AETNA BETTER HEALTH Formulary Guide. Aetna Better Health of Michigan Formulary Guide July 2016

Transcription

1 AETNA BETTER HEALTH Formulary Guide Aetna Better Health of Michigan Formulary Guide July 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 () drugs covered? The plan will cover drugs on the formulary. Some drugs may have coverage rules. If the rules for that drug are met, the plan will cover the drug. Like other drugs, drugs need a prescription from a doctor if they are to be covered by the plan. Updated: 07/01/2016 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: 07/01/2016 Page 3

4 Aetna Better Health Michigan Table of Contents Table of Contents *Adhd/Anti-Narcolepsy/Anti-Obesity/Anorexiants*... 3 *Alternative Medicines*... 3 *Aminoglycosides*... 3 *Analgesics - Anti-Inflammatory*... 3 *Analgesics - Nonnarcotic*... 4 *Analgesics - Opioid*... 5 *Androgens-Anabolic*... 7 *Anorectal Agents*... 7 *Antacids*... 7 *Antianginal Agents*... 8 *Antianxiety Agents*... 8 *Antiarrhythmics*... 9 *Antiasthmatic And Bronchodilator Agents*... 9 *Anticoagulants* *Antidiabetics* *Antidiarrheals* *Antidotes* *Antiemetics* *Antifungals* *Antihistamines* *Antihyperlipidemics* *Antihypertensives* *Anti-Infective Agents - Misc.* *Antimalarials* *Antimycobacterial Agents* *Antineoplastics And Adjunctive Therapies* *Antiparkinson Agents* *Antipsychotics/Antimanic Agents* *Antivirals* *Assorted Classes* *Beta Blockers* *Calcium Channel Blockers* *Cardiotonics* *Cardiovascular Agents - Misc.* *Cephalosporins* *Chemicals* *Contraceptives* *Corticosteroids* *Cough/Cold/Allergy* *Dermatologicals* *Diagnostic Products* *Dietary Products/Dietary Management 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* *Medical Devices* *Migraine Products* *Minerals & Electrolytes* *Mouth/Throat/Dental Agents* *Multivitamins* *Musculoskeletal Therapy Agents* *Nasal Agents - Systemic And Topical* *Nutrients* *Ophthalmic Agents* *Otic Agents* *Oxytocics* *Passive Immunizing Agents* *Penicillins* *Pharmaceutical Adjuvants* *Potassium Removing Agents*** *Progestins* *Psychotherapeutic And Neurological Agents - Misc.* *Respiratory Agents - Misc.* *Sodium-Glucose Co-Transporter 2 Inhibitor-Biguanide Comb*** *Tetracyclines* *Thyroid Agents* *Ulcer Drugs* *Urinary Anti-Infectives* *Urinary Antispasmodics* *Vaginal Products* *Vasopressors* *Vitamins*

6 Aetna Better Health Michigan lowercase italics = Generic drugs UPPERCASE BOLD = Brand name drugs Notes AL = Age Limits Apply = Over the Counter = Prior Authorization Applies QLL = Quantity Level Limits Apply ST = Step Therapy Applies *Adhd/Anti-Narcolepsy/Anti-Obesity /Anorexiants* caffeine anhydrous powder caffeine citrate oral solution 20 /ml, 60 /3ml caffeine citrated powder *Alternative Medicines* PRELIEF ORAL TABLET 340 (65-50) (CA-P) *Aminoglycosides* neomycin sulfate oral tablet 500 paromomycin sulfate oral capsule 250 TOBI PODHALER INHALATION CAPSULE 28 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 Cafcit Tobi CeleBREX Cataflam Voltaren-XR AL (Max 1 Years) ; 3

7 ENBREL SUBCUTANEOUS* 25 /0.5ML, 50 /ML ENBREL SURECLICK SUBCUTANEOUS* 50 /ML fenoprofen calcium oral tablet 600 flurbiprofen oral tablet 50 HUMIRA PEDIATRIC CROHNS START SUBCUTANEOUS* 40 /0.8ML HUMIRA PEN SUBCUTANEOUS* 40 /0.8ML HUMIRA PEN-CROHNS STARTER SUBCUTANEOUS* 40 /0.8ML HUMIRA PEN-PSORIASIS STARTER SUBCUTANEOUS* 40 /0.8ML HUMIRA SUBCUTANEOUS* 10 /0.2ML, 20 /0.4ML, 40 /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 AL (Max 64 Years) AL (Max 64 Years) AL (Max 64 Years) leflunomide oral tablet 10, 20 Arava meloxicam oral tablet 15, 7.5 Mobic 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 er oral tablet extended release 24 hr* 500 piroxicam oral capsule 10, 20 sulindac oral tablet 150 sulindac oral tablet 200 *Analgesics - Nonnarcotic* butalbital-acetaminophen oral tablet EC-Naprosyn Naprosyn Naprosyn Naprosyn Naprelan Feldene Clinoril Tencon QLL (120 per 30 days); AL (Min 10 Years and Max 64 Years) 4

8 butalbital-apap-caffeine oral capsule butalbital-apap-caffeine oral tablet butalbital-aspirin-caffeine oral capsule CACET ORAL CAPSULE choline-mag trisalicylate oral liquid 500 /5ml ESGIC ORAL CAPSULE margesic oral capsule marten-tab oral tablet TENCON ORAL TABLET ZEBUTAL ORAL CAPSULE *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 Zebutal Fioricet Fiorinal Margesic Margesic Zebutal Tencon 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 butalbital-apap-caff-cod oral capsule Butalbital-ASA-Caff-Codeine Fioricet/Codeine QLL (120 per 30 days); AL (Min 10 Years and Max 64 Years) QLL (120 per 30 days); AL (Min 10 Years and Max 64 Years) QLL (120 per 30 days); AL (Max 64 Years) QLL (120 per 30 days); AL (Min 10 Years and Max 64 Years) QLL (120 per 30 days); AL (Min 10 Years and Max 64 Years) QLL (120 per 30 days); AL (Min 10 Years and Max 64 Years) QLL (120 per 30 days); AL (Min 10 Years and Max 64 Years) QLL (120 per 30 days); AL (Min 10 Years and Max 64 Years) QLL (120 per 30 days); AL (Min 10 Years and Max 64 Years) QLL (180 per 30 days) QLL (180 per 30 days) QLL (180 per 30 days) QLL (180 per 30 days) QLL (180 per 30 days) QLL (180 per 30 days) QLL (120 per 30 days) QLL (120 per 30 days) 5

