MG CAPSULE ZANAFLEX 2 MG CAPSULE ZANAFLEX 4 MG CAPSULE ZANAFLEX 4 MG TABLET ZANAFLEX 6 MG CAPSULE

2 2 NC NC NC NC NC 2 2 2 2 2 2 2 2 NC NC NC NC NC NC 2 2 2 2 2 NC NC NC NC

LIMITATIONS/ * NOTES

SLEEP DISORDER AGENTS SLEEP DISORDER AGENTS AMBIEN 10 MG TABLET AMBIEN 5 MG TABLET AMBIEN CR 12.5 MG TABLET AMBIEN CR 6.25 MG TABLET ARMODAFINIL 150 MG TABLET ARMODAFINIL 200 MG TABLET ARMODAFINIL 250 MG TABLET ARMODAFINIL 50 MG TABLET BELSOMRA 10 MG TABLET

NC NC NC NC 3 3 3 3 4

BELSOMRA 15 MG TABLET

4

BELSOMRA 20 MG TABLET

4

BELSOMRA 5 MG TABLET

4

BUTISOL SODIUM 30 MG TABLET BUTISOL SODIUM 30 MG/5 ML ELX BUTISOL SODIUM 50 MG TABLET EDLUAR 10 MG SL TABLET EDLUAR 5 MG SL TABLET

NC NC NC NC NC

VALUE FORMULARY FIVE-TIER DRUG LIST

Prior Authorization required;Max. 1 per day Prior Authorization required;Max. 1 per day Prior Authorization required;Max. 1 per day Prior Authorization required;Max. 1 per day Not covered for members 18 and older;Max. 1 per day;Step Therapy required STA*: 18 and older Not covered for members 18 and older;Max. 1 per day;Step Therapy required STA*: 18 and older Not covered for members 18 and older;Max. 1 per day;Step Therapy required STA*: 18 and older Not covered for members 18 and older;Max. 1 per day;Step Therapy required STA*: 18 and older

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DRUG NAME

TIER

ESZOPICLONE 1 MG TABLET ESZOPICLONE 2 MG TABLET ESZOPICLONE 3 MG TABLET HETLIOZ 20 MG CAPSULE

2 2 2 5

INTERMEZZO 1.75 MG TAB SUBLING INTERMEZZO 3.5 MG TAB SUBLING LUNESTA 1 MG TABLET LUNESTA 2 MG TABLET LUNESTA 3 MG TABLET MODAFINIL 100 MG TABLET MODAFINIL 200 MG TABLET NUVIGIL 150 MG TABLET NUVIGIL 200 MG TABLET NUVIGIL 250 MG TABLET NUVIGIL 50 MG TABLET PROVIGIL 100 MG TABLET PROVIGIL 200 MG TABLET ROZEREM 8 MG TABLET

NC NC NC NC NC 3 3 NC NC NC NC NC NC 4

SECONAL SODIUM 100 MG CAPSULE SILENOR 3 MG TABLET

NC 4

SILENOR 6 MG TABLET

4

SONATA 10 MG CAPSULE SONATA 5 MG CAPSULE XYREM 500 MG/ML ORAL SOLUTION ZALEPLON 10 MG CAPSULE ZALEPLON 5 MG CAPSULE ZOLPIDEM TART 1.75 MG TAB SL ZOLPIDEM TART 3.5 MG TABLET SL ZOLPIDEM TART ER 12.5 MG TAB ZOLPIDEM TART ER 6.25 MG TAB ZOLPIDEM TARTRATE 10 MG TABLET ZOLPIDEM TARTRATE 5 MG TABLET ZOLPIMIST 5 MG ORAL SPRAY

NC NC 5 2 2 2 2 2 2 1 1 NC

LIMITATIONS/ * NOTES

Prior Authorization required;Max. 1 per day SPP*: Must use Accredo

Prior Authorization required for new starts;Max. 1 per day Prior Authorization required for new starts;Max. 1 per day

Not covered for members 18 and older;Step Therapy required STA*: 18 and older Not covered for members 18 and older;Step Therapy required STA*: 18 and older Not covered for members 18 and older;Step Therapy required STA*: 18 and older

LDD*: Express Scripts. 866-997-3688 x66247.

