AETNA BETTER HEALTH Formulary Guide Aetna Better Health of Kentucky Formulary Guide March 2019

Transcription

1 AETNA BETTER HEALTH Formulary Guide Aetna Better Health of Kentucky Formulary Guide March

2 AETNA BETTER HEALTH Formulary Guide What is the Aetna Better Health of Kentucky Formulary? This is a drug list created by Aetna Better Health ( plan ). The plan will cover drugs on this list. Some drugs may have coverage rules. If the rules for that drug are met, the plan will cover the drug. Drugs must also be filled at a plan network pharmacy. Can the Plan s Drug List change? The plan may add or remove drugs on the list. All drug removals from the formulary will be sent to the state for review before the change is made. Utilizing members and their providers will be notified at least 30 days before a drug is removed from the formulary. All changes to the formulary will be posted on the plan s website. How do I use the Plan s Formulary? Column #1: lists the covered drug. Brand drugs are in upper case letters (e.g., DRUG). Generics are in lower case letters (e.g., drug). Column #2: shows brand drug for the generic; brand drugs are not covered if generic equivalent is available. Column #3: tells you if drug has a need for prior authorization or other restrictions Drugs are also grouped by drug class. If you know what class your drug is in, please look for that class name in the table of contents. Then look under that page for your drug. What are generic drugs? The plan covers both brand and generic drugs. Generic drugs cost less and are approved by the Food and Drug Administration (FDA). Are Over-The-Counter (OTC) drugs covered? The plan will cover OTC drugs on the formulary. Some OTC drugs may have coverage rules. If the rules for that OTC drug are met, the plan will cover the OTC drug. Like other drugs, OTC drugs need a prescription from a doctor if they are to be covered by the plan. Are there Medication Copays? Refer to member handbook for copay information. Updated: 03/01/2019 Page 2

3 AETNA BETTER HEALTH Formulary Guide What are some types of coverage rules? Prior Approval (): This means your doctor will need to get approval from the plan first before the drug can be filled at the pharmacy. If it is not approved, the plan will not cover the drug. Quantity Level Limits (QLL): This means there is a limit on the amount of drug the plan will cover. For example, the plan provides 60 pills in 30 days for some drugs. Step Therapy (ST): This means you may need to try certain drugs first to treat your condition. After the first drug is tried, the plan will then cover the other drug for that same condition. For example, Drug A and Drug B may treat your condition. The plan may not cover Drug B unless you try Drug A first. If Drug A does not work for you, then Drug B will be covered. What if my drug is not on the plan s Formulary? First, please call your doctor and ask if your drug is covered. If the plan does not cover the drug, then: Ask your doctor for a similar drug that is covered. Your doctor can ask the plan to cover your drug through the prior approval process. Updated: 03/01/2019 Page 3

4 Aetna Better Health Kentucky Table of Contents *ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS*...3 *AMINOGLYCOSIDES*... 5 *ANALGESICS - ANTI-INFLAMMATORY*... 5 *ANALGESICS - NONNARCOTIC*...7 *ANALGESICS - OPIOID*... 8 *ANDROGENS-ANABOLIC* *ANORECTAL AGENTS*...11 *ANTHELMINTICS* *ANTIANGINAL AGENTS* *ANTIANXIETY AGENTS*...12 *ANTIARRHYTHMICS* *ANTIASTHMATIC AND BRONCHODILATOR AGENTS* *ANTICOAGULANTS* *ANTICONVULSANTS*...16 *ANTIDEPRESSANTS*...18 *ANTIDIABETICS* *ANTIDIARRHEALS*...22 *ANTIDOTES* *ANTIEMETICS* *ANTIFUNGALS*...23 *ANTIHISTAMINES* *ANTIHYPERLIPIDEMICS*...24 *ANTIHYPERTENSIVES* *ANTI-INFECTIVE AGENTS - MISC.* *ANTIMALARIALS*...28 *ANTIMYASTHENIC AGENTS* *ANTIMYASTHENIC/CHOLINERGIC AGENTS* *ANTIMYCOBACTERIAL AGENTS* *ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES*...29 *ANTIRKINSON AGENTS*...31 *ANTIPSYCHOTICS/ANTIMANIC AGENTS* *ANTIRETROVIRALS ADJUVANTS*** *ANTISEPTICS & DISINFECTANTS*...36 *ANTIVIRALS*...36 *ASSORTED CLASSES* *BETA BLOCKERS* *CALCIUM CHANNEL BLOCKERS* *CARDIOTONICS* *CARDIOVASCULAR AGENTS - MISC.* *CEPHALOSPORINS*...44 *CHEMICALS*...45 *CONTRACEPTIVES*...45 *CORTICOSTEROIDS* *COUGH/COLD/ALLERGY*...51 *CYCLIN-DEPENDENT KINASES (CDK) INHIBITORS*** *DERMATOLOGICALS* *DIAGNOSTIC PRODUCTS*

5 *DIGESTIVE AIDS*...58 *DIURETICS*...58 *ENDOCRINE AND METABOLIC AGENTS - MISC.*...59 *ESTROGENS*...61 *FLUOROQUINOLONES* *GASTROINTESTINAL AGENTS - MISC.*...61 *GENITOURINARY AGENTS - MISCELLANEOUS* *GLYCOPEPTIDES***...63 *GOUT AGENTS*...64 *HEMATOLOGICAL AGENTS - MISC.* *HEMATOPOIETIC AGENTS*...64 *HETITIS C AGENT - COMBINATIONS*** *HYPNOTICS* *LAXATIVES* *MACROLIDES*...67 *MEDICAL DEVICES*...68 *MIGRAINE PRODUCTS*...72 *MINERALS & ELECTROLYTES*...72 *MOUTH/THROAT/DENTAL AGENTS*...74 *MULTIVITAMINS*...74 *MUSCULOSKELETAL THERAPY AGENTS*...79 *NASAL AGENTS - SYSTEMIC AND TOPICAL* *NEPRILYSIN INHIB (ARNI)-ANGIOTENSIN II RECEPT ANTAG COMB*** *NEUROMUSCULAR AGENTS* *OPHTHALMIC AGENTS*...80 *OTIC AGENTS*...83 *SSIVE IMMUNIZING AGENTS*...83 *PENICILLINS*...84 *PHARMACEUTICAL ADJUVANTS* *POTASSIUM REMOVING AGENTS***...91 *PROGESTINS*...91 *PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.*...91 *RESPIRATORY AGENTS - MISC.*...97 *SEROTONIN MODULATORS*** *SINUS NODE INHIBITORS**...97 *SODIUM-GLUCOSE CO-TRANSPORTER 2 INHIBITOR-BIGUANIDE COMB*** *SULFONAMIDES*...97 *TETRACYCLINES* *THYROID AGENTS* *ULCER DRUGS* *URINARY ANTI-INFECTIVES* *URINARY ANTISSMODICS* *VACCINES* *VAGINAL PRODUCTS* *VASOPRESSORS* *VITAMINS*

6 Aetna Better Health Kentucky CURRENT AS OF 3/1/2019 *ADHD/ANTI- NARCOLEPSY/ANTI- OBESITY/ANOREXIANTS* *Adhd Agent - Selective Alpha Adrenergic Agonists*** guanfacine hcl er oral tablet extended release 24 hour 1, 2, 3, 4 *Amphetamine Mixtures*** amphetamine-dextroamphet er oral capsule extended release 24 hour 10, 20, 25, 5 amphetamine-dextroamphet er oral capsule extended release 24 hour 15 amphetamine-dextroamphet er oral capsule extended release 24 hour 30 amphetamine-dextroamphetamine oral tablet 10, 12.5, 15, 20, 5, 7.5 amphetamine-dextroamphetamine oral tablet 30 *Amphetamines*** dextroamphetamine sulfate er oral capsule extended release 24 hour 10, 15 dextroamphetamine sulfate er oral capsule extended release 24 hour 5 dextroamphetamine sulfate oral tablet 10, 5 zenzedi oral tablet 10, 5 Intuniv Adderall XR Adderall XR Adderall XR Adderall Adderall Dexedrine Dexedrine Zenzedi Zenzedi QLL (30 EA per 30 days); AL (Min 6 Years) QLL (30 EA per 30 days); AL (Min 6 Years and Max 17 Years) QLL (30 EA per 30 days); AL (Min 6 Years and Max 18 Years) QLL: 1 capsule per day for under age 12 and 2 capsules per day for age 12 and older; AL (Min 6 Years and Max 17 Years) QLL (90 EA per 30 days); AL (Min 6 Years and Max 17 Years) QLL (60 EA per 30 days); AL (Min 6 Years and Max 17 Years) QLL (120 EA per 30 days); AL (Min 6 Years and Max 17 Years) QLL (90 EA per 30 days); AL (Min 6 Years and Max 17 Years) QLL (180 EA per 30 days); AL (Min 6 Years and Max 17 Years) QLL (180 EA per 30 days); AL (Min 6 Years and Max 17 Years) 3

