LEGEND. Tier 1: Covered Medications

Transcription

1 LEGEND : Covered Medications BvD: Part B vs. Part D-This prescription drug may be covered under Medicare Part B or D depending upon the circumstances. HRM: High Risk Medication (PA required for ages 65 or over) LA: Limited Access-This prescription drug is limited to certain pharmacies. : Mail Order Eligible-This prescription may also be available via mail. PA1: Prior Authorization- You (or your physician) are required to get prior authorization before you fill your prescription for this drug. Without prior approval, we may not cover this drug. PA2: Prior Authorization (New Starts Only)- You (or your physician) are required to get prior authorization before you fill your prescription for this drug unless you are a previous user of the drug. If you have a history of using this medication, you will not need prior authorization. QL: Quantity Limit-There is a limit on the amount of this drug that is covered per prescription, or within a specific time frame. ST1: Step Therapy- In some cases, you may be required to first try certain drugs to treat your medical condition before we will cover another drug for that condition. ST2: Step Therapy (New Starts Only)-In some cases, you may be required to first try certain drugs to treat your medical condition before we will cover another drug for that condition unless you are a previous user of the drug. If you have a history of using this medication, you will not need to try other medications first. 1

2 Superior Select Health Plan: TRIBUTE - 1 Tier (List of Covered Drugs) ANALGESICS OPIOID ANALGESICS, LONG-ACTING fentanyl transdermal patch 72 hour 100 mcg/hr, 12 mcg/hr, 25 mcg/hr, 37.5 mcg/hr, 50 mcg/hr, 62.5 mcg/hr, 75 mcg/hr, 87.5 mcg/hr hydromorphone hcl er oral tablet er 24 hour abuse-deterrent 12, 16, 32, 8 morphine sulfate er beads oral capsule extended release 24 hour 120, 30, 45, 60, 75, 90 morphine sulfate er oral capsule extended release 24 hour 10, 100, 20, 30, 40, 50, 60, 80 morphine sulfate er oral tablet extended release 100, 15, 30, 60 OPIOID ANALGESICS, SHORT-ACTING PA1; ; QL (10 per 30 days) 2 acetaminophen-codeine #3 oral tablet acetaminophen-codeine oral solution /5ml acetaminophen-codeine oral tablet , ASCOMP-CODEINE ORAL CAPSULE MG buprenorphine hcl sublingual tablet sublingual 2 buprenorphine hcl sublingual tablet sublingual 8 butalbital-apap-caff-cod oral capsule butalbital-asa-caff-codeine oral capsule codeine sulfate oral tablet 15, 30, 60 duramorph injection solution 0.5 /ml, 1 /ml ENDOCET ORAL TABLET MG, MG, MG FENTORA BUCCAL TABLET 100 MCG, 200 MCG, 400 MCG, 600 MCG, 800 MCG ; QL (180 per 30 days) PA1; ; QL (240 per 30 days) PA1; ; QL (90 per 30 days) ; QL (180 per 30 days) ; QL (180 per 30 days) PA1; ; QL (120 per 30 days)

3 hydrocodone-acetaminophen oral solution /15ml hydrocodone-acetaminophen oral tablet , , , 5-300, 5-325, , hydrocodone-ibuprofen oral tablet , 5-200, hydromorphone hcl injection solution 2 /ml hydromorphone hcl oral liquid 1 /ml hydromorphone hcl oral tablet 2, 4, 8 hydromorphone hcl pf injection solution 10 /ml, 2 /ml, 50 /5ml meperidine hcl injection solution 100 /ml, 25 /ml, 50 /ml PA1; ; HRM meperidine hcl oral tablet 100, 50 PA1; ; HRM methadone hcl oral solution 10 /5ml, 5 /5ml methadone hcl oral tablet 10, 5 morphine sulfate (concentrate) oral solution 100 /5ml morphine sulfate injection solution 2 /ml BvD; morphine sulfate injection solution 5 /ml morphine sulfate oral solution 10 /5ml, 20 /5ml morphine sulfate oral tablet 15, 30 oxycodone hcl oral capsule 5 oxycodone hcl oral solution 5 /5ml oxycodone hcl oral tablet 10, 15, 20, 30, 5 oxycodone-acetaminophen oral tablet , , 5-325, oxycodone-aspirin oral tablet oxycodone-ibuprofen oral tablet oxymorphone hcl oral tablet 10, 5 pentazocine-naloxone hcl oral tablet PA1; ; HRM tramadol hcl oral tablet 50 ; QL (240 per 30 days) tramadol-acetaminophen oral tablet ; QL (240 per 30 days)

4 ANESTHETICS LOCAL ANESTHETICS lidocaine hcl external gel 2 % PA1; ; QL (30 per 30 days) lidocaine-prilocaine external cream % PA1; ; QL (30 per 30 days) ANTI-ADDICTION/SUBSTANCE ABUSE TREATMENT AGENTS ALCOHOL DETERRENTS/ANTI-CRAVING acamprosate calcium oral tablet delayed release disulfiram oral tablet 250, 500 OPIOID ANTAGONISTS buprenorphine hcl-naloxone hcl sublingual tablet sublingual buprenorphine hcl-naloxone hcl sublingual tablet sublingual 8-2 ; QL (90 per 30 days) ; QL (120 per 30 days) butorphanol tartrate nasal solution 10 /ml ; QL (10 per 30 days) naloxone hcl injection solution 0.4 /ml naloxone hcl injection solution cartridge 0.4 /ml naloxone hcl injection solution prefilled syringe 2 /2ml naltrexone hcl oral tablet 50 NARCAN NASAL LIQUID 4 MG/0.1ML ; QL (2 per 30 days) SUBOXONE SUBLINGUAL FILM 12-3 MG, MG, 4-1 MG ; QL (90 per 30 days) SUBOXONE SUBLINGUAL FILM 8-2 MG ; QL (120 per 30 days) VIVITROL INTRAMUSCULAR SUSPENSION RECONSTITUTED 380 MG SKING CESSATION AGENTS bupropion hcl er (smoking det) oral tablet extended release 12 hour 150 CHANTIX CONTINUING NTH PAK ORAL TABLET 1 MG CHANTIX ORAL TABLET 0.5 MG, 1 MG CHANTIX STARTING NTH PAK ORAL TABLET 0.5 MG X 11 & 1 MG X 42 NICOTROL INHALATION INHALER 10 MG

5 NICOTROL NS NASAL SOLUTION 10 MG/ML ANTIBACTERIALS AMINOGLYCOSIDES amikacin sulfate injection solution 500 /2ml BvD; ARIKAYCE INHALATION SUSPENSION 590 MG/8.4ML BETHKIS INHALATION NEBULIZATION SOLUTION 300 MG/4ML gentamicin in saline intravenous solution /ml-%, /ml-%, /ml-%, /ml-% PA1; PA1; ; QL (224 per 56 days) 5 gentamicin sulfate injection solution 40 /ml neomycin sulfate oral tablet 500 paromomycin sulfate oral capsule 250 streptomycin sulfate intramuscular solution reconstituted 1 gm TOBI PODHALER INHALATION CAPSULE 28 MG tobramycin inhalation nebulization solution 300 /5ml tobramycin sulfate injection solution 10 /ml, 80 /2ml ANTIBACTERIALS, OTHER clindamycin hcl oral capsule 150, 300, 75 clindamycin palmitate hcl oral solution reconstituted 75 /5ml clindamycin phosphate in d5w intravenous solution 300 /50ml, 600 /50ml, 900 /50ml clindamycin phosphate injection solution 300 /2ml, 900 /6ml clindamycin phosphate injection solution 600 /4ml colistimethate sodium (cba) injection solution reconstituted 150 PA1; ; QL (224 per 56 days) PA1; ; QL (280 per 42 days) BvD; dapsone oral tablet 100, 25 daptomycin intravenous solution reconstituted 350, 500 PA1;

6 linezolid intravenous solution 600 /300ml PA1; linezolid oral tablet 600 PA1; ; QL (60 per 30 days) methenamine hippurate oral tablet 1 gm metronidazole in nacl intravenous solution /100ml-% metronidazole oral capsule 375 metronidazole oral tablet 250, 500 BvD; NUROL ORAL PACKET 3 GM ; QL (2 per 30 days) NEBUPENT INHALATION SOLUTION RECONSTITUTED 300 MG nitrofurantoin macrocrystal oral capsule 100, 25, 50 nitrofurantoin monohyd macro oral capsule 100 BvD; 6 nitrofurantoin oral suspension 25 /5ml PENTAM INJECTION SOLUTION RECONSTITUTED 300 MG tigecycline intravenous solution reconstituted 50 tinidazole oral tablet 250, 500 trimethoprim oral tablet 100 vancomycin hcl in dextrose intravenous solution /150ml-% vancomycin hcl in nacl intravenous solution gm/200ml-%, /100ml-%, /250ml-% vancomycin hcl intravenous solution reconstituted 1 gm, 1000, 250, 500, 5000, 750 vancomycin hcl oral capsule 125, 250 XIFAXAN ORAL TABLET 200 MG, 550 MG BETA-LACTAM, CEPHALOSPORINS cefaclor oral capsule 250, 500 cefaclor oral suspension reconstituted 125 /5ml, 250 /5ml, 375 /5ml BvD; BvD; BvD; BvD; BvD; cefadroxil oral capsule 500 cefadroxil oral suspension reconstituted 250 /5ml, 500 /5ml

