Your Guide to Prescription Drug Benefits 2018 PREFERRED FORMULARY AND PRESCRIPTION DRUG LIST

Transcription

1 Your Guide to Prescription Drug Benefits 2018 PREFERRED FORMULARY AND PRESCRIPTION DRUG LIST

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3 2018 Preferred Formulary Table of Contents Abbreviations and Key to Drug Tiers...2 Drug Classes: Anti - Infectives... 6 Antineoplastic & Immunosuppressant Drugs...16 Autonomic & Cns Drugs, Neurology & Psych...21 Cardiovascular, Hypertension & Lipids...44 Dermatologicals/Topical Therapy...57 Diagnostics & Miscellaneous Agents...69 Ear, Nose & Throat Medications...72 Endocrine/Diabetes Gastroenterology Immunology, Vaccines & Biotechnology...98 Musculoskeletal & Rheumatology Obstetrics & Gynecology Ophthalmology Respiratory, Allergy, Cough & Cold Urologicals Vitamins, Hematinics & Electrolytes Index of Drugs

4 Requirements/Limits # = Some plans do not cover these medications. Check with BlueCross BlueShield of Tennessee Member Services to determine coverage at the phone number listed on your BlueCross BlueShield of Tennessee member ID card. = Affordable Care Act. The products with the indicator are available to you at no out-of-pocket cost based on the Affordable Care Act () $0 Copay Preventive List. AGE-A = Age edit is applicable. Prior authorization is required for members 17 years of age and younger. Your network provider must call Express Scripts at to request a coverage review. LD = Limited Distribution. This medication may be available only at certain pharmacies. For more information, please call BlueCross BlueShield Member Services at the phone number listed on your BlueCross BlueShield of Tennessee member ID card. PA = Prior Authorization. The plan requires your physician to obtain prior authorization for certain drugs. This means that you will need to get approval before you may fill your prescription. Your network provider must call Express Scripts at to request a coverage review for a drug that requires prior authorization. QL = Quantity Limit. For certain drugs, the plan limits the amount of the drug that will be covered. SPRx = Specialty Medication. Includes high-cost medications for chronic, serious diseases such as hepatitis C, multiple sclerosis, arthritis, hemophilia and other conditions. Some plans may cover specialty medications at different benefit levels or may require the use of a preferred specialty pharmacy. ST = Step Therapy. In some cases, your plan requires you to first try certain drugs to treat your medical condition before we will cover another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, we may not cover Drug B unless you try Drug A first. If Drug A does not work for you, we will then cover Drug B. Your network provider must call Express Scripts at to request a coverage review. Please refer to the Step Therapy list included within this guidebook on page 3 for medications that require step therapy and the agents that are required to be taken first. lowercase italics= Generic drugs UPPERCASE BOLD= Brand name drugs 2

5 Step Therapy Medication(s) Requiring Step Therapy Step Therapy Requirements Edarbi Edarbyclor Trial and failure of generic ARB Non-preferred diabetic test strips (e.g., Accu- Chek, Freestyle) QL Trial and failure of preferred products made by Lifescan (OneTouch) or Ascensia (Contour or Breeze2) QL Apidra Apidra Solostar Humalog Trial and failure of Novolog Humulin Trial and failure of Novolin Proventil HFA QL Ventolin HFA QL Xopenex HFA QL Trial and failure of ProAir HFA QL or ProAir Respiclick QL Nevanac Trial and failure of Prolensa Osphena Premarin Cream Trial and failure of Estrace 0.01% cream 3

6 For drugs used to treat various inflammatory immune conditions, preferred drugs are required to be used before other non-preferred drugs based on a specific medical condition. A trial of one or two preferred agents will be required before a non-preferred drug will be covered. Below is a table of preferred and non-preferred agents based on various medical conditions. Medical Condition Preferred Agents Non-Preferred Agents (directed to ONE Preferred agent) Non-Preferred Agents (directed to TWO Preferred agents) Rheumatoid arthritis Actemra SC Enbrel Humira Xeljanz/XR Cimzia Orencia SC Simponi SC Kineret Ankylosing spondylitis Cosentyx Enbrel Humira Cimzia Simponi SC Juvenile idiopathic arthritis Enbrel Humira Orencia SC Psoriatic arthritis Cosentyx Enbrel Humira Stelara SC Otezla Cimzia Simponi SC Psoriasis Cosentyx Humira Otezla Stelara SC Enbrel* See note below Siliq Taltz Crohn s disease Humira Cimzia Stelara SC Ulcerative colitis Humira Simponi SC SC subcutaneous *Access to Enbrel for Psoriasis will be approved if the patient has tried the Preferred agent Humira specifically. Other Preferred agents not requiring Humira first for Psoriasis are Cosentyx, Otezla, and Stelara SC. 4

7 Drug Tiers = Generic Drugs = Preferred Brand Drugs = Non-Preferred Brand Drugs Pharmacy Appeals To appeal a denial based on the prior authorization criteria or to request a medical exception to the quantity limit, please FAX a written request to: Pharmacy Management Appeals BlueCross BlueShield of Tennessee 1 Cameron Hill Circle Chattanooga, TN Fax: Please provide the following information with your written request: 1. Patient name and cardholder ID number 2. Physician name and phone number 3. Drug and diagnosis information This list is subject to change. Please call Member Services at the phone number listed on your BlueCross BlueShield of Tennessee member ID card or visit our website at bcbst.com for the most up to date information. 5

8 Anti - Infectives Antifungal Agents ANCOBON ORAL CAPSULE clotrimazole mucous membrane troche CRESEMBA ORAL CAPSULE DIFLUCAN ORAL SUSPENSION FOR RECONSTITUTION 6 DIFLUCAN ORAL TABLET fluconazole oral suspension for reconstitution fluconazole oral tablet flucytosine oral capsule griseofulvin microsize oral suspension griseofulvin microsize oral tablet griseofulvin ultramicrosize oral tablet GRIS-PEG (ULTRAMICROSIZE) ORAL TABLET itraconazole oral capsule ketoconazole oral tablet NOXAFIL ORAL SUSPENSION NOXAFIL ORAL TABLET,DELAYED RELEASE (DR/EC) nystatin oral powder 150 million unit, 500 million unit nystatin oral suspension nystatin oral tablet ONMEL ORAL TABLET ORAVIG BUCCAL MUCO-ADHESIVE BUCCAL TABLET SPORANOX ORAL SOLUTION SPORANOX PULSEPAK ORAL CAPSULE terbinafine hcl oral tablet VFEND ORAL SUSPENSION FOR RECONSTITUTION VFEND ORAL TABLET voriconazole oral suspension for reconstitution

9 voriconazole oral tablet Antivirals abacavir oral tablet abacavir-lamivudine oral tablet SPRx abacavir-lamivudine-zidovudine oral tablet acyclovir oral capsule acyclovir oral suspension 200 mg/5 ml acyclovir oral tablet adefovir oral tablet amantadine hcl oral capsule amantadine hcl oral solution amantadine hcl oral tablet APTIVUS ORAL CAPSULE APTIVUS ORAL SOLUTION ATRIPLA ORAL TABLET SPRx BARACLUDE ORAL SOLUTION BARACLUDE ORAL TABLET COMBIVIR ORAL TABLET COMPLERA ORAL TABLET SPRx CRIXIVAN ORAL CAPSULE 200 MG, 400 MG 7 DESCOVY ORAL TABLET SPRx didanosine oral capsule,delayed release(dr/ec) EDURANT ORAL TABLET EMTRIVA ORAL CAPSULE EMTRIVA ORAL SOLUTION entecavir oral tablet EPCLUSA ORAL TABLET PA; SPRx EPIVIR HBV ORAL SOLUTION EPIVIR HBV ORAL TABLET EPIVIR ORAL SOLUTION EPIVIR ORAL TABLET EPZICOM ORAL TABLET SPRx

10 EVOTAZ ORAL TABLET SPRx famciclovir oral tablet FLUMADINE ORAL TABLET FUZEON SUBCUTANEOUS RECON SOLN SPRx GENVOYA ORAL TABLET SPRx HARVONI ORAL TABLET PA; SPRx HEPSERA ORAL TABLET INTELENCE ORAL TABLET INVIRASE ORAL CAPSULE INVIRASE ORAL TABLET ISENTRESS HD ORAL TABLET SPRx ISENTRESS ORAL POWDER IN PACKET SPRx ISENTRESS ORAL TABLET SPRx ISENTRESS ORAL TABLET,CHEWABLE SPRx KALETRA ORAL SOLUTION KALETRA ORAL TABLET lamivudine oral solution lamivudine oral tablet lamivudine-zidovudine oral tablet LEXIVA ORAL SUSPENSION LEXIVA ORAL TABLET lopinavir-ritonavir oral solution MAVYRET ORAL TABLET PA; SPRx nevirapine oral suspension nevirapine oral tablet nevirapine oral tablet extended release 24 hr NORVIR ORAL CAPSULE NORVIR ORAL SOLUTION NORVIR ORAL TABLET ODEFSEY ORAL TABLET SPRx oseltamivir oral capsule 30 mg QL (20 EA per 180 days) oseltamivir oral capsule 45 mg, 75 mg QL (10 EA per 180 days) PREZCOBIX ORAL TABLET SPRx 8

