AETNA BETTER HEALTH Formulary Guide Aetna Better Health Pennsylvania Formulary Guide April 2019

Transcription

1 AETNA BETTER HEALTH Formulary Guide 2019 Aetna Better Health Pennsylvania Formulary Guide April 2019

2 AETNA BETTER HEALTH Formulary Guide 2019 What is the Aetna Better Health in Pennsylvania Formulary? This is a drug list created by Aetna Better Health in Pennsylvania ( 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 s network pharmacy. This list is for drugs covered under you prescription benefit. Drugs may not be listed here if they are covered under your medical benefit. Drugs covered under your medical benefit are usually those a health care professional gives to you, like an IV infusion or other injection, and not typically a medication you would take on your own. Are there any exclusions from the formulary? Yes, some drugs are excluded from coverage by direction of the department of Health Services (DHS). Examples include: 2 PA A

3 AETNA BETTER HEALTH Formulary Guide 2019 Drugs and devices classified as experimental by the FDA or whose use is classified as experimental by the FDA Drugs and devices not approved by the FDA or whose use is not approved by the FDA Drugs and other items prescribed for obesity or appetite control Drugs marketed by a drug company who does not participate in the Medicaid Drug Rebate Program. Drugs designated as a DESI (Drug Efficacy Study Implementation). A DESI drug is one that was approved by the FDA solely on the basis of their safety prior to Subsequent to 1962, Congress required drugs to be shown to be effective as well. As a result, the FDA initiated a DESI to evaluate the effectiveness of medications previously approved based on safety alone. DESI drugs may continue to be marketed until proceedings evaluating efficacy have been concluded, at which point continued marketing would only be permitted if a New Drug Application is submitted for those drugs. Durable Medical Equipment (DME) items (with the exception of preferred diabetic supplies, syringes, lancets, alcohol wipes and condoms) Items prescribed or ordered by a physician who has been barred or suspended from participating in the Medical Assistance Program Pharmaceutical services provided to a hospitalized person Placebos 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 at least 30 days before the change is made. Utilizing members 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: lists the brand name of the drug when a generic is covered Column #3: 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, Otic. 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. 3 PA A

4 AETNA BETTER HEALTH Formulary Guide 2019 What are generic drugs? Generic drugs are copies of brand name drugs. They are the same as those brand name drugs in dosage form, safety, strength, route of administration, quality, and intended use. When a drug is available as a generic, you will be required to use the generic version for your prescription. If your provider feels it is medically necessary that you take only the brand, then your provider must request a prior authorization from the plan before the brand will be covered. 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. A list of covered products can be found on our website: How much will I pay for covered drugs? s There are no copays for: Pregnant women Children under 21 years of age Members in a nursing home or other facility (Intermediate Care Facility for Mental Retardation) Family planning drugs Emergency situation (condition in which emergency medical care is needed to prevent death or serious injury of a member) Certain drug groups listed below do not have copays. For those drug groups that will not require a copay the drug group will be marked with a no copay on the formulary. o o o o o o o o o o o Anti glaucoma drugs Anti Parkinson drugs Antipsychotic drugs (except for those anti anxiety drugs that are controlled substances, like alprazolam or diazepam) Cancer drugs Diabetes drugs Drugs used only to treat HIV/AIDS Epilepsy drugs Heart disease drugs High blood pressure drugs Naloxone injection/nasal spray for drug overdose Preventative vaccines 4 PA A

5 AETNA BETTER HEALTH Formulary Guide 2019 Copays Members 21 years of age and older: generic drugs on formulary are $1; brand drugs on formulary are $3 per prescription. Services cannot be denied if the member cannot afford the copay. What are some types of coverage rules? Prior Approval (PA): 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. Your doctor will need to get approval from the plan first before the drug can be filled for more than the plans limits. 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 or you cannot take Drug A, 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 on the formulary. If the drug is not listed on the formulary then: Ask your doctor for a similar drug that is on the formulary, or Your doctor can ask the plan to cover your drug through the prior approval process. Where can I fill my prescriptions? You can fill your prescriptions at any network pharmacy. You can find the location of an in network pharmacy by visiting the CVS Caremark pharmacy locator. This allows you to search for a pharmacy by zip code so you can find a location close to you. 5 PA A

