South Carolina Medicaid Comprehensive Preferred Drug List (List of Covered Drugs)

Transcription

1 2014 South Carolina Medicaid Comprehensive referred Drug List (List of Covered Drugs) WellCare of South Carolina 00 lease read: This document contains information about the drugs we cover in this plan. lease note that the South Carolina Medicaid referred Drug List is updated quarterly. roviders, please visit our website at to view updates to the preferred drug list. Members, please visit our website at to view updates to the preferred drug list. Last updated (01/01/2014)

2 Vaccines: Vaccines are covered under the Vaccines for Children program for members through 18 years of age. Coverage beyond the age of 18 is evaluated through the A process. UERCASE = Brand name drugs italics = Generic drugs reference Details = referred Dagger ( ) = N/A Asterisk (*) = N/A Asterisk (**) = N/A Asterisk (***) = N/A XX = N/A Coverage Details A = rior Authorization ST = Step Therapy QL = Quantity Limit AL = Age Limit = - Covered w/rx Drug Name reference Details Coverage Details *Adhd/Anti-Narcolepsy/Anti-Obesity/Anorexia nts* *Amphetamines** *Amphetamine Mixtures*** ADDERALL XR ORAL CASULE EXTENDED RELEASE 24 HOUR 10, 15, 20, 25, 30, 5 Amphetamine-Dextroamphetamine ORAL TABLET 10, 15, 5 Amphetamine-Dextroamphetamine ORAL TABLET 12.5 Amphetamine-Dextroamphetamine ORAL TABLET 20, 30 Amphetamine-Dextroamphetamine ORAL TABLET 7.5 *Amphetamines*** Dextroamphetamine Sulfate ORAL TABLET 10 Dextroamphetamine Sulfate ORAL TABLET 5 Dextroamphetamine Sulfate ER ORAL CASULE EXTENDED RELEASE 24 HOUR 10, 15 QL (62 EA per 31 day(s)); AL (Min 6 Years and Max 20 Years) QL (124 EA per 31 day(s)); AL (Min 3 Years and Max 20 Years) QL (155 EA per 31 day(s)); AL (Min 3 Years and Max 20 Years) QL (62 EA per 31 day(s)); AL (Min 3 Years and Max 20 Years) QL (248 EA per 31 day(s)); AL (Min 3 Years and Max 20 Years) QL (186 EA per 31 day(s)); AL (Min 3 Years and Max 20 Years) QL (93 EA per 31 day(s)); AL (Min 3 Years and Max 20 Years) QL (124 EA per 31 day(s)); AL (Min 6 Years and Max 20 Years) 1

3 Drug Name reference Details Coverage Details Dextroamphetamine Sulfate ER ORAL CASULE EXTENDED RELEASE 24 HOUR 5 VYVANSE ORAL CASULE 20, 30, 40, 50, 60, 70 *Analeptics** *Analeptics*** Caffeine Citrate INTRAVENOUS* SOLUTION 60 /3ML Caffeine Citrate ORAL SOLUTION 20 /ML *Attention-Deficit/Hyperactivity Disorder (Adhd) Agents** *Adhd Agent - Selective Alpha Adrenergic Agonists*** INTUNIV ORAL TABLET EXTENDED RELEASE 24 HR* 1, 2, 3, 4 *Adhd Agent - Selective Norepinephrine Reuptake Inhibitor*** STRATTERA ORAL CASULE 10, 100, 18, 25, 40, 60, 80 *Stimulants - Misc.** *Stimulants - Misc.*** Methylphenidate HCl ORAL TABLET 10, 5 Methylphenidate HCl ORAL TABLET 20 Methylphenidate HCl ER ORAL TABLET EXTENDEDRELEASE* 10, 36 Methylphenidate HCl ER ORAL TABLET EXTENDEDRELEASE* 18, 27, 54 Methylphenidate HCl ER ORAL TABLET EXTENDEDRELEASE* 20 Methylphenidate HCl ER (LA) ORAL CASULE EXTENDED RELEASE 24 HOUR 20, 30, 40 *Aminoglycosides* *Aminoglycosides** QL (62 EA per 31 day(s)); AL (Min 6 Years and Max 20 Years) QL (31 EA per 31 day(s)); AL (Min 6 Years and Max 20 Years) AL (Min 6 Years) QL (31 EA per 31 day(s)); AL (Min 6 Years) QL (186 EA per 31 day(s)); AL (Min 6 Years and Max 20 Years) QL (124 EA per 31 day(s)); AL (Min 6 Years and Max 20 Years) QL (62 EA per 31 day(s)); AL (Min 6 Years and Max 20 Years) QL (31 EA per 31 day(s)); AL (Min 6 Years and Max 20 Years) QL (93 EA per 31 day(s)); AL (Min 6 Years and Max 20 Years) QL (31 EA per 31 day(s)); AL (Min 6 Years and Max 20 Years) 2

4 Drug Name reference Details Coverage Details *Aminoglycosides*** Neomycin Sulfate ORAL TABLET 500 aromomycin Sulfate ORAL CASULE 250 TOBI INHALATION NEBULIZATION SOLUTION 300 /5ML *Analgesics - Anti-Inflammatory* *Anti-Tnf-Alpha - Monoclonal Antibodies** *Anti-Tnf-Alpha - Monoclonal Antibodies*** HUMIRA SUBCUTANEOUS* KIT 20 /0.4ML, 40 /0.8ML HUMIRA EN SUBCUTANEOUS* KIT 40 /0.8ML HUMIRA EN-CROHNS STARTER SUBCUTANEOUS* KIT 40 /0.8ML HUMIRA EN-SORIASIS STARTER SUBCUTANEOUS* KIT 40 /0.8ML SIMONI SUBCUTANEOUS* SOLUTION 100 /ML, 50 /0.5ML *Gold Compounds** *Gold Compounds*** RIDAURA ORAL CASULE 3 *Interleukin-1 Blockers** *Interleukin-1 Blockers*** ARCALYST SUBCUTANEOUS* SOLUTION RECONSTITUTED 220 *Interleukin-1Beta Blockers** *Interleukin-1Beta Blockers*** ILARIS SUBCUTANEOUS* SOLUTION RECONSTITUTED 180 *Nonsteroidal Anti-Inflammatory Agents (Nsaids)** *Cyclooxygenase 2 (Cox-2) Inhibitors*** CELEBREX ORAL CASULE 100, 200, 400 A A A A A A A A A; QL (62 EA per 31 day(s)) CELEBREX ORAL CASULE 50 QL (62 EA per 31 day(s)) *Nonsteroidal Anti-Inflammatory Agents (Nsaids)*** 3

5 Drug Name reference Details Coverage Details Childrens Ibuprofen ORAL SUSENSION 100 /5ML Diclofenac Sodium ORAL TABLET DELAYED RELEASE 25, 50, 75 Etodolac ORAL CASULE 200, 300 Etodolac ORAL TABLET 400, 500 Fenoprofen Calcium ORAL TABLET 600 Ibuprofen ORAL SUSENSION 100 /5ML Ibuprofen ORAL TABLET 200 Ibuprofen ORAL TABLET 400, 600, 800 Ibuprofen Junior Strength ORAL TABLET CHEWABLE 100 Indomethacin ORAL CASULE 25, 50 Indomethacin ER ORAL CASULE EXTENDED RELEASE* 75 Infants Ibuprofen ORAL SUSENSION 50 /1.25ML Ketoprofen ORAL CASULE 50, 75 Ketorolac Tromethamine ORAL TABLET 10 QL (20 EA per 31 day(s)) Meloxicam ORAL TABLET 15, 7.5 QL (31 EA per 31 day(s)) Naproxen ORAL SUSENSION 125 /5ML Naproxen ORAL TABLET 250, 375, 500 Naproxen Sodium ORAL TABLET 220 Naproxen Sodium ORAL TABLET 275, 550 Oxaprozin ORAL TABLET 600 iroxicam ORAL CASULE 10, 20 SM Ibuprofen Jr ORAL TABLET 100 Sulindac ORAL TABLET 150, 200 *yrimidine Synthesis Inhibitors** *yrimidine Synthesis Inhibitors*** Leflunomide ORAL TABLET 10, 20 4

6 Drug Name reference Details Coverage Details *Analgesics - Nonnarcotic* *Analgesic Combinations** *Analgesic Combinations*** EXCEDRIN MIGRAINE ORAL TABLET *Analgesics-Sedatives*** Butalbital-Acetaminophen ORAL TABLET Butalbital-AA-Caffeine ORAL CASULE Butalbital-AA-Caffeine ORAL TABLET , Butalbital-ASA-Caffeine ORAL CASULE QL (186 EA per 31 day(s)) QL (186 EA per 31 day(s)) QL (186 EA per 31 day(s)) QL (186 EA per 31 day(s)) Marten-Tab ORAL TABLET QL (186 EA per 31 day(s)) Repan ORAL TABLET QL (186 EA per 31 day(s)) TENCON ORAL TABLET QL (186 EA per 31 day(s)) ZEBUTAL ORAL CASULE QL (186 EA per 31 day(s)) *Analgesics Other** *Analgesics Other*** ACEHEN RE SUOSITORY 120, 325 Acetaminophen ORAL CASULE 500 Acetaminophen ORAL SOLUTION 160 /5ML Acetaminophen ORAL TABLET 325, 500 Acetaminophen ORAL TABLET CHEWABLE 80 Acetaminophen RE SUOSITORY 120, 650 Acetaminophen ER ORAL TABLET EXTENDEDRELEASE* 650 Acetaminophen Extra Strength ORAL LIQUID 500 /15ML AA 500 ORAL LIQUID 500 /5ML AA Drops ORAL SOLUTION 100 /ML 5

