UNIVERSITY HEALTH CARE ADVANTAGE (HMO) 2015 ABRIDGED FORMULARY (PARTIAL LIST OF COVERED DRUGS)

Transcription

1 UNIVERSITY HEALTH CARE ADVANTAGE (HMO) 2015 ABRIDGED FORMULARY (PARTIAL LIST OF COVERED DRUGS) PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT SOME OF THE DRUGS WE COVER IN THIS PLAN , 16 This abridged formulary was updated on 10/15/2015. This is not a complete list of drugs covered by our plan. For a complete listing or other questions, please contact University Health Care Advantage Member Services at or, for TTY users, Toll-free 711, Monday through Sunday from 8:00 a.m. to 8:00 p.m. (Pacific Standard Time), or visit University Health Care Advantage is an HMO plan with a Medicare contract. Enrollment in University Health Care Advantage depends on contract renewal. This information is available for free in other languages. Please contact Member Services at for additional information. TTY users should call 711. Hours are: 8:00 a.m. until 8:00 p.m., Pacific Standard Time, 7 days a week. Member Services also has free language interpreter services available for non-english speakers. Esta información está disponible gratuitamente en otros idiomas. Llame a nuestro número de servicio al cliente , 8:00 a.m. a 8:00 p.m., hora estándar del pacífico, siete días a la semana. Los usuarios de TTY deben llamar al 711. Thông tin này có sẵn miễn phí bằng các ngôn ngữ khác. Xin vui lòng gọi Dịch Vụ Hội Viên của chúng tôi tại số , 8:00 sáng đến 8:00 chiều, giờ Chuẩn Thái Bình Dương, 7 ngày một tuần. Người dùng TTY gọi số 點至晚上 8 點之間致電我們的會員服務號碼 , 時間為太平洋標準時間 TTY 使用者請撥打 711 H2986_PD_200 Abridged Formulary Page 1

2 Note to existing members: This formulary has changed since last year. Please review this document to make sure that it still contains the drugs you take. When this drug list (formulary) refers to we, us, or our, it means University Health Care Advantage. When it refers to plan or our plan, it means University Health Care Advantage (HMO). This document includes a partial list of the drugs (formulary) for our plan which is current as of November 01, For a complete updated formulary, please contact us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages. You must generally use network pharmacies to use your prescription drug benefit. Benefits, formulary, pharmacy network, and/or copayments/coinsurance may change on January 1, 2016, and from time to time during the year. H2986_PD_200 Abridged Formulary Page 2

3 What is the University Health Care Advantage (HMO) Abridged Formulary? A formulary is a list of covered drugs selected by University Health Care Advantage (HMO) in consultation with a team of health care providers, which represents the prescription therapies believed to be a necessary part of a quality treatment program. University Health Care Advantage (HMO) will generally cover the drugs listed in our formulary as long as the drug is medically necessary, the prescription is filled at a University Health Care Advantage (HMO) network pharmacy, and other plan rules are followed. For more information on how to fill your prescriptions, please review your Evidence of Coverage. This document is a partial formulary and includes only some of the drugs covered by University Health Care Advantage (HMO). For a complete listing of all prescription drugs covered by University Health Care Advantage (HMO), please visit our website or call us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages. Can the Formulary (drug list) change? Generally, if you are taking a drug on our 2015 formulary that was covered at the beginning of the year, we will not discontinue or reduce coverage of the drug during the 2015 coverage year except when a new, less expensive generic drug becomes available or when new adverse information about the safety or effectiveness of a drug is released. Other types of formulary changes, such as removing a drug from our formulary, will not affect members who are currently taking the drug. It will remain available at the same cost-sharing for those members taking it for the remainder of the coverage year. We feel it is important that you have continued access for the remainder of the coverage year to the formulary drugs that were available when you chose our plan, except for cases in which you can save additional money or we can ensure your safety. If we remove drugs from our formulary, or add prior authorization, quantity limits and/or step therapy restrictions on a drug or move a drug to a higher cost-sharing tier, we must notify affected members of the change at least 60 days before the change becomes effective, or at the time the member requests a refill of the drug, at which time the member will receive a 60-day supply of the drug. If the Food and Drug Administration deems a drug on our formulary to be unsafe or the drug s manufacturer removes the drug from the market, we will immediately remove the drug from our formulary and provide notice to members who take the drug. The enclosed formulary is current as of November 01, To get updated information about the drugs covered by University Health Care Advantage (HMO), please contact us. Our contact information appears on the front and back cover pages. In the event we make a non-maintenance change to the formulary, we will post an errata sheet to our website and mail a letter to members. Members will also receive notification via the normal member explanation of benefits process. How do I use the Formulary? There are two ways to find your drug within the formulary: Medical Condition The formulary begins on page 15. The drugs in this formulary are grouped into categories depending on the type of medical conditions that they are used to treat. For example, drugs used to treat a heart condition are listed under the category Cardiovascular Agents. If you know what your drug is used for, look for the category name in the list that begins on page 15. Then look under the category name for your drug. H2986_PD_200 Abridged Formulary Page 3

4 Alphabetical ing If you are not sure what category to look under, you should look for your drug in the Index that begins on page I-1. The Index provides an alphabetical list of all of the drugs included in this document. Both brand name drugs and generic drugs are listed in the Index. Look in the Index and find your drug. Next to your drug, you will see the 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. What are generic drugs? University Health Care Advantage (HMO) covers both brand name drugs and generic drugs. A generic drug is approved by the FDA as having the same active ingredient as the brand name drug. Generally, generic drugs cost less than brand name drugs. Are there any restrictions on my coverage? Some covered drugs may have additional requirements or limits on coverage. These requirements and limits may include: Prior Authorization: University Health Care Advantage (HMO) requires you or your physician to get prior authorization for certain drugs. This means that you will need to get approval from University Health Care Advantage (HMO) before you fill your prescriptions. If you don t get approval, University Health Care Advantage (HMO) may not cover the drug. Quantity Limits: For certain drugs, University Health Care Advantage (HMO) limits the amount of the drug that our plan will cover. For example, University Health Care Advantage (HMO) provides 30 pills per prescription for Ambien. This may be in addition to a standard one-month or three-month supply. Step Therapy: In some cases, University Health Care Advantage (HMO) 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, University Health Care Advantage (HMO) may not cover Drug B unless you try Drug A first. If Drug A does not work for you, our plan will then cover Drug B. You can find out if your drug has any additional requirements or limits by looking in the formulary that begins on Formulary Page 15. You can also get more information about the restrictions applied to specific covered drugs by visiting our Web site. We have posted on line documents that explain our prior authorization and step therapy restrictions. You may also ask us to send you a copy. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages. You can ask University Health Care Advantage (HMO) to make an exception to these restrictions or limits or for a list of other, similar drugs that may treat your health condition. See the section, How do I request an exception to the University Health Care Advantage (HMO) formulary? on page 5 (below) for information about how to request an exception. What if my drug is not on the Formulary? If your drug is not included in this formulary (list of covered drugs), you should first contact Member Services and ask if your drug is covered. This document includes only a partial list of covered drugs, so University H2986_PD_200 Abridged Formulary Page 4

