Your Guide to Prescription Drug Coverage 2018 PREFERRED FORMULARY DRUG LIST

Transcription

1 Your Guide to Prescription Drug Coverage 2018 PREFERRED FORMULARY DRUG LIST This document contains information about the drugs covered in your prescription drug benefit plan.

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3 2018 Preferred Formulary Important Contacts For more information about your prescription drug coverage, call the phone number listed on your BlueCross BlueShield of Tennessee Member ID card. For information about your home delivery prescription, call Visit bcbst.com Locate a participating retail pharmacy Look up possible lower-cost prescription alternatives Compare prescription drug pricing and options Drug Benefit Reconsiderations You or your doctor may ask for reconsideration of the following: A denial of a drug benefit Limits on a drug quantity Criteria for prior authorization Use of a non-covered drug You ll need supportive documentation. That means written reasons from your doctor about why BlueCross shouldn t have denied a benefit, quantity, prior authorization or non-covered drug. Fax all information to Or send a written request to: Pharmacy Management Reconsiderations BlueCross BlueShield of Tennessee 1 Cameron Hill Circle Chattanooga, TN Please provide the following information with your request: Patient name and cardholder ID number Physician name and phone number Drug and diagnosis information All reconsiderations are considered on a caseby-case basis. See your Evidence of Coverage or member handbook for details on your rights to file reconsiderations Preferred Formulary Check often for updates, as this list is subject to change. i

4 2018 Preferred Formulary Understanding the Formulary Drug List This Formulary Drug List will help you understand the drugs your plan covers. The drugs in this formulary are listed by common categories or class then alphabetically. They are placed into cost levels known as tiers. The tiers include generic, preferred brand and non-preferred brand drugs reviewed by a panel of physicians and pharmacists regularly and revised to reflect availability of new drugs and other changes in the market. Some drugs are noted with letters next to them. The letters refer to certain pharmacy benefit programs. To make sure that prescriptions are used safely, some drugs have additional requirements that must be met before the prescription can be filled. Those drugs will have an abbreviation next to the drug name to let you and your doctor know there are additional requirements. For more information on how to fill your prescriptions, please refer to your Evidence of Coverage or member handbook on bcbst.com or call the phone number listed on your BlueCross Member ID card. Abbreviation ACA AGE-A LD PA QL SPRx ST # Description Affordable Care Act means drugs with the ACA indicator may be available to you at no out-of-pocket cost depending on your plan. Check your Evidence of Coverage or member handbook for plan details. Age Requirement means a person must be within a specific age group for a drug to be covered. Prior authorization is required for members 17 years of age and younger. Your doctor must call Express Scripts at to request approval for coverage. Limited Distribution means drugs may only be available at certain pharmacies. For more information, please call BlueCross Member Service at the phone number listed on your Member ID card. Prior Authorization may be required for certain drugs. Your doctor must call Express Scripts at to get approval before you may fill your prescription. Quantity Limit means you may have coverage for a limited amount of a specific drug. Specialty Drugs includes drugs for chronic, serious diseases such as hepatitis C, multiple sclerosis, arthritis, hemophilia and other conditions. Some plans may cover specialty drugs at different benefit levels or may require the use of a Network Specialty Pharmacy. Step Therapy is a prior authorization program that requires you to first try certain drugs to treat your medical condition before we will cover another drug for that condition. Your doctor must call Express Scripts at to request approval for coverage. Please refer to the Step Therapy list included on pages iv-v for drugs that require step therapy. Some plans do not cover these drugs. Check your Evidence of Coverage guide or Member Handbook for plan details. ii 2018 Preferred Formulary Check often for updates, as this list is subject to change.

5 2018 Preferred Formulary What s a Drug Tier? Tiers are the different cost levels you pay for a prescription drug. Each tier is assigned a cost (copay, deductible or coinsurance), which is determined by your employer or health plan. This is how much you will pay when you fill a prescription. If you have a high deductible plan, the tier cost levels may apply once you hit your deductible. Check your Evidence of Coverage or member handbook for plan details. Tier 1 Generic Drugs Generic Drugs have the same strength and active ingredients as the brand name but typically are the most affordable and offer you the lowest available copayment or coinsurance. The active ingredient in a generic drug is chemically identical to the active ingredient of the corresponding brand drug. To help lower your out-of-pocket costs, we encourage you to choose a generic medication whenever possible. Look for these drugs under in this formulary. Tier 2 Preferred Brand Drugs Preferred Brand Drugs will usually have a slightly higher copay or coinsurance than generic drugs, but less than a non-preferred brand drug under your plan. These drugs are designated preferred brand because they have been proven to be safe, effective, and more affordable compared to other brand or over-the-counter drugs that treat the same condition. Look for these drugs under in this formulary. Tier 3 Non-Preferred Brand Drugs Non-Preferred Brand Drugs are those that generally have generic alternatives and/ or one or more preferred options within the same drug class. You will usually pay the highest copay or coinsurance for a non-preferred drug under your plan. These drugs are listed as nonpreferred because they have not been found to be any more effective than available generics, preferred brands, or over-the-counter drugs. Look for these drugs under in this formulary Preferred Formulary Check often for updates, as this list is subject to change. iii

6 2018 Preferred Formulary Step Therapy Requirements Step Therapy is a prior authorization program that requires you to first try certain drugs to treat your medical condition before we will cover another drug for that condition. This chart lists the drugs that require step therapy before your plan will cover the medication. Step Therapy Drugs Edarbi Edarbyclor Non-preferred diabetic test strips (e.g., Accu-Chek, Freestyle) QL Xalatan Zioptan Admelog Admelog SoloStar Apidra Apidra SoloStar Humalog Humalog KwikPen Humalog Junior KwikPen Humulin Proventil HFA QL Ventolin HFA QL Xopenex HFA QL Osphena Premarin cream Step Therapy Requirements Trial and failure of a generic Angiotensin II Receptor Blocker (ARB), including candesartan, candesartan-hydrochlorothiazide, eprosartan, irbesartan, irbesartan-hydrochlorothiazide, losartan, losartan-hydrochlorothiazide, olmesartan, olmesartan-hydrochlorothiazide, telmisartan, telmisartanhydrochlorothiazide, valsartan and valsartan-hydrochlorothiazide Trial and failure of preferred products made by Lifescan (OneTouch) QL or Ascensia (Contour or Breeze2) QL Trial and failure of latanoprost, Lumigan, or Travatan Z Trial and failure of Fiasp, Fiasp FlexTouch or Novolog Trial and failure of Novolin Trial and failure of ProAir HFA QL or ProAir RespiClick QL Trial and failure of Estrace 0.01% cream or estradiol 0.01% cream For certain medical conditions, it is best practice to try a Preferred Drug before your plan will cover a Non-Preferred Drug. iv 2018 Preferred Formulary Check often for updates, as this list is subject to change.