7 Drug Name reference Details Coverage Details Childrens Non-Aspirin ORAL SUSENSION 160 /5ML FEVERALL RE SUOSITORY 325, 80 Non-Aspirin Infant ORAL SUSENSION 80 /0.8ML Non-Aspirin Jr Strength ORAL TABLET CHEWABLE 160 ain & Fever Childrens ORAL TABLET CHEWABLE 80 *Salicylates** *Salicylate Combinations*** Choline & Mag Trisalicylate ORAL TABLET 1000 Choline-Mag Trisalicylate ORAL LIQUID 500 /5ML *Salicylates*** Aspirin ORAL TABLET 325, 81 Aspirin ORAL TABLET DELAYED RELEASE 81 Aspirin RE SUOSITORY 120, 200, 300, 60, 600 Aspirin EC ORAL TABLET DELAYED RELEASE 325 Aspirin Low Dose ORAL TABLET CHEWABLE 81 EQ Aspirin ORAL TABLET DELAYED RELEASE 500 RA Aspirin ORAL TABLET 500 *Analgesics - Opioid* *Opioid Agonists** *Opioid Agonists*** Codeine Sulfate ORAL TABLET 15, 30, 60 FentaNYL TRANSDERMAL ATCH 72 HR 100 MCG/HR FentaNYL TRANSDERMAL ATCH 72 HR 12 MCG/HR, 25 MCG/HR, 50 MCG/HR, 75 MCG/HR QL (186 EA per 31 day(s)) ST; QL (20 EA per 30 day(s)) ST; QL (10 EA per 30 day(s)) 6

8 Drug Name reference Details Coverage Details HYDROmorphone HCl ORAL LIQUID 1 /ML HYDROmorphone HCl ORAL TABLET 2, 4, 8 HYDROmorphone HCl RE SUOSITORY 3 Meperidine HCl ORAL SOLUTION 50 /5ML Meperidine HCl ORAL TABLET 100, 50 Methadone HCl ORAL TABLET 10, 5 Morphine Sulfate ORAL SOLUTION 20 /5ML Morphine Sulfate ORAL TABLET 15, 30 Morphine Sulfate RE SUOSITORY 10, 20, 30, 5 Morphine Sulfate (Concentrate) ORAL SOLUTION 100 /5ML, 20 /ML Morphine Sulfate ER ORAL TABLET EXTENDEDRELEASE* 100, 15, 200, 30, 60 NUCYNTA ER ORAL TABLET EXTENDED RELEASE 12 HR* 100, 150, 200, 250, 50 QL (248 EA per 31 day(s)) QL (248 EA per 31 day(s)) A; QL (248 EA per 31 day(s)) QL (248 EA per 31 day(s)) QL (248 EA per 31 day(s)) QL (62 EA per 31 day(s)) OxyCODONE HCl ORAL CASULE 5 QL (248 EA per 31 day(s)) OxyCODONE HCl ORAL CONCENTRATE 20 /ML OxyCODONE HCl ORAL SOLUTION 5 /5ML OxyCODONE HCl ORAL TABLET 15, 20, 30, 5 OXYCONTIN ORAL T12A 10, 15, 20, 30, 40, 60, 80 Oxymorphone HCl ER ORAL TABLET EXTENDED RELEASE 12 HR* 10, 15, 20, 30, 40, 5, 7.5 QL (248 ML per 31 day(s)) QL (248 EA per 31 day(s)) QL (62 EA per 31 day(s)) QL (62 EA per 31 day(s)) TraMADol HCl ORAL TABLET 50 QL (248 EA per 31 day(s)) *Opioid Combinations** 7

9 Drug Name reference Details Coverage Details *Codeine Combinations*** Acetaminophen-Codeine ORAL SOLUTION /5ML Acetaminophen-Codeine #2 ORAL TABLET Acetaminophen-Codeine #3 ORAL TABLET Acetaminophen-Codeine #4 ORAL TABLET ASCOM-CODEINE ORAL CASULE Butalbital-AA-Caff-Cod ORAL CASULE Butalbital-ASA-Caff-Codeine ORAL CASULE *Hydrocodone Combinations*** Hydrocodone-Acetaminophen ORAL SOLUTION /15ML, /15ML Hydrocodone-Acetaminophen ORAL TABLET , , , , , , 5-325, 5-500, , , , *Opioid Combinations*** QL (248 EA per 31 day(s)) QL (248 EA per 31 day(s)) QL (248 EA per 31 day(s)) QL (186 EA per 31 day(s)) QL (186 EA per 31 day(s)) QL (186 EA per 31 day(s)) QL (3720 ML per 31 day(s)) QL (248 EA per 31 day(s)) ENDOCET ORAL TABLET QL (248 EA per 31 day(s)) ENDODAN ORAL TABLET QL (186 EA per 31 day(s)) Oxycodone-Acetaminophen ORAL CASULE Oxycodone-Acetaminophen ORAL TABLET Oxycodone-Aspirin ORAL TABLET *Opioid artial Agonists** *Opioid artial Agonists*** Buprenorphine HCl SUBLINGUAL TABLET SUBLINGUAL 2, 8 Butorphanol Tartrate NASAL SOLUTION 10 /ML QL (248 EA per 31 day(s)) QL (248 EA per 31 day(s)) QL (186 EA per 31 day(s)) A; QL (62 EA per 31 day(s)) QL (10 ML per 31 day(s)) 8

10 Drug Name reference Details Coverage Details SUBOXONE SUBLINGUAL FILM 12-3, 2-0.5, 4-1, 8-2 *Androgens-Anabolic* *Androgens** *Androgens*** Danazol ORAL CASULE 100, 200, 50 TESTIM TRANSDERMAL GEL 50 /5GM Testosterone Cypionate INTRAMUSCULAR* OIL 100 /ML, 200 /ML Testosterone Enanthate INTRAMUSCULAR* OIL 200 /ML *Anorectal Agents* *Intrarectal Steroids** *Intrarectal Steroids*** Hydrocortisone RE ENEMA 100 /60ML *Rectal Combinations** *Rectal Combinations - Misc.*** FORMULATION R RE CREAM % Hemorrhoidal RE OINTMENT % Hemorrhoidal RE SUOSITORY % *Rectal roducts - Misc.** *Rectal roducts - Misc.*** A; QL (62 EA per 31 day(s)) A TUCKS RE SUOSITORY 51 % *Rectal Steroids** *Rectal Steroids*** Hydrocortisone Acetate RE SUOSITORY 25 ROCTOSOL HC RE CREAM 2.5 % ST *Vasodilating Agents** *Nitrate Vasodilating Agents*** RECTIV RE OINTMENT 0.4 % A *Antacids* *Antacid Combinations** 9

11 Drug Name reference Details Coverage Details *Antacid & Simethicone*** MAALOX ADVANCED MAX ST ORAL TABLET CHEWABLE MAALOX JUNIOR LUS ANTIGAS ORAL TABLET CHEWABLE MAALOX MAX ORAL SUSENSION /5ML MAALOX MAX ORAL TABLET CHEWABLE MINTOX LUS ORAL TABLET CHEWABLE MYLANTA ORAL SUSENSION /5ML *Antacid Combinations*** ACID GONE ORAL SUSENSION /15ML ACID GONE ORAL TABLET CHEWABLE Heartburn Antacid Ex St ORAL TABLET CHEWABLE MAALOX TC ORAL CONCENTRATE /5ML MYLANTA ORAL TABLET MYLANTA SUREME ORAL SUSENSION /5ML MYLANTA ULTIMATE STRENGTH ORAL SUSENSION /5ML MYLANTA ULTRA ORAL TABLET CHEWABLE *Antacids - Bicarbonate** *Antacids - Bicarbonate*** Sodium Bicarbonate ORAL OWDER Sodium Bicarbonate ORAL TABLET 325, 650 *Antacids - Calcium Salts** *Antacids - Calcium Salts*** Calcium Antacid ORAL TABLET CHEWABLE

12 Drug Name reference Details Coverage Details Calcium Antacid Ultra Max St ORAL TABLET CHEWABLE 1000 Calcium Carbonate Antacid ORAL TABLET 648 MAALOX ORAL TABLET CHEWABLE 600 MAALOX CHILDRENS ORAL TABLET CHEWABLE 400 Smooth Antacid Extra Strength ORAL TABLET CHEWABLE 750 *Antacids - Magnesium Salts** *Antacids - Magnesium Salts*** Magnesium Oxide ORAL TABLET 400, 420 *Anthelmintics* *Anthelmintics** *Anthelmintics*** IN-X ORAL SUSENSION 50 /ML Reeses inworm Medicine ORAL SUSENSION 144 /ML *Antianginal Agents* *Antianginals-Other** *Antianginals-Other*** RANEXA ORAL TABLET EXTENDED RELEASE 12 HR* 1000, 500 *Nitrates** *Nitrates*** Isosorbide Dinitrate ORAL TABLET 10, 20, 30, 5 Isosorbide Dinitrate ER ORAL TABLET EXTENDEDRELEASE* 40 Isosorbide Mononitrate ORAL TABLET 10, 20 Isosorbide Mononitrate ER ORAL TABLET EXTENDED RELEASE 24 HR* 120, 30, 60 NITRO-BID TRANSDERMAL OINTMENT 2 % ST 11