9 butalbital-asa-caff-codeine oral capsule codeine sulfate oral tablet 15, 30, 60 DEMEROL ORAL TABLET 100, 50 ENDOCET ORAL TABLET , 5-325, Fiorinal/Codeine #3 Meperitab Oxycodone-Acetaminophen fentanyl transdermal patch 72 hr 100 mcg/hr Duragesic-100 fentanyl transdermal patch 72 hr 12 mcg/hr Duragesic-12 fentanyl transdermal patch 72 hr 25 mcg/hr Duragesic-25 fentanyl transdermal patch 72 hr 50 mcg/hr Duragesic-50 fentanyl transdermal patch 72 hr 75 mcg/hr Duragesic-75 hydrocodone-acetaminophen oral solution /5ml, /10ml, /15ml hydrocodone-acetaminophen oral tablet hydrocodone-acetaminophen oral tablet hydrocodone-acetaminophen oral tablet Hycet Norco Lorcet Lorcet Plus hydrocodone-ibuprofen oral tablet Vicoprofen QLL (120 per 30 days) QLL (90 per 30 days) ; AL (Max 64 Years) QLL (120 per 30 days) QLL (1800 per 30 days) QLL (120 per 30 days) QLL (120 per 30 days) QLL (120 per 30 days) QLL (240 per 30 days) hydromorphone hcl oral tablet 2, 4 Dilaudid QLL (120 per 30 days) hydromorphone hcl suppository 3 LORCET HD ORAL TABLET Hydrocodone-Acetaminophen QLL (120 per 30 days) QLL (120 per 30 days) LORCET ORAL TABLET Hydrocodone-Acetaminophen QLL (120 per 30 days) LORCET PLUS ORAL TABLET LORTAB ORAL TABLET , 5-325, meperidine hcl oral solution 50 /5ml METHADONE HCL INTENSOL ORAL CONCENTRATE 10 /ML Hydrocodone-Acetaminophen Hydrocodone-Acetaminophen Methadone HCl QLL (120 per 30 days) QLL (120 per 30 days) QLL (300 per 30 days); AL (Max 64 Years) QLL (240 per 30 days) methadone hcl oral concentrate 10 /ml Methadose Sugar-Free QLL (240 per 30 days) methadone hcl oral solution 10 /5ml methadone hcl oral solution 5 /5ml QLL (600 per 30 days) QLL (900 per 30 days) methadone hcl oral tablet 10, 5 Dolophine QLL (120 per 30 days) methadone hcl oral tablet soluble 40 Methadose QLL (90 per 30 days) METHADOSE ORAL TABLET SOLUBLE 40 6 Methadone HCl QLL (90 per 30 days)

10 morphine sulfate (concentrate) oral solution 100 /5ml morphine sulfate (concentrate) oral solution 20 /ml 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 oxycodone hcl oral solution 5 /5ml MS Contin QLL (240 per 30 days) QLL (240 per 30 days) QLL (120 per 30 days) oxycodone hcl oral tablet 5 Roxicodone QLL (120 per 30 days) oxycodone-acetaminophen oral tablet , 5-325, pentazocine-naloxone hcl oral tablet Percocet QLL (120 per 30 days) QLL (12 Max Qty Per Fill Retail) ROXICET ORAL TABLET Oxycodone-Acetaminophen QLL (120 per 30 days) tramadol hcl oral tablet 50 Ultram QLL (120 per 30 days) tramadol-acetaminophen oral tablet *Androgens-Anabolic* danazol oral capsule 100, 200, 50 testosterone cypionate intramuscular* solution 100 /ml, 200 /ml *Anorectal Agents* LIDAZONE HC CREAM % lidocaine-hydrocortisone ace cream % PROCTO-K CREAM 1 % *Antacids* ALKA-SELTZER GOLD ORAL TABLET EFFERVESCENT ALKA-SELTZER HEARTBURN ORAL TABLET EFFERVESCENT aluminum hydroxide gel oral suspension 320 /5ml antacid ultra strength oral tablet chewable DEWEES CARMINATIVE ORAL LIQUID E-Z-GAS II ORAL CKET GM Ultracet Depo-Testosterone Lidocaine-Hydrocortisone Ace LidaZone HC Hydrocortisone QLL (240 per 30 days) 7

11 GAVISCON EXTRA RELIEF FORMULA ORAL SUSPENSION /10ML GAVISCON ORAL TABLET CHEWABLE mag-al oral liquid /5ml magnesium oxide oral capsule 400 URO-MAG ORAL CAPSULE 140 *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 /HR, 0.2 /HR, 0.4 /HR, 0.6 /HR NITRO-BID TRANSDERMAL OINTMENT 2 % nitroglycerin er oral capsule extended release* 2.5, 6.5, 9 nitroglycerin transdermal patch 24 hr 0.1 /hr, 0.2 /hr, 0.4 /hr, 0.6 /hr nitroglycerin translingual solution 0.4 /spray NITROSTAT SUBLINGUAL TABLET SUBLINGUAL 0.3, 0.4, 0.6 NITRO-TIME ORAL CAPSULE EXTENDED RELEASE* 2.5, 6.5, 9 RANEXA ORAL TABLET EXTENDED RELEASE 12 HR* 1000, 500 *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 Isordil Titradose Imdur Nitroglycerin Nitro-Time Nitro-Dur Nitrolingual Nitroglycerin ER Vistaril AL (Max 12 Years) AL (Max 64 Years) AL (Max 64 Years) AL (Max 64 Years) 8

12 *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 CERONE ORAL TABLET 100, 200, 400 propafenone hcl oral tablet 150, 225 propafenone hcl oral tablet 300 quinidine sulfate oral tablet 200 quinidine sulfate oral tablet 300 *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 AEROSN INHALATION AEROSOL, SOLUTION 80 MCG/ACT 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 Pacerone Cordarone Norpace Tambocor Amiodarone HCl Rythmol AccuNeb Pulmicort AL (Max 64 Years) QLL (49 per 365 days) QLL (18 per 30 days) QLL (225 per 30 days) ; AL (Max 6 Years) 9

13 DULERA INHALATION AEROSOL MCG/ACT, MCG/ACT ELIXOPHYLLIN ORAL ELIXIR 80 /15ML FLOVENT DISKUS INHALATION AEROSOL POWDER, BREATH ACTIVATED 100 MCG/BLIST, 250 MCG/BLIST, 50 MCG/BLIST INCRUSE ELLIPTA INHALATION AEROSOL POWDER, BREATH ACTIVATED 62.5 MCG/INH ipratropium bromide inhalation solution 0.02 % ipratropium-albuterol inhalation solution (3) /3ml metaproterenol sulfate oral tablet 10, 20 montelukast sodium oral packet 4 montelukast sodium oral tablet 10 Theophylline DuoNeb Singulair Singulair montelukast sodium oral tablet chewable 4 Singulair montelukast sodium oral tablet chewable 5 Singulair PULMICORT FLEXHALER INHALATION AEROSOL POWDER, BREATH ACTIVATED 180 MCG/ACT, 90 MCG/ACT PULMICORT INHALATION SUSPENSION 1 /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 Budesonide QLL (13 per 30 days) QLL (30 per 60 days) QLL (90 per 30 days) ; AL (Max 5 Years) ; AL (Min 15 Years) ; AL (Max 5 Years) ; AL (Min 6 Years and Max 14 Years) QLL (1 per 30 days) ; AL (Max 6 Years) 10

