Your Guide to Prescription Drug Benefits

Transcription

1 Your Guide to Prescription Drug Benefits 206 Essential Formulary with Preventive Drug Copays Applies to the following Small Group plans: BlueCross SG Bronze BlueCross SG Silver 23 BlueCross SG Silver 25 BlueCross SG Silver 28 BlueCross SG Gold 24 BlueCross SG Gold 25 BlueCross SG Gold 26

2 CURRENT AS OF 8//206 Table of Contents Abbreviations and Key to Drug Tiers..-2 Drug Classes: ANTI - INFECTIVES... 3 ANTINEOPLASTIC & IMMUNOSUPPRESSANT DRUGS... 3 AUTONOMIC & CNS DRUGS, NEUROLOGY & PSYCH... 7 CARDIOVASCULAR, HYPERTENSION & LIPIDS DERMATOLOGICALS/TOPICAL THERAPY DIAGNOSTICS & MISCELLANEOUS AGENTS EAR, NOSE & THROAT MEDICATIONS... 7 ENDOCRINE/DIABETES GASTROENTEROLOGY IMMUNOLOGY, VACCINES & BIOTECHNOLOGY MUSCULOSKELETAL & RHEUMATOLOGY OBSTETRICS & GYNECOLOGY OPHTHALMOLOGY... 2 RESPIRATORY, ALLERGY, COUGH & COLD... 9 UROLOGICALS VITAMINS, HEMATINICS & ELECTROLYTES Index... 42

3 List of Abbreviations #: Some plans do not cover these medications. Check with BlueCross BlueShield of Tennessee Member Services to determine coverage at the phone number listed on your BlueCross BlueShield of Tennessee member ID card. ACA: Affordable Care Act AGE-A: Age edit is applicable. Prior authorization is required for members 7 years of age and younger. Your network provider must call Express Scripts at to request a coverage review. AGE-B: Age edit is applicable. Prior authorization is required for males 30 years of age and younger; prior authorization is required for all females. Your network physician must call Express Scripts at to request a coverage review. GEN: Only applies to two and three tiered plans with flat copays under the retail benefit. The brand name drug will process at the generic copay tier. The brand name drug s generic equivalent is a non-covered drug. If your plan has a coinsurance or percentage benefit for drugs, the brand name drug will be covered at the assigned brand copay and the generic equivalent will be a covered benefit. LD: Limited Distribution. This medication may be available only at certain pharmacies. For more information, please call BlueCross BlueShield Member Services at the phone number listed on your BlueCross BlueShield of Tennessee member ID card. OTC: Over the Counter. An OTC drug is a medication that can be purchased without a prescription from your physician. PA: Prior Authorization. The plan requires your physician to obtain prior authorization for certain drugs. This means that you will need to get approval before you may fill your prescription. Your network provider must call Express Scripts at to request a coverage review for a drug that requires prior authorization. QL: Quantity Limit. For certain drugs, the plan limits the amount of the drug that will be covered. Please visit the following link for additional details regarding quantity limits: SPRx: Product is on the Specialty Drug List. Please visit the following link for additional details regarding the Specialty Drug List: ST: Step Therapy. In some cases, your plan requires you to first try certain drugs to treat your medical condition before we will cover another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, we may not cover Drug B unless you try Drug A first. If Drug A does not work for you, we will then cover Drug B. Your network provider must call Express Scripts at to request a coverage review. Please visit the following link for additional details regarding the Step Therapy list:

4 Drug Tier Key Tier : Generic or Brand Non-Specialty Drugs with deductible/coinsurance Tier 2: Drugs with $0 Cost Share per Affordable Care Act (ACA) and U.S. Preventive Services Task Force Recommendations Tier 3: Generic Drugs with a copay based on BlueCross preventive drug list Tier 4: Preferred Brand Drugs with a copay based on BlueCross preventive drug list Tier 5: Non-Preferred Brand Drugs with a copay based on BlueCross preventive drug list Tier 6: Specialty Drugs with deductible/coinsurance Pharmacy Appeals: To appeal a denial based on the Prior Authorization criteria or to request a medical exception to the quantity limit, please FAX a written request to: Pharmacy Management Appeals BlueCross BlueShield of Tennessee Cameron Hill Circle Chattanooga, TN Fax: Please provide the following information with your written request:. Patient name and cardholder ID number 2. Physician name and phone number 3. Drug and diagnosis information 2

5 ANTI - INFECTIVES ANTIFUNGAL AGENTS ANCOBON ORAL CAPSULE clotrimazole mucous membrane troche CRESEMBA ORAL CAPSULE DIFLUCAN ORAL SUSPENSION FOR RECONSTITUTION DIFLUCAN ORAL TABLET fluconazole oral suspension for reconstitution fluconazole oral tablet flucytosine oral capsule griseofulvin microsize oral suspension griseofulvin microsize oral tablet griseofulvin ultramicrosize oral tablet GRIS-PEG (ULTRAMICROSIZE) ORAL TABLET itraconazole oral capsule ketoconazole oral tablet NOXAFIL ORAL SUSPENSION NOXAFIL ORAL TABLET,DELAYED RELEASE (DR/EC) nystatin oral powder nystatin oral suspension nystatin oral tablet ONMEL ORAL TABLET ORAVIG BUCCAL MUCO-ADHESIVE BUCCAL TABLET SPORANOX ORAL SOLUTION SPORANOX PULSEPAK ORAL CAPSULE terbinafine hcl oral tablet VFEND ORAL SUSPENSION FOR RECONSTITUTION VFEND ORAL TABLET voriconazole oral suspension for reconstitution 3

6 voriconazole oral tablet ANTIVIRALS abacavir oral tablet abacavir-lamivudine-zidovudine oral tablet acyclovir oral capsule acyclovir oral suspension acyclovir oral tablet adefovir oral tablet amantadine hcl oral capsule amantadine hcl oral solution amantadine hcl oral tablet APTIVUS ORAL CAPSULE APTIVUS ORAL SOLUTION ATRIPLA ORAL TABLET 6 SPRx BARACLUDE ORAL SOLUTION BARACLUDE ORAL TABLET COMBIVIR ORAL TABLET COMPLERA ORAL TABLET 6 SPRx CRIXIVAN ORAL CAPSULE didanosine oral capsule,delayed release(dr/ec) EDURANT ORAL TABLET EMTRIVA ORAL CAPSULE EMTRIVA ORAL SOLUTION entecavir oral tablet EPIVIR HBV ORAL SOLUTION EPIVIR HBV ORAL TABLET EPIVIR ORAL SOLUTION EPIVIR ORAL TABLET EPZICOM ORAL TABLET EVOTAZ ORAL TABLET 6 SPRx famciclovir oral tablet FAMVIR ORAL TABLET FLUMADINE ORAL TABLET 4

7 FUZEON SUBCUTANEOUS RECON SOLN 6 SPRx GENVOYA ORAL TABLET 6 SPRx HARVONI ORAL TABLET 6 PA; SPRx HEPSERA ORAL TABLET INTELENCE ORAL TABLET INVIRASE ORAL CAPSULE INVIRASE ORAL TABLET ISENTRESS ORAL POWDER IN PACKET ISENTRESS ORAL TABLET ISENTRESS ORAL TABLET,CHEWABLE KALETRA ORAL SOLUTION KALETRA ORAL TABLET lamivudine oral solution lamivudine oral tablet lamivudine-zidovudine oral tablet LEXIVA ORAL SUSPENSION LEXIVA ORAL TABLET nevirapine oral suspension nevirapine oral tablet nevirapine oral tablet extended release 24 hr NORVIR ORAL CAPSULE NORVIR ORAL SOLUTION NORVIR ORAL TABLET ODEFSEY ORAL TABLET 6 SPRx PREZCOBIX ORAL TABLET 6 SPRx PREZISTA ORAL SUSPENSION PREZISTA ORAL TABLET RELENZA DISKHALER INHALATION BLISTER WITH DEVICE RESCRIPTOR ORAL TABLET RESCRIPTOR ORAL TABLET, DISPERSIBLE RETROVIR ORAL CAPSULE REYATAZ ORAL CAPSULE QL (20 per 80 days) 5

8 REYATAZ ORAL POWDER IN PACKET rimantadine oral tablet SELZENTRY ORAL TABLET SOVALDI ORAL TABLET 6 PA; SPRx stavudine oral capsule stavudine oral recon soln STRIBILD ORAL TABLET 6 SPRx SUSTIVA ORAL CAPSULE SUSTIVA ORAL TABLET TAMIFLU ORAL CAPSULE 30 MG QL (20 per 80 days) TAMIFLU ORAL CAPSULE 45 MG, 75 MG QL (0 per 80 days) TAMIFLU ORAL SUSPENSION FOR RECONSTITUTION 6 QL (80 per 80 days) TIVICAY ORAL TABLET 6 SPRx TRIUMEQ ORAL TABLET 6 SPRx TRIZIVIR ORAL TABLET TRUVADA ORAL TABLET TYBOST ORAL TABLET TYZEKA ORAL TABLET valacyclovir oral tablet VALCYTE ORAL RECON SOLN VALCYTE ORAL TABLET valganciclovir oral tablet VALTREX ORAL TABLET VIDEX 2 GRAM PEDIATRIC ORAL RECON SOLN VIDEX EC ORAL CAPSULE,DELAYED RELEASE(DR/EC) VIRACEPT ORAL TABLET VIRAMUNE ORAL SUSPENSION VIRAMUNE ORAL TABLET VIRAMUNE XR ORAL TABLET EXTENDED RELEASE 24 HR VIRAZOLE INHALATION RECON SOLN

