List of Covered Drugs (Formulary)

Transcription

1 2019 List of Covered Drugs (Formulary) Formulary ID: Version 6 Updated 09/2018. If you have questions, please call AmeriHealth Caritas VIP Care Plus at (TTY 711), 8 a.m. 8 p.m., seven days a week. The call is free. For more information, visit H0192_001_FOR_278761_Approved_ _FINAL

2 AmeriHealth Caritas VIP Care Plus (Medicare-Medicaid Plan) 2019 List of Covered Drugs (Formulary) Introduction This document is called the List of Covered Drugs (also known as the Drug List). It tells you which prescription drugs, over-the-counter drugs and items are covered by AmeriHealth Caritas VIP Care Plus. The Drug List also tells you if there are any special rules or restrictions on any drugs covered by AmeriHealth Caritas VIP Care Plus. Key terms and their definitions appear in the last chapter of the Member Handbook. If you have questions, please call AmeriHealth Caritas VIP Care Plus at (TTY 711), 8 a.m. 8 p.m., seven days a week. The call is free. For more information, visit i

3 Table of Contents A. Disclaimers...iii B. Frequently Asked Questions (FAQ)...iii B1. What prescription drugs are on the List of Covered Drugs? (We call the List of Covered Drugs the Drug List for short.)...iii B2. Does the Drug List ever change?...iv B3. What happens when there is change to the Drug List?...v B4. Are there any restrictions or limits on drug coverage? Or are there any required actions to take to get certain drugs?...vi B5. How will you know if the drug you want has limitations or if there are required actions to take to get the drug?...vi B6. What happens if we change our rules about some drugs (for example, prior authorization (approval), quantity limits, and/or step therapy restrictions)?...vi B7. How can you find a drug on the Drug List?...vii B8. What if the drug you want to take is not on the Drug List?...vii B9. What if you are a new AmeriHealth Caritas VIP Care Plus member and can t find your drug on the Drug List or have a problem getting your drug?...vii B10. Can you ask for an exception to cover your drug?... viii B11. How can you ask for an exception?... viii B12. How long does it take to get an exception?...ix B13. What are generic drugs?...ix B14. What are OTC drugs?...ix B15. Does AmeriHealth Caritas VIP Care Plus cover OTC non-drug products?...ix B16. What is your copay?...ix B17. What are drug tiers?...ix C. List of Covered Drugs...x D. List of Drugs by Medical Condition...xi E. Index of Covered Drugs If you have questions, please call AmeriHealth Caritas VIP Care Plus at (TTY 711), 8 a.m. 8 p.m., seven days a week. The call is free. For more information, visit ii

4 A. Disclaimers This is a list of drugs that members can get in AmeriHealth Caritas VIP Care Plus. AmeriHealth Caritas VIP Care Plus is a health plan that contracts with both Medicare and Michigan Medicaid to provide benefits of both programs to enrollees. This is not a complete list. The benefit information is a brief summary, not a complete description of benefits. For more information contact the plan or read the Member Handbook. ATENCIÓN: Si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al (TTY 711) de 8 a.m. a 8 p.m., los siete días de la semana. La llamada es gratuita. You can also get this document for free in other formats, such as large print, Braille, or audio. Call (TTY 711), 8 a.m. 8 p.m., seven days a week. The call is free. To make a request to get the List of Covered Drugs, now and in the future, in a language other than English or in an alternate format, call Member Services at (TTY 711), 8 a.m. 8 p.m., seven days a week. The call is free. B. Frequently Asked Questions (FAQ) Find answers here to questions you have about this List of Covered Drugs. You can read all of the FAQ to learn more, or look for a question and answer. B1. What prescription drugs are on the List of Covered Drugs? (We call the List of Covered Drugs the Drug List for short.) The drugs on the List of Covered Drugs that starts on page 1 are the drugs covered by AmeriHealth Caritas VIP Care Plus. These drugs are available at pharmacies within our network. A pharmacy is in our network if we have an agreement with them to work with us and provide you services. We refer to these pharmacies as network pharmacies. AmeriHealth Caritas VIP Care Plus will cover all medically necessary drugs on the Drug List if: your doctor or other prescriber says you need them to get better or stay healthy, and you fill the prescription at an AmeriHealth Caritas VIP Care Plus network pharmacy. AmeriHealth Caritas VIP Care Plus may have additional steps to access certain drugs (see question B4 below). You can also see an up-to-date list of drugs that we cover on our website at or call Member Services toll-free at (TTY 711), 8 a.m. 8 p.m., seven days a week. If you have questions, please call AmeriHealth Caritas VIP Care Plus at (TTY 711), 8 a.m. 8 p.m., seven days a week. The call is free. For more information, visit iii

5 B2. Does the Drug List ever change? Yes. AmeriHealth Caritas VIP Care Plus may add or remove drugs on the Drug List during the year. We may also change our rules about drugs. For example, we could: Decide to require or not require prior approval for a drug. (Prior approval is permission from AmeriHealth Caritas VIP Care Plus before you can get a drug.) Add or change the amount of a drug you can get (called quantity limits ). Add or change step therapy restrictions on a drug. (Step therapy means you must try one drug before we will cover another drug.) For more information on these drug rules, see question B4. If you are taking a drug that was covered at the beginning of the year, we will generally not remove or change coverage of that drug during the rest of the year unless: a new, cheaper drug comes along that works as well as a drug on the Drug List now, or we learn that a drug is not safe, or a drug is removed from the market. Questions B3 and B6 below have more information on what happens when the Drug List changes. You can always check AmeriHealth Caritas VIP Care Plus' up to date Drug List online at You can also call Member Services to check the current Drug List at (TTY 711), 8 a.m. 8 p.m., seven days a week. If you have questions, please call AmeriHealth Caritas VIP Care Plus at (TTY 711), 8 a.m. 8 p.m., seven days a week. The call is free. For more information, visit iv

6 B3. What happens when there is change to the Drug List? Some changes to the Drug List will happen immediately. For example: A new generic drug becomes available. Sometimes, a new and cheaper drug comes along that works as well as a drug on the Drug List now. When that happens, we may remove the current drug, but your cost for the new drug will stay the same. When we add the new generic drug, we may also decide to keep the current drug on the list but change its coverage rules or limits. We may not tell you before we make this change, but we will send you information about the specific change or changes we made. You or your provider can ask for an exception from these changes. We will send you a notice with the steps you can take to ask for an exception. Please see question B10 for more information on exceptions. A drug is taken off the market. If the Food and Drug Administration (FDA) says a drug you are taking is not safe or the drug s manufacturer takes a drug off the market, we will take it off the Drug List. If you are taking the drug, we will let you know. If you are notified that your medication has been taken off the market and is removed from the drug list, you should contact the provider who wrote the prescription. We may make other changes that affect the drugs you take. We will tell you in advance about these other changes to the Drug List. These changes might happen if: The FDA provides new guidance or there are new clinical guidelines about a drug. We add a generic drug that is not new to the market and Replace a brand name drug currently on the Drug List or Change the coverage rules or limits for the brand name drug. When these changes happen, we will tell you at least 30 days before we make the change to the Drug List or when you ask for a refill. This will give you time to talk to your doctor or other prescriber. He or she can help you decide if there is a similar drug on the Drug List you can take instead or whether to ask for an exception. Then you can: Get a 30-day supply of the drug before the change to the Drug List is made, or Ask for an exception from these changes. Please see question B10 for more information about exceptions. If you have questions, please call AmeriHealth Caritas VIP Care Plus at (TTY 711), 8 a.m. 8 p.m., seven days a week. The call is free. For more information, visit v