5 Health Care Advantage (HMO) may cover your drug. For more information, please contact us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages. If you learn that University Health Care Advantage (HMO) does not cover your drug, you have two options: You can ask Member Services for a list of similar drugs that are covered by University Health Care Advantage (HMO). When you receive the list, show it to your doctor and ask him or her to prescribe a similar drug that is covered by our plan. You can ask University Health Care Advantage (HMO) to make an exception and cover your drug. See below for information about how to request an exception. How do I request an exception to the University Health Care Advantage (HMO) s Formulary? You can ask University Health Care Advantage (HMO) to make an exception to our coverage rules. There are several types of exceptions that you can ask us to make. You can ask us to cover a drug even if it is not on our formulary. If approved, this drug will be covered at a pre-determined cost-sharing level, and you would not be able to ask us to provide the drug at a lower cost-sharing level. You can ask us to cover a formulary drug at a lower cost-sharing level if this drug is not on the specialty tier. If approved this would lower the amount you must pay for your drug. You can ask us to waive coverage restrictions or limits on your drug. For example, for certain drugs, University Health Care Advantage (HMO) limits the amount of the drug that we will cover. If your drug has a quantity limit, you can ask us to waive the limit and cover a greater amount. Generally, University Health Care Advantage (HMO) will only approve your request for an exception if the alternative drugs included on the plan s formulary, the lower cost-sharing drug or additional utilization restrictions would not be as effective in treating your condition and/or would cause you to have adverse medical effects. You should contact us to ask us for an initial coverage decision for a formulary, tiering or utilization restriction exception. When you request a formulary, tiering or utilization restriction exception, you should submit a statement from your prescriber or physician supporting your request. Generally, we must make our decision within 72 hours of getting your prescriber s supporting statement. You can request an expedited (fast) exception if you or your doctor believes that your health could be seriously harmed by waiting up to 72 hours for a decision. If your request to expedite is granted, we must give you a decision no later than 24 hours after we get a supporting statement from your doctor or other prescriber. What do I do before I can talk to my doctor about changing my drugs or requesting an exception? H2986_PD_200 Abridged Formulary Page 5

6 As a new or continuing member in our plan you may be taking drugs that are not on our formulary. Or, you may be taking a drug that is on our formulary but your ability to get it is limited. For example, you may need a prior authorization from us before you can fill your prescription. You should talk to your doctor to decide if you should switch to an appropriate drug that we cover or request a formulary exception so that we will cover the drug you take. While you talk to your doctor to determine the right course of action for you, we may cover your drug in certain cases during the first 90 days you are a member of our plan. For each of your drugs that is not on our formulary or if your ability to get your drugs is limited, we will cover a temporary 30-day supply (unless you have a prescription written for fewer when you go to a network pharmacy. After your first 30-day supply, we will not pay for these drugs, even if you have been a member of the plan less than 90 days. If you are a resident of a long-term care facility, we will allow you to refill your prescription until we have provided you with at least a 91 and may be up to a 98-day transition supply, consistent with dispensing increment (unless you have a prescription written for fewer. We will cover more than one refill of these drugs for the first 90 days you are a member of our plan. If you need a drug that is not on our formulary or if your ability to get your drugs is limited, but you are past the first 90 days of membership in our plan, we will cover a 31-day emergency supply of that drug (unless you have a prescription for fewer while you pursue a formulary exception. In circumstances where a member is changing from one treatment setting to another, University Health Care Advantage (HMO) will ensure a transition process for approving non-formulary Part D drugs. This process shall also apply to formulary Part D drugs that require prior authorization or step-therapy. Examples of level of care changes include: members who are discharged from a hospital to a home; members who end their skilled nursing facility Medicare Part A stay and who need to revert to their Part D plan formulary; members who end a long-term care facility stay and return to the community; and, members who are discharged from psychiatric hospitals with medication regimens that are highly individualized. The pharmacy benefit manager for University Health Care Advantage (HMO) will provide pharmacies with access to representatives of the plan who have the ability to override pharmacy claims processing issues. This access will allow pharmacies to obtain prescription claims overrides at the point-of-sale and ensure that members receive reliable access to medications. For more information For more detailed information about your University Health Care Advantage (HMO) prescription drug coverage, please review your Evidence of Coverage and other plan materials. If you have questions about University Health Care Advantage (HMO), please contact us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages. If you have general questions about Medicare prescription drug coverage, please call Medicare at MEDICARE ( ) 24 hours a day/7 days a week. TTY users should call Or, visit H2986_PD_200 Abridged Formulary Page 6

7 University Health Care Advantage (HMO) s Formulary The abridged formulary that begins page 15 provides coverage information about some of the drugs covered by University Health Care Advantage (HMO). If you have trouble finding your drug in the list, turn to the Index that begins on Index Page I-1. Remember: This is only a partial list of drugs covered by University Health Care Advantage (HMO). If your prescription is not in this partial formulary, please contact us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages. The first column of the chart lists the drug name. Brand name drugs are capitalized (e.g., AVINZA) and generic drugs are listed in lower-case italics (e.g., acetaminophen). The information in the Requirements/Limits column tells you if University Health Care Advantage (HMO) has any special requirements for coverage of your drug The second column of the chart lists the drug tier. Every drug on the plan s Drug is in one of six costsharing tiers. The tables below provide an explanation of each tier. Network Retail Pharmacy Drug Tier Copayment Levels Tier Copay for up to a one-month supply Copay for up to a three-month supply Tier 1 (Preferred Generic) $2 $6 Tier 2 (NON-Preferred Generic) $15 $45 Tier 3 (Preferred Brand) $45 $135 Tier 4 (NON-Preferred Brand Name) $95 $285 Tier 5 (Specialty) 33% of cost 33% of cost Tier 6 (Select Diabetic Drugs) $2 $6 Network Mail Order Drug Tier Copayment Levels Tier Copay for up to a one-month supply Copay for up to a three-month supply Tier 1 (Preferred Generic) $2 $4 Tier 2 (NON-Preferred Generic) $15 $30 Tier 3 (Preferred Brand) $45 $90 Tier 4 (NON-Preferred Brand Name) $95 $190 Tier 5 (Specialty) 33% of cost 33% of cost Tier 6 (Select Diabetic Drugs) $2 $4 H2986_PD_200 Abridged Formulary Page 7

8 The following coverage abbreviations appear in the Requirements/Limits column: COVERAGE NOTES ABBREVIATIONS ABBREVIATION DESCRIPTION EXPLANATION PA PA BvD PA-HRM PA NSO QL ST Prior Authorization Restriction Prior Authorization Restriction for Part B vs Part D Determination Prior Authorization Restriction for High Risk Medications Prior Authorization Restriction for New Starts Only Quantity Limit Restriction Step Therapy Restriction Utilization Management Restrictions You (or your physician) are required to get prior authorization from University Health Care Advantage (HMO) before you fill your prescription for this drug. Without prior approval, University Health Care Advantage (HMO) may not cover this drug. This drug may be eligible for payment under Medicare Part B or Part D. You (or your physician) are required to get prior authorization from University Health Care Advantage (HMO) to determine whether this drug is covered under Medicare Part D before you fill your prescription for this drug. Without prior approval, University Health Care Advantage (HMO) may not cover this drug. This drug has been deemed by CMS to be potentially harmful and therefore, a High Risk Medication for Medicare beneficiaries 65 years or older. Members age 65 years or older are required to get prior authorization from University Health Care Advantage (HMO) before filling your prescription for this drug. Without prior approval, University Health Care Advantage (HMO) may not cover this drug. If you are a new member or if you have not taken this drug previously, you (or your physician) are required to get prior authorization from University Health Care Advantage (HMO) before you fill your prescription for this drug. Without prior approval, University Health Care Advantage (HMO) may not cover this drug. University Health Care Advantage (HMO) limits the amount of this drug that is covered per prescription, or within a specific time frame. Before University Health Care Advantage (HMO) will provide coverage for this drug, you must first try another drug(s) to treat your medical condition. This drug may only be covered if the other drug(s) does not work for you. H2986_PD_200 Abridged Formulary Page 8