7 *Analeptics*** caffeine citrate oral solution 20 /ml, 60 /3ml *Stimulants - Misc.*** armodafinil oral tablet 150, 200, 250 Nuvigil ; QLL (30 EA per 30 days) armodafinil oral tablet 50 Nuvigil ; QLL (60 EA per 30 days) dexmethylphenidate hcl er oral capsule extended release 24 hour 10, 15, 20, 25, 30, 35, 40, 5 dexmethylphenidate hcl oral tablet 10, 2.5, 5 metadate er oral tablet extended release 20 methylphenidate hcl er (cd) oral capsule extended release 10, 20, 30, 40, 50, 60 methylphenidate hcl er (la) oral capsule extended release 24 hour 20, 40 methylphenidate hcl er (la) oral capsule extended release 24 hour 30 methylphenidate hcl er (la) oral capsule extended release 24 hour 60 methylphenidate hcl er oral tablet extended release 10 methylphenidate hcl er oral tablet extended release 18, 27, 54 methylphenidate hcl er oral tablet extended release 20 methylphenidate hcl er oral tablet extended release 24 hour 18, 27, 54 methylphenidate hcl er oral tablet extended release 24 hour 36 Focalin XR Focalin Metadate ER Ritalin LA Ritalin LA Concerta Metadate ER QLL (30 EA per 30 days); AL (Min 6 Years and Max 18 Years) QLL (60 EA per 30 days); AL (Min 6 Years and Max 17 Years) QLL (90 EA per 30 days); AL (Min 6 Years and Max 17 Years) QLL (30 EA per 30 days); AL (Min 6 Years and Max 17 Years) QLL (30 EA per 30 days); AL (Min 6 Years and Max 17 Years) QLL (60 EA per 30 days); AL (Min 6 Years and Max 17 Years) QLL (30 EA per 30 days); AL (Min 6 Years and Max 18 Years) QLL (90 EA per 30 days); AL (Min 6 Years and Max 17 Years) QLL (30 EA per 30 days); AL (Min 6 Years and Max 17 Years) QLL (90 EA per 30 days); AL (Min 6 Years and Max 17 Years) QLL (30 EA per 30 days); AL (Min 6 Years and Max 17 Years) QLL (60 EA per 30 days); AL (Min 6 Years and Max 17 Years) 4

8 methylphenidate hcl er oral tablet extended release 36 methylphenidate hcl oral solution 10 /5ml, 5 /5ml methylphenidate hcl oral tablet 10, 20, 5 methylphenidate hcl oral tablet chewable 10, 2.5, 5 *AMINOGLYCOSIDES* *Aminoglycosides*** neomycin sulfate oral tablet 500 paromomycin sulfate oral capsule 250 tobramycin inhalation nebulization solution 300 /5ml KITABIS K INHALATION NEBULIZATION SOLUTION 300 MG/5ML *ANALGESICS - ANTI- INFLAMMATORY* *Anti-Tnf-Alpha - Monoclonal Antibodies*** HUMIRA PEDIATRIC CROHNS START SUBCUTANEOUS PREFILLED SYRINGE KIT 40 MG/0.8ML HUMIRA PEDIATRIC CROHNS START SUBCUTANEOUS PREFILLED SYRINGE KIT 80 MG/0.8ML HUMIRA PEDIATRIC CROHNS START SUBCUTANEOUS PREFILLED SYRINGE KIT 80 MG/0.8ML & 40MG/0.4ML HUMIRA PEN SUBCUTANEOUS PEN- INJECTOR KIT 40 MG/0.4ML HUMIRA PEN SUBCUTANEOUS PEN- INJECTOR KIT 40 MG/0.8ML HUMIRA PEN-CD/UC/HS STARTER SUBCUTANEOUS PEN-INJECTOR KIT 40 MG/0.8ML HUMIRA PEN-CD/UC/HS STARTER SUBCUTANEOUS PEN-INJECTOR KIT 80 MG/0.8ML Concerta Methylin Ritalin Kitabis Pak Kitabis Pak QLL (60 EA per 30 days); AL (Min 6 Years and Max 17 Years) QLL (900 ML per 30 days); AL (Min 6 Years and Max 17 Years) QLL (90 EA per 30 days); AL (Min 6 Years and Max 17 Years) QLL (4 EA per 1 day); AL (Min 6 Years and Max 17 Years) ; QLL (3 EA per 180 days) ; QLL (2 EA per 180 days) ; QLL (2 EA per 28 days) ; QLL (3 EA per 180 days) 5

9 HUMIRA PEN-PS/UV/ADOL HS START SUBCUTANEOUS PEN-INJECTOR KIT 40 MG/0.8ML HUMIRA PEN-PS/UV/ADOL HS START SUBCUTANEOUS PEN-INJECTOR KIT ; QLL (3 EA per 180 days) 80 MG/0.8ML & 40MG/0.4ML HUMIRA SUBCUTANEOUS PREFILLED SYRINGE KIT 10 MG/0.1ML, 20 ; QLL (2 EA per 28 days) MG/0.2ML, 40 MG/0.4ML HUMIRA SUBCUTANEOUS PREFILLED SYRINGE KIT 20 MG/0.4ML, 40 MG/0.8ML *Cyclooxygenase 2 (Cox-2) Inhibitors*** celecoxib oral capsule 100, 200, 400, 50 CeleBREX ST; AL (Min 65 Years) *Gold Compounds*** RIDAURA ORAL 3 MG *Nonsteroidal Anti-Inflammatory Agents (Nsaids)*** diclofenac potassium oral tablet 50 diclofenac sodium er oral tablet extended release 24 hour 100 diclofenac sodium oral tablet delayed release 25, 50, 75 etodolac er oral tablet extended release 24 hour 400, 500, 600 etodolac oral capsule 200, 300 etodolac oral tablet 400 Lodine etodolac oral tablet 500 flurbiprofen oral tablet 100, 50 ibuprofen oral suspension 100 /5ml Childrens Advil ibuprofen oral tablet 400, 600, 800 IBU indomethacin er oral capsule extended release 75 indomethacin oral capsule 25, 50 ketorolac tromethamine oral tablet 10 QLL (2 Claims per 180 days) meloxicam oral tablet 15, 7.5 Mobic nabumetone oral tablet 500, 750 naproxen dr oral tablet delayed release 375 EC-Naprosyn 6

10 naproxen dr oral tablet delayed release 500 naproxen oral suspension 125 /5ml Naprosyn ST naproxen oral tablet 250, 500 Naprosyn naproxen oral tablet 375 naproxen sodium oral tablet 275 piroxicam oral capsule 10, 20 Feldene sulindac oral tablet 150, 200 tolmetin sodium oral capsule 400 tolmetin sodium oral tablet 200, 600 *Pyrimidine Synthesis Inhibitors*** leflunomide oral tablet 10, 20 Arava *Soluble Tumor Necrosis Factor Receptor Agents*** ENBREL MINI SUBCUTANEOUS SOLUTION CARTRIDGE 50 MG/ML ENBREL SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 25 MG/0.5ML, 50 MG/ML ENBREL SURECLICK SUBCUTANEOUS SOLUTION AUTO-INJECTOR 50 MG/ML *ANALGESICS - NONNARCOTIC* *Analgesics-Sedatives*** butalbital-acetaminophen oral tablet Tencon QLL (6 EA per 1 day) butalbital-apap-caffeine oral capsule Fioricet QLL (6 EA per 1 day) butalbital-apap-caffeine oral capsule Esgic QLL (6 EA per 1 day) butalbital-apap-caffeine oral tablet Esgic QLL (6 EA per 1 day) butalbital-aspirin-caffeine oral capsule Fiorinal QLL (6 EA per 1 day) butalbital-aspirin-caffeine oral tablet QLL (6 EA per 1 day) *Salicylate Combinations*** choline-mag trisalicylate oral liquid 500 /5ml *Salicylates*** diflunisal oral tablet 500 7

