Drug Name Reference Copay Note *Adhd/Anti-Narcolepsy/Anti- Obesity/Anorexiants* *Stimulants - Misc.***

Transcription

1 County Health Plan Formulary lowercase = drugs UPPERCASE = name drugs Copay = 100% = $3.00 = $3.00 = $0.00 Note QL = Quantity Limit *Adhd/Anti-Narcolepsy/Anti- Obesity/Anorexiants* *Stimulants - Misc.*** methylphenidate hcl er oral tablet extended release 20 methylphenidate hcl oral tablet 10, 20, 5 *Analgesics - Anti-Inflammatory* *Nonsteroidal Anti-Inflammatory Agents (Nsaids)*** diclofenac sodium oral tablet delayed release 25, 50, 75 etodolac oral capsule 300 Metadate ER Prior Auth Required Ritalin Prior Auth Required etodolac oral tablet 400 Lodine etodolac oral tablet 500 fenoprofen calcium oral tablet 600 Nalfon flurbiprofen oral tablet 100, 50 ibuprofen oral tablet 200 Advil ibuprofen oral tablet 400, 600, 800 indomethacin er oral capsule extended release 75 indomethacin oral capsule 25, 50 meclofenamate sodium oral capsule 100, 50 IBU meloxicam oral tablet 15, 7.5 Mobic nabumetone oral tablet 500, 750 naproxen oral tablet 250, 500 Naprosyn naproxen oral tablet 375 naproxen sodium oral tablet 220 Aleve piroxicam oral capsule 10, 20 Feldene sulindac oral tablet 150, 200 tolmetin sodium oral capsule 400 1

2 tolmetin sodium oral tablet 200 *Analgesics - Nonnarcotic* *Analgesics Other*** acetaminophen extra strength oral tablet 500 Healthy Mama Shake That Ache acetaminophen oral tablet 325 Pharbetol *Analgesics-Sedatives*** butalbital-aspirin-caffeine oral capsule *Salicylates*** diflunisal oral tablet 500 salsalate oral tablet 500, 750 *Analgesics - Opioid* *Codeine Combinations*** acetaminophen-codeine #2 oral tablet acetaminophen-codeine #3 oral tablet acetaminophen-codeine #4 oral tablet acetaminophen-codeine oral solution /5ml butalbital-asa-caff-codeine oral capsule *Hydrocodone Combinations*** hydrocodone-acetaminophen oral solution /15ml hydrocodone-acetaminophen oral tablet hydrocodone-acetaminophen oral tablet hydrocodone-acetaminophen oral tablet *Opioid Agonists*** Fiorinal Tylenol with Codeine #3 Tylenol with Codeine #4 Ascomp-Codeine Lorcet HD Lorcet Lorcet Plus methadone hcl oral tablet 10, 5 Dolophine 2 Discount applies to only 6 fills per year.; QL (12 tabs per 1 day) Discount applies to only 6 fills per year.; QL (12 tabs per 1 day) Discount applies to only 6 fills per year.; QL (12 tabs per 1 day) Discount applies to only 6 fills per year. Discount applies to only 6 fills per year. Discount applies to only 6 fills per year. Discount applies to only 6 fills per year.; QL (12 tabs per 1 day) Discount applies to only 6 fills per year.; QL (12 tabs per 1 day) Discount applies to only 6 fills per year.; QL (12 tabs per 1 day) Discount applies to only 6 fills per year.

3 morphine sulfate er oral tablet extended release 100, 15, 30, 60 MS Contin Prior Auth Required tramadol hcl oral tablet 50 Ultram *Opioid Combinations*** oxycodone-acetaminophen oral tablet oxycodone-aspirin oral tablet *Anorectal Agents* *Rectal Steroids*** hydrocortisone acetate rectal suppository 25 *Antianginal Agents* *Nitrates*** NITRO-BID TRANSDERMAL OINTMENT 2 % isosorbide dinitrate er oral tablet extended release 40 isosorbide dinitrate oral tablet 10, 20, 30 Endocet Anusol-HC isosorbide dinitrate oral tablet 5 Isordil Titradose isosorbide mononitrate er oral tablet extended release 24 hour 120, 30, 60 nitroglycerin er oral capsule extended release 2.5, 6.5, 9 nitroglycerin sublingual tablet sublingual 0.3, 0.4, 0.6 *Antianxiety Agents* *Antianxiety Agents - Misc.*** buspirone hcl oral tablet 10, 15, 5 hydroxyzine hcl oral tablet 10, 25, 50 hydroxyzine pamoate oral capsule 25, 50 meprobamate oral tablet 200, 400 Nitro-Time Nitrostat Vistaril Discount applies to only 6 fills per year. Discount applies to only 6 fills per year.; QL (12 tabs per 1 day) Discount applies to only 6 fills per year.; QL (12 EA per 1 day) 3