9 OTHER COVERAGE ABBREVIATIONS ABBREVIATION DESCRIPTION EXPLANATION LA GC Limited Access Drug Gap Coverage This prescription may be available only at certain pharmacies. For more information consult your Pharmacy Directory or call Member Services at number at , 8:00 a.m. to 8:00 p.m., Pacific Standard Time, 7 days a week. TTY users call 711. We provide coverage of this prescription drug in the coverage gap. Please refer to our Evidence of Coverage for more information about this coverage. STRENGTH AND DOSAGE FORM ABBREVIATIONS ABBREVIATION adh. patch aer br act aer pow aer pow ba aer refill aer w/adap ampul blkbaginj cap dr mp cap ds pk cap er 12h cap er 24h cap er deg cap er pel cap mphase cap.sa 24h cap.sr 12h cap.sr 24h cap24h pct DESCRIPTION adhesive patch aerosol, breath activated aerosol, powder aerosol powder, breath activated aerosol refill aerosol with adapter ampule bulk bag injection capsule, delayed release multiphasic capsule, dose pack capsule, 12 hour extended release capsule, 24 hour extended release capsule, extended release degradable capsule, extended release pellets capsule, multiphasic capsule, 24 hour sustained action capsule, 12 hour sustained release capsule, 24 hour sustained release capsule, 24 hour controlled-onset pellets H2986_PD_200 Abridged Formulary Page 9

10 ABBREVIATION DESCRIPTION cap24h pel capsule, 24 hour sustained release pellets cap sprink capsule, sprinkle cap sr pel capsule sustained release pellets cap w/dev capsule with device capsule dr capsule, delayed release capsule er capsule, extended release capsule sa capsule, sustained action cmb cappad combination: capsule, pad cmb ont fm combination: ointment, foam cmb ont lt combination: ointment, lotion cmb tabpad combination: tablet, pad combo. pkg combination package cpmp 12hr capsule, 12 hour multiphasic cpmp 24hr capsule, 24 hour multiphasic cpmp capsule, multiphasic, 30%-70% cpmp capsule, multiphasic, 50%-50% cream(g), cream(gm) cream (grams) cream(ml) cream (milliliters) cream/appl cream with applicator cream, er (g) cream, extended release (grams) cream pack cream, package dehp fr bg di(2-ethylhexyl)phthalate free bag dis needle disposable needle disk w/dev disk with inhalation device disp syrin disposable syringe drops susp drops, suspension drps hpvis drops, hyperviscous emul adhes emulsion adhesive emul packt emulsion packet emulsn(g) emulsion (grams) foam/appl. foam with applicator H2986_PD_200 Abridged Formulary Page 10

11 ABBREVIATION froz.piggy g gel/pf app gel (gm) gel (ml) gel md pmp gel w/appl gel w/pump gran pack hfa aer ad infus. Btl insuln pen ip soln irrig soln iv soln. jel jelly/app jel/pf app kit cl&crm kt crm le kt lotn ce kt oint le lotion, er lozenge hd m.ht patch ma buc tab mcg med. pad med. swab med. tape mg DESCRIPTION frozen piggyback gram gel with prefilled applicator gel (grams) gel (milliliters) gel in metered dose pump gel with applicator gel with pump granule pack hfa aerosol adapter infusion bottle insulin pen intraperitoneal solution irrigating solution intravenous solution jelly jelly with applicator jelly with pre-filled applicator kit: cleanser and cream kit: cream, lotion emollient kit: lotion, cream emollient kit: ointment, lotion emollient lotion, extended release lozenge handle medicated heated patch mucoadhesive buccal tablet microgram medicated pad medicated swab medicated tape milligram H2986_PD_200 Abridged Formulary Page 11

12 ABBREVIATION ml muc er 12h ndl fr inj nl fm susp oint. (g), oint.(gm) oral conc oral susp paste (g) patch td24 patch td72 patch tdsw patch tdwk pca syring pca vial pellet(ea) pen ij kit pen injctr pggybk btl plast. Bag powd pack sol md pmp sol w/appl sol/pf app sol-gel soln recon soln(gram) spray susp spray/pump stick(ea) supp.rect supp.vag DESCRIPTION milliliter mucoadhesive system, 12 hour extended release needle for injection nail film suspension ointment (grams) oral concentrate oral suspension paste (grams) patch, 24 hour transdermal patch, 72 hour transdermal patch, biweekly transdermal patch, weekly transdermal patient-controlled analgesic syringe patient-controlled analgesic vial pellet (each) pen injector kit pen injector piggyback bottle plastic bag powder pack solution with multi-dose pump solution with applicator solution with pre-filled applicator solution, gel-forming solution, reconstituted solution (grams) spray, suspension spray with pump stick (each) suppository, rectal suppository, vaginal H2986_PD_200 Abridged Formulary Page 12

13 ABBREVIATION suppos. sus er 24h sus er rec sus mc rec suspdr pkt susp recon syringekit tab chew tab er 12h tab er 24h tab er prt tab er seq tab disper tab ds pk tab er 24 tab mphase tab part tab rap dr tab rapdis tab subl tab.sr 12h tab.sr 24h tabergr24hr tablet dr tablet, er tablet eff tablet sa tablet sol tb er dspk tb mp dspk tb rd dspk DESCRIPTION suppository suspension, 24 hour extended release suspension, extended release reconstituted suspension, microcapsule reconstituted suspension, delayed release packet suspension, reconstituted syringe kit tablet, chewable tablet, 12 hour extended release tablet, 24 hour extended release tablet, extended release particles tablet, extended release sequels tablet, dispersible tablet, dose pack tablet, 24 hour extended release tablet, multiphasic tablet, particles tablet, rapid disintegrating delayed release tablet, rapid disintegrating tablet, sublingual tablet, 12 hour sustained release tablet, 24 hour sustained release tablet, 24 hour gradual extended release tablet, delayed release tablet, extended release tablet, effervescent tablet, sustained action tablet, soluble tablet, extended release dose pack tablet, multiphasic dose pack tablet, rapid disintegrating dose pack H2986_PD_200 Abridged Formulary Page 13

14 ABBREVIATION tbdspk 3mo tbmp 12hr tbmp 24hr u vag ring DESCRIPTION tablet, 3-month dose pack tablet, 12 hour multiphasic tablet, 24 hour multiphasic Unit vaginal ring H2986_PD_200 Abridged Formulary Page 14

15 Analgesics Analgesics, Miscellaneous acetaminophen-codeine oral solution (Acetaminophen with Codeine) 2 GC; QL (2700 per 30 acetaminophen-codeine oral tablet (Tylenol-Codeine 2 GC; QL (360 per 30 mg, mg No.3) acetaminophen-codeine oral tablet (Tylenol-Codeine 2 GC; QL (180 per 30 mg No.3) butalbital-acetaminophen-caff oral tablet mg (Esgic) 2 PA-HRM; GC; QL (180 per 30 CAPITAL WITH CODEINE 4 QL (2700 per 30 CONZIP 4 QL (30 per 30 DILAUDID ORAL LIQUID 4 QL (1200 per 30 DILAUDID ORAL TABLET 2 MG, 4 4 QL (180 per 30 MG DILAUDID ORAL TABLET 8 MG 4 QL (240 per 30 DOLOPHINE ORAL 4 QL (360 per 30 DURAGESIC TRANSDERMAL PATCH 72 HOUR 100 MCG/HR 4 PA; QL (20 per 30 DURAGESIC TRANSDERMAL PATCH 72 HOUR 12 MCG/HR, 25 4 PA; QL (10 per 30 MCG/HR, 50 MCG/HR, 75 MCG/HR ESGIC ORAL TABLET 4 PA-HRM; QL (180 per 30 EXALGO ER ORAL TABLET EXTENDED RELEASE 24 HR 12 MG, 16 MG, 8 MG EXALGO ER ORAL TABLET EXTENDED RELEASE 24 HR 32 MG fentanyl transdermal patch 72 hour 100 mcg/hr 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 4 PA; QL (30 per 30 4 PA; QL (60 per 30 (Duragesic) 2 PA; GC; QL (20 per 30 (Duragesic) 2 PA; GC; QL (10 per 30 15