SYMPATHOLYTIC ADRENERGIC BLOCKING AGENTS ALPHA-ADRENERGIC BLOCKING AGENTS PHENTO 0.5MG-ALPRSTDL 20MCG/ML

2

URINE AND FECES CONTENTS KETONES CHEMSTRIP K CVS KETONE CARE TEST STRIPS DIASCREEN 1K REAGENT STRIPS KETONE TEST STRIPS KETOSTIX REAGENT STRIPS TRUEPLUS KETONE TEST STRIPS

VALUE FORMULARY FIVE-TIER DRUG LIST

3 3 3 3 3 3

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DRUG NAME

TIER

LIMITATIONS/ * NOTES

PROTEIN ALBUSTIX REAGENT STRIPS CHEMSTRIP MICRAL TEST STRIP

NC NC

SUGAR DIASCREEN 1G REAGENT STRIPS

3

DIASTIX REAGENT STRIPS

3

NO-STICK GLUCOSE TEST STRIPS

3

Prior Authorization required HSA* Prior Authorization required HSA* Prior Authorization required HSA*

URINE AND FECES CONTENTS CHEK-STIX STRIPS CHEMSTRIP 10 MD CHEMSTRIP 10 WITH SG CHEMSTRIP 2 GP CHEMSTRIP 50B CHEMSTRIP 7 CHEMSTRIP UGK CHEMSTRIP-9 COMBISTIX REAGENT STRIPS DIASCREEN 10 REAGENT STRIPS DIASCREEN 1B REAGENT STRIPS DIASCREEN 2GK REAGENT STRIPS DIASCREEN 2GP STRIPS DIASCREEN 3 REAGENT STRIPS DIASCREEN 4NL REAGENT STRIPS DIASCREEN 4OBL REAGENT STRIPS DIASCREEN 4PH REAGENT STRIPS DIASCREEN 5 REAGENT STRIPS DIASCREEN 7 REAGENT STRIPS DIASCREEN 8 REAGENT STRIPS DIASCREEN 9 REAGENT STRIPS HEMA-COMBISTIX REAGENT STRIPS KETO-DIASTIX REAGENT STRIPS LABSTIX REAGENT STRIPS MULTISTIX 10 SG REAGENT STRIPS MULTISTIX 5 STRIPS MULTISTIX 7 REAGENT STRIPS MULTISTIX 8 SG REAGENT STRIPS MULTISTIX 9 REAGENT STRIPS MULTISTIX 9 SG REAGENT STRIPS MULTISTIX REAGENT STRIPS URISTIX 4 REAGENT STRIPS URISTIX REAGENT STRIPS

3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3

HSA*

HSA* HSA* HSA* HSA* HSA* HSA* HSA* HSA* HSA*

VASODILATING AGENTS VASODILATING AGENTS ADCIRCA 20 MG TABLET

4

ADEMPAS 0.5 MG TABLET

4

VALUE FORMULARY FIVE-TIER DRUG LIST

Prior Authorization required;Max. 2 per day SPP*: Must use Accredo SPP*: Must use Accredo

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DRUG NAME

TIER

LIMITATIONS/ * NOTES

ADEMPAS 1 MG TABLET ADEMPAS 1.5 MG TABLET ADEMPAS 2 MG TABLET ADEMPAS 2.5 MG TABLET CAVERJECT 20 MCG VIAL CAVERJECT 40 MCG VIAL CAVERJECT IMPULSE 10 MCG KIT CAVERJECT IMPULSE 20 MCG KIT CIALIS 10 MG TABLET

4 4 4 4 NC NC NC NC 3

SPP*: Must use Accredo SPP*: Must use Accredo SPP*: Must use Accredo SPP*: Must use Accredo