4 *Benzodiazepines*** alprazolam oral tablet 0.25, 0.5, 1, 2 chlordiazepoxide hcl oral capsule 10, 25, 5 clorazepate dipotassium oral tablet 15, 3.75 Xanax clorazepate dipotassium oral tablet 7.5 Tranxene-T diazepam oral tablet 10, 2, 5 Valium lorazepam oral tablet 0.5, 1, 2 Ativan oxazepam oral capsule 10, 15, 30 *Antiarrhythmics* *Antiarrhythmics Type I-A*** disopyramide phosphate oral capsule 150 quinidine gluconate er oral tablet extended release 324 quinidine sulfate oral tablet 200, 300 *Antiarrhythmics Type I-B*** mexiletine hcl oral capsule 150, 200, 250 *Antiarrhythmics Type Iii*** Norpace amiodarone hcl oral tablet 200 Pacerone *Antiasthmatic And Bronchodilator Agents* *Anti-Inflammatory Agents*** cromolyn sodium inhalation nebulization solution 20 /2ml Limit of 1 fill of any Benzodiazepine per 30 days Limit of 1 fill of any Benzodiazepine per 30 days Limit of 1 fill of any Benzodiazepine per 30 days Limit of 1 fill of any Benzodiazepine per 30 days Limit of 1 fill of any Benzodiazepine per 30 days Limit of 1 fill of any Benzodiazepine per 30 days Limit of 1 fill of any Benzodiazepine per 30 days 4

5 *Beta Adrenergics*** PROAIR HFA AEROSOL SOLUTION 108 (90 BASE) MCG/ACT INHALATION 108 (90 BASE) MCG/ACT PROAIR RESPICLICK AEROSOL POWDER BREATH ACTIVATED 108 (90 BASE) MCG/ACT INHALATION 108 (90 BASE) MCG/ACT albuterol sulfate inhalation nebulization solution (2.5 /3ml) 0.083%, (5 /ml) 0.5% albuterol sulfate oral syrup 2 /5ml albuterol sulfate oral tablet 2, 4 metaproterenol sulfate oral syrup 10 /5ml metaproterenol sulfate oral tablet 10 *Bronchodilators - Anticholinergics*** ipratropium bromide inhalation solution 0.02 % *Leukotriene Receptor Antagonists*** montelukast sodium oral tablet 10 Singulair *Xanthines*** ELIXOPHYLLIN ORAL ELIXIR 80 MG/15ML theophylline er oral tablet extended release 12 hour 100, 200, 300 *Anticoagulants* *Coumarin Anticoagulants*** COUMADIN ORAL TABLET 1 MG, 10 MG, 2 MG, 2.5 MG, 3 MG, 4 MG, 5 MG, 6 MG, 7.5 MG warfarin sodium oral tablet 1, 10, 2, 2.5, 3, 4, 5, 6, 7.5 Theochron Coumadin Coumadin 5

6 *Anticonvulsants* *Anticonvulsants - Benzodiazepines*** clonazepam oral tablet 0.5, 1, 2 KlonoPIN *Anticonvulsants - Misc.*** TEGRETOL ORAL TABLET 200 MG Epitol carbamazepine oral tablet 200 Epitol carbamazepine oral tablet chewable 100 gabapentin oral capsule 100, 300, 400 Neurontin gabapentin oral tablet 600, 800 Neurontin lamotrigine oral tablet 100, 150, 200, 25 LaMICtal primidone oral tablet 250, 50 Mysoline *Hydantoins*** DILANTIN ORAL CAPSULE 100 MG Dilantin DILANTIN ORAL SUSPENSION 125 MG/5ML Dilantin phenytoin oral suspension 125 /5ml Dilantin phenytoin sodium extended oral capsule 100 *Valproic Acid*** divalproex sodium oral tablet delayed release 125, 250, 500 Dilantin Depakote valproic acid oral capsule 250 Depakene *Antidepressants* *Antidepressants - Misc.*** bupropion hcl er (sr) oral tablet extended release 12 hour 100, 150 bupropion hcl oral tablet 100, 75 maprotiline hcl oral tablet 25, 50, 75 *Modified Cyclics*** trazodone hcl oral tablet 100, 150, 300, 50 Wellbutrin SR Limit of 1 fill of any Benzodiazepine per 30 days 6

7 *Selective Serotonin Reuptake Inhibitors (Ssris)*** citalopram hydrobromide oral tablet 10, 20, 40 escitalopram oxalate oral tablet 10, 20, 5 fluoxetine hcl oral capsule 10, 20, 40 paroxetine hcl oral tablet 10, 20, 30, 40 sertraline hcl oral tablet 100, 25, 50 *Serotonin-Norepinephrine Reuptake Inhibitors (Snris)*** duloxetine hcl oral capsule delayed release particles 20, 30, 60 venlafaxine hcl er oral capsule extended release 24 hour 150, 37.5, 75 venlafaxine hcl oral tablet 100, 25, 37.5, 50, 75 *Tricyclic Agents*** amitriptyline hcl oral tablet 10, 100, 150, 25, 50, 75 amoxapine oral tablet 100, 150, 25, 50 clomipramine hcl oral capsule 25, 50, 75 CeleXA Lexapro PROzac Paxil Zoloft Cymbalta Effexor XR Anafranil desipramine hcl oral tablet 10, 25 Norpramin desipramine hcl oral tablet 100, 150, 50, 75 doxepin hcl oral capsule 10, 100, 150, 25, 50, 75 doxepin hcl oral concentrate 10 /ml imipramine hcl oral tablet 10, 25, 50 nortriptyline hcl oral capsule 10, 25, 50, 75 protriptyline hcl oral tablet 10, 5 *Antidiabetics* *Biguanides*** metformin hcl oral tablet 1000, 500, 850 Tofranil Pamelor Glucophage 7