14 THEOCHRON ORAL TABLET EXTENDED RELEASE 12 HR* 100, 200, 300 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 VENTOLIN HFA INHALATION AEROSOL, SOLUTION 108 (90 BASE) MCG/ACT *Anticoagulants* 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 heparin sodium (porcine) injection solution 1000 unit/ml, unit/ml, 5000 unit/ml JANTOVEN ORAL TABLET 1, 10, 2, 2.5, 3, 4, 5, 6, 7.5 warfarin sodium oral tablet 1, 10, 2, 2.5, 3, 4, 5, 6, 7.5 XARELTO ORAL TABLET 10, 15, 20 *Antidiabetics* Theophylline ER Theochron Lovenox Arixtra Warfarin Sodium Coumadin QLL (1 per 30 days) QLL (18 per 30 days) ; acarbose oral tablet 100 Precose QLL (120 per 30 days) acarbose oral tablet 25, 50 Precose QLL (90 per 30 days) APIDRA INJECTION SOLUTION 100 UNIT/ML APIDRA SOLOSTAR SUBCUTANEOUS* 100 UNIT/ML chlorpropamide oral tablet 100 chlorpropamide oral tablet 250 Diabinese ; AL (Max 21 Years) QLL (120 per 30 days); AL (Max 64 Years) QLL (90 per 30 days); AL (Max 64 Years) 11

15 FARXIGA ORAL TABLET 10, 5 ST; glimepiride oral tablet 1, 2, 4 Amaryl glipizide er oral tablet extended release 24 hr* 10, 2.5, 5 GlipiZIDE XL glipizide oral tablet 10 Glucotrol QLL (120 per 30 days) glipizide oral tablet 5 Glucotrol QLL (240 per 30 days) glipizide xl oral tablet extended release 24 hr* 10, 2.5, 5 GlipiZIDE XL glipizide-metformin hcl oral tablet Metaglip glipizide-metformin hcl oral tablet , GLUCAGEN HYPOKIT INJECTION SOLUTION RECONSTITUTED 1 GLUCAGON EMERGENCY INJECTION KIT 1 glyburide micronized oral tablet 1.5, 3, 6 Glynase QLL (1 per 28 days) glyburide oral tablet 1.25, 2.5, 5 Diabeta QLL (120 per 30 days) glyburide-metformin oral tablet 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 INVOKANA ORAL TABLET 100, 300 JANUMET ORAL TABLET , Glucovance Glucovance AL (Max 21 Years) AL (Max 21 Years) AL (Max 21 Years) ; ST; ST; 12

16 JANUMET XR ORAL TABLET EXTENDED RELEASE 24 HR* , , JANUVIA ORAL TABLET 100, 25, 50 JENTADUETO ORAL TABLET , , LANTUS SOLOSTAR SUBCUTANEOUS* 100 UNIT/ML LANTUS SUBCUTANEOUS* SOLUTION 100 UNIT/ML metformin hcl er oral tablet extended release 24 hr* 500, 750 metformin hcl oral tablet 1000, 500, 850 Glucophage XR Glucophage ST; ST; ST AL (Max 21 Years) nateglinide oral tablet 120, 60 Starlix QLL (90 per 30 days) NOVOLOG FLEXPEN SUBCUTANEOUS* 100 UNIT/ML NOVOLOG MIX 70/30 FLEXPEN SUBCUTANEOUS* (70-30) 100 UNIT/ML NOVOLOG MIX 70/30 SUBCUTANEOUS* SUSPENSION (70-30) 100 UNIT/ML NOVOLOG SUBCUTANEOUS* SOLUTION 100 UNIT/ML pioglitazone hcl oral tablet 15, 30, 45 Actos AL (Max 21 Years) AL (Max 21 Years) repaglinide oral tablet 0.5, 1, 2 Prandin QLL (120 per 30 days) TANZEUM SUBCUTANEOUS* 30, 50 tolazamide oral tablet 250, 500 tolbutamide oral tablet 500 TRADJENTA ORAL TABLET 5 TRULICITY SUBCUTANEOUS* 0.75 /0.5ML, 1.5 /0.5ML VICTOZA SUBCUTANEOUS* 18 /3ML *Antidiarrheals* diphenoxylate-atropine oral liquid /5ml diphenoxylate-atropine oral tablet lofene oral tablet Lonox Lonox ST; QLL (4 per 28 days) ST ST ST 13

17 loperamide hcl oral capsule 2 *Antidotes* CHEMET ORAL CAPSULE 100 *Antiemetics* granisetron hcl oral tablet 1 MARINOL ORAL CAPSULE 10, 2.5, 5 ondansetron hcl oral solution 4 /5ml ondansetron hcl oral tablet 24 Dronabinol Zofran ST; QLL (4 per 30 days) QLL (150 per 30 days); AL (Max 12 Years) ondansetron hcl oral tablet 4, 8 Zofran QLL (90 per 30 days) ondansetron oral tablet dispersible 4, 8 Zofran ODT *Antifungals* 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 tablet unit Diflucan Diflucan Grifulvin V Gris-PEG Sporanox Pulsepak QLL (90 per 30 days) AL (Max 12 Years) terbinafine hcl oral tablet 250 LamISIL *Antihistamines* ARBINOXA ORAL TABLET 4 Carbinoxamine Maleate BENADRYL ORAL TABLET 25 EQL Allergy ; AL (Max 64 Years) carbinoxamine maleate oral solution 4 /5ml Palgic 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 Arbinoxa Wal-Zyr Childrens QLL (300 per 30 days); AL (Max 12 Years) AL (Max 64 Years) AL (Max 64 Years) diphenhydramine hcl oral capsule 50 Banophen ; AL (Max 64 Years) PHENADOZ SUPPOSITORY 12.5, 25 Promethazine HCl AL (Min 2 Years and Max 64 Years) 14

