AETNA BETTER HEALTH Formulary Guide. Aetna Better Health of Michigan

Transcription

1 AETNA BETTER HEALTH Formulary Guide Aetna Better Health of Michigan Formulary Guide April 2016

2 AETNA BETTER HEALTH Formulary Guide What is the Aetna Better Health of Michigan 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 coverage rules for the drug Drugs are also grouped by the type of condition they treat. Drugs used to treat an earache are listed under the section, Ear-Nose-Throat Medications. If you know what your drug is used for, please look for that section name on the drug list. Then look under that section 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. Updated: 04/01/2016 Page 2

3 AETNA BETTER HEALTH Formulary Guide Are there Medication Copays? Copays for brand drugs are $0 and copays for generic drugs are $0. 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: 04/01/2016 Page 3

4 Aetna Better Health Michigan Table of Contents Table of Contents *Adhd/Anti-Narcolepsy/Anti-Obesity/Anorexiants*... 3 *Aminoglycosides*... 3 *Analgesics - Anti-Inflammatory*... 3 *Analgesics - Nonnarcotic*... 5 *Analgesics - Opioid*... 5 *Androgens-Anabolic*... 7 *Anorectal Agents*... 8 *Anthelmintics*... 8 *Antianginal Agents*... 8 *Antianxiety Agents*... 9 *Antiarrhythmics*... 9 *Antiasthmatic And Bronchodilator Agents* *Anticoagulants* *Antidiabetics* *Antidiarrheals* *Antidotes* *Antiemetics* *Antifungals* *Antihistamines* *Antihyperlipidemics* *Antihypertensives* *Anti-Infective Agents - Misc.* *Antimalarials* *Antimyasthenic Agents* *Antimycobacterial Agents* *Antineoplastics And Adjunctive Therapies* *Antiparkinson Agents* *Antipsychotics/Antimanic Agents* *Antiseptics & Disinfectants* *Antivirals* *Assorted Classes* *Beta Blockers* *Calcium Channel Blockers* *Cardiotonics* *Cardiovascular Agents - Misc.* *Cephalosporins* *Chemicals* *Contraceptives* *Corticosteroids* *Cough/Cold/Allergy* *Dermatologicals* *Diagnostic Products* *Digestive Aids* *Diuretics* *Endocrine And Metabolic Agents - Misc.* *Estrogens*

5 Table of Contents *Fluoroquinolones* *Gastrointestinal Agents - Misc.* *Genitourinary Agents - Miscellaneous* *Gout Agents* *Hematological Agents - Misc.* *Hematopoietic Agents* *Laxatives* *Macrolides* *Migraine Products* *Minerals & Electrolytes* *Mouth/Throat/Dental Agents* *Multivitamins* *Musculoskeletal Therapy Agents* *Nasal Agents - Systemic And Topical* *Neuromuscular Agents* *Ophthalmic Agents* *Otic Agents* *Oxytocics* *Passive Immunizing Agents* *Penicillins* *Potassium Removing Agents*** *Progestins* *Psychotherapeutic And Neurological Agents - Misc.* *Sulfonamides* *Tetracyclines* *Thyroid Agents* *Ulcer Drugs* *Urinary Anti-Infectives* *Urinary Antispasmodics* *Vaccines* *Vaginal Products* *Vasopressors* *Vitamins*

6 Aetna Better Health Michigan lowercase italics = Generic drugs UPPERCASE BOLD = Brand name drugs Notes AL = Age Limits Apply OTC = Over the Counter = Prior Authorization Applies QLL = Quantity Level Limits Apply ST = Step Therapy Applies *Adhd/Anti-Narcolepsy/Anti-Obesity /Anorexiants* caffeine citrate oral solution 20 /ml, 60 /3ml caffeine citrated powder *Aminoglycosides* neomycin sulfate oral tablet 500 paromomycin sulfate oral capsule 250 tobramycin inhalation nebulization solution 300 /5ml *Analgesics - Anti-Inflammatory* celecoxib oral capsule 100, 200, 400, 50 diclofenac potassium oral tablet 50 diclofenac sodium er oral tablet extended release 24 hr* 100 diclofenac sodium oral tablet delayed release 25, 50, 75 ENBREL SUBCUTANEOUS* 25 MG/0.5ML, 50 MG/ML ENBREL SURECLICK SUBCUTANEOUS* 50 MG/ML etodolac er oral tablet extended release 24 hr* 400, 500, 600 Cafcit Tobi CeleBREX Cataflam Voltaren-XR ST 3

7 etodolac oral capsule 200, 300 etodolac oral tablet 400, 500 fenoprofen calcium oral tablet 600 flurbiprofen oral tablet 100, 50 HUMIRA PEDIATRIC CROHNS START SUBCUTANEOUS* 40 MG/0.8ML HUMIRA PEN SUBCUTANEOUS* 40 MG/0.8ML HUMIRA PEN-CROHNS STARTER SUBCUTANEOUS* 40 MG/0.8ML HUMIRA PEN-PSORIASIS STARTER SUBCUTANEOUS* 40 MG/0.8ML HUMIRA SUBCUTANEOUS* 10 MG/0.2ML, 20 MG/0.4ML, 40 MG/0.8ML ibuprofen oral tablet 400, 600, 800 indomethacin er oral capsule extended release* 75 indomethacin oral capsule 25, 50 ketoprofen oral capsule 50, 75 ketorolac tromethamine oral tablet 10 leflunomide oral tablet 10, 20 meclofenamate sodium oral capsule 100, 50 meloxicam oral suspension 7.5 /5ml meloxicam oral tablet 15, 7.5 nabumetone oral tablet 500, 750 naproxen dr oral tablet delayed release 375, 500 naproxen kit oral tablet 500 naproxen oral suspension 125 /5ml naproxen oral tablet 250, 375, 500 naproxen sodium oral tablet 275 naproxen sodium oral tablet 550 oxaprozin oral tablet 600 piroxicam oral capsule 10, 20 RHEUMATREX ORAL TABLET 2.5 MG RIDAURA ORAL CAPSULE 3 MG sulindac oral tablet 150 sulindac oral tablet 200 tolmetin sodium oral capsule 400 Arava Mobic Mobic EC-Naprosyn Naprosyn Naprosyn Naprosyn Anaprox Anaprox DS Daypro Feldene Clinoril QLL (20 per 30 days) 4

8 tolmetin sodium oral tablet 200, 600 *Analgesics - Nonnarcotic* butalbital-acetaminophen oral tablet butalbital-apap-caffeine oral capsule butalbital-apap-caffeine oral capsule butalbital-apap-caffeine oral tablet butalbital-aspirin-caffeine oral capsule CACET ORAL CAPSULE MG choline & mag trisalicylate oral tablet 1000 choline-mag trisalicylate oral liquid 500 /5ml diflunisal oral tablet 500 ESGIC ORAL CAPSULE MG Tencon Orbivan Capacet Fioricet Fiorinal Margesic Margesic QLL (180 per 30 days) QLL (180 per 30 days) QLL (180 per 30 days) QLL (180 per 30 days) margesic oral capsule Capacet QLL (180 per 30 days) marten-tab oral tablet salsalate oral tablet 500, 750 TENCON ORAL TABLET MG ZEBUTAL ORAL CAPSULE MG *Analgesics - Opioid* acetaminophen-codeine #2 oral tablet acetaminophen-codeine #3 oral tablet acetaminophen-codeine #4 oral tablet acetaminophen-codeine oral solution /5ml acetaminophen-codeine oral tablet Tencon Disalcid Butalbital-Acetaminophen Margesic Tylenol with Codeine #3 Tylenol with Codeine #4 acetaminophen-codeine oral tablet Tylenol with Codeine #3 acetaminophen-codeine oral tablet Tylenol with Codeine #4 ASCOMP-CODEINE ORAL CAPSULE MG butalbital-apap-caff-cod oral capsule , Butalbital-ASA-Caff-Codeine Fioricet/Codeine QLL (180 per 30 days) 5