13 Drug Name reference Details Coverage Details Nitroglycerin TRANSDERMAL ATCH 24 HR 0.1 /HR, 0.2 /HR, 0.4 /HR, 0.6 /HR Nitroglycerin TRANSLINGUAL SOLUTION 0.4 /SRAY NITROSTAT SUBLINGUAL TABLET SUBLINGUAL 0.3, 0.4, 0.6 *Antianxiety Agents* *Antianxiety Agents - Misc.** *Antianxiety Agents - Misc.*** BusIRone HCl ORAL TABLET 10, 15, 30, 5, 7.5 HydrOXYzine HCl ORAL SOLUTION 10 /5ML HydrOXYzine HCl ORAL TABLET 10, 25, 50 HydrOXYzine amoate ORAL CASULE 100, 25, 50 *Benzodiazepines** *Benzodiazepines*** ALRAZolam ORAL TABLET 0.25, 0.5, 1, 2 ChlordiazeOXIDE HCl ORAL CASULE 10, 25, 5 Clorazepate Dipotassium ORAL TABLET 15, 3.75, 7.5 QL (31 EA per 31 day(s)) QL (124 EA per 31 day(s)) Diazepam ORAL SOLUTION 1 /ML QL (1240 ML per 31 day(s)) Diazepam ORAL TABLET 10, 2, 5 LORazepam ORAL TABLET 0.5, 1, 2 Oxazepam ORAL CASULE 10, 15, 30 *Antiarrhythmics* *Antiarrhythmics Type I-A** *Antiarrhythmics Type I-A*** Disopyramide hosphate ORAL CASULE 100, 150 QL (124 EA per 31 day(s)) QL (155 EA per 31 day(s)) QL (93 EA per 31 day(s)) 12

14 Drug Name reference Details Coverage Details NORACE CR ORAL CASULE EXTENDED RELEASE 12 HOUR 100, 150 QuiNIDine Gluconate ER ORAL TABLET EXTENDEDRELEASE* 324 QuiNIDine Sulfate ORAL TABLET 200, 300 QuiNIDine Sulfate ER ORAL TABLET EXTENDEDRELEASE* 300 *Antiarrhythmics Type I-B** *Antiarrhythmics Type I-B*** Mexiletine HCl ORAL CASULE 150, 200, 250 *Antiarrhythmics Type I-C** *Antiarrhythmics Type I-C*** Flecainide Acetate ORAL TABLET 100, 150, 50 ropafenone HCl ORAL TABLET 150, 225, 300 *Antiarrhythmics Type Iii** *Antiarrhythmics Type Iii*** Amiodarone HCl INTRAVENOUS* SOLUTION 150 /3ML Amiodarone HCl ORAL TABLET 200, 400 ACERONE ORAL TABLET 200, 400 TIKOSYN ORAL CASULE 125 MCG, 250 MCG, 500 MCG *Antiasthmatic And Bronchodilator Agents* *Antiasthmatic - Monoclonal Antibodies** *Anti-Ige Monoclonal Antibodies*** XOLAIR SUBCUTANEOUS* SOLUTION RECONSTITUTED 150 *Anti-Inflammatory Agents** *Anti-Inflammatory Agents*** Cromolyn Sodium INHALATION NEBULIZATION SOLUTION 20 /2ML *Bronchodilators - Anticholinergics** A QL (248 ML per 31 day(s)) 13

15 Drug Name reference Details Coverage Details *Bronchodilators - Anticholinergics*** ATROVENT HFA INHALATION AEROSOL, SOLUTION 17 MCG/ACT Ipratropium Bromide INHALATION SOLUTION 0.02 % TUDORZA RESSAIR INHALATION AEROSOL OWDER, BREATH ACTIVATED 400 MCG/ACT *Leukotriene Modulators** *Leukotriene Receptor Antagonists*** QL (480 ML per 31 day(s)) QL (1 EA per 30 day(s)) Montelukast Sodium ORAL ACKET 4 QL (31 EA per 31 day(s)) Montelukast Sodium ORAL TABLET 10 QL (31 EA per 31 day(s)) Montelukast Sodium ORAL TABLET CHEWABLE 4, 5 *Steroid Inhalants** *Steroid Inhalants*** ASMANEX 120 METERED DOSES INHALATION AEROSOL OWDER, BREATH ACTIVATED 220 MCG/INH ASMANEX 30 METERED DOSES INHALATION AEROSOL OWDER, BREATH ACTIVATED 110 MCG/INH, 220 MCG/INH ASMANEX 60 METERED DOSES INHALATION AEROSOL OWDER, BREATH ACTIVATED 220 MCG/INH Budesonide INHALATION SUSENSION 0.25 /2ML Budesonide INHALATION SUSENSION 0.5 /2ML FLOVENT DISKUS INHALATION AEROSOL OWDER, BREATH ACTIVATED 100 MCG/BLIST, 250 MCG/BLIST, 50 MCG/BLIST FLOVENT HFA INHALATION AEROSOL 110 MCG/ACT FLOVENT HFA INHALATION AEROSOL 220 MCG/ACT FLOVENT HFA INHALATION AEROSOL 44 MCG/ACT QL (31 EA per 31 day(s)) QL (1 EA per 30 day(s)) QL (1 EA per 30 day(s)) QL (1 EA per 30 day(s)) QL (62 ML per 31 day(s)); AL (Max 7 Years) QL (124 ML per 31 day(s)); AL (Max 7 Years) QL (60 EA per 30 day(s)) QL (12 GM per 30 day(s)) QL (24 GM per 30 day(s)) QL (10.6 GM per 30 day(s)) 14

16 Drug Name reference Details Coverage Details ULMICORT INHALATION SUSENSION 1 /2ML ULMICORT FLEXHALER INHALATION AEROSOL OWDER, BREATH ACTIVATED 180 MCG/ACT, 90 MCG/ACT QVAR INHALATION AEROSOL, SOLUTION 40 MCG/ACT QVAR INHALATION AEROSOL, SOLUTION 80 MCG/ACT *Sympathomimetics** *Adrenergic Combinations*** ADVAIR DISKUS INHALATION AEROSOL OWDER, BREATH ACTIVATED MCG/DOSE, MCG/DOSE, MCG/DOSE ADVAIR HFA INHALATION AEROSOL MCG/ACT, MCG/ACT, MCG/ACT COMBIVENT INHALATION AEROSOL MCG/ACT COMBIVENT RESIMAT INHALATION AEROSOL, SOLUTION MCG/ACT DULERA INHALATION AEROSOL MCG/ACT, MCG/ACT Ipratropium-Albuterol INHALATION SOLUTION (3) /3ML SYMBICORT INHALATION AEROSOL MCG/ACT, MCG/ACT *Beta Adrenergics*** Albuterol Sulfate INHALATION NEBULIZATION SOLUTION (2.5 /3ML) 0.083%, (5 /ML) 0.5% Albuterol Sulfate INHALATION NEBULIZATION SOLUTION 0.63 /3ML, 1.25 /3ML Albuterol Sulfate ORAL SYRU 2 /5ML Albuterol Sulfate ORAL TABLET 2, 4 FORADIL AEROLIZER INHALATION CASULE 12 MCG QL (124 ML per 31 day(s)); AL (Max 7 Years) QL (8.7 GM per 30 day(s)) QL (17.4 GM per 30 day(s)) ST; QL (60 EA per 30 day(s)) ST; QL (12 GM per 30 day(s)) QL (29.4 GM per 31 day(s)) ST ST A; AL (Max 8 Years) 15

17 Drug Name reference Details Coverage Details Levalbuterol HCl INHALATION NEBULIZATION SOLUTION 0.31 /3ML, 0.63 /3ML, 1.25 /3ML Levalbuterol HCl INHALATION NEBULIZATION SOLUTION 1.25 /0.5ML Metaproterenol Sulfate ORAL SYRU 10 /5ML SEREVENT DISKUS INHALATION AEROSOL OWDER, BREATH ACTIVATED 50 MCG/DOSE Terbutaline Sulfate INJECTION SOLUTION 1 /ML Terbutaline Sulfate ORAL TABLET 2.5, 5 VENTOLIN HFA INHALATION AEROSOL, SOLUTION 108 (90 BASE) MCG/ACT *Xanthines** *Xanthines*** ELIXOHYLLIN ORAL ELIXIR 80 /15ML THEO-24 ORAL CASULE EXTENDED RELEASE 24 HOUR 100, 200, 300, 400 Theophylline ORAL SOLUTION 80 /15ML Theophylline ER ORAL TABLET EXTENDED RELEASE 12 HR* 100, 200, 300, 450 Theophylline ER ORAL TABLET EXTENDED RELEASE 24 HR* 400, 600 *Anticoagulants* *Coumarin Anticoagulants** *Coumarin Anticoagulants*** COUMADIN ORAL TABLET 1, 10, 2, 2.5, 3, 4, 5, 6, 7.5 QL (298 ML per 31 day(s)) QL (62 EA per 31 day(s)) QL (60 EA per 30 day(s)) QL (36 GM per 31 day(s)) 16