18 PHENERGAN SUPPOSITORY 12.5, 25, 50 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, 25, 50 *Antihyperlipidemics* atorvastatin calcium oral tablet 10, 20, 40, 80 cholestyramine light oral packet 4 gm Promethazine HCl Phenadoz Promethegan Promethazine HCl Lipitor Questran Light AL (Min 2 Years and Max 64 Years) AL (Min 2 Years and Max 64 Years) AL (Min 2 Years and Max 64 Years) AL (Min 2 Years and Max 64 Years) AL (Min 2 Years and Max 64 Years) AL (Min 2 Years and Max 64 Years) AL (Min 2 Years and Max 64 Years) cholestyramine light oral powder 4 gm/dose Questran Light QLL (240 per 30 days) cholestyramine oral packet 4 gm Questran cholestyramine oral powder 4 gm/dose Questran QLL (378 per 30 days) 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 capsule 150, 50 Colestid Flavored Colestid Colestid Lofibra Lipofen fenofibrate oral tablet 145, 48 Tricor fenofibrate oral tablet 160, 54 Lofibra fenofibric acid oral capsule delayed release 135, 45 fenofibric acid oral tablet 105, 35 Trilipix Fibricor fluvastatin sodium oral capsule 20 Lescol fluvastatin sodium oral capsule 40 Lescol gemfibrozil oral tablet 600 Lopid lovastatin oral tablet 10 lovastatin oral tablet 20, 40 Mevacor niacin er (antihyperlipidemic) oral tablet extendedrelease* 1000 niacin er (antihyperlipidemic) oral tablet extendedrelease* 500 Niaspan Niaspan QLL (120 per 30 days) 15

19 niacin er (antihyperlipidemic) oral tablet extendedrelease* 750 Niaspan omega-3-acid ethyl esters oral capsule 1 gm Lovaza 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 *Antihypertensives* Pravachol Cholestyramine Light Cholestyramine Light Zocor amlodipine besy-benazepril hcl oral capsule 10-20, 10-40, , 5-10, 5-20 Lotrel, 5-40 atenolol-chlorthalidone oral tablet Tenoretic 100 atenolol-chlorthalidone oral tablet Tenoretic 50 QLL (90 per 30 days) QLL (240 per 30 days) benazepril hcl oral tablet 10, 20 Lotensin QLL (45 per 30 days) benazepril hcl oral tablet 40 Lotensin benazepril hcl oral tablet 5 bisoprolol-hydrochlorothiazide oral tablet 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 clonidine hcl oral tablet 0.1, 0.2, 0.3 doxazosin mesylate oral tablet 1, 2, 4 Ziac Ziac Atacand Atacand HCT Catapres Cardura QLL (45 per 30 days) QLL (45 per 30 days) doxazosin mesylate oral tablet 8 Cardura enalapril maleate oral tablet 10, 2.5, 5 Vasotec QLL (45 per 30 days) enalapril maleate oral tablet 20 Vasotec enalapril-hydrochlorothiazide oral tablet Vaseretic 16

20 enalapril-hydrochlorothiazide oral tablet ENED ORAL SOLUTION RECONSTITUTED 1 /ML fenoldopam mesylate intravenous* solution 10 /ml fosinopril sodium oral tablet 10, 20 fosinopril sodium oral tablet 40 Corlopam AL (Max 12 Years) QLL (45 per 30 days) guanfacine hcl oral tablet 1, 2 Tenex hydralazine hcl injection solution 20 /ml hydralazine hcl oral tablet 10, 100, 50 hydralazine hcl oral tablet 25 QLL (90 per 30 days) QLL (120 per 30 days) irbesartan oral tablet 150, 300, 75 Avapro irbesartan-hydrochlorothiazide oral tablet , lisinopril oral tablet 10, 2.5, 20, 30, 5 Avalide Zestril QLL (45 per 30 days) lisinopril oral tablet 40 Zestril 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 , minoxidil oral tablet 10, 2.5 perindopril erbumine oral tablet 2 Zestoretic Cozaar Hyzaar Lopressor HCT AL (Max 64 Years) QLL (45 per 30 days) perindopril erbumine oral tablet 4 Aceon QLL (45 per 30 days) prazosin hcl oral capsule 1, 2, 5 Minipress quinapril hcl oral tablet 10, 20, 40, 5 quinapril-hydrochlorothiazide oral tablet , , ramipril oral capsule 1.25, 10, 2.5, 5 Accupril Accuretic Altace 17

21 TEKTURNA HCT ORAL TABLET , , , TEKTURNA ORAL TABLET 150, 300 terazosin hcl oral capsule 1, 5 terazosin hcl oral capsule 10, 2 ; ; trandolapril oral tablet 1, 2, 4 Mavik valsartan oral tablet 160, 320, 40, 80 valsartan-hydrochlorothiazide oral tablet , , valsartan-hydrochlorothiazide oral tablet , *Anti-Infective Agents - Misc.* CAYSTON INHALATION SOLUTION RECONSTITUTED 75 clindamycin hcl oral capsule 150, 300, 75 clindamycin palmitate hcl oral solution reconstituted 75 /5ml dapsone oral tablet 100, 25 linezolid oral suspension reconstituted 100 /5ml Diovan Diovan HCT Diovan HCT Cleocin Cleocin Zyvox linezolid oral tablet 600 Zyvox MEPRON ORAL SUSPENSION 750 /5ML metronidazole oral tablet 250, 500 sulfamethoxazole-trimethoprim oral suspension /5ml sulfamethoxazole-trimethoprim oral tablet sulfamethoxazole-trimethoprim oral tablet SULFATRIM PEDIATRIC ORAL SUSPENSION /5ML tinidazole oral tablet 250, 500 trimethoprim oral tablet 100 vancomycin hcl intravenous* solution reconstituted 10 gm, 1000, 500, 5000, 750 Atovaquone Flagyl Sulfatrim Pediatric Bactrim Bactrim DS Sulfamethoxazole-Trimethopri m Tindamax AL (Max 12 Years) 18

22 *Antimalarials* chloroquine phosphate oral tablet 250 chloroquine phosphate oral tablet 500 Aralen DARAPRIM ORAL TABLET 25 hydroxychloroquine sulfate oral tablet 200 Plaquenil mefloquine hcl oral tablet 250 primaquine phosphate oral tablet 26.3 *Antimycobacterial Agents* ethambutol hcl oral tablet 100, 400 isoniazid oral syrup 50 /5ml isoniazid oral tablet 100, 300 pyrazinamide oral tablet 500 rifabutin oral capsule 150 rifampin oral capsule 150, 300 SEROMYCIN ORAL CAPSULE 250 TRECATOR ORAL TABLET 250 *Antineoplastics And Adjunctive Therapies* AFINITOR DISPERZ ORAL TABLET SOLUBLE 2, 3, 5 AFINITOR ORAL TABLET 10 AFINITOR ORAL TABLET 2.5, 5 AFINITOR ORAL TABLET 7.5 ALKERAN ORAL TABLET 2 anastrozole oral tablet 1 Myambutol Mycobutin Rifadin CycloSERINE Arimidex bexarotene oral capsule 75 Targretin bicalutamide oral tablet 50 Casodex capecitabine oral tablet 150, 500 Xeloda cyclophosphamide oral capsule 25, 50 EMCYT ORAL CAPSULE 140 ERIVEDGE ORAL CAPSULE 150 etoposide oral capsule 50 exemestane oral tablet 25 FARESTON ORAL TABLET 60 FARYDAK ORAL CAPSULE 10, 15, 20 flutamide oral capsule 125 Aromasin ; ; ; ; 19

