AETNA BETTER HEALTH Formulary Guide. Aetna Better Health of Florida Florida Healthy Kids Formulary Guide January 2019

Transcription

1 AETNA BETTER HEALTH Formulary Guide Aetna Better Health of Florida Florida Healthy Kids Formulary Guide January 2019

2 AETNA BETTER HEALTH Formulary Guide What is a Formulary? A formulary is a list of drugs that are covered by the health plan. A formulary also tells you if there are any rules or restrictions on drugs, such as a limit on the amount you can get. If the rules for that drug are met, the plan will cover the drug. Drugs must also be filled at a plan network pharmacy. Can the Plan s Drug List change? The plan may add or remove drugs on the list. Utilizing members and their providers will be notified at least 30 days before a drug is removed from the formulary. All changes to the formulary will be posted on the plan s website. How do I use the Plan s Formulary? Column #1: lists the covered drug. Brand drugs are in upper case letters (e.g., DRUG). Generics are in lower case letters (e.g., drug). Column #2: shows coverage rules for the drug Drugs are also grouped by the type of condition they treat. Drugs used to treat an earache are listed under the section, Ear-Nose-Throat Medications. If you know what your drug is used for, please look for that section name on the drug list. Then look under that section for your drug. What are generic drugs? The plan covers both brand and generic drugs. Generic drugs cost less and are approved by the Food and Drug Administration (FDA). Are Over-The-Counter () drugs covered? The plan will cover drugs on the formulary. Some drugs may have coverage rules. If the rules for that drug are met, the plan will cover the drug. Like other drugs, drugs need a prescription from a doctor if they are to be covered by the plan. Updated: 01/01/2019 Pa g e 2

3 AETNA BETTER HEALTH Formulary Guide Are there Medication Copays? Refer to member handbook for copay information. What are some types of coverage rules? Prior Approval (PA): This means your doctor will need to get approval from the plan first before the drug can be filled at the pharmacy. If it is not approved, the plan will not cover the drug. Call Member Services team at for more information. Quantity Level Limits (QLL): This means there is a limit on the amount of drug the plan will cover. For example, the plan provides 60 pills in 30 days for some drugs. Step Therapy (ST): This means you may need to try certain drugs first to treat your condition. After the first drug is tried, the plan will then cover the other drug for that same condition. For example, Drug A and Drug B may treat your condition. The plan may not cover Drug B unless you try Drug A first. If Drug A does not work for you, then Drug B will be covered. What if my drug is not on the plan s Formulary? First, please call your doctor and ask if your drug is covered. If the plan does not cover the drug, then: Ask your doctor for a similar drug that is covered. Your doctor can ask the plan to cover your drug through the prior approval process. Updated: 01/01/2019 Pa g e 3

4 Aetna Better Health Florida CHIP Table of Contents *ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS*...5 *ALTERNATIVE MEDICINES* *AMINOGLYCOSIDES* *ANALGESICS - ANTI-INFLAMMATORY* *ANALGESICS - NONNARCOTIC*...14 *ANALGESICS - OPIOID* *ANDROGENS-ANABOLIC* *ANORECTAL AGENTS*...19 *ANTACIDS*...19 *ANTHELMINTICS* *ANTIANGINAL AGENTS* *ANTIANXIETY AGENTS*...21 *ANTIARRHYTHMICS* *ANTIASTHMATIC AND BRONCHODILATOR AGENTS* *ANTICOAGULANTS* *ANTICONVULSANTS*...25 *ANTIDEPRESSANTS*...30 *ANTIDIABETICS* *ANTIDIARRHEALS*...36 *ANTIDOTES AND SPECIFIC ANTAGONISTS*...36 *ANTIDOTES* *ANTIEMETICS* *ANTIFUNGALS*...37 *ANTIHEMOPHILIC PRODUCTS - MONOCLONAL ANTIBODIES***...38 *ANTIHISTAMINES* *ANTIHYPERLIPIDEMICS*...40 *ANTIHYPERTENSIVES* *ANTI-INFECTIVE AGENTS - MISC.* *ANTIMALARIALS*...43 *ANTIMYASTHENIC AGENTS* *ANTIMYASTHENIC/CHOLINERGIC AGENTS* *ANTIMYCOBACTERIAL AGENTS* *ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES*...44 *ANTIPARKINSON AGENTS*...49 *ANTIPSYCHOTICS/ANTIMANIC AGENTS* *ANTIRETROVIRALS - CD4-DIRECTED POST-ATTACHMENT INHIBITOR***...60 *ANTIRETROVIRALS ADJUVANTS*** *ANTIVIRALS*...60 *ASSORTED CLASSES* *BETA BLOCKERS* *BIOLOGICALS MISC* *CALCIUM CHANNEL BLOCKERS* *CARDIOTONICS* *CARDIOVASCULAR AGENTS - MISC.* *CEPHALOSPORINS*...68 *CHEMICALS*...69 *CONTRACEPTIVES*

5 *CORTICOSTEROIDS* *COUGH/COLD/ALLERGY*...81 *DERMATOLOGICALS* *DIAGNOSTIC PRODUCTS*...89 *DIGESTIVE AIDS*...90 *DIRECT-ACTING P2Y12 INHIBITORS*** *DIURETICS*...90 *ENDOCRINE AND METABOLIC AGENTS - MISC.*...91 *ESTROGENS*...93 *FLUOROQUINOLONES* *GASTROINTESTINAL AGENTS - MISC.*...94 *GENITOURINARY AGENTS - MISCELLANEOUS* *GLYCOPEPTIDES***...96 *GOUT AGENTS*...96 *HEMATOLOGICAL AGENTS - MISC.* *HEMATOPOIETIC AGENTS*...99 *HEMOSTATICS* *HEPATITIS C AGENT - COMBINATIONS*** *HYPNOTICS* *LAXATIVES* *LHRH/GNRH AGONIST ANALOG COMBINATIONS*** *LOCAL ANESTHETICS-PARENTERAL* *MACROLIDES* *MEDICAL DEVICES* *MIGRAINE PRODUCTS* *MINERALS & ELECTROLYTES* *MONOBACTAMS*** *MOUTH/THROAT/DENTAL AGENTS* *MUCOPOLYSACCHARIDOSIS VII (MPS VII) - AGENTS*** *MULTIVITAMINS* *MUSCULOSKELETAL THERAPY AGENTS* *NASAL AGENTS - SYSTEMIC AND TOPICAL* *NEPRILYSIN INHIB (ARNI)-ANGIOTENSIN II RECEPT ANTAG COMB*** *NEUROMUSCULAR AGENTS* *NUTRIENTS* *OPHTHALMIC AGENTS* *OTIC AGENTS* *OXYTOCICS* *PASSIVE IMMUNIZING AGENTS - COMBINATIONS*** *PASSIVE IMMUNIZING AGENTS* *PENICILLINS* *PERITONEAL DIALYSIS SOLUTIONS*** *PHARMACEUTICAL ADJUVANTS* *PHOSPHODIESTERASE 4 (PDE4) INHIBITORS - TOPICAL*** *POTASSIUM REMOVING AGENTS*** *PROGESTINS* *PROTEIN-CARBOHYDRATE-LIPID WITH ELECTROLYTE COMBINATIONS*** *PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.* *PULMONARY FIBROSIS AGENTS - KINASE INHIBITORS*** *RESPIRATORY AGENTS - MISC.* *SEROTONIN MODULATORS*** *SGLT2 INHIBITOR - DPP-4 INHIBITOR COMBINATIONS***

6 *SODIUM-GLUCOSE CO-TRANSPORTER 2 INHIBITOR-BIGUANIDE COMB*** *SULFONAMIDES* *TETRACYCLINES* *THYROID AGENTS* *ULCER DRUGS* *URINARY ANTI-INFECTIVES* *URINARY ANTISPASMODICS* *VAGINAL PRODUCTS* *VASOPRESSORS* *VITAMINS*