8 *Human Insulin*** BASAGLAR KWIKPEN SUBCUTANEOUS SOLUTION PEN- INJECTOR 100 UNIT/ML HUMALOG MIX 50/50 SUBCUTANEOUS SUSPENSION (50-50) 100 UNIT/ML HUMALOG MIX 75/25 SUBCUTANEOUS SUSPENSION (75-25) 100 UNIT/ML HUMALOG SUBCUTANEOUS SOLUTION 100 UNIT/ML HUMULIN 70/30 SUSPENSION (70-30) 100 UNIT/ML SUBCUTANEOUS (70-30) 100 UNIT/ML HUMULIN N SUSPENSION 100 UNIT/ML SUBCUTANEOUS 100 UNIT/ML HUMULIN R SOLUTION 100 UNIT/ML INJECTION 100 UNIT/ML LANTUS SUBCUTANEOUS SOLUTION 100 UNIT/ML *Sulfonylureas*** chlorpropamide oral tablet 100, 250 glimepiride oral tablet 1, 2, 4 Amaryl glipizide oral tablet 10, 5 Glucotrol glipizide xl oral tablet extended release 24 hour 10, 2.5, 5 glyburide micronized oral tablet 1.5, 3, 6 glyburide oral tablet 1.25, 2.5, 5 tolazamide oral tablet 250, 500 tolbutamide oral tablet 500 *Antidiarrheals* *Antidiarrheal Agents - Misc.*** pink bismuth oral suspension 262 /15ml *Antiperistaltic Agents*** diphenoxylate-atropine oral liquid /5ml Glucotrol XL Glynase Kao-Tin 8

9 diphenoxylate-atropine oral tablet Lomotil loperamide hcl oral capsule 2 Imodium A-D *Antiemetics* *5-Ht3 Receptor Antagonists*** ondansetron hcl oral tablet 4, 8 Zofran *Antiemetics - Anticholinergic*** meclizine hcl oral tablet 12.5 meclizine hcl oral tablet 25 Dramamine Less Drowsy *Antifungals* *Antifungals*** nystatin oral tablet unit *Imidazoles*** ketoconazole oral tablet 200 *Triazoles*** fluconazole oral tablet 100, 150, 200, 50 *Antihistamines* *Antihistamines - Alkylamines*** Diflucan chlorpheniramine maleate oral tablet 4 Chlor-Trimeton *Antihistamines - Ethanolamines*** clemastine fumarate oral tablet 2.68 diphenhydramine hcl oral capsule 25, 50 *Antihistamines - Phenothiazines*** promethazine hcl oral tablet 12.5, 25, 50 *Antihistamines - Piperidines*** cyproheptadine hcl oral syrup 2 /5ml cyproheptadine hcl oral tablet 4 *Antihyperlipidemics* *Bile Acid Sequestrants*** cholestyramine light oral powder 4 gm/dose Banophen Prevalite cholestyramine oral packet 4 gm Questran 9

10 *Fibric Acid Derivatives*** gemfibrozil oral tablet 600 Lopid *H Coa Reductase Inhibitors*** atorvastatin calcium oral tablet 10, 20, 40, 80 pravastatin sodium oral tablet 10 pravastatin sodium oral tablet 20, 40, 80 simvastatin oral tablet 10, 20, 40, 5, 80 *Antihypertensives* *Ace Inhibitors*** benazepril hcl oral tablet 10, 20, 40 benazepril hcl oral tablet 5 captopril oral tablet 100, 12.5, 25, 50 enalapril maleate oral tablet 10, 2.5, 20, 5 Lipitor Pravachol Zocor Lotensin Vasotec lisinopril oral tablet 10, 20, 5 Prinivil lisinopril oral tablet 2.5, 30, 40 Zestril quinapril hcl oral tablet 10, 20, 40, 5 *Adrenolytics-Central & Thiazide/Thiazide-Like Comb*** methyldopa-hydrochlorothiazide oral tablet , *Angiotensin Ii Receptor Antagonists*** losartan potassium oral tablet 100, 25, 50 valsartan oral tablet 160, 320, 40, 80 *Antiadrenergics - Centrally Acting*** clonidine hcl oral tablet 0.1, 0.2, 0.3 guanfacine hcl oral tablet 1, 2 methyldopa oral tablet 250, 500 Accupril Cozaar Diovan Catapres 10

11 *Antiadrenergics - Peripherally Acting*** doxazosin mesylate oral tablet 1, 2, 4, 8 prazosin hcl oral capsule 1, 2, 5 terazosin hcl oral capsule 1, 10, 2, 5 *Beta Blocker & Diuretic Combinations*** atenolol-chlorthalidone oral tablet atenolol-chlorthalidone oral tablet *Vasodilators*** hydralazine hcl oral tablet 10, 100, 25, 50 minoxidil oral tablet 10, 2.5 *Anti-Infective Agents - Misc.* *Anti-Infective Agents - Misc.*** Cardura Minipress Tenoretic 100 Tenoretic 50 metronidazole oral capsule 375 Flagyl metronidazole oral tablet 250, 500 Flagyl trimethoprim oral tablet 100 *Anti-Infective Misc. - Combinations*** sulfamethoxazole-trimethoprim oral suspension /5ml sulfamethoxazole-trimethoprim oral tablet sulfamethoxazole-trimethoprim oral tablet *Lincosamides*** Sulfatrim Pediatric Bactrim Bactrim DS clindamycin hcl oral capsule 150 Cleocin *Antimalarials* *Antimalarials*** hydroxychloroquine sulfate oral tablet 200 Plaquenil quinine sulfate oral capsule 324 Qualaquin 11