11 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 acetaminophen-codeine oral tablet Tylenol with Codeine #3 Tylenol with Codeine #4 acetaminophen-codeine oral tablet Tylenol with Codeine #4 butalbital-apap-caff-cod oral capsule butalbital-apap-caff-cod oral capsule butalbital-asa-caff-codeine oral capsule *Hydrocodone Combinations*** hydrocodone-acetaminophen oral solution /5ml, /10ml, /15ml hydrocodone-acetaminophen oral tablet hydrocodone-acetaminophen oral tablet hydrocodone-acetaminophen oral tablet hydrocodone-acetaminophen oral tablet hydrocodone-ibuprofen oral tablet Fioricet/Codeine Ascomp-Codeine Lorcet HD Verdrocet Lorcet Lorcet Plus LORCET HD ORAL TABLET MG Lorcet HD LORCET ORAL TABLET MG LORCET PLUS ORAL TABLET MG Lorcet Lorcet Plus QLL (120 EA per 30 days); AL (Min 18 Years) QLL (120 EA per 30 days); AL (Min 18 Years) QLL (120 EA per 30 days); AL (Min 18 Years) QLL (2700 ML per 30 days); QLL (120 EA per 30 days); AL (Min 18 Years) QLL (120 EA per 30 days); AL (Min 18 Years) QLL (4 EA per 1 day); AL (Min 18 Years) QLL (4 EA per 1 day); AL (Min 18 Years) QLL (4 EA per 1 day); AL (Min 18 Years) QLL (1800 ML per 30 days); QLL (120 EA per 30 days); AL (Min 18 Years) QLL (120 EA per 30 days); AL (Min 18 Years) QLL (120 EA per 30 days); AL (Min 18 Years) QLL (120 EA per 30 days); AL (Min 18 Years) QLL (120 EA per 30 days); AL (Min 18 Years) QLL (120 EA per 30 days); AL (Min 18 Years) QLL (120 EA per 30 days); AL (Min 18 Years) QLL (120 EA per 30 days); AL (Min 18 Years) 8

12 *Opioid Agonists*** codeine sulfate oral tablet 15, 30, 60 fentanyl citrate buccal lozenge on a handle 1200 mcg, 1600 mcg, 200 mcg, 400 mcg, 600 mcg, 800 mcg fentanyl transdermal patch 72 hour 100 mcg/hr Actiq Duragesic-100 fentanyl transdermal patch 72 hour 12 mcg/hr Duragesic-12 fentanyl transdermal patch 72 hour 25 mcg/hr Duragesic-25 fentanyl transdermal patch 72 hour 50 mcg/hr Duragesic-50 fentanyl transdermal patch 72 hour 75 mcg/hr Duragesic-75 QLL (120 EA per 30 days); AL (Min 18 Years) ST; QLL (120 EA per 30 days) ; QLL (10 Patches per 30 days) ; QLL (10 Patches per 30 days) ; QLL (10 Patches per 30 days) ; QLL (10 Patches per 30 days) ; QLL (10 Patches per 30 days) hydromorphone hcl oral tablet 2, 4 Dilaudid QLL (120 EA per 30 days) hydromorphone hcl oral tablet 8 Dilaudid QLL (3 EA per 1 day) methadone hcl intensol oral concentrate 10 /ml Methadone HCl Intensol ; QLL (2 ML per 1 day) methadone hcl oral concentrate 10 /ml Methadone HCl Intensol ; QLL (2 ML per 1 day) methadone hcl oral solution 10 /5ml ; QLL (11 ML per 1 day) methadone hcl oral solution 5 /5ml ; QLL (22 ML per 1 day) methadone hcl oral tablet 10 Dolophine ; QLL (2 EA per 1 day) methadone hcl oral tablet 5 Dolophine ; QLL (4 EA per 1 day) methadone hcl oral tablet soluble 40 Methadose ; QLL (22 EA per 30 days) methadose oral tablet soluble 40 Methadose ; QLL (22 EA per 30 days) morphine sulfate (concentrate) oral solution 100 /5ml QLL (4 ML per 1 day) morphine sulfate er oral tablet extended release 100, 200, 60 MS Contin ; QLL (1 EA per 1 day) morphine sulfate er oral tablet extended release 15 MS Contin ; QLL (6 EA per 1 day) morphine sulfate er oral tablet extended release 30 MS Contin ; QLL (3 EA per 1 day) morphine sulfate oral solution 10 /5ml, 20 /5ml QLL (600 ML per 30 days) morphine sulfate oral tablet 15 QLL (120 EA per 30 days) morphine sulfate oral tablet 30 QLL (3 EA per 1 day) morphine sulfate rectal suppository 10, 20, 5 QLL (120 EA per 30 days) oxycodone hcl oral solution 5 /5ml QLL (1800 ML per 30 days) 9

13 oxycodone hcl oral tablet 10 QLL (120 EA per 30 days) oxycodone hcl oral tablet 15 Roxicodone QLL (4 EA per 1 day) oxycodone hcl oral tablet 20 QLL (3 EA per 1 day) oxycodone hcl oral tablet 30 Roxicodone QLL (2 EA per 1 day) oxycodone hcl oral tablet 5 Roxicodone QLL (120 EA per 30 days) tramadol hcl oral tablet 50 Ultram QLL (120 EA per 30 days); AL (Min 18 Years) HYDROMORPHONE HCL RECTAL SUPPOSITORY 3 MG QLL (120 EA per 30 days) MORPHINE SULFATE RECTAL SUPPOSITORY 30 MG QLL (3 EA per 1 day) *Opioid Combinations*** oxycodone-acetaminophen oral tablet , , 5-325, Endocet QLL (120 EA per 30 days) oxycodone-aspirin oral tablet QLL (120 EA per 30 days) *Opioid Partial Agonists*** buprenorphine hcl sublingual tablet sublingual 2, 8 buprenorphine hcl-naloxone hcl sublingual tablet sublingual 2-0.5, 8-2 butorphanol tartrate nasal solution 10 /ml QLL (0.08 ML per 1 day) pentazocine-naloxone hcl oral tablet QLL (120 EA per 30 days) *Tramadol Combinations*** tramadol-acetaminophen oral tablet *ANDROGENS-ANABOLIC* *Androgens*** danazol oral capsule 100, 200, 50 testosterone cypionate intramuscular solution 100 /ml testosterone cypionate intramuscular solution 200 /ml testosterone transdermal gel 10 /act (2%) Ultracet Depo-Testosterone Depo-Testosterone Fortesta testosterone transdermal gel 12.5 /act (1%) Vogelxo Pump testosterone transdermal gel 25 /2.5gm AndroGel (1%) testosterone transdermal gel 50 /5gm (1%) AndroGel QLL (120 EA per 30 days); AL (Min 18 Years) ; QLL (10 ML per 90 days) ; QLL (2 canisters per 30 days) ; QLL (4 canisters per 30 days) ; QLL (2.5 GM per 1 day) ; QLL (10 GM per 1 day) 10

14 ANDROGEL PUMP TRANSDERMAL GEL MG/ACT (1.62%) Testosterone *ANORECTAL AGENTS* *Intrarectal Steroids*** colocort rectal enema 100 /60ml Colocort hydrocortisone rectal enema 100 /60ml Colocort *Rectal Anesthetic/Steroids*** lidocaine-hydrocortisone ace rectal cream % PROCTOFOAM HC RECTAL FOAM 1-1 % *Rectal Steroids*** procto-pak rectal cream 1 % Hydrocortisone proctosol hc rectal cream 2.5 % Hydrocortisone proctozone-hc rectal cream 2.5 % Hydrocortisone *ANTHELMINTICS* *Anthelmintics*** albendazole oral tablet 200 Albenza ST ivermectin oral tablet 3 Stromectol praziquantel oral tablet 600 Biltricide reeses pinworm medicine oral suspension 144 (50 base) /ml OTC REESES PINWORM MEDICINE ORAL TABLET 180 MG OTC *ANTIANGINAL AGENTS* *Nitrates*** isosorbide dinitrate er oral tablet extended release 40 isosorbide dinitrate oral tablet 10, 20, 30 isosorbide dinitrate oral tablet 5 Isordil Titradose isosorbide mononitrate er oral tablet extended release 24 hour 120, 30, 60 isosorbide mononitrate oral tablet 10, 20 minitran transdermal patch 24 hour 0.1 /hr, 0.2 /hr, 0.4 /hr, 0.6 /hr Minitran nitroglycerin er oral capsule extended release Nitro-Time 2.5, 6.5, 9 11