11 PREZISTA ORAL SUSPENSION SPRx PREZISTA ORAL TABLET 150 MG, 600 MG, 75 MG, 800 MG RELENZA DISKHALER INHALATION BLISTER WITH DEVICE 9 RESCRIPTOR ORAL TABLET RESCRIPTOR ORAL TABLET, DISPERSIBLE RETROVIR ORAL CAPSULE REYATAZ ORAL CAPSULE 150 MG, 200 MG, 300 MG SPRx QL (20 EA per 180 days) SPRx REYATAZ ORAL POWDER IN PACKET SPRx rimantadine oral tablet SELZENTRY ORAL SOLUTION SELZENTRY ORAL TABLET SOVALDI ORAL TABLET PA; SPRx stavudine oral capsule stavudine oral recon soln STRIBILD ORAL TABLET SPRx SUSTIVA ORAL CAPSULE SUSTIVA ORAL TABLET TAMIFLU ORAL CAPSULE 30 MG QL (20 EA per 180 days) TAMIFLU ORAL CAPSULE 45 MG, 75 MG QL (10 EA per 180 days) TAMIFLU ORAL SUSPENSION FOR RECONSTITUTION TIVICAY ORAL TABLET SPRx TRIUMEQ ORAL TABLET SPRx TRIZIVIR ORAL TABLET TRUVADA ORAL TABLET SPRx TYBOST ORAL TABLET valacyclovir oral tablet VALCYTE ORAL RECON SOLN VALCYTE ORAL TABLET valganciclovir oral recon soln valganciclovir oral tablet QL (180 ML per 180 days)

12 VALTREX ORAL TABLET VEMLIDY ORAL TABLET SPRx VIDEX 2 GRAM PEDIATRIC ORAL RECON SOLN VIDEX EC ORAL CAPSULE,DELAYED RELEASE(DR/EC) 10 VIRACEPT ORAL TABLET VIRAMUNE ORAL SUSPENSION VIRAMUNE ORAL TABLET VIRAMUNE XR ORAL TABLET EXTENDED RELEASE 24 HR VIRAZOLE INHALATION RECON SOLN VIREAD ORAL POWDER VIREAD ORAL TABLET ZERIT ORAL CAPSULE ZERIT ORAL RECON SOLN ZIAGEN ORAL SOLUTION ZIAGEN ORAL TABLET zidovudine oral capsule zidovudine oral syrup zidovudine oral tablet ZOVIRAX ORAL CAPSULE ZOVIRAX ORAL SUSPENSION ZOVIRAX ORAL TABLET Cephalosporins CEDAX ORAL CAPSULE CEDAX ORAL SUSPENSION FOR RECONSTITUTION cefaclor oral capsule cefaclor oral suspension for reconstitution 125 mg/5 ml, 250 mg/5 ml, 375 mg/5 ml cefaclor oral tablet extended release 12 hr cefadroxil oral capsule cefadroxil oral suspension for reconstitution 250 mg/5 ml, 500 mg/5 ml

13 cefadroxil oral tablet cefdinir oral capsule cefdinir oral suspension for reconstitution cefditoren pivoxil oral tablet cefixime oral suspension for reconstitution cefpodoxime oral suspension for reconstitution cefpodoxime oral tablet cefprozil oral suspension for reconstitution cefprozil oral tablet ceftibuten oral capsule ceftibuten oral suspension for reconstitution CEFTIN ORAL SUSPENSION FOR RECONSTITUTION 11 cefuroxime axetil oral tablet cephalexin oral capsule cephalexin oral suspension for reconstitution cephalexin oral tablet SUPRAX ORAL CAPSULE SUPRAX ORAL SUSPENSION FOR RECONSTITUTION SUPRAX ORAL TABLET,CHEWABLE Erythromycins & Other Macrolides azithromycin oral packet azithromycin oral suspension for reconstitution azithromycin oral tablet clarithromycin oral suspension for reconstitution clarithromycin oral tablet clarithromycin oral tablet extended release 24 hr DIFICID ORAL TABLET e.e.s. 400 oral tablet E.E.S. GRANULES ORAL SUSPENSION FOR RECONSTITUTION ERYPED 200 ORAL SUSPENSION FOR RECONSTITUTION

14 ERYPED 400 ORAL SUSPENSION FOR RECONSTITUTION ery-tab oral tablet,delayed release (dr/ec) 250 mg, 333 mg ERY-TAB ORAL TABLET,DELAYED RELEASE (DR/EC) 500 MG 12 erythrocin (as stearate) oral tablet 250 mg erythromycin ethylsuccinate oral tablet erythromycin oral capsule,delayed release(dr/ec) erythromycin oral tablet PCE ORAL TABLET, PARTICLES/CRYSTALS ZITHROMAX ORAL PACKET ZITHROMAX ORAL SUSPENSION FOR RECONSTITUTION ZITHROMAX ORAL TABLET ZMAX ORAL SUSPENSION,EXTENDED REL RECON Miscellaneous Antiinfectives ALBENZA ORAL TABLET ALINIA ORAL SUSPENSION FOR RECONSTITUTION ALINIA ORAL TABLET atovaquone oral suspension atovaquone-proguanil oral tablet BILTRICIDE ORAL TABLET CAYSTON INHALATION SOLUTION FOR NEBULIZATION chloroquine phosphate oral tablet CLEOCIN HCL ORAL CAPSULE CLEOCIN PEDIATRIC ORAL RECON SOLN clindamycin hcl oral capsule clindamycin palmitate hcl oral recon soln clindamycin pediatric oral recon soln COARTEM ORAL TABLET PA; LD; SPRx

15 CYCLOSERINE ORAL CAPSULE DARAPRIM ORAL TABLET PA; LD; SPRx ethambutol oral tablet FLAGYL ORAL CAPSULE FLAGYL ORAL TABLET hydroxychloroquine oral tablet isoniazid oral solution isoniazid oral tablet ivermectin oral tablet KITABIS PAK INHALATION SOLUTION FOR NEBULIZATION 13 LD; SPRx; QL (56 ML per 30 days) linezolid oral suspension for reconstitution QL (14 day supply per 30 days) linezolid oral tablet QL (14 day supply per 30 days) MALARONE ORAL TABLET MALARONE PEDIATRIC ORAL TABLET mefloquine oral tablet MEPRON ORAL SUSPENSION metronidazole oral capsule metronidazole oral tablet MYAMBUTOL ORAL TABLET 400 MG MYCOBUTIN ORAL CAPSULE NEBUPENT INHALATION RECON SOLN neomycin oral tablet paromomycin oral capsule PASER ORAL GRANULES DR FOR SUSP IN PACKET PLAQUENIL ORAL TABLET PRIFTIN ORAL TABLET PRIMAQUINE ORAL TABLET pyrazinamide oral tablet QUALAQUIN ORAL CAPSULE quinine sulfate oral capsule rifabutin oral capsule RIFADIN ORAL CAPSULE

16 RIFAMATE ORAL CAPSULE rifampin oral capsule RIFATER ORAL TABLET SIRTURO ORAL TABLET LD; SPRx STROMECTOL ORAL TABLET TINDAMAX ORAL TABLET 500 MG tinidazole oral tablet TOBI INHALATION SOLUTION FOR NEBULIZATION tobramycin in % nacl inhalation solution for nebulization 14 TRECATOR ORAL TABLET XIFAXAN ORAL TABLET 200 MG XIFAXAN ORAL TABLET 550 MG ZYVOX ORAL SUSPENSION FOR RECONSTITUTION SPRx; QL (56 ML per 30 days) SPRx; QL (56 ML per 30 days) QL (14 day supply per 30 days) ZYVOX ORAL TABLET QL (14 day supply per 30 days) Penicillins amoxicillin oral capsule amoxicillin oral suspension for reconstitution amoxicillin oral tablet amoxicillin oral tablet,chewable 125 mg, 250 mg amoxicillin-pot clavulanate oral suspension for reconstitution amoxicillin-pot clavulanate oral tablet amoxicillin-pot clavulanate oral tablet extended release 12 hr amoxicillin-pot clavulanate oral tablet,chewable ampicillin oral capsule AUGMENTIN ES-600 ORAL SUSPENSION FOR RECONSTITUTION AUGMENTIN ORAL SUSPENSION FOR RECONSTITUTION MG/5 ML, MG/5 ML AUGMENTIN ORAL TABLET MG, MG