9 butalbital-asa-caff-codeine oral capsule butorphanol tartrate nasal solution 10 /ml codeine sulfate oral tablet 15, 30, 60 ENDOCET ORAL TABLET MG, MG, MG, MG fentanyl citrate buccal lollipop 1200 mcg, 1600 mcg, 200 mcg, 400 mcg, 600 mcg, 800 mcg Ascomp-Codeine Oxycodone-Acetaminophen Actiq QLL (180 per 30 days) QLL (1 per 30 days) QLL (30 per 30 days) QLL (90 per 30 days) fentanyl transdermal patch 72 hr 100 mcg/hr Duragesic-100 ; QLL (10 per 30 days) fentanyl transdermal patch 72 hr 12 mcg/hr Duragesic-12 ; QLL (10 per 30 days) fentanyl transdermal patch 72 hr 25 mcg/hr Duragesic-25 ; QLL (10 per 30 days) fentanyl transdermal patch 72 hr 50 mcg/hr Duragesic-50 ; QLL (10 per 30 days) fentanyl transdermal patch 72 hr 75 mcg/hr Duragesic-75 ; QLL (10 per 30 days) hydrocodone-acetaminophen oral solution /5ml, /10ml, /15ml hydrocodone-acetaminophen oral tablet hydrocodone-acetaminophen oral tablet hydrocodone-acetaminophen oral tablet 5-325, Hycet Norco Verdrocet Lortab hydrocodone-ibuprofen oral tablet Vicoprofen hydromorphone hcl oral tablet 2 Dilaudid QLL (240 per 30 days) hydromorphone hcl oral tablet 4 Dilaudid QLL (180 per 30 days) hydromorphone hcl oral tablet 8 Dilaudid QLL (120 per 30 days) hydromorphone hcl suppository 3 IBUDONE ORAL TABLET MG Hydrocodone-Ibuprofen QLL (240 per 30 days) LORCET HD ORAL TABLET MG Hydrocodone-Acetaminophen LORCET ORAL TABLET MG LORCET PLUS ORAL TABLET MG LORTAB ORAL TABLET MG, MG, MG METHADONE HCL INTENSOL ORAL CONCENTRATE 10 MG/ML Hydrocodone-Acetaminophen Hydrocodone-Acetaminophen Hydrocodone-Acetaminophen Methadone HCl methadone hcl oral concentrate 10 /ml Methadose methadone hcl oral solution 10 /5ml, 5 /5ml methadone hcl oral tablet 10, 5 Dolophine ; QLL (240 per 30 days) 6

10 methadone hcl oral tablet soluble 40 Methadose ; QLL (240 per 30 days) METHADOSE ORAL TABLET SOLUBLE 40 MG morphine sulfate (concentrate) oral solution 100 /5ml, 20 /ml morphine sulfate er oral capsule extended release 24 hour 10, 100, 20, 30, 50, 60, 80 morphine sulfate er oral tablet extendedrelease* 100, 15, 200, 30, 60 morphine sulfate oral solution 10 /5ml, 20 /5ml morphine sulfate oral tablet 15, 30 morphine sulfate suppository 10, 20, 30, 5 oxycodone hcl oral capsule 5 oxycodone hcl oral concentrate 100 /5ml oxycodone hcl oral solution 5 /5ml oxycodone hcl oral tablet 10, 20 Methadone HCl Kadian MS Contin ; QLL (60 per 30 days) ; QLL (60 per 30 days) QLL (180 per 30 days) QLL (240 per 30 days) QLL (180 per 30 days) oxycodone hcl oral tablet 15, 30 Roxicodone QLL (180 per 30 days) oxycodone hcl oral tablet 5 Roxicodone QLL (240 per 30 days) oxycodone-acetaminophen oral tablet , oxycodone-acetaminophen oral tablet oxycodone-acetaminophen oral tablet Percocet Endocet Roxicet oxycodone-aspirin oral tablet Percodan QLL (240 per 30 days) oxymorphone hcl er oral tablet extended release 12 hr* 10, 15, 20, 30, 40, 5, 7.5 oxymorphone hcl oral tablet 10, 5 pentazocine-naloxone hcl oral tablet ROXICET ORAL TABLET MG Opana Oxycodone-Acetaminophen ST; QLL (60 per 30 days) tramadol hcl oral tablet 50 Ultram QLL (240 per 30 days) tramadol-acetaminophen oral tablet *Androgens-Anabolic* ANDRODERM TRANSDERMAL TCH 24 HR 2 MG/24HR, 4 MG/24HR Ultracet QLL (240 per 30 days) 7

11 ANDROGEL PUMP TRANSDERMAL MG/ACT (1.62) ANDROGEL TRANSDERMAL 25 MG/2.5GM (1) ANDROID ORAL CAPSULE 10 MG danazol oral capsule 100, 200, 50 testosterone cypionate intramuscular* solution 200 /ml testosterone transdermal 12.5 /act (1) testosterone transdermal 50 /5gm (1) *Anorectal Agents* COLOCORT ENEMA 100 MG/60ML CORTIFOAM FOAM 10 hydrocortisone acetate suppository 30 hydrocortisone enema 100 /60ml LIDAZONE HC CREAM lidocaine-hydrocortisone ace cream lidocaine-hydrocortisone ace kit 3-0.5, 3-1 PROCTOFOAM HC FOAM 1-1 PROCTO-K CREAM 1 PROCTOSOL HC CREAM 2.5 PROCTOZONE-HC CREAM 2.5 *Anthelmintics* ALBENZA ORAL TABLET 200 MG ivermectin oral tablet 3 *Antianginal Agents* isosorbide dinitrate er oral tablet extendedrelease* 40 isosorbide dinitrate oral tablet 10, 20, 30 isosorbide dinitrate oral tablet 5 isosorbide mononitrate er oral tablet extended release 24 hr* 120, 30, 60 isosorbide mononitrate oral tablet 10, 20 MINITRAN TRANSDERMAL TCH 24 HR 0.1 MG/HR, 0.2 MG/HR, 0.4 MG/HR, 0.6 MG/HR Testosterone MethylTESTOSTERone Depo-Testosterone Vogelxo Pump Vogelxo Hydrocortisone Hemmorex-HC Colocort Lidocaine-Hydrocortisone Ace LidaZone HC Hydrocortisone Hemorrhoidal-HC Hemorrhoidal-HC Stromectol Isordil Titradose Imdur Nitroglycerin 8

12 NITRO-BID TRANSDERMAL OINTMENT 2 nitroglycerin er oral capsule extended release* 2.5, 6.5, 9 nitroglycerin transdermal patch 24 hr 0.1 /hr nitroglycerin transdermal patch 24 hr 0.2 /hr, 0.4 /hr, 0.6 /hr nitroglycerin translingual solution 0.4 /spray NITROSTAT SUBLINGUAL TABLET SUBLINGUAL 0.3 MG, 0.4 MG, 0.6 MG NITRO-TIME ORAL CAPSULE EXTENDED RELEASE* 2.5 MG, 6.5 MG, 9 MG *Antianxiety Agents* hydroxyzine hcl oral syrup 10 /5ml hydroxyzine hcl oral tablet 10, 25, 50 hydroxyzine pamoate oral capsule 100 hydroxyzine pamoate oral capsule 25, 50 *Antiarrhythmics* amiodarone hcl oral tablet 100, 400 amiodarone hcl oral tablet 200 disopyramide phosphate oral capsule 100, 150 flecainide acetate oral tablet 100, 150, 50 mexiletine hcl oral capsule 150, 200, 250 MULTAQ ORAL TABLET 400 MG CERONE ORAL TABLET 100 MG, 200 MG, 400 MG propafenone hcl oral tablet 150, 225 propafenone hcl oral tablet 300 quinidine gluconate er oral tablet extendedrelease* 324 quinidine sulfate er oral tablet extendedrelease* 300 quinidine sulfate oral tablet 200, 300 Nitro-Time Nitro-Dur Minitran Nitrolingual Nitroglycerin ER Vistaril Pacerone Cordarone Norpace Tambocor Amiodarone HCl Rythmol 9