7 cefadroxil oral tablet 1 gm cefazolin sodium injection solution reconstituted 1 gm, 10 gm, cefdinir oral capsule 300 cefdinir oral suspension reconstituted 125 /5ml, 250 /5ml cefepime hcl injection solution reconstituted 1 gm, 2 gm cefixime oral suspension reconstituted 100 /5ml, 200 /5ml cefotaxime sodium injection solution reconstituted 1 gm, 500 cefoxitin sodium injection solution reconstituted 10 gm cefoxitin sodium intravenous solution reconstituted 1 gm, 2 gm cefpodoxime proxetil oral suspension reconstituted 100 /5ml, 50 /5ml BvD; cefpodoxime proxetil oral tablet 100, 200 cefprozil oral suspension reconstituted 125 /5ml, 250 /5ml cefprozil oral tablet 250, 500 ceftazidime injection solution reconstituted 1 gm, 2 gm, 6 gm ceftriaxone sodium injection solution reconstituted 1 gm, 2 gm, 250, 500 cefuroxime axetil oral tablet 250, 500 cefuroxime sodium injection solution reconstituted 7.5 gm, 750 cefuroxime sodium intravenous solution reconstituted 1.5 gm BvD; cephalexin oral capsule 250, 500 cephalexin oral suspension reconstituted 125 /5ml, 250 /5ml cephalexin oral tablet 250 SUPRAX ORAL CAPSULE 400 MG TEFLARO INTRAVENOUS SOLUTION RECONSTITUTED 400 MG, 600 MG PA1;

8 ZERBAXA INTRAVENOUS SOLUTION RECONSTITUTED 1.5 (1-0.5) GM BETA-LACTAM, OTHER AZACTAM INJECTION SOLUTION RECONSTITUTED 1 GM, 2 GM aztreonam injection solution reconstituted 1 gm CAYSTON INHALATION SOLUTION RECONSTITUTED 75 MG doripenem intravenous solution reconstituted 500 ertapenem sodium injection solution reconstituted 1 gm imipenem-cilastatin intravenous solution reconstituted 250, 500 meropenem intravenous solution reconstituted 1 gm, 500 BETA-LACTAM, PENICILLINS BvD; BvD; PA1; LA BvD; 8 amoxicillin oral capsule 250, 500 amoxicillin oral suspension reconstituted 125 /5ml, 200 /5ml, 250 /5ml, 400 /5ml BvD; BvD; amoxicillin oral tablet 500, 875 amoxicillin oral tablet chewable 125, 250 amoxicillin-pot clavulanate oral suspension reconstituted /5ml, /5ml, /5ml, /5ml amoxicillin-pot clavulanate oral tablet , , amoxicillin-pot clavulanate oral tablet chewable , ampicillin oral capsule 500 ampicillin sodium injection solution reconstituted 1 gm, 125 ampicillin-sulbactam sodium injection solution reconstituted 1.5 (1-0.5) gm, 3 (2-1) gm ampicillin-sulbactam sodium injection solution reconstituted 15 (10-5) gm BACTOCILL IN DEXTROSE INTRAVENOUS SOLUTION 1 GM/50ML, 2 GM/50ML BvD; BvD;

9 BICILLIN C-R 900/300 INTRAMUSCULAR SUSPENSION UNIT/2ML BICILLIN C-R INTRAMUSCULAR SUSPENSION UNIT/2ML BICILLIN L-A INTRAMUSCULAR SUSPENSION UNIT/2ML, UNIT/4ML, UNIT/ML dicloxacillin sodium oral capsule 250, 500 nafcillin sodium injection solution reconstituted 1 gm, 2 gm nafcillin sodium intravenous solution reconstituted 10 gm oxacillin sodium injection solution reconstituted 1 gm, 10 gm, 2 gm penicillin g pot in dextrose intravenous solution unit/ml, unit/ml penicillin g potassium injection solution reconstituted unit penicillin g sodium injection solution reconstituted unit penicillin v potassium oral solution reconstituted 125 /5ml, 250 /5ml BvD; penicillin v potassium oral tablet 250, 500 piperacillin sod-tazobactam so intravenous solution reconstituted 2.25 (2-0.25) gm, ( ) gm, 4.5 (4-0.5) gm, 40.5 (36-4.5) gm ZOSYN INTRAVENOUS SOLUTION GM/50ML, GM/50ML MACROLIDES azithromycin intravenous solution reconstituted 500 azithromycin oral packet 1 gm azithromycin oral suspension reconstituted 100 /5ml, 200 /5ml azithromycin oral tablet 250, 250 (6 pack), 500, 500 (3 pack), 600 clarithromycin er oral tablet extended release 24 hour 500 BvD; BvD; BvD; 9

10 clarithromycin oral suspension reconstituted 125 /5ml, 250 /5ml 10 clarithromycin oral tablet 250, 500 DIFICID ORAL TABLET 200 MG ST1; ERYPED 400 ORAL SUSPENSION RECONSTITUTED 400 MG/5ML ERY-TAB ORAL TABLET DELAYED RELEASE 250 MG, 333 MG, 500 MG ERYTHROCIN LACTOBIONATE INTRAVENOUS SOLUTION RECONSTITUTED 500 MG ERYTHROCIN STEARATE ORAL TABLET 250 MG erythromycin base oral capsule delayed release particles 250 BvD; erythromycin base oral tablet 250, 500 erythromycin ethylsuccinate oral suspension reconstituted 200 /5ml QUINOLONES ciprofloxacin hcl oral tablet 100, 250, 500, 750 ciprofloxacin in d5w intravenous solution 200 /100ml ciprofloxacin oral suspension reconstituted 250 /5ml (5%), 500 /5ml (10%) ciprofloxacin-ciproflox hcl er oral tablet extended release 24 hour 1000, 500 levofloxacin in d5w intravenous solution 500 /100ml, 750 /150ml BvD; BvD; levofloxacin intravenous solution 25 /ml BvD; levofloxacin oral solution 25 /ml levofloxacin oral tablet 250, 500, 750 moxifloxacin hcl in nacl intravenous solution 400 /250ml moxifloxacin hcl intravenous solution 400 /250ml moxifloxacin hcl oral tablet 400 ofloxacin oral tablet 300, 400 BvD; BvD;

11 SULFONAMIDES sulfadiazine oral tablet 500 sulfamethoxazole-trimethoprim oral suspension /5ml sulfamethoxazole-trimethoprim oral tablet , SULFATRIM PEDIATRIC ORAL SUSPENSION MG/5ML TETRACYCLINES demeclocycline hcl oral tablet 150, 300 DOXY 100 INTRAVENOUS SOLUTION RECONSTITUTED 100 MG doxycycline hyclate oral capsule 100, 50 doxycycline hyclate oral tablet 100, 20 doxycycline monohydrate oral capsule 100, 50 doxycycline monohydrate oral suspension reconstituted 25 /5ml doxycycline monohydrate oral tablet 100, 50, 75 minocycline hcl oral capsule 100, 50, 75 BvD; minocycline hcl oral tablet 100, 50, 75 tetracycline hcl oral capsule 250, 500 ANTICONVULSANTS ANTICONVULSANTS, OTHER BRIVIACT ORAL SOLUTION 10 MG/ML PA2; BRIVIACT ORAL TABLET 10 MG, 100 MG, 25 MG, 50 MG, 75 MG PA2; EPIDIOLEX ORAL SOLUTION 100 MG/ML PA2; levetiracetam er oral tablet extended release 24 hour 500, 750 levetiracetam oral solution 100 /ml levetiracetam oral tablet 1000, 250, 500,

12 ROWEEPRA ORAL TABLET 1000 MG, 500 MG, 750 MG ROWEEPRA XR ORAL TABLET EXTENDED RELEASE 24 HOUR 500 MG, 750 MG SPRITAM ORAL TABLET DISINTEGRATING SOLUBLE 1000 MG SPRITAM ORAL TABLET DISINTEGRATING SOLUBLE 250 MG, 500 MG, 750 MG BARBITURATES phenobarbital oral tablet 100, 15, 16.2, 30, 32.4, 60, 64.8, ; QL (90 per 30 days) ; QL (120 per 30 days) primidone oral tablet 250, 50 BENZODIAZEPINES clobazam oral suspension 2.5 /ml PA2; clobazam oral tablet 10, 20 PA2; ; QL (60 per 30 days) clonazepam oral tablet 0.5, 1, 2 clonazepam oral tablet dispersible 0.125, 0.25, 0.5, 1, 2 DIASTAT ACUDIAL RECTAL GEL 10 MG, 20 MG DIASTAT PEDIATRIC RECTAL GEL 2.5 MG diazepam rectal gel 10, 2.5, 20 CALCIUM CHANNEL DIFYING AGENTS CELONTIN ORAL CAPSULE 300 MG ethosuximide oral capsule 250 ethosuximide oral solution 250 /5ml LYRICA ORAL CAPSULE 200 MG, 225 MG, 25 MG, 50 MG, 75 MG ; QL (120 per 30 days) LYRICA ORAL CAPSULE 300 MG ; QL (60 per 30 days) LYRICA ORAL SOLUTION 20 MG/ML ; QL (900 per 30 days) zonisamide oral capsule 100, 25, 50 GAMMA-AMINOBUTYRIC ACID (GABA) AUGMENTING AGENTS divalproex sodium er oral tablet extended release 24 hour 250, 500 divalproex sodium oral capsule delayed release sprinkle 125