12 *Antimycobacterial Agents* *Antimycobacterial Agents*** ethambutol hcl oral tablet 100, 400 Myambutol isoniazid oral tablet 100, 300 pyrazinamide oral tablet 500 rifampin oral capsule 150, 300 Rifadin *Antineoplastics And Adjunctive Therapies* *Antimetabolites*** methotrexate oral tablet 2.5 *Folic Acid Antagonists Rescue Agents*** leucovorin calcium oral tablet 5 *Progestins-Antineoplastic*** megestrol acetate oral tablet 20, 40 *Antiparkinson Agents* *Antiparkinson Anticholinergics*** benztropine mesylate oral tablet 0.5, 1, 2 trihexyphenidyl hcl oral elixir 0.4 /ml trihexyphenidyl hcl oral tablet 2, 5 *Antiparkinson Dopaminergics*** amantadine hcl oral syrup 50 /5ml amantadine hcl oral tablet 100 *Levodopa Combinations*** carbidopa-levodopa oral tablet , , *Antipsychotics/Antimanic Agents* *Antimanic Agents*** lithium carbonate oral capsule 150, 300, 600 *Benzisoxazoles*** risperidone oral tablet 0.25, 0.5, 1, 2, 3 Sinemet RisperDAL 12

13 *Butyrophenones*** haloperidol lactate oral concentrate 2 /ml haloperidol oral tablet 0.5, 1, 10, 2, 20, 5 *Dibenzoxazepines*** loxapine succinate oral capsule 10, 25, 5, 50 *Phenothiazines*** chlorpromazine hcl oral tablet 10, 100, 200, 25, 50 fluphenazine hcl oral tablet 1, 10, 2.5, 5 prochlorperazine maleate oral tablet 10, 5 thioridazine hcl oral tablet 10, 100, 25, 50 trifluoperazine hcl oral tablet 1, 10, 2, 5 *Quinolinone Derivatives*** aripiprazole oral tablet 10, 15, 2, 20, 30, 5 *Thienbenzodiazepines*** olanzapine oral tablet 10, 15, 2.5, 20, 5, 7.5 *Thioxanthenes*** thiothixene oral capsule 1, 10, 2, 5 *Antivirals* *Herpes Agents - Purine Analogues*** Abilify ZyPREXA acyclovir oral capsule 200 Zovirax acyclovir oral tablet 400, 800 Zovirax *Neuraminidase Inhibitors*** RELENZA DISKHALER INHALATION AEROSOL POWDER BREATH ACTIVATED 5 MG/BLISTER oseltamivir phosphate oral capsule 75 Tamiflu 13

14 *Assorted Classes* *Purine Analogs*** azathioprine oral tablet 50 Imuran *Beta Blockers* *Alpha-Beta Blockers*** carvedilol oral tablet 12.5, 25, 3.125, 6.25 *Beta Blockers Cardio- Selective*** acebutolol hcl oral capsule 200, 400 Coreg atenolol oral tablet 100, 25, 50 Tenormin metoprolol succinate er oral tablet extended release 24 hour 100, 200, 25, 50 metoprolol tartrate oral tablet 100, 50 metoprolol tartrate oral tablet 25 *Beta Blockers Non-Selective*** Toprol XL Lopressor nadolol oral tablet 20, 40, 80 Corgard pindolol oral tablet 10, 5 propranolol hcl er oral capsule extended release 24 hour 120, 160, 60, 80 propranolol hcl oral tablet 10, 20, 40, 60, 80 timolol maleate oral tablet 10, 20, 5 *Calcium Channel Blockers* *Calcium Channel Blockers*** amlodipine besylate oral tablet 10, 2.5, 5 diltiazem hcl er coated beads oral capsule extended release 24 hour 120, 180, 240, 300 diltiazem hcl er oral capsule extended release 12 hour 120, 60, 90 diltiazem hcl oral tablet 120, 30, 60 diltiazem hcl oral tablet 90 nicardipine hcl oral capsule 20, Inderal LA Norvasc Cardizem CD Cardizem

15 nifedipine er oral tablet extended release 24 hour 30, 60, 90 nifedipine er osmotic release oral tablet extended release 24 hour 30, 90 nifedipine er osmotic release oral tablet extended release 24 hour 60 Adalat CC Procardia XL Nifedical XL nifedipine oral capsule 10 Procardia nifedipine oral capsule 20 verapamil hcl er oral tablet extended release 120, 180, 240 Calan SR verapamil hcl oral tablet 120, 80 Calan verapamil hcl oral tablet 40 *Cardiotonics* *Cardiac Glycosides*** LANOXIN ORAL TABLET 125 MCG, 250 MCG digoxin oral solution 0.05 /ml Digitek digoxin oral tablet 125 mcg, 250 mcg Digitek *Cardiovascular Agents - Misc.* *Peripheral Vasodilators*** isoxsuprine hcl oral tablet 10, 20 *Cephalosporins* *Cephalosporins - 1St Generation*** cefadroxil oral capsule 500 cephalexin oral suspension reconstituted 250 /5ml cephalexin oral tablet 250, 500 *Cephalosporins - 2Nd Generation*** cefaclor oral capsule 250, 500 cefaclor oral suspension reconstituted 250 /5ml, 375 /5ml *Contraceptives* *Triphasic Contraceptives - Oral*** norgestim-eth estrad triphasic oral tablet 0.18/0.215/ mcg Ortho Tri-Cyclen (28) Prior Auth Required 15