23 GLEOSTINE ORAL CAPSULE 10, 100, 40 HEXALEN ORAL CAPSULE 50 HYCAMTIN ORAL CAPSULE 0.25, 1 hydroxyurea oral capsule 500 INTRON A INJECTION SOLUTION UNIT/ML, UNIT/ML JAKAFI ORAL TABLET 10, 15, 20, 25, 5 letrozole oral tablet 2.5 leucovorin calcium oral tablet 10, 15, 25, 5 LEUKERAN ORAL TABLET 2 LYSODREN ORAL TABLET 500 MATULANE ORAL CAPSULE 50 megestrol acetate oral suspension 40 /ml, 400 /10ml megestrol acetate oral tablet 20, 40 mercaptopurine oral tablet 50 MESNEX ORAL TABLET 400 methotrexate oral tablet 2.5 MYLERAN ORAL TABLET 2 NILANDRON ORAL TABLET 150 POMALYST ORAL CAPSULE 1, 2, 3, 4 TABLOID ORAL TABLET 40 tamoxifen citrate oral tablet 10, 20 temozolomide oral capsule 100, 140, 180, 20, 250, 5 tretinoin oral capsule 10 XTANDI ORAL CAPSULE 40 ZOLINZA ORAL CAPSULE 100 ZYTIGA ORAL TABLET 250 *Antiparkinson Agents* amantadine hcl oral capsule 100 amantadine hcl oral syrup 50 /5ml amantadine hcl oral tablet 100 bromocriptine mesylate oral capsule 5 Lomustine Hydrea Femara Megace Oral Purinethol Temodar Parlodel ; ; AL (Min 18 Years) ; QLL (120 per 30 days) ; QLL (120 per 30 days) QLL (120 per 30 days) 20

24 bromocriptine mesylate oral tablet 2.5 Parlodel QLL (180 per 30 days) carbidopa-levodopa er oral tablet extendedrelease* , carbidopa-levodopa oral tablet , , carbidopa-levodopa oral tablet dispersible , carbidopa-levodopa oral tablet dispersible Sinemet CR Sinemet Parcopa Parcopa MIRAPEX ORAL TABLET 0.75 Pramipexole Dihydrochloride pramipexole dihydrochloride oral tablet 0.125, 0.25, 0.5, 0.75, 1, 1.5 ropinirole hcl oral tablet 0.25, 0.5, 1, 2, 3, 4, 5 Mirapex Requip selegiline hcl oral capsule 5 Eldepryl *Antipsychotics/Antimanic Agents* COMZINE SUPPOSITORY 25 Prochlorperazine COMPRO SUPPOSITORY 25 Prochlorperazine prochlorperazine maleate oral tablet 10, 5 Compazine prochlorperazine suppository 25 Compro *Antivirals* acyclovir oral capsule 200 Zovirax acyclovir oral suspension 200 /5ml Zovirax AL (Max 12 Years) acyclovir oral tablet 400 Zovirax acyclovir oral tablet 800 Zovirax entecavir oral tablet 0.5, 1 famciclovir oral tablet 125, 250, 500 HEPSERA ORAL TABLET 10 lamivudine oral tablet 100 RELENZA DISKHALER INHALATION AEROSOL POWDER, BREATH ACTIVATED 5 /BLISTER rimantadine hcl oral tablet 100 TAMIFLU ORAL CAPSULE 30, 45, 75 TAMIFLU ORAL SUSPENSION RECONSTITUTED 6 /ML Baraclude Famvir Adefovir Dipivoxil Epivir HBV Flumadine QLL (90 per 30 days) QLL (20 per 180 days); AL (Min 5 Years) QLL (10 Max Qty Per Fill Retail) QLL (3 Max Qty Per Fill Retail); AL (Max 12 Years) valacyclovir hcl oral tablet 1 gm Valtrex valacyclovir hcl oral tablet 500 Valtrex 21

25 valganciclovir hcl oral tablet 450 Valcyte ; *Assorted Classes* ARGYLE STERILE WATER IRRIGATION SOLUTION Sterile Water for Irrigation azathioprine oral tablet 50 Imuran QLL (240 per 30 days) cyclosporine modified oral capsule 100, 25 cyclosporine modified oral capsule 50 Gengraf Gengraf cyclosporine modified oral solution 100 /ml Gengraf AL (Max 12 Years) cyclosporine oral capsule 100 SandIMMUNE QLL (150 per 30 days) cyclosporine oral capsule 25 GENGRAF ORAL CAPSULE 100, 25 GENGRAF ORAL SOLUTION 100 /ML KIONEX ORAL POWDER KIONEX ORAL SUSPENSION 15 GM/60ML SandIMMUNE CycloSPORINE Modified CycloSPORINE Modified Sodium Polystyrene Sulfonate Sodium Polystyrene Sulfonate AL (Max 12 Years) mycophenolate mofetil oral capsule 250 CellCept mycophenolate mofetil oral suspension reconstituted 200 /ml mycophenolate mofetil oral tablet 500 mycophenolic acid oral tablet delayed release 180, 360 REVLIMID ORAL CAPSULE 10, 15, 25, 5 REVLIMID ORAL CAPSULE 2.5, 20 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 tacrolimus oral capsule 5 *Beta Blockers* acebutolol hcl oral capsule 200, 400 atenolol oral tablet 100, 25, CellCept CellCept Myfortic Rapamune Kayexalate SPS Sodium Polystyrene Sulfonate Argyle Sterile Water Prograf Hecoria Sectral Tenormin AL (Max 12 Years) ST ;

26 betaxolol hcl oral tablet 10, 20 Kerlone bisoprolol fumarate oral tablet 10 Zebeta bisoprolol fumarate oral tablet 5 Zebeta QLL (45 per 30 days) carvedilol oral tablet 12.5, 25, 3.125, 6.25 HEMANGEOL ORAL SOLUTION 4.28 /ML labetalol hcl oral tablet 100, 200, 300 metoprolol succinate er oral tablet extended release 24 hr* 100, 25, 50 metoprolol succinate er oral tablet extended release 24 hr* 200 Coreg Trandate Toprol XL Toprol XL AL (Max 4 Years) QLL (45 per 30 days) metoprolol tartrate oral tablet 100, 50 Lopressor QLL (90 per 30 days) 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 propranolol hcl er oral capsule extended release 24 hour 60 propranolol hcl er oral capsule extended release 24 hour 80 propranolol hcl oral solution 20 /5ml, 40 /5ml propranolol hcl oral tablet 10, 20, 40, 60, 80 SORINE ORAL TABLET 120, 160, 240, 80 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, 60 amlodipine besylate oral tablet 10, 2.5, 5 Corgard Inderal LA Inderal LA Inderal LA Sotalol HCl Betapace AF Sorine NIFEdipine ER Norvasc QLL (90 per 30 days) QLL (120 per 30 days) QLL (90 per 30 days) 23