13 divalproex sodium oral tablet delayed release 125, 250, 500 FYCOMPA ORAL SUSPENSION 0.5 MG/ML PA2; FYCOMPA ORAL TABLET 10 MG, 12 MG, 2 MG, 4 MG, 6 MG, 8 MG 13 gabapentin oral capsule 100, 300, 400 gabapentin oral solution 250 /5ml gabapentin oral tablet 600, 800 PA2; SABRIL ORAL TABLET 500 MG PA2; LA tiagabine hcl oral tablet 12, 16, 2, 4 valproate sodium oral solution 250 /5ml valproic acid oral capsule 250 vigabatrin oral packet 500 PA2; LA VIGADRONE ORAL PACKET 500 MG PA2; LA GLUTAMATE REDUCING AGENTS felbamate oral suspension 600 /5ml felbamate oral tablet 400, 600 LAMICTAL XR ORAL KIT 25 & 50 & 100 MG, 25 (21)-50 (7) MG, 50 & 100 & 200 MG lamotrigine er oral tablet extended release 24 hour 100, 200, 25, 250, 300, 50 lamotrigine oral tablet 100, 150, 200, 25 lamotrigine oral tablet chewable 25, 5 lamotrigine oral tablet dispersible 100, 200, 25, 50 lamotrigine starter kit-blue oral kit 25 (35) lamotrigine starter kit-green oral kit 25 (84)- 100(14) lamotrigine starter kit-orange oral kit 25 (42)-100 (7) QUDEXY XR ORAL CAPSULE ER 24 HOUR SPRINKLE 100 MG, 150 MG, 200 MG, 25 MG, 50 MG SUBVENITE ORAL TABLET 100 MG, 150 MG, 200 MG, 25 MG

14 SUBVENITE STARTER KIT-BLUE ORAL KIT 25 (35) MG SUBVENITE STARTER KIT-GREEN ORAL KIT 25 (84)-100(14) MG SUBVENITE STARTER KIT-ORANGE ORAL KIT 25 (42)-100 (7) MG topiramate er oral capsule er 24 hour sprinkle 100, 150, 200, 25, topiramate oral capsule sprinkle 15, 25 topiramate oral tablet 100, 200, 25, 50 TROKENDI XR ORAL CAPSULE EXTENDED RELEASE 24 HOUR 100 MG, 200 MG, 25 MG, 50 MG SODIUM CHANNEL AGENTS APTIOM ORAL TABLET 200 MG, 400 MG PA2; ; QL (30 per 30 days) APTIOM ORAL TABLET 600 MG PA2; ; QL (60 per 30 days) APTIOM ORAL TABLET 800 MG PA2; ; QL (45 per 30 days) BANZEL ORAL SUSPENSION 40 MG/ML PA2; ; QL (2400 per 30 days) BANZEL ORAL TABLET 200 MG, 400 MG PA2; ; QL (240 per 30 days) carbamazepine er oral capsule extended release 12 hour 100, 200, 300 carbamazepine er oral tablet extended release 12 hour 100, 200, 400 carbamazepine oral suspension 100 /5ml carbamazepine oral tablet 200 carbamazepine oral tablet chewable 100 DILANTIN ORAL CAPSULE 30 MG EPITOL ORAL TABLET 200 MG oxcarbazepine oral suspension 300 /5ml oxcarbazepine oral tablet 150, 300, 600 OXTELLAR XR ORAL TABLET EXTENDED RELEASE 24 HOUR 150 MG, 300 MG, 600 MG PEGANONE ORAL TABLET 250 MG phenytoin oral suspension 125 /5ml phenytoin oral tablet chewable 50

15 phenytoin sodium extended oral capsule 100, 200, 300 VIMPAT ORAL SOLUTION 10 MG/ML ; QL (1200 per 30 days) VIMPAT ORAL TABLET 100 MG, 150 MG, 200 MG, 50 MG ANTIDEMENTIA AGENTS CHOLINESTERASE INHIBITORS donepezil hcl oral tablet 10, 23, 5 donepezil hcl oral tablet dispersible 10, 5 galantamine hydrobromide er oral capsule extended release 24 hour 16, 24, 8 ; QL (60 per 30 days) galantamine hydrobromide oral solution 4 /ml galantamine hydrobromide oral tablet 12, 4, 8 rivastigmine tartrate oral capsule 1.5, 3, 4.5, 6 rivastigmine transdermal patch 24 hour 13.3 /24hr, 4.6 /24hr, 9.5 /24hr N-METHYL-D-ASPARTATE (NMDA) RECEPTOR ANTAGONIST memantine hcl er oral capsule extended release 24 hour 14, 21, 28, 7 ; QL (30 per 30 days) memantine hcl oral solution 2 /ml memantine hcl oral tablet 10, 5 (28)-10 (21), 5 NAMENDA XR TITRATION PACK ORAL CAPSULE EXTENDED RELEASE 24 HOUR 7 & 14 & 21 &28 MG NAMZARIC ORAL CAPSULE ER 24 HOUR THERAPY PACK 7 & 14 & 21 &28-10 MG NAMZARIC ORAL CAPSULE EXTENDED RELEASE 24 HOUR MG, MG, MG, 7-10 MG ANTIDEPRESSANTS ANTIDEPRESSANTS, OTHER bupropion hcl er (sr) oral tablet extended release 12 hour 100, 150, 200 PA1; PA1; 15

16 bupropion hcl er (xl) oral tablet extended release 24 hour 150, 300 bupropion hcl er (xl) oral tablet extended release 24 hour 450 bupropion hcl oral tablet 100, 75 maprotiline hcl oral tablet 25, 50, 75 mirtazapine oral tablet 15, 30, 45, 7.5 mirtazapine oral tablet dispersible 15, 30, 45 nefazodone hcl oral tablet 100, 150, 200, 250, 50 trazodone hcl oral tablet 100, 150, 300, 50 TRINTELLIX ORAL TABLET 10 MG, 20 MG, 5 MG VIIBRYD ORAL TABLET 10 MG, 20 MG, 40 MG VIIBRYD STARTER PACK ORAL KIT 10 & 20 MG NOAMINE OXIDASE INHIBITORS EMSAM TRANSDERMAL PATCH 24 HOUR 12 MG/24HR, 6 MG/24HR, 9 MG/24HR ST2; ; QL (30 per 30 days) ; QL (30 per 30 days) ; QL (30 per 30 days) MARPLAN ORAL TABLET 10 MG phenelzine sulfate oral tablet 15 tranylcypromine sulfate oral tablet 10 SEROTONIN/NOREPINEPHRINE REUPTAKE INHIBITORS citalopram hydrobromide oral solution 10 /5ml citalopram hydrobromide oral tablet 10, 20, 40 desvenlafaxine er oral tablet extended release 24 hour 100, 50 desvenlafaxine succinate er oral tablet extended release 24 hour 100, 25, 50 duloxetine hcl oral capsule delayed release particles 20, 30, 40, 60 PA2; ; QL (30 per 30 days) escitalopram oxalate oral solution 5 /5ml 16

17 escitalopram oxalate oral tablet 10, 20, 5 FETZIMA ORAL CAPSULE EXTENDED RELEASE 24 HOUR 120 MG, 20 MG, 40 MG, 80 MG FETZIMA TITRATION ORAL CAPSULE ER 24 HOUR THERAPY PACK 20 & 40 MG fluoxetine hcl oral capsule 10, 20, 40 fluoxetine hcl oral capsule delayed release 90 fluoxetine hcl oral solution 20 /5ml fluoxetine hcl oral tablet 10, 20, 60 fluvoxamine maleate er oral capsule extended release 24 hour 100, 150 fluvoxamine maleate oral tablet 100, 25, 50 olanzapine-fluoxetine hcl oral capsule 12-25, 12-50, 3-25, 6-25, 6-50 paroxetine hcl er oral tablet extended release 24 hour 12.5, 25, 37.5 paroxetine hcl oral tablet 10, 20, 30, 40 ; QL (30 per 30 days) ; QL (56 per 365 days) PAXIL ORAL SUSPENSION 10 MG/5ML PEXEVA ORAL TABLET 10 MG, 20 MG, 30 MG, 40 MG sertraline hcl oral concentrate 20 /ml sertraline hcl oral tablet 100, 25, 50 venlafaxine hcl er oral capsule extended release 24 hour 150, 37.5, 75 venlafaxine hcl er oral tablet extended release 24 hour 150, 225, 37.5, 75 venlafaxine hcl oral tablet 100, 25, 37.5, 50, 75 TRICYCLICS amitriptyline hcl oral tablet 10, 100, 150, 25, 50, 75 amoxapine oral tablet 100, 150, 25, 50 ST2; 17