15 nitroglycerin sublingual tablet sublingual 0.3, 0.4, 0.6 Nitrostat nitroglycerin transdermal patch 24 hour 0.1 /hr, 0.2 /hr, 0.4 /hr, 0.6 /hr Minitran nitro-time oral capsule extended release 2.5, 6.5, 9 Nitro-Time NITRO-BID TRANSDERMAL OINTMENT 2 % *ANTIANXIETY AGENTS* *Antianxiety Agents - Misc.*** buspirone hcl oral tablet 10, 5, 7.5 QLL (90 EA per 30 days) buspirone hcl oral tablet 15 QLL (120 EA per 30 days) hydroxyzine hcl oral syrup 10 /5ml hydroxyzine hcl oral tablet 10, 25, 50 QLL (4 EA per 1 day) hydroxyzine pamoate oral capsule 100 hydroxyzine pamoate oral capsule 25, 50 Vistaril *Benzodiazepines*** alprazolam er oral tablet extended release 24 hour 0.5, 1, 2, 3 Xanax XR alprazolam oral tablet 0.25, 0.5 Xanax QLL (4 EA per 1 day) alprazolam oral tablet 1 Xanax QLL (6 EA per 1 day) alprazolam oral tablet 2 Xanax QLL (5 EA per 1 day) alprazolam xr oral tablet extended release 24 hour 0.5, 1, 2, 3 Xanax XR chlordiazepoxide hcl oral capsule 10, 5 QLL (4 EA per 1 day) chlordiazepoxide hcl oral capsule 25 QLL (12 EA per 1 day) diazepam intensol oral concentrate 5 /ml Diazepam Intensol diazepam oral concentrate 5 /ml Diazepam Intensol diazepam oral tablet 10, 2, 5 Valium lorazepam intensol oral concentrate 2 /ml LORazepam Intensol lorazepam oral concentrate 2 /ml LORazepam Intensol lorazepam oral tablet 0.5 Ativan QLL (4 EA per 1 day) lorazepam oral tablet 1 Ativan QLL (6 EA per 1 day) lorazepam oral tablet 2 Ativan QLL (5 EA per 1 day) oxazepam oral capsule 10, 15, 30 QLL (4 EA per 1 day) ALPRAZOLAM INTENSOL ORAL CONCENTRATE 1 MG/ML 12

16 *ANTIARRHYTHMICS* *Antiarrhythmics Type I-A*** disopyramide phosphate oral capsule 100, Norpace 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 I-C*** flecainide acetate oral tablet 100, 150, 50 propafenone hcl oral tablet 150, 225, 300 *Antiarrhythmics Type Iii*** amiodarone hcl oral tablet 100, 200, 400 Pacerone pacerone oral tablet 100, 200, 400 Pacerone MULTAQ ORAL TABLET 400 MG ; QLL (60 EA per 30 days) *ANTIASTHMATIC AND BRONCHODILATOR AGENTS* *Adrenergic Combinations*** fluticasone-salmeterol inhalation aerosol powder breath activated mcg/act AirDuo RespiClick 113/14 QLL (1 EA per 30 days) fluticasone-salmeterol inhalation aerosol powder breath activated mcg/act AirDuo RespiClick 232/14 QLL (1 EA per 30 days) fluticasone-salmeterol inhalation aerosol powder breath activated mcg/act AirDuo RespiClick 55/14 QLL (1 EA per 30 days) ipratropium-albuterol inhalation solution (3) /3ml ANORO ELLIPTA INHALATION AEROSOL POWDER BREATH ACTIVATED MCG/INH QLL (1 EA per 30 Days) BREO ELLIPTA INHALATION AEROSOL POWDER BREATH ACTIVATED MCG/INH, MCG/INH COMBIVENT RESPIMAT INHALATION AEROSOL SOLUTION MCG/ACT STIOLTO RESPIMAT INHALATION AEROSOL SOLUTION MCG/ACT QLL (1 EA per 30 days); AL (Min 18 Years) ST; QLL (1 canister per 30 days) 13

17 *Anti-Inflammatory Agents*** cromolyn sodium inhalation nebulization solution 20 /2ml *Beta Adrenergics*** albuterol sulfate hfa inhalation aerosol solution 108 (90 base) mcg/act ProAir HFA QLL (36 GM per 30 days) albuterol sulfate inhalation nebulization solution (2.5 /3ml) 0.083%, (5 /ml) 0.5% QLL (130 vials per 30 days) albuterol sulfate inhalation nebulization solution 0.63 /3ml, 1.25 /3ml albuterol sulfate oral syrup 2 /5ml levalbuterol tartrate inhalation aerosol 45 mcg/act metaproterenol sulfate oral syrup 10 /5ml metaproterenol sulfate oral tablet 10, 20 VENTOLIN HFA INHALATION AEROSOL SOLUTION 108 (90 BASE) MCG/ACT *Bronchodilators - Anticholinergics*** ipratropium bromide inhalation solution 0.02 % ATROVENT HFA INHALATION AEROSOL SOLUTION 17 MCG/ACT INCRUSE ELLIPTA INHALATION AEROSOL POWDER BREATH ACTIVATED 62.5 MCG/INH *Leukotriene Receptor Antagonists*** Xopenex HFA ProAir HFA ST; QLL (130 ML per 1 day); AL (Max 18 Years) ST; QLL (2 INH per 30 days) QLL (2 Inhalers per 30 days) QLL (1 Kit per 30 days) montelukast sodium oral packet 4 Singulair ; QLL (30 packet per 30 days); AL (Max 1 Years) montelukast sodium oral tablet 10 Singulair QLL (30 EA per 30 days) montelukast sodium oral tablet chewable 4, 5 Singulair QLL (30 EA per 30 days) zafirlukast oral tablet 10, 20 Accolate ST; QLL (60 EA per 30 days) *Steroid Inhalants*** budesonide inhalation suspension 0.25 /2ml, 0.5 /2ml, 1 /2ml Pulmicort QLL (527 ML per 30 days); AL (Max 5 Years) 14

18 ARNUITY ELLIPTA INHALATION AEROSOL POWDER BREATH ACTIVATED 100 MCG/ACT, 200 MCG/ACT, 50 MCG/ACT FLOVENT HFA INHALATION AEROSOL 110 MCG/ACT, 220 MCG/ACT FLOVENT HFA INHALATION AEROSOL 44 MCG/ACT QVAR REDIHALER INHALATION AEROSOL BREATH ACTIVATED 40 MCG/ACT QVAR REDIHALER INHALATION AEROSOL BREATH ACTIVATED 80 MCG/ACT *Xanthines*** theochron oral tablet extended release 12 hour 100, 200, 300 theophylline er oral tablet extended release 12 hour 100, 200, 300 theophylline er oral tablet extended release 12 hour 450 theophylline er oral tablet extended release 24 hour 400, 600 theophylline oral solution 80 /15ml *ANTICOAGULANTS* *Coumarin Anticoagulants*** jantoven oral tablet 1, 10, 2, 2.5, 3, 4, 5, 6, 7.5 warfarin sodium oral tablet 1, 10, 2, 2.5, 3, 4, 5, 6, 7.5 *Direct Factor Xa Inhibitors*** ELIQUIS ORAL TABLET 2.5 MG, 5 MG XARELTO ORAL TABLET 10 MG, 15 MG, 20 MG XARELTO STARTER CK ORAL TABLET THERAPY CK 15 & 20 MG *Heparins And Heparinoid-Like Agents*** heparin sodium (porcine) injection solution 1000 unit/ml, unit/ml, unit/ml, 5000 unit/ml heparin sodium (porcine) pf injection solution 5000 unit/0.5ml Theochron Theochron Coumadin Coumadin QLL (0.4 GM per 1 day); AL (Max 12 Years) QLL (0.35 GM per 1 day); AL (Max 12 Years) QLL (10.6 GM per 30 days) QLL (21.2 GM per 30 days) ; QLL (60 EA per 30 days) ; QLL (30 EA per 30 days) ; QLL (1 EA per 90 days) 15