9 VIREAD ORAL POWDER VIREAD ORAL TABLET VITEKTA ORAL TABLET 6 SPRx ZERIT ORAL CAPSULE ZERIT ORAL RECON SOLN ZIAGEN ORAL SOLUTION ZIAGEN ORAL TABLET zidovudine oral capsule zidovudine oral syrup zidovudine oral tablet ZOVIRAX ORAL CAPSULE ZOVIRAX ORAL SUSPENSION ZOVIRAX ORAL TABLET CEPHALOSPORINS CEDAX ORAL CAPSULE CEDAX ORAL SUSPENSION FOR RECONSTITUTION cefaclor oral capsule cefaclor oral suspension for reconstitution cefaclor oral tablet extended release 2 hr cefadroxil oral capsule cefadroxil oral suspension for reconstitution cefadroxil oral tablet cefdinir oral capsule cefdinir oral suspension for reconstitution cefditoren pivoxil oral tablet cefixime oral suspension for reconstitution cefpodoxime oral suspension for reconstitution cefpodoxime oral tablet cefprozil oral suspension for reconstitution cefprozil oral tablet ceftibuten oral capsule ceftibuten oral suspension for reconstitution 7

10 CEFTIN ORAL SUSPENSION FOR RECONSTITUTION CEFTIN ORAL TABLET cefuroxime axetil oral tablet cephalexin oral capsule cephalexin oral suspension for reconstitution cephalexin oral tablet KEFLEX ORAL CAPSULE SPECTRACEF ORAL TABLET SUPRAX ORAL CAPSULE SUPRAX ORAL SUSPENSION FOR RECONSTITUTION SUPRAX ORAL TABLET,CHEWABLE ERYTHROMYCINS & OTHER MACROLIDES azithromycin oral packet azithromycin oral suspension for reconstitution azithromycin oral tablet BIAXIN ORAL SUSPENSION FOR RECONSTITUTION BIAXIN ORAL TABLET clarithromycin oral suspension for reconstitution clarithromycin oral tablet clarithromycin oral tablet extended release 24 hr DIFICID ORAL TABLET e.e.s. 400 oral tablet E.E.S. GRANULES ORAL SUSPENSION FOR RECONSTITUTION ERYPED 200 ORAL SUSPENSION FOR RECONSTITUTION ERYPED 400 ORAL SUSPENSION FOR RECONSTITUTION ery-tab oral tablet,delayed release (dr/ec) erythrocin (as stearate) oral tablet erythromycin ethylsuccinate oral tablet erythromycin oral capsule,delayed release(dr/ec) 8

11 erythromycin oral tablet PCE ORAL TABLET, PARTICLES/CRYSTALS ZITHROMAX ORAL PACKET ZITHROMAX ORAL SUSPENSION FOR RECONSTITUTION ZITHROMAX ORAL TABLET ZMAX ORAL SUSPENSION,EXTENDED REL RECON MISCELLANEOUS ANTIINFECTIVES ALBENZA ORAL TABLET ALINIA ORAL SUSPENSION FOR RECONSTITUTION ALINIA ORAL TABLET atovaquone oral suspension atovaquone-proguanil oral tablet BILTRICIDE ORAL TABLET CAYSTON INHALATION SOLUTION FOR NEBULIZATION chloroquine phosphate oral tablet CLEOCIN ORAL CAPSULE CLEOCIN ORAL RECON SOLN clindamycin hcl oral capsule clindamycin palmitate hcl oral recon soln clindamycin pediatric oral recon soln COARTEM ORAL TABLET CYCLOSERINE ORAL CAPSULE dapsone oral tablet 9 6 PA; SPRx; LD DARAPRIM ORAL TABLET 6 PA; SPRx ethambutol oral tablet FLAGYL ER ORAL TABLET EXTENDED RELEASE FLAGYL ORAL CAPSULE FLAGYL ORAL TABLET hydroxychloroquine oral tablet isoniazid oral solution

12 isoniazid oral tablet ivermectin oral tablet KETEK ORAL TABLET linezolid oral suspension for reconstitution QL (4 per 30 days) linezolid oral tablet QL (4 per 30 days) MALARONE ORAL TABLET MALARONE PEDIATRIC ORAL TABLET mefloquine oral tablet MEPRON ORAL SUSPENSION metronidazole oral capsule metronidazole oral tablet MYAMBUTOL ORAL TABLET MYCOBUTIN ORAL CAPSULE NEBUPENT INHALATION RECON SOLN neomycin oral tablet paromomycin oral capsule PASER ORAL GRANULES DR FOR SUSP IN PACKET PLAQUENIL ORAL TABLET PRIFTIN ORAL TABLET PRIMAQUINE ORAL TABLET pyrazinamide oral tablet QUALAQUIN ORAL CAPSULE quinine sulfate oral capsule rifabutin oral capsule RIFADIN ORAL CAPSULE RIFAMATE ORAL CAPSULE rifampin oral capsule RIFATER ORAL TABLET SIRTURO ORAL TABLET STROMECTOL ORAL TABLET TINDAMAX ORAL TABLET tinidazole oral tablet 0

13 TOBI INHALATION SOLUTION FOR NEBULIZATION 6 SPRx; LD; QL (56 per 30 days) TOBI PODHALER INHALATION CAPSULE 6 SPRx; LD; QL (224 per 30 days) TOBI PODHALER INHALATION CAPSULE, W/INHALATION DEVICE tobramycin in % nacl inhalation solution for nebulization TRECATOR ORAL TABLET XIFAXAN ORAL TABLET ZYVOX ORAL SUSPENSION FOR RECONSTITUTION 6 SPRx; LD; QL (224 per 30 days) 6 SPRx; QL (56 per 30 days) QL (4 per 30 days) ZYVOX ORAL TABLET QL (4 per 30 days) PENICILLINS amoxicillin oral capsule amoxicillin oral suspension for reconstitution amoxicillin oral tablet amoxicillin oral tablet,chewable amoxicillin-pot clavulanate oral suspension for reconstitution amoxicillin-pot clavulanate oral tablet amoxicillin-pot clavulanate oral tablet extended release 2 hr amoxicillin-pot clavulanate oral tablet,chewable ampicillin oral capsule ampicillin oral suspension for reconstitution AUGMENTIN ES-600 ORAL SUSPENSION FOR RECONSTITUTION AUGMENTIN ORAL SUSPENSION FOR RECONSTITUTION AUGMENTIN ORAL TABLET AUGMENTIN XR ORAL TABLET EXTENDED RELEASE 2 HR dicloxacillin oral capsule penicillin v potassium oral recon soln penicillin v potassium oral tablet QUINOLONES

14 AVELOX ABC PACK ORAL TABLET AVELOX ORAL TABLET CIPRO ORAL SUSPENSION,MICROCAPSULE RECON CIPRO ORAL TABLET CIPRO XR ORAL TABLET, ER MULTIPHASE 24 HR ciprofloxacin (mixture) oral tablet, er multiphase 24 hr ciprofloxacin hcl oral tablet ciprofloxacin oral suspension,microcapsule recon FACTIVE ORAL TABLET LEVAQUIN ORAL TABLET levofloxacin oral solution levofloxacin oral tablet moxifloxacin oral tablet ofloxacin oral tablet SULFA'S & RELATED AGENTS BACTRIM DS ORAL TABLET BACTRIM ORAL TABLET sulfadiazine oral tablet sulfamethoxazole-trimethoprim oral suspension sulfamethoxazole-trimethoprim oral tablet sulfatrim oral suspension TETRACYCLINES AVIDOXY DK KIT avidoxy oral tablet demeclocycline oral tablet doxycycline hyclate oral capsule doxycycline hyclate oral tablet doxycycline hyclate oral tablet,delayed release (dr/ec) doxycycline monohydrate oral capsule doxycycline monohydrate oral suspension for reconstitution 2