13 *Antiasthmatic And Bronchodilator Agents* ADVAIR DISKUS INHALATION AEROSOL POWDER, BREATH ACTIVATED MCG/DOSE, MCG/DOSE, MCG/DOSE ADVAIR HFA INHALATION AEROSOL MCG/ACT, MCG/ACT, MCG/ACT albuterol sulfate er oral tablet extended release 12 hr* 4, 8 albuterol sulfate inhalation nebulization solution (2.5 /3ml) 0.083, (5 /ml) 0.5 albuterol sulfate inhalation nebulization solution 0.63 /3ml, 1.25 /3ml albuterol sulfate oral syrup 2 /5ml albuterol sulfate oral tablet 2, 4 ATROVENT HFA INHALATION AEROSOL, SOLUTION 17 MCG/ACT budesonide inhalation suspension 0.25 /2ml, 0.5 /2ml, 1 /2ml COMBIVENT RESPIMAT INHALATION AEROSOL, SOLUTION MCG/ACT cromolyn sodium inhalation nebulization solution 20 /2ml DULERA INHALATION AEROSOL MCG/ACT, MCG/ACT FLOVENT DISKUS INHALATION AEROSOL POWDER, BREATH ACTIVATED 100 MCG/BLIST, 250 MCG/BLIST, 50 MCG/BLIST FLOVENT HFA INHALATION AEROSOL 110 MCG/ACT, 220 MCG/ACT, 44 MCG/ACT ipratropium bromide inhalation solution 0.02 ipratropium-albuterol inhalation solution (3) /3ml levalbuterol hcl inhalation nebulization solution 0.31 /3ml, 0.63 /3ml, 1.25 /3ml levalbuterol hcl inhalation nebulization solution 1.25 /0.5ml VoSpire ER AccuNeb Pulmicort DuoNeb Xopenex Xopenex Concentrate AL (Max 12 Years) QLL (13 per 1 day) QLL (13 per 1 day) QLL (120 per 30 days) QLL (1 per 30 days) 10

14 metaproterenol sulfate oral syrup 10 /5ml metaproterenol sulfate oral tablet 10, 20 montelukast sodium oral packet 4 Singulair QLL (30 per 30 days) montelukast sodium oral tablet 10 Singulair QLL (30 per 30 days) montelukast sodium oral tablet chewable 4, 5 PROAIR HFA INHALATION AEROSOL, SOLUTION 108 (90 BASE) MCG/ACT PROVENTIL HFA INHALATION AEROSOL, SOLUTION 108 (90 BASE) MCG/ACT PULMICORT FLEXHALER INHALATION AEROSOL POWDER, BREATH ACTIVATED 180 MCG/ACT, 90 MCG/ACT PULMICORT INHALATION SUSPENSION 1 MG/2ML QVAR INHALATION AEROSOL, SOLUTION 40 MCG/ACT, 80 MCG/ACT SEREVENT DISKUS INHALATION AEROSOL POWDER, BREATH ACTIVATED 50 MCG/DOSE SPIRIVA HANDIHALER INHALATION CAPSULE 18 MCG SPIRIVA RESPIMAT INHALATION AEROSOL, SOLUTION 2.5 MCG/ACT SYMBICORT INHALATION AEROSOL MCG/ACT, MCG/ACT terbutaline sulfate oral tablet 2.5, 5 THEOCHRON ORAL TABLET EXTENDED RELEASE 12 HR* 100 MG, 200 MG, 300 MG theophylline er oral tablet extended release 12 hr* 100, 200, 300 theophylline er oral tablet extended release 12 hr* 450 theophylline er oral tablet extended release 24 hr* 400, 600 theophylline oral solution 80 /15ml TUDORZA PRESSAIR INHALATION AEROSOL POWDER, BREATH ACTIVATED 400 MCG/ACT Singulair Budesonide Theophylline ER Theochron QLL (30 per 30 days) QLL (1 per 30 days) ST; QLL (30 per 30 days) QLL (30 per 30 days) 11

15 VENTOLIN HFA INHALATION AEROSOL, SOLUTION 108 (90 BASE) MCG/ACT zafirlukast oral tablet 10, 20 Accolate QLL (60 per 30 days) *Anticoagulants* enoxaparin sodium injection solution 300 /3ml 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 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 JANTOVEN ORAL TABLET 1 MG, 10 MG, 2 MG, 2.5 MG, 3 MG, 4 MG, 5 MG, 6 MG, 7.5 MG warfarin sodium oral tablet 1, 10, 2, 2.5, 3, 5, 6, 7.5 warfarin sodium oral tablet 4 *Antidiabetics* acarbose oral tablet 100, 25, 50 AVANDIA ORAL TABLET 2 MG, 4 MG BYETTA 10 MCG PEN SUBCUTANEOUS* 10 MCG/0.04ML BYETTA 5 MCG PEN SUBCUTANEOUS* 5 MCG/0.02ML chlorpropamide oral tablet 100 chlorpropamide oral tablet 250 glimepiride oral tablet 1, 2, 4 glipizide er oral tablet extended release 24 hr* 10, 2.5 Lovenox Lovenox Arixtra Warfarin Sodium Coumadin Jantoven Precose Diabinese Amaryl Glucotrol XL QLL (20 per 10 days) QLL (20 per 10 days) QLL (10 per 10 days) QLL (30 per 30 days) ST ST 12

16 glipizide er oral tablet extended release 24 hr* 5 glipizide oral tablet 10, 5 glipizide xl oral tablet extended release 24 hr* 10, 2.5 glipizide xl oral tablet extended release 24 hr* 5 GlipiZIDE XL Glucotrol Glucotrol XL GlipiZIDE XL glipizide-metformin hcl oral tablet Metaglip glipizide-metformin hcl oral tablet , GLUCAGEN HYPOKIT INJECTION SOLUTION RECONSTITUTED 1 MG GLUCAGON EMERGENCY INJECTION KIT 1 MG glyburide micronized oral tablet 1.5, 3, 6 glyburide oral tablet 1.25, 2.5, 5 glyburide-metformin oral tablet , , HUMALOG KWIKPEN SUBCUTANEOUS* 100 UNIT/ML HUMALOG MIX 50/50 SUBCUTANEOUS* SUSPENSION (50-50) 100 UNIT/ML HUMALOG MIX 75/25 KWIKPEN SUBCUTANEOUS* (75-25) 100 UNIT/ML HUMALOG MIX 75/25 SUBCUTANEOUS* SUSPENSION (75-25) 100 UNIT/ML HUMALOG SUBCUTANEOUS* 100 UNIT/ML HUMALOG SUBCUTANEOUS* SOLUTION 100 UNIT/ML HUMULIN R U-500 (CONCENTRATED) SUBCUTANEOUS* SOLUTION 500 UNIT/ML JANUMET ORAL TABLET MG, MG JANUMET XR ORAL TABLET EXTENDED RELEASE 24 HR* MG, MG, MG JANUVIA ORAL TABLET 100 MG, 25 MG, 50 MG Glynase Diabeta Glucovance ST ST ST 13

17 LANTUS SUBCUTANEOUS* SOLUTION 100 UNIT/ML LEVEMIR SUBCUTANEOUS* SOLUTION 100 UNIT/ML metformin hcl er oral tablet extended release 24 hr* 500, 750 metformin hcl oral tablet 1000, 500, 850 nateglinide oral tablet 120, 60 NOVOLOG MIX 70/30 SUBCUTANEOUS* SUSPENSION (70-30) 100 UNIT/ML NOVOLOG SUBCUTANEOUS* SOLUTION 100 UNIT/ML pioglitazone hcl oral tablet 15, 30, 45 pioglitazone hcl-glimepiride oral tablet 30-2, 30-4 pioglitazone hcl-metformin hcl oral tablet , repaglinide oral tablet 0.5, 1, 2 tolazamide oral tablet 250, 500 tolbutamide oral tablet 500 *Antidiarrheals* diphenoxylate-atropine oral liquid /5ml diphenoxylate-atropine oral tablet lofene oral tablet loperamide hcl oral capsule 2 *Antidotes* CHEMET ORAL CAPSULE 100 MG naltrexone hcl oral tablet 50 *Antiemetics* EMEND ORAL CAPSULE 125 MG, 40 MG, 80 & 125 MG, 80 MG granisetron hcl oral tablet 1 ondansetron hcl oral solution 4 /5ml ondansetron hcl oral tablet 24 ondansetron hcl oral tablet 4, 8 Glucophage XR Glucophage Starlix Actos Duetact Actoplus Met Prandin Lonox Lonox ReVia Zofran Zofran ondansetron oral tablet dispersible 4, 8 Zofran ODT 14 QLL (30 per 30 days) QLL (30 per 30 days) QLL (90 per 30 days)