7 B4. Are there any restrictions or limits on drug coverage? Or are there any required actions to take to get certain drugs? Yes, some drugs have coverage rules or have limits on the amount you can get. In some cases you or your doctor or other prescriber must do something before you can get the drug. For example: Prior approval (or prior authorization): For some drugs, you or your doctor or other prescriber must get approval from AmeriHealth Caritas VIP Care Plus before you fill your prescription. If you don t get approval, AmeriHealth Caritas VIP Care Plus may not cover the drug if you do not get approval. Quantity limits: Sometimes AmeriHealth Caritas VIP Care Plus limits the amount of a drug you can get. Step therapy: Sometimes AmeriHealth Caritas VIP Care Plus requires you to do step therapy. This means you will have to try drugs in a certain order for your medical condition. You might have to try one drug before we will cover another drug. If your prescriber thinks the first drug doesn t work for you, then we will cover the second. You can find out if your drug has any additional requirements or limits by looking in the tables on pages You can also get more information by visiting our web site at We have posted online documents that explain our prior authorization and step therapy restrictions. You may also ask us to send you a copy. You can also ask for an exception from these limits. This will give you time to talk to your doctor or other prescriber. He or she can help you decide if there is a similar drug on the Drug List you can take instead or whether to ask for an exception. Please see questions B10 B12 for more information about exceptions. B5. How will you know if the drug you want has limitations or if there are required actions to take to get the drug? The List of Covered Drugs on pages has a column labeled. B6. What happens if we change our rules about some drugs (for example, prior authorization (approval), quantity limits, and/or step therapy restrictions)? In some cases, we will tell you in advance if we add or change prior approval, quantity limits, and/or step therapy restrictions on a drug. See question B3 for more information about this advance notice and situations where we may not be able to tell you in advance when our rules about drugs on the Drug List change. If you have questions, please call AmeriHealth Caritas VIP Care Plus at (TTY 711), 8 a.m. 8 p.m., seven days a week. The call is free. For more information, visit vi

8 B7. How can you find a drug on the Drug List? There are two ways to find a drug: You can search alphabetically (if you know how to spell the drug), or You can search by medical condition. To search alphabetically, go to the Index of Covered Drugs section. You can find it after the drug listing on page 191. The Index provides an alphabetical list of all of the covered drugs. The list includes brand, generic, and over-the-counter drugs. Find your drug name in the index, and next to the drug will be a page number where you can find coverage information. Turn to the page listed in the index and find the name of your drug in the first column of the list. To search by medical condition, find the section labeled List of drugs by medical condition on page 1. The drugs in this section are grouped into categories depending on the type of medical conditions they are used to treat. For example, if you have a heart condition, you should look in the category Cardiovascular Agents. That is where you will find drugs that treat heart conditions. B8. What if the drug you want to take is not on the Drug List? If you don t see your drug on the Drug List, call Member Services at (TTY 711), 8 a.m. 8 p.m., seven days a week, and ask about it. If you learn that AmeriHealth Caritas VIP Care Plus will not cover the drug, you can do one of these things: Ask Member Services for a list of drugs like the one you want to take. Then show the list to your doctor or other prescriber. He or she can prescribe a drug on the Drug List that is like the one you want to take. Or You can ask the health plan to make an exception to cover your drug. Please see questions B10-B12 for more information about exceptions. B9. What if you are a new AmeriHealth Caritas VIP Care Plus member and can t find your drug on the Drug List or have a problem getting your drug? We can help. We may cover a temporary 30-day supply of your drug during the first 180 days you are a member of AmeriHealth Caritas VIP Care Plus. This will give you time to talk to your doctor or other prescriber. He or she can help you decide if there is a similar drug on the Drug List you can take instead or whether to ask for an exception. If your prescription is written for fewer days, we will allow multiple fills to provide up to a maximum of 30 days of medication. We will cover a 30-day supply of your drug if: you are taking a drug that is not on our Drug List, or health plan rules do not let you get the amount ordered by your prescriber, or If you have questions, please call AmeriHealth Caritas VIP Care Plus at (TTY 711), 8 a.m. 8 p.m., seven days a week. The call is free. For more information, visit vii

9 the drug requires prior approval by AmeriHealth Caritas VIP Care Plus, or you are taking a drug that is part of a step therapy restriction. If you are in a nursing home or other long-term care facility, and need a drug that is not on the Drug List or if you cannot easily get the drug you need, we can help. If you have been in the plan for more than 90 days, live in a long-term care facility, and need a supply right away: We will cover one 31-day supply of the drug you need (unless you have a prescription for fewer days), whether or not you are a new AmeriHealth Caritas VIP Care Plus member. This is in addition to the temporary supply during the first 180 days you are a member of AmeriHealth Caritas VIP Care Plus. A level of care change occurs when a member changes from one treatment setting to another. Examples include entering a long-term care facility from an acute-care hospital or being discharged from hospital to home. Current members who experience a Level of Care Change are eligible to receive a transition supply of a non-formulary drug (a drug not on the drug list) upon admission or discharge from an applicable setting. If a member has more than one change in level of care in a month, the pharmacy will have to call Member Services to request an extension of the transition policy. B10. Can you ask for an exception to cover your drug? Yes. You can ask AmeriHealth Caritas VIP Care Plus to make an exception to cover a drug that is not on the Drug List. You can also ask us to change the rules on your drug. For example, AmeriHealth Caritas VIP Care Plus may limit the amount of a drug we will cover. If your drug has a limit, you can ask us to change the limit and cover more. Other examples: You can ask us to drop step therapy restrictions or prior approval requirements. B11. How can you ask for an exception? To ask for an exception, call Member Services. A Member Services representative will work with you and your provider to help you ask for an exception. You can also read Chapter 9, Section 6.4, of the Member Handbook to learn more about exceptions. If you have questions, please call AmeriHealth Caritas VIP Care Plus at (TTY 711), 8 a.m. 8 p.m., seven days a week. The call is free. For more information, visit viii

10 B12. How long does it take to get an exception? First, we must get a statement from your prescriber supporting your request for an exception. After we get the statement, we will give you a decision on your exception request within 72 hours. If you or your prescriber think your health may be harmed if you have to wait 72 hours for a decision, you can ask for an expedited exception. This is a faster decision. If your prescriber supports your request, we will give you a decision within 24 hours of getting your prescriber s supporting statement. B13. What are generic drugs? Generic drugs are made up of the same active ingredients as brand name drugs. They usually cost less than the brand name drug and usually don t have well-known names. Generic drugs are approved by the Food and Drug Administration (FDA). AmeriHealth Caritas VIP Care Plus covers both brand name drugs and generic drugs. B14. What are OTC drugs? OTC stands for over-the-counter. AmeriHealth Caritas VIP Care Plus covers some OTC drugs when they are written as prescriptions by your provider. You can read the AmeriHealth Caritas VIP Care Plus Drug List to see what OTC drugs are covered. B15. Does AmeriHealth Caritas VIP Care Plus cover OTC non-drug products? AmeriHealth Caritas VIP Care Plus covers some OTC non-drug products when they are written as prescriptions by your provider. You can read the AmeriHealth Caritas VIP Care Plus Drug List to see what OTC non-drug products are covered. B16. What is your copay? As an AmeriHealth Caritas VIP Care Plus member, you have no copays for prescription and OTC drugs as long as you follow AmeriHealth Caritas VIP Care Plus' rules. B17. What are drug tiers? Tiers are groups of drugs. There are no copays for drugs in any tier. Tier 1 drugs are Part D covered generic drugs. Tier 2 drugs are Part D covered brand name drugs. Tier 3 drugs are non-part D covered/otc drugs. If you have questions, please call AmeriHealth Caritas VIP Care Plus at (TTY 711), 8 a.m. 8 p.m., seven days a week. The call is free. For more information, visit ix