27 CARTIA XT ORAL CAPSULE EXTENDED RELEASE 24 HOUR 120, 180, 240, 300 diltiazem cd oral capsule extended release 24 hour 120 diltiazem cd oral capsule extended release 24 hour 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, 300 diltiazem hcl er coated beads oral capsule extended release 24 hour 180, 240 diltiazem hcl er coated beads oral tablet extended release 24 hr* 180, 300 diltiazem hcl er oral capsule extended release 24 hour 120, 180 diltiazem hcl er oral capsule extended release 24 hour 240 Diltiazem HCl ER Coated Beads Cartia XT Cardizem CD Tiazac Cartia XT Cardizem CD Cardizem LA Dilacor XR diltiazem hcl oral tablet 120, 30, 60 Cardizem diltiazem hcl oral tablet 90 Cardizem QLL (120 per 30 days) dilt-xr oral capsule extended release 24 hour 120, 180 dilt-xr oral capsule extended release 24 hour 240 felodipine er oral tablet extended release 24 hr* 10 felodipine er oral tablet extended release 24 hr* 2.5, 5 isradipine oral capsule 2.5, 5 MATZIM LA ORAL TABLET EXTENDED RELEASE 24 HR* 180, 300 nicardipine hcl oral capsule 20, 30 NIFEDIAC CC ORAL TABLET EXTENDED RELEASE 24 HR* 30 NIFEDICAL XL ORAL TABLET EXTENDED RELEASE 24 HR* 30, 60 nifedipine er oral tablet extended release 24 hr* 30, 60, 90 nifedipine er osmotic release oral tablet extended release 24 hr* 30, Dilacor XR Diltiazem HCl ER Coated Beads NIFEdipine ER NIFEdipine ER Osmotic Nifediac CC Procardia XL

28 nifedipine er osmotic release oral tablet extended release 24 hr* 60 nifedipine oral capsule 10 nifedipine oral capsule 20 Nifedical XL Procardia QLL (120 per 30 days); AL (Max 64 Years) QLL (120 per 30 days); AL (Max 64 Years) nimodipine oral capsule 30 Nimotop TAZTIA XT ORAL CAPSULE EXTENDED RELEASE 24 HOUR 120, 180, 240, 300, 360 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 verapamil hcl er oral tablet extendedrelease* 240 verapamil hcl oral tablet 120, 80 verapamil hcl oral tablet 40 VERELAN PM ORAL CAPSULE EXTENDED RELEASE 24 HOUR 100, 200 *Cardiotonics* DIGITEK ORAL TABLET 125 MCG, 250 MCG DIGOX ORAL TABLET 125 MCG, 250 MCG digoxin oral solution 0.05 /ml digoxin oral tablet 125 mcg digoxin oral tablet 250 mcg *Cardiovascular Agents - Misc.* ADCIRCA ORAL TABLET 20 ADEMS ORAL TABLET 0.5, 1, 1.5, 2, 2.5 LETAIRIS ORAL TABLET 10, 5 Diltiazem HCl ER Beads Verelan PM Verelan Isoptin SR Calan SR Calan Verapamil HCl ER Digoxin Digoxin Lanoxin Digox sildenafil citrate oral tablet 20 Revatio TRACLEER ORAL TABLET 125, 62.5 *Cephalosporins* cefaclor oral capsule 250, 500 ; ; QLL (90 per 30 days) ; ; 25

29 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 ceftriaxone sodium injection solution reconstituted 250 ceftriaxone sodium injection solution reconstituted 500 cefuroxime axetil oral tablet 250, 500 cephalexin oral capsule 250, 500 cephalexin oral suspension reconstituted 125 /5ml, 250 /5ml *Chemicals* acidophilus lactobacillus powder glycerine liquid hydroxyprogesterone caproate powder leucovorin calcium powder pyrimethamine powder sorbitol powder stevia extract powder steviol glycosides powder 95 % stevioside fluid extract 15 % stevioside powder 90 % *Contraceptives* ALTAVERA ORAL TABLET MCG Rocephin Ceftin Keflex Levonorgestrel-Ethinyl Estrad alyacen 1/35 oral tablet mcg Necon 1/35 (28) alyacen 7/7/7 oral tablet 0.5/0.75/1-35 -mcg 26 Nortrel 7/7/7 AL (Max 12 Years) AL (Max 12 Years) AL (Max 12 Years) AL (Max 12 Years) AL (Max 12 Years) QLL (2 Max Qty Per Fill Retail) QLL (2 Max Qty Per Fill Retail) AL (Max 12 Years)

30 AMETHYST ORAL TABLET MCG Levonorgestrel-Ethinyl Estrad APRI ORAL TABLET MCG ARANELLE ORAL TABLET 0.5/1/ MCG Desogestrel-Ethinyl Estradiol AUBRA ORAL TABLET MCG Levonorgestrel-Ethinyl Estrad AVIANE ORAL TABLET MCG AZURETTE ORAL TABLET /0.01 (21/5) BALZIVA ORAL TABLET MCG briellyn oral tablet mcg CAMILA ORAL TABLET 0.35 CAZIANT ORAL TABLET 0.1/0.125/ CESIA ORAL TABLET 0.1/0.125/ CHATEAL ORAL TABLET MCG CRYSELLE-28 ORAL TABLET MCG CYCLAFEM 1/35 ORAL TABLET MCG CYCLAFEM 7/7/7 ORAL TABLET 0.5/0.75/1-35 -MCG CYRED ORAL TABLET MCG DASETTA 1/35 ORAL TABLET MCG DASETTA 7/7/7 ORAL TABLET 0.5/0.75/1-35 -MCG DEBLITANE ORAL TABLET 0.35 DELYLA ORAL TABLET MCG 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 Levonorgestrel-Ethinyl Estrad Desogestrel-Ethinyl Estradiol Briellyn Philith Norethindrone Levonorgestrel-Ethinyl Estrad Alyacen 1/35 Alyacen 7/7/7 Desogestrel-Ethinyl Estradiol Alyacen 1/35 Alyacen 7/7/7 Norethindrone Levonorgestrel-Ethinyl Estrad Pimtrea Reclipsen Loryna Ocella 27