6 AETNA BETTER HEALTH Formulary Guide 2019citalopram F AL Definition of Symbols Formulary Age Restriction: We require that the appropriate dose of medication based on age (e.g., pediatric and elderly populations) and indication AND Dosage requested must be based on national established/ recognized guidelines pertaining to the treatment and management of the diagnosis and age for which the medication is being used to treat. OR FDA-approved age limitations. Click this symbol the online search tool for more information. on Names in Italics PA QLL ST Generic Drug - The plan covers both brand and generic drugs. Generic drugs have the same active ingredient formula as a brand name drug. Generic drugs usually cost less than brand name drugs and are rated by the Food and Drug Administration (FDA) to be as safe and effective as brand name drugs. 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. 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. 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. For a complete list of all drugs requiring step therapy; click on the following PA A

7 Aetna Better Health Pennsylvania Table of Contents *ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS*...3 *AMINOGLYCOSIDES*... 4 *ANALGESICS - ANTI-INFLAMMATORY*... 4 *ANALGESICS - NONNARCOTIC*...6 *ANALGESICS - OPIOID*... 7 *ANDROGENS-ANABOLIC*... 9 *ANORECTAL AGENTS*...10 *ANTHELMINTICS* *ANTIANGINAL AGENTS* *ANTIANXIETY AGENTS*...11 *ANTIARRHYTHMICS* *ANTIASTHMATIC AND BRONCHODILATOR AGENTS* *ANTICOAGULANTS* *ANTICONVULSANTS*...15 *ANTIDEPRESSANTS*...17 *ANTIDIABETICS* *ANTIDIARRHEALS*...22 *ANTIDOTES* *ANTIEMETICS* *ANTIFUNGALS*...23 *ANTIHISTAMINES* *ANTIHYPERLIPIDEMICS*...24 *ANTIHYPERTENSIVES* *ANTI-INFECTIVE AGENTS - MISC.* *ANTIMALARIALS*...29 *ANTIMYASTHENIC AGENTS* *ANTIMYCOBACTERIAL AGENTS* *ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES*...29 *ANTIPARKINSON AGENTS*...32 *ANTIPSYCHOTICS/ANTIMANIC AGENTS* *ANTIRETROVIRALS ADJUVANTS*** *ANTISEPTICS & DISINFECTANTS*...36 *ANTIVIRALS*...37 *ASSORTED CLASSES* *BETA BLOCKERS* *CALCIUM CHANNEL BLOCKERS* *CARDIOTONICS* *CARDIOVASCULAR AGENTS - MISC.* *CEPHALOSPORINS*...45 *CONTRACEPTIVES*...46 *CORTICOSTEROIDS* *COUGH/COLD/ALLERGY*...52 *CYCLIN-DEPENDENT KINASES (CDK) INHIBITORS*** *DERMATOLOGICALS* *DIAGNOSTIC PRODUCTS*...59 *DIGESTIVE AIDS*...59 *DIURETICS*

8 *ENDOCRINE AND METABOLIC AGENTS - MISC.*...60 *ESTROGENS*...61 *FLUOROQUINOLONES* *GASTROINTESTINAL AGENTS - MISC.*...62 *GENITOURINARY AGENTS - MISCELLANEOUS* *GLYCOPEPTIDES***...64 *GOUT AGENTS*...64 *HEMATOLOGICAL AGENTS - MISC.* *HEMATOPOIETIC AGENTS*...65 *HEPATITIS C AGENT - COMBINATIONS*** *HYPNOTICS* *LAXATIVES* *MACROLIDES*...67 *MEDICAL DEVICES*...67 *MIGRAINE PRODUCTS*...77 *MINERALS & ELECTROLYTES*...77 *MOUTH/THROAT/DENTAL AGENTS*...78 *MULTIVITAMINS*...79 *MUSCULOSKELETAL THERAPY AGENTS*...83 *NASAL AGENTS - SYSTEMIC AND TOPICAL* *NEPRILYSIN INHIB (ARNI)-ANGIOTENSIN II RECEPT ANTAG COMB*** *NEUROMUSCULAR AGENTS* *OPHTHALMIC AGENTS*...84 *OTIC AGENTS*...87 *PASSIVE IMMUNIZING AGENTS*...88 *PENICILLINS*...89 *PHARMACEUTICAL ADJUVANTS* *POTASSIUM REMOVING AGENTS***...90 *PROGESTINS*...90 *PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.*...90 *RESPIRATORY AGENTS - MISC.*...93 *SEROTONIN MODULATORS*** *SINUS NODE INHIBITORS**...93 *SODIUM-GLUCOSE CO-TRANSPORTER 2 INHIBITOR-BIGUANIDE COMB*** *SULFONAMIDES*...94 *TETRACYCLINES* *THYROID AGENTS* *TOXOIDS* *ULCER DRUGS* *URINARY ANTI-INFECTIVES*...97 *URINARY ANTISPASMODICS*...97 *VACCINES*...98 *VAGINAL PRODUCTS*...99 *VASOPRESSORS* *VITAMINS*