11 C. List of Covered Drugs The following list of covered drugs gives you information about the drugs covered by AmeriHealth Caritas VIP Care Plus. If you have trouble finding your drug in the list, turn to the Index of Covered Drugs that begins on page 191. The index alphabetically lists all drugs covered by AmeriHealth Caritas VIP Care Plus. The first column of the chart lists the name of the drug. Brand name drugs are capitalized (e.g., COUMADIN) and generic drugs are listed in lower-case italics (e.g., warfarin). The information in the necessary actions, restrictions, or column tells you if AmeriHealth Caritas VIP Care Plus has any rules for covering your drug. Here are the meanings of the codes used in the limits on use column: B/D: This prescription drug has a Part B versus Part D administrative prior authorization requirement. This drug may be covered under Medicare Part B or Part D depending upon the circumstances. Information may need to be submitted describing the use and setting of the drug to make the determination. QL: Quantity Limit. For certain drugs, AmeriHealth Caritas VIP Care Plus limits the amount of the drug that the plan will cover. For example, our plan provides twelve tablets per prescription for sumatriptan succinate. This may be in addition to a standard one month or three month supply. ST: Step Therapy. In some cases, AmeriHealth Caritas VIP Care Plus 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, AmeriHealth Caritas VIP Care Plus may not cover drug B unless you try Drug A first. If Drug A does not work for you, AmeriHealth Caritas VIP Care Plus will then cover Drug B. PA: Prior Authorization. AmeriHealth Caritas VIP Care Plus requires you or your physician to get prior authorization for certain drugs. This means that you will need to get approval from AmeriHealth Caritas VIP Care Plus before you fill your prescriptions. If you don't get approval, AmeriHealth Caritas VIP Care Plus may not cover the drug. LA: Limited Availability. This prescription may be available only at certain pharmacies. For more information consult your Provider and Pharmacy Directory or call Member Services. MO: Mail Order. This prescription may be filled by an AmeriHealth Caritas VIP Care Plus network mail order pharmacy. Please review your Provider and Pharmacy Directory for more information about which pharmacies offer mail order service. For more information consult your Provider and Pharmacy Directory or call our Member Services department. If you have questions, please call AmeriHealth Caritas VIP Care Plus at (TTY 711), 8 a.m. 8 p.m., seven days a week. The call is free. For more information, visit x

12 Note: The DP next to a drug means the drug is not a Part D drug. These drugs have different rules for appeals. An appeal is a formal way of asking us to review a coverage decision and to change it if you think we made a mistake. For example, we might decide that a drug that you want is not covered or is no longer covered by Medicare or Michigan Medicaid. If you or your prescriber disagrees with our decision, you can appeal. To ask for instructions on how to appeal, call Member Services at (TTY 711), 8 a.m. 8 p.m., seven days a week. You can also read Chapter 9 in the Member Handbook to learn how to appeal a decision. D. List of Drugs by Medical Condition The drugs in this section are grouped into categories depending on the type of medical conditions they are used to treat. For example, if you have a heart condition, you should look in the category Cardiovascular Agents. That is where you will find drugs that treat heart conditions. Prescription type Analgesics Anesthetics Anti-addiction/substance abuse treatment agents Antibacterials Anticonvulsants Antidementia agents Antidepressants Antiemetics Antifungals Antigout agents Anti-inflammatory agents Antimigraine agents Medical condition Treatment of pain Local treatment of pain Treatment of substance abuse disorders Treatment of bacterial infections Treatment of seizures Management of dementia Treatment of depression Treatment of vomiting or nausea Treatment of fungal or yeast infections Treatment or prevention of gouty arthritis Treatment of inflammation Treatment of migraine headaches If you have questions, please call AmeriHealth Caritas VIP Care Plus at (TTY 711), 8 a.m. 8 p.m., seven days a week. The call is free. For more information, visit xi

13 Prescription type Antimyasthenic agents Antimycobacterials Antineoplastics Antiparasitics Antiparkinson agents Antipsychotics Antispasticity agents Antivirals Anxiolytics Bipolar agents Blood glucose regulators Blood products/modifiers/volume expanders Cardiovascular agents Central nervous system agents Dental and oral agents Dermatological agents Diabetic supplies Enzyme replacement/modifiers Medical condition Treatment for myasthenia Treatment for infections by tuberculosistype organisms Treatment of cancer Treatment of infections from parasites Treatment of Parkinson s disease Treatment of behavioral and emotional disorders Treatment of muscle spasms Treatment of infections by viruses Treatment of anxiety or nervousness Treatment for bipolar illnesses Control of diabetes Prevention of clotting and increasing blood cell production Treatment of conditions affecting the heart and blood vessels Treatment of disorders of the brain and spinal column Treatment of mouth and gum disorders Treatment of skin conditions Supplies used for diabetes Medications to replace missing or deficient enzyme production If you have questions, please call AmeriHealth Caritas VIP Care Plus at (TTY 711), 8 a.m. 8 p.m., seven days a week. The call is free. For more information, visit xii

14 Prescription type Gastrointestinal agents Genitourinary agents Hormonal agents, stimulant/replacement/ modifying (adrenal) Hormonal agents, stimulant/replacement/ modifying (pituitary) Hormonal agents, stimulant/replacement/ modifying (sex hormones/modifiers) Hormonal agents, stimulant/replacement/ modifying (thyroid) Hormonal agents, suppressant (adrenal) Hormonal agents, suppressant (parathyroid) Hormonal agents, suppressant (pituitary) Hormonal agents, suppressant (thyroid) Immunological agents Inflammatory bowel disease agents Metabolic bone disease agents Ophthalmic agents Otic agents Respiratory tract agents Medical condition Treatment of stomach and intestinal conditions Treatment of urinary tract and prostate conditions Treatment of conditions requiring steroids Treatment of pituitary gland conditions For the replacement or modification of sex hormones Treatment of thyroid conditions Treatment of inoperable adrenal cancer Treatment of parathyroid conditions Treatment of or modification of pituitary hormone secretion Treatment for overactive thyroid Medications that alter the immune system including vaccinations Treatment of ulcerative colitis or Crohn s disease Treatment of bone diseases including osteoporosis Treatment of eye conditions Treatment of ear conditions Treatment of breathing conditions If you have questions, please call AmeriHealth Caritas VIP Care Plus at (TTY 711), 8 a.m. 8 p.m., seven days a week. The call is free. For more information, visit xiii

15 Prescription type Respiratory tract/pulmonary agents Skeletal muscle relaxants Sleep disorder agents Therapeutic nutrients/minerals/ electrolytes Medical condition Treatment of breathing conditions Treatment of muscle tightness Treatment of insomnia Replacement or supplementation of minerals, nutrients, and vitamins If you have questions, please call AmeriHealth Caritas VIP Care Plus at (TTY 711), 8 a.m. 8 p.m., seven days a week. The call is free. For more information, visit xiv