CIALIS 2.5 MG TABLET

3

CIALIS 20 MG TABLET

3

CIALIS 5 MG TABLET

3

EDEX 10 MCG CARTRIDGE 2-PK KIT EDEX 20 MCG CARTRIDGE 2-PK KIT EDEX 40 MCG CARTRIDGE 2-PK KIT LETAIRIS 10 MG TABLET LETAIRIS 5 MG TABLET LEVITRA 10 MG TABLET LEVITRA 2.5 MG TABLET LEVITRA 20 MG TABLET LEVITRA 5 MG TABLET MUSE 1,000 MCG URETHRAL SUPP

NC NC NC 4 4 NC NC NC NC 3

MUSE 125 MCG URETHRAL SUPPOS

3

MUSE 250 MCG URETHRAL SUPPOS

3

MUSE 500 MCG URETHRAL SUPPOS

3

OPSUMIT 10 MG TABLET ORENITRAM ER 0.125 MG TABLET ORENITRAM ER 0.25 MG TABLET ORENITRAM ER 1 MG TABLET ORENITRAM ER 2.5 MG TABLET REVATIO 10 MG/ML ORAL SUSP REVATIO 20 MG TABLET SILDENAFIL 20 MG TABLET

4 5 5 5 5 NC NC 2

STAXYN 10 MG ODT STENDRA 100 MG TABLET STENDRA 200 MG TABLET STENDRA 50 MG TABLET TRACLEER 125 MG TABLET TRACLEER 62.5 MG TABLET TYVASO 1.74 MG/2.9 ML SOLUTION TYVASO INHALATION REFILL KIT TYVASO INHALATION STARTER KIT UPTRAVI 1,000 MCG TABLET UPTRAVI 1,200 MCG TABLET UPTRAVI 1,400 MCG TABLET UPTRAVI 1,600 MCG TABLET

NC NC NC NC 4 4 4 4 4 NC NC NC NC

VALUE FORMULARY FIVE-TIER DRUG LIST

Covered for males only;Not covered for members 17 and younger; Max. 4 in 30 days PAQ*: If > than 4 tabs/30 days Not covered for members 17 and younger; Max. 4 in 30 days PAQ*: If > than 4 tabs/30 days Covered for males only;Not covered for members 17 and younger; Max. 4 in 30 days PAQ*: If > than 4 tabs/30 days Covered for males only;Not covered for members 17 and younger; Max. 4 in 30 days PAQ*: If > than 4 tabs/30 days

SPP*: Accredo SPP*: Accredo

Covered for males only;Not covered for members 17 and younger; Max. 6 in 30 days Covered for males only;Not covered for members 17 and younger; Max. 6 in 30 days Covered for males only;Not covered for members 17 and younger; Max. 6 in 30 days Covered for males only;Not covered for members 17 and younger; Max. 6 in 30 days SPP*: Must use Accredo SPP*: Must use Accredo SPP*: Must use Accredo SPP*: Must use Accredo SPP*: Must use Accredo

Prior Authorization required SPP*: Must use Accredo

SPP*: Accredo SPP*: Accredo SPP*: Must use Accredo SPP*: Must use Accredo SPP*: Must use Accredo

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DRUG NAME

TIER

UPTRAVI 200 MCG TABLET UPTRAVI 200-800 TITRATION PACK UPTRAVI 400 MCG TABLET UPTRAVI 600 MCG TABLET UPTRAVI 800 MCG TABLET VENTAVIS 10 MCG/1 ML SOLUTION VENTAVIS 20 MCG/1 ML SOLUTION VIAGRA 100 MG TABLET

NC NC NC NC NC 5 5 3

VIAGRA 25 MG TABLET

3

VIAGRA 50 MG TABLET

3

LIMITATIONS/ * NOTES

LDD*: Accredo Nova Factor LDD*: Accredo Nova Factor Covered for males only;Not covered for members 17 and younger; Max. 4 in 30 days PAQ*: If > than 4 tabs/30 days Covered for males only;Not covered for members 17 and younger; Max. 4 in 30 days PAQ*: If > than 4 tabs/30 days Covered for males only;Not covered for members 17 and younger; Max. 4 in 30 days PAQ*: If > than 4 tabs/30 days