7 2018 Preferred Formulary A trial of one or two Preferred Drugs will be required before a Non-Preferred Drug will be covered. Below is a table of Preferred and Non-Preferred Drugs aligned with various medical conditions. Find your condition in the first column of the chart. If there are drugs listed in the second column, this means your doctor must prescribe one of those in order to determine effectiveness prior to prescribing a drug listed in the third or fourth columns. Tier 2 Tier 3 Tier 3 Medical Condition Rheumatoid arthritis Ankylosing spondylitis Juvenile idiopathic arthritis Preferred Drug Actemra SC Enbrel Humira Xeljanz/XR Cosentyx Enbrel Humira Enbrel Humira Non - Preferred Drug Non - Preferred Drug (directed to ONE Preferred Drug) (directed to TWO Preferred Drugs) Cimzia Kevzara Kineret Orencia SC Simponi SC Cimzia Simponi SC Orencia SC Psoriatic arthritis Cosentyx Enbrel Humira Stelara SC Otezla Cimzia Orencia SC Simponi SC Taltz Xeljanz/CR Psoriasis Cosentyx Humira Otezla Enbrel* Tremfya* Siliq Taltz Stelara SC Crohn s disease Humira Stelara SC Cimzia Ulcerative colitis Humira Simponi SC SC subcutaneous *For the treatment of Psoriasis, you must try Humira first before Enbrel or Tremfya is approved. Cosentyx, Otezla or Stelara SC don t meet the requirement for coverage of Enbrel or Tremfya for Psoriasis Preferred Formulary Check often for updates, as this list is subject to change. v

8 2018 Preferred Formulary Where to Get Your Prescriptions Filled You ll need to show this card when you have a prescription filled. The card shown is an example. You may have to pay part of the cost for prescription medicines and supplies. Check your Evidence of Coverage or member handbook for specific plan details. Network Pharmacies The BlueCross pharmacy networks include many retail drug store chains and independent pharmacies across the country. If your medication is not considered a maintenance medication, the prescription is typically written for less than a 30-day supply. (See Retail 90 and Home Delivery Network for information on 90-day supplies). Always use a network pharmacy. If you use a non-network pharmacy, you must pay all of the costs for your prescription. If you re out of the state, you can find a pharmacy in the nationwide network. Check your Evidence of Coverage or member handbook for your Pharmacy Network details. How to find a network pharmacy: Call Member Service at the number on the back of your card Online, go to bcbst.com Sign up for BlueAccess SM, our secure member portal Click on Find a Doctor Click on Pharmacy and select your Pharmacy Network Or On bcbst.com, click on Find A Doctor Click on Pharmacy Select your Pharmacy Network RX04 vi 2018 Preferred Formulary Check often for updates, as this list is subject to change.

9 2018 Preferred Formulary Retail 90 Networks Through Retail 90 Networks you can get up to a 90-day (three-month) supply of your prescriptions. * With a three-month supply, you're less likely to miss a dose, which can keep you healthier. Also, you don't have to refill as often, which can save you time and money. If you use a pharmacy that s not part of your Retail 90 Network, you re limited to a 30-day (one-month) supply. These networks are made up of some local pharmacies and drug store chains. Ask your pharmacy if they are part of your Retail 90 Network. Home Delivery You can sign up for home delivery and have your prescription delivered right to your door. Home Delivery is for prescriptions with a 30-day (one-month) or a 90-day (three-month) supply. * Call to get started. Specialty Pharmacies Some serious medical conditions need specialty drugs. They may be given at the doctor s office or at home. Our Specialty Pharmacies are a special network of vendors, experienced in managing these specialty drugs and providing support to you and your doctor. You and your doctor can find a list of Specialty Pharmacies at bcbst.com. Specialty drugs: Usually require a Prior Authorization Usually are limited to a 30-day supply Are usually only available from Specialty Pharmacies who are part of the BlueCross network. Check your Evidence of Coverage or member handbook for your Pharmacy Network details. *Your doctor will need to write your prescription for a 90-day supply. **Standard shipping costs are included as part of your pharmacy plan benefit With home delivery you get: FREE standard shipping ** Access to a pharmacist 24/7 Automatic refill reminders so you re less likely to miss a dose Extended Payment Plan available 2018 Preferred Formulary Check often for updates, as this list is subject to change. vii

10 2018 Preferred Formulary Tips to Remember When Using Your Prescription Drug Benefits Talk with your doctor. Doctors are your partners in achieving and maintaining your good health, so discuss every aspect of the prescribed treatment, including the selection of drugs. The more you know, the better your choices. Ask your doctor to check the drug list before prescribing a medicine. Give your doctor a list of all the medicines you take. Include medicines that don t need a prescription. This helps them choose medicines that work well together. Advertising, social media or the internet may not be your best source of information. Discuss all your concerns with your doctor. Ask for generic drugs. The U.S. Food and Drug Administration (FDA) requires generic drugs to have the same quality, strength and purity as brand-name drugs. Generic drugs work the same as brand name drugs, but cost less. Talk to your doctor about the different kinds of generic drugs. The Formulary Drug List has different tiers (levels) of drugs that you can use (see What s a Drug Tier? on page iii). You will pay less for generic drugs almost every time. Under most BlueCross plans, if you request a brand name drug that has a generic equivalent, you will pay the cost difference between the generic and brand name drug. Check your Evidence of Coverage or member handbook to see if this applies to your plan. viii 2018 Preferred Formulary Check often for updates, as this list is subject to change.

11 2018 Preferred Formulary Talk to your pharmacist. Your pharmacist can answer questions about the drugs you take, help you avoid harmful drug interactions, and help you select appropriate, lower-cost generics and preferred brands whenever available. Have all of your family s prescriptions filled at the same pharmacy. By knowing all your prescriptions, your pharmacist can make sure all of your drugs work well together. This can help keep you or your family safe. Use over-the counter (OTC) medicines to save money. OTC medicines are sold without a prescription. Some prescription drugs may not be covered under your plan because there is an OTC available that works just as well. Don t switch from a prescription drugs to an OTC without talking with your doctor. Be smart with your prescriptions. Never share prescription drugs. That includes not giving drugs prescribed for one family member to another. Keep all medicines safe from children. Keep out of sight and out of reach. The best choice is locking them away. Don t stop taking or giving a prescription without talking to the doctor. Follow-up with the doctor about any side effects. Some prescriptions need an approval for coverage. Some prescriptions require prior authorization or step therapy. Network doctors are usually familiar with these requirements and know how to get authorizations. However, you may want to show this formulary drug list to your doctor especially if you use an out-of-network doctor or a doctor outside Tennessee. There are also limits on the amount of some prescription drugs that your plan will pay for Preferred Formulary Check often for updates, as this list is subject to change. ix