18 trimethobenzamide hcl oral capsule 300 *Antifungals* bio-statin oral powder fluconazole oral suspension reconstituted 10 /ml, 40 /ml fluconazole oral tablet 100, 150, 200, 50 griseofulvin microsize oral suspension 125 /5ml griseofulvin microsize oral tablet 500 griseofulvin ultramicrosize oral tablet 125, 250 itraconazole oral capsule 100 ketoconazole oral tablet 200 nystatin oral powder nystatin oral tablet unit SPORANOX ORAL SOLUTION 10 MG/ML Tigan Diflucan Diflucan Grifulvin V Gris-PEG Sporanox Pulsepak terbinafine hcl oral tablet 250 LamISIL QLL (84 per 1 Year) *Antihistamines* ARBINOXA ORAL TABLET 4 MG brompheniramine tannate oral tablet chewable 12 carbinoxamine maleate oral tablet 4 cetirizine hcl oral solution 1 /ml clemastine fumarate oral tablet 2.68 cyproheptadine hcl oral syrup 2 /5ml cyproheptadine hcl oral tablet 4 PHENADOZ SUPPOSITORY 12.5 MG, 25 MG PHENERGAN SUPPOSITORY 12.5 MG, 25 MG, 50 MG promethazine hcl oral solution 6.25 /5ml promethazine hcl oral syrup 6.25 /5ml promethazine hcl oral tablet 12.5, 25, 50 promethazine hcl suppository 12.5 promethazine hcl suppository 25, 50 PROMETHEGAN SUPPOSITORY 12.5 MG, 25 MG, 50 MG Carbinoxamine Maleate Arbinoxa Wal-Zyr Childrens Promethazine HCl Promethazine HCl Phenadoz Promethegan Promethazine HCl 15

19 *Antihyperlipidemics* atorvastatin calcium oral tablet 10, 20, 40, 80 cholestyramine light oral packet 4 gm cholestyramine light oral powder 4 gm/dose cholestyramine oral packet 4 gm cholestyramine oral powder 4 gm/dose colestipol hcl oral granules 5 gm colestipol hcl oral packet 5 gm colestipol hcl oral tablet 1 gm fenofibrate micronized oral capsule 134, 200, 67 fenofibrate oral tablet 145, 48 fenofibrate oral tablet 160, 54 fenofibric acid oral capsule delayed release 135, 45 Lipitor Questran Light Questran Light Questran Questran Colestid Colestid Flavored Colestid Lofibra Tricor Lofibra Trilipix QLL (30 per 30 days) fluvastatin sodium oral capsule 20, 40 Lescol QLL (30 per 30 days) gemfibrozil oral tablet 600 Lopid QLL (60 per 30 days) LESCOL XL ORAL TABLET EXTENDED RELEASE 24 HR* 80 MG lovastatin oral tablet 10 Fluvastatin Sodium ER QLL (30 per 30 days) QLL (30 per 30 days) lovastatin oral tablet 20 Mevacor QLL (30 per 30 days) lovastatin oral tablet 40 Mevacor QLL (60 per 30 days) micronized colestipol hcl oral tablet 1 gm niacin er (antihyperlipidemic) oral tablet extendedrelease* 1000, 500, 750 pravastatin sodium oral tablet 10 pravastatin sodium oral tablet 20, 40, 80 PREVALITE ORAL CKET 4 GM PREVALITE ORAL POWDER 4 GM/DOSE simvastatin oral tablet 10, 20, 40, 5, 80 ZETIA ORAL TABLET 10 MG *Antihypertensives* Colestid Niaspan Pravachol Cholestyramine Light Cholestyramine Light Zocor amlodipine besy-benazepril hcl oral capsule 10-20, 10-40, , 5-10, 5-20 Lotrel, 5-40 QLL (30 per 30 days) QLL (30 per 30 days) QLL (30 per 30 days) ST 16

20 amlodipine-valsartan-hctz oral tablet , , , , Exforge HCT atenolol-chlorthalidone oral tablet Tenoretic 100 atenolol-chlorthalidone oral tablet Tenoretic 50 benazepril hcl oral tablet 10, 20, 40 Lotensin benazepril hcl oral tablet 5 benazepril-hydrochlorothiazide oral tablet , , benazepril-hydrochlorothiazide oral tablet BENICAR HCT ORAL TABLET MG, MG, MG BENICAR ORAL TABLET 20 MG, 40 MG, 5 MG bisoprolol-hydrochlorothiazide oral tablet , , candesartan cilexetil oral tablet 16, 32, 4, 8 candesartan cilexetil-hctz oral tablet , , captopril oral tablet 100, 12.5, 25, 50 captopril-hydrochlorothiazide oral tablet 25-15, 25-25, 50-15, clonidine hcl oral tablet 0.1, 0.2, 0.3 clonidine hcl transdermal patch weekly 0.1 /24hr clonidine hcl transdermal patch weekly 0.2 /24hr clonidine hcl transdermal patch weekly 0.3 /24hr doxazosin mesylate oral tablet 1, 2, 4, 8 enalapril maleate oral tablet 10, 2.5, 20, 5 enalapril-hydrochlorothiazide oral tablet enalapril-hydrochlorothiazide oral tablet fosinopril sodium oral tablet 10, 20, 40 Lotensin HCT Ziac Atacand Atacand HCT Catapres Catapres-TTS-1 Catapres-TTS-2 Catapres-TTS-3 Cardura Vasotec Vaseretic QLL (30 per 30 days) ST; QLL (30 per 30 days) ST; QLL (30 per 30 days) QLL (30 per 30 days) 17

21 fosinopril sodium-hctz oral tablet , guanfacine hcl oral tablet 1, 2 hydralazine hcl oral tablet 10, 100, 25, 50 irbesartan oral tablet 150, 300, 75 irbesartan-hydrochlorothiazide oral tablet , lisinopril oral tablet 10, 2.5, 20, 30, 5 Tenex Avapro Avalide Zestril QLL (30 per 30 days) lisinopril oral tablet 40 Zestril QLL (60 per 30 days) lisinopril-hydrochlorothiazide oral tablet , , losartan potassium oral tablet 100, 25, 50 losartan potassium-hctz oral tablet , , methyldopa oral tablet 250, 500 methyldopa-hydrochlorothiazide oral tablet , metoprolol-hydrochlorothiazide oral tablet , metoprolol-hydrochlorothiazide oral tablet minoxidil oral tablet 10, 2.5 moexipril hcl oral tablet 15, 7.5 moexipril-hydrochlorothiazide oral tablet , 15-25, nadolol-bendroflumethiazide oral tablet 40-5, 80-5 perindopril erbumine oral tablet 2 perindopril erbumine oral tablet 4, 8 prazosin hcl oral capsule 1, 2, 5 propranolol-hctz oral tablet 40-25, quinapril hcl oral tablet 10, 20, 40, 5 quinapril-hydrochlorothiazide oral tablet , , ramipril oral capsule 1.25, 10, 2.5, 5 reserpine oral tablet 0.1, 0.25 Zestoretic Cozaar Hyzaar Lopressor HCT Univasc Uniretic Corzide Aceon Minipress Accupril Accuretic Altace 18

22 terazosin hcl oral capsule 1, 10, 2, 5 trandolapril oral tablet 1, 2, 4 valsartan oral tablet 160, 320, 40, 80 valsartan-hydrochlorothiazide oral tablet , , , , *Anti-Infective Agents - Misc.* clindamycin hcl oral capsule 150, 300, 75 clindamycin palmitate hcl oral solution reconstituted 75 /5ml dapsone oral tablet 100, 25 metronidazole oral capsule 375 metronidazole oral tablet 250, 500 sulfamethoxazole-trimethoprim oral suspension /5ml sulfamethoxazole-trimethoprim oral tablet sulfamethoxazole-trimethoprim oral tablet SULFATRIM PEDIATRIC ORAL SUSPENSION MG/5ML trimethoprim oral tablet 100 vancomycin hcl intravenous* solution reconstituted 10 gm, 1000, 500, 5000 vancomycin hcl oral capsule 125, 250 *Antimalarials* chloroquine phosphate oral tablet 250 chloroquine phosphate oral tablet 500 DARAPRIM ORAL TABLET 25 MG Mavik Diovan Diovan HCT Cleocin Cleocin Flagyl Flagyl Sulfatrim Pediatric Bactrim Bactrim DS Sulfamethoxazole-Trimethopri m Vancocin HCl Aralen hydroxychloroquine sulfate oral tablet 200 Plaquenil mefloquine hcl oral tablet 250 *Antimyasthenic Agents* pyridostigmine bromide oral tablet 60 *Antimycobacterial Agents* ethambutol hcl oral tablet 100, 400 isoniazid oral syrup 50 /5ml isoniazid oral tablet 100, 300 Mestinon Myambutol QLL (30 per 30 days) QLL (60 per 30 days) QLL (30 per 30 days) 19