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8 Aetna Better Health Florida CHIP CURRENT AS OF 01/01/2019 Formulary Drug Name Reference Restrictions *ADHD/ANTI- NARCOLEPSY/ANTI- OBESITY/ANOREXIANTS* *Adhd Agent - Selective Alpha Adrenergic Agonists*** guanfacine hcl er oral tablet extended release 24 hour Intuniv *Adhd Agent - Selective Norepinephrine Reuptake Inhibitor*** atomoxetine hcl oral capsule Strattera AL (Min 6 Years) *Amphetamine Mixtures*** amphetamine-dextroamphet er oral capsule extended release 24 hour amphetamine-dextroamphetamine tablet 10 mg oral amphetamine-dextroamphetamine tablet 12.5 mg oral amphetamine-dextroamphetamine tablet 15 mg oral amphetamine-dextroamphetamine tablet 20 mg oral amphetamine-dextroamphetamine tablet 30 mg oral amphetamine-dextroamphetamine tablet 5 mg oral Adderall XR Adderall Adderall Adderall Adderall Adderall Adderall QL: ages =/>18: maximum 50mg/day; QLL (1 EA per 1 day); AL (Min 13 Years) QL: ages 0-5: maximum of 2 tablets/day, ages =/>18: maximum of 6 tablets/day; AL (Min 3 Years) QL: ages 0-5: maximum of 1 tablets/day, ages =/>18: maximum of 4 tablets/day; AL (Min 3 Years) QL: ages 0-5: maximum of 1 tablets/day, ages =/>18: maximum of 4 tablets/day; AL (Min 3 Years) QL: ages 0-5: maximum of 0.75 tablets/day, ages =/>18: maximum of 3 tablets/day; AL (Min 3 Years) QL: ages 0-5: maximum of 0.05 tablets/day, ages =/>18: maximum of 2 tablets/day; AL (Min 3 Years) QL: ages 0-5: maximum of 2 tablets/day, ages =/>18: maximum of 6 tablets/day; AL (Min 3 Years) 5

9 amphetamine-dextroamphetamine tablet 7.5 mg oral *Amphetamines*** dextroamphetamine sulfate er capsule extended release 24 hour 5 mg oral dextroamphetamine sulfate er oral capsule extended release 24 hour 10 mg dextroamphetamine sulfate er oral capsule extended release 24 hour 15 mg dextroamphetamine sulfate er oral capsule extended release 24 hour 5 mg dextroamphetamine sulfate tablet 10 mg oral dextroamphetamine sulfate tablet 5 mg oral ADZENYS XR-ODT ORAL TABLET EXTENDED RELEASE DISPERSIBLE VYVANSE ORAL CAPSULE VYVANSE ORAL TABLET CHEWABLE *Analeptics*** caffeine citrate intravenous solution caffeine citrate oral solution *Stimulants - Misc.*** dexmethylphenidate hcl er capsule extended release 24 hour 10 mg oral dexmethylphenidate hcl er capsule extended release 24 hour 15 mg oral dexmethylphenidate hcl er capsule extended release 24 hour 20 mg oral Adderall Dexedrine Dexedrine Dexedrine Dexedrine Zenzedi Zenzedi Cafcit Focalin XR Focalin XR Focalin XR QL: ages 0-5: maximum of 2 tablets/day, ages =/>18: maximum of 6 tablets/day; AL (Min 3 Years) QL: ages 0-5: maximum 2 capsule/day, ages =/>18: maximum 2 capsule/day; AL (Min 6 Years) QL: ages 0-5: maximum 1 capsule/day, ages =/>18: maximum 2 capsule/day; AL (Min 6 Years) QL: ages 0-5: maximum 1 capsule/day, ages =/>18: maximum 4 capsule/day; AL (Min 6 Years) QL: ages 0-5: maximum 2 capsule/day, ages =/>18: maximum 2 capsule/day; AL (Min 6 Years) QL: ages 0-5: maximum 1 tablet/day, ages =/>18: maximum 2 tablets/day QL: ages 0-5: maximum of 2 tablets/day, ages =/;18: maximum of 2 tablets/day AL (Min 6 Years) 6 Years) QLL (90 ML per 30 days); AL (Max 11 Months) QLL (90 ML per 30 days); AL (Max 11 Months) 6 Years) 6 Years) 6 Years) 6

10 dexmethylphenidate hcl er capsule extended release 24 hour 25 mg oral dexmethylphenidate hcl er capsule extended release 24 hour 30 mg oral dexmethylphenidate hcl er capsule extended release 24 hour 35 mg oral dexmethylphenidate hcl er capsule extended release 24 hour 40 mg oral dexmethylphenidate hcl er capsule extended release 24 hour 5 mg oral dexmethylphenidate hcl tablet 10 mg oral dexmethylphenidate hcl tablet 2.5 mg oral dexmethylphenidate hcl tablet 5 mg oral methylphenidate hcl er (cd) capsule extended release 10 mg oral methylphenidate hcl er (cd) capsule extended release 20 mg oral methylphenidate hcl er (cd) capsule extended release 30 mg oral methylphenidate hcl er (cd) capsule extended release 40 mg oral Focalin XR Focalin XR Focalin XR Focalin XR Focalin XR Focalin Focalin Focalin QL: ages 0-5: maximum of 0.6 capsule/day, ages =/>18: maximum of 1 capsule/day; AL (Min 6 Years) QL: ages 0-5: maximum of 0.75 capsule/day, ages =/>18: maximum of 1 capsule/day; AL (Min 6 Years) QL: ages 0-5: maximum of capsule/day, ages =/>18: maximum of 1 capsule/day; AL (Min 6 Years) QL: ages 0-5: maximum of capsule/day, ages =/>18: maximum of 1 capsule/day; AL (Min 6 Years) 6 Years) QL: ages 0-5: maximum of 1.5 tablets/day, ages =/>18: maximum of 2 tablets/day; AL (Min 6 Years) QL: ages 0-5: maximum of 2 tablets/day, ages =/>18: maximum of 2 tablets/day; AL (Min 6 Years) QL: ages 0-5: maximum of 2 tablets/day, ages =/>18: maximum of 2 tablets/day; AL (Min 6 Years) QL: ages 0-5: maximum of 1 capsules/day, ages =/;18: maximum of 1 capsules/day; AL (Min 6 Years) QL: ages 0-5: maximum of 1 capsules/day, ages =/;18: maximum of 1 capsules/day; AL (Min 6 Years) QL: ages 0-5: maximum capsule/day, ages =/;18: maximum 1 capsule/day; AL (Min 6 Years) QL: ages 0-5: maximum capsule/day, ages =/;18: maximum 1 capsule/day; AL (Min 6 Years) 7

11 methylphenidate hcl er (cd) capsule extended release 50 mg oral methylphenidate hcl er (cd) capsule extended release 60 mg oral methylphenidate hcl er (la) oral capsule extended release 24 hour 20 mg methylphenidate hcl er (la) oral capsule extended release 24 hour 30 mg methylphenidate hcl er (la) oral capsule extended release 24 hour 40 mg methylphenidate hcl er (la) oral capsule extended release 24 hour 60 mg methylphenidate hcl tablet 10 mg oral Ritalin LA Ritalin LA Ritalin LA Ritalin QL: ages 0-5: maximum 0.50 capsule/day, ages =/;18: maximum 1 capsule/day; AL (Min 6 Years) QL: ages 0-5: maximum capsule/day, ages =/;18: maximum 1 capsule/day; AL (Min 6 Years) QL: ages 0-5: maximum of 1 capsules/day, ages =/;18: maximum of 1 capsules/day; AL (Min 6 Years) QL: ages 0-5: maximum of capsule/day, ages =/>18: maximum of 1 capsule/day; AL (Min 6 Years) QL: ages 0-5: maximum of capsule/day, ages =/>18: maximum of 1 capsule/day; AL (Min 6 Years) QL: ages 0-5: maximum of capsule/day, ages =/>18: maximum of 1 capsule/day; AL (Min 6 Years) QL: ages 0-5: maximum of 2 tablets/day, ages =/;18: maximum of 3 tablets/day; AL (Min 6 Years) methylphenidate hcl tablet 10 mg oral Ritalin AL (Min 6 Years) methylphenidate hcl tablet 10 mg oral Ritalin QL: ages 0-5: maximum of 2 tablets/day, ages =/;18: maximum of 3 tablets/day; AL (Min 6 Years) methylphenidate hcl tablet 20 mg oral Ritalin AL (Min 6 Years) methylphenidate hcl tablet 20 mg oral Ritalin QL: ages 0-5: maximum of 1 tablet/day, ages =/>18: maximum of 3 tablets/day; AL (Min 6 Years) methylphenidate hcl tablet 5 mg oral Ritalin AL (Min 6 Years) methylphenidate hcl tablet 5 mg oral Ritalin QL: ages 0-5: maximum of 1 tablet/day, ages =/>18: maximum of 3 tablets/day; AL (Min 6 Years) 8