12 2018 Preferred Formulary Table of Contents Anti - Infectives... 2 Antineoplastic & Immunosuppressant Drugs...13 Autonomic & Cns Drugs, Neurology & Psych...18 Cardiovascular, Hypertension & Lipids...41 Dermatologicals/Topical Therapy...55 Diagnostics & Miscellaneous Agents...67 Ear, Nose & Throat Medications...73 Endocrine/Diabetes Gastroenterology Immunology, Vaccines & Biotechnology Musculoskeletal & Rheumatology Obstetrics & Gynecology Ophthalmology Respiratory, Allergy, Cough & Cold Urologicals Vitamins, Hematinics & Electrolytes Index of Drugs

13 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 itraconazole oral capsule ketoconazole oral tablet NOXAFIL ORAL SUSPENSION NOXAFIL ORAL TABLET,DELAYED RELEASE (DR/EC) nystatin oral powder 150 million unit, 500 million unit 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 2

14 voriconazole oral tablet Antivirals abacavir oral solution abacavir oral tablet abacavir-lamivudine oral tablet SPRx abacavir-lamivudine-zidovudine oral tablet acyclovir oral capsule acyclovir oral suspension 200 mg/5 ml acyclovir oral tablet adefovir oral tablet amantadine hcl oral capsule amantadine hcl oral solution amantadine hcl oral tablet APTIVUS ORAL CAPSULE APTIVUS ORAL SOLUTION atazanavir oral capsule SPRx ATRIPLA ORAL TABLET SPRx BARACLUDE ORAL SOLUTION BARACLUDE ORAL TABLET BIKTARVY ORAL TABLET SPRx CIMDUO ORAL TABLET SPRx COMBIVIR ORAL TABLET COMPLERA ORAL TABLET SPRx CRIXIVAN ORAL CAPSULE 200 MG, 400 MG DESCOVY ORAL TABLET SPRx didanosine oral capsule,delayed release(dr/ec) EDURANT ORAL TABLET efavirenz oral capsule efavirenz oral tablet EMTRIVA ORAL CAPSULE EMTRIVA ORAL SOLUTION entecavir oral tablet 3

15 EPCLUSA ORAL TABLET PA; SPRx EPIVIR HBV ORAL SOLUTION EPIVIR HBV ORAL TABLET EPIVIR ORAL SOLUTION EPIVIR ORAL TABLET EPZICOM ORAL TABLET SPRx EVOTAZ ORAL TABLET SPRx famciclovir oral tablet FLUMADINE ORAL TABLET fosamprenavir oral tablet FUZEON SUBCUTANEOUS RECON SOLN SPRx GENVOYA ORAL TABLET SPRx HARVONI ORAL TABLET PA; SPRx HEPSERA ORAL TABLET INTELENCE ORAL TABLET INVIRASE ORAL CAPSULE INVIRASE ORAL TABLET ISENTRESS HD ORAL TABLET SPRx ISENTRESS ORAL POWDER IN PACKET SPRx ISENTRESS ORAL TABLET SPRx ISENTRESS ORAL TABLET,CHEWABLE SPRx JULUCA ORAL TABLET SPRx KALETRA ORAL SOLUTION KALETRA ORAL TABLET lamivudine oral solution lamivudine oral tablet lamivudine-zidovudine oral tablet LEXIVA ORAL SUSPENSION LEXIVA ORAL TABLET lopinavir-ritonavir oral solution MAVYRET ORAL TABLET PA; SPRx nevirapine oral suspension nevirapine oral tablet 4

16 nevirapine oral tablet extended release 24 hr NORVIR ORAL CAPSULE NORVIR ORAL POWDER IN PACKET NORVIR ORAL SOLUTION NORVIR ORAL TABLET ODEFSEY ORAL TABLET SPRx oseltamivir oral capsule 30 mg QL (20 EA per 180 days) oseltamivir oral capsule 45 mg, 75 mg QL (10 EA per 180 days) oseltamivir oral suspension for reconstitution QL (180 ML per 180 days) PREZCOBIX ORAL TABLET SPRx PREZISTA ORAL SUSPENSION SPRx PREZISTA ORAL TABLET 150 MG, 600 MG, 75 MG, 800 MG RELENZA DISKHALER INHALATION BLISTER WITH DEVICE SPRx QL (20 EA per 180 days) RESCRIPTOR ORAL TABLET RESCRIPTOR ORAL TABLET, DISPERSIBLE RETROVIR ORAL CAPSULE REYATAZ ORAL CAPSULE 150 MG, 200 MG, 300 MG SPRx REYATAZ ORAL POWDER IN PACKET SPRx rimantadine oral tablet ritonavir oral tablet SELZENTRY ORAL SOLUTION SELZENTRY ORAL TABLET SOVALDI ORAL TABLET PA; SPRx stavudine oral capsule STRIBILD ORAL TABLET SPRx SUSTIVA ORAL CAPSULE SUSTIVA ORAL TABLET SYMFI LO ORAL TABLET SPRx SYMFI ORAL TABLET SPRx TAMIFLU ORAL CAPSULE 30 MG QL (20 EA per 180 days) 5

17 TAMIFLU ORAL CAPSULE 45 MG, 75 MG QL (10 EA per 180 days) TAMIFLU ORAL SUSPENSION FOR RECONSTITUTION QL (180 ML per 180 days) tenofovir disoproxil fumarate oral tablet TIVICAY ORAL TABLET SPRx TRIUMEQ ORAL TABLET SPRx TRIZIVIR ORAL TABLET TRUVADA ORAL TABLET SPRx TYBOST ORAL TABLET valacyclovir oral tablet VALCYTE ORAL RECON SOLN VALCYTE ORAL TABLET valganciclovir oral recon soln valganciclovir oral tablet VALTREX ORAL TABLET VEMLIDY ORAL TABLET SPRx VIDEX 2 GRAM PEDIATRIC ORAL RECON SOLN VIDEX 4 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 VIREAD ORAL POWDER VIREAD ORAL TABLET VOSEVI ORAL TABLET PA; SPRx ZERIT ORAL CAPSULE ZERIT ORAL RECON SOLN ZIAGEN ORAL SOLUTION 6

18 ZIAGEN ORAL TABLET zidovudine oral capsule zidovudine oral syrup zidovudine oral tablet ZOVIRAX ORAL CAPSULE ZOVIRAX ORAL SUSPENSION ZOVIRAX ORAL TABLET Cephalosporins cefaclor oral capsule cefaclor oral suspension for reconstitution 125 mg/5 ml, 250 mg/5 ml, 375 mg/5 ml cefaclor oral tablet extended release 12 hr cefadroxil oral capsule cefadroxil oral suspension for reconstitution 250 mg/5 ml, 500 mg/5 ml 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 cefuroxime axetil oral tablet cephalexin oral capsule cephalexin oral suspension for reconstitution cephalexin oral tablet SUPRAX ORAL CAPSULE SUPRAX ORAL SUSPENSION FOR RECONSTITUTION SUPRAX ORAL TABLET,CHEWABLE Erythromycins & Other Macrolides azithromycin oral packet 7