23 PRIFTIN ORAL TABLET 150 MG pyrazinamide oral tablet 500 rifabutin oral capsule 150 RIFAMATE ORAL CAPSULE MG rifampin oral capsule 150, 300 *Antineoplastics And Adjunctive Therapies* AFINITOR ORAL TABLET 10 MG, 2.5 MG, 5 MG, 7.5 MG ALKERAN ORAL TABLET 2 MG anastrozole oral tablet 1 bicalutamide oral tablet 50 capecitabine oral tablet 150, 500 EMCYT ORAL CAPSULE 140 MG etoposide oral capsule 50 exemestane oral tablet 25 FARESTON ORAL TABLET 60 MG flutamide oral capsule 125 GLEOSTINE ORAL CAPSULE 10 MG, 100 MG, 40 MG HEXALEN ORAL CAPSULE 50 MG hydroxyurea oral capsule 500 letrozole oral tablet 2.5 leucovorin calcium oral tablet 10, 15, 25, 5 LEUKERAN ORAL TABLET 2 MG LYSODREN ORAL TABLET 500 MG MATULANE ORAL CAPSULE 50 MG megestrol acetate oral suspension 40 /ml, 400 /10ml megestrol acetate oral tablet 20, 40 mercaptopurine oral tablet 50 MESNEX ORAL TABLET 400 MG methotrexate oral tablet 2.5 MYLERAN ORAL TABLET 2 MG NILANDRON ORAL TABLET 150 MG SOLTAMOX ORAL SOLUTION 10 MG/5ML TABLOID ORAL TABLET 40 MG 20 Mycobutin Rifadin Arimidex Casodex Xeloda Aromasin Lomustine Hydrea Femara Megace Oral Purinethol

24 tamoxifen citrate oral tablet 10, 20 temozolomide oral capsule 100, 140, 180, 20, 250, 5 tretinoin oral capsule 10 TREXALL ORAL TABLET 10 MG, 15 MG, 5 MG, 7.5 MG ZOLINZA ORAL CAPSULE 100 MG *Antiparkinson Agents* amantadine hcl oral capsule 100 amantadine hcl oral syrup 50 /5ml amantadine hcl oral tablet 100 bromocriptine mesylate oral capsule 5 bromocriptine mesylate oral tablet 2.5 carbidopa-levodopa er oral tablet extendedrelease* , carbidopa-levodopa oral tablet , , carbidopa-levodopa oral tablet dispersible , , carbidopa-levodopa-entacapone oral tablet carbidopa-levodopa-entacapone oral tablet carbidopa-levodopa-entacapone oral tablet carbidopa-levodopa-entacapone oral tablet carbidopa-levodopa-entacapone oral tablet carbidopa-levodopa-entacapone oral tablet Temodar Parlodel Parlodel Sinemet CR Sinemet Parcopa Stalevo 50 Stalevo 75 Stalevo 100 Stalevo 125 Stalevo 150 Stalevo 200 QLL (270 per 30 days) QLL (270 per 30 days) QLL (270 per 30 days) QLL (270 per 30 days) QLL (270 per 30 days) QLL (270 per 30 days) entacapone oral tablet 200 Comtan QLL (120 per 30 days) MIRAPEX ORAL TABLET 0.75 MG pramipexole dihydrochloride oral tablet 0.125, 0.25, 0.5, 0.75, 1, 1.5 ropinirole hcl er oral tablet extended release 24 hr* 12, 2, 4, 6, 8 ropinirole hcl oral tablet 0.25, 0.5, 1, 2, 3, 4, 5 selegiline hcl oral capsule 5 selegiline hcl oral tablet 5 Pramipexole Dihydrochloride Mirapex Requip XL Requip Eldepryl QLL (90 per 30 days) 21

25 *Antipsychotics/Antimanic Agents* COMZINE SUPPOSITORY 25 MG COMPRO SUPPOSITORY 25 MG prochlorperazine maleate oral tablet 10, 5 prochlorperazine suppository 25 *Antiseptics & Disinfectants* chlorhexidine gluconate solution 20 *Antivirals* Prochlorperazine Prochlorperazine Compazine Compro acyclovir oral capsule 200 Zovirax QLL (60 per 30 days) acyclovir oral suspension 200 /5ml Zovirax acyclovir oral tablet 400, 800 Zovirax QLL (60 per 30 days) BARACLUDE ORAL SOLUTION 0.05 MG/ML entecavir oral tablet 0.5, 1 famciclovir oral tablet 125, 250, 500 MODERIBA ORAL 200 & 400 MG, 400 & 600 MG Baraclude Famvir MODERIBA ORAL TABLET 200 MG Ribavirin ST PEGASYS PROCLICK SUBCUTANEOUS* SOLUTION 135 MCG/0.5ML, 180 MCG/0.5ML PEGASYS SUBCUTANEOUS* SOLUTION 180 MCG/0.5ML, 180 MCG/ML PEG-INTRON REDIPEN K 4 SUBCUTANEOUS* KIT 120 MCG/0.5ML PEG-INTRON REDIPEN SUBCUTANEOUS* KIT 120 MCG/0.5ML, 150 MCG/0.5ML, 50 MCG/0.5ML, 80 MCG/0.5ML PEG-INTRON SUBCUTANEOUS* KIT 120 MCG/0.5ML, 150 MCG/0.5ML, 50 MCG/0.5ML, 80 MCG/0.5ML PEGINTRON SUBCUTANEOUS* KIT 120 MCG/0.5ML, 150 MCG/0.5ML, 80 MCG/0.5ML PEGINTRON SUBCUTANEOUS* KIT 50 MCG/0.5ML REBETOL ORAL SOLUTION 40 MG/ML ST ST 22

26 RELENZA DISKHALER INHALATION AEROSOL POWDER, BREATH ACTIVATED 5 MG/BLISTER RIBASPHERE ORAL CAPSULE 200 MG Ribavirin ST RIBASPHERE ORAL TABLET 200 MG Ribavirin ST RIBASPHERE ORAL TABLET 400 MG, 600 MG RIBASPHERE RIBAK ORAL TABLET 200 & 400 MG, 400 & 600 MG, 400 MG, 600 MG ribavirin oral capsule 200 Rebetol ST ribavirin oral tablet 200 Copegus ST rimantadine hcl oral tablet 100 SOVALDI ORAL TABLET 400 MG TAMIFLU ORAL CAPSULE 30 MG TAMIFLU ORAL CAPSULE 45 MG, 75 MG TAMIFLU ORAL SUSPENSION RECONSTITUTED 6 MG/ML TYZEKA ORAL TABLET 600 MG Flumadine QLL (1 Max Qty Per Fill Retail) ST ST QLL (14 Max Qty Per Fill Retail) QLL (20 Max Qty Per Fill Retail) QLL (10 Max Qty Per Fill Retail) QLL (3 Max Qty Per Fill Retail) valacyclovir hcl oral tablet 1 gm Valtrex QLL (30 per 30 days) valacyclovir hcl oral tablet 500 Valtrex QLL (60 per 30 days) *Assorted Classes* ARGYLE STERILE WATER IRRIGATION SOLUTION AZASAN ORAL TABLET 100 MG, 75 MG azathioprine oral tablet 50 CUPRIMINE ORAL CAPSULE 250 MG cyclosporine modified oral capsule 100, 25 cyclosporine modified oral capsule 50 Sterile Water for Irrigation Imuran Gengraf cyclosporine modified oral solution 100 /ml Gengraf cyclosporine oral capsule 100, 25 GENGRAF ORAL CAPSULE 100 MG, 25 MG GENGRAF ORAL SOLUTION 100 MG/ML KIONEX ORAL POWDER SandIMMUNE CycloSPORINE Modified CycloSPORINE Modified Sodium Polystyrene Sulfonate 23