16 *Corticosteroids* *Glucocorticosteroids*** dexamethasone oral solution 0.5 /5ml dexamethasone oral tablet 0.5, 0.75, 4, 6 dexamethasone oral tablet 1, 1.5, 2 methylprednisolone oral tablet therapy pack 4 prednisone oral tablet 1, 10, 2.5, 5 Decadron Medrol prednisone oral tablet 20 Deltasone *Mineralocorticoids*** fludrocortisone acetate oral tablet 0.1 *Cough/Cold/Allergy* *Antitussive - Nonnarcotic*** benzonatate oral capsule 100 Tessalon Perles benzonatate oral capsule 200 *Expectorants*** guaifenesin oral syrup 100 /5ml Diabetic Tussin EX guaifenesin oral tablet 200 *Dermatologicals* *Acne Antibiotics*** clindamycin phosphate external solution 1 % Cleocin-T erythromycin external gel 2 % Erygel erythromycin external solution 2 % *Acne Combinations*** sulfacetamide sodium-sulfur external emulsion 10-5 % *Antibiotics - Topical*** gentamicin sulfate external cream 0.1 % gentamicin sulfate external ointment 0.1 % *Antifungals - Topical Combinations*** nystatin-triamcinolone external cream unit/gm-% Avar Cleanser 16

17 nystatin-triamcinolone external ointment unit/gm-% *Antifungals - Topical*** nystatin external cream unit/gm nystatin external ointment unit/gm *Antiseborrheic Products*** selenium sulfide external shampoo 2.3 % SelRx *Burn Products*** silver sulfadiazine external cream 1 % Silvadene *Corticosteroids - Topical*** betamethasone dipropionate external cream 0.05 % betamethasone dipropionate external lotion 0.05 % betamethasone dipropionate external ointment 0.05 % betamethasone valerate external cream 0.1 % betamethasone valerate external lotion 0.1 % betamethasone valerate external ointment 0.1 % desonide external cream 0.05 % DesOwen desoximetasone external cream 0.05 %, 0.25 % Topicort desoximetasone external ointment 0.25 % Topicort fluocinolone acetonide external cream % fluocinolone acetonide external ointment % fluocinolone acetonide external solution 0.01 % fluocinonide emulsified base external cream 0.05 % fluocinonide external cream 0.05 % fluocinonide external gel 0.05 % fluocinonide external ointment 0.05 % fluocinonide external solution 0.05 % Synalar Synalar Synalar hydrocortisone external cream 1 % Aveeno Anti-Itch Max St hydrocortisone external cream 2.5 % 17

18 hydrocortisone external lotion 1 % hydrocortisone external lotion 2.5 % Anti-Itch Intensive Healing hydrocortisone external ointment 1 % Cortizone-10 hydrocortisone external ointment 2.5 % triamcinolone acetonide external cream % triamcinolone acetonide external cream 0.1 %, 0.5 % triamcinolone acetonide external lotion %, 0.1 % triamcinolone acetonide external ointment 0.1 % *Imidazole-Related Antifungals - Topical*** ketoconazole external cream 2 % *Scabicides & Pediculicides*** Triderm lice treatment external liquid 1 % Nix Creme Rinse permethrin external cream 5 % Elimite *Diagnostic Products* *Diagnostic Tests*** FREESTYLE INSULINX TEST STRIP IN VITRO FREESTYLE LITE TEST STRIP IN VITRO FREESTYLE PRECISION NEO TEST STRIP IN VITRO FREESTYLE TEST STRIP IN VITRO PRECISION XTRA BLOOD GLUCOSE STRIP IN VITRO *Diuretics* *Carbonic Anhydrase Inhibitors*** acetazolamide oral tablet 125, 250 methazolamide oral tablet 25, 50 *Diuretic Combinations*** amiloride-hydrochlorothiazide oral tablet 5-50 spironolactone-hctz oral tablet Aldactazide ; QL (100 strips per 30 days) ; QL (100 strips per 30 days) ; QL (100 strips per 30 days) ; QL (100 strips per 30 days) ; QL (100 strips per 30 days) 18