31 ELINEST ORAL TABLET MCG ELLA ORAL TABLET 30 EMOQUETTE ORAL TABLET MCG ENPRESSE-28 ORAL TABLET ENSKYCE ORAL TABLET MCG ERRIN ORAL TABLET 0.35 ESTARYLLA ORAL TABLET MCG FALMINA ORAL TABLET MCG GIANVI ORAL TABLET GILDAGIA ORAL TABLET MCG GILDESS 1.5/30 ORAL TABLET MCG GILDESS 1/20 ORAL TABLET MCG GILDESS FE 1.5/30 ORAL TABLET MCG GILDESS FE 1/20 ORAL TABLET MCG HEATHER ORAL TABLET 0.35 INTROVALE ORAL TABLET JENCYCLA ORAL TABLET 0.35 JOLESSA ORAL TABLET JOLIVETTE ORAL TABLET 0.35 JUNEL 1.5/30 ORAL TABLET MCG JUNEL 1/20 ORAL TABLET MCG JUNEL FE 1.5/30 ORAL TABLET MCG JUNEL FE 1/20 ORAL TABLET MCG KARIVA ORAL TABLET /0.01 (21/5) KELNOR 1/35 ORAL TABLET MCG 28 Desogestrel-Ethinyl Estradiol Levonorg-Eth Estrad Triphasic Desogestrel-Ethinyl Estradiol Norethindrone 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 Desogestrel-Ethinyl Estradiol

32 KIMIDESS ORAL TABLET /0.01 (21/5) KURVELO ORAL TABLET MCG LARIN 1.5/30 ORAL TABLET MCG LARIN 1/20 ORAL TABLET MCG LARIN FE 1.5/30 ORAL TABLET MCG LARIN FE 1/20 ORAL TABLET MCG LEENA ORAL TABLET 0.5/1/ MCG LESSINA ORAL TABLET MCG LEVONEST ORAL TABLET levonorgest-eth estrad 91-day oral tablet Desogestrel-Ethinyl Estradiol Levonorgestrel-Ethinyl Estrad Norethindrone Acet-Ethinyl Est Norethin Ace-Eth Estrad-FE Levonorgestrel-Ethinyl Estrad Levonorg-Eth Estrad Triphasic Introvale levonorgestrel oral tablet 1.5 Plan B One-Step 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 MCG LO LOESTRIN FE ORAL TABLET 1-10 MCG / 10 MCG LORYNA ORAL TABLET LOW-OGESTREL ORAL TABLET MCG LUTERA ORAL TABLET MCG LYZA ORAL TABLET 0.35 marlissa oral tablet mcg medroxyprogesterone acetate intramuscular* suspension 150 /ml MICROGESTIN 1.5/30 ORAL TABLET MCG MICROGESTIN 1/20 ORAL TABLET MCG Lessina-28 Chateal Amethyst Levonorgestrel-Ethinyl Estrad Drospirenone-Ethinyl Estradiol Levonorgestrel-Ethinyl Estrad Norethindrone Chateal Depo-Provera Norethindrone Acet-Ethinyl Est QLL (90 per 1 day) 29

33 MICROGESTIN FE 1.5/30 ORAL TABLET MCG MICROGESTIN FE 1/20 ORAL TABLET MCG MINASTRIN 24 FE ORAL TABLET CHEWABLE MCG(24) MONO-LINYAH ORAL TABLET MCG MONONESSA ORAL TABLET MCG Norethin Ace-Eth Estrad-FE Norgestimate-Eth Estradiol Norgestimate-Eth Estradiol MY WAY ORAL TABLET 1.5 Levonorgestrel MYZILRA ORAL TABLET NECON 0.5/35 (28) ORAL TABLET MCG NECON 1/35 (28) ORAL TABLET MCG NECON 1/50 (28) ORAL TABLET MCG NECON 10/11 (28) ORAL TABLET 35 MCG NECON 7/7/7 ORAL TABLET 0.5/0.75/1-35 -MCG NIKKI ORAL TABLET NORA-BE ORAL TABLET 0.35 norethin ace-eth estrad-fe oral tablet mcg norethindrone acet-ethinyl est oral tablet mcg norethindrone oral tablet 0.35 norethin-eth estradiol-fe oral tablet chewable mcg norgestimate-eth estradiol oral tablet mcg norgestim-eth estrad triphasic oral tablet 0.18/0.215/ mcg NORLYROC ORAL TABLET 0.35 NORTREL 0.5/35 (28) ORAL TABLET MCG NORTREL 1/35 (21) ORAL TABLET MCG NORTREL 1/35 (28) ORAL TABLET MCG Levonorg-Eth Estrad Triphasic Alyacen 1/35 Alyacen 7/7/7 Drospirenone-Ethinyl Estradiol Norethindrone Blisovi FE 1/20 Loestrin 1/20 (21) Jencycla Generess FE Mono-Linyah Ortho Tri-Cyclen (28) Norethindrone Alyacen 1/35 Alyacen 1/35 30

34 NORTREL 7/7/7 ORAL TABLET 0.5/0.75/1-35 -MCG NUVARING VAGINAL RING /24HR OCELLA ORAL TABLET OGESTREL ORAL TABLET MCG ORSYTHIA ORAL TABLET MCG PHILITH ORAL TABLET MCG PIMTREA ORAL TABLET /0.01 (21/5) PIRMELLA 1/35 ORAL TABLET MCG PIRMELLA 7/7/7 ORAL TABLET 0.5/0.75/1-35 -MCG PORTIA-28 ORAL TABLET MCG PREVIFEM ORAL TABLET MCG QUASENSE ORAL TABLET RECLIPSEN ORAL TABLET MCG SAFYRAL ORAL TABLET SETLAKIN ORAL TABLET SHAROBEL ORAL TABLET 0.35 Alyacen 7/7/7 Drospirenone-Ethinyl Estradiol Levonorgestrel-Ethinyl Estrad Briellyn Desogestrel-Ethinyl Estradiol 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 MCG Desogestrel-Ethinyl Estradiol SPRINTEC 28 ORAL TABLET MCG SRONYX ORAL TABLET MCG SYEDA ORAL TABLET TARINA FE 1/20 ORAL TABLET MCG TILIA FE ORAL TABLET 1-20/1-30/1-35 -MCG TRI-ESTARYLLA ORAL TABLET 0.18/0.215/ MCG Norgestimate-Eth Estradiol Levonorgestrel-Ethinyl Estrad Drospirenone-Ethinyl Estradiol Norethin Ace-Eth Estrad-FE Norgestim-Eth Estrad Triphasic 31