VITAMINS AND MINERALS VITAMINS AND MINERALS B-PLEX TABLET BACMIN CAPLET CHOICE-TABS TABLET CORVITA TABLET CORVITE TABLET CVS VITAMIN D3 400 UNIT SFTGL

NC NC NC NC NC 0

CYANOCOBALAMIN 1,000 MCG/ML DECARA 50,000 UNIT SOFTGEL DELTA D3 400 UNIT TABLET

2 4 0

DIALYVITE TABLET DIALYVITE WITH ZINC TABLET DRISDOL 50,000 UNITS CAPSULE ELDERCAPS CAPSULE ESCAVITE D TABLET CHEWABLE FABB TABLET FEROCON CAPSULE FERREX 150 FORTE CAPSULE FERREX 150 FORTE PLUS CAPSULE FERROCITE PLUS TABLET FERROGELS FORTE SOFTGEL FOLBEE PLUS TABLET FOLCAPS TABLET FOLGARD OS TABLET FOLGARD RX TABLET FOLIC ACID 1 MG TABLET FOLIC ACID-VIT B6-VIT B12 TAB FOLPLEX 2.2 TABLET FOLTRATE TABLET FORTAVIT SOFTGEL FUSION SPRINKLES POWDER PACKET HEMATINIC-FOLIC ACID TABLET HEMATINIC-VITAMIN-MINERAL TAB HEMATOGEN FA SOFTGEL HEMATOGEN FORTE SOFTGEL HEMATRON LIQUID

2 2 NC NC 3 2 2 NC NC NC 2 NC 2 NC NC 1 2 2 NC NC NC 2 NC 2 2 NC

VALUE FORMULARY FIVE-TIER DRUG LIST

Not covered for members 64 and younger ACA*

Not covered for members 64 and younger ACA*

ACA*: Females 12-50 years of age

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DRUG NAME

TIER

HEMOCYTE PLUS CAPSULE HEMOCYTE-F TABLET HYDROXOCOBALAMIN 1,000 MCG/ML IFEREX 150 FORTE CAPSULE IRON AG-PS-ASC-B12-FA-THRE-SUC KIDS VITAMIN D3 TAB CHEW LYSIPLEX PLUS TABLET MEPHYTON 5 MG TABLET MULTICHEW CHEWABLE TABLET MULTIVIT-FLUOR 0.5 MG TAB CHEW MULTIVITAMINS CHEWABLES TABLET MULTIVITAMINS PEDIATRIC DROPS MVW COMPLETE FORMUL D3000 SFGL MVW COMPLETE FORMUL PEDIA DRPS MYFERON-150 FORTE CAPSULE MYNEPHRON CAPSULE NASCOBAL 500 MCG NASAL SPRAY NEPHRO-VITE RX TABLET NEPHROCAPS QT TABLET NEPHRON FA TABLET NEURIN-SL TABLET SL NOXIFOL-D3 2,500 UNIT-1 MG TAB NUTRICAP CAPLET PNV PRENATAL PLUS MULTIVIT TAB POLY-IRON 150 FORTE CAPSULE POLY-VI-FLOR FS 0.25 MG FILM PRENA1 PEARL SOFTGEL PROFERRIN-FORTE TABLET PROMAR CAPSULE RENA-VITE RX TABLET RENAL CAPS SOFTGEL RENAX CAPLET RENO CAPS SOFTGEL ROXIFOL-D TABLET SIDEROL LIQUID STROVITE FORTE CAPLET STROVITE ONE CAPLET STROVITE PLUS CAPLET STROVITE TABLET SUPERVITE LIQUID TEXAVITE LQ DROPS THERAPEUTIC HEMATINIC TAB TL G-FOL OS TABLET TL GARD RX TABLET TL-FOL 500 CAPLET TRIGELS-F FORTE SOFTGEL V-C FORTE CAPSULE VIC-FORTE CAPSULE VINATE DHA GELCAP VIRT-CAPS SOFTGEL VIT D2 1.25 MG (50,000 UNIT) VIT E ACETATE 125 UNITS/ML LIQ VITAFOL CAPLET VITAFOL FE+ DOCUSATE COMBO PCK VITAMIN D 400 UNIT TAB CHEW