19 triamterene-hctz oral capsule Dyazide triamterene-hctz oral tablet Maxzide-25 triamterene-hctz oral tablet Maxzide *Loop Diuretics*** bumetanide oral tablet 0.5, 1, 2 Bumex furosemide oral tablet 20, 40, 80 Lasix torsemide oral tablet 10, 20 Demadex torsemide oral tablet 100, 5 *Potassium Sparing Diuretics*** spironolactone oral tablet 100, 25, 50 *Thiazides And Thiazide-Like Diuretics*** chlorothiazide oral tablet 250, 500 chlorthalidone oral tablet 25, 50 Aldactone hydrochlorothiazide oral capsule 12.5 Microzide hydrochlorothiazide oral tablet 12.5, 25, 50 indapamide oral tablet 1.25, 2.5 methyclothiazide oral tablet 5 *Endocrine And Metabolic Agents - Misc.* *Bisphosphonates*** alendronate sodium oral tablet 10, 5 alendronate sodium oral tablet 70 Fosamax *Hyperparathyroid Treatment - Vitamin D Analogs*** calcitriol oral capsule 0.25 mcg, 0.5 mcg Rocaltrol *Estrogens* *Estrogens*** estradiol oral tablet 0.5, 1, 2 Estrace *Fluoroquinolones* *Fluoroquinolones*** ciprofloxacin hcl oral tablet 250, 500 ciprofloxacin hcl oral tablet 750 Cipro 19

20 levofloxacin oral tablet 250, 500, 750 *Gastrointestinal Agents - Misc.* *Gallstone Solubilizing Agents*** Levaquin ursodiol oral capsule 300 Actigall *Gastrointestinal Stimulants*** metoclopramide hcl oral solution 5 /5ml metoclopramide hcl oral tablet 10, 5 *Inflammatory Bowel Agents*** AZULFIDINE ORAL TABLET 500 MG *Genitourinary Agents - Miscellaneous* *Alpha 1-Adrenoceptor Antagonists*** Reglan tamsulosin hcl oral capsule 0.4 Flomax *Urinary Analgesics*** phenazopyridine hcl oral tablet 100 Pyridium phenazopyridine hcl oral tablet 200 Phenazo *Gout Agents* *Gout Agent Combinations*** colchicine-probenecid oral tablet *Gout Agents*** allopurinol oral tablet 100, 300 Zyloprim *Uricosurics*** probenecid oral tablet 500 *Hematological Agents - Misc.* *Hematorheologic Agents*** pentoxifylline er oral tablet extended release 400 *Phosphodiesterase Iii Inhibitors*** cilostazol oral tablet 100, 50 20

21 *Platelet Aggregation Inhibitors*** dipyridamole oral tablet 25, 50, 75 *Thienopyridine Derivatives*** clopidogrel bisulfate oral tablet 75 Plavix *Hematopoietic Agents* *Folic Acid/Folates*** folic acid oral tablet 1 *Hypnotics* *Barbiturate Hypnotics*** phenobarbital oral tablet 100, 15, 30, 60 *Benzodiazepine Hypnotics*** flurazepam hcl oral capsule 15, 30 temazepam oral capsule 15, 30 Restoril *Laxatives* *Bowel Evacuant Combinations*** peg 3350/electrolytes oral solution reconstituted 240 gm peg-3350/electrolytes oral solution reconstituted 236 gm *Laxatives - Miscellaneous*** lactulose oral solution 10 gm/15ml *Laxatives & Dss*** stool softener plus laxative oral tablet *Surfactant Laxatives*** Colyte with Flavor Packs GaviLyte-G Colace 2-IN-1 docusate sodium oral capsule 100 Colace ra col-rite oral capsule 50 Colace Clear *Macrolides* *Azithromycin*** azithromycin oral tablet 250, 500 Zithromax Limit of 1 fill of any Benzodiazepine per 30 days Limit of 1 fill of any Benzodiazepine per 30 days 21

22 *Erythromycins*** erythromycin base oral capsule delayed release particles 250 erythromycin ethylsuccinate oral tablet 400 E.E.S. 400 erythromycin stearate oral tablet 250 Erythrocin Stearate *Medical Devices* *Glucose Monitoring Test Supplies*** lancets lancets 28g lancets 30g lancets thin *Needles & Syringes*** BD INSULIN SYR ULTRAFINE II 31G X 5/16" 0.3 ML, 31G X 5/16" 1 ML BD INSULIN SYR ULTRAFINE II 31G X 5/16" 0.5 ML BD INSULIN SYRINGE 25G X 1" 1 ML, 25G X 5/8" 1 ML, 26G X 1/2" 1 ML, 27.5G X 5/8" 2 ML BD INSULIN SYRINGE 27G X 1/2" 1 ML BD INSULIN SYRINGE MICROFINE 27G X 5/8" 1 ML BD INSULIN SYRINGE MICROFINE 28G X 1/2" 0.5 ML BD INSULIN SYRINGE MICROFINE 28G X 1/2" 1 ML BD INSULIN SYRINGE U/F 30G X 1/2" 1 ML BD INSULIN SYRINGE ULTRAFINE 29G X 1/2" 0.3 ML, 29G X 1/2" 1 ML BD INSULIN SYRINGE ULTRAFINE 29G X 1/2" 0.5 ML BD SAFETYGLIDE INSULIN SYRINGE 30G X 5/16" 0.5 ML Accu-Chek FastClix Lancets Accu-Chek FastClix Lancets Accu-Chek FastClix Lancets Accu-Chek FastClix Lancets Advocate Insulin Syringe Advocate Insulin Syringe BD Insulin Syringe MicroFine BD Insulin Syringe MicroFine BD Insulin Syringe U/F Advocate Insulin Syringe Advocate Insulin Syringe Advocate Insulin Syringe 22