17 AUGMENTIN XR ORAL TABLET EXTENDED RELEASE 12 HR 15 dicloxacillin oral capsule penicillin v potassium oral recon soln penicillin v potassium oral tablet Quinolones AVELOX ORAL TABLET CIPRO ORAL SUSPENSION,MICROCAPSULE RECON CIPRO ORAL TABLET 250 MG, 500 MG CIPRO XR ORAL TABLET, ER MULTIPHASE 24 HR ciprofloxacin (mixture) oral tablet, er multiphase 24 hr ciprofloxacin hcl oral tablet ciprofloxacin oral suspension,microcapsule recon FACTIVE ORAL TABLET LEVAQUIN ORAL TABLET levofloxacin oral solution levofloxacin oral tablet moxifloxacin oral tablet ofloxacin oral tablet 300 mg, 400 mg Sulfa's & Related Agents BACTRIM DS ORAL TABLET BACTRIM ORAL TABLET sulfadiazine oral tablet sulfamethoxazole-trimethoprim oral suspension sulfamethoxazole-trimethoprim oral tablet sulfatrim oral suspension Tetracyclines avidoxy oral tablet demeclocycline oral tablet doxycycline hyclate oral capsule doxycycline hyclate oral tablet 100 mg, 20 mg

18 doxycycline hyclate oral tablet,delayed release (dr/ec) 100 mg, 150 mg, 75 mg doxycycline monohydrate oral capsule doxycycline monohydrate oral suspension for reconstitution doxycycline monohydrate oral tablet minocycline oral capsule minocycline oral tablet tetracycline oral capsule VIBRAMYCIN ORAL CAPSULE 100 MG VIBRAMYCIN ORAL SUSPENSION FOR RECONSTITUTION VIBRAMYCIN ORAL SYRUP Urinary Tract Agents FURADANTIN ORAL SUSPENSION HIPREX ORAL TABLET MACROBID ORAL CAPSULE MACRODANTIN ORAL CAPSULE methenamine hippurate oral tablet methenamine mandelate oral tablet MONUROL ORAL PACKET nitrofurantoin macrocrystal oral capsule nitrofurantoin monohyd/m-cryst oral capsule nitrofurantoin oral suspension PRIMSOL ORAL SOLUTION trimethoprim oral tablet Vancomycin VANCOCIN ORAL CAPSULE vancomycin oral capsule Antineoplastic & Immunosuppressant Drugs Adjunctive Agents leucovorin calcium oral tablet MESNEX ORAL TABLET 16

19 Antineoplastic & Immunosuppressant Drugs AFINITOR DISPERZ ORAL TABLET FOR SUSPENSION 17 PA; SPRx AFINITOR ORAL TABLET PA; SPRx ALECENSA ORAL CAPSULE PA; LD; SPRx ALKERAN ORAL TABLET ALUNBRIG ORAL TABLET PA; LD; SPRx anastrozole oral tablet ARIMIDEX ORAL TABLET AROMASIN ORAL TABLET ASTAGRAF XL ORAL CAPSULE,EXTENDED RELEASE 24HR AZASAN ORAL TABLET azathioprine oral tablet SPRx bexarotene oral capsule SPRx bicalutamide oral tablet BOSULIF ORAL TABLET PA; LD; SPRx CABOMETYX ORAL TABLET PA; LD; SPRx capecitabine oral tablet SPRx CAPRELSA ORAL TABLET PA; LD; SPRx CASODEX ORAL TABLET CELLCEPT ORAL CAPSULE CELLCEPT ORAL SUSPENSION FOR RECONSTITUTION COMETRIQ ORAL CAPSULE LD; SPRx COTELLIC ORAL TABLET PA; LD; SPRx CYCLOPHOSPHAMIDE ORAL CAPSULE cyclosporine modified oral capsule cyclosporine modified oral solution cyclosporine oral capsule DROXIA ORAL CAPSULE EMCYT ORAL CAPSULE ERIVEDGE ORAL CAPSULE PA; LD; SPRx etoposide oral capsule

20 exemestane oral tablet FARESTON ORAL TABLET FARYDAK ORAL CAPSULE PA; LD; SPRx FEMARA ORAL TABLET flutamide oral capsule gengraf oral capsule gengraf oral solution GILOTRIF ORAL TABLET PA; LD; SPRx GLEEVEC ORAL TABLET SPRx GLEOSTINE ORAL CAPSULE HEXALEN ORAL CAPSULE HYCAMTIN ORAL CAPSULE SPRx HYDREA ORAL CAPSULE hydroxyurea oral capsule IBRANCE ORAL CAPSULE PA; LD; SPRx ICLUSIG ORAL TABLET PA; LD; SPRx IDHIFA ORAL TABLET PA; SPRx imatinib oral tablet SPRx IMBRUVICA ORAL CAPSULE PA; LD; SPRx IMURAN ORAL TABLET INLYTA ORAL TABLET PA; LD; SPRx IRESSA ORAL TABLET PA; LD; SPRx JAKAFI ORAL TABLET PA; LD; SPRx KISQALI FEMARA CO-PACK ORAL TABLET PA; SPRx KISQALI ORAL TABLET PA; SPRx LENVIMA ORAL CAPSULE PA; LD; SPRx letrozole oral tablet LEUKERAN ORAL TABLET leuprolide subcutaneous kit PA; SPRx LONSURF ORAL TABLET PA; LD; SPRx LYNPARZA ORAL CAPSULE PA; LD; SPRx LYNPARZA ORAL TABLET PA; SPRx 18

21 LYSODREN ORAL TABLET MATULANE ORAL CAPSULE SPRx MEGACE ES ORAL SUSPENSION megestrol oral suspension 400 mg/10 ml (40 mg/ml), 625 mg/5 ml 19 megestrol oral tablet MEKINIST ORAL TABLET PA; SPRx melphalan oral tablet mercaptopurine oral tablet methotrexate sodium (pf) injection recon soln methotrexate sodium (pf) injection solution methotrexate sodium injection solution methotrexate sodium oral tablet mycophenolate mofetil oral capsule mycophenolate mofetil oral suspension for reconstitution mycophenolate mofetil oral tablet mycophenolate sodium oral tablet,delayed release (dr/ec) MYFORTIC ORAL TABLET,DELAYED RELEASE (DR/EC) MYLERAN ORAL TABLET NEORAL ORAL CAPSULE NEORAL ORAL SOLUTION NERLYNX ORAL TABLET PA; SPRx NEXAVAR ORAL TABLET PA; LD; SPRx NILANDRON ORAL TABLET SPRx nilutamide oral tablet SPRx NINLARO ORAL CAPSULE PA; LD; SPRx octreotide acetate injection solution SPRx octreotide acetate injection syringe SPRx ODOMZO ORAL CAPSULE PA; SPRx PROGRAF ORAL CAPSULE PURIXAN ORAL SUSPENSION SPRx

22 RAPAMUNE ORAL SOLUTION RAPAMUNE ORAL TABLET RUBR ORAL TABLET PA; LD; SPRx RYDAPT ORAL CAPSULE PA; SPRx SANDIMMUNE ORAL CAPSULE SANDIMMUNE ORAL SOLUTION SANDOSTATIN INJECTION SOLUTION SPRx SIGNIFOR SUBCUTANEOUS SOLUTION PA; LD; SPRx sirolimus oral tablet SOLTAMOX ORAL SOLUTION SPRYCEL ORAL TABLET SPRx STIVARGA ORAL TABLET PA; LD; SPRx SUTENT ORAL CAPSULE PA; LD; SPRx TABLOID ORAL TABLET tacrolimus oral capsule TAFINLAR ORAL CAPSULE PA; LD; SPRx TAGRISSO ORAL TABLET PA; LD; SPRx tamoxifen oral tablet TARCEVA ORAL TABLET PA; LD; SPRx TARGRETIN ORAL CAPSULE SPRx TARGRETIN TOPICAL GEL PA; SPRx TASIGNA ORAL CAPSULE SPRx TEMODAR ORAL CAPSULE PA; SPRx temozolomide oral capsule PA; SPRx THALOMID ORAL CAPSULE PA; LD; SPRx tretinoin (chemotherapy) oral capsule TREXALL ORAL TABLET TYKERB ORAL TABLET PA; LD; SPRx VENCLEXTA ORAL TABLET PA; LD; SPRx VENCLEXTA STARTING PACK ORAL TABLETS,DOSE PACK PA; LD; SPRx VOTRIENT ORAL TABLET PA; LD; SPRx XALKORI ORAL CAPSULE PA; LD; SPRx 20