12 methylphenidate hcl tablet 5 mg oral methylphenidate hcl tablet chewable 10 mg oral methylphenidate hcl tablet chewable 2.5 mg oral methylphenidate hcl tablet chewable 5 mg oral modafinil tablet 100 mg oral modafinil tablet 200 mg oral APTENSIO XR CAPSULE EXTENDED RELEASE 24 HOUR 10 MG ORAL APTENSIO XR CAPSULE EXTENDED RELEASE 24 HOUR 15 MG ORAL APTENSIO XR CAPSULE EXTENDED RELEASE 24 HOUR 20 MG ORAL APTENSIO XR CAPSULE EXTENDED RELEASE 24 HOUR 30 MG ORAL APTENSIO XR CAPSULE EXTENDED RELEASE 24 HOUR 40 MG ORAL APTENSIO XR CAPSULE EXTENDED RELEASE 24 HOUR 50 MG ORAL APTENSIO XR CAPSULE EXTENDED RELEASE 24 HOUR 60 MG ORAL Ritalin Provigil Provigil QL: ages 0-5: maximum of 5 tablets/day, ages =/;18: maximum of 3 tablets/day; AL (Min 6 Years) QL: ages 0-5: maximum of 2 tablets/day, ages =/>18: maximum of 3 tablets/day QL: ages 0-5: maximum of 5 tablets/day, ages =/>18: maximum of 3 tablets/day QL: ages 0-5: maximum of 5 tablets/day, ages =/>18: maximum of 3 tablets/day Auto-PA; QLL (3 EA per 1 day); AL (Min 18 Years) Auto-PA; QLL (2 EA per 1 day); AL (Min 18 Years) QL: ages 0-5: maximum of 1 capsules/day, ages =/;18: maximum of 1 capsules/day; AL (Min 6 Years) QL: ages 0-5: maximum of 1 capsules/day, ages =/;18: maximum of 1 capsules/day; AL (Min 6 Years) QL: ages 0-5: maximum of 1 capsules/day, ages =/;18: maximum of 1 capsules/day; AL (Min 6 Years) QL: ages 0-5: maximum capsule/day, ages =/>18: maximum 1 capsule/day; AL (Min 6 Years) QL: ages 0-5: maximum capsule/day, ages =/>18: maximum 1 capsule/day; AL (Min 6 Years) QL: ages 0-5: maximum 0.50 capsule/day, ages =/>18: maximum 1 capsule/day; AL (Min 6 Years) QL: ages 0-5: maximum capsule/day, ages =/>18: maximum 1 capsule/day; AL (Min 6 Years) 9

13 DAYTRANA PATCH 10 MG/9HR TRANSDERMAL DAYTRANA PATCH 15 MG/9HR TRANSDERMAL DAYTRANA PATCH 20 MG/9HR TRANSDERMAL DAYTRANA PATCH 30 MG/9HR TRANSDERMAL QUILLICHEW ER ORAL TABLET CHEWABLE EXTENDED RELEASE QUILLIVANT XR ORAL SUSPENSION RECONSTITUTED *ALTERNATIVE MEDICINES* *Alternative Medicine - St's*** stevia oral packet *AMINOGLYCOSIDES* *Aminoglycosides*** gentamicin in saline intravenous solution gentamicin sulfate injection solution neomycin sulfate oral tablet tobramycin sulfate injection solution *ANALGESICS - ANTI- INFLAMMATORY* *Antirheumatic - Janus Kinase (Jak) Inhibitors*** XELJANZ ORAL TABLET XELJANZ XR ORAL TABLET EXTENDED RELEASE 24 HOUR *Anti-Tnf-Alpha - Monoclonal Antibodies*** HUMIRA PEDIATRIC CROHNS START PREFILLED SYRINGE KIT 40 MG/0.8ML SUBCUTANEOUS 10 QL: age 0-5: maximum 30 patches/30 days, age =/>18: maximum 30 patches/30 days; AL (Min 6 Years) QL: age 0-5: maximum 30 patches/30 days, age =/>18: maximum 30 patches/30 days; AL (Min 6 Years) QL: age 0-5: maximum 30 patches/30 days, age =/>18: maximum 30 patches/30 days; AL (Min 6 Years) QL: age 0-5: maximum patches/30 days, age =/>18: maximum 30 patches/30 days; AL (Min 6 Years) AL (Min 6 Years) AL (Min 6 Years) Auto-PA; QLL (2 EA per 1 day); AL (Min 18 Years) Auto-PA; QLL (1 EA per 1 day); AL (Min 18 Years) Auto-PA; QLL (1 KIT per 365 days)

14 HUMIRA PEDIATRIC CROHNS START PREFILLED SYRINGE KIT 80 MG/0.8ML & 40MG/0.4ML SUBCUTANEOUS HUMIRA PEDIATRIC CROHNS START PREFILLED SYRINGE KIT 80 MG/0.8ML SUBCUTANEOUS HUMIRA PEN SUBCUTANEOUS PEN- INJECTOR KIT HUMIRA PEN-CD/UC/HS STARTER PEN-INJECTOR KIT 40 MG/0.8ML SUBCUTANEOUS HUMIRA PEN-CD/UC/HS STARTER PEN-INJECTOR KIT 80 MG/0.8ML SUBCUTANEOUS HUMIRA PEN-CD/UC/HS STARTER SUBCUTANEOUS PEN-INJECTOR KIT 80 MG/0.8ML HUMIRA PEN-PS/UV/ADOL HS START PEN-INJECTOR KIT 40 MG/0.8ML SUBCUTANEOUS HUMIRA PEN-PS/UV/ADOL HS START PEN-INJECTOR KIT 80 MG/0.8ML & 40MG/0.4ML SUBCUTANEOUS HUMIRA PEN-PS/UV/ADOL HS START SUBCUTANEOUS PEN-INJECTOR KIT 80 MG/0.8ML & 40MG/0.4ML HUMIRA PREFILLED SYRINGE KIT 10 MG/0.1ML SUBCUTANEOUS HUMIRA PREFILLED SYRINGE KIT 10 MG/0.2ML SUBCUTANEOUS HUMIRA PREFILLED SYRINGE KIT 20 MG/0.2ML SUBCUTANEOUS HUMIRA PREFILLED SYRINGE KIT 20 MG/0.4ML SUBCUTANEOUS HUMIRA PREFILLED SYRINGE KIT 40 MG/0.4ML SUBCUTANEOUS HUMIRA PREFILLED SYRINGE KIT 40 MG/0.8ML SUBCUTANEOUS *Anti-Tnf-Alpha - Monoclonoal Antibodies*** HUMIRA PEDIATRIC CROHNS START PREFILLED SYRINGE KIT 40 MG/0.8ML SUBCUTANEOUS Auto-PA; QLL (1 KIT per 365 days) Auto-PA Auto-PA; QLL (2 KITS per 28 days) Auto-PA; QLL (1 KIT per 365 days) Auto-PA Auto-PA Auto-PA; QLL (1 KIT per 365 days) Auto-PA Auto-PA Auto-PA Auto-PA; QLL (1 KIT per 28 days) Auto-PA Auto-PA; QLL (1 KIT per 28 days) Auto-PA Auto-PA; QLL (2 KITS per 28 days) Auto-PA; QLL (1 KIT per 365 days) 11

15 HUMIRA PEDIATRIC CROHNS START PREFILLED SYRINGE KIT 80 MG/0.8ML & 40MG/0.4ML SUBCUTANEOUS HUMIRA PEDIATRIC CROHNS START PREFILLED SYRINGE KIT 80 MG/0.8ML SUBCUTANEOUS HUMIRA PEN PEN-INJECTOR KIT 40 MG/0.4ML SUBCUTANEOUS HUMIRA PEN PEN-INJECTOR KIT 40 MG/0.8ML SUBCUTANEOUS HUMIRA PEN-CD/UC/HS STARTER PEN-INJECTOR KIT 40 MG/0.8ML SUBCUTANEOUS HUMIRA PEN-CD/UC/HS STARTER PEN-INJECTOR KIT 80 MG/0.8ML SUBCUTANEOUS HUMIRA PEN-CD/UC/HS STARTER SUBCUTANEOUS PEN-INJECTOR KIT 80 MG/0.8ML HUMIRA PEN-PS/UV/ADOL HS START PEN-INJECTOR KIT 40 MG/0.8ML SUBCUTANEOUS HUMIRA PEN-PS/UV/ADOL HS START PEN-INJECTOR KIT 80 MG/0.8ML & 40MG/0.4ML SUBCUTANEOUS HUMIRA PEN-PS/UV/ADOL HS START SUBCUTANEOUS PEN-INJECTOR KIT 80 MG/0.8ML & 40MG/0.4ML HUMIRA PREFILLED SYRINGE KIT 10 MG/0.1ML SUBCUTANEOUS HUMIRA PREFILLED SYRINGE KIT 10 MG/0.2ML SUBCUTANEOUS HUMIRA PREFILLED SYRINGE KIT 20 MG/0.2ML SUBCUTANEOUS HUMIRA PREFILLED SYRINGE KIT 20 MG/0.4ML SUBCUTANEOUS HUMIRA PREFILLED SYRINGE KIT 40 MG/0.4ML SUBCUTANEOUS HUMIRA PREFILLED SYRINGE KIT 40 MG/0.8ML SUBCUTANEOUS *Cyclooxygenase 2 (Cox-2) Inhibitors*** Auto-PA; QLL (1 KIT per 365 days) Auto-PA Auto-PA; QLL (1 KIT per 365 days) Auto-PA; QLL (2 KITS per 28 days) Auto-PA; QLL (1 KIT per 365 days) Auto-PA Auto-PA Auto-PA; QLL (1 KIT per 365 days) Auto-PA Auto-PA Auto-PA Auto-PA; QLL (1 KIT per 28 days) Auto-PA Auto-PA; QLL (1 KIT per 28 days) Auto-PA Auto-PA; QLL (2 KITS per 28 days) celecoxib capsule 100 mg oral CeleBREX QLL (2 EA per 1 day) 12