16 ANALGESICS-Treatment of pain ANALGESICS, OTHER 8 HOUR ER 650 MG CAPLET MUSCLE ACHES & PAIN 650 MG ACEPHEN 120 MG SUPPOSITORY 120 MG ACEPHEN 120 MG SUPPOSITORY OUTER 120 MG ACEPHEN 325 MG SUPPOSITORY 325 MG ACEPHEN 325 MG SUPPOSITORY OUTER 325 MG ACEPHEN 650 MG SUPPOSITORY 650 MG ACEPHEN 650 MG SUPPOSITORY OUTER 650 MG acetaminophen 120 suppos 120 acetaminophen 120 suppos inner 120 acetaminophen 120 suppos outer 120 acetaminophen 160 /5 ml liq a/f,s/f,cherry 160 /5 ml acetaminophen 160 /5 ml sol inner 160 /5 ml (5 ml) acetaminophen 160 /5 ml sol outer 160 /5 ml (5 ml) acetaminophen 325 tablet 325 acetaminophen 325 tablet outer, f/c 325 acetaminophen 325 tablet u-d 325 acetaminophen 325 tablet u-d,10x10,asa-free 325 acetaminophen 325 tablet u-d,25x30,uncoated 325 acetaminophen 325 /10.15 ml inner 325 /10.15 ml acetaminophen 325 /10.15 ml outer 325 /10.15 ml acetaminophen 500 caplet 500 1

17 acetaminophen 500 caplet caplet 500 acetaminophen 500 caplet caplet, ex-strength 500 acetaminophen 500 caplet caplet, extra-strgth 500 acetaminophen 500 caplet caplet,ex-strength 500 acetaminophen 500 caplet caplet,xtra-strength 500 acetaminophen 500 caplet u-d,caplet 500 acetaminophen 500 gelcap 500 acetaminophen 500 tablet 12's,extra strength 500 acetaminophen 500 tablet 2x125,u-d,extra-str 500 acetaminophen 500 tablet 2x250,extra strength 500 acetaminophen 500 tablet 2x50, extra strength 500 acetaminophen 500 tablet 500 acetaminophen 500 tablet asa-free,ex-str 500 acetaminophen 500 tablet aspirin free, u/d 500 acetaminophen 500 tablet aspirin free, u-d 500 acetaminophen 500 tablet ex-strength 500 acetaminophen 500 tablet extra strength 500 acetaminophen 500 tablet extra-strength 500 acetaminophen 500 tablet u-d 500 acetaminophen 650 suppos 650 acetaminophen 650 suppos outer 650 2

18 acetaminophen 650 /20.3 ml inner 650 /20.3 ml acetaminophen 650 /20.3 ml outer 650 /20.3 ml acetaminophen er 650 tablet inner 650 acetaminophen er 650 tablet outer 650 acetaminophen-codeine oral solution /5 ml acetaminophen-codeine oral tablet , , ARTHRITIS PAIN ER 650 MG CAPLT 8 HOUR, CAPLET 650 MG ARTHRITIS PAIN ER 650 MG CAPLT CAPLET 650 MG ARTHRITIS PAIN ER 650 MG CAPLT CAPLET, 8 HOUR 650 MG ARTHRITIS PAIN RELIEF ER 650 MG CAPLET CAPLET 650 MG ASCOMP WITH CODEINE ORAL CAPSULE MG BUTALBITAL COMPOUND W/CODEINE ORAL CAPSULE MG butalbital-acetaminop-caf-cod oral capsule $0 (Tier 1) $0 (Tier 1) $0 (Tier 1) PA $0 (Tier 1) PA $0 (Tier 1) PA butalbital-acetaminophen oral tablet $0 (Tier 1) PA butalbital-acetaminophen-caff oral capsule butalbital-acetaminophen-caff oral tablet butalbital-aspirin-caffeine oral capsule carisoprodol-asa-codeine oral tablet $0 (Tier 1) PA $0 (Tier 1) PA $0 (Tier 1) PA $0 (Tier 1) PA carisoprodol-aspirin oral tablet $0 (Tier 1) PA CHILD ACETAMINOPHEN 80 MG/2.5 ML ORAL SYRINGE ORAL SYRINGE 32 MG/ML 3

19 CHILD PAIN-FEVER 160 MG/5 ML 160 MG/5 ML CHILD PAIN-FEVER 160 MG/5 ML 160 MG/5 ML CHILD PAIN-FEVER 160 MG/5 ML A/F 160 MG/5 ML CHILD PAIN-FEVER 160 MG/5 ML A/F, ASA/F, IBU/F 160 MG/5 ML CHILD PAIN-FEVER 160 MG/5 ML A/F, CHERRY FLAVOR 160 MG/5 ML CHILD PAIN-FEVER 80 MG TAB CHW 80 MG CHILDREN'S MAPAP 80 MG RAPID 80 MG CHILDREN'S SILAPAP ELIXIR 160 MG/5 ML CHILD'S PAIN RELIEVER RAPID TB RAPID TAB'S 80 MG CHL ACETAMINOPHEN 325 MG/ MG/10.15 ML CHLD ACETAMINOPHEN 160 MG/5 ML 160 MG/5 ML (5 ML) CHLD ACETAMINOPHEN 160 MG/5 ML A/F, GLUTEN/F, GRAPE 160 MG/5 ML CHLD ACETAMINOPHEN 160 MG/5 ML A/F,GLUTEN/F,CHERRY 160 MG/5 ML CHLD ACETAMINOPHEN 160 MG/5 ML INNER 160 MG/5 ML (5 ML) CHLD ACETAMINOPHEN 160 MG/5 ML ORAL SYRINGE U-D, ORAL SYRINGE 32 MG/ML CHLD ACETAMINOPHEN 160 MG/5 ML OUTER 160 MG/5 ML (5 ML) ED-APAP 160 MG/5 ML LIQUID 160 MG/5 ML FEVERALL 120 MG SUPPOSITORY CHILDREN'S, INNER 120 MG FEVERALL 120 MG SUPPOSITORY CHILDRENS, OUTER 120 MG 4

20 FEVERALL 120 MG SUPPOSITORY CHILDREN'S, OUTER 120 MG FEVERALL 325 MG SUPPOSITORY JUNIOR STR, INNER 325 MG FEVERALL 325 MG SUPPOSITORY JUNIOR STR, OUTER 325 MG FEVERALL 650 MG SUPPOSITORY ADULT, INNER 650 MG FEVERALL 650 MG SUPPOSITORY ADULT, OUTER 650 MG FEVERALL 80 MG SUPPOSITORY INFANT'S, INNER 80 MG FEVERALL 80 MG SUPPOSITORY INFANT'S, OUTER 80 MG GNP PAIN RELIEF 500 MG CAPLET EXTRA STR, CAPLET 500 MG GNP PAIN RELIEF 500 MG GELCAP EXTRA STRENGTH 500 MG GNP PAIN RELIEVER 325 MG TAB REGULAR STRENGTH 325 MG GNP PAIN RELIEVER 500 MG CAPLT CAPLET,X-STRENGTH 500 MG GNP PAIN RELIEVER 500 MG CAPLT EX- STR, CAPLET 500 MG GNP PAIN RELIEVER 500 MG TAB EX- STR,EASY TAB 500 MG GNP PAIN RELIEVER 500 MG TAB EXTRA STRENGTH 500 MG GS ARTHRITIS PAIN ER 650 MG CAPLET 650 MG GS INFANT PAIN-FEVER 160 MG/5 CHERRY, DYE-FREE 160 MG/5 ML GS PAIN RELIEF 500 MG CAPLET 500 MG GS PAIN RELIEF 500 MG TABLET 500 MG HM ARTHRITIS PAIN ER 650 MG CAPLET, 8 HOUR 650 MG 5