19 azithromycin oral suspension for reconstitution azithromycin 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) 250 mg, 333 mg ERY-TAB ORAL TABLET,DELAYED RELEASE (DR/EC) 500 MG erythrocin (as stearate) oral tablet 250 mg erythromycin ethylsuccinate oral tablet erythromycin oral capsule,delayed release(dr/ec) erythromycin oral tablet ZITHROMAX ORAL PACKET ZITHROMAX ORAL SUSPENSION FOR RECONSTITUTION ZITHROMAX ORAL TABLET 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 PA; LD; SPRx 8

20 chloroquine phosphate oral tablet CLEOCIN HCL ORAL CAPSULE CLEOCIN PEDIATRIC 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 DARAPRIM ORAL TABLET PA; LD; SPRx ethambutol oral tablet FLAGYL ORAL CAPSULE FLAGYL ORAL TABLET hydroxychloroquine oral tablet isoniazid oral solution isoniazid oral tablet ivermectin oral tablet KITABIS PAK INHALATION SOLUTION FOR NEBULIZATION LD; SPRx; QL (56 ML per 30 days) linezolid oral suspension for reconstitution QL (14 day supply per 30 days) linezolid oral tablet QL (14 day supply 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 400 MG MYCOBUTIN ORAL CAPSULE NEBUPENT INHALATION RECON SOLN neomycin oral tablet paromomycin oral capsule 9

21 PASER ORAL GRANULES DR FOR SUSP IN PACKET PLAQUENIL ORAL TABLET praziquantel 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 LD; SPRx STROMECTOL ORAL TABLET TINDAMAX ORAL TABLET 500 MG tinidazole oral tablet TOBI INHALATION SOLUTION FOR NEBULIZATION tobramycin in % nacl inhalation solution for nebulization SPRx; QL (56 ML per 30 days) SPRx; QL (56 ML per 30 days) TRECATOR ORAL TABLET XIFAXAN ORAL TABLET 200 MG XIFAXAN ORAL TABLET 550 MG ZYVOX ORAL SUSPENSION FOR RECONSTITUTION QL (14 day supply per 30 days) ZYVOX ORAL TABLET QL (14 day supply per 30 days) Penicillins amoxicillin oral capsule amoxicillin oral suspension for reconstitution amoxicillin oral tablet amoxicillin oral tablet,chewable 125 mg, 250 mg 10

22 amoxicillin-pot clavulanate oral suspension for reconstitution amoxicillin-pot clavulanate oral tablet amoxicillin-pot clavulanate oral tablet extended release 12 hr amoxicillin-pot clavulanate oral tablet,chewable ampicillin oral capsule AUGMENTIN ES-600 ORAL SUSPENSION FOR RECONSTITUTION AUGMENTIN ORAL SUSPENSION FOR RECONSTITUTION MG/5 ML, MG/5 ML AUGMENTIN ORAL TABLET MG, MG AUGMENTIN XR ORAL TABLET EXTENDED RELEASE 12 HR dicloxacillin oral capsule penicillin v potassium oral recon soln penicillin v potassium oral tablet Quinolones AVELOX ORAL TABLET CIPRO ORAL SUSPENSION,MICROCAPSULE RECON CIPRO ORAL TABLET 250 MG, 500 MG 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 500 MG, 750 MG levofloxacin oral solution levofloxacin oral tablet moxifloxacin oral tablet 11

23 ofloxacin oral tablet 300 mg, 400 mg 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 oral tablet demeclocycline oral tablet doxycycline hyclate oral capsule doxycycline hyclate oral tablet 100 mg, 20 mg doxycycline hyclate oral tablet,delayed release (dr/ec) 100 mg, 150 mg, 75 mg doxycycline monohydrate oral capsule doxycycline monohydrate oral suspension for reconstitution doxycycline monohydrate oral tablet minocycline oral capsule minocycline oral tablet soloxide oral tablet,delayed release (dr/ec) tetracycline oral capsule VIBRAMYCIN ORAL CAPSULE 100 MG 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 12

24 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 FIRVANQ ORAL RECON SOLN 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 PA; SPRx AFINITOR ORAL TABLET PA; SPRx ALECENSA ORAL CAPSULE PA; LD; SPRx ALKERAN ORAL TABLET ALUNBRIG ORAL TABLET PA; SPRx ALUNBRIG ORAL TABLETS,DOSE PACK PA; SPRx anastrozole oral tablet ARIMIDEX ORAL TABLET AROMASIN ORAL TABLET ASTAGRAF XL ORAL CAPSULE,EXTENDED RELEASE 24HR SPRx AZASAN ORAL TABLET azathioprine oral tablet bexarotene oral capsule SPRx bicalutamide oral tablet BOSULIF ORAL TABLET PA; LD; SPRx 13

25 CABOMETYX ORAL TABLET PA; LD; SPRx CALQUENCE ORAL CAPSULE PA; SPRx capecitabine oral tablet SPRx CAPRELSA ORAL TABLET PA; LD; SPRx CASODEX ORAL TABLET CELLCEPT ORAL CAPSULE CELLCEPT ORAL SUSPENSION FOR RECONSTITUTION COMETRIQ ORAL CAPSULE LD; SPRx COTELLIC ORAL TABLET PA; LD; SPRx cyclophosphamide oral capsule cyclosporine modified oral capsule cyclosporine modified oral solution cyclosporine oral capsule DROXIA ORAL CAPSULE EMCYT ORAL CAPSULE ERIVEDGE ORAL CAPSULE PA; LD; SPRx ERLEADA ORAL TABLET PA; SPRx etoposide oral capsule exemestane oral tablet FARESTON ORAL TABLET FARYDAK ORAL CAPSULE PA; LD; SPRx FEMARA ORAL TABLET flutamide oral capsule gengraf oral capsule 100 mg, 25 mg gengraf oral solution GILOTRIF ORAL TABLET PA; LD; SPRx GLEEVEC ORAL TABLET SPRx GLEOSTINE ORAL CAPSULE HEXALEN ORAL CAPSULE HYCAMTIN ORAL CAPSULE SPRx HYDREA ORAL CAPSULE hydroxyurea oral capsule 14