16 celecoxib capsule 200 mg oral CeleBREX QLL (2 EA per 1 day) celecoxib capsule 400 mg oral CeleBREX QLL (1 EA per 1 day) celecoxib capsule 50 mg oral CeleBREX QLL (2 EA per 1 day) *Nonsteroidal Anti-Inflammatory Agent Combinations*** diclofenac-misoprostol oral tablet delayed release *Nonsteroidal Anti-Inflammatory Agents (Nsaids)*** diclofenac potassium oral tablet diclofenac sodium er oral tablet extended release 24 hour diclofenac sodium oral tablet delayed release ibuprofen oral suspension ibuprofen oral tablet indomethacin oral capsule ketorolac tromethamine injection solution ketorolac tromethamine intramuscular solution ketorolac tromethamine oral tablet meloxicam oral tablet nabumetone oral tablet naproxen dr oral tablet delayed release naproxen oral tablet IBU ORAL TABLET *Pyrimidine Synthesis Inhibitors*** leflunomide oral tablet *Soluble Tumor Necrosis Factor Receptor Agents*** ENBREL MINI SUBCUTANEOUS SOLUTION CARTRIDGE ENBREL SOLUTION PREFILLED SYRINGE 25 MG/0.5ML SUBCUTANEOUS ENBREL SOLUTION PREFILLED SYRINGE 50 MG/ML SUBCUTANEOUS ENBREL SUBCUTANEOUS SOLUTION RECONSTITUTED Arthrotec Childrens Advil IBU Mobic EC-Naprosyn Naprosyn IBU Arava QLL (120 MG per 1 day); AL (Min 17 Years) QLL (120 MG per 1 day); AL (Min 17 Years) QLL (4 EA per 1 day); AL (Min 17 Years) Auto-PA; QLL (7.84 ML per 28 days); AL (Min 2 Years) Auto-PA; QLL (4.08 ML per 28 days); AL (Min 2 Years) Auto-PA; QLL (7.84 ML per 28 days); AL (Min 2 Years) Auto-PA; QLL (2 KITS per 28 days); AL (Min 2 Years) 13

17 ENBREL SURECLICK SUBCUTANEOUS SOLUTION AUTO-INJECTOR *ANALGESICS - NONNARCOTIC* *Analgesics Other*** 8 hour arthritis pain reliever oral tablet Midol extended release 8hr muscle aches & pain oral tablet extended Midol release acetaminophen er oral tablet extended release Midol Auto-PA; QLL (7.84 ML per 28 days); AL (Min 2 Years) acetaminophen oral liquid Little Remedies for Fever ; AL (Max 6 Years) arthritis pain relief oral tablet extended release Midol childrens acetaminophen oral suspension Mapap Childrens ; AL (Max 6 Years) childrens silapap oral liquid Little Remedies for Fever ; AL (Max 6 Years) ed-apap oral liquid Little Remedies for Fever ; AL (Max 6 Years) gnp 8 hour pain reliever oral tablet extended release Midol gnp arthritis pain relief oral tablet extended release Midol gnp infants pain relief oral suspension Mapap Childrens ; AL (Max 6 Years) gnp infants pain/fever oral suspension Mapap Childrens ; AL (Max 6 Years) gnp pain & fever childrens oral suspension Mapap Childrens ; AL (Max 6 Years) goodsense arthritis pain oral tablet extended release Midol goodsense pain & fever child oral suspension Mapap Childrens ; AL (Max 6 Years) goodsense pain & fever infants oral suspension Mapap Childrens ; AL (Max 6 Years) goodsense pain relief oral tablet extended release Midol hm acetaminophen childrens oral tablet chewable Mapap Childrens ; AL (Max 6 Years) hm arthritis pain relief oral tablet extended release Midol hm pain & fever childrens oral suspension Mapap Childrens ; AL (Max 6 Years) hm pain & fever infants oral suspension Mapap Childrens ; AL (Max 6 Years) mapap arthritis pain oral tablet extended release Midol mapap oral liquid Little Remedies for Fever ; AL (Max 6 Years) non-aspirin childrens oral suspension Mapap Childrens ; AL (Max 6 Years) pain & fever childrens oral solution ; AL (Max 6 Years) pain & fever childrens oral suspension Mapap Childrens ; AL (Max 6 Years) 14

18 pain & fever infants oral suspension Mapap Childrens ; AL (Max 6 Years) pain relief childrens oral suspension Mapap Childrens ; AL (Max 6 Years) qc arthritis pain relief oral tablet extended release Midol qc non-aspirin childrens oral suspension Mapap Childrens ; AL (Max 6 Years) qc non-aspirin jr strength oral tablet dispersible ; AL (Max 6 Years) qc pain relief childrens oral suspension Mapap Childrens ; AL (Max 6 Years) qc pain relief infants oral suspension Mapap Childrens ; AL (Max 6 Years) sm 8 hour pain relief oral tablet extended release Midol sm arthritis pain relief oral tablet extended release Midol sm arthritis pain reliever oral tablet extended release Midol sm pain & fever childrens oral suspension Mapap Childrens ; AL (Max 6 Years) sm pain & fever infants oral suspension Mapap Childrens ; AL (Max 6 Years) MAPAP CHILDRENS ORAL TABLET CHEWABLE Mapap Childrens ; AL (Max 6 Years) *Analgesics-Sedatives*** butalbital-acetaminophen oral capsule butalbital-acetaminophen oral tablet Tencon butalbital-apap-caffeine oral capsule Fioricet QLL (120 EA per 360 days) butalbital-apap-caffeine oral tablet Esgic QLL (120 EA per 360 days) butalbital-aspirin-caffeine oral capsule Fiorinal *Salicylates*** adult aspirin regimen oral tablet delayed release Aspir-Low aspir-81 oral tablet delayed release Aspir-Low aspirin adult low strength oral tablet chewable Bayer Low Dose aspirin ec low strength oral tablet delayed release Aspir-Low aspirin ec oral tablet delayed release Aspir-Low aspirin low dose adult oral tablet chewable Bayer Low Dose aspirin low dose oral tablet chewable Bayer Low Dose aspirin low dose oral tablet delayed release Aspir-Low aspirin oral tablet Bayer Advanced Aspirin Reg St aspirin oral tablet chewable Bayer Low Dose 15

19 aspirin oral tablet delayed release Aspir-Low aspirin rectal suppository childrens aspirin low strength oral tablet chewable Bayer Low Dose gnp adult aspirin low strength oral tablet chewable Bayer Low Dose gnp aspirin low dose oral tablet delayed release Aspir-Low gnp aspirin oral tablet Bayer Advanced Aspirin Reg St gnp aspirin oral tablet delayed release Aspir-Low goodsense aspirin oral tablet Bayer Advanced Aspirin Reg St goodsense aspirin oral tablet chewable Bayer Low Dose hm aspirin ec low dose oral tablet delayed release Aspir-Low hm aspirin ec oral tablet delayed release Bayer Aspirin Regimen hm aspirin oral tablet Bayer Advanced Aspirin Reg St hm aspirin oral tablet chewable Bayer Low Dose qc aspirin low dose oral tablet chewable Bayer Low Dose qc aspirin oral tablet Bayer Advanced Aspirin Reg St qc enteric aspirin oral tablet delayed release Bayer Aspirin Regimen salsalate oral tablet sb aspirin oral tablet Bayer Advanced Aspirin Reg St sm aspirin adult low strength oral tablet chewable Bayer Low Dose sm aspirin adult low strength oral tablet delayed release Aspir-Low sm aspirin ec oral tablet delayed release Bayer Aspirin Regimen sm aspirin low dose oral tablet chewable Bayer Low Dose sm aspirin oral tablet Bayer Advanced Aspirin Reg St sm childrens aspirin oral tablet chewable Bayer Low Dose ASPIR-LOW ORAL TABLET DELAYED RELEASE Aspir-Low ECPIRIN ORAL TABLET DELAYED RELEASE Bayer Aspirin Regimen ST JOSEPH LOW DOSE ORAL TABLET Bayer Low Dose CHEWABLE 16