18 chlordiazepoxide-amitriptyline oral tablet 10-25, clomipramine hcl oral capsule 25, 50, 75 desipramine hcl oral tablet 10, 100, 150, 25, 50, 75 doxepin hcl oral capsule 10, 100, 150, 25, 50, 75 doxepin hcl oral concentrate 10 /ml imipramine hcl oral tablet 10, 25, 50 imipramine pamoate oral capsule 100, 125, 150, 75 nortriptyline hcl oral capsule 10, 25, 50, 75 nortriptyline hcl oral solution 10 /5ml protriptyline hcl oral tablet 10, 5 trimipramine maleate oral capsule 100, 25, 50 ANTIEMETICS ANTIEMETICS, OTHER meclizine hcl oral tablet 12.5, 25 scopolamine transdermal patch 72 hour 1 /3days trimethobenzamide hcl oral capsule 300 EMETOGENIC THERAPY ADJUNCTS aprepitant oral capsule 125, 40, 80 BvD; ; QL (8 per 30 days) aprepitant oral capsule 80 & 125 BvD; ; QL (12 per 30 days) dronabinol oral capsule 10, 2.5, 5 PA1; ; QL (60 per 30 days) granisetron hcl oral tablet 1 BvD; ; QL (60 per 30 days) ondansetron hcl oral solution 4 /5ml BvD; ; QL (450 per 30 days) ondansetron hcl oral tablet 24 BvD; ; QL (30 per 30 days) ondansetron hcl oral tablet 4 BvD; ; QL (120 per 30 days) ondansetron hcl oral tablet 8 BvD; ; QL (60 per 30 days) ondansetron oral tablet dispersible 4 BvD; ; QL (120 per 30 days) ondansetron oral tablet dispersible 8 BvD; ; QL (60 per 30 days) 18

19 VARUBI ORAL TABLET 90 MG PA1; ; QL (8 per 30 days) ANTIFUNGALS ANTIFUNGALS ABELCET INTRAVENOUS SUSPENSION 5 MG/ML AMBISOME INTRAVENOUS SUSPENSION RECONSTITUTED 50 MG amphotericin b injection solution reconstituted 50 caspofungin acetate intravenous solution reconstituted 50, 70 clotrimazole mouth/throat lozenge 10 ERAXIS INTRAVENOUS SOLUTION RECONSTITUTED 100 MG, 50 MG fluconazole in sodium chloride intravenous solution /100ml-%, /200ml- % fluconazole oral suspension reconstituted 10 /ml, 40 /ml fluconazole oral tablet 100, 150, 200, 50 BvD; BvD; BvD; PA1; PA1; BvD; 19 flucytosine oral capsule 250, 500 griseofulvin microsize oral suspension 125 /5ml griseofulvin microsize oral tablet 500 griseofulvin ultramicrosize oral tablet 125, 250 itraconazole oral capsule 100 PA1; itraconazole oral solution 10 /ml PA1; ketoconazole oral tablet 200 MYCAMINE INTRAVENOUS SOLUTION RECONSTITUTED 100 MG, 50 MG PA1; NOXAFIL ORAL SUSPENSION 40 MG/ML PA1; NOXAFIL ORAL TABLET DELAYED RELEASE 100 MG nystatin mouth/throat suspension unit/ml nystatin oral tablet unit ORAVIG BUCCAL TABLET 50 MG PA1;

20 terbinafine hcl oral tablet 250 ; QL (84 per 168 days) voriconazole intravenous solution reconstituted 200 voriconazole oral suspension reconstituted 40 /ml BvD; ; QL (300 per 30 days) voriconazole oral tablet 200, 50 ; QL (120 per 30 days) ANTIGOUT AGENTS ANTIGOUT AGENTS allopurinol oral tablet 100 colchicine oral capsule 0.6 colchicine oral tablet 0.6 colchicine-probenecid oral tablet COLCRYS ORAL TABLET 0.6 MG MITIGARE ORAL CAPSULE 0.6 MG probenecid oral tablet 500 ULORIC ORAL TABLET 40 MG, 80 MG ST1; ANTI-INFLAMMATORY AGENTS NONSTEROIDAL ANTI-INFLAMMATORY DRUGS BUPAP ORAL TABLET MG ; QL (180 per 30 days) butalbital-acetaminophen oral tablet ; QL (180 per 30 days) butalbital-apap-caffeine oral capsule ; QL (180 per 30 days) butalbital-apap-caffeine oral tablet ; QL (180 per 30 days) butalbital-aspirin-caffeine oral capsule celecoxib oral capsule 100, 200, 400, 50 diclofenac potassium oral tablet 50 diclofenac sodium er oral tablet extended release 24 hour 100 diclofenac sodium oral tablet delayed release 25, 50, 75 ; QL (180 per 30 days) ST1; ; QL (60 per 30 days) diclofenac sodium transdermal gel 1 % PA1; ; QL (1000 per 30 days) diclofenac sodium transdermal solution 1.5 % PA1; ; QL (450 per 30 days) 20

21 diclofenac-misoprostol oral tablet delayed release , diflunisal oral tablet 500 etodolac er oral tablet extended release 24 hour 400, 500, 600 etodolac oral capsule 200, 300 etodolac oral tablet 400, 500 flurbiprofen oral tablet 100, 50 IBU ORAL TABLET 600 MG, 800 MG ibuprofen oral suspension 100 /5ml ibuprofen oral tablet 400, 600, 800 indomethacin er oral capsule extended release 75 PA1; ; HRM indomethacin oral capsule 25, 50 PA1; ; HRM ketoprofen er oral capsule extended release 24 hour 200 ketoprofen oral capsule 25 ketorolac tromethamine oral tablet 10 PA1; ; HRM meclofenamate sodium oral capsule 100, 50 meloxicam oral tablet 15, 7.5 nabumetone oral tablet 500, 750 naproxen dr oral tablet delayed release 375, 500 naproxen oral suspension 125 /5ml naproxen oral tablet 250, 375, 500 naproxen sodium oral tablet 275, 550 oxaprozin oral tablet 600 piroxicam oral capsule 10, 20 sulindac oral tablet 150, 200 TENCON ORAL TABLET MG ; QL (180 per 30 days) tolmetin sodium oral capsule 400 tolmetin sodium oral tablet 600 ANTIMIGRAINE AGENTS SEROTONIN (5-HT) 1B/1D RECEPTOR AGONISTS

22 almotriptan malate oral tablet 12.5, 6.25 ; QL (12 per 30 days) dihydroergotamine mesylate nasal solution 4 /ml ST1; ; QL (24 per 28 days) eletriptan hydrobromide oral tablet 20, 40 ; QL (12 per 30 days) ergotamine-caffeine oral tablet ; QL (40 per 28 days) naratriptan hcl oral tablet 1, 2.5 ; QL (12 per 30 days) rizatriptan benzoate oral tablet 10, 5 ; QL (12 per 30 days) rizatriptan benzoate oral tablet dispersible 10, 5 sumatriptan succinate oral tablet 100, 25, 50 sumatriptan succinate refill subcutaneous solution cartridge 4 /0.5ml, 6 /0.5ml sumatriptan succinate subcutaneous solution 6 /0.5ml sumatriptan succinate subcutaneous solution autoinjector 6 /0.5ml sumatriptan succinate subcutaneous solution prefilled syringe 6 /0.5ml ; QL (12 per 30 days) ; QL (12 per 30 days) zolmitriptan oral tablet 2.5, 5 ; QL (12 per 30 days) zolmitriptan oral tablet dispersible 2.5, 5 ; QL (12 per 30 days) ANTIMYASTHENIC AGENTS PARASYMPATHOMIMETICS guanidine hcl oral tablet 125 pyridostigmine bromide oral tablet 60 ANTIMYCOBACTERIALS ANTITUBERCULARS ethambutol hcl oral tablet 100, 400 isoniazid oral syrup 50 /5ml isoniazid oral tablet 100, 300 PASER ORAL PACKET 4 GM PRIFTIN ORAL TABLET 150 MG pyrazinamide oral tablet 500 rifabutin oral capsule

23 rifampin intravenous solution reconstituted 600 rifampin oral capsule 150, 300 RIFATER ORAL TABLET MG TRECATOR ORAL TABLET 250 MG ANTINEOPLASTICS ALKYLATING AGENTS BvD; cyclophosphamide oral capsule 25, 50 BvD; GLEOSTINE ORAL CAPSULE 10 MG, 100 MG, 40 MG LEUKERAN ORAL TABLET 2 MG ANTIANGIOGENIC AGENTS REVLIMID ORAL CAPSULE 10 MG, 15 MG, 2.5 MG, 20 MG, 25 MG, 5 MG THALOMID ORAL CAPSULE 100 MG, 150 MG, 200 MG, 50 MG ANTIMETABOLITES PA2; PA2; PA2; DAURIS ORAL TABLET 100 MG, 25 MG PA2; mercaptopurine oral tablet 50 methotrexate sodium (pf) injection solution 50 /2ml methotrexate sodium injection solution 250 /10ml PURIXAN ORAL SUSPENSION 2000 MG/100ML TABLOID ORAL TABLET 40 MG ANTINEOPLASTICS BvD; BvD; PA2; LA abiraterone acetate oral tablet 250 PA2; ; QL (120 per 30 days) ACTIMMUNE SUBCUTANEOUS SOLUTION UNIT/0.5ML AFINITOR DISPERZ ORAL TABLET SOLUBLE 2 MG, 3 MG AFINITOR DISPERZ ORAL TABLET SOLUBLE 5 MG AFINITOR ORAL TABLET 10 MG, 2.5 MG, 5 MG, 7.5 MG PA2; LA PA2; ; QL (30 per 30 days) PA2; ; QL (60 per 30 days) PA2; ; QL (30 per 30 days) 23