18 Drug Name reference Details Coverage Details JANTOVEN ORAL TABLET 1, 10, 2, 2.5, 3, 4, 5, 6, 7.5 Warfarin Sodium ORAL TABLET 1, 10, 2, 2.5, 3, 4, 5, 6, 7.5 *Direct Factor Xa Inhibitors** *Direct Factor Xa Inhibitors*** ELIQUIS ORAL TABLET 2.5, 5 A XARELTO ORAL TABLET 10, 15, 20 *Heparins And Heparinoid-Like Agents** *Heparins And Heparinoid-Like Agents*** Heparin Sodium (orcine) INJECTION SOLUTION UNIT/ML, 5000 UNIT/ML *Low Molecular Weight Heparins*** Enoxaparin Sodium INJECTION SOLUTION 300 /3ML Enoxaparin Sodium SUBCUTANEOUS* SOLUTION 100 /ML, 150 /ML Enoxaparin Sodium SUBCUTANEOUS* SOLUTION 120 /0.8ML, 80 /0.8ML Enoxaparin Sodium SUBCUTANEOUS* SOLUTION 30 /0.3ML Enoxaparin Sodium SUBCUTANEOUS* SOLUTION 40 /0.4ML Enoxaparin Sodium SUBCUTANEOUS* SOLUTION 60 /0.6ML *Anticonvulsants* *Anticonvulsants - Benzodiazepines** *Anticonvulsants - Benzodiazepines*** ClonazeAM ORAL TABLET 0.5, 1, 2 A QL (84 ML per 31 day(s)) QL (28 ML per 31 day(s)) QL (22.4 ML per 31 day(s)) QL (8.4 ML per 31 day(s)) QL (11.2 ML per 31 day(s)) QL (16.8 ML per 31 day(s)) Diazepam RE GEL 10, 2.5, 20 QL (1 EA per 31 day(s)) ONFI ORAL SUSENSION 2.5 /ML ST ONFI ORAL TABLET 10, 20, 5 *Anticonvulsants - Misc.** 17

19 Drug Name reference Details Coverage Details *Anticonvulsants - Misc.*** BANZEL ORAL TABLET 200 QL (93 EA per 31 day(s)) BANZEL ORAL TABLET 400 QL (248 EA per 31 day(s)) CarBAMazepine ORAL SUSENSION 100 /5ML CarBAMazepine ORAL TABLET 200 QL (248 EA per 31 day(s)) CarBAMazepine ORAL TABLET CHEWABLE 100 CarBAMazepine ER ORAL CASULE EXTENDED RELEASE 12 HOUR 100, 200, 300 CarBAMazepine ER ORAL TABLET EXTENDED RELEASE 12 HR* 200, 400 QL (310 EA per 31 day(s)) EITOL ORAL TABLET 200 QL (248 EA per 31 day(s)) Gabapentin ORAL CASULE 100 QL (310 EA per 31 day(s)) Gabapentin ORAL CASULE 300 QL (372 EA per 31 day(s)) Gabapentin ORAL CASULE 400 QL (279 EA per 31 day(s)) Gabapentin ORAL TABLET 600, 800 LAMICTAL ORAL TABLET CHEWABLE 2 LAMICTAL STARTER ORAL KIT 25 (35), 25 (42)-100 (7), 25 (84)-100(14) LamoTRIgine ORAL TABLET 100, 25 LamoTRIgine ORAL TABLET 150, 200 LamoTRIgine ORAL TABLET CHEWABLE 25, 5 LevETIRAcetam ORAL SOLUTION 100 /ML LevETIRAcetam ORAL TABLET 1000, 250 QL (62 EA per 31 day(s)) QL (93 EA per 31 day(s)) QL (124 EA per 31 day(s)) QL (1000 ML per 31 day(s)); AL (Max 9 Years) QL (93 EA per 31 day(s)) LevETIRAcetam ORAL TABLET 500 QL (186 EA per 31 day(s)) LevETIRAcetam ORAL TABLET 750 QL (124 EA per 31 day(s)) LYRICA ORAL CASULE 100, 150, 200, 225, 25, 300, 50, 75 LYRICA ORAL SOLUTION 20 /ML A A 18

20 Drug Name reference Details Coverage Details OXcarbazepine ORAL SUSENSION 300 /5ML OXcarbazepine ORAL TABLET 150, 300 QL (1240 ML per 31 day(s)); AL (Max 9 Years) QL (93 EA per 31 day(s)) OXcarbazepine ORAL TABLET 600 QL (124 EA per 31 day(s)) OTIGA ORAL TABLET 200, 300, 400, 50 AL (Min 18 Years) rimidone ORAL TABLET 250 QL (248 EA per 31 day(s)) rimidone ORAL TABLET 50 QL (310 EA per 31 day(s)) TEGRETOL ORAL SUSENSION 100 /5ML TEGRETOL ORAL TABLET 200 Topiramate ORAL CASULE SRINKLE 15, 25 Topiramate ORAL TABLET 100, 25, 50 QL (310 EA per 31 day(s)) QL (310 EA per 31 day(s)) Topiramate ORAL TABLET 200 QL (248 EA per 31 day(s)) VIMAT ORAL TABLET 100, 150, 200, 50 AL (Min 17 Years) Zonisamide ORAL CASULE 100 QL (186 EA per 31 day(s)) Zonisamide ORAL CASULE 25, 50 QL (93 EA per 31 day(s)) *Gaba Modulators** *Gaba Modulators*** GABITRIL ORAL TABLET 12, 16 ST; AL (Min 12 Years) SABRIL ORAL ACKET 500 A SABRIL ORAL TABLET 500 A TiaGABine HCl ORAL TABLET 2, 4 ST; AL (Min 12 Years) *Hydantoins** *Hydantoins*** DILANTIN ORAL CASULE 100 DILANTIN ORAL CASULE 30 QL (310 EA per 31 day(s)) DILANTIN ORAL SUSENSION 125 /5ML DILANTIN INFATABS ORAL TABLET CHEWABLE 50 HENYTEK ORAL CASULE 200,

21 Drug Name reference Details Coverage Details henytoin ORAL SUSENSION 125 /5ML henytoin ORAL TABLET CHEWABLE 50 HENYTOIN INFATABS ORAL TABLET CHEWABLE 50 henytoin Sodium INJECTION SOLUTION 50 /ML henytoin Sodium Extended ORAL CASULE 100, 200, 300 *Succinimides** *Succinimides*** Ethosuximide ORAL CASULE 250 Ethosuximide ORAL SOLUTION 250 /5ML *Valproic Acid** *Valproic Acid*** Divalproex Sodium ORAL CASULE SRINKLE 125 Divalproex Sodium ORAL TABLET DELAYED RELEASE 125 Divalproex Sodium ORAL TABLET DELAYED RELEASE 250 Divalproex Sodium ORAL TABLET DELAYED RELEASE 500 Divalproex Sodium ER ORAL TABLET EXTENDED RELEASE 24 HR* 250 Divalproex Sodium ER ORAL TABLET EXTENDED RELEASE 24 HR* 500 QL (372 EA per 31 day(s)) QL (310 EA per 31 day(s)) QL (310 EA per 10 day(s)); AL (Min 2 Years) QL (310 EA per 31 day(s)); AL (Min 2 Years) QL (261 EA per 31 day(s)); AL (Min 2 Years) QL (31 EA per 31 day(s)) QL (248 EA per 31 day(s)) Valproic Acid ORAL CASULE 250 QL (310 EA per 31 day(s)) Valproic Acid ORAL SYRU 250 /5ML *Antidepressants* *Alpha-2 Receptor Antagonists (Tetracyclics)** *Alpha-2 Receptor Antagonists (Tetracyclics)*** Mirtazapine ORAL TABLET 15, 30, 45, 7.5 *Antidepressants - Misc.** *Antidepressants - Misc.*** 20

22 Drug Name reference Details Coverage Details BuROion HCl ORAL TABLET 100, 75 BuROion HCl ER (SR) ORAL TABLET EXTENDED RELEASE 12 HR* 100, 150, 200 BuROion HCl ER (XL) ORAL TABLET EXTENDED RELEASE 24 HR* 150, 300 FORFIVO XL ORAL TABLET EXTENDED RELEASE 24 HR* 450 Maprotiline HCl ORAL TABLET 25, 50, 75 *Modified Cyclics** *Modified Cyclics*** TraZODone HCl ORAL TABLET 100, 150, 300, 50 *Monoamine Oxidase Inhibitors (Maois)** *Monoamine Oxidase Inhibitors (Maois)*** Tranylcypromine Sulfate ORAL TABLET 10 *Selective Serotonin Reuptake Inhibitors (Ssris)** *Selective Serotonin Reuptake Inhibitors (Ssris)*** Citalopram Hydrobromide ORAL SOLUTION 10 /5ML Citalopram Hydrobromide ORAL TABLET 10, 40 Citalopram Hydrobromide ORAL TABLET 20 FLUoxetine HCl ORAL CASULE 10, 20 FLUoxetine HCl ORAL SOLUTION 20 /5ML FluvoxaMINE Maleate ORAL TABLET 100, 25, 50 ARoxetine HCl ORAL TABLET 10, 20, 30, 40 QL (62 EA per 31 day(s)) QL (31 EA per 31 day(s)) QL (930 ML per 31 Day(s)) QL (31 EA per 31 Day(s)) QL (47 EA per 31 Day(s)) QL (62 EA per 31 day(s)) Sertraline HCl ORAL TABLET 100 QL (62 EA per 31 day(s)) 21