9 Aetna Better Health Pennsylvania *ADHD/ANTI- NARCOLEPSY/ANTI- OBESITY/ANOREXIANTS* *Adhd Agent - Selective Alpha Adrenergic Agonists*** guanfacine hcl er oral tablet extended release 24 hour 1, 2, 3, 4 *Amphetamine Mixtures*** amphetamine-dextroamphet er oral capsule extended release 24 hour 10, 15, 20, 25, 30, 5 amphetamine-dextroamphetamine oral tablet 10, 12.5, 15, 20, 5, 7.5 amphetamine-dextroamphetamine oral tablet 30 *Amphetamines*** dextroamphetamine sulfate er oral capsule extended release 24 hour 10, 15 dextroamphetamine sulfate er oral capsule extended release 24 hour 5 dextroamphetamine sulfate oral tablet 10, 5 ZENZEDI ORAL TABLET 10 MG, 5 MG Intuniv Adderall XR Adderall Adderall Dexedrine Dexedrine Zenzedi Zenzedi QLL (30 Tablets per 30 ; AL (Min 6 Years) QLL (1 EA per 1 ; AL (Min 6 Years and Max 17 Years) QLL (3 EA per 1 ; AL (Min 6 Years and Max 17 Years) QLL (2 EA per 1 ; AL (Min 6 Years and Max 17 Years) QLL (4 EA per 1 ; AL (Min 6 Years and Max 17 Years) QLL (3 EA per 1 ; AL (Min 6 Years and Max 17 Years) QLL (6 EA per 1 ; AL (Min 6 Years and Max 17 Years) QLL (6 EA per 1 ; AL (Min 6 Years and Max 17 Years) *Analeptics*** caffeine citrate oral solution 20 /ml, 60 /3ml *Stimulants - Misc.*** armodafinil oral tablet 150, 200, 250 Nuvigil PA; QLL (1 EA per 1 armodafinil oral tablet 50 Nuvigil PA; QLL (2 EA per 1 dexmethylphenidate hcl er oral capsule extended release 24 hour 10, 15, 20, 25, 30, 35, 40, 5 dexmethylphenidate hcl oral tablet 10, 2.5, 5 methylphenidate hcl er (cd) oral capsule extended release 10, 20, 30, 40, 50, 60 methylphenidate hcl er (la) oral capsule extended release 24 hour 20, 40 Focalin XR Focalin Ritalin LA QLL (1 EA per 1 ; AL (Min 6 Years and Max 17 Years) QLL (2 EA per 1 ; AL (Min 6 Years and Max 17 Years) QLL (1 EA per 1 ; AL (Min 6 Years and Max 17 Years) QLL (1 EA per 1 ; AL (Min 6 Years and Max 17 Years) 3

10 methylphenidate hcl er (la) oral capsule extended release 24 hour 30 methylphenidate hcl er (la) oral capsule extended release 24 hour 60 methylphenidate hcl er oral tablet extended release 10 methylphenidate hcl er oral tablet extended release 18, 27, 54 methylphenidate hcl er oral tablet extended release 20 methylphenidate hcl er oral tablet extended release 24 hour 18, 27, 36 methylphenidate hcl er oral tablet extended release 24 hour 54 methylphenidate hcl er oral tablet extended release 36 methylphenidate hcl oral solution 10 /5ml, 5 /5ml methylphenidate hcl oral tablet 10, 20, 5 methylphenidate hcl oral tablet chewable 10 methylphenidate hcl oral tablet chewable 2.5, 5 METADATE ER ORAL TABLET EXTENDED RELEASE 20 MG *AMINOGLYCOSIDES* *Aminoglycosides*** neomycin sulfate oral tablet 500 paromomycin sulfate oral capsule 250 tobramycin inhalation nebulization solution 300 /5ml KITABIS PAK INHALATION NEBULIZATION SOLUTION 300 MG/5ML *ANALGESICS - ANTI- INFLAMMATORY* *Anti-Tnf-Alpha - Monoclonal Antibodies*** HUMIRA PEDIATRIC CROHNS START SUBCUTANEOUS PREFILLED SYRINGE KIT 40 MG/0.8ML 4 Ritalin LA Concerta Metadate ER Concerta Methylin Ritalin Metadate ER Kitabis Pak Kitabis Pak QLL (2 EA per 1 ; AL (Min 6 Years and Max 17 Years) QLL (1 EA per 1 ; AL (Min 6 Years and Max 17 Years) QLL (3 EA per 1 ; AL (Min 6 Years and Max 17 Years) QLL (1 EA per 1 ; AL (Min 6 Years and Max 17 Years) QLL (3 EA per 1 ; AL (Min 6 Years and Max 17 Years) QLL (2 EA per 1 ; AL (Min 6 Years and Max 17 Years) QLL (1 EA per 1 ; AL (Min 6 Years and Max 17 Years) QLL (2 EA per 1 ; AL (Min 6 Years and Max 17 Years) QLL (30 ML per 1 ; AL (Min 6 Years and Max 17 Years) QLL (3 EA per 1 ; AL (Min 6 Years and Max 17 Years) QLL (6 EA per 1 ; AL (Min 6 Years and Max 17 Years) QLL (5 EA per 1 ; AL (Min 6 Years and Max 17 Years) QLL (3 EA per 1 ; AL (Min 6 Years and Max 17 Years) PA PA