21 HM CHLD PAIN-FEVER 160 MG/5 ML A/F, DYE-FREE 160 MG/5 ML HM CHLD PAIN-FEVER 160 MG/5 ML GLUTEN-F,A/F,ASA/F 160 MG/5 ML HM INFANT PAIN-FEVER 160 MG/5 A/F,CHERRY,W/SYRINGE 160 MG/5 ML HM INFANT PAIN-FEVER 160 MG/5 A/F,GRAPE,W/SYRINGE 160 MG/5 ML HM PAIN RELIEF 500 MG CAPLET 500 MG HM PAIN RELIEF 500 MG CAPLET CAPLET, EX-STRENGTH 500 MG HM PAIN RELIEF 500 MG CAPLET CAPLET, FREE MG HM PAIN RELIEF 500 MG TABLET EX-STR, GLUTEN-FREE 500 MG HM PAIN RELIEVER 325 MG TABLET REGULAR STRENGTH 325 MG HM PAIN RELIEVER 500 MG TABLET EXTRA STRENGTH 500 MG hydrocodone-acetaminophen oral tablet , , 5-325, hydrocodone-ibuprofen oral tablet , $0 (Tier 1) $0 (Tier 1) IBU ORAL TABLET 600 MG, 800 MG $0 (Tier 1) ibuprofen-oxycodone oral tablet $0 (Tier 1) INFANT PAIN-FEVER 160 MG/5 ML 160 MG/5 ML INFANT PAIN-FEVER 160 MG/5 ML A/F, GRAPE 160 MG/5 ML INFANT PAIN-FEVER 160 MG/5 ML W/SYRINGE, CHERRY 160 MG/5 ML INFANT PAIN-FEVER 160 MG/5 ML W/SYRINGE, GRAPE 160 MG/5 ML INFANTS IBU-DROPS SUSPENSION 50 MG/1.25 ML 6

22 INFANTS PAIN-FEVER 160 MG/5 ML A/F,ASA-F,IBU-F 160 MG/5 ML INFANTS PAIN-FEVER 160 MG/5 ML A/F,DYE-FREE, CHERRY 160 MG/5 ML kro acetaminophen 325 tab gluten free 325 kro acetaminophen 500 cplt caplet, ex-strength 500 kro acetaminophen 500 cplt gluten free, caplet 500 kro acetaminophen 500 tab ex-str, gluten free 500 MAPAP 160 MG/5 ML LIQUID 160 MG/5 ML MAPAP 160 MG/5 ML SUSPENSION 160 MG/5 ML MAPAP 325 MG TABLET 325 MG MAPAP 325 MG TABLET BOXED 325 MG MAPAP 325 MG TABLET REGULAR STRENGTH 325 MG MAPAP 325 MG TABLET U-D 325 MG MAPAP 500 MG CAPLET CAPLET 500 MG MAPAP 500 MG CAPLET CAPLET,BOXED 500 MG MAPAP 500 MG CAPSULE 500 MG MAPAP 500 MG GELCAP GELCAP 500 MG MAPAP 500 MG TABLET 500 MG MAPAP 500 MG TABLET BOXED 500 MG MAPAP 500 MG TABLET U-D 500 MG MAPAP 500 MG/15 ML LIQUID 500 MG/15 ML MAPAP 80 MG TABLET CHEW 80 MG MAPAP ARTHRITIS ER 650 MG CPLT 650 MG NON-ASPIRIN 325 MG TABLET 125'S 325 MG NON-ASPIRIN 325 MG TABLET 250'S, U-D 325 MG 7

23 NON-ASPIRIN 325 MG TABLET 50'S, U-D 325 MG NON-ASPIRIN 500 MG TABLET 125'S 500 MG NON-ASPIRIN 500 MG TABLET 250'S 500 MG NON-ASPIRIN 500 MG TABLET 50'S, U-D 500 MG oxycodone-acetaminophen oral tablet , , 5-325, $0 (Tier 1) oxycodone-aspirin oral tablet $0 (Tier 1) PAIN & FEVER 325 MG TABLET 325 MG PAIN & FEVER 500 MG CAPLET CAPLET 500 MG PAIN & FEVER 500 MG CAPLET CAPTABS 500 MG PAIN & FEVER 500 MG TABLET EXTRA STRENGTH 500 MG PAIN & FEVER 500 MG TABLET WITHOUT ASPIRIN 500 MG PAIN RELIEF 160 MG/5 ML LIQUID A/F, CHERRY 160 MG/5 ML PAIN RELIEF 500 MG CAPLET CAPLET, EX- STRENGTH 500 MG PAIN RELIEF 500 MG CAPLET CAPLET,EX- STRENGTH 500 MG PAIN RELIEF 500 MG CAPLET EXTRA STR, CAPLET 500 MG PAIN RELIEF 500 MG GELCAP EXTRA STRENGTH 500 MG PAIN RELIEF 500 MG TABLET COATED, EX- STRENGTH 500 MG PAIN RELIEF 500 MG TABLET EX- STRENGTH 500 MG PAIN RELIEF 500 MG TABLET EXTRA STRENGTH 500 MG PAIN RELIEF 500 MG TABLET EXTRA STRENGTH 500 MG 8

24 PAIN RELIEF ADULT 500 MG/15 ML 500 MG/15 ML PAIN RELIEF ER 650 MG CAPLET ARTHRITIS PAIN 650 MG PAIN RELIEF ER 650 MG CAPLET CAPLET, 8 HOUR 650 MG PAIN RELIEF ER 650 MG CAPLET CAPLET, ARTHRITIS 650 MG PAIN RELIEVER 325 MG TABLET REGULAR STRENGTH 325 MG PAIN RELIEVER 500 MG CAPLET CAPLET, EX-STRENGTH 500 MG PAIN RELIEVER 500 MG CAPLET CAPLET, EX-STRENGTH 500 MG PAIN RELIEVER 500 MG CAPLET CAPLET,X- STRENGTH 500 MG PAIN RELIEVER 500 MG CAPLET EX-STR, CAPLET 500 MG PAIN RELIEVER 500 MG CAPLET EXTR STRENGTH,CAPLET 500 MG PAIN RELIEVER 500 MG TABLET 500 MG PAIN RELIEVER 500 MG TABLET EX- STR,EASY TAB 500 MG pentazocine-naloxone oral tablet $0 (Tier 1) PA PHARBETOL 325 MG TABLET REG STRENGTH, BULK 325 MG PHARBETOL 325 MG TABLET REGULAR STRENGTH 325 MG PHARBETOL 500 MG CAPLET EXTRA-STR, CAPLET 500 MG PHARBETOL 500 MG TABLET EXTRA STRENGTH 500 MG PUB PAIN RELIEF 500 MG CAPLET CAPLET, EX-STRENGTH 500 MG PUB PAIN RELIEF 500 MG CAPLET EX- STRENGTH, CAPLET 500 MG 9

25 PUB PAIN RELIEF 500 MG GELTAB EX- STRENGTH, GELTAB 500 MG PUB PAIN RELIEF 500 MG TABLET EX- STRENGTH, EASY TB 500 MG QC ARTHRITIS PAIN ER 650 MG CAPLET 650 MG QC CHILD PAIN RLF 160 MG/5 ML A/F,BUBBLE GUM 160 MG/5 ML QC CHILD PAIN RLF 160 MG/5 ML A/F,CHERRY 160 MG/5 ML QC JR. NON-ASPIRIN 160 MG TAB 160 MG QC NON-ASPIRIN 325 MG TABLET 325 MG QC NON-ASPIRIN 500 MG CAPLET CAPLET,EX-STRENGTH 500 MG QC NON-ASPIRIN 500 MG CAPLET XTRA STRENGTH,CAPLET 500 MG QC NON-ASPIRIN 500 MG GELCAP GELCAP, EX-STR 500 MG QC NON-ASPIRIN 500 MG TABLET EXTRA STRENGTH 500 MG QC NON-ASPIRIN PAIN RELIEF TB EXTRA STRENGTH 500 MG SB ARTHRITIS PAIN ER 650 MG CAPLET, NON-ASPIRIN 650 MG SB EX-STRENGTH NON-ASPIRIN TAB SAFETY SEALED 500 MG SB NON-ASPIRIN 325 MG TABLET REGULAR STR 325 MG SB NON-ASPIRIN 325 MG TABLET REGULAR STRENGTH 325 MG SB NON-ASPIRIN 500 MG CAPLET CAPLET 500 MG SB PAIN RELIEVER 500 MG CAPLET EXTRA- STR,NON-ASA 500 MG SB PAIN RELIEVER 500 MG GELCAP EX- STRENGTH, GELCAP 500 MG 10