20 *ANALGESICS - OPIOID* *Codeine Combinations*** acetaminophen-codeine #2 oral tablet QLL (12 EA per 1 day); AL (Min acetaminophen-codeine #3 oral tablet Tylenol with Codeine #3 QLL (12 EA per 1 day); AL (Min acetaminophen-codeine #4 oral tablet Tylenol with Codeine #4 QLL (12 EA per 1 day); AL (Min acetaminophen-codeine oral solution AL (Min 6 Years) acetaminophen-codeine oral tablet Tylenol with Codeine #4 QLL (12 EA per 1 day); AL (Min butalbital-apap-caff-cod oral capsule Auto-PA *Hydrocodone Combinations*** hydrocodone-acetaminophen oral solution hydrocodone-acetaminophen tablet mg Vicodin HP oral QLL (6 EA per 1 day) hydrocodone-acetaminophen tablet mg Lorcet HD oral hydrocodone-acetaminophen tablet mg oral Verdrocet hydrocodone-acetaminophen tablet mg oral Vicodin QLL (8 EA per 1 day) hydrocodone-acetaminophen tablet mg oral Lorcet hydrocodone-acetaminophen tablet mg oral Vicodin ES QLL (6 EA per 1 day) hydrocodone-acetaminophen tablet mg oral Lorcet Plus hydrocodone-ibuprofen oral tablet Ibudone NORCO ORAL TABLET Lorcet VICODIN ES ORAL TABLET Vicodin ES QLL (6 EA per 1 day) VICODIN HP ORAL TABLET Vicodin HP QLL (6 EA per 1 day) VICODIN ORAL TABLET Vicodin QLL (8 EA per 1 day) *Opioid Agonists*** codeine sulfate oral tablet AL (Min fentanyl transdermal patch 72 hour Duragesic-25 QLL (10 EA per 30 days); AL (Min 18 Years) hydromorphone hcl injection solution Dilaudid hydromorphone hcl oral tablet Dilaudid morphine sulfate (concentrate) oral solution morphine sulfate oral solution 17

21 morphine sulfate oral tablet oxycodone hcl oral solution QLL (60 ML per 1 day) oxycodone hcl tablet 10 mg oral QLL (6 EA per 1 day) oxycodone hcl tablet 15 mg oral Roxicodone QLL (6 EA per 1 day) oxycodone hcl tablet 20 mg oral QLL (9 EA per 1 day) oxycodone hcl tablet 30 mg oral Roxicodone QLL (6 EA per 1 day) oxycodone hcl tablet 5 mg oral Roxicodone QLL (12 EA per 1 day) tramadol hcl oral tablet Ultram QL: age 0-15: maximum 60 tablets/27 days; QLL (8 EA per 1 day); AL (Min ARYMO ER ORAL TABLET EXTENDED RELEASE ABUSE-DETERRENT EMBEDA ORAL CAPSULE EXTENDED RELEASE HYSINGLA ER ORAL TABLET ER 24 HOUR ABUSE-DETERRENT MORPHABOND ER ORAL TABLET ER 12 HOUR ABUSE-DETERRENT XTAMPZA ER ORAL CAPSULE ER 12 HOUR ABUSE-DETERRENT *Opioid Combinations*** oxycodone-acetaminophen tablet mg oral oxycodone-acetaminophen tablet mg oral oxycodone-acetaminophen tablet mg oral oxycodone-acetaminophen tablet mg oral *Opioid Partial Agonists*** buprenorphine hcl sublingual tablet sublingual buprenorphine transdermal patch weekly SUBLOCADE SUBCUTANEOUS SOLUTION PREFILLED SYRINGE SUBOXONE SUBLINGUAL FILM Endocet Endocet Endocet Endocet Butrans Auto-PA; QLL (1 EA per 1 day); AL (Min 18 Years) QLL (2 EA per 1 day); AL (Min 18 Years) Auto-PA; QLL (1 EA per 1 day); AL (Min 18 Years) Auto-PA; AL (Min 18 Years) Auto-PA; AL (Min 18 Years) QLL (6 EA per 1 day) QLL (12 EA per 1 day) QLL (12 EA per 1 day) QLL (8 EA per 1 day) PA; Maximum of 7 days of induction therapy every 60 days; QLL (3 EA per 1 day); AL (Min 16 Years) QLL (1 box per 28 days); AL (Min 18 Years) Auto-PA; QLL (300 MG per 30 days) PA; QLL (3 EA per 1 day); AL (Min 16 Years) 18

22 *ANDROGENS-ANABOLIC* *Androgens*** danazol oral capsule testosterone cypionate intramuscular solution Depo-Testosterone testosterone enanthate intramuscular solution ANDROGEL PUMP TRANSDERMAL GEL Testosterone PA; M; AL (Min 18 Years) ANDROGEL TRANSDERMAL GEL Testosterone PA; M; AL (Min 18 Years) *ANORECTAL AGENTS* *Intrarectal Steroids*** hydrocortisone rectal enema Colocort *Rectal Anesthetic/Steroids*** lidocaine-hydrocortisone ace rectal gel lidocaine-hydrocortisone ace rectal kit Ana-Lex PROCTOFOAM HC RECTAL FOAM *Rectal Steroids*** hydrocortisone rectal cream Procto-Pak ANUSOL-HC RECTAL CREAM Anusol-HC PROCTOSOL HC RECTAL CREAM Anusol-HC PROCTOZONE-HC RECTAL CREAM Anusol-HC *ANTACIDS* *Antacids - Bicarbonate*** sodium bicarbonate oral powder *Antacids - Calcium Salts*** antacid calcium oral tablet chewable Cal-Gest Antacid antacid extra strength oral tablet chewable Antacid Flavor Chews antacid oral tablet chewable Cal-Gest Antacid calcium antacid extra strength oral tablet chewable Antacid Flavor Chews calcium antacid oral tablet chewable Cal-Gest Antacid calcium antacid ultra max st oral tablet chewable Tums Ultra 1000 calcium antacid ultra strength oral tablet chewable Tums Ultra 1000 calcium carbonate antacid oral suspension calcium carbonate antacid oral tablet gnp antacid extra strength oral tablet chewable Antacid Flavor Chews 19

23 hm calcium antacid ex st oral tablet chewable Antacid Flavor Chews hm calcium antacid oral tablet chewable Antacid Flavor Chews hm calcium antacid ultra st oral tablet chewable Tums Ultra 1000 sm calcium antacid ex st oral tablet chewable Antacid Flavor Chews sm calcium antacid oral tablet chewable Cal-Gest Antacid sm calcium antacid ultra st oral tablet chewable Tums Ultra 1000 CAL-GEST ANTACID ORAL TABLET CHEWABLE Cal-Gest Antacid TUMS CHEWY DELIGHTS ORAL TABLET CHEWABLE Antacid Soft Chews TUMS E-X 750 ORAL TABLET CHEWABLE Antacid Flavor Chews TUMS EXTRA STRENGTH 750 ORAL TABLET CHEWABLE Antacid Flavor Chews TUMS KIDS ORAL TABLET CHEWABLE Antacid Flavor Chews TUMS ORAL TABLET CHEWABLE Cal-Gest Antacid TUMS SMOOTHIES ORAL TABLET CHEWABLE Antacid Flavor Chews TUMS ULTRA 1000 ORAL TABLET CHEWABLE Tums Ultra 1000 *ANTHELMINTICS* *Anthelmintics*** albendazole oral tablet Albenza ivermectin oral tablet Stromectol praziquantel oral tablet Biltricide ALBENZA ORAL TABLET Albenza QLL (4 EA per 30 days) *ANTIANGINAL AGENTS* *Antianginals-Other*** RANEXA ORAL TABLET EXTENDED RELEASE 12 HOUR *Nitrates*** isosorbide dinitrate oral tablet isosorbide mononitrate er oral tablet extended release 24 hour isosorbide mononitrate oral tablet nitroglycerin sublingual tablet sublingual Nitrostat Maintenance drugs with max 100 day supply; QLL (16 EA per 1 day) 20