23 XELODA ORAL TABLET SPRx XERMELO ORAL TABLET PA; SPRx XTANDI ORAL CAPSULE LD; SPRx ZEJULA ORAL CAPSULE PA; LD; SPRx ZELBORAF ORAL TABLET PA; LD; SPRx ZOLINZA ORAL CAPSULE SPRx ZORTRESS ORAL TABLET SPRx ZYDELIG ORAL TABLET PA; SPRx ZYKADIA ORAL CAPSULE PA; SPRx ZYTIGA ORAL TABLET SPRx Autonomic & Cns Drugs, Neurology & Psych Agents For Narcotic Withdrawal BUNAVAIL BUCCAL FILM QL (90 EA per 30 days) buprenorphine-naloxone sublingual tablet QL (90 EA per 30 days) SUBOXONE SUBLINGUAL FILM QL (90 EA per 30 days) ZUBSOLV SUBLINGUAL TABLET MG, MG Anticonvulsants 21 APTIOM ORAL TABLET BANZEL ORAL SUSPENSION BANZEL ORAL TABLET carbamazepine oral capsule, er multiphase 12 hr carbamazepine oral suspension 100 mg/5 ml carbamazepine oral tablet carbamazepine oral tablet extended release 12 hr carbamazepine oral tablet,chewable CARBATROL ORAL CAPSULE, ER MULTIPHASE 12 HR CELONTIN ORAL CAPSULE 300 MG clonazepam oral tablet clonazepam oral tablet,disintegrating DEPAKENE ORAL CAPSULE DEPAKENE ORAL SOLUTION QL (90 EA per 30 days)

24 DEPAKOTE ER ORAL TABLET EXTENDED RELEASE 24 HR DEPAKOTE ORAL TABLET,DELAYED RELEASE (DR/EC) DEPAKOTE SPRINKLES ORAL CAPSULE, DELAYED REL SPRINKLE 22 DIASTAT ACUDIAL RECTAL KIT DIASTAT RECTAL KIT diazepam rectal kit DILANTIN EXTENDED ORAL CAPSULE DILANTIN INFATABS ORAL TABLET,CHEWABLE DILANTIN ORAL CAPSULE DILANTIN-125 ORAL SUSPENSION divalproex oral capsule, delayed rel sprinkle divalproex oral tablet extended release 24 hr divalproex oral tablet,delayed release (dr/ec) epitol oral tablet EQUETRO ORAL CAPSULE, ER MULTIPHASE 12 HR ethosuximide oral capsule ethosuximide oral solution felbamate oral suspension felbamate oral tablet FELBATOL ORAL SUSPENSION FELBATOL ORAL TABLET FYCOMPA ORAL TABLET gabapentin oral capsule gabapentin oral solution 250 mg/5 ml gabapentin oral tablet 600 mg, 800 mg GABITRIL ORAL TABLET KEPPRA ORAL SOLUTION KEPPRA ORAL TABLET KEPPRA XR ORAL TABLET EXTENDED RELEASE 24 HR

25 KLONOPIN ORAL TABLET LAMICTAL ODT ORAL TABLET,DISINTEGRATING LAMICTAL ODT STARTER (BLUE) ORAL TABLET DISINTEGRATING, DOSE PK LAMICTAL ODT STARTER (GREEN) ORAL TABLET DISINTEGRATING, DOSE PK LAMICTAL ODT STARTER (ORANGE) ORAL TABLET DISINTEGRATING, DOSE PK 23 LAMICTAL ORAL TABLET LAMICTAL ORAL TABLET, CHEWABLE DISPERSIBLE 25 MG, 5 MG LAMICTAL STARTER (BLUE) KIT ORAL TABLETS,DOSE PACK LAMICTAL STARTER (GREEN) KIT ORAL TABLETS,DOSE PACK LAMICTAL STARTER (ORANGE) KIT ORAL TABLETS,DOSE PACK LAMICTAL XR ORAL TABLET EXTENDED RELEASE 24HR LAMICTAL XR STARTER (BLUE) ORAL TABLET EXTENDED REL,DOSE PACK LAMICTAL XR STARTER (GREEN) ORAL TABLET EXTENDED REL,DOSE PACK LAMICTAL XR STARTER (ORANGE) ORAL TABLET EXTENDED REL,DOSE PACK lamotrigine oral tablet lamotrigine oral tablet disintegrating, dose pk lamotrigine oral tablet extended release 24hr lamotrigine oral tablet, chewable dispersible lamotrigine oral tablet,disintegrating levetiracetam oral solution levetiracetam oral tablet levetiracetam oral tablet extended release 24 hr LYRICA ORAL CAPSULE

26 LYRICA ORAL SOLUTION MYSOLINE ORAL TABLET NEURONTIN ORAL CAPSULE NEURONTIN ORAL SOLUTION NEURONTIN ORAL TABLET ONFI ORAL SUSPENSION ONFI ORAL TABLET 10 MG, 20 MG oxcarbazepine oral suspension oxcarbazepine oral tablet OXTELLAR XR ORAL TABLET EXTENDED RELEASE 24 HR 24 PEGANONE ORAL TABLET phenobarbital oral elixir phenobarbital oral tablet PHENYTEK ORAL CAPSULE phenytoin oral suspension 125 mg/5 ml phenytoin oral tablet,chewable phenytoin sodium extended oral capsule primidone oral tablet QUDEXY XR ORAL CAPSULE,SPRINKLE,ER 24HR roweepra oral tablet SABRIL ORAL POWDER IN PACKET LD SABRIL ORAL TABLET LD SPRITAM ORAL TABLET FOR SUSPENSION TEGRETOL ORAL SUSPENSION TEGRETOL ORAL TABLET TEGRETOL XR ORAL TABLET EXTENDED RELEASE 12 HR tiagabine oral tablet TOPAMAX ORAL CAPSULE, SPRINKLE TOPAMAX ORAL TABLET topiramate oral capsule, sprinkle

27 TOPIRAMATE ORAL CAPSULE,SPRINKLE,ER 24HR 25 topiramate oral tablet TRILEPTAL ORAL SUSPENSION TRILEPTAL ORAL TABLET TROKENDI XR ORAL CAPSULE,EXTENDED RELEASE 24HR valproic acid (as sodium salt) oral solution 250 mg/5 ml valproic acid oral capsule vigabatrin oral powder in packet VIMPAT ORAL SOLUTION VIMPAT ORAL TABLET ZARONTIN ORAL CAPSULE ZARONTIN ORAL SOLUTION ZONEGRAN ORAL CAPSULE 100 MG, 25 MG zonisamide oral capsule Antiparkinsonism Agents APOKYN SUBCUTANEOUS CARTRIDGE SPRx AZILECT ORAL TABLET benztropine oral tablet bromocriptine oral capsule bromocriptine oral tablet carbidopa oral tablet carbidopa-levodopa oral tablet carbidopa-levodopa oral tablet extended release carbidopa-levodopa oral tablet,disintegrating carbidopa-levodopa-entacapone oral tablet COMTAN ORAL TABLET DUOPA J-TUBE INTESTINAL PUMP SUSPENSION ELDEPRYL ORAL CAPSULE entacapone oral tablet LODOSYN ORAL TABLET LD; SPRx

28 MIRAPEX ER ORAL TABLET EXTENDED RELEASE 24 HR MIRAPEX ORAL TABLET NEUPRO TRANSDERMAL PATCH 24 HOUR PARLODEL ORAL CAPSULE PARLODEL ORAL TABLET pramipexole oral tablet pramipexole oral tablet extended release 24 hr rasagiline oral tablet REQUIP ORAL TABLET REQUIP XL ORAL TABLET EXTENDED RELEASE 24 HR ropinirole oral tablet ropinirole oral tablet extended release 24 hr selegiline hcl oral capsule selegiline hcl oral tablet SINEMET CR ORAL TABLET EXTENDED RELEASE SINEMET ORAL TABLET STALEVO 100 ORAL TABLET STALEVO 125 ORAL TABLET STALEVO 150 ORAL TABLET STALEVO 200 ORAL TABLET STALEVO 50 ORAL TABLET STALEVO 75 ORAL TABLET TASMAR ORAL TABLET 100 MG tolcapone oral tablet trihexyphenidyl oral elixir trihexyphenidyl oral tablet ZELAPAR ORAL TABLET,DISINTEGRATING Migraine & Cluster Headache Therapy almotriptan malate oral tablet QL (18 EA per 30 days) ALSUMA SUBCUTANEOUS PEN INJECTOR QL (8 ML per 30 days) 26