19 *Low Molecular Weight Heparins*** enoxaparin sodium injection solution 300 /3ml Lovenox QLL (126 ML per 180 days) enoxaparin sodium subcutaneous solution 100 Lovenox /ml, 150 /ml QLL (42 ML per 180 days) enoxaparin sodium subcutaneous solution 120 Lovenox /0.8ml, 80 /0.8ml QLL (33.6 ML per 180 days) enoxaparin sodium subcutaneous solution 30 /0.3ml Lovenox QLL (12.6 ML per 180 days) enoxaparin sodium subcutaneous solution 40 /0.4ml Lovenox QLL (16.8 ML per 180 days) enoxaparin sodium subcutaneous solution 60 /0.6ml Lovenox QLL (25.2 ML per 180 days) *ANTICONVULSANTS* *Anticonvulsants - Benzodiazepines*** clonazepam oral tablet 0.5, 1, 2 KlonoPIN clonazepam oral tablet dispersible 0.125, 0.25, 0.5, 1, 2 diazepam rectal gel 10, 20 Diastat AcuDial QLL (2 EA per 1 Fill) diazepam rectal gel 2.5 Diastat Pediatric QLL (2 EA per 1 Fill) *Anticonvulsants - Misc.*** carbamazepine er oral capsule extended release 12 hour 100, 200, 300 carbamazepine er oral tablet extended release 12 hour 100 carbamazepine er oral tablet extended release 12 hour 200, 400 carbamazepine oral suspension 100 /5ml carbamazepine oral tablet 200 carbamazepine oral tablet chewable 100 epitol oral tablet 200 gabapentin oral capsule 100, 300, 400 gabapentin oral solution 250 /5ml gabapentin oral tablet 600, 800 Carbatrol TEGretol-XR TEGretol-XR TEGretol Epitol Epitol Neurontin Neurontin Neurontin lamotrigine oral tablet 100, 150, 200 LaMICtal, 25 lamotrigine oral tablet chewable 25, 5 LaMICtal QLL (400 EA per 100 days); AL (Min 6 Years) QLL (12 EA per 1 Day) QLL (400 EA per 100 days); AL (Min 6 Years) Gabapentin has a maximum cumulative dose of 3600/day Gabapentin has a maximum cumulative dose of 3600/day Gabapentin has a maximum cumulative dose of 3600/day 16

20 levetiracetam er oral tablet extended release 24 hour 500, 750 Keppra XR levetiracetam oral solution 100 /ml Keppra levetiracetam oral tablet 1000, 250, 500, 750 Keppra oxcarbazepine oral suspension 300 /5ml Trileptal oxcarbazepine oral tablet 150, 300, 600 Trileptal primidone oral tablet 250, 50 Mysoline topiramate oral capsule sprinkle 15, 25 Topamax Sprinkle QLL (120 EA per 30 days) topiramate oral tablet 100, 200, 25, Topamax 50 QLL (120 EA per 30 days) zonisamide oral capsule 100, 25 Zonegran QLL (180 EA per 30 days) zonisamide oral capsule 50 QLL (180 EA per 30 days) TEGRETOL-XR ORAL TABLET EXTENDED RELEASE 12 HOUR 100 MG TEGretol-XR *Carbamates*** felbamate oral suspension 600 /5ml Felbatol felbamate oral tablet 400, 600 Felbatol *Gaba Modulators*** tiagabine hcl oral tablet 2, 4 Gabitril QLL (60 EA per 30 days) GABITRIL ORAL TABLET 12 MG, 16 MG TiaGABine HCl QLL (60 EA per 30 days) *Hydantoins*** phenytoin infatabs oral tablet chewable 50 Dilantin Infatabs phenytoin oral suspension 125 /5ml Dilantin phenytoin oral tablet chewable 50 Dilantin Infatabs phenytoin sodium extended oral capsule 100 Dilantin phenytoin sodium extended oral capsule 200, 300 Phenytek DILANTIN ORAL 30 MG PHENYTEK ORAL 200 MG, 300 MG Phenytek *Succinimides*** ethosuximide oral capsule 250 Zarontin ethosuximide oral solution 250 /5ml Zarontin CELONTIN ORAL 300 MG 17

21 *Valproic Acid*** divalproex sodium er oral tablet extended release 24 hour 250, 500 Depakote ER divalproex sodium oral tablet delayed release 125, 250, 500 Depakote valproic acid oral capsule 250 Depakene valproic acid oral solution 250 /5ml Depakene *ANTIDEPRESSANTS* *Alpha-2 Receptor Antagonists (Tetracyclics)*** mirtazapine oral tablet 15, 30 Remeron QLL (30 EA per 30 days) mirtazapine oral tablet 45, 7.5 QLL (30 EA per 30 days) mirtazapine oral tablet dispersible 15, 30, 45 Remeron SolTab QLL (30 EA per 30 days) *Antidepressants - Misc.*** bupropion hcl er (sr) oral tablet extended release 12 hour 100, 150, 200 Wellbutrin SR QLL (60 EA per 30 days) bupropion hcl er (xl) oral tablet extended release 24 hour 150, 300 Wellbutrin XL QLL (30 EA per 30 days) bupropion hcl oral tablet 100, 75 QLL (90 EA per 30 days) maprotiline hcl oral tablet 25, 50, 75 *Modified Cyclics*** trazodone hcl oral tablet 100, 150, 50 *Monoamine Oxidase Inhibitors (Maois)*** phenelzine sulfate oral tablet 15 Nardil *Selective Serotonin Reuptake Inhibitors (Ssris)*** citalopram hydrobromide oral solution 10 /5ml citalopram hydrobromide oral tablet 10, 20, 40 CeleXA QLL (300 ML per 30 days); AL (Max 12 Years) QLL (30 EA per 30 days) escitalopram oxalate oral solution 5 /5ml QLL (300 ML per 30 days); AL (Max 12 Years) escitalopram oxalate oral tablet 10, 20, Lexapro 5 QLL (30 EA per 30 days) fluoxetine hcl oral capsule 10 PROzac QLL (30 EA per 30 days) fluoxetine hcl oral capsule 20, 40 PROzac QLL (60 EA per 30 days) 18

22 fluoxetine hcl oral solution 20 /5ml QLL (150 ML per 30 days) fluvoxamine maleate oral tablet 100 QLL (90 EA per 30 days) fluvoxamine maleate oral tablet 25 QLL (30 EA per 30 days) fluvoxamine maleate oral tablet 50 QLL (60 EA per 30 days) paroxetine hcl oral tablet 10, 20, 40 Paxil QLL (30 EA per 30 days) paroxetine hcl oral tablet 30 Paxil QLL (60 EA per 30 days) sertraline hcl oral concentrate 20 /ml QLL (75 ML per 30 days) sertraline hcl oral tablet 100, 50 Zoloft QLL (60 EA per 30 days) sertraline hcl oral tablet 25 Zoloft QLL (30 EA per 30 days) *Serotonin-Norepinephrine Reuptake Inhibitors (Snris)*** duloxetine hcl oral capsule delayed release particles 20, 30, 60 Cymbalta QLL (30 EA per 30 days) duloxetine hcl oral capsule delayed release particles 40 QLL (30 EA per 30 days) venlafaxine hcl er oral capsule extended release 24 hour 150, 37.5, 75 Effexor XR QLL (30 EA per 30 days) 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 doxepin hcl oral capsule 10, 100, 150, 25, 50, 75 doxepin hcl oral concentrate 10 /ml imipramine hcl oral tablet 10, 25, 50 Tofranil nortriptyline hcl oral capsule 10, 25, 50, 75 Pamelor nortriptyline hcl oral solution 10 /5ml AL (Max 12 Years) *ANTIDIABETICS* *Alpha-Glucosidase Inhibitors*** acarbose oral tablet 100, 25, 50 Precose *Biguanides*** metformin hcl er oral tablet extended release 24 hour 500, 750 Glucophage XR metformin hcl oral tablet 1000, 500, 850 Glucophage 19

23 *Diabetic Other*** GLUCAGEN HYPOKIT INJECTION SOLUTION RECONSTITUTED 1 MG GLUCAGON EMERGENCY INJECTION KIT 1 MG *Dipeptidyl Peptidase-4 (Dpp-4) Inhibitors*** alogliptin benzoate oral tablet 12.5, 25, 6.25 JANUVIA ORAL TABLET 100 MG, 25 MG, 50 MG *Dipeptidyl Peptidase-4 Inhibitor- Biguanide Combinations*** alogliptin-metformin hcl oral tablet , JANUMET ORAL TABLET MG, MG JANUMET XR ORAL TABLET EXTENDED RELEASE 24 HOUR MG, MG, MG *Dpp-4 Inhibitor-Thiazolidinedione Combinations*** alogliptin-pioglitazone oral tablet , , , 25-15, 25-30, *Human Insulin*** ADMELOG SOLOSTAR SUBCUTANEOUS SOLUTION PEN- INJECTOR 100 UNIT/ML ADMELOG SUBCUTANEOUS SOLUTION 100 UNIT/ML BASAGLAR KWIKPEN SUBCUTANEOUS SOLUTION PEN- INJECTOR 100 UNIT/ML HUMALOG MIX 50/50 KWIKPEN SUBCUTANEOUS SUSPENSION PEN- INJECTOR (50-50) 100 UNIT/ML HUMALOG MIX 50/50 SUBCUTANEOUS SUSPENSION (50-50) 100 UNIT/ML HUMALOG MIX 75/25 KWIKPEN SUBCUTANEOUS SUSPENSION PEN- INJECTOR (75-25) 100 UNIT/ML Nesina Kazano Oseni QLL (30 EA per 30 Days) ST; QLL (30 EA per 30 days) QLL (60 EA per 30 Days) ST; QLL (60 EA per 30 days) ST; QLL (30 EA per 30 days) QLL (30 EA per 30 Days) AL (Max 18 Years) AL (Max 18 Years) AL (Max 18 Years) 20