24 nitroglycerin transdermal patch 24 hour Minitran QLL (1 EA per 1 day) NITROSTAT SUBLINGUAL TABLET SUBLINGUAL Nitrostat *ANTIANXIETY AGENTS* *Antianxiety Agents - Misc.*** buspirone hcl oral tablet droperidol injection solution AL (Min 18 Years) hydroxyzine hcl intramuscular solution hydroxyzine hcl oral syrup hydroxyzine hcl oral tablet hydroxyzine pamoate oral capsule Vistaril *Benzodiazepines*** alprazolam tablet 0.25 mg oral Xanax QLL (5 EA per 1 day); AL (Min 7 Years) alprazolam tablet 0.5 mg oral Xanax QLL (5 EA per 1 day); AL (Min 7 Years) alprazolam tablet 0.5 mg oral Xanax QLL (5 EA per 28 days); AL (Min 7 Years) alprazolam tablet 1 mg oral Xanax QLL (5 EA per 28 days); AL (Min 7 Years) alprazolam tablet 2 mg oral Xanax QLL (5 EA per 28 days); AL (Min 7 Years) chlordiazepoxide hcl oral capsule QLL (4 EA per 1 day); AL (Min 6 Years) clorazepate dipotassium oral tablet QLL (4 EA per 1 day); AL (Min 9 Years) diazepam oral solution QLL (40 ML per 1 day) diazepam oral tablet Valium QLL (4 EA per 1 day) lorazepam injection solution Ativan lorazepam oral concentrate LORazepam Intensol QLL (5 ML per 1 day) lorazepam oral tablet Ativan QLL (5 EA per 1 day) oxazepam oral capsule QLL (4 EA per 1 day); AL (Min 6 Years) LORAZEPAM INTENSOL ORAL CONCENTRATE LORazepam Intensol QLL (5 ML per 1 day) *ANTIARRHYTHMICS* *Antiarrhythmics Type I-A*** disopyramide phosphate oral capsule Norpace quinidine gluconate er oral tablet extended release 21

25 quinidine sulfate oral tablet *Antiarrhythmics Type I-B*** mexiletine hcl oral capsule *Antiarrhythmics Type I-C*** flecainide acetate oral tablet propafenone hcl er oral capsule extended release 12 hour propafenone hcl oral tablet *Antiarrhythmics Type Iii*** amiodarone hcl oral tablet TIKOSYN ORAL CAPSULE *ANTIASTHMATIC AND BRONCHODILATOR AGENTS* *Adrenergic Combinations*** ipratropium-albuterol inhalation solution ADVAIR DISKUS INHALATION AEROSOL POWDER BREATH ACTIVATED ADVAIR HFA INHALATION AEROSOL BEVESPI AEROSPHERE INHALATION AEROSOL DULERA INHALATION AEROSOL STIOLTO RESPIMAT INHALATION AEROSOL SOLUTION SYMBICORT INHALATION AEROSOL UTIBRON NEOHALER INHALATION CAPSULE *Anti-Inflammatory Agents*** cromolyn sodium inhalation nebulization solution *Beta Adrenergics*** albuterol sulfate nebulization solution (2.5 mg/3ml) 0.083% inhalation albuterol sulfate nebulization solution (5 mg/ml) 0.5% inhalation Rythmol SR Pacerone Dofetilide Maintenance drug with max 100 days supply Maintenance drugs with max 100 day supply Maintenance drug with max 100 days supply QLL (1 EA per 30 days); AL (Min 4 Years) QLL (1 GM per 30 days); AL (Min 5 Years) QLL (13 UNITS per 1 Fill); AL (Min QLL (1 INHALER per 30 days); AL (Min 5 Years) QLL (375 ML per 30 days) 22

26 albuterol sulfate nebulization solution 0.63 mg/3ml inhalation albuterol sulfate nebulization solution 1.25 mg/3ml inhalation albuterol sulfate oral syrup terbutaline sulfate injection solution PROAIR HFA INHALATION AEROSOL SOLUTION PROVENTIL HFA INHALATION AEROSOL SOLUTION SEREVENT DISKUS INHALATION AEROSOL POWDER BREATH ACTIVATED *Bronchodilators - Anticholinergics*** ipratropium bromide inhalation solution ATROVENT HFA INHALATION AEROSOL SOLUTION SPIRIVA HANDIHALER INHALATION CAPSULE *Leukotriene Receptor Antagonists*** QLL (375 ML per 30 days) QLL (375 ML per 30 days) QLL (2 INHALERS per 30 days) QLL (2 INHALERS per 30 days) QLL (1 INHALER per 30 days); AL (Min 4 Years) QLL (25.8 GM per 30 days) 18 Years) montelukast sodium oral packet Singulair ST; AL (Min 5 Years) montelukast sodium oral tablet chewable Singulair QLL (1 EA per 1 day) montelukast sodium tablet 10 mg oral Singulair montelukast sodium tablet 10 mg oral Singulair QLL (1 EA per 1 day) SINGULAIR ORAL PACKET Singulair ST; AL (Max 4 Years) *Steroid Inhalants*** budesonide inhalation suspension Pulmicort QLL (120 ML per 30 days); AL (Min 1 Years and Max 8 Years) ASMANEX 120 METERED DOSES INHALATION AEROSOL POWDER BREATH ACTIVATED ASMANEX 14 METERED DOSES INHALATION AEROSOL POWDER BREATH ACTIVATED ASMANEX 30 METERED DOSES INHALATION AEROSOL POWDER BREATH ACTIVATED ASMANEX 60 METERED DOSES INHALATION AEROSOL POWDER BREATH ACTIVATED QLL (1 EA per 30 days); AL (Min 4 Years) QLL (1 EA per 30 days); AL (Min 4 Years) QLL (1 EA per 30 days); AL (Min 4 Years) QLL (1 EA per 30 days); AL (Min 4 Years) 23

27 FLOVENT DISKUS INHALATION AEROSOL POWDER BREATH ACTIVATED FLOVENT HFA AEROSOL 110 MCG/ACT INHALATION FLOVENT HFA AEROSOL 220 MCG/ACT INHALATION FLOVENT HFA AEROSOL 44 MCG/ACT INHALATION *Xanthines*** theophylline er oral tablet extended release 12 hour theophylline er oral tablet extended release 24 hour theophylline oral solution ELIXOPHYLLIN ORAL ELIXIR THEO-24 ORAL CAPSULE EXTENDED RELEASE 24 HOUR *ANTICOAGULANTS* *Coumarin Anticoagulants*** Theochron QLL (2 INHALER per 30 days); AL (Min 4 Years) QLL (24 GM per 30 days) QLL (24 GM per 30 days) QLL (21.2 GM per 30 days) warfarin sodium tablet 1 mg oral Coumadin QLL (4 EA per 1 day) warfarin sodium tablet 10 mg oral Coumadin QLL (4 EA per 1 day) warfarin sodium tablet 2 mg oral Coumadin QLL (4 EA per 1 day) warfarin sodium tablet 2.5 mg oral Coumadin QLL (4 EA per 1 day) warfarin sodium tablet 3 mg oral Coumadin QLL (4 EA per 1 day) warfarin sodium tablet 4 mg oral Coumadin QLL (4 EA per 1 day) warfarin sodium tablet 5 mg oral Coumadin QLL (4 EA per 1 day) warfarin sodium tablet 6 mg oral Coumadin QLL (4 EA per 1 day) warfarin sodium tablet 7.5 mg oral Coumadin warfarin sodium tablet 7.5 mg oral Coumadin QLL (4 EA per 1 day) COUMADIN ORAL TABLET Coumadin QLL (4 EA per 1 day) JANTOVEN ORAL TABLET Coumadin QLL (120 EA per 30 days) *Direct Factor Xa Inhibitors*** ELIQUIS STARTER PACK ORAL TABLET AL (Min 18 Years) ELIQUIS TABLET 2.5 MG ORAL QLL (2 EA per 1 day); AL (Min 18 Years) ELIQUIS TABLET 5 MG ORAL QLL (4 EA per 1 day); AL (Min 18 Years) SAVAYSA ORAL TABLET 18 Years) 24