24 ALECENSA ORAL CAPSULE 150 MG PA2; ALUNBRIG ORAL TABLET 180 MG PA2; LA; QL (30 per 30 days) ALUNBRIG ORAL TABLET 30 MG PA2; LA; QL (180 per 30 days) ALUNBRIG ORAL TABLET 90 MG PA2; LA; QL (60 per 30 days) ALUNBRIG ORAL TABLET THERAPY PACK 90 & 180 MG bexarotene oral capsule 75 PA2; PA2; LA; QL (30 per 30 days) bicalutamide oral tablet 50 ; QL (30 per 30 days) BOSULIF ORAL TABLET 100 MG PA2; ; QL (120 per 30 days) BOSULIF ORAL TABLET 400 MG, 500 MG PA2; ; QL (30 per 30 days) BRAFTOVI ORAL CAPSULE 50 MG, 75 MG PA2; LA CABOMETYX ORAL TABLET 20 MG, 40 MG, 60 MG PA2; LA CALQUENCE ORAL CAPSULE 100 MG PA2; LA; QL (60 per 30 days) CAPRELSA ORAL TABLET 100 MG PA2; LA; QL (60 per 30 days) CAPRELSA ORAL TABLET 300 MG PA2; LA; QL (30 per 30 days) COMETRIQ (100 MG DAILY DOSE) ORAL KIT 1 X 80 & 1 X 20 MG COMETRIQ (140 MG DAILY DOSE) ORAL KIT 1 X 80 & 3 X 20 MG COMETRIQ (60 MG DAILY DOSE) ORAL KIT 20 MG PA2; LA; QL (60 per 30 days) PA2; LA; QL (120 per 30 days) PA2; LA; QL (90 per 30 days) COPIKTRA ORAL CAPSULE 15 MG, 25 MG PA2; LA; QL (60 per 30 days) COTELLIC ORAL TABLET 20 MG PA2; LA DROXIA ORAL CAPSULE 200 MG, 300 MG, 400 MG ELIGARD SUBCUTANEOUS KIT 22.5 MG, 30 MG, 45 MG, 7.5 MG 24 EMCYT ORAL CAPSULE 140 MG PA2; ERIVEDGE ORAL CAPSULE 150 MG PA2; ERLEADA ORAL TABLET 60 MG PA2; LA FARYDAK ORAL CAPSULE 10 MG, 15 MG, 20 MG FIRMAGON SUBCUTANEOUS SOLUTION RECONSTITUTED 120 MG, 80 MG fluorouracil external cream 5 % PA2; PA2;

25 fluorouracil external solution 2 %, 5 % flutamide oral capsule 125 GILOTRIF ORAL TABLET 20 MG, 30 MG, 40 MG hydroxyurea oral capsule 500 IBRANCE ORAL CAPSULE 100 MG, 125 MG, 75 MG PA2; LA PA2; ICLUSIG ORAL TABLET 15 MG PA2; LA; QL (60 per 30 days) ICLUSIG ORAL TABLET 45 MG PA2; LA; QL (30 per 30 days) IDHIFA ORAL TABLET 100 MG PA2; LA; QL (30 per 30 days) IDHIFA ORAL TABLET 50 MG PA2; LA; QL (60 per 30 days) imatinib mesylate oral tablet 100 PA2; ; QL (180 per 30 days) imatinib mesylate oral tablet 400 PA2; ; QL (60 per 30 days) IMBRUVICA ORAL CAPSULE 140 MG, 70 MG PA2; LA IMBRUVICA ORAL TABLET 140 MG, 280 MG, 420 MG, 560 MG PA2; LA INLYTA ORAL TABLET 1 MG PA2; ; QL (180 per 30 days) INLYTA ORAL TABLET 5 MG PA2; ; QL (60 per 30 days) INTRON A INJECTION SOLUTION UNIT/ML, UNIT/ML INTRON A INJECTION SOLUTION RECONSTITUTED UNIT, UNIT, UNIT PA2; PA2; IRESSA ORAL TABLET 250 MG PA2; LA JAKAFI ORAL TABLET 10 MG, 15 MG, 20 MG, 25 MG, 5 MG KISQALI 200 DOSE ORAL TABLET 200 MG PA2; KISQALI 400 DOSE ORAL TABLET 200 MG PA2; KISQALI 600 DOSE ORAL TABLET 200 MG PA2; KISQALI FEMARA 200 DOSE ORAL TABLET THERAPY PACK 200 & 2.5 MG KISQALI FEMARA 400 DOSE ORAL TABLET THERAPY PACK 200 & 2.5 MG KISQALI FEMARA 600 DOSE ORAL TABLET THERAPY PACK 200 & 2.5 MG LENVIMA 10 MG DAILY DOSE ORAL CAPSULE THERAPY PACK 10 MG PA2; LA; QL (60 per 30 days) PA2; PA2; PA2; PA2; 25

26 LENVIMA 12 MG DAILY DOSE ORAL CAPSULE THERAPY PACK 4 (3) MG LENVIMA 14 MG DAILY DOSE ORAL CAPSULE THERAPY PACK 10 & 4 MG LENVIMA 18 MG DAILY DOSE ORAL CAPSULE THERAPY PACK 10 & 4 (2) MG LENVIMA 20 MG DAILY DOSE ORAL CAPSULE THERAPY PACK 10 (2) MG LENVIMA 24 MG DAILY DOSE ORAL CAPSULE THERAPY PACK 10 (2) & 4 MG LENVIMA 4 MG DAILY DOSE ORAL CAPSULE THERAPY PACK 4 MG LENVIMA 8 MG DAILY DOSE ORAL CAPSULE THERAPY PACK 4 (2) MG leucovorin calcium oral tablet 10, 15, 25, 5 PA2; PA2; PA2; PA2; PA2; PA2; PA2; leuprolide acetate injection kit 1 /0.2ml PA2; LONSURF ORAL TABLET MG, MG 26 PA2; LA LORBRENA ORAL TABLET 100 MG, 25 MG PA2; LUPRON DEPOT (1-NTH) INTRAMUSCULAR KIT 3.75 MG, 7.5 MG LUPRON DEPOT (3-NTH) INTRAMUSCULAR KIT MG, 22.5 MG LUPRON DEPOT (4-NTH) INTRAMUSCULAR KIT 30 MG LUPRON DEPOT (6-NTH) INTRAMUSCULAR KIT 45 MG PA2; PA2; PA2; PA2; LYNPARZA ORAL TABLET 100 MG, 150 MG PA2; LA LYSODREN ORAL TABLET 500 MG MATULANE ORAL CAPSULE 50 MG PA2; LA megestrol acetate oral suspension 40 /ml PA2; ; HRM megestrol acetate oral tablet 20, 40 PA2; ; HRM MEKINIST ORAL TABLET 0.5 MG, 2 MG PA2; LA MEKTOVI ORAL TABLET 15 MG PA2; LA NERLYNX ORAL TABLET 40 MG PA2; LA; QL (180 per 30 days) NEXAVAR ORAL TABLET 200 MG PA2; LA; QL (120 per 30 days)

27 nilutamide oral tablet 150 ; QL (60 per 30 days) NINLARO ORAL CAPSULE 2.3 MG, 3 MG, 4 MG PA2; ODOMZO ORAL CAPSULE 200 MG PA2; LA POMALYST ORAL CAPSULE 1 MG, 2 MG, 3 MG, 4 MG RUBRACA ORAL TABLET 200 MG, 250 MG, 300 MG PA2; LA PA2; LA RYDAPT ORAL CAPSULE 25 MG PA2; ; QL (240 per 30 days) SOLTAX ORAL SOLUTION 10 MG/5ML PA2; SPRYCEL ORAL TABLET 100 MG, 50 MG, 70 MG, 80 MG PA2; ; QL (60 per 30 days) SPRYCEL ORAL TABLET 140 MG PA2; ; QL (30 per 30 days) SPRYCEL ORAL TABLET 20 MG PA2; ; QL (90 per 30 days) STIVARGA ORAL TABLET 40 MG PA2; LA SUTENT ORAL CAPSULE 12.5 MG, 25 MG, 37.5 MG, 50 MG SYLATRON SUBCUTANEOUS KIT 200 MCG, 300 MCG, 600 MCG SYNRIBO SUBCUTANEOUS SOLUTION RECONSTITUTED 3.5 MG PA2; PA2; PA2; TAFINLAR ORAL CAPSULE 50 MG, 75 MG PA2; LA TAGRISSO ORAL TABLET 40 MG, 80 MG PA2; LA TALZENNA ORAL CAPSULE 0.25 MG, 1 MG PA2; LA tamoxifen citrate oral tablet 10, 20 TARCEVA ORAL TABLET 100 MG, 150 MG PA2; ; QL (30 per 30 days) TARCEVA ORAL TABLET 25 MG PA2; ; QL (90 per 30 days) TARGRETIN EXTERNAL GEL 1 % PA2; ; QL (60 per 30 days) TASIGNA ORAL CAPSULE 150 MG, 200 MG PA2; ; QL (120 per 30 days) TASIGNA ORAL CAPSULE 50 MG PA2; TIBSOVO ORAL TABLET 250 MG PA2; LA TOLAK EXTERNAL CREAM 4 % TRELSTAR MIXJECT INTRAMUSCULAR SUSPENSION RECONSTITUTED MG, 22.5 MG, 3.75 MG tretinoin oral capsule 10 PA2; 27