26 SHAKE THAT ACHE 500 MG CAPLET 500 MG SM 8 HOUR PAIN RELIEF 650 MG CAPLET 650 MG SM ARTHRITIS PAIN ER 650 MG CAPLET 650 MG SM CHLD PAIN-FEVER 160 MG/5 ML A/F, ASA/F, GLUTEN-F 160 MG/5 ML SM INFANT PAIN-FEVER 160 MG/5 A/F,GLUTEN-F,CHERRY 160 MG/5 ML SM INFANT PAIN-FEVER 160 MG/5 A/F.GLUTEN-F,GRAPE 160 MG/5 ML SM PAIN RELIEVER 325 MG TABLET 325 MG SM PAIN RELIEVER 500 MG CAPLET CAPLET, EXTRA STR 500 MG SM PAIN RELIEVER 500 MG CAPLET CAPLET, EXTRA STR 500 MG SM PAIN RELIEVER 500 MG CAPLET CAPLET, FREE MG SM PAIN RELIEVER 500 MG GELCAP GELCAP,EX STRENGTH 500 MG SM PAIN RELIEVER 500 MG TABLET EX- STR, GLUTEN-FREE 500 MG SM PAIN RELIEVER 500 MG TABLET EXTRA STRENGTH 500 MG TACTINAL 325 MG TABLET 325 MG TACTINAL 500 MG CAPLET CAPLET,X- STRENGTH 500 MG TACTINAL 500 MG TABLET EXTRA- STRENGTH 500 MG tramadol-acetaminophen oral tablet $0 (Tier 1) TRI-BUFFERED ASPIRIN 325 MG BOXED 325 MG NONSTEROIDAL ANTI-INFLAMMATORY DRUGS ALL DAY PAIN RELIEF 220 MG TAB 220 MG ALL DAY PAIN RELIEF 220 MG TAB 8-12 HOUR RELIEF 220 MG 11

27 ALL DAY PAIN RELIEF 220 MG TAB GLUTEN-FREE, 12HR 220 MG ALL DAY PAIN RLF 220 MG CAPLET 220 MG ALL DAY PAIN RLF 220 MG CAPLET CAPLET 220 MG ALL DAY RELIEF 220 MG CAPLET 220 MG ALL DAY RELIEF 220 MG CAPLET CAPLET, GLUTEN-FREE 220 MG ALL DAY RELIEF 220 MG TABLET GLUTEN- FREE 220 MG aspirin 300 suppository 300 aspirin 325 coated tablet coated 325 aspirin 325 tablet 325 aspirin 325 tablet coated 325 aspirin 325 tablet coated, regular str 325 aspirin 325 tablet micro thin coat,na/f 325 aspirin 325 tablet micro-coated 325 aspirin 325 tablet regular strength 325 aspirin 325 tablet u-d 325 aspirin 600 suppository 600 aspirin ec 325 tablet 25x aspirin ec 325 tablet 325 aspirin ec 325 tablet bulk 325 aspirin ec 325 tablet orange 325 aspirin ec 325 tablet regular strength 325 aspirin ec 325 tablet safety coated 325 aspirin ec 325 tablet safety-coated 325 aspirin ec 325 tablet safty coated 325 aspirin ec 325 tablet u-d 325 BAYER ASPIRIN 325 MG CAPLET 325 MG BAYER ASPIRIN 325 MG TABLET 325 MG bayer aspirin 325 tablet coated

28 celecoxib oral capsule 100, 200, 400, 50 CHILD IBUPROFEN 100 MG/5 ML 100 MG/5 ML CHILDREN IBUPROFEN 100 MG/5 ML 100 MG/5 ML CHILDREN IBUPROFEN 100 MG/5 ML A/F 100 MG/5 ML CHILDREN IBUPROFEN 100 MG/5 ML A/F, BERRY 100 MG/5 ML CHILDREN IBUPROFEN 100 MG/5 ML A/F, D/F 100 MG/5 ML CHILDREN IBUPROFEN 100 MG/5 ML A/F, DYE/FREE 100 MG/5 ML CHILDREN IBUPROFEN 100 MG/5 ML A/F, GLUTEN/F, BERRY 100 MG/5 ML CHILDREN IBUPROFEN 100 MG/5 ML A/F, GLUTEN/F, GRAPE 100 MG/5 ML CHILDREN IBUPROFEN 100 MG/5 ML A/F, GRAPE 100 MG/5 ML CHILDREN IBUPROFEN 100 MG/5 ML A/F,BUBBLE GUM 100 MG/5 ML CHILDREN IBUPROFEN 100 MG/5 ML A/F,D/F,BERRY 100 MG/5 ML CHILDREN IBUPROFEN 100 MG/5 ML A/F,GLUTEN/F,BUBBLE 100 MG/5 ML CHILDREN IBUPROFEN 100 MG/5 ML BERRY FLAVOR 100 MG/5 ML CHILDREN IBUPROFEN 100 MG/5 ML INNER 100 MG/5 ML CHILDREN IBUPROFEN 100 MG/5 ML OUTER 100 MG/5 ML CHILDREN IBUPROFEN 100 MG/5 ML U-D 100 MG/5 ML CHILDREN IBUPROFEN 100 MG/5 ML U- D,100'S,HOSP USE 100 MG/5 ML 13

29 CHILDREN IBUPROFEN 100 MG/5 ML U- D,30'S,HOSP USE 100 MG/5 ML diclofenac potassium oral tablet 50 diclofenac sodium oral tablet extended release 24 hr 100 diclofenac sodium oral tablet,delayed release (dr/ec) 25, 50, 75 diflunisal oral tablet 500 ECPIRIN EC 325 MG TABLET 325 MG eq naproxen sod 220 caplet 220 eq naproxen sod 220 caplet caplet 220 eql naproxen sod 220 caplet 220 eql naproxen sodium 220 tab 220 etodolac oral capsule 200, 300 etodolac oral tablet 400, 500 etodolac oral tablet extended release 24 hr 400, 500, 600 FLANAX 220 MG TABLET 220 MG flurbiprofen oral tablet 100, 50 gnp aspirin 325 tablet micro-thin coat,na/f 325 gnp aspirin ec 325 tablet 325 GNP LITE COAT ASA 325 MG TAB CAFFEINE FREE,NA/F 325 MG gs aspirin 325 tablet 325 GS CHILD IBUPROFEN 100 MG/5 ML D/F,A/F,BERRY FLAVOR 100 MG/5 ML gs ibuprofen 200 caplet 200 gs ibuprofen 200 tablet 200 gs naproxen sod 220 caplet 220 hm aspirin 325 tablet 325 hm aspirin 325 tablet adult, gluten-free 325 hm aspirin ec 325 tablet reg strength