24 HUMALOG MIX 75/25 SUBCUTANEOUS SUSPENSION (75-25) 100 UNIT/ML HUMULIN R U-500 (CONCENTRATED) SUBCUTANEOUS SOLUTION 500 UNIT/ML NOVOLOG MIX 70/30 SUBCUTANEOUS SUSPENSION (70-30) 100 UNIT/ML *Incretin Mimetic Agents (Glp-1 Receptor Agonists)*** OZEMPIC SUBCUTANEOUS SOLUTION PEN-INJECTOR 0.25 OR 0.5 MG/DOSE ST; QLL (0.05 ML per 1 day) OZEMPIC SUBCUTANEOUS SOLUTION PEN-INJECTOR 1 MG/DOSE ST; QLL (0.11 ML per 1 day) VICTOZA SUBCUTANEOUS SOLUTION PEN-INJECTOR 18 MG/3ML ST; QLL (0.6 ML per 1 day) *Meglitinide Analogues*** nateglinide oral tablet 120, 60 Starlix repaglinide oral tablet 0.5 repaglinide oral tablet 1, 2 Prandin *Meglitinide-Biguanide Combinations*** repaglinide-metformin hcl oral tablet 1-500, *Sodium-Glucose Co-Transporter 2 (Sglt2) Inhibitors*** JARDIANCE ORAL TABLET 10 MG, 25 MG ; QLL (1 EA per 1 day) STEGLATRO ORAL TABLET 15 MG, 5 MG ST; QLL (1 EA per 1 day) *Sulfonylurea-Biguanide Combinations*** glipizide-metformin hcl oral tablet , , glyburide-metformin oral tablet , , *Sulfonylureas*** glimepiride oral tablet 1, 2, 4 Amaryl glipizide er oral tablet extended release 24 hour 10, 2.5, 5 Glucotrol XL glipizide oral tablet 10, 5 Glucotrol 21

25 glipizide xl oral tablet extended release 24 hour 10, 2.5, 5 Glucotrol XL glyburide micronized oral tablet 1.5, 3, Glynase 6 glyburide oral tablet 1.25, 2.5, 5 *Thiazolidinediones*** pioglitazone hcl oral tablet 15, 30, 45 Actos QLL (30 EA per 30 days) AVANDIA ORAL TABLET 2 MG, 4 MG ST; QLL (30 EA per 30 days) *ANTIDIARRHEALS* *Antiperistaltic Agents*** diphenoxylate-atropine oral liquid /5ml diphenoxylate-atropine oral tablet Lomotil loperamide hcl oral capsule 2 Imodium A-D *ANTIDOTES* *Antidotes - Chelating Agents*** CHEMET ORAL 100 MG *Opioid Antagonists*** naloxone hcl injection solution 0.4 /ml naloxone hcl injection solution prefilled syringe 2 /2ml naltrexone hcl oral tablet 50 NARCAN NASAL LIQUID 4 MG/0.1ML QLL (2 EA per 30 days) *ANTIEMETICS* *5-Ht3 Receptor Antagonists*** granisetron hcl oral tablet 1 ondansetron hcl oral tablet 24 ondansetron hcl oral tablet 4, 8 Zofran QLL (3 EA per 1 day) ondansetron oral tablet dispersible 4, 8 *Antiemetics - Anticholinergic*** meclizine hcl oral tablet 12.5 meclizine hcl oral tablet 25 Dramamine Less Drowsy *Substance P/Neurokinin 1 (Nk1) Receptor Antagonists*** EMEND ORAL 125 MG, 40 MG, 80 MG Aprepitant 22

26 *ANTIFUNGALS* *Antifungals*** bio-statin oral powder griseofulvin microsize oral suspension 125 /5ml ST griseofulvin microsize oral tablet 500 ST griseofulvin ultramicrosize oral tablet 125, 250 ST nystatin oral tablet unit terbinafine hcl oral tablet 250 LamISIL QLL (84 EA per 365 days) *Imidazoles*** ketoconazole oral tablet 200 *Triazoles*** fluconazole oral suspension reconstituted 10 /ml, 40 /ml Diflucan fluconazole oral tablet 100, 150, 200, 50 Diflucan itraconazole oral capsule 100 Sporanox itraconazole oral solution 10 /ml Sporanox *ANTIHISTAMINES* *Antihistamines - Alkylamines*** brompheniramine tannate oral tablet chewable 12 *Antihistamines - Ethanolamines*** carbinoxamine maleate oral tablet 4 clemastine fumarate oral tablet 2.68 diphenhydramine hcl oral liquid 6.25 /ml Vanamine PD OTC *Antihistamines - Non-Sedating*** cetirizine hcl oral solution 1 /ml KLS Aller-Tec Childrens QLL (150 ML per 30 days) loratadine childrens oral tablet chewable 5 Claritin OTC; QLL (2 EA per 1 day) *Antihistamines - Phenothiazines*** phenadoz rectal suppository 12.5, 25 Phenadoz promethazine hcl oral solution 6.25 /5ml promethazine hcl oral syrup 6.25 /5ml promethazine hcl oral tablet 12.5, 25, 50 promethazine hcl rectal suppository 12.5, 25 Phenadoz promethazine hcl rectal suppository 50 Promethegan 23

27 promethegan rectal suppository 12.5, 25 Phenadoz promethegan rectal suppository 50 Promethegan *Antihistamines - Piperidines*** cyproheptadine hcl oral syrup 2 /5ml cyproheptadine hcl oral tablet 4 *ANTIHYPERLIPIDEMICS* *Antihyperlipidemics - Misc.*** omega-3-acid ethyl esters oral capsule 1 gm Lovaza ST; QLL (4 EA per 1 day) *Bile Acid Sequestrants*** cholestyramine light oral packet 4 gm Prevalite cholestyramine light oral powder 4 gm/dose Prevalite cholestyramine oral packet 4 gm Questran cholestyramine oral powder 4 gm/dose Questran colestipol hcl oral granules 5 gm Colestid colestipol hcl oral packet 5 gm Colestid colestipol hcl oral tablet 1 gm Colestid prevalite oral packet 4 gm Prevalite prevalite oral powder 4 gm/dose Prevalite *Fibric Acid Derivatives*** fenofibrate micronized oral capsule 134, 200, 67 fenofibrate oral tablet 160 Triglide fenofibrate oral tablet 54 gemfibrozil oral tablet 600 Lopid QLL (60 EA per 30 days) *H Coa Reductase Inhibitors*** atorvastatin calcium oral tablet 10, 20, Lipitor 40, 80 QLL (30 EA per 30 days) fluvastatin sodium er oral tablet extended release 24 hour 80 Lescol XL QLL (30 EA per 30 days) fluvastatin sodium oral capsule 20 Lescol QLL (30 EA per 30 days) fluvastatin sodium oral capsule 40 QLL (30 EA per 30 days) lovastatin oral tablet 10, 20 QLL (30 EA per 30 days) lovastatin oral tablet 40 QLL (60 EA per 30 days) pravastatin sodium oral tablet 10 QLL (30 EA per 30 days) pravastatin sodium oral tablet 20, 40, 80 Pravachol QLL (30 EA per 30 days) rosuvastatin calcium oral tablet 10, 20, Crestor 40, 5 ST; QLL (1 EA per 1 day) 24