28 TYKERB ORAL TABLET 250 MG PA2; ; QL (150 per 30 days) VALCHLOR EXTERNAL GEL % PA2; ; QL (60 per 30 days) VENCLEXTA ORAL TABLET 10 MG, 100 MG, 50 MG VENCLEXTA STARTING PACK ORAL TABLET THERAPY PACK 10 & 50 & 100 MG VERZENIO ORAL TABLET 100 MG, 150 MG, 200 MG, 50 MG PA2; LA PA2; LA PA2; LA VITRAKVI ORAL CAPSULE 100 MG, 25 MG PA2; VITRAKVI ORAL SOLUTION 20 MG/ML PA2; VIZIMPRO ORAL TABLET 15 MG, 30 MG, 45 MG PA2; ; QL (30 per 30 days) VOTRIENT ORAL TABLET 200 MG PA2; ; QL (120 per 30 days) XALKORI ORAL CAPSULE 200 MG, 250 MG PA2; ; QL (60 per 30 days) XOSPATA ORAL TABLET 40 MG PA2; XTANDI ORAL CAPSULE 40 MG PA2; LA; QL (120 per 30 days) YONSA ORAL TABLET 125 MG PA2; ; QL (120 per 30 days) ZEJULA ORAL CAPSULE 100 MG PA2; LA; QL (90 per 30 days) ZELBORAF ORAL TABLET 240 MG PA2; ; QL (240 per 30 days) ZOLINZA ORAL CAPSULE 100 MG PA2; ; QL (120 per 30 days) ZYDELIG ORAL TABLET 100 MG PA2; LA; QL (90 per 30 days) ZYDELIG ORAL TABLET 150 MG PA2; LA; QL (60 per 30 days) ZYKADIA ORAL CAPSULE 150 MG PA2; ZYTIGA ORAL TABLET 500 MG PA2; ; QL (120 per 30 days) AROMATASE INHIBITORS, 3RD GENERATION anastrozole oral tablet 1 exemestane oral tablet 25 ; QL (60 per 30 days) letrozole oral tablet 2.5 TREATMENT ADJUNCTS allopurinol oral tablet 300 MESNEX ORAL TABLET 400 MG ANTIPARASITICS ANTHELMINTICS ALBENZA ORAL TABLET 200 MG 28

29 benznidazole oral tablet 100, 12.5 EMVERM ORAL TABLET CHEWABLE 100 MG 29 ivermectin oral tablet 3 ANTIPROTOZOALS ALINIA ORAL SUSPENSION RECONSTITUTED 100 MG/5ML PA1; ; QL (180 per 30 days) ALINIA ORAL TABLET 500 MG PA1; ; QL (6 per 30 days) atovaquone oral suspension 750 /5ml atovaquone-proguanil hcl oral tablet , chloroquine phosphate oral tablet 250, 500 COARTEM ORAL TABLET MG hydroxychloroquine sulfate oral tablet 200 mefloquine hcl oral tablet 250 primaquine phosphate oral tablet 26.3 quinine sulfate oral capsule 324 PA1; ANTIPARKINSON AGENTS ANTICHOLINERGICS benztropine mesylate oral tablet 0.5, 1, 2 trihexyphenidyl hcl oral elixir 0.4 /ml trihexyphenidyl hcl oral tablet 2, 5 ANTIPARKINSON AGENTS, OTHER amantadine hcl oral capsule 100 amantadine hcl oral syrup 50 /5ml amantadine hcl oral tablet 100 entacapone oral tablet 200 GOCOVRI ORAL CAPSULE EXTENDED RELEASE 24 HOUR 137 MG GOCOVRI ORAL CAPSULE EXTENDED RELEASE 24 HOUR 68.5 MG DOPAMINE AGONISTS APOKYN SUBCUTANEOUS SOLUTION CARTRIDGE 30 MG/3ML PA1; LA; QL (60 per 30 days) PA1; LA; QL (30 per 30 days) PA1; LA; QL (60 per 30 days)

30 bromocriptine mesylate oral capsule 5 bromocriptine mesylate oral tablet 2.5 NEUPRO TRANSDERMAL PATCH 24 HOUR 1 MG/24HR, 2 MG/24HR, 3 MG/24HR, 4 MG/24HR, 6 MG/24HR, 8 MG/24HR pramipexole dihydrochloride oral tablet 0.125, 0.25, 0.5, 0.75, 1, 1.5 ropinirole hcl er oral tablet extended release 24 hour 12, 2, 4, 6, 8 ropinirole hcl oral tablet 0.25, 0.5, 1, 2, 3, 4, 5 ST1; DOPAMINE PRECURSORS/ L-AMINO ACID DECARBOXYLASE INHIBITORS carbidopa oral tablet 25 carbidopa-levodopa er oral tablet extended release , carbidopa-levodopa oral tablet , , carbidopa-levodopa oral tablet dispersible , , carbidopa-levodopa-entacapone oral tablet , , , , , RYTARY ORAL CAPSULE EXTENDED RELEASE MG, MG, MG, MG NOAMINE OXIDASE B (MAO-B) INHIBITORS ST1; rasagiline mesylate oral tablet 0.5, 1 ; QL (30 per 30 days) selegiline hcl oral capsule 5 selegiline hcl oral tablet 5 ANTIPSYCHOTICS 1ST GENERATION/TYPICAL chlorpromazine hcl oral tablet 10, 100, 200, 25, 50 COMPRO RECTAL SUPPOSITORY 25 MG fluphenazine decanoate injection solution 25 /ml 30

31 fluphenazine hcl injection solution 2.5 /ml fluphenazine hcl oral concentrate 5 /ml fluphenazine hcl oral elixir 2.5 /5ml fluphenazine hcl oral tablet 1, 10, 2.5, 5 haloperidol decanoate intramuscular solution 100 /ml, 100 /ml 1 ml, 50 /ml haloperidol lactate injection solution 5 /ml, 5 /ml(1 ml prefilled syringe) 31 haloperidol lactate oral concentrate 2 /ml haloperidol oral tablet 0.5, 1, 10, 2, 20, 5 loxapine succinate oral capsule 10, 25, 5, 50 molindone hcl oral tablet 10, 25, 5 perphenazine oral tablet 16, 2, 4, 8 perphenazine-amitriptyline oral tablet 2-10, 2-25, 4-10, 4-25, 4-50 pimozide oral tablet 1, 2 prochlorperazine maleate oral tablet 10, 5 prochlorperazine rectal suppository 25 thioridazine hcl oral tablet 10, 100, 25, 50 thiothixene oral capsule 1, 10, 2, 5 trifluoperazine hcl oral tablet 1, 10, 2, 5 2ND GENERATION/ATYPICAL ABILIFY MAINTENA INTRAMUSCULAR PREFILLED SYRINGE 300 MG, 400 MG ABILIFY MAINTENA INTRAMUSCULAR SUSPENSION RECONSTITUTED ER 300 MG, 400 MG PA2; PA2; aripiprazole oral solution 1 /ml ; QL (750 per 30 days) aripiprazole oral tablet 10, 15, 20, 30 ; QL (30 per 30 days) aripiprazole oral tablet 2, 5 ; QL (60 per 30 days) aripiprazole oral tablet dispersible 10, 15 ; QL (60 per 30 days)

32 FANAPT ORAL TABLET 1 MG, 10 MG, 12 MG, 2 MG, 4 MG, 6 MG, 8 MG FANAPT TITRATION PACK ORAL TABLET 1 & 2 & 4 & 6 MG INVEGA SUSTENNA INTRAMUSCULAR SUSPENSION 117 MG/0.75ML, 156 MG/ML, 234 MG/1.5ML, 39 MG/0.25ML, 78 MG/0.5ML INVEGA TRINZA INTRAMUSCULAR SUSPENSION 273 MG/0.875ML, 410 MG/1.315ML, 546 MG/1.75ML, 819 MG/2.625ML LATUDA ORAL TABLET 120 MG, 20 MG, 40 MG PA2; ; QL (60 per 30 days) PA2; ; QL (8 per 180 days) PA2; PA2; PA2; ; QL (30 per 30 days) LATUDA ORAL TABLET 60 MG, 80 MG PA2; ; QL (60 per 30 days) NUPLAZID ORAL CAPSULE 34 MG PA2; LA NUPLAZID ORAL TABLET 10 MG, 17 MG PA2; LA olanzapine oral tablet 10, 15, 2.5, 20, 5, 7.5 olanzapine oral tablet dispersible 10, 15, 20, 5 paliperidone er oral tablet extended release 24 hour 1.5, 3, 6 paliperidone er oral tablet extended release 24 hour 9 quetiapine fumarate er oral tablet extended release 24 hour 150, 200, 300, 400, 50 quetiapine fumarate oral tablet 100, 200, 25, 300, 400, 50 REXULTI ORAL TABLET 0.25 MG, 0.5 MG, 1 MG, 2 MG, 3 MG, 4 MG RISPERDAL CONSTA INTRAMUSCULAR SUSPENSION RECONSTITUTED 12.5 MG, 25 MG, 37.5 MG, 50 MG ; QL (30 per 30 days) ; QL (30 per 30 days) PA2; ; QL (60 per 30 days) PA2; ; QL (30 per 30 days) risperidone oral solution 1 /ml risperidone oral tablet 0.25, 0.5, 1, 2, 3, 4 risperidone oral tablet dispersible 0.25, 0.5, 1, 2, 3, 4 PA2; ; QL (30 per 30 days) PA2; 32