23 Drug Name reference Details Coverage Details Sertraline HCl ORAL TABLET 25, 50 *Serotonin-Norepinephrine Reuptake Inhibitors (Snris)** *Serotonin-Norepinephrine Reuptake Inhibitors (Snris)*** DULoxetine HCl ORAL CASULE DELAYED RELEASE ARTICLES 20, 30, 60 RISTIQ ORAL TABLET EXTENDED RELEASE 24 HR* 100, 50 Venlafaxine HCl ORAL TABLET 100, 25, 37.5, 50, 75 Venlafaxine HCl ER ORAL CASULE EXTENDED RELEASE 24 HOUR 37.5 Venlafaxine HCl ER ORAL CASULE EXTENDED RELEASE 24 HOUR 75 Venlafaxine HCl ER ORAL TABLET EXTENDED RELEASE 24 HR* 150, 225, 37.5 Venlafaxine HCl ER ORAL TABLET EXTENDED RELEASE 24 HR* 75 *Tricyclic Agents** *Tricyclic Agents*** Amitriptyline HCl ORAL TABLET 10, 100, 150, 25, 50, 75 Amoxapine ORAL TABLET 100, 150, 25, 50 ClomiRAMINE HCl ORAL CASULE 25, 50, 75 Desipramine HCl ORAL TABLET 10, 100, 150, 25, 50, 75 Doxepin HCl ORAL CASULE 10, 100, 150, 25, 50, 75 Doxepin HCl ORAL CONCENTRATE 10 /ML Imipramine HCl ORAL TABLET 10, 25, 50 Nortriptyline HCl ORAL CASULE 10, 25, 50, 75 QL (47 EA per 31 day(s)) ST QL (31 EA per 31 day(s)) QL (93 EA per 31 day(s)) ST; QL (31 EA per 31 day(s)) ST; QL (93 EA per 31 day(s)) ST 22

24 Drug Name reference Details Coverage Details *Antidiabetics* *Alpha-Glucosidase Inhibitors** *Alpha-Glucosidase Inhibitors*** Acarbose ORAL TABLET 100, 25, 50 *Antidiabetic - Amylin Analogs** *Antidiabetic - Amylin Analogs*** SYMLINEN 120 SUBCUTANEOUS* SOLUTION 2700 MCG/2.7ML SYMLINEN 60 SUBCUTANEOUS* SOLUTION 1500 MCG/1.5ML *Antidiabetic Combinations** *Dipeptidyl eptidase-4 Inhibitor-Biguanide Combinations*** JANUMET ORAL TABLET , JANUMET XR ORAL TABLET EXTENDED RELEASE 24 HR* , JANUMET XR ORAL TABLET EXTENDED RELEASE 24 HR* JENTADUETO ORAL TABLET , , KOMBIGLYZE XR ORAL TABLET EXTENDED RELEASE 24 HR* , , *Sulfonylurea-Biguanide Combinations*** GlyBURIDE-MetFORMIN ORAL TABLET , , *Sulfonylurea-Thiazolidinedione Combinations*** ioglitazone HCl-Glimepiride ORAL TABLET 30-2, 30-4 *Thiazolidinedione-Biguanide Combinations*** ACTOLUS MET XR ORAL TABLET EXTENDED RELEASE 24 HR* , ioglitazone HCl-Metformin HCl ORAL TABLET , *Biguanides** A A ST; QL (62 EA per 31 day(s)) ST; QL (31 EA per 31 day(s)) ST; QL (62 EA per 31 day(s)) ST; QL (62 EA per 31 day(s)) ST; QL (93 EA per 31 day(s)) 23

25 Drug Name reference Details Coverage Details *Biguanides*** MetFORMIN HCl ORAL TABLET 1000, 500, 850 MetFORMIN HCl ER ORAL TABLET EXTENDED RELEASE 24 HR* 500, 750 MetFORMIN HCl ER (OSM) ORAL TABLET EXTENDED RELEASE 24 HR* 1000, 500 RIOMET ORAL SOLUTION 500 /5ML *Diabetic Other** *Diabetic Other*** GLUCAGEN INJECTION SOLUTION RECONSTITUTED 1 GLUCAGEN HYOKIT INJECTION SOLUTION RECONSTITUTED 1 GLUCAGON EMERGENCY INJECTION KIT 1 Glucose ORAL TABLET CHEWABLE 4 GM *rogesterone Receptor Antagonists*** KORLYM ORAL TABLET 300 A *Dipeptidyl eptidase-4 (Dpp-4) Inhibitors** *Dipeptidyl eptidase-4 (Dpp-4) Inhibitors*** JANUVIA ORAL TABLET 100, 25, 50 QL (2 EA per 31 day(s)) QL (2 EA per 31 day(s)) QL (2 EA per 31 day(s)) ST; QL (31 EA per 31 day(s)) ONGLYZA ORAL TABLET 2.5, 5 QL (31 EA per 31 day(s)) TRADJENTA ORAL TABLET 5 ST; QL (31 EA per 31 day(s)) *Incretin Mimetic Agents (Glp-1 Receptor Agonists)** *Incretin Mimetic Agents (Glp-1 Receptor Agonists)*** BYDUREON SUBCUTANEOUS* SUSENSION RECONSTITUTED 2 *Insulin Sensitizing Agents** *Thiazolidinediones*** ioglitazone HCl ORAL TABLET 15, 30, 45 *Insulin** *Human Insulin*** ST; QL (4 EA per 28 day(s)) ST; QL (31 EA per 31 day(s)) 24

26 Drug Name reference Details Coverage Details AIDRA INJECTION SOLUTION 100 UNIT/ML AIDRA SOLOSTAR SUBCUTANEOUS* SOLUTION 100 UNIT/ML HUMALOG SUBCUTANEOUS* SOLUTION 100 UNIT/ML HUMALOG KWIKEN SUBCUTANEOUS* SOLUTION 100 UNIT/ML HUMALOG MIX 50/50 SUBCUTANEOUS* SUSENSION (50-50) 100 UNIT/ML HUMALOG MIX 50/50 KWIKEN SUBCUTANEOUS* SUSENSION (50-50) 100 UNIT/ML HUMALOG MIX 75/25 SUBCUTANEOUS* SUSENSION (75-25) 100 UNIT/ML HUMALOG MIX 75/25 KWIKEN SUBCUTANEOUS* SUSENSION (75-25) 100 UNIT/ML HUMULIN 70/30 SUBCUTANEOUS* SUSENSION (70-30) 100 UNIT/ML HUMULIN 70/30 EN SUBCUTANEOUS* SUSENSION (70-30) 100 UNIT/ML HUMULIN N SUBCUTANEOUS* SUSENSION 100 UNIT/ML HUMULIN N EN SUBCUTANEOUS* SUSENSION 100 UNIT/ML HUMULIN R INJECTION SOLUTION 100 UNIT/ML HUMULIN R U-500 (CONCENTRATED) SUBCUTANEOUS* SOLUTION 500 UNIT/ML LANTUS SUBCUTANEOUS* SOLUTION 100 UNIT/ML LANTUS SOLOSTAR SUBCUTANEOUS* SOLUTION 100 UNIT/ML *Meglitinide Analogues** *Meglitinide Analogues*** Nateglinide ORAL TABLET 120, 60 Repaglinide ORAL TABLET 0.5, 1, 2 QL (60 ML per 31 day(s)) QL (60 ML per 31 day(s)) QL (60 ML per 31 day(s)) QL (60 ML per 31 day(s)) QL (60 ML per 31 day(s)) QL (60 ML per 31 day(s)) QL (60 ML per 31 day(s)) QL (60 ML per 31 day(s)) ; QL (60 ML per 31 day(s)) ; QL (60 ML per 31 day(s)) ; QL (60 ML per 31 day(s)) ; QL (60 ML per 31 day(s)) ; QL (60 ML per 31 day(s)) QL (60 ML per 31 day(s)) QL (60 ML per 31 day(s)) QL (60 ML per 31 day(s)) 25

27 Drug Name reference Details Coverage Details *Sulfonylureas** *Sulfonylureas*** ChlorproAMIDE ORAL TABLET 100, 250 Glimepiride ORAL TABLET 1, 2, 4 GlipiZIDE ORAL TABLET 10, 5 GlipiZIDE ER ORAL TABLET EXTENDED RELEASE 24 HR* 10, 2.5, 5 GLIIZIDE XL ORAL TABLET EXTENDED RELEASE 24 HR* 10, 2.5, 5 GlyBURIDE ORAL TABLET 1.25, 2.5, 5 GlyBURIDE Micronized ORAL TABLET 1.5, 3, 6 TOLAZamide ORAL TABLET 250, 500 TOLBUTamide ORAL TABLET 500 *Antidiarrheals* *Antidiarrheal Agents - Misc.** *Antidiarrheal Agents - Misc.*** Acidophilus ORAL CASULE Acidophilus ORAL TABLET Acidophilus ORAL TABLET CHEWABLE, Acidophilus ORAL WAFER Acidophilus robiotic Blend ORAL CASULE Acidophilus/Bifidus ORAL WAFER, 100 Acidophilus/L-Sporogenes ORAL TABLET FLORANEX ORAL ACKET FLORANEX ORAL TABLET GN ink Bismuth ORAL TABLET CHEWABLE 262 KAOECTATE ORAL SUSENSION 262 /15ML SM Stomach Relief ORAL TABLET 262 *Antidiarrheal Combinations** 26

28 Drug Name reference Details Coverage Details *Antidiarrheal Combinations*** Acidophilus/Citrus ectin ORAL TABLET Acidophilus/ectin ORAL CASULE *Diarrhea Combinations - Opiates*** Anti-Diarrheal lus Gas Relief ORAL TABLET *Antiperistaltic Agents** *Antiperistaltic Agents*** Anti-Diarrheal ORAL TABLET 2 Diphenoxylate-Atropine ORAL LIQUID /5ML Diphenoxylate-Atropine ORAL TABLET GN Anti-Diarrheal ORAL LIQUID 1 /5ML LOERAMIDE A-D ORAL TABLET 2 Loperamide HCl ORAL CASULE 2 Loperamide HCl ORAL LIQUID 1 /5ML Loperamide HCl ORAL SUSENSION 1 /7.5ML *Antidotes* *Antidotes - Chelating Agents** *Antidotes - Chelating Agents*** CHEMET ORAL CASULE 100 EXJADE ORAL TABLET SOLUBLE 125, 250, 500 *Opioid Antagonists** *Opioid Antagonists*** Naltrexone HCl ORAL TABLET 50 *Antiemetics* *5-Ht3 Receptor Antagonists** *5-Ht3 Receptor Antagonists*** Ondansetron ORAL TABLET DISERSIBLE 4, 8 Ondansetron HCl INJECTION SOLUTION 4 /2ML, 40 /20ML A A 27