15 doxycycline monohydrate oral tablet minocycline oral capsule minocycline oral tablet tetracycline oral capsule VIBRAMYCIN ORAL CAPSULE VIBRAMYCIN ORAL SUSPENSION FOR RECONSTITUTION VIBRAMYCIN ORAL SYRUP URINARY TRACT AGENTS FURADANTIN ORAL SUSPENSION HIPREX ORAL TABLET MACROBID ORAL CAPSULE MACRODANTIN ORAL CAPSULE methenamine hippurate oral tablet methenamine mandelate oral tablet MONUROL ORAL PACKET nitrofurantoin macrocrystal oral capsule nitrofurantoin monohyd/m-cryst oral capsule nitrofurantoin oral suspension PRIMSOL ORAL SOLUTION trimethoprim oral tablet VANCOMYCIN VANCOCIN ORAL CAPSULE vancomycin oral capsule ANTINEOPLASTIC & IMMUNOSUPPRESSANT DRUGS ADJUNCTIVE AGENTS leucovorin calcium oral tablet MESNEX ORAL TABLET ANTINEOPLASTIC & IMMUNOSUPPRESSANT DRUGS AFINITOR DISPERZ ORAL TABLET FOR SUSPENSION 3 6 PA; SPRx AFINITOR ORAL TABLET 6 PA; SPRx ALECENSA ORAL CAPSULE 6 PA; SPRx; AGE-A

16 ALKERAN ORAL TABLET anastrozole oral tablet ARIMIDEX ORAL TABLET AROMASIN ORAL TABLET ASTAGRAF XL ORAL CAPSULE,EXTENDED RELEASE 24HR AZASAN ORAL TABLET azathioprine oral tablet 4 6 SPRx bexarotene oral capsule 6 SPRx bicalutamide oral tablet BOSULIF ORAL TABLET 6 PA; SPRx; LD capecitabine oral tablet 6 SPRx CAPRELSA ORAL TABLET 6 PA; SPRx; LD CASODEX ORAL TABLET CELLCEPT ORAL CAPSULE CELLCEPT ORAL SUSPENSION FOR RECONSTITUTION COMETRIQ ORAL CAPSULE 6 SPRx; LD COTELLIC ORAL TABLET 6 PA; SPRx; AGE-A; LD CYCLOPHOSPHAMIDE ORAL CAPSULE cyclosporine modified oral capsule cyclosporine modified oral solution cyclosporine oral capsule DROXIA ORAL CAPSULE EMCYT ORAL CAPSULE ERIVEDGE ORAL CAPSULE 6 PA; SPRx; LD etoposide oral capsule exemestane oral tablet FARESTON ORAL TABLET FARYDAK ORAL CAPSULE 6 PA; SPRx; LD FEMARA ORAL TABLET flutamide oral capsule gengraf oral capsule gengraf oral solution

17 GILOTRIF ORAL TABLET 6 PA; SPRx; LD GLEEVEC ORAL TABLET 6 SPRx GLEOSTINE ORAL CAPSULE HEXALEN ORAL CAPSULE HYCAMTIN ORAL CAPSULE 6 SPRx HYDREA ORAL CAPSULE hydroxyurea oral capsule IBRANCE ORAL CAPSULE 6 PA; SPRx; LD ICLUSIG ORAL TABLET 6 PA; SPRx; LD imatinib oral tablet 6 SPRx IMBRUVICA ORAL CAPSULE 6 PA; SPRx; LD IMURAN ORAL TABLET INLYTA ORAL TABLET 6 PA; SPRx; LD IRESSA ORAL TABLET 6 PA; SPRx; LD JAKAFI ORAL TABLET 6 PA; SPRx LENVIMA ORAL CAPSULE 0 MG/DAY (0 MG X /DAY), 4 MG/DAY(0 MG X -4 MG X ), 20 MG/DAY (0 MG X 2), 24 MG/DAY(0 MG X 2-4 MG X ) LENVIMA ORAL CAPSULE 8 MG/DAY (0 MG X -4 MG X2), 8 MG/DAY (4 MG X 2) letrozole oral tablet LEUKERAN ORAL TABLET 5 6 PA; SPRx; LD 6 PA; SPRx; LD leuprolide subcutaneous kit 6 SPRx LONSURF ORAL TABLET 6 PA; SPRx; LD LYNPARZA ORAL CAPSULE 6 PA; SPRx; LD LYSODREN ORAL TABLET MATULANE ORAL CAPSULE MEGACE ES ORAL SUSPENSION MEGACE ORAL SUSPENSION megestrol oral suspension megestrol oral tablet MEKINIST ORAL TABLET 6 PA; SPRx mercaptopurine oral tablet

18 methotrexate sodium (pf) injection recon soln methotrexate sodium (pf) injection solution methotrexate sodium injection solution methotrexate sodium oral tablet mycophenolate mofetil oral capsule mycophenolate mofetil oral suspension for reconstitution mycophenolate mofetil oral tablet mycophenolate sodium oral tablet,delayed release (dr/ec) MYFORTIC ORAL TABLET,DELAYED RELEASE (DR/EC) MYLERAN ORAL TABLET NEORAL ORAL CAPSULE NEORAL ORAL SOLUTION NEXAVAR ORAL TABLET 6 PA; SPRx; LD NILANDRON ORAL TABLET NINLARO ORAL CAPSULE 6 PA; SPRx octreotide acetate injection solution 6 SPRx octreotide acetate injection syringe 6 SPRx ODOMZO ORAL CAPSULE 6 PA; SPRx PROGRAF ORAL CAPSULE PURIXAN ORAL SUSPENSION RAPAMUNE ORAL SOLUTION RAPAMUNE ORAL TABLET RHEUMATREX ORAL TABLETS,DOSE PACK SANDIMMUNE ORAL CAPSULE SANDIMMUNE ORAL SOLUTION SANDOSTATIN INJECTION SOLUTION 6 SPRx SIGNIFOR SUBCUTANEOUS SOLUTION 6 PA; SPRx; LD sirolimus oral tablet SOLTAMOX ORAL SOLUTION 2 ACA SPRYCEL ORAL TABLET 6 SPRx STIVARGA ORAL TABLET 6 PA; SPRx; LD 6

19 SUTENT ORAL CAPSULE 6 PA; SPRx; LD TABLOID ORAL TABLET tacrolimus oral capsule TAFINLAR ORAL CAPSULE 6 PA; SPRx; LD TAGRISSO ORAL TABLET 6 PA; SPRx; LD tamoxifen oral tablet 2 ACA TARCEVA ORAL TABLET 6 PA; SPRx; LD TARGRETIN ORAL CAPSULE 6 SPRx TARGRETIN TOPICAL GEL 6 PA; SPRx TASIGNA ORAL CAPSULE 6 SPRx TEMODAR ORAL CAPSULE 6 PA; SPRx temozolomide oral capsule 6 PA; SPRx THALOMID ORAL CAPSULE 6 PA; SPRx; LD tretinoin (chemotherapy) oral capsule TREXALL ORAL TABLET TYKERB ORAL TABLET 6 PA; SPRx; LD VOTRIENT ORAL TABLET 6 PA; SPRx; LD XALKORI ORAL CAPSULE 6 PA; SPRx; LD XELODA ORAL TABLET 6 SPRx XTANDI ORAL CAPSULE 6 PA; SPRx; LD ZELBORAF ORAL TABLET 6 PA; SPRx; LD ZOLINZA ORAL CAPSULE 6 SPRx; LD ZORTRESS ORAL TABLET ZYDELIG ORAL TABLET 6 PA; SPRx; LD ZYKADIA ORAL CAPSULE 6 PA; SPRx; LD ZYTIGA ORAL TABLET 6 SPRx; LD AUTONOMIC & CNS DRUGS, NEUROLOGY & PSYCH ANTICONVULSANTS APTIOM ORAL TABLET BANZEL ORAL SUSPENSION 5 BANZEL ORAL TABLET 5 carbamazepine oral capsule, er multiphase 2 hr 3 carbamazepine oral suspension 3 7

20 carbamazepine oral tablet 3 carbamazepine oral tablet extended release 2 hr 3 carbamazepine oral tablet,chewable 3 CARBATROL ORAL CAPSULE, ER MULTIPHASE 2 HR CELONTIN ORAL CAPSULE 5 clonazepam oral tablet 3 clonazepam oral tablet,disintegrating 3 DEPAKENE ORAL CAPSULE 5 DEPAKENE ORAL SOLUTION 5 DEPAKOTE ER ORAL TABLET EXTENDED RELEASE 24 HR DEPAKOTE ORAL TABLET,DELAYED RELEASE (DR/EC) DEPAKOTE SPRINKLES ORAL CAPSULE, SPRINKLE DIASTAT ACUDIAL RECTAL KIT 5 DIASTAT RECTAL KIT 5 diazepam rectal kit 3 DILANTIN EXTENDED ORAL CAPSULE 4 DILANTIN INFATABS ORAL TABLET,CHEWABLE DILANTIN ORAL CAPSULE 4 DILANTIN-25 ORAL SUSPENSION 4 divalproex oral capsule, sprinkle 3 divalproex oral tablet extended release 24 hr 3 divalproex oral tablet,delayed release (dr/ec) 3 epitol oral tablet 3 EQUETRO ORAL CAPSULE, ER MULTIPHASE 2 HR ethosuximide oral solution 3 felbamate oral suspension 3 felbamate oral tablet 3 FELBATOL ORAL SUSPENSION 5 FELBATOL ORAL TABLET