26 IBRANCE ORAL CAPSULE PA; LD; SPRx ICLUSIG ORAL TABLET PA; LD; SPRx IDHIFA ORAL TABLET PA; SPRx imatinib oral tablet SPRx IMBRUVICA ORAL CAPSULE PA; LD; SPRx IMBRUVICA ORAL TABLET PA; LD; SPRx IMURAN ORAL TABLET INLYTA ORAL TABLET PA; LD; SPRx IRESSA ORAL TABLET PA; LD; SPRx JAKAFI ORAL TABLET PA; LD; SPRx KISQALI FEMARA CO-PACK ORAL TABLET PA; SPRx KISQALI ORAL TABLET PA; SPRx LENVIMA ORAL CAPSULE 10 MG/DAY (10 MG X 1), 14 MG/DAY(10 MG X 1-4 MG X 1), 18 MG/DAY (10 MG X 1-4 MG X2), 20 MG/DAY (10 MG X 2), 24 MG/DAY(10 MG X 2-4 MG X 1), 8 MG/DAY (4 MG X 2) PA; LD; SPRx letrozole oral tablet LEUKERAN ORAL TABLET leuprolide subcutaneous kit PA; SPRx LONSURF ORAL TABLET PA; LD; SPRx LYNPARZA ORAL CAPSULE PA; LD; SPRx LYNPARZA ORAL TABLET PA; SPRx LYSODREN ORAL TABLET MATULANE ORAL CAPSULE SPRx MEGACE ES ORAL SUSPENSION megestrol oral suspension 400 mg/10 ml (40 mg/ml), 625 mg/5 ml megestrol oral tablet MEKINIST ORAL TABLET PA; SPRx melphalan oral tablet mercaptopurine oral tablet methotrexate sodium (pf) injection recon soln methotrexate sodium (pf) injection solution 15

27 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 NERLYNX ORAL TABLET PA; SPRx NEXAVAR ORAL TABLET PA; LD; SPRx NILANDRON ORAL TABLET SPRx nilutamide oral tablet SPRx NINLARO ORAL CAPSULE PA; LD; SPRx octreotide acetate injection solution SPRx octreotide acetate injection syringe SPRx ODOMZO ORAL CAPSULE PA; SPRx PROGRAF ORAL CAPSULE PURIXAN ORAL SUSPENSION SPRx RAPAMUNE ORAL SOLUTION RAPAMUNE ORAL TABLET RUBRACA ORAL TABLET PA; LD; SPRx RYDAPT ORAL CAPSULE PA; SPRx SANDIMMUNE ORAL CAPSULE SANDIMMUNE ORAL SOLUTION SANDOSTATIN INJECTION SOLUTION 100 MCG/ML, 50 MCG/ML, 500 MCG/ML SPRx SIGNIFOR SUBCUTANEOUS SOLUTION PA; LD; SPRx SIKLOS ORAL TABLET sirolimus oral tablet 16

28 SOLTAMOX ORAL SOLUTION ACA SPRYCEL ORAL TABLET SPRx STIVARGA ORAL TABLET PA; LD; SPRx SUTENT ORAL CAPSULE PA; LD; SPRx TABLOID ORAL TABLET tacrolimus oral capsule TAFINLAR ORAL CAPSULE PA; LD; SPRx TAGRISSO ORAL TABLET PA; LD; SPRx tamoxifen oral tablet ACA TARCEVA ORAL TABLET PA; LD; SPRx TARGRETIN ORAL CAPSULE SPRx TARGRETIN TOPICAL GEL SPRx TASIGNA ORAL CAPSULE SPRx TEMODAR ORAL CAPSULE PA; SPRx temozolomide oral capsule PA; SPRx THALOMID ORAL CAPSULE PA; LD; SPRx tretinoin (chemotherapy) oral capsule TREXALL ORAL TABLET TYKERB ORAL TABLET PA; LD; SPRx VENCLEXTA ORAL TABLET PA; LD; SPRx VENCLEXTA STARTING PACK ORAL TABLETS,DOSE PACK PA; LD; SPRx VERZENIO ORAL TABLET PA; SPRx VOTRIENT ORAL TABLET PA; LD; SPRx XALKORI ORAL CAPSULE PA; LD; SPRx XELODA ORAL TABLET SPRx XERMELO ORAL TABLET PA; SPRx XTANDI ORAL CAPSULE LD; SPRx YONSA ORAL TABLET PA; SPRx ZEJULA ORAL CAPSULE PA; LD; SPRx ZELBORAF ORAL TABLET PA; LD; SPRx ZOLINZA ORAL CAPSULE SPRx ZORTRESS ORAL TABLET SPRx 17

29 ZYDELIG ORAL TABLET PA; SPRx ZYKADIA ORAL CAPSULE PA; SPRx ZYTIGA ORAL TABLET SPRx Autonomic & Cns Drugs, Neurology & Psych Agents For Narcotic Withdrawal BUNAVAIL BUCCAL FILM QL (90 EA per 30 days) buprenorphine-naloxone sublingual tablet QL (90 EA per 30 days) SUBOXONE SUBLINGUAL FILM QL (90 EA per 30 days) ZUBSOLV SUBLINGUAL TABLET QL (90 EA per 30 days) Anticonvulsants APTIOM ORAL TABLET BANZEL ORAL SUSPENSION BANZEL ORAL TABLET carbamazepine oral capsule, er multiphase 12 hr carbamazepine oral suspension carbamazepine oral tablet carbamazepine oral tablet extended release 12 hr carbamazepine oral tablet,chewable CARBATROL ORAL CAPSULE, ER MULTIPHASE 12 HR CELONTIN ORAL CAPSULE 300 MG clonazepam oral tablet clonazepam oral tablet,disintegrating DEPAKENE ORAL CAPSULE DEPAKENE ORAL SOLUTION DEPAKOTE ER ORAL TABLET EXTENDED RELEASE 24 HR DEPAKOTE ORAL TABLET,DELAYED RELEASE (DR/EC) DEPAKOTE SPRINKLES ORAL CAPSULE, DELAYED REL SPRINKLE DIASTAT ACUDIAL RECTAL KIT DIASTAT RECTAL KIT diazepam rectal kit 18

30 DILANTIN EXTENDED ORAL CAPSULE DILANTIN INFATABS ORAL TABLET,CHEWABLE DILANTIN KAPSEAL ORAL CAPSULE DILANTIN ORAL CAPSULE DILANTIN-125 ORAL SUSPENSION divalproex oral capsule, delayed rel sprinkle divalproex oral tablet extended release 24 hr divalproex oral tablet,delayed release (dr/ec) epitol oral tablet EQUETRO ORAL CAPSULE, ER MULTIPHASE 12 HR ethosuximide oral capsule ethosuximide oral solution felbamate oral suspension felbamate oral tablet FELBATOL ORAL SUSPENSION FELBATOL ORAL TABLET FYCOMPA ORAL TABLET gabapentin oral capsule gabapentin oral solution gabapentin oral tablet 600 mg, 800 mg GABITRIL ORAL TABLET KEPPRA ORAL SOLUTION KEPPRA ORAL TABLET KEPPRA XR ORAL TABLET EXTENDED RELEASE 24 HR KLONOPIN ORAL TABLET LAMICTAL ODT ORAL TABLET,DISINTEGRATING LAMICTAL ODT STARTER (BLUE) ORAL TABLET DISINTEGRATING, DOSE PK LAMICTAL ODT STARTER (GREEN) ORAL TABLET DISINTEGRATING, DOSE PK 19