28 XARELTO ORAL TABLET AL (Min 18 Years) *Heparins And Heparinoid-Like Agents*** heparin (porcine) in d5w intravenous solution heparin (porcine) in nacl injection solution heparin (porcine) in nacl intravenous solution heparin lock flush intravenous solution heparin sod (porcine) in d5w intravenous solution heparin sodium (porcine) injection solution heparin sodium (porcine) pf injection solution *Low Molecular Weight Heparins*** enoxaparin sodium injection solution Lovenox QLL (180 ML per 30 days) enoxaparin sodium solution 100 mg/ml subcutaneous Lovenox QLL (60 ML per 30 days) enoxaparin sodium solution 120 mg/0.8ml subcutaneous Lovenox QLL (48 ML per 30 days) enoxaparin sodium solution 150 mg/ml subcutaneous Lovenox QLL (60 ML per 30 days) enoxaparin sodium solution 30 mg/0.3ml subcutaneous Lovenox QLL (18 ML per 30 days) enoxaparin sodium solution 40 mg/0.4ml subcutaneous Lovenox QLL (24 ML per 30 days) enoxaparin sodium solution 60 mg/0.6ml subcutaneous Lovenox QLL (36 ML per 30 days) enoxaparin sodium solution 80 mg/0.8ml subcutaneous Lovenox QLL (48 ML per 30 days) *Thrombin Inhibitors - Selective Direct & Reversible*** PRADAXA ORAL CAPSULE AL (Min 18 Years) *ANTICONVULSANTS* *Ampa Glutamate Receptor Antagonists*** FYCOMPA ORAL SUSPENSION Auto-PA FYCOMPA ORAL TABLET Auto-PA; AL (Min *Anticonvulsants - Benzodiazepines*** clobazam oral suspension Onfi AL (Min 2 Years) clobazam oral tablet Onfi AL (Min 2 Years) clonazepam oral tablet KlonoPIN QLL (3 EA per 1 day) 25

29 clonazepam oral tablet dispersible diazepam rectal gel Diastat AcuDial QLL (2 KITS per 30 days); AL (Min 18 Years) KLONOPIN ORAL TABLET KlonoPIN QLL (3 EA per 1 day) ONFI ORAL SUSPENSION Onfi Auto-PA ONFI ORAL TABLET Onfi Auto-PA; AL (Min 2 Years) *Anticonvulsants - Misc.*** carbamazepine er oral capsule extended release 12 hour Carbatrol carbamazepine er oral tablet extended release TEGretol-XR 12 hour carbamazepine oral suspension TEGretol carbamazepine oral tablet Epitol carbamazepine oral tablet chewable gabapentin oral capsule Neurontin gabapentin oral solution Neurontin gabapentin oral tablet Neurontin lamotrigine er oral tablet extended release 24 hour LaMICtal XR AL (Min 13 Years) lamotrigine oral tablet LaMICtal lamotrigine oral tablet chewable LaMICtal lamotrigine oral tablet dispersible LaMICtal ODT lamotrigine starter kit-blue oral kit LaMICtal Starter QLL (35 EA per 30 days) lamotrigine starter kit-green oral kit LaMICtal Starter QLL (98 EA per 30 days) lamotrigine starter kit-orange oral kit LaMICtal Starter QLL (49 EA per 30 days) levetiracetam er oral tablet extended release 24 hour Keppra XR levetiracetam intravenous solution Keppra levetiracetam oral solution Keppra levetiracetam oral tablet Keppra oxcarbazepine oral suspension Trileptal oxcarbazepine oral tablet Trileptal primidone oral tablet Mysoline topiramate er oral capsule er 24 hour sprinkle Qudexy XR AL (Min 6 Years) topiramate oral capsule sprinkle Topamax Sprinkle topiramate oral tablet Topamax zonisamide oral capsule Zonegran APTIOM ORAL TABLET Auto-PA; AL (Min 4 Years) BANZEL ORAL SUSPENSION Auto-PA; AL (Min 1 Years) 26

30 BANZEL ORAL TABLET BRIVIACT INTRAVENOUS SOLUTION BRIVIACT ORAL SOLUTION BRIVIACT ORAL TABLET Auto-PA; AL (Min 1 Years) Auto-PA; AL (Min 16 Years) Auto-PA; AL (Min 4 Years) Auto-PA; AL (Min 4 Years) CARBATROL ORAL CAPSULE EXTENDED RELEASE 12 HOUR Carbatrol Auto-PA EPITOL ORAL TABLET Epitol Auto-PA KEPPRA ORAL SOLUTION Keppra KEPPRA ORAL TABLET Keppra KEPPRA XR ORAL TABLET EXTENDED RELEASE 24 HOUR Keppra XR LAMICTAL ODT KIT 25 & 50 & 100 MG ORAL QLL (35 EA per 30 days) LAMICTAL ODT KIT 25 (21)-50 (7) MG ORAL QLL (28 EA per 30 days) LAMICTAL ODT KIT 50 (42)-100(14) MG ORAL QLL (56 EA per 30 days) LAMICTAL ODT ORAL TABLET DISPERSIBLE LaMICtal ODT LAMICTAL ORAL TABLET LaMICtal LAMICTAL ORAL TABLET CHEWABLE LaMICtal LAMICTAL STARTER ORAL KIT LaMICtal Starter LAMICTAL XR KIT 25 & 50 & 100 MG ORAL LAMICTAL XR KIT 25 (21)-50 (7) MG ORAL LAMICTAL XR KIT 50 & 100 & 200 MG ORAL LAMICTAL XR ORAL TABLET EXTENDED RELEASE 24 HOUR LYRICA CAPSULE 100 MG ORAL LYRICA CAPSULE 150 MG ORAL LYRICA CAPSULE 200 MG ORAL LYRICA CAPSULE 225 MG ORAL LYRICA CAPSULE 25 MG ORAL LYRICA CAPSULE 300 MG ORAL LYRICA CAPSULE 50 MG ORAL LYRICA CAPSULE 75 MG ORAL MYSOLINE ORAL TABLET NEURONTIN ORAL CAPSULE LaMICtal XR Mysoline Neurontin QLL (35 EA per 30 days); AL (Min 13 Years) QLL (28 EA per 30 days); AL (Min 13 Years) QLL (35 EA per 30 days); AL (Min 13 Years) AL (Min 13 Years) QLL (180 EA per 30 days) QLL (120 EA per 30 days) QLL (90 EA per 30 days) QLL (60 EA per 30 days) QLL (720 EA per 30 days) QLL (60 EA per 30 days) QLL (360 EA per 30 days) QLL (240 EA per 30 days) 27

31 NEURONTIN ORAL SOLUTION NEURONTIN ORAL TABLET OXTELLAR XR ORAL TABLET EXTENDED RELEASE 24 HOUR QUDEXY XR ORAL CAPSULE ER 24 HOUR SPRINKLE ROWEEPRA ORAL TABLET ROWEEPRA XR ORAL TABLET EXTENDED RELEASE 24 HOUR SPRITAM ORAL TABLET DISINTEGRATING SOLUBLE SUBVENITE ORAL TABLET SUBVENITE STARTER KIT-BLUE ORAL KIT SUBVENITE STARTER KIT-GREEN ORAL KIT SUBVENITE STARTER KIT-ORANGE ORAL KIT TEGRETOL ORAL SUSPENSION TEGRETOL ORAL TABLET TEGRETOL-XR ORAL TABLET EXTENDED RELEASE 12 HOUR TOPAMAX ORAL TABLET TOPAMAX SPRINKLE ORAL CAPSULE SPRINKLE TRILEPTAL ORAL SUSPENSION TRILEPTAL ORAL TABLET TROKENDI XR ORAL CAPSULE EXTENDED RELEASE 24 HOUR Neurontin Neurontin Qudexy XR Keppra Keppra XR LaMICtal LaMICtal Starter LaMICtal Starter LaMICtal Starter TEGretol Epitol TEGretol-XR Topamax Topamax Sprinkle Trileptal Trileptal AL (Min 6 Years) AL (Min 6 Years) VIMPAT ORAL SOLUTION Auto-PA; QLL (40 ML per 1 day) VIMPAT ORAL TABLET Auto-PA; QLL (2 EA per 1 day) ZONEGRAN ORAL CAPSULE Zonegran *Carbamates*** felbamate oral suspension Felbatol felbamate oral tablet Felbatol FELBATOL ORAL SUSPENSION Felbatol Auto-PA FELBATOL ORAL TABLET Felbatol Auto-PA *Gaba Modulators*** tiagabine hcl oral tablet Gabitril vigabatrin oral packet Sabril PA 28