16 HYCET 4 QL (2700 per 30 hydrocodone-acetaminophen oral solution (Hycet) 2 GC; QL (2700 per mg/15 ml hydrocodone-acetaminophen oral tablet mg, mg, mg (Norco) 2 (includes Vicodin, Vicodin ES and Vicodin HP); GC; QL (390 per 30 hydrocodone-acetaminophen oral tablet mg, mg, mg, mg (Norco) 2 GC; QL (360 per 30 hydromorphone oral liquid (Dilaudid) 2 GC; QL (1200 per 30 hydromorphone oral tablet 2 mg, 4 mg (Dilaudid) 2 GC; QL (180 per 30 hydromorphone oral tablet 8 mg (Dilaudid) 2 GC; QL (240 per 30 hydromorphone oral tablet extended release 24 hr 12 mg, 16 mg, 8 mg (Exalgo) 2 PA; GC; QL (30 per 30 hydromorphone oral tablet extended release 24 hr 32 mg (Exalgo) 2 PA; GC; QL (60 per 30 KADIAN ORAL 4 ST; QL (60 per 30 CAPSULE,EXTEND.RELEASE PELLETS 10 MG, 20 MG, 30 MG, 40 MG, 50 MG, 60 MG, 80 MG KADIAN ORAL CAPSULE,EXTEND.RELEASE PELLETS 100 MG 5 ST; QL (60 per 30 KADIAN ORAL CAPSULE,EXTEND.RELEASE PELLETS 200 MG 5 ST; QL (120 per 30 LORTAB QL (360 per 30 LORTAB QL (360 per 30 LORTAB QL (360 per 30 LORTAB ELIXIR ORAL SOLUTION 4 QL (2025 per MG/15 ML methadone injection (Methadone HCl) 2 GC 16

17 methadone oral (Methadone HCl) 2 GC; QL (1800 per 30 methadone oral (Dolophine HCl) 2 GC; QL (360 per 30 morphine concentrate oral solution (Msir) 2 GC; QL (200 per 30 morphine intravenous cartridge 10 mg/ml, (Morphine Sulfate) 2 GC 2 mg/ml, 4 mg/ml, 8 mg/ml morphine intravenous (Morphine Sulfate) 2 GC morphine oral capsule, er multiphase 24 hr 120 mg, 30 mg, 45 mg, 60 mg, 75 mg (Avinza) 2 ST; GC; QL (30 per 30 morphine oral capsule, er multiphase 24 hr 90 mg (Avinza) 2 ST; GC; QL (60 per 30 morphine oral capsule,extend.release pellets 10 mg, 20 mg, 30 mg, 50 mg, 60 mg, 80 mg morphine oral capsule,extend.release pellets 100 mg (Kadian) 2 ST; GC; QL (60 per 30 (Kadian) 5 ST; QL (60 per 30 morphine oral solution 10 mg/5 ml (Msir) 2 GC; QL (700 per 30 morphine oral solution 20 mg/5 ml (Msir) 2 GC; QL (300 per 30 MORPHINE ORAL TABLET 2 GC; QL (180 per 30 morphine oral tablet extended release 100 (MS Contin) 2 GC; QL (120 per 30 mg, 30 mg, 60 mg morphine oral tablet extended release 15 mg, 200 mg (MS Contin) 2 GC; QL (180 per 30 MS CONTIN ORAL TABLET 4 QL (120 per 30 EXTENDED RELEASE 100 MG, 30 MG, 60 MG MS CONTIN ORAL TABLET 4 QL (180 per 30 EXTENDED RELEASE 15 MG, 200 MG NORCO 4 QL (360 per 30 oxycodone hcl-acetaminophen oral tablet mg, mg, mg (Percocet) 2 GC; QL (360 per 30 17

18 oxycodone oral capsule (Oxycodone HCl) 2 GC; QL (180 per 30 oxycodone oral concentrate (Oxycodone HCl) 2 GC; QL (180 per 30 oxycodone oral solution (Oxycodone HCl) 2 GC; QL (1300 per 30 oxycodone oral tablet (Roxicodone) 2 GC; QL (180 per 30 oxycodone oral tablet,oral only,ext.rel.12 (Oxycodone HCl) 4 QL (60 per 30 hr 10 mg, 20 mg, 40 mg oxycodone oral tablet,oral only,ext.rel.12 hr 80 mg (Oxycodone HCl) 4 QL (120 per 30 oxycodone-acetaminophen oral tablet mg, mg, mg, mg 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 PERCOCET ORAL TABLET MG, MG, MG, MG (Percocet) 2 GC; QL (360 per 30 3 QL (60 per 30 3 QL (120 per 30 4 QL (360 per 30 PRIMLEV 4 QL (390 per 30 ROXICODONE 4 QL (180 per 30 SUBSYS SUBLINGUAL SPRAY,NON-AEROSOL 5 PA; QL (120 per 30 tramadol oral capsule,er biphase 24 hr (Conzip) 2 GC; QL (30 per 30 tramadol oral capsule,er biphase 24 hr mg, 200 mg (Conzip) 2 GC; QL (30 per 30 tramadol oral tablet (Ultram) 2 GC; QL (240 per 30 tramadol oral tablet extended release 24 hr 100 mg (Ultram ER) 2 GC; QL (90 per 30 18

19 tramadol oral tablet extended release 24 hr 200 mg, 300 mg (Ultram ER) 2 GC; QL (30 per 30 tramadol oral tablet, er multiphase 24 hr (Ultram ER) 2 GC; QL (30 per 30 TYLENOL-CODEINE #3 4 QL (360 per 30 TYLENOL-CODEINE #4 4 QL (180 per 30 ULTRAM 4 QL (240 per 30 ULTRAM ER ORAL TABLET 4 QL (90 per 30 EXTENDED RELEASE 24 HR 100 MG ULTRAM ER ORAL TABLET EXTENDED RELEASE 24 HR 200 MG, 300 MG 4 QL (30 per 30 XARTEMIS XR 3 QL (360 per 30 XODOL 10/300 4 QL (390 per 30 XODOL 5/300 4 QL (390 per 30 XODOL 7.5/300 4 QL (390 per 30 ZAMICET 4 QL (2700 per 30 Nonsteroidal Anti-Inflammatory Agents CELEBREX 4 QL (60 per 30 celecoxib (Celebrex) 2 GC; QL (60 per 30 (Voltaren-XR) 2 GC diclofenac sodium oral tablet extended release 24 hr diclofenac sodium oral tablet,delayed (Diclofenac Sodium) 2 GC release (dr/ec) diclofenac sodium topical drops (Pennsaid) 2 GC diclofenac sodium topical gel (Solaraze) 5 EC-NAPROSYN 4 ibuprofen oral (Ibuprofen) 2 GC ibuprofen oral tablet 400 mg, 600 mg, (Ibuprofen) 1 GC 800 mg INDOCIN ORAL 4 PA-HRM indomethacin oral capsule 25 mg (Indomethacin) 2 PA-HRM; GC; QL (240 per 30 19