29 AMERGE ORAL TABLET QL (18 EA per 30 days) CAFERGOT ORAL TABLET D.H.E.45 INJECTION SOLUTION dihydroergotamine injection solution dihydroergotamine nasal spray,non-aerosol QL (8 ML per 30 days) eletriptan hbr oral tablet QL (18 EA per 30 days) ERGOMAR SUBLINGUAL TABLET frovatriptan oral tablet QL (18 EA per 30 days) IMITREX NASAL SPRAY,NON-AEROSOL QL (12 EA per 30 days) IMITREX ORAL TABLET QL (18 EA per 30 days) IMITREX STATDOSE KIT REFILL SUBCUTANEOUS CARTRIDGE 4 MG/0.5 ML IMITREX STATDOSE KIT REFILL SUBCUTANEOUS CARTRIDGE 6 MG/0.5 ML IMITREX STATDOSE PEN SUBCUTANEOUS PEN INJECTOR 4 MG/0.5 ML IMITREX STATDOSE PEN SUBCUTANEOUS PEN INJECTOR 6 MG/0.5 ML 27 QL (12 ML per 30 days) QL (8 ML per 30 days) QL (12 ML per 30 days) QL (8 ML per 30 days) IMITREX SUBCUTANEOUS SOLUTION QL (8 ML per 30 days) isometh-dichloral-acetaminophn oral capsule isomethepten-caf-acetaminophen oral tablet mg migergot rectal suppository MIGRANAL NASAL SPRAY,NON AEROSOL QL (8 ML per 30 days) naratriptan oral tablet QL (18 EA per 30 days) nodolor oral capsule RELPAX ORAL TABLET QL (18 EA per 30 days) rizatriptan oral tablet QL (18 EA per 30 days) rizatriptan oral tablet,disintegrating QL (18 EA per 30 days) sumatriptan nasal spray,non-aerosol QL (12 EA per 30 days) sumatriptan succinate oral tablet QL (18 EA per 30 days)

30 sumatriptan succinate subcutaneous cartridge 4 mg/0.5 ml sumatriptan succinate subcutaneous cartridge 6 mg/0.5 ml sumatriptan succinate subcutaneous pen injector 4 mg/0.5 ml sumatriptan succinate subcutaneous pen injector 6 mg/0.5 ml QL (12 ML per 30 days) QL (8 ML per 30 days) QL (12 ML per 30 days) QL (8 ML per 30 days) sumatriptan succinate subcutaneous solution QL (8 ML per 30 days) sumatriptan succinate subcutaneous syringe 6 mg/0.5 ml SUMAVEL DOSEPRO SUBCUTANEOUS NEEDLE-FREE INJECTOR 4 MG/0.5 ML SUMAVEL DOSEPRO SUBCUTANEOUS NEEDLE-FREE INJECTOR 6 MG/0.5 ML QL (8 ML per 30 days) QL (12 ML per 30 days) QL (8 ML per 30 days) zolmitriptan oral tablet QL (18 EA per 30 days) zolmitriptan oral tablet,disintegrating QL (18 EA per 30 days) Miscellaneous Neurological Therapy AMPYRA ORAL TABLET EXTENDED RELEASE 12 HR ARICEPT ORAL TABLET PA; SPRx AUSTEDO ORAL TABLET PA; LD; SPRx donepezil oral tablet donepezil oral tablet,disintegrating galantamine oral capsule,ext rel. pellets 24 hr galantamine oral solution galantamine oral tablet HORIZANT ORAL TABLET EXTENDED RELEASE KEVEYIS ORAL TABLET PA; LD; SPRx memantine oral solution memantine oral tablet MEMANTINE ORAL TABLETS,DOSE PACK NAMENDA ORAL TABLET 28

31 NAMENDA TITRATION PAK ORAL TABLETS,DOSE PACK NAMENDA XR ORAL CAP,SPRINKLE,ER 24HR DOSE PACK NAMENDA XR ORAL CAPSULE,SPRINKLE,ER 24HR NAMZARIC ORAL CAPSULE,SPRINKLE,ER 24HR 29 NUEDEXTA ORAL CAPSULE RAZADYNE ER ORAL CAPSULE,EXT REL. PELLETS 24 HR RAZADYNE ORAL TABLET rivastigmine tartrate oral capsule rivastigmine transdermal patch 24 hour tetrabenazine oral tablet PA; SPRx XENAZINE ORAL TABLET PA; SPRx Muscle Relaxants & Antispasmodic Therapy baclofen oral tablet carisoprodol oral tablet carisoprodol-asa-codeine oral tablet carisoprodol-aspirin oral tablet chlorzoxazone oral tablet 500 mg cyclobenzaprine oral tablet DANTRIUM ORAL CAPSULE 25 MG, 50 MG dantrolene oral capsule FEXMID ORAL TABLET meprobamate oral tablet MESTINON ORAL SYRUP MESTINON ORAL TABLET MESTINON TIMESPAN ORAL TABLET EXTENDED RELEASE metaxalone oral tablet 800 mg methocarbamol oral tablet orphenadrine citrate oral tablet extended release PARAFON FORTE DSC ORAL TABLET

32 pyridostigmine bromide oral tablet pyridostigmine bromide oral tablet extended release ROBAXIN ORAL TABLET ROBAXIN-750 ORAL TABLET SKELAXIN ORAL TABLET SOMA ORAL TABLET tizanidine oral capsule tizanidine oral tablet ZANAFLEX ORAL CAPSULE ZANAFLEX ORAL TABLET Narcotic Analgesics ABSTRAL SUBLINGUAL TABLET QL (9 EA per 30 days) acetaminophen-caff-dihydrocod oral capsule QL (120 EA per 30 days) acetaminophen-codeine oral solution mg/5 ml QL (4500 ML per 30 days) acetaminophen-codeine oral tablet QL (180 EA per 30 days) ACTIQ BUCCAL LOZENGE ON A HANDLE 1,200 MCG ACTIQ BUCCAL LOZENGE ON A HANDLE 1,600 MCG ACTIQ BUCCAL LOZENGE ON A HANDLE 200 MCG ACTIQ BUCCAL LOZENGE ON A HANDLE 400 MCG ACTIQ BUCCAL LOZENGE ON A HANDLE 600 MCG ACTIQ BUCCAL LOZENGE ON A HANDLE 800 MCG QL (39 EA per 30 days) QL (29 EA per 30 days) QL (120 EA per 30 days) QL (116 EA per 30 days) QL (77 EA per 30 days) QL (58 EA per 30 days) ascomp with codeine oral capsule QL (120 EA per 30 days) aspirin-caffeine-dihydrocodein oral capsule QL (240 EA per 30 days) BUPAP ORAL TABLET MG QL (120 EA per 30 days) butalbital compound w/codeine oral capsule QL (120 EA per 30 days) butalbital-acetaminop-caf-cod oral capsule QL (120 EA per 30 days) butalbital-acetaminophen oral tablet QL (120 EA per 30 days) 30

33 butalbital-acetaminophen-caff oral capsule QL (120 EA per 30 days) butalbital-acetaminophen-caff oral tablet mg QL (120 EA per 30 days) butalbital-aspirin-caffeine oral capsule QL (120 EA per 30 days) butalbital-aspirin-caffeine oral tablet QL (120 EA per 30 days) butorphanol tartrate nasal spray,non-aerosol QL (5 ML per 28 days) BUTRANS TRANSDERMAL PATCH WEEKLY PA; QL (4 EA per 28 days) capacet oral capsule QL (120 EA per 30 days) CAPITAL WITH CODEINE ORAL SUSPENSION codeine sulfate oral tablet QL (180 EA per 30 days) codeine-butalbital-asa-caff oral capsule QL (120 EA per 30 days) DEMEROL ORAL TABLET 100 MG QL (120 EA per 30 days) DILAUDID ORAL LIQUID QL (30 ML per 30 days) DILAUDID ORAL TABLET QL (120 EA per 30 days) diskets oral tablet,soluble PA; QL (50 EA per 30 days) DOLOPHINE ORAL TABLET PA; QL (120 EA per 30 days) DURAGESIC TRANSDERMAL PATCH 72 HOUR endocet oral tablet mg, mg, mg, mg PA; QL (10 EA per 30 days) QL (120 EA per 30 days) ESGIC ORAL CAPSULE QL (120 EA per 30 days) ESGIC ORAL TABLET QL (120 EA per 30 days) fentanyl citrate buccal lozenge on a handle 1,200 mcg fentanyl citrate buccal lozenge on a handle 1,600 mcg fentanyl citrate buccal lozenge on a handle 200 mcg fentanyl citrate buccal lozenge on a handle 400 mcg fentanyl citrate buccal lozenge on a handle 600 mcg fentanyl citrate buccal lozenge on a handle 800 mcg QL (39 EA per 30 days) QL (29 EA per 30 days) QL (120 EA per 30 days) QL (116 EA per 30 days) QL (77 EA per 30 days) QL (58 EA per 30 days) 31