23 BD SAFETYGLIDE INSULIN SYRINGE 31G X 15/64" 0.3 ML BD SAFETYGLIDE INSULIN SYRINGE 31G X 15/64" 0.5 ML, 31G X 15/64" 1 ML insulin syringe 27g x 1/2" 0.5 ml insulin syringe 28g x 1/2" 0.5 ml, 28g x 1/2" 1 ml Easy Touch Insulin Syringe BD Insulin Syringe MicroFine insulin syringe 29g x 1" 0.3 ml insulin syringe 29g x 1/2" 0.3 ml, 29g x 1/2" 0.5 ml, 29g x 1/2" 1 ml, 30g x 5/16" 0.3 ml, 30g x 5/16" 0.5 ml, 30g x 5/16" 1 ml, 31g x 5/16" 0.3 ml, 31g x 5/16" 0.5 ml, 31g x 5/16" 1 ml insulin syringe 30g x 1/2" 0.5 ml, 30g x 1/2" 1 ml insulin syringe-needle u g x 1/4" 0.3 ml, 31g x 1/4" 0.5 ml, 31g x 1/4" 1 ml pen needles 29g x 12mm, 31g x 6 mm, 32g x 5 mm pen needles 3/16" 31g x 5 mm pen needles 30g x 5 mm Advocate Insulin Syringe BD Insulin Syringe U/F UltiCare Insulin Syringe CareFine Pen Needles Advocate Insulin Pen Needles Assure ID Safety Pen Needles pen needles 32g x 4 mm BD Pen Needle Nano U/F pen needles 32g x 6 mm pen needles 5/16" 30g x 8 mm pen needles 5/16" 31g x 8 mm *Migraine Products* *Selective Serotonin Agonists 5- Ht(1)*** BD Pen Needle Micro U/F Assure ID Safety Pen Needles Advocate Insulin Pen Needles rizatriptan benzoate oral tablet 10 Maxalt rizatriptan benzoate oral tablet 5 rizatriptan benzoate oral tablet dispersible 10, 5 Maxalt-MLT sumatriptan succinate oral tablet 100 Imitrex QL (9 tabs per 30 days) QL (9 tabs per 30 days) QL (9 tabs per 30 days) QL (9 TABS per 30 days) 23

24 sumatriptan succinate oral tablet 25, 50 *Minerals & Electrolytes* *Potassium*** potassium bicarbonate oral tablet effervescent 25 meq potassium chloride er oral capsule extended release 10 meq potassium chloride er oral tablet extended release 10 meq, 20 meq, 8 meq potassium chloride oral solution 40 meq/15ml (20%) *Mouth/Throat/Dental Agents* *Anesthetics Topical Oral*** lidocaine viscous mouth/throat solution 2 % *Anti-Infectives - Throat*** nystatin mouth/throat suspension unit/ml *Antiseptics - Mouth/Throat*** chlorhexidine gluconate mouth/throat solution 0.12 % *Steroids - Mouth/Throat*** triamcinolone acetonide mouth/throat paste 0.1 % *Multivitamins* *B-Complex W/ C*** Imitrex Effer-K Klor-Con Sprinkle K-Tab Paroex Oralone b complex-vitamin c oral capsule *B-Complex W/ Folic Acid*** b complex plus oral tablet *Musculoskeletal Therapy Agents* *Central Muscle Relaxants*** baclofen oral tablet 10, 20 chlorzoxazone oral tablet 500 cyclobenzaprine hcl oral tablet 10 methocarbamol oral tablet 500 Robaxin methocarbamol oral tablet 750 Robaxin-750 tizanidine hcl oral tablet 2 24 QL (9 tabs per 30 days)

25 tizanidine hcl oral tablet 4 Zanaflex *Ophthalmic Agents* *Beta-Blockers - Ophthalmic*** levobunolol hcl ophthalmic solution 0.5 % Betagan timolol maleate ophthalmic solution 0.25 %, 0.5 % *Cycloplegic Mydriatics*** Timoptic tropicamide ophthalmic solution 1 % Mydriacyl *Miotics - Direct Acting*** pilocarpine hcl ophthalmic solution 1 %, 2 %, 4 % *Ophthalmic Antibiotics*** GENTAK OPHTHALMIC OINTMENT 0.3 % bacitracin ophthalmic ointment 500 unit/gm erythromycin ophthalmic ointment 5 /gm gentamicin sulfate ophthalmic solution 0.3 % Isopto Carpine tobramycin ophthalmic solution 0.3 % Tobrex *Ophthalmic Anti-Infective Combinations*** neomycin-bacitracin zn-polymyx ophthalmic ointment neomycin-polymyxin-gramicidin ophthalmic solution *Ophthalmic Decongestant Combinations*** eye allergy relief ophthalmic solution % *Ophthalmic Steroid Combinations*** bacitra-neomycin-polymyxin-hc ophthalmic ointment 1 % neomycin-polymyxin-dexameth ophthalmic ointment neomycin-polymyxin-dexameth ophthalmic suspension 0.1 % neomycin-polymyxin-hc ophthalmic suspension Neo-Polycin Neosporin Naphcon-A Neo-Polycin HC Maxitrol Maxitrol 25