20 indomethacin oral capsule 50 mg (Indomethacin) 2 PA-HRM; GC; QL (120 per 30 indomethacin oral capsule, extended release (Indomethacin) 2 PA-HRM; GC; QL (60 per 30 meloxicam oral suspension (Mobic) 2 GC meloxicam oral tablet (Mobic) 1 GC MOBIC 4 nabumetone (Nabumetone) 2 GC NAPROSYN ORAL TABLET 4 naproxen oral suspension (Naprosyn) 2 GC naproxen oral tablet (Naprosyn) 1 GC naproxen oral tablet,delayed release (Ec-Naprosyn) 2 GC (dr/ec) PENNSAID TOPICAL SOLUTION 4 IN METERED-DOSE PUMP SOLARAZE 5 VOLTAREN TOPICAL 3 Anesthetics Local Anesthetics lidocaine hcl injection solution 20 mg/ml (Xylocaine) 2 PA BvD; (PA for (2 %) ESRD Only); GC lidocaine hcl mucous membrane gel (Lidocaine HCl) 2 GC lidocaine hcl mucous membrane jelly in (Lidocaine HCl) 2 GC applicator lidocaine hcl mucous membrane solution (Xylocaine) 2 GC lidocaine hcl urethral (Lidocaine HCl) 2 GC lidocaine topical adhesive patch,medicated (Lidoderm) 2 PA; GC lidocaine topical ointment (Lidocaine) 2 PA BvD; (PA for ESRD Only); GC LIDODERM 4 PA XYLOCAINE INJECTION 4 SOLUTION XYLOCAINE MUCOUS MEMBRANE SOLUTION 4 20

21 Anti-Addiction/Substance Abuse Treatment Agents Anti-Addiction/Substance Abuse Treatment Agents BUNAVAIL 4 PA; QL (60 per 30 buprenorphine hcl sublingual (Subutex) 2 PA; GC; QL (90 per 30 buprenorphine-naloxone (Buprenorphine HCl/Naloxone HCl) 2 PA; GC; QL (90 per 30 CHANTIX 3 QL (168 per 84 CHANTIX CONTINUING MONTH 3 QL (56 per 28 BOX CHANTIX CONTINUING MONTH 3 QL (56 per 28 PAK CHANTIX STARTING MONTH 3 QL (53 per 28 BOX SUBOXONE SUBLINGUAL FILM 12-3 MG 4 PA; QL (60 per 30 SUBOXONE SUBLINGUAL FILM MG, 4-1 MG, 8-2 MG 4 PA; QL (90 per 30 ZUBSOLV SUBLINGUAL TABLET MG 3 PA; QL (120 per 30 ZUBSOLV SUBLINGUAL TABLET MG 3 PA; QL (90 per 30 ZUBSOLV SUBLINGUAL TABLET MG 3 PA; QL (60 per 30 Antianxiety Agents Benzodiazepines ALPRAZOLAM INTENSOL 4 QL (180 per 30 alprazolam oral tablet (Xanax) 2 GC; QL (90 per 30 (Xanax XR) 2 GC; QL (90 per 30 (Xanax XR) 2 GC; QL (60 per 30 alprazolam oral tablet extended release 24 hr 0.5 mg alprazolam oral tablet extended release 24 hr 1 mg, 2 mg, 3 mg alprazolam oral tablet,disintegrating (Alprazolam) 2 GC; QL (90 per 30 21

22 ATIVAN ORAL 4 QL (90 per 30 clonazepam oral tablet 0.5 mg, 1 mg (Klonopin) 2 GC; QL (90 per 30 clonazepam oral tablet 2 mg (Klonopin) 2 GC; QL (300 per 30 clonazepam oral tablet,disintegrating mg, 0.25 mg, 0.5 mg, 1 mg (Clonazepam) 2 GC; QL (90 per 30 clonazepam oral tablet,disintegrating 2 mg (Clonazepam) 2 GC; QL (300 per 30 KLONOPIN ORAL TABLET 0.5 MG, 4 QL (90 per 30 1 MG KLONOPIN ORAL TABLET 2 MG 4 QL (300 per 30 lorazepam oral solution (Ativan) 2 GC; QL (150 per 30 lorazepam oral tablet (Ativan) 2 GC; QL (90 per 30 XANAX 4 QL (90 per 30 XANAX XR ORAL TABLET 4 QL (90 per 30 EXTENDED RELEASE 24 HR 0.5 MG XANAX XR ORAL TABLET EXTENDED RELEASE 24 HR 1 MG, 2 MG, 3 MG 4 QL (60 per 30 Antibacterials Aminoglycosides gentamicin injection solution (Garamycin) 2 GC neomycin (Neomycin Sulfate) 2 GC TOBI 5 PA BvD tobramycin in % nacl (Tobi) 5 PA BvD Antibacterials, Miscellaneous clindamycin hcl (Cleocin HCl) 2 GC clindamycin palmitate hcl (Cleocin Palmitate) 2 GC CLINDAMYCIN PHOSPHATE ORAL CAPSULE 150 MG, 300 MG, 75 MG 4 22

23 CLINDAMYCIN PHOSPHATE 4 ORAL RECON SOLN 75 MG/5 ML MACROBID MACRODANTIN 4 4 PA-HRM; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use of nitrofurantoin drugs); QL (120 per 30 PA-HRM; (High Risk nitrofurantoin macrocrystal oral capsule (Macrodantin/Macrobi 2 Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use of nitrofurantoin drugs); QL (120 per 30 PA-HRM; GC; QL 100 mg d) (120 per 30 nitrofurantoin macrocrystal oral capsule (Macrodantin/Macrobi d) 2 PA-HRM; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use of nitrofurantoin drugs); GC; QL (120 per 30 nitrofurantoin monohyd/m-cryst (Macrobid) 2 PA-HRM; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use of nitrofurantoin drugs); GC; QL (120 per 30 23

24 PRIMSOL 4 trimethoprim (Trimethoprim) 2 GC XIFAXAN ORAL TABLET 200 MG 5 PA; QL (9 per 30 XIFAXAN ORAL TABLET 550 MG 5 ST; QL (60 per 30 Cephalosporins cefadroxil oral capsule (Cefadroxil) 2 GC cefadroxil oral suspension for (Cefadroxil) 2 GC reconstitution 250 mg/5 ml, 500 mg/5 ml cefadroxil oral tablet (Cefadroxil) 2 GC cefdinir (Cefdinir) 2 GC cefpodoxime (Cefpodoxime Proxetil) 2 GC cefprozil (Cefprozil) 2 GC CEFTIN ORAL SUSPENSION FOR 4 RECONSTITUTION CEFTIN ORAL TABLET 250 MG, MG ceftriaxone injection recon soln (Rocephin) 2 GC cefuroxime axetil oral tablet (Ceftin) 2 GC cephalexin oral capsule (Keflex) 1 GC cephalexin oral suspension for (Cephalexin) 1 GC reconstitution cephalexin oral tablet (Cephalexin) 1 GC KEFLEX ORAL CAPSULE 4 Macrolides azithromycin (Zithromax) 2 GC BIAXIN ORAL SUSPENSION FOR 4 RECONSTITUTION 250 MG/5 ML BIAXIN ORAL TABLET 4 clarithromycin oral suspension for (Biaxin) 2 GC reconstitution clarithromycin oral tablet (Biaxin) 2 GC clarithromycin oral tablet extended (Biaxin XL) 2 GC release 24 hr ZITHROMAX 4 ZITHROMAX TRI-PAK 4 24