29 Drug Name reference Details Coverage Details Ondansetron HCl ORAL SOLUTION 4 /5ML Ondansetron HCl ORAL TABLET 24, 4, 8 *Antiemetics - Anticholinergic** *Antiemetics - Anticholinergic*** Meclizine HCl ORAL TABLET 12.5, 25 Motion Sickness ORAL TABLET 50 Travel Sickness ORAL TABLET CHEWABLE 25 Trimethobenzamide HCl ORAL CASULE 300 UniVert ORAL TABLET 32 *Antiemetics - Miscellaneous** *Antiemetic Combinations*** Anti-Nausea ORAL SOLUTION *Antiemetics - Miscellaneous*** Dronabinol ORAL CASULE 10, 2.5, 5 *Substance /Neurokinin 1 (Nk1) Receptor Antagonists** *Substance /Neurokinin 1 (Nk1) Receptor Antagonists*** EMEND ORAL CASULE 125, 40, 80 & 125, 80 *Antifungals* *Antifungals** *Antifungals*** Griseofulvin Microsize ORAL SUSENSION 125 /5ML Griseofulvin Microsize ORAL TABLET 500 Griseofulvin Ultramicrosize ORAL TABLET 125, 250 Nystatin ORAL TABLET UNIT Terbinafine HCl ORAL TABLET 250 QL (90 EA per 180 day(s)) *Imidazole-Related Antifungals** A 28

30 Drug Name reference Details Coverage Details *Imidazoles*** Ketoconazole ORAL TABLET 200 *Triazoles*** Fluconazole ORAL SUSENSION RECONSTITUTED 10 /ML Fluconazole ORAL SUSENSION RECONSTITUTED 40 /ML Fluconazole ORAL TABLET 100, 150, 50 QL (1240 ML per 31 day(s)) QL (310 ML per 31 day(s)) QL (31 EA per 31 day(s)) Fluconazole ORAL TABLET 200 QL (62 EA per 31 day(s)) Itraconazole ORAL CASULE 100 A SORANOX ORAL SOLUTION 10 /ML A; QL (1860 ML per 31 day(s)) *Antihistamines* *Antihistamines - Alkylamines** *Antihistamines - Alkylamines*** Aller-Chlor ORAL SYRU 2 /5ML Chlorpheniramine Maleate ER ORAL TABLET EXTENDEDRELEASE* 12 *Antihistamines - Ethanolamines** *Antihistamines - Ethanolamines*** Aler-Dryl ORAL TABLET 50 Allergy ORAL TABLET 25 Altaryl ORAL SYRU 12.5 /5ML Childrens Complete Allergy ORAL TABLET CHEWABLE 12.5 Clemastine Fumarate ORAL SYRU 0.67 /5ML Clemastine Fumarate ORAL TABLET 1.34 Clemastine Fumarate ORAL TABLET 2.68 DiphenhydrAMINE HCl ORAL CASULE 25, 50 DiphenhydrAMINE HCl ORAL ELIXIR 12.5 /5ML DiphenhydrAMINE HCl ORAL LIQUID 12.5 /5ML *Antihistamines - Non-Sedating** 29

31 Drug Name reference Details Coverage Details *Antihistamines - Non-Sedating*** All Day Allergy Childrens ORAL SOLUTION 5 /5ML Allergy Relief Child ORAL SYRU 5 /5ML Cetirizine HCl ORAL TABLET 10, 5 Cetirizine HCl ORAL TABLET CHEWABLE 10, 5 Cetirizine HCl Childrens Alrgy ORAL SYRU 1 /ML Levocetirizine Dihydrochloride ORAL TABLET 5 Loratadine ORAL TABLET 10 Loratadine Childrens ORAL SOLUTION 5 /5ML SM Loratadine ORAL TABLET DISERSIBLE 10 *Antihistamines - henothiazines** *Antihistamines - henothiazines*** romethazine HCl INJECTION SOLUTION 25 /ML, 50 /ML romethazine HCl ORAL SYRU 6.25 /5ML romethazine HCl ORAL TABLET 12.5, 25, 50 romethazine HCl RE SUOSITORY 12.5, 25 ROMETHEGAN RE SUOSITORY 25, 50 *Antihistamines - iperidines** *Antihistamines - iperidines*** Cyproheptadine HCl ORAL SYRU 2 /5ML Cyproheptadine HCl ORAL TABLET 4 *Antihyperlipidemics* *Antihyperlipidemics - Combinations** *Intest Cholest Absorp Inhib-Hmg Coa Reductase Inhib Comb*** 30

32 Drug Name reference Details Coverage Details VYTORIN ORAL TABLET 10-10, 10-20, 10-40, *Bile Acid Sequestrants** *Bile Acid Sequestrants*** Cholestyramine ORAL ACKET 4 GM Cholestyramine ORAL OWDER 4 GM/DOSE Cholestyramine Light ORAL ACKET 4 GM Cholestyramine Light ORAL OWDER 4 GM/DOSE *Fibric Acid Derivatives** *Fibric Acid Derivatives*** Fenofibrate ORAL TABLET 160, 54 ST Fenofibrate Micronized ORAL CASULE 134, 200, 67 Gemfibrozil ORAL TABLET 600 *Hmg Coa Reductase Inhibitors** *Hmg Coa Reductase Inhibitor Combinations*** SIMCOR ORAL TABLET EXTENDED RELEASE 24 HR* , , , , *Hmg Coa Reductase Inhibitors*** Atorvastatin Calcium ORAL TABLET 10, 20, 80 Atorvastatin Calcium ORAL TABLET 40 ST; QL (31 EA per 31 day(s)) Lovastatin ORAL TABLET 10, 20 QL (31 EA per 31 day(s)) Lovastatin ORAL TABLET 40 QL (62 EA per 31 day(s)) ravastatin Sodium ORAL TABLET 10, 20, 80 ST ST QL (31 EA per 31 day(s)) ravastatin Sodium ORAL TABLET 40 QL (62 EA per 31 day(s)) Simvastatin ORAL TABLET 10, 20, 40, 5, 80 *Microsomal Triglyceride Transfer rotein (Mtp) Inhibitors** *Microsomal Triglyceride Transfer rotein Inhibitors*** JUXTAID ORAL CASULE 10, 20, 5 QL (31 EA per 31 day(s)) A 31

33 Drug Name reference Details Coverage Details *Nicotinic Acid Derivatives** *Nicotinic Acid Derivatives*** Niacin ER (Antihyperlipidemic) ORAL TABLET EXTENDEDRELEASE* 750 NIACOR ORAL TABLET 500 NIASAN ORAL TABLET EXTENDEDRELEASE* 1000, 500 *Antihypertensives* *Ace Inhibitors** *Ace Inhibitors*** Benazepril HCl ORAL TABLET 10, 20, 40, 5 Captopril ORAL TABLET 100, 12.5, 25, 50 Enalapril Maleate ORAL TABLET 10, 2.5, 20, 5 Fosinopril Sodium ORAL TABLET 10, 20, 40 Lisinopril ORAL TABLET 10, 2.5, 20, 30, 40, 5 Quinapril HCl ORAL TABLET 10, 20, 40, 5 *Angiotensin Ii Receptor Antagonists** *Angiotensin Ii Receptor Antagonists*** Losartan otassium ORAL TABLET 100, 25, 50 *Antiadrenergic Antihypertensives** *Antiadrenergics - Centrally Acting*** CloNIDine HCl ORAL TABLET 0.1, 0.2, 0.3 CloNIDine HCl TRANSDERMAL ATCH WEEKLY 0.1 /24HR, 0.2 /24HR, 0.3 /24HR GuanFACINE HCl ORAL TABLET 1, 2 Methyldopa ORAL TABLET 250, 500 Methyldopate HCl INTRAVENOUS* SOLUTION 250 /5ML *Antiadrenergics - eripherally Acting*** QL (62 EA per 31 day(s)) 32

34 Drug Name reference Details Coverage Details Doxazosin Mesylate ORAL TABLET 1, 2, 4, 8 razosin HCl ORAL CASULE 1, 2, 5 Terazosin HCl ORAL CASULE 1, 10, 2, 5 *Antihypertensive Combinations** *Ace Inhibitors & Thiazide/Thiazide-Like*** Benazepril-Hydrochlorothiazide ORAL TABLET , , 20-25, Captopril-Hydrochlorothiazide ORAL TABLET 25-15, 25-25, 50-15, Enalapril-Hydrochlorothiazide ORAL TABLET 10-25, Fosinopril Sodium-HCTZ ORAL TABLET , Lisinopril-Hydrochlorothiazide ORAL TABLET , , Quinapril-Hydrochlorothiazide ORAL TABLET , , *Adrenolytics-Central & Thiazide/Thiazide-Like Comb*** Methyldopa-Hydrochlorothiazide ORAL TABLET , *Angiotensin Ii Receptor Antag & Thiazide/Thiazide-Like*** Losartan otassium-hctz ORAL TABLET , , *Beta Blocker & Diuretic Combinations*** Atenolol-Chlorthalidone ORAL TABLET , Bisoprolol-Hydrochlorothiazide ORAL TABLET , , ropranolol-hctz ORAL TABLET 40-25, *Vasodilators** *Vasodilators*** QL (62 EA per 31 day(s)) 33