34 fentanyl transdermal patch 72 hour 100 mcg/hr, 12 mcg/hr, 25 mcg/hr, 50 mcg/hr, 75 mcg/hr FENTORA BUCCAL TABLET, EFFERVESCENT 32 PA; QL (10 EA per 30 days) QL (9 EA per 30 days) FIORICET ORAL CAPSULE QL (120 EA per 30 days) FIORINAL ORAL CAPSULE QL (120 EA per 30 days) FIORINAL-CODEINE #3 ORAL CAPSULE QL (120 EA per 30 days) HYCET ORAL SOLUTION QL (5550 ML per 30 days) hydrocodone-acetaminophen oral solution mg/15 ml hydrocodone-acetaminophen oral tablet mg, mg, mg, mg, mg, mg, mg hydrocodone-ibuprofen oral tablet mg, mg, mg QL (5550 ML per 30 days) QL (120 EA per 30 days) QL (120 EA per 30 days) hydromorphone oral liquid QL (30 ML per 30 days) hydromorphone oral tablet QL (120 EA per 30 days) hydromorphone rectal suppository QL (60 EA per 30 days) IBUDONE ORAL TABLET QL (120 EA per 30 days) ibuprofen-oxycodone oral tablet QL (28 EA per 30 days) KADIAN ORAL CAPSULE,EXTEND.RELEASE PELLETS 10 MG, 100 MG, 20 MG, 200 MG, 30 MG, 40 MG, 50 MG, 60 MG, 80 MG PA; QL (60 EA per 30 days) levorphanol tartrate oral tablet QL (120 EA per 30 days) lorcet (hydrocodone) oral tablet QL (120 EA per 30 days) lorcet hd oral tablet QL (120 EA per 30 days) lorcet plus oral tablet mg QL (120 EA per 30 days) LORTAB ELIXIR ORAL SOLUTION MG/15 ML QL (480 ML per 30 days) marten-tab oral tablet QL (120 EA per 30 days) meperidine oral solution QL (480 ML per 30 days) meperidine oral tablet QL (120 EA per 30 days) methadone oral concentrate PA; QL (120 ML per 30 days) methadone oral solution 10 mg/5 ml PA; QL (480 ML per 30 days) methadone oral solution 5 mg/5 ml PA; QL (960 ML per 30 days)

35 methadone oral tablet PA; QL (120 EA per 30 days) methadone oral tablet,soluble PA; QL (50 EA per 30 days) methadose oral concentrate PA; QL (120 ML per 30 days) methadose oral tablet,soluble PA; QL (50 EA per 30 days) morphine concentrate oral solution QL (300 ML per 30 days) morphine oral capsule, er multiphase 24 hr 120 mg morphine oral capsule, er multiphase 24 hr 30 mg, 45 mg, 60 mg, 75 mg, 90 mg 33 PA; QL (50 EA per 30 days) PA; QL (60 EA per 30 days) morphine oral capsule,extend.release pellets PA; QL (60 EA per 30 days) morphine oral solution QL (900 ML per 30 days) morphine oral tablet QL (120 EA per 30 days) morphine oral tablet extended release 100 mg, 15 mg, 30 mg, 60 mg PA; QL (60 EA per 30 days) morphine oral tablet extended release 200 mg PA; QL (30 EA per 30 days) morphine rectal suppository QL (120 EA per 30 days) MS CONTIN ORAL TABLET EXTENDED RELEASE PA; QL (60 EA per 30 days) NORCO ORAL TABLET QL (120 EA per 30 days) NUCYNTA ER ORAL TABLET EXTENDED RELEASE 12 HR PA; QL (60 EA per 30 days) NUCYNTA ORAL TABLET QL (120 EA per 30 days) OPANA ORAL TABLET QL (120 EA per 30 days) oxycodone oral capsule QL (120 EA per 30 days) oxycodone oral concentrate QL (120 ML per 30 days) oxycodone oral solution QL (480 ML per 30 days) oxycodone oral tablet QL (120 EA per 30 days) oxycodone-acetaminophen oral solution QL (480 ML per 30 days) oxycodone-acetaminophen oral tablet mg, mg, mg, mg QL (120 EA per 30 days) oxycodone-aspirin oral tablet QL (120 EA per 30 days) OXYCONTIN ORAL TABLET,ORAL ONLY,EXT.REL.12 HR 10 MG, 15 MG, 20 MG, 30 MG, 40 MG, 60 MG OXYCONTIN ORAL TABLET,ORAL ONLY,EXT.REL.12 HR 80 MG PA; QL (60 EA per 30 days) PA; QL (50 EA per 30 days)

36 oxymorphone oral tablet QL (120 EA per 30 days) oxymorphone oral tablet extended release 12 hr PA; QL (60 EA per 30 days) pentazocine-naloxone oral tablet QL (120 EA per 30 days) PERCOCET ORAL TABLET MG, MG, MG, MG QL (120 EA per 30 days) PRIMLEV ORAL TABLET QL (120 EA per 30 days) reprexain oral tablet mg QL (120 EA per 30 days) ROXICODONE ORAL TABLET QL (120 EA per 30 days) SYNALGOS-DC ORAL CAPSULE QL (240 EA per 30 days) tencon oral tablet mg QL (120 EA per 30 days) tramadol oral tablet QL (240 EA per 30 days) tramadol oral tablet extended release 24 hr PA; QL (30 EA per 30 days) tramadol oral tablet, er multiphase 24 hr PA; QL (30 EA per 30 days) tramadol-acetaminophen oral tablet QL (240 EA per 30 days) TREZIX ORAL CAPSULE MG QL (120 EA per 30 days) TYLENOL-CODEINE #3 ORAL TABLET QL (180 EA per 30 days) TYLENOL-CODEINE #4 ORAL TABLET QL (180 EA per 30 days) ULTRACET ORAL TABLET QL (240 EA per 30 days) ULTRAM ER ORAL TABLET EXTENDED RELEASE 24 HR 300 MG PA; QL (30 EA per 30 days) ULTRAM ORAL TABLET QL (240 EA per 30 days) verdrocet oral tablet QL (120 EA per 30 days) vicodin es oral tablet QL (120 EA per 30 days) vicodin hp oral tablet QL (120 EA per 30 days) vicodin oral tablet QL (120 EA per 30 days) XODOL 10/300 ORAL TABLET QL (120 EA per 30 days) XODOL 5/300 ORAL TABLET QL (120 EA per 30 days) XODOL 7.5/300 ORAL TABLET QL (120 EA per 30 days) xylon 10 oral tablet QL (150 EA per 30 days) zamicet oral solution QL (480 ML per 30 days) zebutal oral capsule mg QL (120 EA per 30 days) Non-Narcotic Analgesics ANAPROX DS ORAL TABLET 34

37 ARTHROTEC 50 ORAL TABLET,IR,DELAYED REL,BIPHASIC ARTHROTEC 75 ORAL TABLET,IR,DELAYED REL,BIPHASIC 35 CELEBREX ORAL CAPSULE celecoxib oral capsule choline,magnesium salicylate oral liquid DAYPRO ORAL TABLET diclofenac potassium oral tablet diclofenac sodium oral tablet extended release 24 hr diclofenac sodium oral tablet,delayed release (dr/ec) diclofenac sodium topical gel 1 % QL (500 GM per 30 days) diclofenac-misoprostol oral tablet,ir,delayed rel,biphasic diflunisal oral tablet DISALCID ORAL TABLET EC-NAPROSYN ORAL TABLET,DELAYED RELEASE (DR/EC) etodolac oral capsule etodolac oral tablet etodolac oral tablet extended release 24 hr FELDENE ORAL CAPSULE fenoprofen oral tablet flurbiprofen oral tablet ibuprofen oral suspension ibuprofen oral tablet 400 mg, 600 mg, 800 mg INDOCIN ORAL SUSPENSION INDOCIN RECTAL SUPPOSITORY indomethacin oral capsule indomethacin oral capsule, extended release ketoprofen oral capsule ketoprofen oral capsule,ext rel. pellets 24 hr 200 mg