27 KIONEX ORAL SUSPENSION 15 GM/60ML mycophenolate mofetil oral capsule 250 mycophenolate mofetil oral suspension reconstituted 200 /ml mycophenolate mofetil oral tablet 500 mycophenolic acid oral tablet delayed release 180, 360 RAMUNE ORAL SOLUTION 1 MG/ML REVLIMID ORAL CAPSULE 10 MG, 15 MG, 2.5 MG, 25 MG, 5 MG sirolimus oral tablet 0.5, 1, 2 sodium polystyrene sulfonate oral powder sodium polystyrene sulfonate oral suspension 15 gm/60ml sodium polystyrene sulfonate suspension 30 gm/120ml, 50 gm/200ml SPS ORAL SUSPENSION 15 GM/60ML sterile water for irrigation irrigation solution tacrolimus oral capsule 0.5, 1, 5 THALOMID ORAL CAPSULE 100 MG, 150 MG, 200 MG, 50 MG *Beta Blockers* acebutolol hcl oral capsule 200, 400 atenolol oral tablet 100, 25, 50 betaxolol hcl oral tablet 10, 20 bisoprolol fumarate oral tablet 10, 5 carvedilol oral tablet 12.5, 25, 3.125, 6.25 labetalol hcl oral tablet 100, 200, 300 metoprolol succinate er oral tablet extended release 24 hr* 100, 200, 25, 50 metoprolol tartrate oral tablet 100, 50 metoprolol tartrate oral tablet 25 nadolol oral tablet 20, 40, 80 pindolol oral tablet 10, 5 propranolol hcl er oral capsule extended release 24 hour 120, 160, 60, 80 Sodium Polystyrene Sulfonate CellCept CellCept CellCept Myfortic Rapamune Kayexalate SPS Sodium Polystyrene Sulfonate Argyle Sterile Water Hecoria Sectral Tenormin Kerlone Zebeta Coreg Trandate QLL (60 per 30 days) Toprol XL QLL (60 per 30 days) Lopressor Corgard Inderal LA 24

28 propranolol hcl oral solution 20 /5ml, 40 /5ml propranolol hcl oral tablet 10, 20, 40, 60, 80 SORINE ORAL TABLET 120 MG, 160 MG, 240 MG, 80 MG sotalol hcl (af) oral tablet 120, 160, 80 sotalol hcl oral tablet 120, 160, 240, 80 timolol maleate oral tablet 10, 20, 5 *Calcium Channel Blockers* AFEDITAB CR ORAL TABLET EXTENDED RELEASE 24 HR* 30 MG, 60 MG amlodipine besylate oral tablet 10, 2.5, 5 CARTIA XT ORAL CAPSULE EXTENDED RELEASE 24 HOUR 120 MG, 180 MG, 240 MG, 300 MG diltiazem cd oral capsule extended release 24 hour 120, 180, 240 diltiazem hcl er beads oral capsule extended release 24 hour 120, 180, 240, 300, 360, 420 diltiazem hcl er coated beads oral capsule extended release 24 hour 120, 180, 240, 300, 360 diltiazem hcl er coated beads oral tablet extended release 24 hr* 180, 240, 300, 360, 420 diltiazem hcl er oral capsule extended release 12 hour 120, 60, 90 diltiazem hcl er oral capsule extended release 24 hour 120, 180 diltiazem hcl er oral capsule extended release 24 hour 240 diltiazem hcl oral tablet 120, 30, 60, 90 dilt-xr oral capsule extended release 24 hour 120, 180 dilt-xr oral capsule extended release 24 hour 240 Sotalol HCl Betapace AF Sorine NIFEdipine ER Norvasc Diltiazem HCl ER Coated Beads Cardizem CD Tiazac Cardizem CD Cardizem LA Dilacor XR Cardizem Dilacor XR QLL (30 per 30 days) QLL (60 per 30 days) QLL (60 per 30 days) QLL (60 per 30 days) QLL (60 per 30 days) QLL (60 per 30 days) QLL (120 per 30 days) 25

29 felodipine er oral tablet extended release 24 hr* 10, 2.5, 5 isradipine oral capsule 2.5, 5 MATZIM LA ORAL TABLET EXTENDED RELEASE 24 HR* 180 MG, 240 MG, 300 MG, 360 MG, 420 MG nicardipine hcl oral capsule 20, 30 NIFEDIAC CC ORAL TABLET EXTENDED RELEASE 24 HR* 30 MG NIFEDICAL XL ORAL TABLET EXTENDED RELEASE 24 HR* 30 MG, 60 MG nifedipine er oral tablet extended release 24 hr* 30, 90 nifedipine er oral tablet extended release 24 hr* 60 nifedipine er osmotic release oral tablet extended release 24 hr* 30 nifedipine er osmotic release oral tablet extended release 24 hr* 60 nifedipine er osmotic release oral tablet extended release 24 hr* 90 nifedipine oral capsule 10 nifedipine oral capsule 20 nimodipine oral capsule 30 nisoldipine er oral tablet extended release 24 hr* 17, 34, 8.5 nisoldipine er oral tablet extended release 24 hr* 20, 30, 40 nisoldipine er oral tablet extended release 24 hr* 25.5 TAZTIA XT ORAL CAPSULE EXTENDED RELEASE 24 HOUR 120 MG, 180 MG, 240 MG, 300 MG, 360 MG verapamil hcl er oral capsule extended release 24 hour 100, 200, 300 verapamil hcl er oral capsule extended release 24 hour 120, 180, 240, 360 verapamil hcl er oral tablet extendedrelease* 120, 180, 240 Diltiazem HCl ER Coated Beads NIFEdipine ER NIFEdipine ER Osmotic Adalat CC Nifediac CC Procardia XL Nifedical XL Procardia XL Procardia Nimotop Sular Diltiazem HCl ER Beads Verelan PM Verelan Isoptin SR QLL (60 per 30 days) QLL (30 per 30 days) QLL (30 per 30 days) QLL (30 per 30 days) QLL (30 per 30 days) QLL (30 per 30 days) QLL (30 per 30 days) QLL (60 per 30 days) verapamil hcl oral tablet 120, 80 Calan QLL (120 per 30 days) verapamil hcl oral tablet 40 QLL (120 per 30 days) 26

30 *Cardiotonics* DIGITEK ORAL TABLET 125 MCG, 250 MCG DIGOX ORAL TABLET MG, 0.25 MG digoxin oral solution 0.05 /ml digoxin oral tablet 125 mcg, 250 mcg LANOXIN ORAL TABLET MG, MCG *Cardiovascular Agents - Misc.* ADCIRCA ORAL TABLET 20 MG amlodipine-atorvastatin oral tablet 10-10, 10-20, 10-40, 10-80, , , , 5-10, 5-20, 5-40, 5-80 Digoxin Digoxin Lanoxin Caduet ; QLL (60 per 30 days) sildenafil citrate oral tablet 20 Revatio ; QLL (90 per 30 days) *Cephalosporins* cefaclor oral capsule 250, 500 cefaclor oral suspension reconstituted 125 /5ml, 250 /5ml, 375 /5ml cefadroxil oral capsule 500 cefadroxil oral suspension reconstituted 250 /5ml, 500 /5ml cefadroxil oral tablet 1 gm cefdinir oral capsule 300 cefdinir oral suspension reconstituted 125 /5ml, 250 /5ml cefpodoxime proxetil oral suspension reconstituted 100 /5ml, 50 /5ml cefpodoxime proxetil oral tablet 100, 200 cefprozil oral suspension reconstituted 125 /5ml, 250 /5ml cefprozil oral tablet 250, 500 CEFTIN ORAL SUSPENSION RECONSTITUTED 125 MG/5ML CEFTIN ORAL SUSPENSION RECONSTITUTED 250 MG/5ML ceftriaxone sodium injection solution reconstituted 1 gm, 500 ceftriaxone sodium injection solution reconstituted 2 gm, 250 Cefuroxime Axetil Rocephin QLL (2 Max Qty Per Fill Retail) QLL (2 Max Qty Per Fill Retail) 27