35 TRI-LEGEST FE ORAL TABLET 1-20/1-30/1-35 -MCG TRI-LINYAH ORAL TABLET 0.18/0.215/ MCG TRI-LO-SPRINTEC ORAL TABLET 0.18/0.215/ MCG TRINESSA (28) ORAL TABLET 0.18/0.215/ MCG TRI-PREVIFEM ORAL TABLET 0.18/0.215/ MCG TRI-SPRINTEC ORAL TABLET 0.18/0.215/ MCG TRIVORA (28) ORAL TABLET VELIVET ORAL TABLET 0.1/0.125/ VESTURA ORAL TABLET viorele oral tablet /0.01 (21/5) VYFEMLA ORAL TABLET MCG WERA ORAL TABLET MCG XULANE TRANSDERMAL TCH WEEKLY MCG/24HR ZARAH ORAL TABLET ZENCHENT ORAL TABLET MCG ZOVIA 1/35E (28) ORAL TABLET MCG ZOVIA 1/50E (28) ORAL TABLET MCG *Corticosteroids* budesonide oral capsule delayed release particles 3 DELTASONE ORAL TABLET 20 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 Norgestimate-Eth Estradiol Norgestim-Eth Estrad Triphasic Norgestim-Eth Estrad Triphasic Norgestim-Eth Estrad Triphasic Levonorg-Eth Estrad Triphasic Drospirenone-Ethinyl Estradiol Pimtrea Briellyn Drospirenone-Ethinyl Estradiol Briellyn Entocort EC PredniSONE Baycadron hydrocortisone oral tablet 10, 20, 5 Cortef methylprednisolone oral tablet 16, 32, 4, 8 prednisolone oral solution 15 /5ml 32 Medrol Prelone QLL (4 per 28 days)

36 prednisolone oral syrup 15 /5ml prednisolone sodium phosphate oral solution 15 /5ml prednisolone sodium phosphate oral solution 25 /5ml prednisolone sodium phosphate oral solution 6.7 (5 base) /5ml prednisone oral solution 5 /5ml prednisone oral tablet 1, 10, 2.5, 5, 50 prednisone oral tablet 20 *Cough/Cold/Allergy* acetylcysteine inhalation solution 10 %, 20 % benzonatate oral capsule 100 benzonatate oral capsule 200 hydrocodone-homatropine oral syrup /5ml hydromet oral syrup /5ml promethazine-codeine oral syrup /5ml promethazine-dm oral syrup /5ml PULMOSAL INHALATION NEBULIZATION SOLUTION 7 % sodium chloride inhalation nebulization solution 0.9 % sodium chloride inhalation nebulization solution 7 % *Dermatologicals* ABREVA EXTERNAL CREAM 10 % Prelone Orapred Pediapred Deltasone Tessalon Perles Tessalon Sodium Chloride HyperSal acitretin oral capsule 10, 17.5, 25 Soriatane adapalene external cream 0.1 % Differin ST; QLL (45 per 30 days) adapalene external gel 0.1 % Differin ST; QLL (45 per 30 days) ala cort external cream 1 % alphatrex external gel 0.05 % AVITA EXTERNAL CREAM % AVITA EXTERNAL GEL % benzoyl peroxide-erythromycin external gel 5-3 % Preparation H Hydrocortisone Tretinoin Tretinoin Benzamycin QLL (45 per 30 days); AL (Min 10 Years and Max 29 Years) QLL (45 per 30 days); AL (Min 10 Years and Max 29 Years) QLL (47 per 30 days) 33

37 betamethasone dipropionate aug external cream 0.05 % betamethasone dipropionate aug external gel 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 valerate external cream 0.1 % betamethasone valerate external lotion 0.1 % betamethasone valerate external ointment 0.1 % bp foaming wash external liquid 10 % Diprolene AF Diprolene Diprolene PanOxyl Wash calcipotriene external cream % Dovonex QLL (45 per 30 days) QLL (45 per 30 days) QLL (45 per 30 days) calcipotriene external ointment % Calcitrene ; calcipotriene external solution % CALCITRENE EXTERNAL OINTMENT % Calcipotriene CICLODAN EXTERNAL CREAM 0.77 % Ciclopirox Olamine CICLODAN EXTERNAL SOLUTION 8 % Ciclopirox ciclopirox external solution 8 % ciclopirox olamine external cream 0.77 % CLARAVIS ORAL CAPSULE 10, 20, 30, 40 Ciclodan Ciclodan ; ; ; CLEARPLEX X EXTERNAL GEL 10 % BP Gel CLINDACIN ETZ EXTERNAL SWAB 1 % CLINDACIN-P EXTERNAL SWAB 1 % CLINDAMAX EXTERNAL GEL 1 % clindamycin phosphate external gel 1 % clindamycin phosphate external lotion 1 % clindamycin phosphate external solution 1 % clindamycin phosphate external swab 1 % Clindamycin Phosphate Clindamycin Phosphate Clindamycin Phosphate Clindagel Cleocin-T Cleocin-T Cleocin-T clobetasol propionate external cream 0.05 % Temovate ; clobetasol propionate external ointment 0.05 % Temovate clobetasol propionate external solution 0.05 % Cormax Scalp Application 34 ; ; QLL (50 per 30 days)

38 clotrimazole-betamethasone external cream % CORMAX SCALP APPLICATION EXTERNAL SOLUTION 0.05 % Lotrisone Clobetasol Propionate diclofenac sodium transdermal gel 3 % Solaraze econazole nitrate external cream 1 % ELIDEL EXTERNAL CREAM 1 % erythromycin external solution 2 % essentra wipes 9x9" external 70 % fluocinolone acetonide powder fluocinonide external cream 0.05 % fluocinonide external ointment 0.05 % fluocinonide external solution 0.05 % fluocinonide-e external cream 0.05 % fluorouracil external cream 0.5 % fluorouracil external cream 5 % fluticasone propionate external ointment % gentamicin sulfate external cream 0.1 % gentamicin sulfate external ointment 0.1 % gentamicin sulfate powder GLYDO EXTERNAL GEL 2 % Carac Efudex Cutivate Lidocaine HCl halobetasol propionate external cream 0.05 % Ultravate halobetasol propionate external ointment 0.05 % hydrocortisone acetate powder hydrocortisone external cream 2.5 % hydrocortisone external lotion 2.5 % hydrocortisone external ointment 2.5 % hydrocortisone micronized powder hydrocortisone powder hydrocortisone valerate external cream 0.2 % Ultravate Proctozone-HC hydrocortisone-aloe external cream 1 % Cortizone-10 Plus ; QLL (50 per 30 days) ; QLL (120 per 30 days) imiquimod external cream 5 % Aldara ; QLL (12 per 30 days) ketoconazole external cream 2 % ketoconazole external shampoo 2 % Nizoral QLL (120 per 30 days) kp clotrimazole external cream 1 % Lotrimin AF lidocaine external cream 4 % Lidocream lidocaine external patch 5 % Lidoderm 35