30 HM CHILD IBUPROFEN 100 MG/5 ML 100 MG/5 ML HM CHILD IBUPROFEN 100 MG/5 ML A/F, BERRY 100 MG/5 ML HM CHILD IBUPROFEN 100 MG/5 ML A/F, BUBBLE GUM 100 MG/5 ML HM CHILD IBUPROFEN 100 MG/5 ML A/F, GRAPE 100 MG/5 ML HM CHILD IBUPROFEN 100 MG/5 ML A/F,GLUTEN/F,BERRY 100 MG/5 ML hm ibuprofen 200 caplet caplet 200 hm ibuprofen 200 capsule liquid filled sftgel 200 hm ibuprofen 200 tablet coated, free hm ibuprofen 200 tablet coated,gluten-free 200 HM IBUPROFEN IB 200 MG CAPLET COATED, GLUTEN-FREE 200 MG HM IBUPROFEN IB 200 MG TABLET COATED. GLUTEN-FREE 200 MG HM INF IBUPROFEN 50 MG/1.25 ML A/F, BERRY FLAVOR 50 MG/1.25 ML HM INF IBUPROFEN 50 MG/1.25 ML D/F,A/F,BERRY FLAVOR 50 MG/1.25 ML hm naproxen sod 220 caplet caplet, gluten-free 220 hm naproxen sodium 220 cap liquidgel 220 hydrocodone-ibuprofen oral tablet $0 (Tier 1) ibuprofen 100 /5 ml susp a/f,dye-free (otc) 100 /5 ml ibuprofen 100 /5 ml susp u-d,50's,hosp use (otc) 100 /5 ml ibuprofen 200 caplet caplet 200 ibuprofen 200 caplet caplet, coated 200 ibuprofen 200 caplet coated caplet

31 ibuprofen 200 softgel liquid filled 200 ibuprofen 200 softgel liquid filled caps 200 ibuprofen 200 softgel softgel 200 ibuprofen 200 tablet 200 ibuprofen 200 tablet coated 200 ibuprofen 200 tablet coated caplet 200 ibuprofen 200 tablet u-d 200 ibuprofen 200 /10 ml susp 100's, u-d cups (otc) 100 /5 ml ibuprofen 200 /10 ml susp 30's, u-d cups (otc) 100 /5 ml ibuprofen 200 /10 ml susp u-d (otc) 100 /5 ml IBUPROFEN JR STR 100 MG CHEW 100 MG IBUPROFEN JR STR 100 MG CHEW CHEWABLE TABLET 100 MG IBUPROFEN JR STR 100 MG TB CHW 100 MG IBUPROFEN JR STR 100 MG TB CHW TAB CHEW,ORANGE 100 MG ibuprofen oral suspension 100 /5 ml ibuprofen oral tablet 400, 600, 800 indomethacin oral capsule 25, 50 $0 (Tier 1) PA; MO indomethacin oral capsule, extended release 75 INFANT IBUPROFEN 50 MG/1.25 ML A/F, BERRY 50 MG/1.25 ML INFANT IBUPROFEN 50 MG/1.25 ML A/F, D/F, BERRY 50 MG/1.25 ML INFANT IBUPROFEN 50 MG/1.25 ML A/F, GLUTEN/F, BERRY 50 MG/1.25 ML INFANT IBUPROFEN 50 MG/1.25 ML A/F,BERRY,INFANT 50 MG/1.25 ML INFANT IBUPROFEN 50 MG/1.25 ML A/F,D/F,BERRY,INFANT 50 MG/1.25 ML $0 (Tier 1) PA; MO 16

32 INFANT IBUPROFEN 50 MG/1.25 ML A/F,INFANT 50 MG/1.25 ML INFANT IBUPROFEN 50 MG/1.25 ML D/F, A/F, W/SYRINGE 50 MG/1.25 ML INFANT IBUPROFEN 50 MG/1.25 ML D/F,A/F,NON-STAINING 50 MG/1.25 ML ketoprofen oral capsule 75 ketorolac oral tablet 10 $0 (Tier 1) PA; MO; QL (20 EA per 30 days) kro aspirin 325 tablet for adults, coated 325 kro aspirin ec 325 tablet gluten-free, reg str 325 kro naproxen sod 220 caplet caplet 220 kro naproxen sod 220 caplet caplet, gluten-free 220 kro naproxen sodium 220 tab gluten free, 12 hour 220 LITE COAT ASPIRIN 325 MG TAB CAFFEINE FREE,NA/F 325 MG meclofenamate oral capsule 100, 50 MEDIPROXEN TABLET INNER, F/C 220 MG MEDIPROXEN TABLET OUTER, F/C 220 MG MEDIPROXEN TABLET U-D, 50'S 220 MG meloxicam oral tablet 15, 7.5 nabumetone oral tablet 500, 750 naproxen oral suspension 125 /5 ml naproxen oral tablet 250, 375, 500 naproxen oral tablet,delayed release (dr/ec) 375, 500 naproxen sodium 220 caplet caplet 220 naproxen sodium 220 caplet cplt, 8-12 hr relief 220 naproxen sodium 220 capsule liquidgel

33 naproxen sodium 220 capsule liquidgels 220 naproxen sodium 220 tablet 220 naproxen sodium 220 tablet caplet 220 naproxen sodium 220 tablet caplet,boxed 220 naproxen sodium oral tablet 275, 550 piroxicam oral capsule 10, 20 PROVIL 200 MG TABLET 200 MG PUB ALL DAY RELIEF 220 MG TAB 220 MG PUB ALL DAY RLF 220 MG CAPLET CAPLET 220 MG pub aspirin 325 tablet 325 pub aspirin 325 tablet caffeine free 325 qc aspirin 325 tablet 325 qc aspirin ec 325 tablet 325 qc aspirin ec 325 tablet regular strength 325 QC CHILD IBUPROFEN 100 MG/5 ML A/F, BUBBLE GUM 100 MG/5 ML qc ibuprofen 100 /5 ml susp children's (otc) 100 /5 ml QC IBUPROFEN IB 200 MG CAPLET CAPLET 200 MG QC IBUPROFEN IB 200 MG TABLET 200 MG qc naproxen sod 220 tablet 220 sb aspirin 325 tablet 325 sb aspirin 325 tablet na/f, caffeine-free 325 sb ibuprofen 200 caplet caplet 200 sb ibuprofen 200 tablet 200 sb ibuprofen 200 tablet safety sealed 200 sm aspirin 325 tablet 325 sm aspirin ec 325 tablet reg-str, gluten-free

34 sm ibuprofen 100 /5 ml susp (otc) 100 /5 ml sm ibuprofen 100 /5 ml susp a/f (otc) 100 /5 ml sm ibuprofen 100 /5 ml susp children's (otc) 100 /5 ml sm ibuprofen 200 caplet caplet 200 sm ibuprofen 200 softgel softgel 200 sm ibuprofen 200 tablet 200 sm ibuprofen 200 tablet coated, free SM IBUPROFEN IB 100 MG CHEW TAB 100 MG SM IBUPROFEN IB 200 MG CAPLET CAPLET 200 MG SM IBUPROFEN IB 200 MG CAPLET CAPLET, GLUTEN-FREE 200 MG SM IBUPROFEN IB 200 MG TABLET COATED 200 MG SM INFANT IBUPROFEN SUSP DROP A/F, D/F 50 MG/1.25 ML SM INFANT IBUPROFEN SUSP DROP W/DROPPER 50 MG/1.25 ML sm naproxen sod 220 caplet gluten free, caplet 220 sm naproxen sod 220 tablet gluten free 220 sulindac oral tablet 150, 200 WAL-PROXEN 220 MG CAPLET 220 MG WAL-PROXEN 220 MG TABLET 220 MG OPIOID ANALGESICS, LONG-ACTING buprenorphine transdermal patch weekly 10 mcg/hour, 15 mcg/hour, 20 mcg/hour, 5 mcg/hour fentanyl transdermal patch 72 hour 100 mcg/hr $0 (Tier 1) PA fentanyl transdermal patch 72 hour 12 mcg/hr, 25 mcg/hr, 37.5 mcg/hour, 50 mcg/hr, 62.5 mcg/hour, 75 mcg/hr, 87.5 mcg/hour ; QL (4 EA per 28 days) $0 (Tier 1) QL (10 EA per 30 days) 19