26 *Ophthalmic Steroids*** dexamethasone sodium phosphate ophthalmic solution 0.1 % fluorometholone ophthalmic suspension 0.1 % prednisolone acetate ophthalmic suspension 1 % *Ophthalmic Sulfonamides*** sulfacetamide sodium ophthalmic ointment 10 % sulfacetamide sodium ophthalmic solution 10 % *Otic Agents* *Otic Agents - Miscellaneous*** acetic acid otic solution 2 % *Otic Steroid-Anti-Infective Combinations*** neomycin-polymyxin-hc otic solution 1 % neomycin-polymyxin-hc otic suspension *Otic Steroids*** hydrocortisone-acetic acid otic solution 1-2 % *Penicillins* *Aminopenicillins*** amoxicillin oral capsule 250, 500 amoxicillin oral suspension reconstituted 250 /5ml amoxicillin oral tablet chewable 250 ampicillin oral capsule 500 *Natural Penicillins*** penicillin v potassium oral solution reconstituted 250 /5ml penicillin v potassium oral tablet 250, 500 *Penicillin Combinations*** amoxicillin-pot clavulanate oral tablet , FML Liquifilm Omnipred Bleph-10 Acetasol HC Augmentin 26

27 *Penicillinase-Resistant Penicillins*** dicloxacillin sodium oral capsule 250, 500 *Progestins* *Progestins*** medroxyprogesterone acetate oral tablet 10, 2.5, 5 *Psychotherapeutic And Neurological Agents - Misc.* *Benzodiazepines & Tricyclic Agents*** chlordiazepoxide-amitriptyline oral tablet 10-25, *Phenothiazines & Tricyclic Agents*** perphenazine-amitriptyline oral tablet 2-10, 2-25, 4-10, 4-25 *Tetracyclines* *Tetracyclines*** doxycycline hyclate oral capsule 100, 50 minocycline hcl oral capsule 100, 50 tetracycline hcl oral capsule 250, 500 *Thyroid Agents* *Antithyroid Agents*** Provera Morgidox Minocin methimazole oral tablet 10, 5 Tapazole propylthiouracil oral tablet 50 *Thyroid Hormones*** SYNTHROID ORAL TABLET 100 MCG, 112 MCG, 125 MCG, 137 MCG, 150 MCG, 175 MCG, 200 MCG, 25 MCG, 300 MCG, 50 MCG, 75 MCG, 88 MCG levothyroxine sodium oral tablet 100 mcg, 112 mcg, 125 mcg, 137 mcg, 150 mcg, 175 mcg, 200 mcg, 25 mcg, 300 mcg, 50 mcg, 75 mcg, 88 mcg Levo-T Levo-T 27

28 levothyroxine-liothyronine oral tablet 120, 15, 30, 60, 90 *Ulcer Drugs* *Anticholinergic Combinations*** chlordiazepoxide-clidinium oral capsule *Antispasmodics*** dicyclomine hcl oral capsule 10 dicyclomine hcl oral tablet 20 *Belladonna Alkaloids*** hyoscyamine sulfate er oral tablet extended release 12 hour hyoscyamine sulfate sl sublingual tablet sublingual *H-2 Antagonists*** cimetidine oral tablet 300, 400, 800 ranitidine hcl oral tablet 150 Armour Thyroid Librax Levbid Levsin/SL Wal-Zan 150 Maximum Strength ranitidine hcl oral tablet 300 Zantac *Misc. Anti-Ulcer*** sucralfate oral tablet 1 gm Carafate *Proton Pump Inhibitors*** omeprazole oral capsule delayed release 10, 20, 40 pantoprazole sodium oral tablet delayed release 20, 40 *Urinary Anti-Infectives* *Urinary Anti-Infectives*** nitrofurantoin macrocrystal oral capsule 100, 25, 50 nitrofurantoin monohyd macro oral capsule 100 *Urinary Antispasmodics* *Urinary Antispasmodic - Antimuscarinics (Antichol)***(New) oxybutynin chloride oral tablet 5 Protonix Macrodantin Macrobid 28

29 *Urinary Antispasmodics - Cholinergic Agonists*** (New) bethanechol chloride oral tablet 10, 25, 5, 50 *Vaccines* *Bacterial Vaccines*** PNEUMOVAX 23 INJECTION INJECTABLE 25 MCG/0.5ML PREVNAR 13 INTRAMUSCULAR SUSPENSION *Viral Vaccines*** AFLURIA INTRAMUSCULAR SUSPENSION AFLURIA PRESERVATIVE FREE INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE 0.5 ML FLUZONE HIGH-DOSE INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE 0.5 ML FLUZONE QUADRIVALENT INTRAMUSCULAR SUSPENSION, 0.5 ML FLUZONE QUADRIVALENT INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE 0.5 ML SHINGRIX INTRAMUSCULAR SUSPENSION RECONSTITUTED 50 MCG/0.5ML *Vaginal Products* *Imidazole-Related Antifungals*** Urecholine clotrimazole-7 vaginal cream 1 % Gyne-Lotrimin miconazole 3 vaginal suppository 200 miconazole 7 vaginal cream 2 % Monistat 7 Simply Cure *Vasopressors* *Anaphylaxis Therapy Agents*** EPIPEN 2-PAK INJECTION SOLUTION AUTO-INJECTOR 0.3 MG/0.3ML epinephrine injection solution autoinjector 0.3 /0.3ml Auvi-Q Auvi-Q 29

30 *Vitamins* *Vitamin D*** vitamin d (ergocalciferol) oral capsule unit Drisdol 30