31 cefuroxime axetil oral tablet 250, 500 cephalexin oral capsule 250, 500 cephalexin oral suspension reconstituted 125 /5ml, 250 /5ml cephalexin oral tablet 250, 500 SUPRAX ORAL SUSPENSION RECONSTITUTED 100 MG/5ML, 200 MG/5ML SUPRAX ORAL TABLET CHEWABLE 100 MG, 200 MG *Chemicals* glycerine liquid hydroxyprogesterone caproate powder stevia extract powder steviol glycosides powder 95 stevioside fluid extract 15 stevioside powder 90 *Contraceptives* ALTAVERA ORAL TABLET Ceftin Keflex Cefixime Levonorgestrel-Ethinyl Estrad alyacen 1/35 oral tablet mcg Norinyl 1+35 (28) alyacen 7/7/7 oral tablet 0.5/0.75/1-35 -mcg AMETHIA LO ORAL TABLET & 0.01 MG AMETHIA ORAL TABLET &0.01 MG Ortho-Novum 7/7/7 (28) Levonorgest-Eth Estrad 91-Day Levonorgest-Eth Estrad 91-Day AMETHYST ORAL TABLET MCG Levonorgestrel-Ethinyl Estrad APRI ORAL TABLET ARANELLE ORAL TABLET 0.5/1/ ASHLYNA ORAL TABLET &0.01 MG Desogestrel-Ethinyl Estradiol Levonorgest-Eth Estrad 91-Day AUBRA ORAL TABLET Levonorgestrel-Ethinyl Estrad AVIANE ORAL TABLET AZURETTE ORAL TABLET /0.01 MG (21/5) BALZIVA ORAL TABLET briellyn oral tablet mcg Levonorgestrel-Ethinyl Estrad Viorele Briellyn Gildagia QLL (1 Max Qty Per Fill Retail) 28

32 CAMILA ORAL TABLET 0.35 MG CAMRESE ORAL TABLET &0.01 MG CAZIANT ORAL TABLET 0.1/0.125/ MG CESIA ORAL TABLET 0.1/0.125/ MG CHATEAL ORAL TABLET CRYSELLE-28 ORAL TABLET CYCLAFEM 1/35 ORAL TABLET 1-35 CYCLAFEM 7/7/7 ORAL TABLET 0.5/0.75/1-35 CYRED ORAL TABLET DASETTA 1/35 ORAL TABLET 1-35 DASETTA 7/7/7 ORAL TABLET 0.5/0.75/1-35 DAYSEE ORAL TABLET &0.01 MG DEBLITANE ORAL TABLET 0.35 MG DELYLA ORAL TABLET desogestrel-ethinyl estradiol oral tablet /0.01 (21/5) desogestrel-ethinyl estradiol oral tablet mcg drospirenone-ethinyl estradiol oral tablet drospirenone-ethinyl estradiol oral tablet ELINEST ORAL TABLET ELLA ORAL TABLET 30 MG EMOQUETTE ORAL TABLET ENPRESSE-28 ORAL TABLET ENSKYCE ORAL TABLET ERRIN ORAL TABLET 0.35 MG Norethindrone Levonorgest-Eth Estrad 91-Day Levonorgestrel-Ethinyl Estrad Alyacen 1/35 Alyacen 7/7/7 Desogestrel-Ethinyl Estradiol Alyacen 1/35 Alyacen 7/7/7 Levonorgest-Eth Estrad 91-Day Norethindrone Levonorgestrel-Ethinyl Estrad Pimtrea Enskyce Vestura Yasmin 28 Desogestrel-Ethinyl Estradiol Levonorg-Eth Estrad Triphasic Desogestrel-Ethinyl Estradiol Norethindrone 29

33 ESTARYLLA ORAL TABLET FALMINA ORAL TABLET GIANVI ORAL TABLET MG GILDAGIA ORAL TABLET GILDESS 1.5/30 ORAL TABLET GILDESS 1/20 ORAL TABLET 1-20 GILDESS FE 1.5/30 ORAL TABLET GILDESS FE 1/20 ORAL TABLET 1-20 HEATHER ORAL TABLET 0.35 MG INTROVALE ORAL TABLET MG JENCYCLA ORAL TABLET 0.35 MG JOLESSA ORAL TABLET MG JOLIVETTE ORAL TABLET 0.35 MG JUNEL 1.5/30 ORAL TABLET JUNEL 1/20 ORAL TABLET 1-20 JUNEL FE 1.5/30 ORAL TABLET JUNEL FE 1/20 ORAL TABLET 1-20 KARIVA ORAL TABLET /0.01 MG (21/5) KELNOR 1/35 ORAL TABLET 1-35 KIMIDESS ORAL TABLET /0.01 MG (21/5) KURVELO ORAL TABLET LARIN 1.5/30 ORAL TABLET LARIN 1/20 ORAL TABLET 1-20 Norgestimate-Eth Estradiol Levonorgestrel-Ethinyl Estrad Drospirenone-Ethinyl Estradiol Briellyn Norethindrone Acet-Ethinyl Est Norethin Ace-Eth Estrad-FE Norethindrone Levonorgest-Eth Estrad 91-Day Norethindrone Levonorgest-Eth Estrad 91-Day Norethindrone Norethindrone Acet-Ethinyl Est Norethin Ace-Eth Estrad-FE Viorele Viorele Levonorgestrel-Ethinyl Estrad Norethindrone Acet-Ethinyl Est 30

34 LARIN FE 1.5/30 ORAL TABLET LARIN FE 1/20 ORAL TABLET 1-20 LEENA ORAL TABLET 0.5/1/ LESSINA ORAL TABLET LEVONEST ORAL TABLET levonorgest-eth estrad 91-day oral tablet & 0.01 levonorgest-eth estrad 91-day oral tablet &0.01 levonorgest-eth estrad 91-day oral tablet levonorgestrel oral tablet 1.5 levonorgestrel-ethinyl estrad oral tablet mcg levonorgestrel-ethinyl estrad oral tablet mcg levonorgestrel-ethinyl estrad oral tablet mcg LEVORA 0.15/30 (28) ORAL TABLET LORYNA ORAL TABLET MG LOW-OGESTREL ORAL TABLET LUTERA ORAL TABLET LYZA ORAL TABLET 0.35 MG Norethin Ace-Eth Estrad-FE Levonorgestrel-Ethinyl Estrad Levonorg-Eth Estrad Triphasic Camrese Lo Ashlyna Jolessa Plan B One-Step Sronyx Levora 0.15/30 (28) Amethyst Levonorgestrel-Ethinyl Estrad Drospirenone-Ethinyl Estradiol Levonorgestrel-Ethinyl Estrad Norethindrone marlissa oral tablet mcg Levora 0.15/30 (28) medroxyprogesterone acetate intramuscular* suspension 150 /ml MICROGESTIN 1.5/30 ORAL TABLET MICROGESTIN 1/20 ORAL TABLET 1-20 MICROGESTIN FE 1.5/30 ORAL TABLET MICROGESTIN FE 1/20 ORAL TABLET 1-20 MIRENA INTRAUTERINE INTRAUTERINE DEVICE 20 MCG/24HR Depo-Provera Norethindrone Acet-Ethinyl Est Norethin Ace-Eth Estrad-FE QLL (1 per 90 days) QLL (1 per 5 Yearss) 31