21 FYCOMPA ORAL TABLET gabapentin oral capsule 00 mg, 300 mg 3 gabapentin oral capsule 400 mg 3 QL (350 per 30 days) gabapentin oral solution 3 gabapentin oral tablet 600 mg 3 gabapentin oral tablet 800 mg 3 QL (350 per 30 days) GABITRIL ORAL TABLET 5 KEPPRA ORAL SOLUTION 5 KEPPRA ORAL TABLET 5 KEPPRA XR ORAL TABLET EXTENDED RELEASE 24 HR KLONOPIN ORAL TABLET 5 LAMICTAL ODT ORAL TABLET,DISINTEGRATING 00 MG, 25 MG, 50 MG LAMICTAL ODT ORAL TABLET,DISINTEGRATING 200 MG LAMICTAL ODT STARTER (BLUE) ORAL TABLET DISINTEGRATING, DOSE PK LAMICTAL ODT STARTER (GREEN) ORAL TABLET DISINTEGRATING, DOSE PK LAMICTAL ODT STARTER (ORANGE) ORAL TABLET DISINTEGRATING, DOSE PK LAMICTAL ORAL TABLET 00 MG, 50 MG, 25 MG QL (350 per 30 days) LAMICTAL ORAL TABLET 200 MG 5 QL (350 per 30 days) LAMICTAL ORAL TABLET, CHEWABLE DISPERSIBLE LAMICTAL STARTER (BLUE) KIT ORAL TABLETS,DOSE PACK LAMICTAL STARTER (GREEN) KIT ORAL TABLETS,DOSE PACK LAMICTAL STARTER (ORANGE) KIT ORAL TABLETS,DOSE PACK LAMICTAL XR ORAL TABLET EXTENDED RELEASE 24HR 00 MG, 25 MG, 250 MG, 300 MG, 50 MG

22 LAMICTAL XR ORAL TABLET EXTENDED RELEASE 24HR 200 MG LAMICTAL XR STARTER (BLUE) ORAL TABLET EXTENDED REL,DOSE PACK LAMICTAL XR STARTER (GREEN) ORAL TABLET EXTENDED REL,DOSE PACK LAMICTAL XR STARTER (ORANGE) ORAL TABLET EXTENDED REL,DOSE PACK lamotrigine oral tablet 00 mg, 50 mg, 25 mg 3 5 QL (350 per 30 days) lamotrigine oral tablet 200 mg 3 QL (350 per 30 days) lamotrigine oral tablet disintegrating, dose pk 3 lamotrigine oral tablet extended release 24hr 00 mg, 25 mg, 250 mg, 300 mg, 50 mg lamotrigine oral tablet extended release 24hr 200 mg lamotrigine oral tablet, chewable dispersible 3 lamotrigine oral tablet,disintegrating 00 mg, 25 mg, 50 mg QL (350 per 30 days) lamotrigine oral tablet,disintegrating 200 mg 3 QL (350 per 30 days) levetiracetam oral solution 3 levetiracetam oral tablet 3 levetiracetam oral tablet extended release 24 hr 3 LYRICA ORAL CAPSULE LYRICA ORAL SOLUTION MYSOLINE ORAL TABLET 5 NEURONTIN ORAL CAPSULE 00 MG, 300 MG NEURONTIN ORAL CAPSULE 400 MG 5 QL (350 per 30 days) NEURONTIN ORAL SOLUTION 5 NEURONTIN ORAL TABLET 600 MG 5 NEURONTIN ORAL TABLET 800 MG 5 QL (350 per 30 days) ONFI ORAL SUSPENSION 5 ONFI ORAL TABLET 5 oxcarbazepine oral suspension 3 oxcarbazepine oral tablet

23 OXTELLAR XR ORAL TABLET EXTENDED RELEASE 24 HR PEGANONE ORAL TABLET 5 phenobarbital oral elixir 3 phenobarbital oral tablet 3 PHENYTEK ORAL CAPSULE 5 phenytoin oral suspension 3 phenytoin oral tablet,chewable 3 phenytoin sodium extended oral capsule 3 POTIGA ORAL TABLET 5 primidone oral tablet 3 QUDEXY XR ORAL CAPSULE,SPRINKLE,ER 24HR 00 MG, 50 MG, 50 MG QUDEXY XR ORAL CAPSULE,SPRINKLE,ER 24HR 200 MG, 25 MG roweepra oral tablet 3 4 QL (350 per 30 days) SABRIL ORAL POWDER IN PACKET 5 SPRx; LD SABRIL ORAL TABLET 5 SPRx; LD SPRITAM ORAL TABLET FOR SUSPENSION TEGRETOL ORAL SUSPENSION 5 TEGRETOL ORAL TABLET 5 TEGRETOL XR ORAL TABLET EXTENDED RELEASE 2 HR tiagabine oral tablet 3 TOPAMAX ORAL CAPSULE, SPRINKLE 5 MG TOPAMAX ORAL CAPSULE, SPRINKLE 25 MG TOPAMAX ORAL TABLET 00 MG, 50 MG QL (350 per 30 days) TOPAMAX ORAL TABLET 200 MG, 25 MG 5 QL (350 per 30 days) topiramate oral capsule, sprinkle 5 mg 3 topiramate oral capsule, sprinkle 25 mg 3 QL (350 per 30 days) TOPIRAMATE ORAL CAPSULE,SPRINKLE,ER 24HR 00 MG, 50 MG, 50 MG 2

24 TOPIRAMATE ORAL CAPSULE,SPRINKLE,ER 24HR 200 MG, 25 MG topiramate oral tablet 00 mg, 50 mg 3 22 QL (350 per 30 days) topiramate oral tablet 25 mg 3 QL (350 per 30 days) TRILEPTAL ORAL SUSPENSION 5 TRILEPTAL ORAL TABLET 5 TROKENDI XR ORAL CAPSULE,EXTENDED RELEASE 24HR 00 MG, 50 MG TROKENDI XR ORAL CAPSULE,EXTENDED RELEASE 24HR 200 MG, 25 MG valproic acid (as sodium salt) oral solution 3 valproic acid oral capsule 3 VIMPAT ORAL SOLUTION 4 VIMPAT ORAL TABLET 4 ZARONTIN ORAL CAPSULE 5 ZARONTIN ORAL SOLUTION 5 ZONEGRAN ORAL CAPSULE 5 zonisamide oral capsule 3 ANTIPARKINSONISM AGENTS QL (350 per 30 days) APOKYN SUBCUTANEOUS CARTRIDGE 6 SPRx; LD AZILECT ORAL TABLET benztropine oral tablet bromocriptine oral capsule bromocriptine oral tablet 3 carbidopa oral tablet carbidopa-levodopa oral tablet carbidopa-levodopa oral tablet extended release carbidopa-levodopa oral tablet,disintegrating carbidopa-levodopa-entacapone oral tablet COMTAN ORAL TABLET DUOPA J-TUBE INTESTINAL PUMP SUSPENSION ELDEPRYL ORAL CAPSULE entacapone oral tablet 6 PA; SPRx; LD

25 LODOSYN ORAL TABLET MIRAPEX ER ORAL TABLET EXTENDED RELEASE 24 HR MIRAPEX ORAL TABLET NEUPRO TRANSDERMAL PATCH 24 HOUR PARLODEL ORAL CAPSULE PARLODEL ORAL TABLET pramipexole oral tablet pramipexole oral tablet extended release 24 hr REQUIP ORAL TABLET REQUIP XL ORAL TABLET EXTENDED RELEASE 24 HR ropinirole oral tablet ropinirole oral tablet extended release 24 hr selegiline hcl oral capsule selegiline hcl oral tablet SINEMET CR ORAL TABLET EXTENDED RELEASE SINEMET ORAL TABLET STALEVO 00 ORAL TABLET STALEVO 25 ORAL TABLET STALEVO 50 ORAL TABLET STALEVO 200 ORAL TABLET STALEVO 50 ORAL TABLET STALEVO 75 ORAL TABLET TASMAR ORAL TABLET tolcapone oral tablet trihexyphenidyl oral elixir trihexyphenidyl oral tablet ZELAPAR ORAL TABLET,DISINTEGRATING MIGRAINE & CLUSTER HEADACHE THERAPY almotriptan malate oral tablet QL (8 per 30 days) ALSUMA SUBCUTANEOUS PEN INJECTOR QL (8 per 30 days) AMERGE ORAL TABLET QL (8 per 30 days) 23