NC NC 2 NC NC NC NC 4 NC 2 2 2 3 3 NC NC NC NC NC NC NC NC NC 2 NC NC 3 NC 2 NC 2 NC 2 NC 2 NC NC NC NC NC NC 2 NC 2 NC 2 NC NC 2 NC 1 NC NC NC 0

VITAMIN D 400 UNIT TABLET VITAMIN D2 400 UNIT TABLET VITAMIN D3 400 UNIT TAB CHEW

0 0 0

VALUE FORMULARY FIVE-TIER DRUG LIST

LIMITATIONS/ * NOTES

HSA*

HSA*

HSA*

Not covered for members 64 and younger ACA* ACA* ACA*

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DRUG NAME

TIER

LIMITATIONS/ * NOTES

VITAMIN D3 400 UNIT TABLET

0

Not covered for members 64 and younger ACA*

VOL-CARE RX TABLET VP-VITE RX TABLET

NC NC

VALUE FORMULARY FIVE-TIER DRUG LIST

Last Updated: 01/17/2017

Page 157

Glossary of Notes * Keyword Description HSA HSA Preventive Drug. If your plan includes the Preventive Drug Benefit, covered preventive health drugs will not be subject to your plan deductible. Applicable copayment will apply. Examples include diabetes medications, medications for high blood pressure, prenatal vitamins. ACA Affordable Care Act. This medication is eligible for $0 cost share under most benefit plans. Age restrictions may apply. Examples of these medications include oral contraceptives, hormone replacement therapy (HRT), fluoride. CH Oral Chemotherapy Mandate. This includes oral chemotherapy (anti-cancer) medications used to treat cancer. These drugs may be eligible for a $0 copayment under certain benefit plans. SPP Specialty Pharmacy Medications. These medications should be obtained from one of our Specialty Pharmacy vendors such as Accredo (866)815-4717, Magellan Rx (866)554-2673, Caremark (800)237-2767, or Walgreens Specialty Pharmacy (800)424-9002. All specialty pharmacy drugs are limited to a maximum 30-day supply. IVF IVF/Fertility Pharmacy Medications. These medications must be obtained from one of our designated IVF Pharmacy vendors - Freedom Drug (877)585-4603, Village Pharmacy (866)890-8930, or Walgreens Specialty Pharmacy (800)424-9002. LDD Limited Distribution Drug. Some medications may only be obtained through one or more pharmacies in a limited distribution network as required by the Food and Drug Administration (FDA) or product manufacturer. See specific note for Pharmacy information. PAQ Prior Authorization for Quantity Limit Exceeded. Some medications require Prior Authorization only when the quantity requested for treatment exceeds the standard quantity limit. MQC Maximum Quantity per Copay. Some medications may have quantity limitations with fixed-copays per measure of drug that you receive. For example, if your prescription benefit allows for up to 1 package or unit per copay, you will pay two copays for every 2 units or packages of medications that you receive, and so on. STA Step Therapy/Age. Harvard Pilgrim may require that members above or below a certain age first try one drug to treat a condition before we will cover another drug for that condition. This ensures that certain medications are used safely and effectively for members in specified age groups. PA NTM Prior Authorization for New-to-Market Drugs. Some medications that have recently come to market may have their use restricted through an initial prior authorization review. This may apply to both new medications and older medications with new indications or uses in order to give the health plan and its Pharmacy and Therapeutics (P&T) Committee time to evaluate the risks and benefits to members of the health plan.

VALUE FORMULARY FIVE-TIER DRUG LIST

Last Updated: 01/17/2017

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