33 SAPHRIS SUBLINGUAL TABLET SUBLINGUAL 10 MG, 2.5 MG, 5 MG PA2; ; QL (60 per 30 days) VRAYLAR ORAL CAPSULE 1.5 MG PA2; ; QL (120 per 30 days) VRAYLAR ORAL CAPSULE 3 MG PA2; ; QL (60 per 30 days) VRAYLAR ORAL CAPSULE 4.5 MG, 6 MG PA2; ; QL (30 per 30 days) VRAYLAR ORAL CAPSULE THERAPY PACK 1.5 & 3 MG ziprasidone hcl oral capsule 20, 40, 60, 80 ZYPREXA RELPREVV INTRAMUSCULAR SUSPENSION RECONSTITUTED 210 MG TREATMENT-RESISTANT clozapine oral tablet 100, 200, 25, 50 clozapine oral tablet dispersible 100, 12.5, 150, 200, 25 olanzapine intramuscular solution reconstituted 10 ANTIVIRALS ANTI-CYTOMEGALOVIRUS (CMV) AGENTS PA2; ; QL (60 per 30 days) PA2; PREVYMIS ORAL TABLET 240 MG, 480 MG PA1; ; QL (100 per 100 days) valganciclovir hcl oral solution reconstituted 50 /ml 33 valganciclovir hcl oral tablet 450 ANTIHEPATITIS AGENTS adefovir dipivoxil oral tablet 10 PA1; ; QL (30 per 30 days) BARACLUDE ORAL SOLUTION 0.05 MG/ML PA1; ; QL (600 per 30 days) entecavir oral tablet 0.5, 1 PA1; ; QL (30 per 30 days) EPIVIR HBV ORAL SOLUTION 5 MG/ML lamivudine oral tablet 100 REBETOL ORAL SOLUTION 40 MG/ML RIBASPHERE ORAL CAPSULE 200 MG RIBASPHERE ORAL TABLET 200 MG, 400 MG, 600 MG RIBASPHERE RIBAPAK ORAL TABLET 400 MG, 600 MG

34 RIBASPHERE RIBAPAK ORAL TABLET THERAPY PACK 200 & 400 MG, 400 & 600 MG ribavirin oral capsule 200 ; QL (180 per 30 days) ribavirin oral tablet 200 ; QL (180 per 30 days) VEMLIDY ORAL TABLET 25 MG PA1; ANTI-HEPATITIS C (HCV) AGENTS, DIRECT ACTING MAVYRET ORAL TABLET MG PA1; sofosbuvir-velpatasvir oral tablet PA1; VOSEVI ORAL TABLET MG PA1; ANTI-HEPATITIS C (HCV) AGENTS, OTHER DERIBA 1200 DOSE PACK ORAL TABLET 600 MG DERIBA ORAL TABLET 200 MG PEGASYS PROCLICK SUBCUTANEOUS SOLUTION 135 MCG/0.5ML, 180 MCG/0.5ML PEGASYS SUBCUTANEOUS SOLUTION 180 MCG/0.5ML, 180 MCG/ML ANTIHERPETIC AGENTS acyclovir oral capsule 200 acyclovir oral suspension 200 /5ml acyclovir oral tablet 400, 800 PA1; PA1; acyclovir sodium intravenous solution 50 /ml BvD; famciclovir oral tablet 125, 250, 500 valacyclovir hcl oral tablet 1 gm, 500 ANTI-HIV AGENTS, NON-NUCLEOSIDE REVERSE TRANSCRIPTASE INHIBITORS ATRIPLA ORAL TABLET MG COMPLERA ORAL TABLET MG EDURANT ORAL TABLET 25 MG efavirenz oral capsule 200, 50 efavirenz oral tablet 600 GENVOYA ORAL TABLET MG 34

35 INTELENCE ORAL TABLET 100 MG, 200 MG, 25 MG nevirapine er oral tablet extended release 24 hour 100, nevirapine oral tablet 200 ODEFSEY ORAL TABLET MG PIFELTRO ORAL TABLET 100 MG RESCRIPTOR ORAL TABLET 100 MG, 200 MG SYMFI LO ORAL TABLET MG SYMFI ORAL TABLET MG SYMTUZA ORAL TABLET MG VIRAMUNE ORAL SUSPENSION 50 MG/5ML ANTI-HIV AGENTS, NUCLEOSIDE AND NUCLEOTIDE REVERSE TRANSCRIPTASE INHIBITORS abacavir sulfate oral solution 20 /ml abacavir sulfate oral tablet 300 abacavir sulfate-lamivudine oral tablet abacavir-lamivudine-zidovudine oral tablet BIKTARVY ORAL TABLET MG CIMDUO ORAL TABLET MG DELSTRIGO ORAL TABLET MG DESCOVY ORAL TABLET MG didanosine oral capsule delayed release 200, 250, 400 EMTRIVA ORAL CAPSULE 200 MG EMTRIVA ORAL SOLUTION 10 MG/ML EVOTAZ ORAL TABLET MG JULUCA ORAL TABLET MG lamivudine oral solution 10 /ml lamivudine oral tablet 150, 300 lamivudine-zidovudine oral tablet PREZCOBIX ORAL TABLET MG

36 stavudine oral capsule 15, 20, 30, 40 STRIBILD ORAL TABLET MG tenofovir disoproxil fumarate oral tablet 300 TRIUMEQ ORAL TABLET MG TRUVADA ORAL TABLET MG, MG, MG, MG VIDEX EC ORAL CAPSULE DELAYED RELEASE 125 MG VIDEX ORAL SOLUTION RECONSTITUTED 4 GM VIREAD ORAL POWDER 40 MG/GM VIREAD ORAL TABLET 150 MG, 200 MG, 250 MG zidovudine oral capsule 100 zidovudine oral syrup 50 /5ml zidovudine oral tablet 300 ANTI-HIV AGENTS, OTHER FUZEON SUBCUTANEOUS SOLUTION RECONSTITUTED 90 MG ISENTRESS HD ORAL TABLET 600 MG ISENTRESS ORAL PACKET 100 MG ISENTRESS ORAL TABLET 400 MG ISENTRESS ORAL TABLET CHEWABLE 100 MG, 25 MG SELZENTRY ORAL SOLUTION 20 MG/ML SELZENTRY ORAL TABLET 150 MG, 25 MG, 300 MG, 75 MG TIVICAY ORAL TABLET 10 MG, 25 MG, 50 MG TYBOST ORAL TABLET 150 MG ANTI-HIV AGENTS, PROTEASE INHIBITORS APTIVUS ORAL CAPSULE 250 MG APTIVUS ORAL SOLUTION 100 MG/ML 36

37 atazanavir sulfate oral capsule 150, 200, CRIXIVAN ORAL CAPSULE 200 MG, 400 MG fosamprenavir calcium oral tablet 700 INVIRASE ORAL TABLET 500 MG KALETRA ORAL TABLET MG, MG LEXIVA ORAL SUSPENSION 50 MG/ML lopinavir-ritonavir oral solution /5ml NORVIR ORAL PACKET 100 MG NORVIR ORAL SOLUTION 80 MG/ML PREZISTA ORAL SUSPENSION 100 MG/ML PREZISTA ORAL TABLET 150 MG, 600 MG, 75 MG, 800 MG REYATAZ ORAL PACKET 50 MG ritonavir oral tablet 100 VIRACEPT ORAL TABLET 250 MG, 625 MG ANTI-INFLUENZA AGENTS oseltamivir phosphate oral capsule 30, 45, 75 oseltamivir phosphate oral suspension reconstituted 6 /ml RELENZA DISKHALER INHALATION AEROSOL POWDER BREATH ACTIVATED 5 MG/BLISTER rimantadine hcl oral tablet 100 XOFLUZA ORAL TABLET THERAPY PACK 20 (2) MG, 40 (2) MG ANXIOLYTICS ANXIOLYTICS, OTHER buspirone hcl oral tablet 10, 15, 30, 5, 7.5 hydroxyzine hcl oral syrup 10 /5ml hydroxyzine hcl oral tablet 10, 25, 50 hydroxyzine pamoate oral capsule 100, 25, 50