26 AXERT ORAL TABLET QL (8 per 30 days) CAFERGOT ORAL TABLET D.H.E.45 INJECTION SOLUTION dihydroergotamine injection solution dihydroergotamine nasal spray,non-aerosol QL (8 per 30 days) ERGOMAR SUBLINGUAL TABLET FROVA ORAL TABLET QL (8 per 30 days) frovatriptan oral tablet QL (8 per 30 days) IMITREX NASAL SPRAY,NON-AEROSOL QL (2 per 30 days) IMITREX ORAL TABLET QL (8 per 30 days) IMITREX STATDOSE KIT REFILL SUBCUTANEOUS CARTRIDGE 4 MG/0.5 ML IMITREX STATDOSE KIT REFILL SUBCUTANEOUS CARTRIDGE 6 MG/0.5 ML IMITREX STATDOSE PEN SUBCUTANEOUS PEN INJECTOR 4 MG/0.5 ML IMITREX STATDOSE PEN SUBCUTANEOUS PEN INJECTOR 6 MG/0.5 ML 24 QL (2 per 30 days) QL (8 per 30 days) QL (2 per 30 days) QL (8 per 30 days) IMITREX SUBCUTANEOUS SOLUTION QL (8 per 30 days) isometh-dichloral-acetaminophn oral capsule isomethepten-caf-acetaminophen oral tablet MAXALT ORAL TABLET QL (8 per 30 days) MAXALT-MLT ORAL TABLET,DISINTEGRATING migergot rectal suppository QL (8 per 30 days) MIGRANAL NASAL SPRAY,NON-AEROSOL QL (8 per 30 days) naratriptan oral tablet QL (8 per 30 days) nodolor oral capsule RELPAX ORAL TABLET QL (8 per 30 days) rizatriptan oral tablet QL (8 per 30 days) rizatriptan oral tablet,disintegrating QL (8 per 30 days) sumatriptan nasal spray,non-aerosol QL (2 per 30 days) sumatriptan succinate oral tablet QL (8 per 30 days) sumatriptan succinate subcutaneous cartridge 4 mg/0.5 ml QL (2 per 30 days)

27 sumatriptan succinate subcutaneous cartridge 6 mg/0.5 ml sumatriptan succinate subcutaneous pen injector 4 mg/0.5 ml sumatriptan succinate subcutaneous pen injector 6 mg/0.5 ml 25 QL (8 per 30 days) QL (2 per 30 days) QL (8 per 30 days) sumatriptan succinate subcutaneous solution QL (8 per 30 days) sumatriptan succinate subcutaneous syringe QL (8 per 30 days) SUMAVEL DOSEPRO SUBCUTANEOUS NEEDLE-FREE INJECTOR 4 MG/0.5 ML SUMAVEL DOSEPRO SUBCUTANEOUS NEEDLE-FREE INJECTOR 6 MG/0.5 ML QL (2 per 30 days) QL (8 per 30 days) zolmitriptan oral tablet QL (8 per 30 days) zolmitriptan oral tablet,disintegrating QL (8 per 30 days) ZOMIG NASAL SPRAY,NON-AEROSOL QL (2 per 30 days) ZOMIG ZMT ORAL TABLET,DISINTEGRATING MISCELLANEOUS NEUROLOGICAL THERAPY AMPYRA ORAL TABLET EXTENDED RELEASE 2 HR ARICEPT ORAL TABLET donepezil oral tablet donepezil oral tablet,disintegrating EXELON ORAL CAPSULE EXELON TRANSDERMAL PATCH 24 HOUR galantamine oral capsule,ext rel. pellets 24 hr galantamine oral solution galantamine oral tablet HORIZANT ORAL TABLET EXTENDED RELEASE QL (8 per 30 days) 6 PA; SPRx; LD KEVEYIS ORAL TABLET 6 PA; SPRx; LD memantine oral solution memantine oral tablet MEMANTINE ORAL TABLETS,DOSE PACK NAMENDA ORAL SOLUTION NAMENDA ORAL TABLET

28 NAMENDA TITRATION PAK ORAL TABLETS,DOSE PACK NAMENDA XR ORAL CAP,SPRINKLE,ER 24HR DOSE PACK NAMENDA XR ORAL CAPSULE,SPRINKLE,ER 24HR NAMZARIC ORAL CAPSULE,SPRINKLE,ER 24HR NUEDEXTA ORAL CAPSULE RAZADYNE ER ORAL CAPSULE,EXT REL. PELLETS 24 HR RAZADYNE ORAL TABLET rivastigmine tartrate oral capsule rivastigmine transdermal patch 24 hour 26 PA tetrabenazine oral tablet 6 PA; SPRx XENAZINE ORAL TABLET 6 PA; SPRx; LD MUSCLE RELAXANTS & ANTISPASMODIC THERAPY AMRIX ORAL CAPSULE,EXTENDED RELEASE 24HR baclofen oral tablet QL (350 per 30 days) carisoprodol oral tablet carisoprodol-asa-codeine oral tablet carisoprodol-aspirin oral tablet chlorzoxazone oral tablet cyclobenzaprine oral tablet 0 mg QL (350 per 30 days) cyclobenzaprine oral tablet 5 mg, 7.5 mg DANTRIUM ORAL CAPSULE dantrolene oral capsule FEXMID ORAL TABLET LORZONE ORAL TABLET meprobamate oral tablet MESTINON ORAL SYRUP MESTINON ORAL TABLET MESTINON TIMESPAN ORAL TABLET EXTENDED RELEASE

29 metaxalone oral tablet methocarbamol oral tablet orphenadrine citrate oral tablet extended release PARAFON FORTE DSC ORAL TABLET pyridostigmine bromide oral tablet pyridostigmine bromide oral tablet extended release ROBAXIN ORAL TABLET ROBAXIN-750 ORAL TABLET SKELAXIN ORAL TABLET SOMA ORAL TABLET tizanidine oral capsule 2 mg, 6 mg tizanidine oral capsule 4 mg QL (350 per 30 days) tizanidine oral tablet 2 mg tizanidine oral tablet 4 mg QL (350 per 30 days) ZANAFLEX ORAL CAPSULE 2 MG, 6 MG ZANAFLEX ORAL CAPSULE 4 MG QL (350 per 30 days) ZANAFLEX ORAL TABLET QL (350 per 30 days) NARCOTIC ANALGESICS ABSTRAL SUBLINGUAL TABLET QL (8 per 30 days) acetaminophen-codeine oral solution acetaminophen-codeine oral tablet QL (80 per 30 days) ACTIQ BUCCAL LOZENGE ON A HANDLE QL (6 per 30 days) ascomp with codeine oral capsule QL (80 per 30 days) BUPAP ORAL TABLET QL (80 per 30 days) buprenorphine hcl sublingual tablet QL (90 per 30 days) butalbital compound w/codeine oral capsule QL (80 per 30 days) butalbital-acetaminop-caf-cod oral capsule QL (80 per 30 days) butalbital-acetaminophen oral tablet QL (80 per 30 days) butalbital-acetaminophen-caff oral capsule QL (80 per 30 days) butalbital-acetaminophen-caff oral tablet QL (80 per 30 days) butalbital-aspirin-caffeine oral capsule QL (80 per 30 days) BUTRANS TRANSDERMAL PATCH WEEKLY 27

30 capacet oral capsule QL (80 per 30 days) CAPITAL WITH CODEINE ORAL SUSPENSION codeine sulfate oral tablet QL (80 per 30 days) codeine-butalbital-asa-caff oral capsule QL (80 per 30 days) DEMEROL ORAL TABLET QL (80 per 30 days) dihydrocode-acetaminophen-caff oral capsule QL (360 per 30 days) dihydrocodeine-aspirin-caff oral capsule DILAUDID ORAL LIQUID DILAUDID ORAL TABLET QL (80 per 30 days) diskets oral tablet,soluble QL (80 per 30 days) DOLOPHINE ORAL TABLET QL (80 per 30 days) DURAGESIC TRANSDERMAL PATCH 72 HOUR endocet oral tablet QL (240 per 30 days) ESGIC ORAL CAPSULE QL (80 per 30 days) ESGIC ORAL TABLET QL (80 per 30 days) fentanyl citrate buccal lozenge on a handle QL (6 per 30 days) fentanyl transdermal patch 72 hour FENTORA BUCCAL TABLET, EFFERVESCENT 28 QL (8 per 30 days) FIORICET ORAL CAPSULE QL (80 per 30 days) FIORICET WITH CODEINE ORAL CAPSULE QL (80 per 30 days) FIORINAL ORAL CAPSULE QL (80 per 30 days) FIORINAL-CODEINE #3 ORAL CAPSULE QL (80 per 30 days) HYCET ORAL SOLUTION hydrocodone-acetaminophen oral solution hydrocodone-acetaminophen oral tablet QL (240 per 30 days) hydrocodone-ibuprofen oral tablet QL (50 per 30 days) hydromorphone oral liquid hydromorphone oral tablet QL (80 per 30 days) hydromorphone rectal suppository IBUDONE ORAL TABLET QL (50 per 30 days) ibuprofen-oxycodone oral tablet QL (50 per 30 days)