25 ZITHROMAX Z-PAK 4 ZMAX 4 Miscellaneous B-Lactam Antibiotics CAYSTON 5 LA INVANZ INJECTION 4 Penicillins amoxicillin oral capsule (Amoxicillin) 1 GC amoxicillin oral suspension for (Amoxil) 1 GC reconstitution amoxicillin oral tablet (Amoxicillin) 1 GC amoxicillin oral tablet,chewable 125 mg, (Amoxicillin) 1 GC 250 mg amoxicillin-pot clavulanate oral (Augmentin) 2 GC suspension for reconstitution amoxicillin-pot clavulanate oral tablet (Augmentin) 2 GC amoxicillin-pot clavulanate oral tablet (Augmentin XR) 2 GC extended release 12 hr amoxicillin-pot clavulanate oral (Amoxicillin/Potassium 2 GC tablet,chewable Clav) ampicillin (Ampicillin Trihydrate) 1 GC AUGMENTIN ORAL SUSPENSION 4 FOR RECONSTITUTION MG/5 ML dicloxacillin (Dicloxacillin Sodium) 2 GC penicillin v potassium (Penicillin V Potassium) 2 GC Quinolones AVELOX 4 AVELOX ABC PACK 4 CIPRO ORAL TABLET 250 MG, MG ciprofloxacin hcl oral (Cipro) 1 GC LEVAQUIN ORAL 4 levofloxacin intravenous (Levofloxacin) 2 GC levofloxacin oral solution (Levaquin) 2 GC 25

26 levofloxacin oral tablet (Levaquin) 1 GC moxifloxacin (Avelox) 2 GC Sulfonamides AZULFIDINE 4 AZULFIDINE EN-TABS 4 BACTRIM 4 BACTRIM DS 4 sulfamethoxazole-trimethoprim (Sulfamethoxazole/Tri 2 GC intravenous methoprim) sulfamethoxazole-trimethoprim oral (Sulfamethoxazole/Tri 2 GC suspension methoprim) sulfamethoxazole-trimethoprim oral (Bactrim DS) 1 GC tablet sulfasalazine (Azulfidine) 2 GC sulfazine ec (Azulfidine) 2 GC Tetracyclines ADOXA ORAL CAPSULE 4 doxycycline hyclate oral capsule 100 mg (Monodox) 2 GC doxycycline hyclate oral tablet 100 mg, (Avidoxy) 2 GC 50 mg doxycycline monohydrate oral capsule (Monodox) 2 GC doxycycline monohydrate oral suspension (Vibramycin) 2 GC for reconstitution doxycycline monohydrate oral tablet (Avidoxy) 2 GC MINOCIN ORAL 4 minocycline oral capsule (Minocin) 2 GC minocycline oral tablet (Minocycline HCl) 2 GC minocycline oral tablet extended release (Minocycline HCl) 2 GC 24 hr ORACEA 4 SOLODYN ORAL TABLET 5 EXTENDED RELEASE 24 HR 105 MG, 115 MG, 55 MG, 65 MG, 80 MG VIBRAMYCIN ORAL SUSPENSION FOR RECONSTITUTION 4 26

27 Anticancer Agents Anticancer Agents AFINITOR DISPERZ 5 PA NSO; QL (112 per 28 AFINITOR ORAL TABLET 10 MG 5 PA NSO; QL (56 per 28 AFINITOR ORAL TABLET 2.5 MG, 5 MG, 7.5 MG anastrozole (Arimidex) 2 GC ARIMIDEX 4 AROMASIN 4 bicalutamide (Casodex) 2 GC CASODEX 4 DROXIA 3 5 PA NSO; QL (28 per 28 ELIGARD SUBCUTANEOUS 4 QL (1 per 84 SYRINGE 22.5 MG (3 MONTH) ELIGARD SUBCUTANEOUS 4 QL (1 per 112 SYRINGE 30 MG (4 MONTH) ELIGARD SUBCUTANEOUS 5 QL (1 per 168 SYRINGE 45 MG (6 MONTH) ELIGARD SUBCUTANEOUS 4 QL (1 per 28 SYRINGE 7.5 MG (1 MONTH) exemestane (Aromasin) 2 GC FEMARA 4 flutamide (Flutamide) 2 GC GLEEVEC ORAL TABLET 100 MG 5 PA NSO; QL (90 per 30 GLEEVEC ORAL TABLET 400 MG 5 PA NSO; QL (60 per 30 HYDREA 4 hydroxyurea (Hydrea) 2 GC INLYTA ORAL TABLET 1 MG 5 PA NSO; QL (180 per 30 INLYTA ORAL TABLET 5 MG 5 PA NSO; QL (60 per 30 27

28 JAKAFI 5 PA NSO; QL (60 per 30 letrozole (Femara) 2 GC LEUKERAN 4 leuprolide (Leuprolide Acetate) 2 GC LUPRON DEPOT 5 QL (1 per 28 LUPRON DEPOT (3 MONTH) 5 QL (1 per 84 LUPRON DEPOT (4 MONTH) 5 QL (1 per 84 LUPRON DEPOT (6 MONTH) 5 QL (1 per 168 LUPRON DEPOT-PED 5 QL (1 per 28 INTRAMUSCULAR KIT LYSODREN 3 MEGACE 4 MEGACE ES 5 megestrol oral suspension (Megace Es) 2 GC megestrol oral suspension 625 mg/5 ml (Megace Es) 5 megestrol oral tablet (Megestrol Acetate) 2 GC mercaptopurine (Purinethol) 2 GC methotrexate sodium (pf) injection (Methotrexate Sodium) 2 PA BvD; GC solution methotrexate sodium injection (Methotrexate Sodium) 2 PA BvD; GC methotrexate sodium oral (Methotrexate Sodium) 2 PA BvD; ST; GC NEXAVAR 5 PA NSO; QL (120 per 30 paclitaxel (Paclitaxel) 2 GC POMALYST 5 PA NSO; QL (21 per 28 PURIXAN 5 REVLIMID 5 PA NSO; LA; QL (21 per 28 RHEUMATREX 4 PA BvD; ST SOLTAMOX 4 SPRYCEL ORAL TABLET 100 MG, 140 MG, 50 MG, 70 MG, 80 MG 5 PA NSO; QL (30 per 30 SPRYCEL ORAL TABLET 20 MG 5 PA NSO; QL (60 per 30 28

29 STIVARGA 5 PA NSO; QL (84 per 28 SUTENT 5 PA NSO; QL (30 per 30 tamoxifen (Tamoxifen Citrate) 2 GC TARCEVA ORAL TABLET 100 MG, 25 MG 5 PA NSO; QL (60 per 30 TARCEVA ORAL TABLET 150 MG 5 PA NSO; QL (90 per 30 TASIGNA 5 PA NSO; QL (112 per 28 tretinoin (chemotherapy) (Tretinoin) 5 (capsule: 10mg) TREXALL 4 PA BvD; ST TYKERB 5 VOTRIENT 5 PA NSO; QL (120 per 30 XALKORI 5 PA NSO; QL (60 per 30 XTANDI 5 PA NSO; QL (120 per 30 ZELBORAF 5 PA NSO; QL (240 per 30 ZYTIGA 5 PA NSO; QL (120 per 30 Anticholinergic Agents Antimuscarinics/Antispasmodics atropine injection syringe 0.05 mg/ml, 0.1 mg/ml propantheline Anticonvulsants Anticonvulsants (Atropine Sulfate) 2 GC (Propantheline Bromide) 2 GC carbamazepine (Tegretol) 2 GC carbamazepine oral capsule, er (Carbatrol) 2 GC multiphase 12 hr 29