38 ketorolac oral tablet LODINE ORAL TABLET meclofenamate oral capsule mefenamic acid oral capsule meloxicam oral suspension meloxicam oral tablet MOBIC ORAL TABLET nabumetone oral tablet NALFON ORAL CAPSULE 400 MG NAPRELAN CR ORAL TABLET, ER MULTIPHASE 24 HR 36 NAPROSYN ORAL SUSPENSION NAPROSYN ORAL TABLET 500 MG naproxen oral suspension naproxen oral tablet naproxen oral tablet,delayed release (dr/ec) naproxen sodium oral tablet 275 mg, 550 mg oxaprozin oral tablet piroxicam oral capsule PONSTEL ORAL CAPSULE REVIA ORAL TABLET salsalate oral tablet SPRIX NASAL SPRAY,NON-AEROSOL LD; SPRx sulindac oral tablet tolmetin oral capsule tolmetin oral tablet VOLTAREN-XR ORAL TABLET EXTENDED RELEASE 24 HR ZUBSOLV SUBLINGUAL TABLET MG, MG, MG, MG Opiate/Narcotic Reversal Agents - Opiate Antagonists QL (90 EA per 30 days) naloxone injection solution QL (2 units per 1 claim) naloxone injection syringe QL (2 units per 1 claim) naltrexone oral tablet

39 NARCAN NASAL SPRAY,NON-AEROSOL 4 MG/ACTUATION Psychotherapeutic Drugs ABILIFY MAINTENA INTRAMUSCULAR SUSPENSION,EXTENDED REL RECON ABILIFY MAINTENA INTRAMUSCULAR SUSPENSION,EXTENDED REL SYRING 37 QL (2 EA per 30 days) SPRx; AGE-A SPRx; AGE-A ABILIFY ORAL TABLET AGE-A ADDERALL ORAL TABLET alprazolam intensol oral concentrate alprazolam oral tablet alprazolam oral tablet extended release 24 hr alprazolam oral tablet,disintegrating AMBIEN CR ORAL TABLET,EXT RELEASE MULTIPHASE AMBIEN ORAL TABLET amitriptyline oral tablet amitriptyline-chlordiazepoxide oral tablet amoxapine oral tablet ANAFRANIL ORAL CAPSULE aripiprazole oral solution AGE-A aripiprazole oral tablet AGE-A aripiprazole oral tablet,disintegrating AGE-A ARISTADA INTRAMUSCULAR SUSPENSION,EXTENDED REL SYRING armodafinil oral tablet PA ATIVAN ORAL TABLET atomoxetine oral capsule bupropion hcl oral tablet bupropion hcl oral tablet extended release 12 hr bupropion hcl oral tablet extended release 24 hr buspirone oral tablet BUTISOL ORAL TABLET 30 MG CELEXA ORAL TABLET chlordiazepoxide hcl oral capsule SPRx; AGE-A

40 chlorpromazine oral tablet citalopram oral solution citalopram oral tablet clomipramine oral capsule clonidine hcl oral tablet extended release 12 hr clorazepate dipotassium oral tablet clozapine oral tablet AGE-A clozapine oral tablet,disintegrating 100 mg, 12.5 mg, 25 mg CLOZAPINE ORAL TABLET,DISINTEGRATING 150 MG, 200 MG 38 AGE-A AGE-A CLOZARIL ORAL TABLET AGE-A CYMBALTA ORAL CAPSULE,DELAYED RELEASE(DR/EC) DAYTRANA TRANSDERMAL PATCH 24 HOUR desipramine oral tablet desvenlafaxine succinate oral tablet extended release 24 hr DEXEDRINE SPANSULE ORAL CAPSULE, EXTENDED RELEASE 15 MG dexmethylphenidate oral capsule,er biphasic dexmethylphenidate oral tablet dextroamphetamine oral capsule, extended release dextroamphetamine oral solution dextroamphetamine oral tablet dextroamphetamine-amphetamine oral capsule,extended release 24hr dextroamphetamine-amphetamine oral tablet diazepam intensol oral concentrate diazepam oral solution 5 mg/5 ml (1 mg/ml) diazepam oral tablet DORAL ORAL TABLET doxepin oral capsule

41 doxepin oral concentrate duloxetine oral capsule,delayed release(dr/ec) EFFEXOR XR ORAL CAPSULE,EXTENDED RELEASE 24HR EMSAM TRANSDERMAL PATCH 24 HOUR ergoloid oral tablet escitalopram oxalate oral solution escitalopram oxalate oral tablet estazolam oral tablet eszopiclone oral tablet FANAPT ORAL TABLET AGE-A FANAPT ORAL TABLETS,DOSE PACK AGE-A FAZACLO ORAL TABLET,DISINTEGRATING fluoxetine oral capsule fluoxetine oral capsule,delayed release(dr/ec) fluoxetine oral solution fluoxetine oral tablet 10 mg, 20 mg FLUOXETINE ORAL TABLET 60 MG fluphenazine hcl oral concentrate fluphenazine hcl oral elixir fluphenazine hcl oral tablet flurazepam oral capsule fluvoxamine oral capsule,extended release 24hr fluvoxamine oral tablet AGE-A GEODON ORAL CAPSULE AGE-A guanfacine oral tablet extended release 24 hr guanidine oral tablet HALCION ORAL TABLET 0.25 MG haloperidol lactate oral concentrate haloperidol oral tablet imipramine hcl oral tablet imipramine pamoate oral capsule 39

42 INTUNIV ER ORAL TABLET EXTENDED RELEASE 24 HR INVEGA ORAL TABLET EXTENDED RELEASE 24HR INVEGA SUSTENNA INTRAMUSCULAR SYRINGE INVEGA TRINZA INTRAMUSCULAR SYRINGE KAPVAY ORAL TABLET EXTENDED RELEASE 12 HR AGE-A SPRx; AGE-A SPRx; AGE-A LATUDA ORAL TABLET AGE-A LEXAPRO ORAL TABLET lithium carbonate oral capsule lithium carbonate oral tablet lithium carbonate oral tablet extended release lithium citrate oral solution 8 meq/5 ml LITHOBID ORAL TABLET EXTENDED RELEASE lorazepam intensol oral concentrate lorazepam oral concentrate lorazepam oral tablet loxapine succinate oral capsule LUNESTA ORAL TABLET maprotiline oral tablet MARPLAN ORAL TABLET metadate er oral tablet extended release methamphetamine oral tablet METHYLIN ORAL SOLUTION methylphenidate hcl oral capsule, er biphasic methylphenidate hcl oral capsule,er biphasic methylphenidate hcl oral solution methylphenidate hcl oral tablet methylphenidate hcl oral tablet extended release 40

43 methylphenidate hcl oral tablet extended release 24hr methylphenidate hcl oral tablet,chewable midazolam oral syrup 2 mg/ml mirtazapine oral tablet mirtazapine oral tablet,disintegrating modafinil oral tablet PA NARDIL ORAL TABLET nefazodone oral tablet NORPRAMIN ORAL TABLET 10 MG, 25 MG nortriptyline oral capsule nortriptyline oral solution NUPLAZID ORAL TABLET PA; SPRx NUVIGIL ORAL TABLET PA olanzapine oral tablet AGE-A olanzapine oral tablet,disintegrating AGE-A olanzapine-fluoxetine oral capsule AGE-A ORAP ORAL TABLET oxazepam oral capsule paliperidone oral tablet extended release 24hr AGE-A PAMELOR ORAL CAPSULE PARNATE ORAL TABLET paroxetine hcl oral tablet paroxetine hcl oral tablet extended release 24 hr PAXIL CR ORAL TABLET EXTENDED RELEASE 24 HR PAXIL ORAL SUSPENSION PAXIL ORAL TABLET perphenazine oral tablet perphenazine-amitriptyline oral tablet PEXEVA ORAL TABLET phenelzine oral tablet pimozide oral tablet 41