31 KADIAN ORAL CAPSULE,EXTEND.RELEASE PELLETS 29 QL (20 per 30 days) levorphanol tartrate oral tablet QL (80 per 30 days) lorcet (hydrocodone) oral tablet QL (240 per 30 days) lorcet hd oral tablet QL (240 per 30 days) lorcet plus oral tablet QL (240 per 30 days) lortab oral tablet QL (240 per 30 days) lortab oral tablet QL (240 per 30 days) lortab oral tablet QL (240 per 30 days) LORTAB ELIXIR ORAL SOLUTION margesic oral capsule QL (80 per 30 days) marten-tab oral tablet QL (80 per 30 days) meperidine oral solution meperidine oral tablet QL (80 per 30 days) methadone oral concentrate methadone oral solution methadone oral tablet QL (80 per 30 days) methadone oral tablet,soluble QL (80 per 30 days) methadose oral concentrate methadose oral tablet,soluble QL (80 per 30 days) morphine concentrate oral solution morphine oral capsule, er multiphase 24 hr QL (20 per 30 days) morphine oral capsule,extend.release pellets QL (20 per 30 days) morphine oral solution morphine oral tablet QL (80 per 30 days) morphine oral tablet extended release QL (90 per 30 days) morphine rectal suppository MS CONTIN ORAL TABLET EXTENDED RELEASE QL (90 per 30 days) NORCO ORAL TABLET QL (240 per 30 days) OPANA ER ORAL TABLET,ORAL ONLY,EXT.REL.2 HR QL (20 per 30 days) OPANA ORAL TABLET QL (20 per 30 days) oxycodone oral capsule QL (20 per 30 days)

32 oxycodone oral concentrate oxycodone oral solution oxycodone oral tablet QL (20 per 30 days) oxycodone-acetaminophen oral tablet QL (240 per 30 days) oxycodone-aspirin oral tablet QL (240 per 30 days) OXYCONTIN ORAL TABLET,ORAL ONLY,EXT.REL.2 HR QL (20 per 30 days) oxymorphone oral tablet QL (20 per 30 days) oxymorphone oral tablet extended release 2 hr QL (20 per 30 days) PERCOCET ORAL TABLET QL (240 per 30 days) PRIMLEV ORAL TABLET QL (240 per 30 days) reprexain oral tablet QL (50 per 30 days) ROXICODONE ORAL TABLET QL (20 per 30 days) SYNALGOS-DC ORAL CAPSULE tencon oral tablet QL (80 per 30 days) TREZIX ORAL CAPSULE QL (360 per 30 days) TYLENOL-CODEINE #3 ORAL TABLET QL (80 per 30 days) TYLENOL-CODEINE #4 ORAL TABLET QL (80 per 30 days) verdrocet oral tablet QL (240 per 30 days) vicodin es oral tablet QL (240 per 30 days) vicodin hp oral tablet QL (240 per 30 days) vicodin oral tablet QL (240 per 30 days) VICOPROFEN ORAL TABLET QL (50 per 30 days) XODOL 0/300 ORAL TABLET QL (240 per 30 days) XODOL 5/300 ORAL TABLET QL (240 per 30 days) XODOL 7.5/300 ORAL TABLET QL (240 per 30 days) xylon 0 oral tablet QL (50 per 30 days) zamicet oral solution zebutal oral capsule QL (80 per 30 days) NON-NARCOTIC ANALGESICS ANAPROX DS ORAL TABLET ARTHROTEC 50 ORAL TABLET,IR,DELAYED REL,BIPHASIC 30

33 ARTHROTEC 75 ORAL TABLET,IR,DELAYED REL,BIPHASIC BUNAVAIL BUCCAL FILM QL (90 per 30 days) buprenorphine-naloxone sublingual tablet QL (90 per 30 days) butorphanol tartrate nasal spray,non-aerosol CELEBREX ORAL CAPSULE celecoxib oral capsule choline,magnesium salicylate oral liquid DAYPRO ORAL TABLET diclofenac potassium oral tablet QL (350 per 30 days) diclofenac sodium oral tablet extended release 24 hr diclofenac sodium oral tablet,delayed release (dr/ec) 25 mg, 50 mg diclofenac sodium oral tablet,delayed release (dr/ec) 75 mg diclofenac sodium topical gel diclofenac-misoprostol oral tablet,ir,delayed rel,biphasic diflunisal oral tablet DISALCID ORAL TABLET EC-NAPROSYN ORAL TABLET,DELAYED RELEASE (DR/EC) etodolac oral capsule etodolac oral tablet etodolac oral tablet extended release 24 hr FELDENE ORAL CAPSULE fenoprofen oral tablet FLECTOR TRANSDERMAL PATCH 2 HOUR 3 QL (350 per 30 days) QL (350 per 30 days) flurbiprofen oral tablet 00 mg QL (350 per 30 days) flurbiprofen oral tablet 50 mg ibuprofen oral suspension ibuprofen oral tablet INDOCIN ORAL SUSPENSION INDOCIN RECTAL SUPPOSITORY

34 indomethacin oral capsule indomethacin oral capsule, extended release ketoprofen oral capsule QL (350 per 30 days) ketoprofen oral capsule,ext rel. pellets 24 hr ketorolac oral tablet meclofenamate oral capsule mefenamic acid oral capsule meloxicam oral suspension meloxicam oral tablet 5 mg QL (350 per 30 days) meloxicam oral tablet 7.5 mg MOBIC ORAL SUSPENSION MOBIC ORAL TABLET 5 MG QL (350 per 30 days) MOBIC ORAL TABLET 7.5 MG nabumetone oral tablet NALFON ORAL CAPSULE naltrexone oral tablet NAPRELAN CR ORAL TABLET, ER MULTIPHASE 24 HR NAPROSYN ORAL SUSPENSION NAPROSYN ORAL TABLET naproxen oral suspension naproxen oral tablet naproxen oral tablet,delayed release (dr/ec) naproxen sodium oral tablet NUCYNTA ER ORAL TABLET EXTENDED RELEASE 2 HR 32 QL (80 per 30 days) NUCYNTA ORAL TABLET QL (80 per 30 days) oxaprozin oral tablet pentazocine-naloxone oral tablet piroxicam oral capsule PONSTEL ORAL CAPSULE REVIA ORAL TABLET salsalate oral tablet SPRIX NASAL SPRAY,NON-AEROSOL LD

35 SUBOXONE SUBLINGUAL FILM QL (90 per 30 days) sulindac oral tablet tolmetin oral capsule tolmetin oral tablet tramadol oral tablet QL (350 per 30 days) tramadol oral tablet extended release 24 hr tramadol oral tablet, er multiphase 24 hr tramadol-acetaminophen oral tablet ULTRACET ORAL TABLET ULTRAM ER ORAL TABLET EXTENDED RELEASE 24 HR ULTRAM ORAL TABLET QL (350 per 30 days) VOLTAREN TOPICAL GEL VOLTAREN-XR ORAL TABLET EXTENDED RELEASE 24 HR 33 QL (350 per 30 days) ZUBSOLV SUBLINGUAL TABLET QL (90 per 30 days) PSYCHOTHERAPEUTIC DRUGS ABILIFY MAINTENA INTRAMUSCULAR SUSPENSION,EXTENDED REL RECON 5 SPRx; AGE-A ABILIFY ORAL TABLET 5 AGE-A ADDERALL ORAL TABLET ADDERALL XR ORAL CAPSULE,EXTENDED RELEASE 24HR GEN amphetamine mix er GEN alprazolam intensol oral concentrate alprazolam oral tablet alprazolam oral tablet extended release 24 hr alprazolam oral tablet,disintegrating AMBIEN CR ORAL TABLET,EXT RELEASE MULTIPHASE AMBIEN ORAL TABLET amitriptyline oral tablet 3 amitriptyline-chlordiazepoxide oral tablet 3 amoxapine oral tablet 3 ANAFRANIL ORAL CAPSULE

36 aripiprazole oral solution 3 AGE-A aripiprazole oral tablet 3 AGE-A aripiprazole oral tablet,disintegrating 3 AGE-A ARISTADA INTRAMUSCULAR SUSPENSION,EXTENDED REL SYRING 34 6 SPRx; AGE-A armodafinil oral tablet PA ATIVAN ORAL TABLET bupropion hcl oral tablet 3 bupropion hcl oral tablet extended release 3 bupropion hcl oral tablet extended release 24 hr 3 buspirone oral tablet BUTISOL ORAL TABLET CELEXA ORAL TABLET chlordiazepoxide hcl oral capsule chlorpromazine oral tablet 3 citalopram oral solution 3 citalopram oral tablet 3 clomipramine oral capsule 3 clonidine hcl oral tablet extended release 2 hr clorazepate dipotassium oral tablet clozapine oral tablet 3 AGE-A clozapine oral tablet,disintegrating 00 mg, 2.5 mg, 25 mg CLOZAPINE ORAL TABLET,DISINTEGRATING 50 MG, 200 MG 3 AGE-A AGE-A CLOZARIL ORAL TABLET AGE-A CONCERTA ORAL TABLET EXTENDED RELEASE 24HR CYMBALTA ORAL CAPSULE,DELAYED RELEASE(DR/EC) DAYTRANA TRANSDERMAL PATCH 24 HOUR desipramine oral tablet 3 DESOXYN ORAL TABLET dexedrine oral tablet GEN