35 methadone oral solution 10 /5 ml $0 (Tier 1) QL (1200 ML per 30 days) methadone oral solution 5 /5 ml $0 (Tier 1) QL (2400 ML per 30 days) methadone oral tablet 10 $0 (Tier 1) PA methadone oral tablet 5 $0 (Tier 1) QL (180 EA per 30 days) morphine oral tablet extended release 100, 200 morphine oral tablet extended release 15, 30, 60 oxycodone oral tablet,oral only,ext.rel.12 hr 10, 15, 20, 30, 40, 60, 80 OPIOID ANALGESICS, SHORT-ACTING butorphanol tartrate nasal spray,non-aerosol 10 /ml DURAMORPH (PF) INJECTION SOLUTION 0.5 MG/ML, 1 MG/ML fentanyl citrate buccal lozenge on a handle 1,200 mcg, 1,600 mcg, 200 mcg, 400 mcg, 600 mcg, 800 mcg hydromorphone (pf) injection solution 10 (/ml) (5 ml), 10 /ml $0 (Tier 1) PA $0 (Tier 1) QL (60 EA per 30 days) $0 (Tier 1) PA $0 (Tier 1) QL (5 ML per 30 days) $0 (Tier 1) B/D $0 (Tier 1) PA; QL (120 EA per 30 days) $0 (Tier 1) hydromorphone injection syringe 2 /ml $0 (Tier 1) hydromorphone oral tablet 2, 4, 8 $0 (Tier 1) QL (120 EA per 30 days) LAZANDA NASAL SPRAY,NON-AEROSOL 100 MCG/SPRAY LAZANDA NASAL SPRAY,NON-AEROSOL 300 MCG/SPRAY, 400 MCG/SPRAY ; QL (600 EA per 30 days) ; QL (150 EA per 30 days) meperidine oral solution 50 /5 ml $0 (Tier 1) PA; QL (900 ML per 30 days) meperidine oral tablet 100, 50 $0 (Tier 1) PA; QL (180 EA per 30 days) morphine oral tablet 15, 30 $0 (Tier 1) QL (120 EA per 30 days) oxycodone oral solution 5 /5 ml $0 (Tier 1) QL (5400 ML per 30 days) oxycodone oral tablet 10, 15, 20, 30, 5 $0 (Tier 1) QL (120 EA per 30 days) tramadol oral tablet 50 $0 (Tier 1) QL (240 EA per 30 days) ANESTHETICS-Local treatment of pain 20

36 LOCAL ANESTHETICS diclofenac sodium topical gel 1 % lidocaine hcl mucous membrane jelly 2 % lidocaine hcl mucous membrane solution 4 % (40 /ml) lidocaine topical adhesive patch,medicated 5 % $0 (Tier 1) PA; MO; QL (90 EA per 30 days) lidocaine topical ointment 5 % lidocaine-prilocaine topical cream % ANTI-ADDICTION/ SUBSTANCE ABUSE TREATMENT AGENTS-Treatment of substance abuse disorders ALCOHOL DETERRENTS/ ANTI-CRAVING acamprosate oral tablet,delayed release (dr/ec) 333 disulfiram oral tablet 250, 500 OPIOID DEPENDENCE TREATMENTS buprenorphine hcl sublingual tablet 2, 8 buprenorphine-naloxone sublingual tablet 2-0.5, 8-2 naltrexone oral tablet 50 OPIOID REVERSAL AGENTS naloxone injection solution 0.4 /ml naloxone injection syringe 0.4 /ml $0 (Tier 1) naloxone injection syringe 1 /ml NARCAN NASAL SPRAY,NON-AEROSOL 4 MG/ACTUATION SMOKING CESSATION AGENTS bupropion hcl (smoking deter) oral tablet extended release 12 hr 150 CHANTIX CONTINUING MONTH BOX ORAL TABLET 1 MG $0 (Tier 2) ; QL (336 EA per 365 days) CHANTIX ORAL TABLET 0.5 MG, 1 MG ; QL (336 EA per 365 days) CHANTIX STARTING MONTH BOX ORAL TABLETS,DOSE PACK 0.5 MG (11)- 1 MG (42) ; QL (106 EA per 365 days) 21

37 gnp nicotine 2 lozenge mint, 3 quittube 2 gnp nicotine 2 mini lozenge mini,mint,3 quittube 2 hm nicotine 14 /24hr patch step 2 (otc) 14 /24 hr hm nicotine 2 chewing gum mint 2 hm nicotine 2 lozenge mint 2 hm nicotine 2 lozenge mint, 3 quittube 2 hm nicotine 21 /24hr patch step 1 (otc) 21 /24 hr hm nicotine 4 chewing gum mint 4 hm nicotine 4 lozenge mint 4 hm nicotine 4 lozenge mint, 3 quittube 4 hm nicotine 7 /24hr patch step 3 (otc) 7 /24 hr kro nicotine 2 lozenge 3 quittube, cherry 2 kro nicotine 2 lozenge 3 quittube, mint 2 kro nicotine 2 mini lozenge 2 NICODERM CQ 14 MG/24HR PATCH 14 MG/24 HR NICODERM CQ 14 MG/24HR PATCH INNER 14 MG/24 HR NICODERM CQ 14 MG/24HR PATCH OUTER 14 MG/24 HR NICODERM CQ 21 MG/24HR PATCH 21 MG/24 HR NICODERM CQ 21 MG/24HR PATCH CLEAR PATCH 21 MG/24 HR NICODERM CQ 21 MG/24HR PATCH INNER 21 MG/24 HR NICODERM CQ 21 MG/24HR PATCH OUTER 21 MG/24 HR NICODERM CQ 7 MG/24HR PATCH 7 MG/24 HR NICORELIEF 2 MG GUM 2 MG 22

38 NICORELIEF 4 MG GUM 4 MG NICORETTE 2 MG CHEWING GUM CINNAMON SURGE 2 MG NICORETTE 2 MG CHEWING GUM FRESH MINT 2 MG NICORETTE 2 MG CHEWING GUM FRUIT CHILL 2 MG NICORETTE 2 MG CHEWING GUM MINT 2 MG NICORETTE 2 MG CHEWING GUM ORIGINAL FLAVOR 2 MG NICORETTE 2 MG CHEWING GUM STARTER KIT 2 MG NICORETTE 2 MG CHEWING GUM WHITE ICE MINT 2 MG NICORETTE 2 MG LOZENGE 2 MG NICORETTE 2 MG LOZENGE CHERRY 2 MG NICORETTE 2 MG LOZENGE MINT 2 MG NICORETTE 2 MG LOZENGE ORIGINAL 2 MG NICORETTE 2 MG MINI LOZENGE 2 MG NICORETTE 2 MG MINI LOZENGE MINT 2 MG NICORETTE 4 MG CHEWING GUM 4 MG NICORETTE 4 MG CHEWING GUM CINNAMON SURGE 4 MG NICORETTE 4 MG CHEWING GUM FRESH MINT 4 MG NICORETTE 4 MG CHEWING GUM FRUIT CHILL 4 MG NICORETTE 4 MG CHEWING GUM MINT 4 MG NICORETTE 4 MG CHEWING GUM ORIGINAL 4 MG NICORETTE 4 MG CHEWING GUM ORIGINAL FLAVOR 4 MG 23