35 MONO-LINYAH ORAL TABLET MONONESSA ORAL TABLET Norgestimate-Eth Estradiol Norgestimate-Eth Estradiol MY WAY ORAL TABLET 1.5 MG Levonorgestrel QLL (3 per 1 Years) MYZILRA ORAL TABLET NECON 0.5/35 (28) ORAL TABLET NECON 1/35 (28) ORAL TABLET 1-35 NECON 1/50 (28) ORAL TABLET 1-50 NECON 10/11 (28) ORAL TABLET 35 MCG NECON 7/7/7 ORAL TABLET 0.5/0.75/1-35 NEXPLANON SUBCUTANEOUS* IMPLANT 68 MG NIKKI ORAL TABLET MG NORA-BE ORAL TABLET 0.35 MG norethin ace-eth estrad-fe oral tablet mcg norethindrone acet-ethinyl est oral tablet mcg norethindrone oral tablet 0.35 norgestimate-eth estradiol oral tablet mcg norgestim-eth estrad triphasic oral tablet 0.18/0.215/ mcg NORLYROC ORAL TABLET 0.35 MG NORTREL 0.5/35 (28) ORAL TABLET NORTREL 1/35 (21) ORAL TABLET 1-35 NORTREL 1/35 (28) ORAL TABLET 1-35 NORTREL 7/7/7 ORAL TABLET 0.5/0.75/1-35 NUVARING VAGINAL RING MG/24HR OCELLA ORAL TABLET MG OGESTREL ORAL TABLET Levonorg-Eth Estrad Triphasic Alyacen 1/35 Alyacen 7/7/7 Drospirenone-Ethinyl Estradiol Norethindrone Loestrin Fe 1/20 Loestrin 1/20 (21) Errin Mono-Linyah Ortho Tri-Cyclen (28) Norethindrone Alyacen 1/35 Alyacen 1/35 Alyacen 7/7/7 Drospirenone-Ethinyl Estradiol QLL (1 per 3 Yearss) QLL (1 per 30 days)

36 ORSYTHIA ORAL TABLET PHILITH ORAL TABLET PIMTREA ORAL TABLET /0.01 MG (21/5) PIRMELLA 1/35 ORAL TABLET 1-35 PIRMELLA 7/7/7 ORAL TABLET 0.5/0.75/1-35 PORTIA-28 ORAL TABLET PREVIFEM ORAL TABLET QUASENSE ORAL TABLET MG RECLIPSEN ORAL TABLET SETLAKIN ORAL TABLET MG SHAROBEL ORAL TABLET 0.35 MG SKYLA INTRAUTERINE INTRAUTERINE DEVICE 13.5 MG Levonorgestrel-Ethinyl Estrad Briellyn Viorele Alyacen 1/35 Alyacen 7/7/7 Levonorgestrel-Ethinyl Estrad Norgestimate-Eth Estradiol Levonorgest-Eth Estrad 91-Day Desogestrel-Ethinyl Estradiol Levonorgest-Eth Estrad 91-Day Norethindrone SOLIA ORAL TABLET Desogestrel-Ethinyl Estradiol SPRINTEC 28 ORAL TABLET SRONYX ORAL TABLET SYEDA ORAL TABLET MG TARINA FE 1/20 ORAL TABLET 1-20 TILIA FE ORAL TABLET 1-20/1-30/1-35 TRI-ESTARYLLA ORAL TABLET 0.18/0.215/0.25 MG-35 MCG TRI-LEGEST FE ORAL TABLET 1-20/1-30/1-35 TRI-LINYAH ORAL TABLET 0.18/0.215/0.25 MG-35 MCG TRINESSA (28) ORAL TABLET 0.18/0.215/0.25 MG-35 MCG TRI-PREVIFEM ORAL TABLET 0.18/0.215/0.25 MG-35 MCG Norgestimate-Eth Estradiol Levonorgestrel-Ethinyl Estrad Drospirenone-Ethinyl Estradiol Norethin Ace-Eth Estrad-FE Norgestim-Eth Estrad Triphasic Norgestim-Eth Estrad Triphasic Norgestim-Eth Estrad Triphasic Norgestim-Eth Estrad Triphasic QLL (1 per 3 Yearss) 33

37 TRI-SPRINTEC ORAL TABLET 0.18/0.215/0.25 MG-35 MCG TRIVORA (28) ORAL TABLET VELIVET ORAL TABLET 0.1/0.125/ MG VESTURA ORAL TABLET MG viorele oral tablet /0.01 (21/5) VYFEMLA ORAL TABLET WERA ORAL TABLET XULANE TRANSDERMAL TCH WEEKLY MCG/24HR ZARAH ORAL TABLET MG ZENCHENT ORAL TABLET ZOVIA 1/35E (28) ORAL TABLET 1-35 ZOVIA 1/50E (28) ORAL TABLET 1-50 *Corticosteroids* cortisone acetate oral tablet 25 DELTASONE ORAL TABLET 20 MG dexamethasone oral elixir 0.5 /5ml dexamethasone oral solution 0.5 /5ml dexamethasone oral tablet 0.5, 0.75, 1, 1.5, 2, 4, 6 fludrocortisone acetate oral tablet 0.1 Norgestim-Eth Estrad Triphasic Levonorg-Eth Estrad Triphasic Drospirenone-Ethinyl Estradiol Pimtrea Briellyn Drospirenone-Ethinyl Estradiol Briellyn PredniSONE Baycadron hydrocortisone oral tablet 10, 20, 5 Cortef methylprednisolone oral tablet 16, 32, 4, 8 prednisolone oral solution 15 /5ml prednisolone oral syrup 15 /5ml prednisolone sodium phosphate oral solution 15 /5ml prednisolone sodium phosphate oral solution 25 /5ml prednisone oral solution 5 /5ml prednisone oral tablet 1, 10, 2.5, 5, 50 prednisone oral tablet 20 Medrol Prelone Prelone Orapred Deltasone QLL (3 per 28 days) 34

38 *Cough/Cold/Allergy* acetylcysteine inhalation solution 10, 20 benzonatate oral capsule 100 benzonatate oral capsule 200 biotuss oral liquid /5ml hydrocodone-homatropine oral syrup /5ml hydrocodone-homatropine oral tablet hydromet oral syrup /5ml HYPERSAL INHALATION NEBULIZATION SOLUTION 3.5 NEBUSAL INHALATION NEBULIZATION SOLUTION 3 NEBUSAL INHALATION NEBULIZATION SOLUTION 6 phenyleph-promethazine-cod oral syrup /5ml phenylephrine-chlorphen-dm oral liquid /ml promethazine vc plain oral syrup /5ml promethazine vc/codeine oral syrup /5ml promethazine-codeine oral syrup /5ml promethazine-dm oral syrup /5ml promethazine-phenylephrine oral syrup /5ml PULMOSAL INHALATION NEBULIZATION SOLUTION 7 sodium chloride inhalation nebulization solution 0.9, 10 sodium chloride inhalation nebulization solution 3 sodium chloride inhalation nebulization solution 7 tgq 50pse/3brm/30dm oral syrup /5ml TUSSIGON ORAL TABLET MG *Dermatologicals* acyclovir external ointment 5 Tessalon Perles Tessalon Tussigon Sodium Chloride Neo DM Sodium Chloride Nebusal PulmoSal Neo DM Hydrocodone-Homatropine Zovirax 35

39 adapalene external 0.1 adapalene external cream 0.1 ala cort external cream 1 alclometasone dipropionate external cream 0.05 alclometasone dipropionate external ointment 0.05 alphatrex external 0.05 amcinonide external cream 0.1 amcinonide external lotion 0.1 amcinonide external ointment 0.1 ARZOL SILVER NIT APPLICATORS EXTERNAL AVAR CLEANSER EXTERNAL EMULSION 10-5 Differin Differin Preparation H Hydrocortisone Aclovate Grafco Silver Nit Applicator Sulfacetamide Sodium-Sulfur AVITA EXTERNAL Tretinoin QLL (20 per 30 days) AVITA EXTERNAL CREAM Tretinoin QLL (20 per 30 days) BENZEPRO CREAMY WASH EXTERNAL LIQUID 7 BENZIQ WASH EXTERNAL LIQUID 5.25 BP Wash BP Wash benzoyl peroxide-erythromycin external 5-3 Benzamycin betamethasone dipropionate aug external 0.05 betamethasone dipropionate aug external cream 0.05 betamethasone dipropionate aug external lotion 0.05 betamethasone dipropionate aug external ointment 0.05 betamethasone dipropionate external cream 0.05 betamethasone dipropionate external lotion 0.05 betamethasone dipropionate external ointment 0.05 betamethasone valerate external cream 0.1 betamethasone valerate external lotion 0.1 betamethasone valerate external ointment 0.1 bp 10-1 external emulsion 10-1 bp cleansing wash external emulsion Diprolene AF Diprolene Diprolene Cerisa Wash Claris Clarifying Wash