37 DEXEDRINE SPANSULE ORAL CAPSULE, EXTENDED RELEASE dexmethylphenidate oral capsule,er biphasic dexmethylphenidate oral tablet dextroamphetamine oral capsule, extended release dextroamphetamine oral solution dextroamphetamine oral tablet dextroamphetamine-amphetamine oral tablet diazepam intensol oral concentrate diazepam oral solution diazepam oral tablet DORAL ORAL TABLET doxepin oral capsule 3 doxepin oral concentrate 3 duloxetine oral capsule,delayed release(dr/ec) 3 EFFEXOR XR ORAL CAPSULE,EXTENDED RELEASE 24HR EMSAM TRANSDERMAL PATCH 24 HOUR ergoloid oral tablet escitalopram oxalate oral solution 3 escitalopram oxalate oral tablet 3 estazolam oral tablet eszopiclone oral tablet FANAPT ORAL TABLET AGE-A FANAPT ORAL TABLETS,DOSE PACK AGE-A FAZACLO ORAL TABLET,DISINTEGRATING AGE-A fluoxetine oral capsule 3 fluoxetine oral capsule,delayed release(dr/ec) 3 fluoxetine oral solution 3 fluoxetine oral tablet 0 mg, 20 mg 3 FLUOXETINE ORAL TABLET 60 MG fluphenazine hcl oral concentrate 3 fluphenazine hcl oral elixir 3 35

38 fluphenazine hcl oral tablet 3 flurazepam oral capsule fluvoxamine oral capsule,extended release 24hr 3 fluvoxamine oral tablet 3 FOCALIN ORAL TABLET FOCALIN XR ORAL CAPSULE,ER BIPHASIC GEODON ORAL CAPSULE AGE-A guanfacine oral tablet extended release 24 hr guanidine oral tablet HALCION ORAL TABLET haloperidol lactate oral concentrate 3 haloperidol oral tablet 3 imipramine hcl oral tablet 3 imipramine pamoate oral capsule 3 INTUNIV ER ORAL TABLET EXTENDED RELEASE 24 HR INVEGA ORAL TABLET EXTENDED RELEASE 24HR INVEGA SUSTENNA INTRAMUSCULAR SYRINGE INVEGA TRINZA INTRAMUSCULAR SYRINGE KAPVAY ORAL TABLET EXTENDED RELEASE 2 HR 36 AGE-A 6 SPRx; AGE-A 6 PA; SPRx; AGE-A LATUDA ORAL TABLET 4 AGE-A LEXAPRO ORAL SOLUTION LEXAPRO ORAL TABLET lithium carbonate oral capsule lithium carbonate oral tablet lithium carbonate oral tablet extended release lithium citrate oral solution LITHOBID ORAL TABLET EXTENDED RELEASE lorazepam intensol oral concentrate

39 lorazepam oral concentrate lorazepam oral tablet loxapine succinate oral capsule 3 LUNESTA ORAL TABLET maprotiline oral tablet 3 MARPLAN ORAL TABLET METADATE CD ORAL CAPSULE, ER BIPHASIC metadate er oral tablet extended release methamphetamine oral tablet METHYLIN ORAL SOLUTION METHYLIN ORAL TABLET,CHEWABLE methylphenidate oral capsule, er biphasic methylphenidate oral capsule,er biphasic methylphenidate oral solution methylphenidate oral tablet methylphenidate oral tablet er, 24 hr GEN methylphenidate oral tablet extended release methylphenidate oral tablet,chewable midazolam oral syrup mirtazapine oral tablet 3 mirtazapine oral tablet,disintegrating 3 modafinil oral tablet PA NARDIL ORAL TABLET nefazodone oral tablet 3 NORPRAMIN ORAL TABLET nortriptyline oral capsule 3 nortriptyline oral solution 3 NUVIGIL ORAL TABLET PA olanzapine oral tablet 3 AGE-A olanzapine oral tablet,disintegrating 3 AGE-A olanzapine-fluoxetine oral capsule 3 AGE-A OLEPTRO ER ORAL TABLET EXTENDED RELEASE 24 HR 37

40 ORAP ORAL TABLET oxazepam oral capsule paliperidone oral tablet extended release 24hr 3 AGE-A PAMELOR ORAL CAPSULE PARNATE ORAL TABLET paroxetine hcl oral tablet 3 paroxetine hcl oral tablet extended release 24 hr 3 PAXIL CR ORAL TABLET EXTENDED RELEASE 24 HR PAXIL ORAL SUSPENSION PAXIL ORAL TABLET perphenazine oral tablet 3 perphenazine-amitriptyline oral tablet 3 PEXEVA ORAL TABLET phenelzine oral tablet 3 pimozide oral tablet 3 PRISTIQ ORAL TABLET EXTENDED RELEASE 24 HR procentra oral solution protriptyline oral tablet 3 PROZAC ORAL CAPSULE PROZAC WEEKLY ORAL CAPSULE,DELAYED RELEASE(DR/EC) quazepam oral tablet quetiapine oral tablet 3 AGE-A QUILLIVANT XR ORAL SUSPENSION,EXT REL 24HR,RECON REMERON ORAL TABLET REMERON SOLTAB ORAL TABLET,DISINTEGRATING RESTORIL ORAL CAPSULE RISPERDAL CONSTA INTRAMUSCULAR SYRINGE RISPERDAL M-TAB ORAL TABLET,DISINTEGRATING 38 6 SPRx; AGE-A AGE-A

41 RISPERDAL ORAL SOLUTION AGE-A RISPERDAL ORAL TABLET AGE-A risperidone oral solution 3 AGE-A risperidone oral tablet 3 AGE-A risperidone oral tablet,disintegrating 3 AGE-A RITALIN LA ORAL CAPSULE,ER BIPHASIC RITALIN ORAL TABLET ROZEREM ORAL TABLET SAPHRIS (BLACK CHERRY) SUBLINGUAL TABLET SARAFEM ORAL TABLET seconal sodium oral capsule 39 AGE-A SEROQUEL ORAL TABLET AGE-A SEROQUEL XR ORAL TABLET EXTENDED RELEASE 24 HR sertraline oral concentrate 3 sertraline oral tablet 3 SONATA ORAL CAPSULE STRATTERA ORAL CAPSULE SURMONTIL ORAL CAPSULE 4 AGE-A SYMBYAX ORAL CAPSULE AGE-A temazepam oral capsule thioridazine oral tablet 3 thiothixene oral capsule 3 TOFRANIL ORAL TABLET TRANXENE T-TAB ORAL TABLET tranylcypromine oral tablet 3 trazodone oral tablet 3 triazolam oral tablet trifluoperazine oral tablet 3 trimipramine oral capsule 3 VALIUM ORAL TABLET venlafaxine oral capsule,extended release 24hr 3

42 venlafaxine oral tablet 3 VIIBRYD ORAL TABLET VIIBRYD ORAL TABLETS,DOSE PACK VYVANSE ORAL CAPSULE WELLBUTRIN SR ORAL TABLET EXTENDED RELEASE WELLBUTRIN XL ORAL TABLET EXTENDED RELEASE 24 HR XANAX ORAL TABLET XANAX XR ORAL TABLET EXTENDED RELEASE 24 HR XYREM ORAL SOLUTION PA zaleplon oral capsule zenzedi oral tablet ziprasidone hcl oral capsule 3 AGE-A ZOLOFT ORAL CONCENTRATE ZOLOFT ORAL TABLET zolpidem oral tablet zolpidem oral tablet,ext release multiphase ZYPREXA ORAL TABLET AGE-A ZYPREXA RELPREVV INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION ZYPREXA ZYDIS ORAL TABLET,DISINTEGRATING CARDIOVASCULAR, HYPERTENSION & LIPIDS ANTIARRHYTHMIC AGENTS amiodarone oral tablet 3 BETAPACE AF ORAL TABLET BETAPACE ORAL TABLET CORDARONE ORAL TABLET disopyramide phosphate oral capsule 3 flecainide oral tablet 3 mexiletine oral capsule 3 MULTAQ ORAL TABLET 6 SPRx; AGE-A AGE-A 40