35 Drug Name reference Details Coverage Details HydrALAZINE HCl INJECTION SOLUTION 20 /ML HydrALAZINE HCl ORAL TABLET 10, 100, 25, 50 Minoxidil ORAL TABLET 10, 2.5 *Anti-Infective Agents - Misc.* *Anti-Infective Agents - Misc.** *Anti-Infective Agents - Misc.*** MetroNIDAZOLE ORAL TABLET 250, 500 ENTAM INJECTION SOLUTION RECONSTITUTED 300 Trimethoprim ORAL TABLET 100 Vancomycin HCl INTRAVENOUS* SOLUTION RECONSTITUTED 1000, 500, 5000, 750 Vancomycin HCl ORAL CASULE 125, 250 Vancomycin HCl in Dextrose INTRAVENOUS* SOLUTION 1 GM/200ML, 500 /100ML, 750 /150ML *Anti-Infective Misc. - Combinations** *Anti-Infective Misc. - Combinations*** Erythromycin-Sulfisoxazole ORAL SUSENSION RECONSTITUTED /5ML Sulfamethoxazole-TM DS ORAL TABLET Sulfamethoxazole-Trimethoprim ORAL SUSENSION /5ML Sulfamethoxazole-Trimethoprim ORAL TABLET *Antiprotozoal Agents** *Antiprotozoal Agents*** MERON ORAL SUSENSION 750 /5ML *Leprostatics** *Leprostatics*** Dapsone ORAL TABLET 100, 25 A ST A 34

36 Drug Name reference Details Coverage Details *Lincosamides** *Lincosamides*** Clindamycin HCl ORAL CASULE 150, 300 Clindamycin almitate HCl ORAL SOLUTION RECONSTITUTED 75 /5ML *Oxazolidinones** *Oxazolidinones*** ZYVOX INTRAVENOUS* SOLUTION 2 /ML ZYVOX ORAL SUSENSION RECONSTITUTED 100 /5ML ZYVOX ORAL TABLET 600 A *Antimalarials* *Antimalarials** *Antimalarials*** Chloroquine hosphate ORAL TABLET 250, 500 DARARIM ORAL TABLET 25 Hydroxychloroquine Sulfate ORAL TABLET 200 Mefloquine HCl ORAL TABLET 250 rimaquine hosphate ORAL TABLET 26.3 *Antimyasthenic/Cholinergic Agents* *Antimyasthenic/Cholinergic Agents** *Antimyasthenic/Cholinergic Agents*** MESTINON ORAL SYRU 60 /5ML MESTINON ORAL TABLET EXTENDEDRELEASE* 180 yridostigmine Bromide ORAL TABLET 60 REGONOL INJECTION SOLUTION 5 /ML *Antimycobacterial Agents* *Antimycobacterial Agents** *Antimycobacterial Agents*** A A 35

37 Drug Name reference Details Coverage Details Ethambutol HCl ORAL TABLET 100, 400 Isoniazid ORAL SYRU 50 /5ML Isoniazid ORAL TABLET 100, 300 MYCOBUTIN ORAL CASULE 150 yrazinamide ORAL TABLET 500 Rifampin ORAL CASULE 150, 300 *Antineoplastics And Adjunctive Therapies* *Alkylating Agents** *Alkylating Agents*** HEXALEN ORAL CASULE 50 MYLERAN ORAL TABLET 2 *Imidazotetrazines*** Temozolomide ORAL CASULE 100, 140, 180, 20, 250, 5 *Nitrogen Mustards*** ALKERAN ORAL TABLET 2 Cyclophosphamide INJECTION SOLUTION RECONSTITUTED 1 GM, 2 GM, 500 Cyclophosphamide ORAL TABLET 25, 50 LEUKERAN ORAL TABLET 2 Melphalan HCl INTRAVENOUS* SOLUTION RECONSTITUTED 50 *Nitrosoureas*** Lomustine ORAL CASULE 10, 100, 40 *Antimetabolites** *Antimetabolites*** Fludarabine hosphate INTRAVENOUS* SOLUTION 50 /2ML Fludarabine hosphate INTRAVENOUS* SOLUTION RECONSTITUTED 50 Mercaptopurine ORAL TABLET 50 Methotrexate ORAL TABLET 2.5 Methotrexate Sodium INJECTION SOLUTION 25 /ML A A A A 36

38 Drug Name reference Details Coverage Details Methotrexate Sodium INJECTION SOLUTION RECONSTITUTED 1 GM Methotrexate Sodium (F) INJECTION SOLUTION 1 GM/40ML, 100 /4ML, 200 /8ML, 25 /ML, 250 /10ML, 50 /2ML TABLOID ORAL TABLET 40 XELODA ORAL TABLET 150, 500 A *Antineoplastic - Hedgehog athway Inhibitors** *Antineoplastic - Hedgehog athway Inhibitors*** ERIVEDGE ORAL CASULE 150 A *Antineoplastic - Hormonal And Related Agents** *Androgen Biosynthesis Inhibitors*** ZYTIGA ORAL TABLET 250 A *Antiadrenals*** LYSODREN ORAL TABLET 500 *Antiandrogens*** Bicalutamide ORAL TABLET 50 Flutamide ORAL CASULE 125 XTANDI ORAL CASULE 40 A *Antiestrogens*** FARESTON ORAL TABLET 60 Tamoxifen Citrate ORAL TABLET 20 *Aromatase Inhibitors*** Anastrozole ORAL TABLET 1 Exemestane ORAL TABLET 25 Letrozole ORAL TABLET 2.5 *Estrogens-Antineoplastic*** EMCYT ORAL CASULE 140 *Lhrh Analogs*** Leuprolide Acetate INJECTION KIT 1 /0.2ML LURON DEOT INTRAMUSCULAR* KIT 11.25, 22.5, 3.75, 30, 45, 7.5 A A 37

39 Drug Name reference Details Coverage Details *rogestins-antineoplastic*** Megestrol Acetate ORAL SUSENSION 40 /ML, 400 /10ML Megestrol Acetate ORAL TABLET 20, 40 *Antineoplastic Enzyme Inhibitors** *Antineoplastic - Braf Kinase Inhibitors*** ZELBORAF ORAL TABLET 240 A *Antineoplastic - Histone Deacetylase Inhibitors*** ZOLINZA ORAL CASULE 100 A *Antineoplastic - Mtor Kinase Inhibitors*** AFINITOR ORAL TABLET 10, 2.5, 5, 7.5 AFINITOR DISERZ ORAL TABLET SOLUBLE 2, 3, 5 *Antineoplastic - Multikinase Inhibitors*** NEXAVAR ORAL TABLET 200 A STIVARGA ORAL TABLET 40 A SUTENT ORAL CASULE 12.5, 25, 50 *Antineoplastic - Tyrosine Kinase Inhibitors*** BOSULIF ORAL TABLET 100, 500 A CARELSA ORAL TABLET 100, 300 COMETRIQ (100 DAILY DOSE) ORAL KIT 1 X 80 & 1 X 20 COMETRIQ (140 DAILY DOSE) ORAL KIT 1 X 80 & 3 X 20 COMETRIQ (60 DAILY DOSE) ORAL KIT 20 GILOTRIF ORAL TABLET 20, 30, 40 A A A A A A A A; QL (31 EA per 31 day(s)) GLEEVEC ORAL TABLET 100 A; QL (186 EA per 31 day(s)) GLEEVEC ORAL TABLET 400 A; QL (62 EA per 31 day(s)) ICLUSIG ORAL TABLET 15, 45 A INLYTA ORAL TABLET 1, 5 A 38

40 Drug Name reference Details Coverage Details SRYCEL ORAL TABLET 100, 140, 20, 50, 70, 80 TARCEVA ORAL TABLET 100, 150, 25 TASIGNA ORAL CASULE 150, 200 TYKERB ORAL TABLET 250 A VOTRIENT ORAL TABLET 200 A XALKORI ORAL CASULE 200, 250 *Janus Associated Kinase (Jak) Inhibitors*** JAKAFI ORAL TABLET 10, 15, 20, 25, 5 *Antineoplastics Misc.** *Antineoplastics Misc.*** Hydroxyurea ORAL CASULE 500 INTRON-A INJECTION SOLUTION RECONSTITUTED UNIT, UNIT, UNIT MATULANE ORAL CASULE 50 SYLATRON SUBCUTANEOUS* KIT 296 MCG, 444 MCG, 888 MCG *Retinoids*** Tretinoin ORAL CASULE 10 *Selective Retinoid X Receptor Agonists*** TARGRETIN ORAL CASULE 75 *Chemotherapy Rescue/Antidote Agents** *Folic Acid Antagonists Rescue Agents*** Leucovorin Calcium ORAL TABLET 10 *Mitotic Inhibitors** *Mitotic Inhibitors*** Etoposide INTRAVENOUS* SOLUTION 500 /25ML Etoposide ORAL CASULE 50 *Antiparkinson Agents* *Antiparkinson Anticholinergics** *Antiparkinson Anticholinergics*** A A A A A A A 39