30 carbamazepine oral suspension (Tegretol) 2 GC carbamazepine oral tablet extended (Tegretol XR) 2 GC release 12 hr carbamazepine oral tablet,chewable (Carbamazepine) 2 GC CARBATROL 4 DEPAKOTE 4 DEPAKOTE ER 4 DEPAKOTE SPRINKLES 4 DILANTIN CAPSULE 30 MG 3 DILANTIN EXTENDED 4 divalproex oral capsule, sprinkle (Depakote Sprinkle) 2 GC divalproex oral tablet extended release 24 (Depakote ER) 2 GC hr divalproex oral tablet,delayed release (Depakote) 2 GC (dr/ec) EQUETRO 4 gabapentin oral capsule (Neurontin) 2 GC gabapentin oral solution (Neurontin) 2 GC gabapentin oral tablet 600 mg, 800 mg (Neurontin) 2 GC GRALISE 4 ST; QL (90 per 30 GRALISE 30-DAY STARTER PACK 4 ST; QL (78 per 30 KEPPRA ORAL 4 KEPPRA XR 4 LAMICTAL ODT 4 LAMICTAL ORAL TABLET 4 LAMICTAL ORAL TABLET, 4 CHEWABLE DISPERSIBLE 25 MG, 5 MG LAMICTAL STARTER (BLUE) KIT 4 LAMICTAL STARTER (GREEN) 4 KIT LAMICTAL STARTER (ORANGE) 4 KIT LAMICTAL XR 4 LAMICTAL XR STARTER (BLUE) 4 30

31 LAMICTAL XR STARTER (GREEN) 4 LAMICTAL XR STARTER 4 (ORANGE) lamotrigine oral tablet (Lamictal) 2 GC lamotrigine oral tablet extended release (Lamictal XR) 2 GC 24hr lamotrigine oral tablet, chewable (Lamictal) 2 GC dispersible lamotrigine oral tablet,disintegrating (Lamictal Odt) 2 GC levetiracetam intravenous (Keppra) 2 GC levetiracetam oral solution (Keppra) 2 GC levetiracetam oral tablet (Keppra) 2 GC levetiracetam oral tablet extended release (Keppra XR) 2 GC 24 hr LYRICA ORAL CAPSULE 3 QL (90 per 30 LYRICA ORAL SOLUTION 3 QL (900 per 30 NEURONTIN 4 PHENYTEK 3 phenytoin sodium extended (Dilantin) 2 GC QUDEXY XR 4 TEGRETOL ORAL SUSPENSION 4 TEGRETOL ORAL TABLET 4 TEGRETOL XR ORAL TABLET 3 EXTENDED RELEASE 12 HR 100 MG TEGRETOL XR ORAL TABLET 4 EXTENDED RELEASE 12 HR 200 MG, 400 MG TOPAMAX 4 topiramate oral capsule, sprinkle (Topamax) 2 GC topiramate oral capsule,sprinkle,er 24hr (Qudexy XR) 2 GC topiramate oral tablet (Topamax) 2 GC TROKENDI XR 4 31

32 Antidementia Agents Antidementia Agents ARICEPT 4 QL (30 per 30 donepezil oral tablet (Aricept) 2 GC; QL (30 per 30 donepezil oral tablet,disintegrating (Aricept Odt) 2 GC; QL (30 per 30 memantine oral tablet (Namenda) 2 GC; QL (60 per 30 memantine oral tablets,dose pack (Namenda) 2 GC; QL (49 per 28 NAMENDA ORAL SOLUTION 3 QL (360 per 30 NAMENDA ORAL TABLET 3 QL (60 per 30 NAMENDA TITRATION PAK 3 QL (49 per 28 NAMENDA XR ORAL 3 QL (28 per 28 CAP,SPRINKLE,ER 24HR DOSE PACK NAMENDA XR ORAL CAPSULE,SPRINKLE,ER 24HR 3 QL (30 per 30 Antidepressants Antidepressants amitriptyline (Amitriptyline HCl) 2 PA NSO-HRM; GC bupropion hcl oral tablet (Wellbutrin SR) 2 GC bupropion hcl oral tablet extended release (Wellbutrin SR) 2 GC, 150 mg bupropion hcl oral tablet extended release (Wellbutrin XL) 2 GC 24 hr CELEXA ORAL TABLET 4 QL (30 per 30 citalopram oral solution (Citalopram 2 GC Hydrobromide) citalopram oral tablet (Celexa) 1 GC; QL (30 per 30 CYMBALTA ORAL CAPSULE,DELAYED RELEASE(DR/EC) 20 MG, 60 MG 4 QL (60 per 30 32

33 CYMBALTA ORAL 4 QL (30 per 30 CAPSULE,DELAYED RELEASE(DR/EC) 30 MG duloxetine oral capsule,delayed release(dr/ec) 20 mg, 60 mg (Cymbalta) 2 GC; QL (60 per 30 duloxetine oral capsule,delayed release(dr/ec) 30 mg (Cymbalta) 2 GC; QL (30 per 30 duloxetine oral capsule,delayed (Cymbalta) 4 QL (30 per 30 release(dr/ec) 40 mg EFFEXOR XR 4 escitalopram oxalate (Lexapro) 2 GC fluoxetine oral capsule (Prozac) 1 GC fluoxetine oral capsule,delayed (Prozac Weekly) 2 GC release(dr/ec) fluoxetine oral solution (Fluoxetine HCl) 2 GC fluoxetine oral tablet 10 mg, 20 mg (Fluoxetine HCl) 2 GC FLUOXETINE ORAL TABLET 60 2 GC MG FORFIVO XL 4 IRENKA 4 QL (30 per 30 LEXAPRO 4 paroxetine hcl oral tablet (Paxil) 2 GC paroxetine hcl oral tablet extended (Paxil CR) 2 GC release 24 hr PAXIL 4 PAXIL CR 4 PROZAC ORAL CAPSULE 4 PROZAC WEEKLY 4 SARAFEM ORAL TABLET 10 MG, 4 20 MG sertraline oral concentrate (Zoloft) 2 GC sertraline oral tablet (Zoloft) 1 GC trazodone (Trazodone HCl) 1 GC venlafaxine oral capsule,extended release (Effexor XR) 2 GC 24hr venlafaxine oral tablet (Venlafaxine HCl) 2 GC 33

34 venlafaxine oral tablet extended release 24hr 150 mg, 37.5 mg, 75 mg venlafaxine oral tablet extended release 24hr 225 mg (Venlafaxine HCl) 2 GC (Venlafaxine HCl) 3 WELLBUTRIN 4 WELLBUTRIN SR 4 WELLBUTRIN XL 4 ZOLOFT 4 Antidiabetic Agents Antidiabetic Agents, Miscellaneous ACTOS 4 QL (30 per 30 BYDUREON 3 QL (4 per 28 BYETTA SUBCUTANEOUS PEN 3 QL (2.4 per 28 INJECTOR 10 MCG/DOSE(250 MCG/ML) 2.4 ML BYETTA SUBCUTANEOUS PEN 3 QL (1.2 per 28 INJECTOR 5 MCG/DOSE (250 MCG/ML) 1.2 ML FORTAMET ORAL TABLET 4 QL (60 per 30 EXTENDED RELEASE 24HR 1,000 MG FORTAMET ORAL TABLET 4 QL (120 per 30 EXTENDED RELEASE 24HR 500 MG GLUCOPHAGE ORAL TABLET 4 QL (60 per 30 1,000 MG GLUCOPHAGE ORAL TABLET QL (120 per 30 MG GLUCOPHAGE ORAL TABLET QL (90 per 30 MG GLUCOPHAGE XR ORAL TABLET 4 QL (120 per 30 EXTENDED RELEASE 24 HR 500 MG GLUCOPHAGE XR ORAL TABLET EXTENDED RELEASE 24 HR 750 MG 4 QL (60 per 30 34