31 LAMICTAL ODT STARTER (ORANGE) ORAL TABLET DISINTEGRATING, DOSE PK LAMICTAL ORAL TABLET LAMICTAL ORAL TABLET, CHEWABLE DISPERSIBLE 25 MG, 5 MG 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 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 lamotrigine oral tablet disintegrating, dose pk lamotrigine oral tablet extended release 24hr lamotrigine oral tablet, chewable dispersible lamotrigine oral tablet,disintegrating lamotrigine oral tablets,dose pack levetiracetam oral solution levetiracetam oral tablet levetiracetam oral tablet extended release 24 hr LYRICA CR ORAL TABLET EXTENDED RELEASE 24 HR LYRICA ORAL CAPSULE LYRICA ORAL SOLUTION MYSOLINE ORAL TABLET NEURONTIN ORAL CAPSULE NEURONTIN ORAL SOLUTION 20

32 NEURONTIN ORAL TABLET ONFI ORAL SUSPENSION ONFI ORAL TABLET 10 MG, 20 MG oxcarbazepine oral suspension oxcarbazepine oral tablet OXTELLAR XR ORAL TABLET EXTENDED RELEASE 24 HR PEGANONE ORAL TABLET phenobarbital oral elixir phenobarbital oral tablet PHENYTEK ORAL CAPSULE phenytoin oral suspension phenytoin oral tablet,chewable phenytoin sodium extended oral capsule primidone oral tablet QUDEXY XR ORAL CAPSULE,SPRINKLE,ER 24HR roweepra oral tablet roweepra xr oral tablet extended release 24 hr SABRIL ORAL POWDER IN PACKET LD SABRIL ORAL TABLET LD SPRITAM ORAL TABLET FOR SUSPENSION subvenite oral tablet subvenite starter (blue) kit oral tablets,dose pack subvenite starter (green) kit oral tablets,dose pack subvenite starter (orange) kit oral tablets,dose pack TEGRETOL ORAL SUSPENSION TEGRETOL ORAL TABLET TEGRETOL XR ORAL TABLET EXTENDED RELEASE 12 HR tiagabine oral tablet TOPAMAX ORAL CAPSULE, SPRINKLE 21

33 TOPAMAX ORAL TABLET topiramate oral capsule, sprinkle TOPIRAMATE ORAL CAPSULE,SPRINKLE,ER 24HR topiramate oral tablet TRILEPTAL ORAL SUSPENSION TRILEPTAL ORAL TABLET TROKENDI XR ORAL CAPSULE,EXTENDED RELEASE 24HR valproic acid (as sodium salt) oral solution valproic acid oral capsule vigabatrin oral powder in packet vigadrone oral powder in packet VIMPAT ORAL SOLUTION VIMPAT ORAL TABLET ZARONTIN ORAL CAPSULE ZARONTIN ORAL SOLUTION ZONEGRAN ORAL CAPSULE 100 MG, 25 MG zonisamide oral capsule Antiparkinsonism Agents APOKYN SUBCUTANEOUS CARTRIDGE SPRx AZILECT ORAL TABLET benztropine oral tablet bromocriptine oral capsule bromocriptine oral tablet 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 LD; SPRx 22

34 ELDEPRYL ORAL CAPSULE entacapone oral tablet 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 rasagiline oral tablet 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 100 ORAL TABLET STALEVO 125 ORAL TABLET STALEVO 150 ORAL TABLET STALEVO 200 ORAL TABLET STALEVO 50 ORAL TABLET STALEVO 75 ORAL TABLET TASMAR ORAL TABLET 100 MG tolcapone oral tablet trihexyphenidyl oral elixir trihexyphenidyl oral tablet 23

35 ZELAPAR ORAL TABLET,DISINTEGRATING Migraine & Cluster Headache Therapy almotriptan malate oral tablet QL (18 EA per 30 days) ALSUMA SUBCUTANEOUS PEN INJECTOR QL (8 ML per 30 days) AMERGE ORAL TABLET QL (18 EA per 30 days) CAFERGOT ORAL TABLET D.H.E.45 INJECTION SOLUTION dihydroergotamine injection solution dihydroergotamine nasal spray,non-aerosol QL (8 ML per 30 days) eletriptan oral tablet QL (18 EA per 30 days) ERGOMAR SUBLINGUAL TABLET ergotamine-caffeine oral tablet frovatriptan oral tablet QL (18 EA per 30 days) IMITREX NASAL SPRAY,NON-AEROSOL QL (12 EA per 30 days) IMITREX ORAL TABLET QL (18 EA 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 QL (12 ML per 30 days) QL (8 ML per 30 days) QL (12 ML per 30 days) QL (8 ML per 30 days) IMITREX SUBCUTANEOUS SOLUTION QL (8 ML per 30 days) isometh-dichloral-acetaminophn oral capsule isomethepten-caf-acetaminophen oral tablet mg migergot rectal suppository MIGRANAL NASAL SPRAY,NON AEROSOL QL (8 ML per 30 days) naratriptan oral tablet QL (18 EA per 30 days) 24

36 RELPAX ORAL TABLET QL (18 EA per 30 days) rizatriptan oral tablet QL (18 EA per 30 days) rizatriptan oral tablet,disintegrating QL (18 EA per 30 days) sumatriptan nasal spray,non-aerosol QL (12 EA per 30 days) sumatriptan succinate oral tablet QL (18 EA per 30 days) sumatriptan succinate subcutaneous cartridge 4 mg/0.5 ml 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 QL (12 ML per 30 days) QL (8 ML per 30 days) QL (12 ML per 30 days) QL (8 ML per 30 days) sumatriptan succinate subcutaneous solution QL (8 ML 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 (12 ML per 30 days) QL (8 ML per 30 days) zolmitriptan oral tablet QL (18 EA per 30 days) zolmitriptan oral tablet,disintegrating QL (18 EA per 30 days) Miscellaneous Neurological Therapy AMPYRA ORAL TABLET EXTENDED RELEASE 12 HR PA; SPRx ARICEPT ORAL TABLET AUSTEDO ORAL TABLET PA; LD; SPRx donepezil oral tablet donepezil oral tablet,disintegrating galantamine oral capsule,ext rel. pellets 24 hr galantamine oral solution galantamine oral tablet HORIZANT ORAL TABLET EXTENDED RELEASE KEVEYIS ORAL TABLET PA; LD; SPRx memantine oral capsule,sprinkle,er 24hr memantine oral solution 25