38 meprobamate oral tablet 200, 400 BENZODIAZEPINES alprazolam er oral tablet extended release 24 hour 0.5, 1, 2, 3 ALPRAZOLAM INTENSOL ORAL CONCENTRATE 1 MG/ML alprazolam oral tablet 0.25, 0.5, 1, 2 alprazolam oral tablet dispersible 0.25, 0.5, 1, 2 chlordiazepoxide hcl oral capsule 10, 25, 5 clorazepate dipotassium oral tablet 15, 3.75, 7.5 DIAZEPAM INTENSOL ORAL CONCENTRATE 5 MG/ML 38 diazepam oral solution 1 /ml, 5 /5ml diazepam oral tablet 10, 2, 5 lorazepam oral concentrate 2 /ml lorazepam oral tablet 0.5, 1, 2 oxazepam oral capsule 10, 15, 30 BIPOLAR AGENTS OD STABILIZERS EQUETRO ORAL CAPSULE EXTENDED RELEASE 12 HOUR 100 MG, 200 MG, 300 MG GEODON INTRAMUSCULAR SOLUTION RECONSTITUTED 20 MG lithium carbonate er oral tablet extended release 300, 450 lithium carbonate oral capsule 150, 300, 600 PA2; ; QL (60 per 30 days) lithium carbonate oral tablet 300 lithium oral solution 8 meq/5ml BLOOD GLUCOSE REGULATORS ANTIDIABETIC AGENTS acarbose oral tablet 100, 25, 50

39 AVANDIA ORAL TABLET 2 MG, 4 MG chlorpropamide oral tablet 100, 250 PA1; ; HRM CYCLOSET ORAL TABLET 0.8 MG glimepiride oral tablet 1, 2, 4 glipizide er oral tablet extended release 24 hour 10, 2.5, 5 39 glipizide oral tablet 10, 5 glipizide-metformin hcl oral tablet , , glyburide micronized oral tablet 1.5, 3, 6 PA1; ; HRM glyburide oral tablet 1.25, 2.5, 5 PA1; ; HRM glyburide-metformin oral tablet , , INVOKAMET ORAL TABLET MG, MG, MG, MG INVOKAMET XR ORAL TABLET EXTENDED RELEASE 24 HOUR MG, MG, MG, MG PA1; ; HRM ST1; ST1; INVOKANA ORAL TABLET 100 MG, 300 MG ST1; JANUMET ORAL TABLET MG, MG JANUMET XR ORAL TABLET EXTENDED RELEASE 24 HOUR MG JANUMET XR ORAL TABLET EXTENDED RELEASE 24 HOUR MG, MG JANUVIA ORAL TABLET 100 MG, 25 MG, 50 MG JARDIANCE ORAL TABLET 10 MG, 25 MG ST1; metformin hcl er oral tablet extended release 24 hour 500, 750 metformin hcl oral tablet 1000, 500, 850 ; QL (60 per 30 days) ; QL (30 per 30 days) ; QL (60 per 30 days) ; QL (30 per 30 days) miglitol oral tablet 100, 25, 50 nateglinide oral tablet 120, 60 OZEMPIC SUBCUTANEOUS SOLUTION PEN- INJECTOR 0.25 OR 0.5 MG/DOSE, 1 MG/DOSE pioglitazone hcl oral tablet 15, 30, 45 ; QL (6 per 30 days)

40 pioglitazone hcl-glimepiride oral tablet 30-2, 30-4 pioglitazone hcl-metformin hcl oral tablet , repaglinide oral tablet 0.5, 1, 2 repaglinide-metformin hcl oral tablet 1-500, RIOMET ORAL SOLUTION 500 MG/5ML SOLIQUA SUBCUTANEOUS SOLUTION PEN- INJECTOR UNT-MCG/ML SYMLINPEN 120 SUBCUTANEOUS SOLUTION PEN-INJECTOR 2700 MCG/2.7ML SYMLINPEN 60 SUBCUTANEOUS SOLUTION PEN-INJECTOR 1500 MCG/1.5ML SYNJARDY ORAL TABLET MG, MG, MG, MG SYNJARDY XR ORAL TABLET EXTENDED RELEASE 24 HOUR MG, MG, MG, MG tolazamide oral tablet 250, 500 tolbutamide oral tablet 500 TRULICITY SUBCUTANEOUS SOLUTION PEN-INJECTOR 0.75 MG/0.5ML, 1.5 MG/0.5ML VICTOZA SUBCUTANEOUS SOLUTION PEN- INJECTOR 18 MG/3ML XULTOPHY SUBCUTANEOUS SOLUTION PEN-INJECTOR UNIT-MG/ML GLYCEMIC AGENTS GLUCAGEN HYPOKIT INJECTION SOLUTION RECONSTITUTED 1 MG GLUCAGON EMERGENCY INJECTION KIT 1 MG ST1; ; QL (18 per 30 days) PA1; ; QL (10.8 per 28 days) PA1; ; QL (10.8 per 28 days) ST1; ST1; ; QL (2 per 30 days) ; QL (9 per 30 days) ST1; ; QL (15 per 30 days) PROGLYCEM ORAL SUSPENSION 50 MG/ML INSULINS FIASP FLEXTOUCH SUBCUTANEOUS SOLUTION PEN-INJECTOR 100 UNIT/ML FIASP SUBCUTANEOUS SOLUTION 100 UNIT/ML

41 LANTUS SOLOSTAR SUBCUTANEOUS SOLUTION PEN-INJECTOR 100 UNIT/ML LANTUS SUBCUTANEOUS SOLUTION 100 UNIT/ML LEVEMIR FLEXTOUCH SUBCUTANEOUS SOLUTION PEN-INJECTOR 100 UNIT/ML LEVEMIR SUBCUTANEOUS SOLUTION 100 UNIT/ML NOVOLIN 70/30 SUBCUTANEOUS SUSPENSION (70-30) 100 UNIT/ML NOVOLIN N SUBCUTANEOUS SUSPENSION 100 UNIT/ML NOVOLIN R INJECTION SOLUTION 100 UNIT/ML NOVOLOG FLEXPEN SUBCUTANEOUS SOLUTION PEN-INJECTOR 100 UNIT/ML NOVOLOG MIX 70/30 FLEXPEN SUBCUTANEOUS SUSPENSION PEN- INJECTOR (70-30) 100 UNIT/ML NOVOLOG MIX 70/30 SUBCUTANEOUS SUSPENSION (70-30) 100 UNIT/ML NOVOLOG PENFILL SUBCUTANEOUS SOLUTION CARTRIDGE 100 UNIT/ML NOVOLOG SUBCUTANEOUS SOLUTION 100 UNIT/ML TOUJEO MAX SOLOSTAR SUBCUTANEOUS SOLUTION PEN-INJECTOR 300 UNIT/ML TOUJEO SOLOSTAR SUBCUTANEOUS SOLUTION PEN-INJECTOR 300 UNIT/ML TRESIBA FLEXTOUCH SUBCUTANEOUS SOLUTION PEN-INJECTOR 100 UNIT/ML, 200 UNIT/ML BLOOD PRODUCTS/DIFIERS/ VOLUME EXPANDERS ANTICOAGULANTS ELIQUIS ORAL TABLET 2.5 MG, 5 MG ELIQUIS STARTER PACK ORAL TABLET 5 MG 41

42 enoxaparin sodium subcutaneous solution 100 /ml, 120 /0.8ml, 150 /ml, 30 /0.3ml, 40 /0.4ml, 60 /0.6ml, 80 /0.8ml fondaparinux sodium subcutaneous solution 10 /0.8ml, 2.5 /0.5ml, 5 /0.4ml, 7.5 /0.6ml FRAGMIN SUBCUTANEOUS SOLUTION UNIT/ML, UNIT/0.5ML, UNIT/0.6ML, UNT/0.72ML, 2500 UNIT/0.2ML, 5000 UNIT/0.2ML, 7500 UNIT/0.3ML, UNIT/3.8ML heparin sodium (porcine) injection solution 1000 unit/ml, unit/ml, unit/ml, 5000 unit/ml JANTOVEN ORAL TABLET 1 MG, 10 MG, 2 MG, 2.5 MG, 3 MG, 4 MG, 5 MG, 6 MG, 7.5 MG PRADAXA ORAL CAPSULE 110 MG, 150 MG, 75 MG warfarin sodium oral tablet 1, 10, 2, 2.5, 3, 4, 5, 6, 7.5 XARELTO ORAL TABLET 10 MG, 15 MG, 2.5 MG, 20 MG XARELTO STARTER PACK ORAL TABLET THERAPY PACK 15 & 20 MG BLOOD FORMATION DIFIERS ARANESP (ALBUMIN FREE) INJECTION SOLUTION 100 MCG/ML, 200 MCG/ML, 25 MCG/ML, 300 MCG/ML, 40 MCG/ML, 60 MCG/ML ARANESP (ALBUMIN FREE) INJECTION SOLUTION PREFILLED SYRINGE 10 MCG/0.4ML, 100 MCG/0.5ML, 150 MCG/0.3ML, 200 MCG/0.4ML, 25 MCG/0.42ML, 300 MCG/0.6ML, 40 MCG/0.4ML, 500 MCG/ML, 60 MCG/0.3ML EPOGEN INJECTION SOLUTION UNIT/ML, 2000 UNIT/ML, UNIT/ML, 3000 UNIT/ML, 4000 UNIT/ML LEUKINE INTRAVENOUS SOLUTION RECONSTITUTED 250 MCG NEUPOGEN INJECTION SOLUTION 300 MCG/ML, 480 MCG/1.6ML 42 ST1; PA1; ST1; PA1; ST1; PA1; ST1; PA1; PA1;