41 Drug Name reference Details Coverage Details Benztropine Mesylate INJECTION SOLUTION 1 /ML Benztropine Mesylate ORAL TABLET 0.5, 1, 2 Trihexyphenidyl HCl ORAL ELIXIR 0.4 /ML Trihexyphenidyl HCl ORAL TABLET 2, 5 *Antiparkinson Comt Inhibitors** *Central/eripheral Comt Inhibitors*** TASMAR ORAL TABLET 100 *eripheral Comt Inhibitors*** Entacapone ORAL TABLET 200 *Antiparkinson Dopaminergics** *Antiparkinson Dopaminergics*** Amantadine HCl ORAL CASULE 100 Amantadine HCl ORAL SYRU 50 /5ML Bromocriptine Mesylate ORAL CASULE 5 Bromocriptine Mesylate ORAL TABLET 2.5 *Levodopa Combinations*** Carbidopa-Levodopa ORAL TABLET , , Carbidopa-Levodopa ER ORAL TABLET EXTENDEDRELEASE* , *Nonergoline Dopamine Receptor Agonists*** ramipexole Dihydrochloride ORAL TABLET 0.125, 0.25, 0.5, 0.75, 1, 1.5 ROINIRole HCl ORAL TABLET 0.25, 0.5, 1, 2, 3, 4, 5 *Antiparkinson Monoamine Oxidase Inhibitors** *Antiparkinson Monoamine Oxidase Inhibitors*** Selegiline HCl ORAL TABLET 5 *Antipsychotics/Antimanic Agents* 40

42 Drug Name reference Details Coverage Details *Antimanic Agents** *Antimanic Agents*** Lithium Carbonate ORAL CASULE 300 Lithium Carbonate ORAL TABLET 300 Lithium Carbonate ER ORAL TABLET EXTENDEDRELEASE* 300, 450 Lithium Citrate ORAL SOLUTION 8 MEQ/5ML *Antipsychotics - Misc.** *Antipsychotics - Misc.*** Ziprasidone HCl ORAL CASULE 20, 40, 60, 80 *Benzisoxazoles** *Benzisoxazoles*** INVEGA SUSTENNA INTRAMUSCULAR* SUSENSION 117 /0.75ML INVEGA SUSTENNA INTRAMUSCULAR* SUSENSION 156 /ML INVEGA SUSTENNA INTRAMUSCULAR* SUSENSION 234 /1.5ML INVEGA SUSTENNA INTRAMUSCULAR* SUSENSION 39 /0.25ML INVEGA SUSTENNA INTRAMUSCULAR* SUSENSION 78 /0.5ML RISERDAL CONSTA INTRAMUSCULAR* SUSENSION RECONSTITUTED 12.5, 25, 37.5, 50 RisperiDONE ORAL SOLUTION 1 /ML RisperiDONE ORAL TABLET 0.25, 0.5, 1, 2, 3, 4 *Butyrophenones** *Butyrophenones*** QL (62 EA per 31 day(s)); AL (Min 18 Years) QL (0.75 ML per 28 day(s)); AL (Min 18 Years) QL (1 ML per 28 day(s)); AL (Min 18 Years) QL (1.5 ML per 28 day(s)); AL (Min 18 Years) QL (0.25 ML per 28 day(s)); AL (Min 18 Years) QL (0.5 ML per 28 day(s)); AL (Min 18 Years) QL (2 EA per 28 day(s)); AL (Min 18 Years) QL (248 ML per 31 day(s)); AL (Min 5 Years) QL (62 EA per 31 day(s)); AL (Min 5 Years) 41

43 Drug Name reference Details Coverage Details Haloperidol ORAL TABLET 0.5, 1, 10, 2, 20, 5 Haloperidol Decanoate INTRAMUSCULAR* SOLUTION 100 /ML, 50 /ML *Dibenzapines** *Dibenzodiazepines*** CloZAine ORAL TABLET 100, 200, 25, 50 *Dibenzo-Oxepino yrroles*** SAHRIS SUBLINGUAL TABLET SUBLINGUAL 10, 5 *Dibenzothiazepines*** QUEtiapine Fumarate ORAL TABLET 100, 200, 25, 50 QUEtiapine Fumarate ORAL TABLET 300, 400 *Dibenzoxazepines*** Loxapine Succinate ORAL CASULE 10, 25, 5, 50 *Thienbenzodiazepines*** OLANZapine ORAL TABLET 10, 15, 2.5, 20, 5, 7.5 *henothiazines** *henothiazines*** ChlorproMAZINE HCl INJECTION SOLUTION 25 /ML ChlorproMAZINE HCl ORAL TABLET 10, 100, 200, 25, 50 FluHENAZine Decanoate INJECTION SOLUTION 25 /ML FluHENAZine HCl ORAL CONCENTRATE 5 /ML FluHENAZine HCl ORAL ELIXIR 2.5 /5ML FluHENAZine HCl ORAL TABLET 1, 10, 2.5, 5 erphenazine ORAL TABLET 16, 2, 4, 8 rochlorperazine RE SUOSITORY 25 AL (Min 18 Years) ST QL (93 EA per 31 day(s)); AL (Min 10 Years) QL (62 EA per 31 day(s)); AL (Min 10 Years) QL (31 EA per 31 day(s)); AL (Min 13 Years) 42

44 Drug Name reference Details Coverage Details rochlorperazine Edisylate INJECTION SOLUTION 5 /ML rochlorperazine Maleate ORAL TABLET 10, 5 Thioridazine HCl ORAL TABLET 10, 100, 25, 50 Trifluoperazine HCl ORAL TABLET 1, 10, 2, 5 *Quinolinone Derivatives** *Quinolinone Derivatives*** ABILIFY INTRAMUSCULAR* SOLUTION 9.75 /1.3ML ABILIFY ORAL SOLUTION 1 /ML ABILIFY ORAL TABLET 10, 15, 2, 20, 30, 5 ABILIFY DISCMELT ORAL TABLET DISERSIBLE 10, 15 ABILIFY MAINTENA INTRAMUSCULAR* SUSENSION RECONSTITUTED 300, 400 *Thioxanthenes** *Thioxanthenes*** Thiothixene ORAL CASULE 1, 10, 2, 5 *Antiseptics & Disinfectants* *Iodine Antiseptics** *Iodine Antiseptics*** ovidone-iodine EXTERNAL SOLUTION 10 % *Antivirals* *Antiretrovirals** *Antiretroviral Combinations*** ATRILA ORAL TABLET COMLERA ORAL TABLET EZICOM ORAL TABLET KALETRA ORAL SOLUTION /5ML ST; QL (83.2 ML per 31 Day(s)); AL (Min 5 Years) ST; QL (930 ML per 31 Day(s)); AL (Min 5 Years) ST; QL (31 EA per 31 Day(s)); AL (Min 6 Years) ST; QL (62 EA per 31 day(s)); AL (Min 5 Years) ST 43

45 Drug Name reference Details Coverage Details KALETRA ORAL TABLET , Lamivudine-Zidovudine ORAL TABLET STRIBILD ORAL TABLET TRIZIVIR ORAL TABLET TRUVADA ORAL TABLET *Antiretrovirals - Ccr5 Antagonists (Entry Inhibitor)*** SELZENTRY ORAL TABLET 150, 300 *Antiretrovirals - Fusion Inhibitors*** FUZEON SUBCUTANEOUS* SOLUTION RECONSTITUTED 90 *Antiretrovirals - Integrase Inhibitors*** ISENTRESS ORAL TABLET 400 ISENTRESS ORAL TABLET CHEWABLE 100, 25 TIVICAY ORAL TABLET 50 QL (62 EA per 31 day(s)) *Antiretrovirals - rotease Inhibitors*** ATIVUS ORAL CASULE 250 ATIVUS ORAL SOLUTION 100 /ML CRIXIVAN ORAL CASULE 200, 400 INVIRASE ORAL CASULE 200 INVIRASE ORAL TABLET 500 LEXIVA ORAL SUSENSION 50 /ML LEXIVA ORAL TABLET 700 NORVIR ORAL CASULE 100 NORVIR ORAL SOLUTION 80 /ML NORVIR ORAL TABLET 100 REZISTA ORAL SUSENSION 100 /ML REZISTA ORAL TABLET 150, 400, 600, 75, 800 REYATAZ ORAL CASULE 150, 200,

46 Drug Name reference Details Coverage Details VIRACET ORAL TABLET 250, 625 *Antiretrovirals - Rti-Non-Nucleoside Analogues*** EDURANT ORAL TABLET 25 INTELENCE ORAL TABLET 100, 200, 25 Nevirapine ORAL SUSENSION 50 /5ML Nevirapine ORAL TABLET 200 RESCRITOR ORAL TABLET 100 SUSTIVA ORAL CASULE 200, 50 SUSTIVA ORAL TABLET 600 VIRAMUNE ORAL SUSENSION 50 /5ML VIRAMUNE XR ORAL TABLET EXTENDED RELEASE 24 HR* 400 *Antiretrovirals - Rti-Nucleoside Analogues-urines*** Abacavir Sulfate ORAL TABLET 300 Didanosine ORAL CASULE DELAYED RELEASE 125, 200, 250, 400 VIDEX ORAL SOLUTION RECONSTITUTED 2 GM, 4 GM ZIAGEN ORAL SOLUTION 20 /ML *Antiretrovirals - Rti-Nucleoside Analogues-yrimidines*** EMTRIVA ORAL CASULE 200 EMTRIVA ORAL SOLUTION 10 /ML EIVIR ORAL SOLUTION 10 /ML EIVIR HBV ORAL SOLUTION 5 /ML EIVIR HBV ORAL TABLET 100 LamiVUDine ORAL TABLET 150, 300 *Antiretrovirals - Rti-Nucleoside Analogues-Thymidines*** Stavudine ORAL CASULE 15, 20, 30, 40 QL (310 EA per 31 day(s)) 45