44 PRISTIQ ORAL TABLET EXTENDED RELEASE 24 HR 42 procentra oral solution protriptyline oral tablet PROZAC ORAL CAPSULE quazepam oral tablet quetiapine oral tablet AGE-A quetiapine oral tablet extended release 24 hr AGE-A QUILLIVANT XR ORAL SUSPENSION,EXT REL 24HR,RECON REMERON ORAL TABLET REMERON SOLTAB ORAL TABLET,DISINTEGRATING RESTORIL ORAL CAPSULE RISPERDAL CONSTA INTRAMUSCULAR SYRINGE RISPERDAL M-TAB ORAL TABLET,DISINTEGRATING SPRx; AGE-A AGE-A RISPERDAL ORAL SOLUTION AGE-A RISPERDAL ORAL TABLET AGE-A risperidone oral solution AGE-A risperidone oral tablet AGE-A risperidone oral tablet,disintegrating AGE-A RITALIN ORAL TABLET ROZEREM ORAL TABLET SAPHRIS (BLACK CHERRY) SUBLINGUAL TABLET SARAFEM ORAL TABLET 10 MG, 20 MG seconal sodium oral capsule AGE-A SEROQUEL ORAL TABLET AGE-A SEROQUEL XR ORAL TABLET EXTENDED RELEASE 24 HR sertraline oral concentrate sertraline oral tablet SONATA ORAL CAPSULE AGE-A

45 STRATTERA ORAL CAPSULE SURMONTIL ORAL CAPSULE SYMBYAX ORAL CAPSULE AGE-A temazepam oral capsule thioridazine oral tablet thiothixene oral capsule TOFRANIL ORAL TABLET TRANXENE T-TAB ORAL TABLET 7.5 MG tranylcypromine oral tablet trazodone oral tablet triazolam oral tablet trifluoperazine oral tablet trimipramine oral capsule TRINTELLIX ORAL TABLET VALIUM ORAL TABLET venlafaxine oral capsule,extended release 24hr venlafaxine oral tablet venlafaxine oral tablet extended release 24hr VIIBRYD ORAL TABLET VIIBRYD ORAL TABLETS,DOSE PACK 10 MG (7)- 20 MG (23) 43 VRAYLAR ORAL CAPSULE AGE-A VRAYLAR ORAL CAPSULE,DOSE PACK AGE-A VYVANSE ORAL CAPSULE VYVANSE ORAL TABLET,CHEWABLE WELLBUTRIN SR ORAL TABLET EXTENDED RELEASE 12 HR WELLBUTRIN XL ORAL TABLET EXTENDED RELEASE 24 HR XANAX ORAL TABLET XANAX XR ORAL TABLET EXTENDED RELEASE 24 HR XYREM ORAL SOLUTION PA; SPRx zaleplon oral capsule

46 zenzedi oral tablet 10 mg, 5 mg ZENZEDI ORAL TABLET 15 MG, 2.5 MG, 20 MG, 30 MG, 7.5 MG ziprasidone hcl oral capsule AGE-A ZOLOFT ORAL CONCENTRATE ZOLOFT ORAL TABLET zolpidem oral tablet zolpidem oral tablet,ext release multiphase ZYPREXA ORAL TABLET AGE-A ZYPREXA RELPREVV INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION ZYPREXA ZYDIS ORAL TABLET,DISINTEGRATING Cardiovascular, Hypertension & Lipids Antiarrhythmic Agents amiodarone oral tablet BETAPACE AF ORAL TABLET BETAPACE ORAL TABLET disopyramide phosphate oral capsule dofetilide oral capsule flecainide oral tablet mexiletine oral capsule MULTAQ ORAL TABLET NORPACE CR ORAL CAPSULE, EXTENDED RELEASE NORPACE ORAL CAPSULE pacerone oral tablet 100 mg, 200 mg, 400 mg propafenone oral capsule,extended release 12 hr propafenone oral tablet quinidine gluconate oral tablet extended release quinidine sulfate oral tablet RYTHMOL SR ORAL CAPSULE,EXTENDED RELEASE 12 HR sorine oral tablet SPRx; AGE-A AGE-A 44

47 sotalol af oral tablet sotalol oral tablet SOTYLIZE ORAL SOLUTION TIKOSYN ORAL CAPSULE Antihypertensive Therapy ACCUPRIL ORAL TABLET ACCURETIC ORAL TABLET acebutolol oral capsule ADALAT CC ORAL TABLET EXTENDED RELEASE 45 afeditab cr oral tablet extended release ALDACTAZIDE ORAL TABLET ALDACTONE ORAL TABLET ALTACE ORAL CAPSULE amiloride oral tablet amiloride-hydrochlorothiazide oral tablet amlodipine oral tablet amlodipine-benazepril oral capsule amlodipine-olmesartan oral tablet amlodipine-valsartan oral tablet amlodipine-valsartan-hcthiazid oral tablet ATND HCT ORAL TABLET ATND ORAL TABLET atenolol oral tablet atenolol-chlorthalidone oral tablet AVALIDE ORAL TABLET AVAPRO ORAL TABLET AZOR ORAL TABLET benazepril oral tablet benazepril-hydrochlorothiazide oral tablet BENICAR HCT ORAL TABLET BENICAR ORAL TABLET betaxolol oral tablet

48 BIDIL ORAL TABLET bisoprolol fumarate oral tablet bisoprolol-hydrochlorothiazide oral tablet bumetanide oral tablet BYSTOLIC ORAL TABLET CALAN ORAL TABLET CALAN SR ORAL TABLET EXTENDED RELEASE candesartan oral tablet candesartan-hydrochlorothiazid oral tablet captopril oral tablet captopril-hydrochlorothiazide oral tablet CARDIZEM CD ORAL CAPSULE,EXTENDED RELEASE 24HR CARDIZEM LA ORAL TABLET EXTENDED RELEASE 24 HR CARDIZEM ORAL TABLET 120 MG, 30 MG, 60 MG CARDURA ORAL TABLET CARDURA XL ORAL TABLET EXTENDED RELEASE 24HR carvedilol oral tablet CATAPRES ORAL TABLET CATAPRES-TTS-1 TRANSDERMAL PATCH WEEKLY CATAPRES-TTS-2 TRANSDERMAL PATCH WEEKLY CATAPRES-TTS-3 TRANSDERMAL PATCH WEEKLY chlorothiazide oral tablet chlorthalidone oral tablet 25 mg, 50 mg clonidine hcl oral tablet clonidine transdermal patch weekly clorpres oral tablet mg, mg CLORPRES ORAL TABLET MG 46

49 COREG CR ORAL CAPSULE, ER MULTIPHASE 24 HR 47 COREG ORAL TABLET CORGARD ORAL TABLET CORZIDE ORAL TABLET COZAAR ORAL TABLET DEMADEX ORAL TABLET 10 MG, 20 MG DIBENZYLINE ORAL CAPSULE diltiazem hcl oral capsule,extended release 24 hr 240 mg diltiazem hcl oral capsule,extended release 24hr 120 mg DIOVAN HCT ORAL TABLET DIOVAN ORAL TABLET DIURIL ORAL SUSPENSION doxazosin oral tablet DUTOPROL ORAL TABLET EXTENDED RELEASE 24 HR DYAZIDE ORAL CAPSULE DYRENIUM ORAL CAPSULE EDARBI ORAL TABLET ST EDARBYCLOR ORAL TABLET ST EDECRIN ORAL TABLET enalapril maleate oral tablet enalapril-hydrochlorothiazide oral tablet EPANED ORAL SOLUTION eplerenone oral tablet epoprostenol (glycine) intravenous recon soln PA; SPRx eprosartan oral tablet ethacrynic acid oral tablet EXFORGE HCT ORAL TABLET EXFORGE ORAL TABLET felodipine oral tablet extended release 24 hr FLOLAN INTRAVENOUS RECON SOLN PA; LD; SPRx

50 fosinopril oral tablet fosinopril-hydrochlorothiazide oral tablet furosemide oral solution 10 mg/ml, 40 mg/5 ml (8 mg/ml) 48 furosemide oral tablet guanfacine oral tablet hydralazine oral tablet hydrochlorothiazide oral capsule hydrochlorothiazide oral tablet HYZAAR ORAL TABLET indapamide oral tablet INDERAL LA ORAL CAPSULE,EXTENDED RELEASE 24 HR INDERAL XL ORAL CAPSULE,EXTENDED RELEASE 24HR INNOPRAN XL ORAL CAPSULE,EXTENDED RELEASE 24HR INSPRA ORAL TABLET irbesartan oral tablet irbesartan-hydrochlorothiazide oral tablet isradipine oral capsule labetalol oral tablet LASIX ORAL TABLET LEVATOL ORAL TABLET lisinopril oral tablet lisinopril-hydrochlorothiazide oral tablet LOPRESSOR HCT ORAL TABLET LOPRESSOR ORAL TABLET losartan oral tablet losartan-hydrochlorothiazide oral tablet LOTENSIN HCT ORAL TABLET LOTENSIN ORAL TABLET 20 MG, 40 MG LOTREL ORAL CAPSULE MG, MG, 5-10 MG, 5-20 MG matzim la oral tablet extended release 24 hr