35 GLUMETZA ORAL TABLET,ER 4 QL (60 per 30 GAST.RETENTION 24 HR 1,000 MG GLUMETZA ORAL TABLET,ER 4 QL (120 per 30 GAST.RETENTION 24 HR 500 MG JANUMET 3 QL (60 per 30 JANUMET XR ORAL TABLET, ER 3 QL (30 per 30 MULTIPHASE 24 HR 100-1,000 MG, MG JANUMET XR ORAL TABLET, ER 3 QL (60 per 30 MULTIPHASE 24 HR 50-1,000 MG JANUVIA 3 QL (30 per 30 metformin oral tablet 1,000 mg (Glucophage) 1 GC; QL (60 per 30 metformin oral tablet 500 mg (Glucophage) 1 GC; QL (120 per 30 metformin oral tablet 850 mg (Glucophage) 1 GC; QL (90 per 30 metformin oral tablet extended release 24 hr 500 mg (Glucophage XR) 2 GC; QL (120 per 30 metformin oral tablet extended release 24 hr 750 mg (Glucophage XR) 2 GC; QL (90 per 30 metformin oral tablet extended release 24hr (Glucophage XR) 2 GC; QL (60 per 30 ONGLYZA 4 QL (30 per 30 pioglitazone (Actos) 2 GC; QL (30 per 30 RIOMET 4 QL (765 per 30 TRADJENTA 3 QL (30 per 30 VICTOZA 4 PA; QL (9 per 28 Insulins HUMALOG KWIKPEN 6 QL (30 per 28 SUBCUTANEOUS INSULIN PEN 100 UNIT/ML HUMALOG KWIKPEN SUBCUTANEOUS INSULIN PEN 200 UNIT/ML (3 ML) 6 QL (12 per 28 35

36 HUMALOG SUBCUTANEOUS 6 QL (30 per 28 CARTRIDGE HUMALOG SUBCUTANEOUS 6 QL (40 per 28 LANTUS 6 QL (40 per 28 LANTUS SOLOSTAR 6 QL (30 per 28 NOVOLOG 6 QL (40 per 28 NOVOLOG FLEXPEN 6 QL (30 per 28 NOVOLOG PENFILL 6 QL (30 per 28 TOUJEO SOLOSTAR 6 QL (7.5 per 28 Sulfonylureas AMARYL ORAL TABLET 1 MG, 2 4 QL (30 per 30 MG AMARYL ORAL TABLET 4 MG 4 QL (60 per 30 DIABETA ORAL TABLET 1.25 MG 4 PA-HRM; QL (280 per 30 DIABETA ORAL TABLET 2.5 MG 4 PA-HRM; QL (240 per 30 DIABETA ORAL TABLET 5 MG 4 PA-HRM; QL (120 per 30 glimepiride oral tablet 1 mg, 2 mg (Amaryl) 1 GC; QL (30 per 30 glimepiride oral tablet 4 mg (Amaryl) 1 GC; QL (60 per 30 glipizide oral tablet 10 mg (Glucotrol) 1 GC; QL (120 per 30 glipizide oral tablet 5 mg (Glucotrol) 1 GC; QL (60 per 30 glipizide oral tablet extended release 24hr (Glucotrol XL) 2 GC; QL (60 per mg glipizide oral tablet extended release 24hr (Glucotrol XL) 2 GC; QL (30 per mg, 5 mg GLUCOTROL ORAL TABLET 10 4 QL (120 per 30 MG GLUCOTROL ORAL TABLET 5 MG 4 QL (30 per 30 GLUCOTROL XL ORAL TABLET EXTENDED RELEASE 24HR 10 MG 4 QL (60 per 30 36

37 GLUCOTROL XL ORAL TABLET EXTENDED RELEASE 24HR 2.5 MG, 5 MG 4 QL (30 per 30 glyburide oral tablet 1.25 mg (Glyburide) 2 PA-HRM; GC; QL (280 per 30 glyburide oral tablet 2.5 mg (Glyburide) 2 PA-HRM; GC; QL (240 per 30 glyburide oral tablet 5 mg (Glyburide) 2 PA-HRM; GC; QL (120 per 30 Antifungals Antifungals ciclopirox topical gel (Loprox) 2 GC ciclopirox topical shampoo (Loprox) 2 GC ciclopirox topical solution (Penlac) 2 GC clotrimazole mucous membrane (Clotrimazole) 2 GC clotrimazole topical cream (Clotrimazole) 2 GC clotrimazole topical solution (Lotrimin) 2 GC clotrimazole-betamethasone topical (Lotrisone) 2 GC cream clotrimazole-betamethasone topical (Clotrimazole/Betamet 2 GC lotion hasone Dip) DIFLUCAN 4 econazole topical (Econazole Nitrate) 2 GC EXTINA 4 fluconazole (Diflucan) 2 GC ketoconazole oral (Ketoconazole) 2 GC ketoconazole topical cream (Ketoconazole) 2 GC ketoconazole topical foam (Ketoconazole) 2 GC ketoconazole topical shampoo (Nizoral) 2 GC LAMISIL 4 LOPROX TOPICAL SHAMPOO 4 LOTRISONE TOPICAL CREAM 4 NIZORAL TOPICAL SHAMPOO 4 nystatin oral (Nystatin) 2 GC nystatin oral (Nystatin) 2 GC 37

38 nystatin topical (Nystatin) 2 GC nystatin topical powder 100,000 (Nystatin) 2 GC unit/gram nystatin-triamcinolone (Nystatin/Triamcin) 2 GC terbinafine hcl oral (Lamisil) 2 GC Antihistamines Antihistamines CLARINEX ORAL SYRUP 4 CLARINEX ORAL TABLET 4 cyproheptadine (Cyproheptadine HCl) 2 PA-HRM; GC desloratadine oral tablet (Clarinex) 2 GC desloratadine oral tablet,disintegrating (Desloratadine) 2 GC levocetirizine (Xyzal) 2 GC XYZAL 4 Anti-Infectives (Skin And Mucous Membrane) Anti-Infectives (Skin And Mucous Membrane) METROGEL VAGINAL 4 metronidazole vaginal (Metrogel-Vaginal) 2 GC NUVESSA 4 TERAZOL 3 VAGINAL CREAM 4 TERAZOL 7 4 terconazole vaginal cream (Terazol 7) 2 GC terconazole vaginal suppository (Terconazole) 2 GC VANDAZOLE 4 Antimigraine Agents Antimigraine Agents ALSUMA 4 QL (4 per 28 IMITREX ORAL 4 QL (18 per 28 IMITREX STATDOSE KIT REFILL 4 QL (4 per 28 IMITREX STATDOSE PEN 4 QL (4 per 28 SUBCUTANEOUS PEN INJECTOR IMITREX SUBCUTANEOUS 4 QL (4 per 28 MAXALT 4 QL (18 per 28 MAXALT-MLT 4 QL (18 per 28 38