37 memantine oral tablet MEMANTINE ORAL TABLETS,DOSE PACK NAMENDA ORAL TABLET 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 CAP,SPRINKLE,ER 24HR DOSE PACK 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 tetrabenazine oral tablet PA; SPRx XENAZINE ORAL TABLET PA; SPRx Muscle Relaxants & Antispasmodic Therapy baclofen oral tablet 10 mg, 20 mg carisoprodol oral tablet carisoprodol-asa-codeine oral tablet carisoprodol-aspirin oral tablet chlorzoxazone oral tablet cyclobenzaprine oral tablet DANTRIUM ORAL CAPSULE 25 MG, 50 MG dantrolene oral capsule FEXMID ORAL TABLET meprobamate oral tablet MESTINON ORAL SYRUP MESTINON ORAL TABLET 26

38 MESTINON TIMESPAN ORAL TABLET EXTENDED RELEASE metaxalone oral tablet 800 mg methocarbamol oral tablet orphenadrine citrate oral tablet extended release 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 tizanidine oral tablet ZANAFLEX ORAL CAPSULE ZANAFLEX ORAL TABLET Narcotic Analgesics ABSTRAL SUBLINGUAL TABLET QL (9 EA per 30 days) acetaminophen-caff-dihydrocod oral capsule QL (120 EA per 30 days) acetaminophen-codeine oral solution mg/5 ml QL (4500 ML per 30 days) acetaminophen-codeine oral tablet QL (180 EA per 30 days) ACTIQ BUCCAL LOZENGE ON A HANDLE 1,200 MCG ACTIQ BUCCAL LOZENGE ON A HANDLE 1,600 MCG ACTIQ BUCCAL LOZENGE ON A HANDLE 200 MCG ACTIQ BUCCAL LOZENGE ON A HANDLE 400 MCG ACTIQ BUCCAL LOZENGE ON A HANDLE 600 MCG ACTIQ BUCCAL LOZENGE ON A HANDLE 800 MCG QL (39 EA per 30 days) QL (29 EA per 30 days) QL (120 EA per 30 days) QL (116 EA per 30 days) QL (77 EA per 30 days) QL (58 EA per 30 days) ascomp with codeine oral capsule QL (120 EA per 30 days) BUPAP ORAL TABLET MG QL (120 EA per 30 days) 27

39 butalbital compound w/codeine oral capsule QL (120 EA per 30 days) butalbital-acetaminop-caf-cod oral capsule QL (120 EA per 30 days) butalbital-acetaminophen oral tablet QL (120 EA per 30 days) butalbital-acetaminophen-caff oral capsule QL (120 EA per 30 days) butalbital-acetaminophen-caff oral tablet mg QL (120 EA per 30 days) butalbital-aspirin-caffeine oral capsule QL (120 EA per 30 days) butalbital-aspirin-caffeine oral tablet QL (120 EA per 30 days) butorphanol tartrate nasal spray,non-aerosol QL (5 ML per 28 days) BUTRANS TRANSDERMAL PATCH WEEKLY PA; QL (4 EA per 28 days) capacet oral capsule QL (120 EA per 30 days) codeine sulfate oral tablet QL (180 EA per 30 days) codeine-butalbital-asa-caff oral capsule QL (120 EA per 30 days) DEMEROL ORAL TABLET 100 MG QL (120 EA per 30 days) DILAUDID ORAL LIQUID QL (30 ML per 30 days) DILAUDID ORAL TABLET QL (120 EA per 30 days) diskets oral tablet,soluble PA; QL (50 EA per 30 days) DOLOPHINE ORAL TABLET PA; QL (120 EA per 30 days) DURAGESIC TRANSDERMAL PATCH 72 HOUR endocet oral tablet mg, mg, mg, mg PA; QL (10 EA per 30 days) QL (120 EA per 30 days) ESGIC ORAL CAPSULE QL (120 EA per 30 days) ESGIC ORAL TABLET QL (120 EA per 30 days) fentanyl citrate buccal lozenge on a handle 1,200 mcg fentanyl citrate buccal lozenge on a handle 1,600 mcg fentanyl citrate buccal lozenge on a handle 200 mcg fentanyl citrate buccal lozenge on a handle 400 mcg fentanyl citrate buccal lozenge on a handle 600 mcg QL (39 EA per 30 days) QL (29 EA per 30 days) QL (120 EA per 30 days) QL (116 EA per 30 days) QL (77 EA per 30 days) 28

40 fentanyl citrate buccal lozenge on a handle 800 mcg fentanyl transdermal patch 72 hour 100 mcg/hr, 12 mcg/hr, 25 mcg/hr, 50 mcg/hr, 75 mcg/hr FENTORA BUCCAL TABLET, EFFERVESCENT QL (58 EA per 30 days) PA; QL (10 EA per 30 days) QL (9 EA per 30 days) FIORICET ORAL CAPSULE QL (120 EA per 30 days) FIORINAL ORAL CAPSULE QL (120 EA per 30 days) FIORINAL-CODEINE #3 ORAL CAPSULE QL (120 EA per 30 days) HYCET ORAL SOLUTION QL (5550 ML per 30 days) hydrocodone-acetaminophen oral solution mg/15 ml hydrocodone-acetaminophen oral tablet mg, mg, mg, mg, mg, mg, mg hydrocodone-ibuprofen oral tablet mg, mg, mg QL (5550 ML per 30 days) QL (120 EA per 30 days) QL (120 EA per 30 days) hydromorphone oral liquid QL (30 ML per 30 days) hydromorphone oral tablet QL (120 EA per 30 days) hydromorphone rectal suppository QL (60 EA per 30 days) IBUDONE ORAL TABLET QL (120 EA per 30 days) ibuprofen-oxycodone oral tablet QL (28 EA per 30 days) KADIAN ORAL CAPSULE,EXTEND.RELEASE PELLETS 10 MG, 100 MG, 20 MG, 200 MG, 30 MG, 40 MG, 50 MG, 60 MG, 80 MG PA; QL (60 EA per 30 days) levorphanol tartrate oral tablet QL (120 EA per 30 days) lorcet (hydrocodone) oral tablet QL (120 EA per 30 days) lorcet hd oral tablet QL (120 EA per 30 days) lorcet plus oral tablet mg QL (120 EA per 30 days) LORTAB ELIXIR ORAL SOLUTION MG/15 ML QL (480 ML per 30 days) meperidine oral solution QL (480 ML per 30 days) meperidine oral tablet QL (120 EA per 30 days) methadone oral concentrate PA; QL (120 ML per 30 days) methadone oral solution 10 mg/5 ml PA; QL (480 ML per 30 days) 29