28 simvastatin oral tablet 10, 20, 40, 5 Zocor, 80 QLL (30 EA per 30 days) *Intestinal Cholesterol Absorption Inhibitors*** ezetimibe oral tablet 10 Zetia ST *ANTIHYPERTENSIVES* *Ace Inhibitor & Calcium Channel Blocker Combinations*** amlodipine besy-benazepril hcl oral capsule 10-20, 10-40, 5-10, 5-20 Lotrel amlodipine besy-benazepril hcl oral capsule , 5-40 *Ace Inhibitors & Thiazide/Thiazide- Like*** benazepril-hydrochlorothiazide oral tablet 10- Lotensin HCT 12.5, , benazepril-hydrochlorothiazide oral tablet enalapril-hydrochlorothiazide oral tablet Vaseretic enalapril-hydrochlorothiazide oral tablet fosinopril sodium-hctz oral tablet , lisinopril-hydrochlorothiazide oral tablet , , Zestoretic moexipril-hydrochlorothiazide oral tablet , 15-25, quinapril-hydrochlorothiazide oral tablet , , Accuretic *Ace Inhibitors*** benazepril hcl oral tablet 10, 20 Lotensin QLL (2 EA per 1 day) benazepril hcl oral tablet 40 Lotensin benazepril hcl oral tablet 5 QLL (2 EA per 1 day) enalapril maleate oral tablet 10, 2.5, 5 Vasotec QLL (2 EA per 1 day) enalapril maleate oral tablet 20 Vasotec fosinopril sodium oral tablet 10, 20 QLL (2 EA per 1 day) fosinopril sodium oral tablet 40 lisinopril oral tablet 10, 20, 5 Prinivil QLL (2 EA per 1 day) lisinopril oral tablet 2.5, 30, 40 Zestril QLL (2 EA per 1 day) 25

29 moexipril hcl oral tablet 15, 7.5 perindopril erbumine oral tablet 2, 4, 8 quinapril hcl oral tablet 10, 20, 5 Accupril QLL (2 EA per 1 day) quinapril hcl oral tablet 40 Accupril ramipril oral capsule 1.25, 2.5, 5 Altace QLL (2 EA per 1 day) ramipril oral capsule 10 Altace trandolapril oral tablet 1, 2 trandolapril oral tablet 4 Mavik *Adrenolytics-Central & Thiazide/Thiazide-Like Comb*** methyldopa-hydrochlorothiazide oral tablet , *Angiotensin Ii Receptor Antag & Thiazide/Thiazide-Like*** candesartan cilexetil-hctz oral tablet , , Atacand HCT irbesartan-hydrochlorothiazide oral tablet , Avalide losartan potassium-hctz oral tablet , , Hyzaar valsartan-hydrochlorothiazide oral tablet , , , , Diovan HCT QLL (30 EA per 30 days) *Angiotensin Ii Receptor Antagonists*** candesartan cilexetil oral tablet 16, 32, Atacand 4, 8 irbesartan oral tablet 150, 300, 75 Avapro losartan potassium oral tablet 100 Cozaar losartan potassium oral tablet 25, 50 Cozaar QLL (2 EA per 1 day) telmisartan oral tablet 20, 40, 80 Micardis QLL (1 EA per 1 day) valsartan oral tablet 160, 320, 40, 80 Diovan QLL (60 EA per 30 days) *Antiadrenergics - Centrally Acting*** clonidine hcl oral tablet 0.1, 0.2, 0.3 Catapres clonidine transdermal patch weekly 0.1 /24hr Catapres-TTS-1 ST 26

30 clonidine transdermal patch weekly 0.2 /24hr Catapres-TTS-2 ST clonidine transdermal patch weekly 0.3 /24hr Catapres-TTS-3 ST guanfacine hcl oral tablet 1 QLL (240 EA per 30 days) guanfacine hcl oral tablet 2 QLL (120 EA per 30 days) methyldopa oral tablet 250, 500 *Antiadrenergics - Peripherally Acting*** doxazosin mesylate oral tablet 1, 2, 4, 8 Cardura QLL (30 EA per 30 days) prazosin hcl oral capsule 1, 2, 5 Minipress terazosin hcl oral capsule 1, 10, 2, 5 QLL (30 EA per 30 days) *Beta Blocker & Diuretic Combinations*** atenolol-chlorthalidone oral tablet Tenoretic 100 atenolol-chlorthalidone oral tablet Tenoretic 50 bisoprolol-hydrochlorothiazide oral tablet , , Ziac metoprolol-hydrochlorothiazide oral tablet , metoprolol-hydrochlorothiazide oral tablet Lopressor HCT nadolol-bendroflumethiazide oral tablet 40-5 Corzide propranolol-hctz oral tablet 40-25, *Vasodilators*** hydralazine hcl oral tablet 10, 100, 25, 50 minoxidil oral tablet 10, 2.5 *ANTI-INFECTIVE AGENTS - MISC.* *Anti-Infective Agents - Misc.*** metronidazole oral capsule 375 Flagyl metronidazole oral tablet 250, 500 Flagyl trimethoprim oral tablet

31 *Anti-Infective Misc. - Combinations*** sulfamethoxazole-trimethoprim oral Sulfatrim Pediatric suspension /5ml sulfamethoxazole-trimethoprim oral tablet Bactrim sulfamethoxazole-trimethoprim oral tablet Bactrim DS sulfatrim pediatric oral suspension Sulfatrim Pediatric /5ml *Leprostatics*** dapsone oral tablet 100, 25 *Lincosamides*** clindamycin hcl oral capsule 150, 300, Cleocin 75 clindamycin palmitate hcl oral solution Cleocin reconstituted 75 /5ml *ANTIMALARIALS* *Antimalarials*** chloroquine phosphate oral tablet 250, 500 hydroxychloroquine sulfate oral tablet 200 Plaquenil mefloquine hcl oral tablet 250 DARAPRIM ORAL TABLET 25 MG *ANTIMYASTHENIC AGENTS* *Antimyasthenic Agents*** pyridostigmine bromide oral tablet 60 Mestinon *Antimyasthenic/Cholinergic Agents*** pyridostigmine bromide oral tablet 60 Mestinon *ANTIMYASTHENIC/CHOLINER GIC AGENTS* pyridostigmine bromide oral tablet 60 Mestinon *ANTIMYCOBACTERIAL AGENTS* *Anti Tb Combinations*** RIFAMATE ORAL MG 28

32 *Antimycobacterial Agents*** ethambutol hcl oral tablet 100, 400 Myambutol isoniazid oral syrup 50 /5ml isoniazid oral tablet 100, 300 pyrazinamide oral tablet 500 rifabutin oral capsule 150 Mycobutin rifampin oral capsule 150, 300 Rifadin PRIFTIN ORAL TABLET 150 MG *ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES* *Alkylating Agents*** MYLERAN ORAL TABLET 2 MG *Antiadrenals*** LYSODREN ORAL TABLET 500 MG *Antiandrogens*** bicalutamide oral tablet 50 Casodex flutamide oral capsule 125 nilutamide oral tablet 150 Nilandron QLL (60 EA per 30 days) *Antiestrogens*** tamoxifen citrate oral tablet 10, 20 toremifene citrate oral tablet 60 Fareston SOLTAMOX ORAL SOLUTION 10 MG/5ML *Antimetabolites*** capecitabine oral tablet 150 Xeloda ; QLL (140 EA per 21 days) capecitabine oral tablet 500 Xeloda ; QLL (154 EA per 21 days) mercaptopurine oral tablet 50 methotrexate oral tablet 2.5 TABLOID ORAL TABLET 40 MG *Antineoplastic - Histone Deacetylase Inhibitors*** ZOLINZA ORAL 100 MG *Antineoplastic - Mtor Kinase Inhibitors*** AFINITOR ORAL TABLET 10 MG, 2.5 MG, 5 MG, 7.5 MG 29

33 *Antineoplastic - Multikinase Inhibitors*** NEXAVAR ORAL TABLET 200 MG ; QLL (4 EA per 1 day) SUTENT ORAL 12.5 MG, 25 MG, 37.5 MG ; QLL (1 EA per 1 day) SUTENT ORAL 50 MG ; QLL (28 EA per 42 days) *Antineoplastic - Tyrosine Kinase Inhibitors*** imatinib mesylate oral tablet 400 Gleevec CABOMETYX ORAL TABLET 20 MG, 40 MG, 60 MG ; QLL (1 EA per 1 day) IMBRUVICA ORAL 70 MG ; QLL (1 EA per 1 day) IMBRUVICA ORAL TABLET 140 MG ; QLL (4 EA per 1 day) SPRYCEL ORAL TABLET 100 MG, 140 MG, 20 MG, 50 MG, 70 MG, 80 MG ; QLL (1 EA per 1 day) TARCEVA ORAL TABLET 100 MG, 150 MG, 25 MG TASIGNA ORAL 150 MG, 200 MG TASIGNA ORAL 50 MG ; QLL (4 EA per 1 day) TYKERB ORAL TABLET 250 MG ; QLL (6 EA per 1 day) VOTRIENT ORAL TABLET 200 MG *Antineoplastics Misc.*** hydroxyurea oral capsule 500 Hydrea MATULANE ORAL 50 MG *Aromatase Inhibitors*** anastrozole oral tablet 1 Arimidex exemestane oral tablet 25 Aromasin letrozole oral tablet 2.5 Femara *Estrogens-Antineoplastic*** EMCYT ORAL 140 MG *Folic Acid Antagonists Rescue Agents*** leucovorin calcium oral tablet 10, 15, 25, 5 *Imidazotetrazines*** temozolomide oral capsule 100, 140, 180, 20, 250, 5 Temodar 30