43 NORPACE CR ORAL CAPSULE, EXTENDED RELEASE NORPACE ORAL CAPSULE pacerone oral tablet 3 propafenone oral capsule,extended release 2 hr 3 propafenone oral tablet 3 quinidine gluconate oral tablet extended release 3 quinidine sulfate oral tablet 3 RYTHMOL ORAL TABLET RYTHMOL SR ORAL CAPSULE,EXTENDED RELEASE 2 HR sorine oral tablet 3 sotalol af oral tablet 3 sotalol oral tablet 3 SOTYLIZE ORAL SOLUTION TIKOSYN ORAL CAPSULE ANTIHYPERTENSIVE THERAPY ACCUPRIL ORAL TABLET ACCURETIC ORAL TABLET acebutolol oral capsule 3 ACEON ORAL TABLET ADALAT CC ORAL TABLET EXTENDED RELEASE afeditab cr oral tablet extended release 3 ALDACTAZIDE ORAL TABLET ALDACTONE ORAL TABLET ALTACE ORAL CAPSULE amiloride oral tablet 3 amiloride-hydrochlorothiazide oral tablet 3 amlodipine oral tablet 3 amlodipine-benazepril oral capsule 3 amlodipine-valsartan oral tablet amlodipine-valsartan-hcthiazid oral tablet ATACAND HCT ORAL TABLET 4

44 ATACAND ORAL TABLET atenolol oral tablet 3 atenolol-chlorthalidone oral tablet 3 AVALIDE ORAL TABLET AVAPRO ORAL TABLET AZOR ORAL TABLET 4 benazepril oral tablet 3 benazepril-hydrochlorothiazide oral tablet 3 BENICAR HCT ORAL TABLET 4 BENICAR ORAL TABLET 4 betaxolol oral tablet 3 BIDIL ORAL TABLET bisoprolol fumarate oral tablet 3 bisoprolol-hydrochlorothiazide oral tablet 3 bumetanide oral tablet 3 BYSTOLIC ORAL TABLET 4 CALAN ORAL TABLET CALAN SR ORAL TABLET EXTENDED RELEASE candesartan oral tablet 3 candesartan-hydrochlorothiazid oral tablet 3 captopril oral tablet 3 captopril-hydrochlorothiazide oral tablet 3 CARDIZEM CD ORAL CAPSULE,EXTENDED RELEASE 24HR CARDIZEM LA ORAL TABLET EXTENDED RELEASE 24 HR CARDIZEM ORAL TABLET CARDURA ORAL TABLET CARDURA XL ORAL TABLET EXTENDED RELEASE 24HR carvedilol oral tablet 3 CATAPRES ORAL TABLET CATAPRES-TTS- TRANSDERMAL PATCH WEEKLY 42

45 CATAPRES-TTS-2 TRANSDERMAL PATCH WEEKLY CATAPRES-TTS-3 TRANSDERMAL PATCH WEEKLY chlorothiazide oral tablet 3 chlorthalidone oral tablet 3 clonidine hcl oral tablet 3 clonidine transdermal patch weekly clorpres oral tablet 0.-5 mg, mg 3 CLORPRES ORAL TABLET MG COREG CR ORAL CAPSULE, ER MULTIPHASE 24 HR COREG ORAL TABLET CORGARD ORAL TABLET CORZIDE ORAL TABLET COZAAR ORAL TABLET DEMADEX ORAL TABLET DEMSER ORAL CAPSULE DIBENZYLINE ORAL CAPSULE diltiazem hcl oral capsule,extended release 24hr 3 DIOVAN HCT ORAL TABLET DIOVAN ORAL TABLET DIURIL ORAL SUSPENSION doxazosin oral tablet 3 DUTOPROL ORAL TABLET EXTENDED RELEASE 24 HR DYAZIDE ORAL CAPSULE DYRENIUM ORAL CAPSULE EDARBI ORAL TABLET ST EDARBYCLOR ORAL TABLET ST EDECRIN ORAL TABLET enalapril maleate oral tablet 3 enalapril-hydrochlorothiazide oral tablet 3 EPANED ORAL RECON SOLN 43 4

46 eplerenone oral tablet 3 epoprostenol (glycine) intravenous recon soln 6 PA; SPRx eprosartan oral tablet 3 EXFORGE HCT ORAL TABLET EXFORGE ORAL TABLET felodipine oral tablet extended release 24 hr 3 FLOLAN INTRAVENOUS RECON SOLN 6 PA; SPRx; LD fosinopril oral tablet 3 fosinopril-hydrochlorothiazide oral tablet 3 furosemide oral solution 3 furosemide oral tablet 3 guanfacine oral tablet 3 hydralazine oral tablet 3 hydrochlorothiazide oral capsule 3 hydrochlorothiazide oral tablet 3 HYZAAR ORAL TABLET indapamide oral tablet 3 INDERAL LA ORAL CAPSULE,EXTENDED RELEASE 24 HR INDERAL XL ORAL CAPSULE,EXTENDED RELEASE 24HR INNOPRAN XL ORAL CAPSULE,EXTENDED RELEASE 24HR INSPRA ORAL TABLET irbesartan oral tablet 3 irbesartan-hydrochlorothiazide oral tablet 3 isradipine oral capsule 3 labetalol oral tablet 3 LASIX ORAL TABLET LEVATOL ORAL TABLET lisinopril oral tablet 3 lisinopril-hydrochlorothiazide oral tablet 3 LOPRESSOR HCT ORAL TABLET LOPRESSOR ORAL TABLET 44

47 losartan oral tablet 3 losartan-hydrochlorothiazide oral tablet 3 LOTENSIN HCT ORAL TABLET LOTENSIN ORAL TABLET LOTREL ORAL CAPSULE MAVIK ORAL TABLET MAXZIDE ORAL TABLET MAXZIDE-25MG ORAL TABLET methyclothiazide oral tablet 3 methyldopa oral tablet 3 methyldopa-hydrochlorothiazide oral tablet 3 metolazone oral tablet 3 metoprolol succinate oral tablet extended release 24 hr metoprolol ta-hydrochlorothiaz oral tablet 3 metoprolol tartrate oral tablet 3 MICARDIS HCT ORAL TABLET MICARDIS ORAL TABLET MICROZIDE ORAL CAPSULE MINIPRESS ORAL CAPSULE minoxidil oral tablet 3 moexipril oral tablet 3 moexipril-hydrochlorothiazide oral tablet 3 nadolol oral tablet 3 nadolol-bendroflumethiazide oral tablet 3 nicardipine oral capsule 3 nifedical xl oral tablet extended release 24hr 3 nifedipine oral capsule 3 nifedipine oral tablet extended release 3 nifedipine oral tablet extended release 24hr 3 nimodipine oral capsule 3 nisoldipine oral tablet extended release 24 hr 3 NORVASC ORAL TABLET 3 45

48 ORENITRAM ORAL TABLET EXTENDED RELEASE perindopril erbumine oral tablet 3 phenoxybenzamine oral capsule pindolol oral tablet 3 prazosin oral capsule 3 PRINIVIL ORAL TABLET PROCARDIA ORAL CAPSULE PROCARDIA XL ORAL TABLET EXTENDED RELEASE 24HR propranolol oral capsule,extended release 24 hr 3 propranolol oral solution 3 propranolol oral tablet 3 propranolol-hydrochlorothiazid oral tablet 3 quinapril oral tablet 3 quinapril-hydrochlorothiazide oral tablet 3 ramipril oral capsule PA; SPRx; LD REMODULIN INJECTION SOLUTION 6 PA; SPRx reserpine oral tablet 3 SECTRAL ORAL CAPSULE spironolactone oral tablet 3 spironolacton-hydrochlorothiaz oral tablet 3 SULAR ORAL TABLET EXTENDED RELEASE 24 HR TARKA ORAL TABLET, IR - ER, BIPHASIC 24HR TEKTURNA HCT ORAL TABLET TEKTURNA ORAL TABLET telmisartan oral tablet 3 telmisartan-amlodipine oral tablet 3 telmisartan-hydrochlorothiazid oral tablet 3 TENEX ORAL TABLET TENORETIC 00 ORAL TABLET TENORETIC 50 ORAL TABLET

49 TENORMIN ORAL TABLET terazosin oral capsule 3 TIAZAC ORAL CAPSULE, EXTENDED RELEASE timolol maleate oral tablet 3 TOPROL XL ORAL TABLET EXTENDED RELEASE 24 HR torsemide oral tablet 3 trandolapril oral tablet 3 trandolapril-verapamil oral tablet, ir - er, biphasic 24hr triamterene-hydrochlorothiazid oral capsule 3 triamterene-hydrochlorothiazid oral tablet 3 TRIBENZOR ORAL TABLET 4 TWYNSTA ORAL TABLET valsartan oral tablet 3 valsartan-hydrochlorothiazide oral tablet 3 VASERETIC ORAL TABLET VASOTEC ORAL TABLET veletri intravenous recon soln 6 PA; SPRx; LD verapamil oral capsule, 24 hr er pellet ct 3 verapamil oral capsule,ext rel. pellets 24 hr 3 verapamil oral tablet 3 verapamil oral tablet extended release 3 VERELAN ORAL CAPSULE,EXT REL. PELLETS 24 HR VERELAN PM ORAL CAPSULE, 24 HR ER PELLET CT ZEBETA ORAL TABLET ZESTORETIC ORAL TABLET ZESTRIL ORAL TABLET ZIAC ORAL TABLET CARDIAC GLYCOSIDES digitek oral tablet 3 digox oral tablet