32 GABITRIL ORAL TABLET Gabitril Auto-PA SABRIL ORAL PACKET Sabril Auto-PA SABRIL ORAL TABLET VIGADRONE ORAL PACKET *Hydantoins*** phenytoin oral suspension phenytoin oral tablet chewable phenytoin sodium extended oral capsule Sabril Dilantin Dilantin Infatabs Dilantin Auto-PA DILANTIN CAPSULE 100 MG ORAL Dilantin Auto-PA DILANTIN CAPSULE 30 MG ORAL DILANTIN ORAL SUSPENSION Dilantin Auto-PA PEGANONE ORAL TABLET Auto-PA PHENYTEK ORAL CAPSULE Phenytek Auto-PA PHENYTOIN INFATABS ORAL TABLET Dilantin Infatabs CHEWABLE *Succinimides*** ethosuximide oral capsule Zarontin ethosuximide oral solution Zarontin CELONTIN ORAL CAPSULE Auto-PA ZARONTIN ORAL CAPSULE Zarontin Auto-PA ZARONTIN ORAL SOLUTION Zarontin Auto-PA *Valproic Acid*** divalproex sodium er tablet extended release 24 hour 250 mg oral Depakote ER divalproex sodium er tablet extended release 24 hour 500 mg oral Depakote ER divalproex sodium er tablet extended release 24 hour 500 mg oral Depakote ER PA divalproex sodium oral capsule delayed release sprinkle Depakote Sprinkles divalproex sodium oral tablet delayed release Depakote valproate sodium oral solution Depakene valproic acid oral capsule Depakene valproic acid oral solution Depakene DEPAKENE ORAL CAPSULE Depakene Auto-PA DEPAKENE ORAL SOLUTION Depakene Auto-PA DEPAKOTE ER ORAL TABLET EXTENDED RELEASE 24 HOUR Depakote ER Auto-PA 29

33 DEPAKOTE ORAL TABLET DELAYED RELEASE Depakote Auto-PA DEPAKOTE SPRINKLES ORAL CAPSULE DELAYED RELEASE Depakote Sprinkles Auto-PA SPRINKLE *ANTIDEPRESSANTS* *Alpha-2 Receptor Antagonists (Tetracyclics)*** mirtazapine oral tablet AL (Min 6 Years) mirtazapine oral tablet dispersible Remeron SolTab AL (Min 6 Years) *Antidepressants - Misc.*** bupropion hcl er (sr) oral tablet extended release 12 hour bupropion hcl er (xl) tablet extended release 24 hour 150 mg oral bupropion hcl er (xl) tablet extended release 24 hour 300 mg oral bupropion hcl er (xl) tablet extended release 24 hour 300 mg oral bupropion hcl er (xl) tablet extended release 24 hour 450 mg oral bupropion hcl oral tablet *Modified Cyclics*** trazodone hcl oral tablet TRINTELLIX ORAL TABLET VIIBRYD ORAL TABLET *Selective Serotonin Reuptake Inhibitors (Ssris)*** Wellbutrin SR Wellbutrin XL Wellbutrin XL Wellbutrin XL Forfivo XL QLL (2 EA per 1 day); AL (Min 6 Years) 6 Years) 6 Years) AL (Min 18 Years) AL (Min 6 Years) AL (Min 6 Years) Auto-PA; QLL (1 EA per 1 day); AL (Min 18 Years) AL (Min 18 Years) QLL (30 ML per 1 day); AL citalopram hydrobromide oral solution (Min 6 Years and Max 11 Years) citalopram hydrobromide tablet 10 mg oral CeleXA 6 Years) citalopram hydrobromide tablet 20 mg oral CeleXA QLL (1.5 EA per 1 day); AL (Min 6 Years) citalopram hydrobromide tablet 40 mg oral CeleXA 6 Years) escitalopram oxalate oral tablet Lexapro 6 Years) fluoxetine hcl oral capsule PROzac AL (Min 6 Years) 30

34 fluoxetine hcl oral solution AL (Min 6 Years and Max 11 Years) fluvoxamine maleate oral tablet AL (Min 6 Years) paroxetine hcl oral tablet Paxil QLL (2 EA per 1 day); AL (Min 6 Years) sertraline hcl oral concentrate QLL (10 ML per 1 day); AL (Min 6 Years and Max 11 Years) sertraline hcl oral tablet Zoloft AL (Min 6 Years) *Serotonin-Norepinephrine Reuptake Inhibitors (Snris)*** desvenlafaxine succinate er oral tablet extended release 24 hour duloxetine hcl oral capsule delayed release particles venlafaxine hcl er oral capsule extended release 24 hour venlafaxine hcl oral tablet *Tricyclic Agents*** amitriptyline hcl oral tablet amoxapine oral tablet Pristiq Cymbalta Effexor XR 18 Years) QLL (2 EA per 1 day); AL (Min 6 Years) 6 Years) AL (Min 6 Years) AL (Min AL (Min 16 Years) clomipramine hcl oral capsule Anafranil Auto-PA; AL (Min 6 Years) desipramine hcl oral tablet AL (Min 13 Years) doxepin hcl oral capsule AL (Min doxepin hcl oral concentrate AL (Min imipramine hcl oral tablet Tofranil AL (Min 6 Years) nortriptyline hcl oral capsule Pamelor AL (Min 13 Years) nortriptyline hcl oral solution AL (Min 13 Years) *ANTIDIABETICS* *Alpha-Glucosidase Inhibitors*** acarbose oral tablet Precose miglitol oral tablet Glyset *Antidiabetic - Amylin Analogs*** SYMLINPEN 120 SUBCUTANEOUS SOLUTION PEN-INJECTOR SYMLINPEN 60 SUBCUTANEOUS SOLUTION PEN-INJECTOR 31

35 *Biguanides*** metformin hcl er oral tablet extended release 24 hour 500 mg metformin hcl er oral tablet extended release 24 hour 750 mg metformin hcl er tablet extended release 24 hour 500 mg oral metformin hcl er tablet extended release 24 hour 750 mg oral metformin hcl tablet 1000 mg oral metformin hcl tablet 1000 mg oral metformin hcl tablet 500 mg oral metformin hcl tablet 850 mg oral metformin hcl tablet 850 mg oral *Diabetic Other*** GLUCAGEN HYPOKIT INJECTION SOLUTION RECONSTITUTED GLUCAGON EMERGENCY INJECTION KIT PROGLYCEM ORAL SUSPENSION *Dipeptidyl Peptidase-4 (Dpp-4) Inhibitors*** alogliptin benzoate oral tablet JANUVIA ORAL TABLET ONGLYZA ORAL TABLET TRADJENTA ORAL TABLET Glucophage XR Glucophage XR Glucophage XR Glucophage XR Glucophage Glucophage Glucophage Glucophage Glucophage Nesina Maintenance drug with max 100 days supply; QLL (5 EA per 1 day) Maintenance drug with max 100 days supply; QLL (3.5 EA per 1 day) Maintenance drug with max 100 days supply; QLL (5 EA per 1 day) Maintenance drug with max 100 days supply; QLL (3.5 EA per 1 day) Maintenance drug with max 100 days supply; QLL (2.5 EA per 1 day) Maintenance drug with max 100 days supply; QLL (5 EA per 1 day) Maintenance drug with max 100 days supply Maintenance drug with max 100 days supply; QLL (3 EA per 1 day) 18 Years) 18 Years) 18 Years) 18 Years) 32

36 *Dipeptidyl Peptidase-4 Inhibitor- Biguanide Combinations*** alogliptin-metformin hcl oral tablet JANUMET ORAL TABLET JANUMET XR TABLET EXTENDED RELEASE 24 HOUR MG ORAL JANUMET XR TABLET EXTENDED RELEASE 24 HOUR MG ORAL JANUMET XR TABLET EXTENDED RELEASE 24 HOUR MG ORAL JENTADUETO ORAL TABLET KOMBIGLYZE XR TABLET EXTENDED RELEASE 24 HOUR MG ORAL KOMBIGLYZE XR TABLET EXTENDED RELEASE 24 HOUR MG ORAL KOMBIGLYZE XR TABLET EXTENDED RELEASE 24 HOUR MG ORAL *Dpp-4 Inhibitor-Thiazolidinedione Combinations*** alogliptin-pioglitazone oral tablet *Human Insulin*** ADMELOG SOLOSTAR SUBCUTANEOUS SOLUTION PEN- INJECTOR ADMELOG SUBCUTANEOUS SOLUTION BASAGLAR KWIKPEN SUBCUTANEOUS SOLUTION PEN- INJECTOR HUMALOG KWIKPEN SOLUTION PEN- INJECTOR 100 UNIT/ML SUBCUTANEOUS HUMALOG KWIKPEN SOLUTION PEN- INJECTOR 100 UNIT/ML SUBCUTANEOUS Kazano Oseni QLL (60 EA per 30 days); AL (Min 18 Years) QLL (2 EA per 1 day); AL (Min 18 Years) 18 Years) QLL (2 EA per 1 day); AL (Min 18 Years) QLL (2 EA per 1 day); AL (Min 18 Years) QLL (2 EA per 1 day); AL (Min 18 Years) AL (Min 18 Years) AL (Min 18 Years) AL (Min 18 Years) QLL (30 EA per 30 days); AL (Min 18 Years) QLL (2 BOXES per 30 days); AL (Max 18 Years) QLL (70 ML per 30 days) QLL (2 BOXES per 30 days) ST; QLL (2 BOXES per 30 days) 33