34 *Lhrh Analogs*** leuprolide acetate injection kit 1 /0.2ml ELIGARD SUBCUTANEOUS KIT 22.5 MG, 30 MG, 45 MG, 7.5 MG TRELSTAR MIXJECT INTRAMUSCULAR SUSPENSION RECONSTITUTED MG, 22.5 MG, 3.75 MG VANTAS SUBCUTANEOUS KIT 50 MG ZOLADEX SUBCUTANEOUS IMPLANT 10.8 MG, 3.6 MG *Mitotic Inhibitors*** etoposide oral capsule 50 *Nitrogen Mustards*** melphalan oral tablet 2 LEUKERAN ORAL TABLET 2 MG *Nitrosoureas*** GLEOSTINE ORAL 10 MG, 100 MG, 40 MG *Progestins-Antineoplastic*** hydroxyprogesterone caproate intramuscular solution 1.25 gm/5ml megestrol acetate oral suspension 40 /ml, 400 /10ml megestrol acetate oral tablet 20, 40 *Retinoids*** tretinoin oral capsule 10 *Urinary Tract Protective Agents*** MESNEX ORAL TABLET 400 MG *ANTIRKINSON 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 capsule 100 amantadine hcl oral syrup 50 /5ml amantadine hcl oral tablet 100 Alkeran 31

35 bromocriptine mesylate oral capsule 5 Parlodel bromocriptine mesylate oral tablet 2.5 Parlodel *Antiparkinson Monoamine Oxidase Inhibitors*** selegiline hcl oral capsule 5 selegiline hcl oral tablet 5 *Levodopa Combinations*** carbidopa-levodopa er oral tablet extended release , Sinemet CR carbidopa-levodopa oral tablet , , Sinemet carbidopa-levodopa oral tablet dispersible , , carbidopa-levodopa-entacapone oral tablet Stalevo 50 QLL (270 EA per 30 days) carbidopa-levodopa-entacapone oral tablet Stalevo 75 QLL (270 EA per 30 days) carbidopa-levodopa-entacapone oral tablet Stalevo 100 QLL (270 EA per 30 days) carbidopa-levodopa-entacapone oral tablet Stalevo 125 QLL (270 EA per 30 days) carbidopa-levodopa-entacapone oral tablet Stalevo 150 QLL (270 EA per 30 days) carbidopa-levodopa-entacapone oral tablet Stalevo 200 QLL (270 EA per 30 days) *Nonergoline Dopamine Receptor Agonists*** pramipexole dihydrochloride oral tablet Mirapex, 0.25, 0.5, 0.75, 1, 1.5 ropinirole hcl er oral tablet extended release 24 hour 12, 6 ropinirole hcl er oral tablet extended release 24 hour 2, 4, 8 Requip XL ropinirole hcl oral tablet 0.25, 1, 2, 3 QLL (90 EA per 30 days) ropinirole hcl oral tablet 0.5, 4, 5 Requip QLL (90 EA per 30 days) *Peripheral Comt Inhibitors*** entacapone oral tablet 200 Comtan QLL (120 EA per 30 days) 32

36 *ANTIPSYCHOTICS/ANTIMANIC AGENTS* *Antimanic Agents*** lithium carbonate er oral tablet extended release 300 Lithobid QLL (8 EA per 1 day) lithium carbonate er oral tablet extended release 450 QLL (6 EA per 1 day) lithium carbonate oral capsule 150 QLL (16 EA per 1 day) lithium carbonate oral capsule 300 QLL (8 EA per 1 day) lithium carbonate oral capsule 600 QLL (4 EA per 1 day) lithium carbonate oral tablet 300 QLL (8 EA per 1 day) LITHIUM ORAL SOLUTION 8 MEQ/5ML QLL (40 ML per 1 day) *Antipsychotics - Misc.*** ziprasidone hcl oral capsule 20, 40, 60 Geodon, 80 QLL (2 EA per 1 day) *Benzisoxazoles*** risperidone m-tab oral tablet dispersible 0.5, 1, 2 risperidone oral solution 1 /ml risperidone oral tablet 0.25, 0.5, 1, 2 risperidone oral tablet 3 risperidone oral tablet 4 risperidone oral tablet dispersible 0.25 risperidone oral tablet dispersible 0.5, 1, 2 risperidone oral tablet dispersible 3 risperidone oral tablet dispersible 4 INVEGA SUSTENNA INTRAMUSCULAR SUSPENSION 117 MG/0.75ML INVEGA SUSTENNA INTRAMUSCULAR SUSPENSION 156 MG/ML INVEGA SUSTENNA INTRAMUSCULAR SUSPENSION 234 MG/1.5ML RisperiDONE M-TAB RisperDAL RisperDAL RisperDAL RisperDAL RisperiDONE M-TAB QLL (2 EA per 1 day); AL (Min 5 Years) QLL (16 ML per 1 day); AL (Min 5 Years) QLL (2 EA per 1 day); AL (Min 5 Years) QLL (3 EA per 1 day); AL (Min 5 Years) QLL (4 EA per 1 day); AL (Min 5 Years) QLL (2 EA per 1 day); AL (Min 5 Years) QLL (2 EA per 1 day); AL (Min 5 Years) QLL (3 EA per 1 day); AL (Min 5 Years) QLL (4 EA per 1 day); AL (Min 5 Years) ; QLL (0.75 ML per 28 days) ; QLL (1 ML per 28 days) ; QLL (1.5 ML per 28 days) 33

37 INVEGA SUSTENNA INTRAMUSCULAR SUSPENSION 39 MG/0.25ML ; QLL (0.25 ML per 28 days) INVEGA SUSTENNA INTRAMUSCULAR SUSPENSION 78 MG/0.5ML ; QLL (0.5 ML per 28 days) INVEGA TRINZA INTRAMUSCULAR SUSPENSION 273 MG/0.875ML ; QLL (0.88 ML per 84 days) INVEGA TRINZA INTRAMUSCULAR SUSPENSION 410 MG/1.315ML ; QLL (1.31 ML per 84 days) INVEGA TRINZA INTRAMUSCULAR SUSPENSION 546 MG/1.75ML ; QLL (1.75 ML per 84 days) INVEGA TRINZA INTRAMUSCULAR SUSPENSION 819 MG/2.625ML ; QLL (2.63 ML per 28 days) RISPERDAL CONSTA INTRAMUSCULAR SUSPENSION RECONSTITUTED 12.5 MG, 25 MG, 37.5 ; QLL (2 ml per 28 days) MG, 50 MG *Butyrophenones*** haloperidol decanoate intramuscular solution 100 /ml haloperidol decanoate intramuscular solution 50 /ml haloperidol lactate injection solution 5 /ml Haldol haloperidol lactate oral concentrate 2 /ml haloperidol oral tablet 0.5, 20, 5 haloperidol oral tablet 1, 10, 2 *Dibenzodiazepines*** clozapine oral tablet 100 clozapine oral tablet 200, 50 clozapine oral tablet 25 *Dibenzothiazepines*** quetiapine fumarate oral tablet 100, 200, 25, 50 quetiapine fumarate oral tablet 300, 400 Haldol Decanoate Haldol Decanoate Clozaril Clozaril SEROquel SEROquel QLL (5 ML per 28 days); AL (Min 3 Years) QLL (9 ML per 28 days); AL (Min 3 Years) QLL (4 ML per 1 day); AL (Min 3 Years) QLL (50 ML per 1 day); AL (Min 3 Years) QLL (5 EA per 1 day); AL (Min 3 Years) QLL (10 EA per 1 day); AL (Min 3 Years) QLL (9 EA per 1 day); AL (Min 9 Years) QLL (4 EA per 1 day); AL (Min 9 Years) QLL (3 EA per 1 day); AL (Min 9 Years) QLL (3 EA per 1 day); AL (Min 10 Years) QLL (2 EA per 1 day); AL (Min 10 Years) 34