41 methadone oral solution 5 mg/5 ml PA; QL (960 ML per 30 days) methadone oral tablet PA; QL (120 EA per 30 days) methadone oral tablet,soluble PA; QL (50 EA per 30 days) methadose oral concentrate PA; QL (120 ML per 30 days) methadose oral tablet,soluble PA; QL (50 EA per 30 days) morphine concentrate oral solution QL (300 ML per 30 days) morphine oral capsule, er multiphase 24 hr 120 mg morphine oral capsule, er multiphase 24 hr 30 mg, 45 mg, 60 mg, 75 mg, 90 mg PA; QL (50 EA per 30 days) PA; QL (60 EA per 30 days) morphine oral capsule,extend.release pellets PA; QL (60 EA per 30 days) morphine oral solution QL (900 ML per 30 days) morphine oral tablet QL (120 EA per 30 days) morphine oral tablet extended release 100 mg, 15 mg, 30 mg, 60 mg PA; QL (60 EA per 30 days) morphine oral tablet extended release 200 mg PA; QL (30 EA per 30 days) morphine rectal suppository QL (120 EA per 30 days) MS CONTIN ORAL TABLET EXTENDED RELEASE PA; QL (60 EA per 30 days) NORCO ORAL TABLET QL (120 EA per 30 days) NUCYNTA ER ORAL TABLET EXTENDED RELEASE 12 HR PA; QL (60 EA per 30 days) NUCYNTA ORAL TABLET QL (120 EA per 30 days) OPANA ORAL TABLET QL (120 EA per 30 days) oxycodone oral capsule QL (120 EA per 30 days) oxycodone oral concentrate QL (120 ML per 30 days) oxycodone oral solution QL (480 ML per 30 days) oxycodone oral tablet QL (120 EA per 30 days) oxycodone-acetaminophen oral tablet mg, mg, mg, mg QL (120 EA per 30 days) oxycodone-aspirin oral tablet QL (120 EA per 30 days) OXYCONTIN ORAL TABLET,ORAL ONLY,EXT.REL.12 HR 10 MG, 15 MG, 20 MG, 30 MG, 40 MG, 60 MG OXYCONTIN ORAL TABLET,ORAL ONLY,EXT.REL.12 HR 80 MG PA; QL (60 EA per 30 days) PA; QL (50 EA per 30 days) 30

42 oxymorphone oral tablet QL (120 EA per 30 days) oxymorphone oral tablet extended release 12 hr PA; QL (60 EA per 30 days) pentazocine-naloxone oral tablet QL (120 EA per 30 days) PERCOCET ORAL TABLET MG, MG, MG, MG QL (120 EA per 30 days) phrenilin forte(with caffeine) oral capsule QL (120 EA per 30 days) PRIMLEV ORAL TABLET QL (120 EA per 30 days) reprexain oral tablet mg QL (120 EA per 30 days) ROXICODONE ORAL TABLET QL (120 EA per 30 days) tencon oral tablet mg QL (120 EA per 30 days) tramadol oral tablet QL (240 EA per 30 days) tramadol oral tablet extended release 24 hr PA; QL (30 EA per 30 days) tramadol oral tablet, er multiphase 24 hr PA; QL (30 EA per 30 days) tramadol-acetaminophen oral tablet QL (240 EA per 30 days) TREZIX ORAL CAPSULE MG QL (120 EA per 30 days) TYLENOL-CODEINE #3 ORAL TABLET QL (180 EA per 30 days) TYLENOL-CODEINE #4 ORAL TABLET QL (180 EA per 30 days) ULTRACET ORAL TABLET QL (240 EA per 30 days) ULTRAM ER ORAL TABLET EXTENDED RELEASE 24 HR 300 MG PA; QL (30 EA per 30 days) ULTRAM ORAL TABLET QL (240 EA per 30 days) verdrocet oral tablet QL (120 EA per 30 days) vicodin es oral tablet QL (120 EA per 30 days) vicodin hp oral tablet QL (120 EA per 30 days) vicodin oral tablet QL (120 EA per 30 days) xylon 10 oral tablet QL (150 EA per 30 days) zebutal oral capsule mg QL (120 EA per 30 days) Non-Narcotic Analgesics ANAPROX DS ORAL TABLET ARTHROTEC 50 ORAL TABLET,IR,DELAYED REL,BIPHASIC ARTHROTEC 75 ORAL TABLET,IR,DELAYED REL,BIPHASIC aspirin oral tablet,delayed release (dr/ec) 81 mg ACA 31

43 CELEBREX ORAL CAPSULE celecoxib oral capsule choline,magnesium salicylate oral liquid DAYPRO ORAL TABLET diclofenac potassium oral tablet diclofenac sodium oral tablet extended release 24 hr diclofenac sodium oral tablet,delayed release (dr/ec) diclofenac sodium topical gel 1 % QL (500 GM per 30 days) 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 flurbiprofen oral tablet ibu oral tablet ibuprofen oral suspension ibuprofen oral tablet 400 mg, 600 mg, 800 mg INDOCIN ORAL SUSPENSION INDOCIN RECTAL SUPPOSITORY indomethacin oral capsule indomethacin oral capsule, extended release ketoprofen oral capsule ketoprofen oral capsule,ext rel. pellets 24 hr 200 mg ketorolac oral tablet LODINE ORAL TABLET 32

44 LUCEMYRA ORAL TABLET meclofenamate oral capsule mefenamic acid oral capsule meloxicam oral suspension meloxicam oral tablet MOBIC ORAL TABLET nabumetone oral tablet NALFON ORAL CAPSULE 400 MG NAPRELAN CR ORAL TABLET, ER MULTIPHASE 24 HR NAPROSYN ORAL SUSPENSION NAPROSYN ORAL TABLET 500 MG naproxen oral suspension naproxen oral tablet naproxen oral tablet,delayed release (dr/ec) naproxen sodium oral tablet 275 mg, 550 mg oxaprozin oral tablet piroxicam oral capsule REVIA ORAL TABLET salsalate oral tablet SPRIX NASAL SPRAY,NON-AEROSOL LD; SPRx sulindac oral tablet tolmetin oral capsule tolmetin oral tablet VOLTAREN-XR ORAL TABLET EXTENDED RELEASE 24 HR Opiate/Narcotic Reversal Agents - Opiate Antagonists naloxone injection solution QL (2 units per 1 claim) naloxone injection syringe QL (2 units per 1 claim) naltrexone oral tablet NARCAN NASAL SPRAY,NON-AEROSOL 4 MG/ACTUATION Psychotherapeutic Drugs QL (2 units per 1 claim) 33