11 HUMIRA PEDIATRIC CROHNS START SUBCUTANEOUS PREFILLED PA; QLL (3 EA per 180 SYRINGE KIT 80 MG/0.8ML HUMIRA PEDIATRIC CROHNS START SUBCUTANEOUS PREFILLED SYRINGE KIT 80 MG/0.8ML & PA; QLL (2 EA per MG/0.4ML HUMIRA PEN SUBCUTANEOUS PEN- INJECTOR KIT 40 MG/0.4ML PA; QLL (2 EA per 25 HUMIRA PEN SUBCUTANEOUS PEN- INJECTOR KIT 40 MG/0.8ML PA HUMIRA PEN-CD/UC/HS STARTER SUBCUTANEOUS PEN-INJECTOR KIT PA 40 MG/0.8ML HUMIRA PEN-CD/UC/HS STARTER SUBCUTANEOUS PEN-INJECTOR KIT PA; QLL (3 EA per MG/0.8ML HUMIRA PEN-PS/UV/ADOL HS START SUBCUTANEOUS PEN-INJECTOR KIT PA 40 MG/0.8ML HUMIRA PEN-PS/UV/ADOL HS START SUBCUTANEOUS PEN-INJECTOR KIT PA; QLL (3 EA per MG/0.8ML & 40MG/0.4ML HUMIRA SUBCUTANEOUS PREFILLED SYRINGE KIT 10 MG/0.1ML PA; QLL (2 EA per 28 HUMIRA SUBCUTANEOUS PREFILLED SYRINGE KIT 20 MG/0.2ML, 40 PA; QLL (2 EA per 25 MG/0.4ML *Cyclooxygenase 2 (Cox-2) Inhibitors*** celecoxib oral capsule 100, 200, 400, 50 CeleBREX ST *Gold Compounds*** RIDAURA ORAL CAPSULE 3 MG *Nonsteroidal Anti-Inflammatory Agents (Nsaids)*** diclofenac potassium oral tablet 50 diclofenac sodium er oral tablet extended release 24 hour 100 diclofenac sodium oral tablet delayed release 25, 50, 75 etodolac er oral tablet extended release 24 hour 400, 500, 600 5

12 etodolac oral capsule 200, 300 etodolac oral tablet 400 Lodine etodolac oral tablet 500 flurbiprofen oral tablet 100, 50 ibuprofen oral tablet 400, 600, 800 IBU indomethacin er oral capsule extended release 75 indomethacin oral capsule 25, 50 ketorolac tromethamine oral tablet 10 QLL (20 Tablets per 30 meloxicam oral tablet 15, 7.5 Mobic nabumetone oral tablet 500, 750 naproxen dr oral tablet delayed release 375 EC-Naprosyn naproxen dr oral tablet delayed release 500 naproxen oral suspension 125 /5ml Naprosyn ST naproxen oral tablet 250, 500 Naprosyn naproxen oral tablet 375 naproxen sodium oral tablet 275 piroxicam oral capsule 10, 20 Feldene sulindac oral tablet 150, 200 tolmetin sodium oral capsule 400 tolmetin sodium oral tablet 200, 600 *Pyrimidine Synthesis Inhibitors*** leflunomide oral tablet 10, 20 Arava *Soluble Tumor Necrosis Factor Receptor Agents*** ENBREL MINI SUBCUTANEOUS SOLUTION CARTRIDGE 50 MG/ML PA ENBREL SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 25 MG/0.5ML, 50 PA MG/ML ENBREL SURECLICK SUBCUTANEOUS SOLUTION AUTO-INJECTOR 50 PA MG/ML *ANALGESICS - NONNARCOTIC* *Analgesics-Sedatives*** butalbital-acetaminophen oral tablet Tencon QLL (60 EA per 30 6

13 butalbital-apap-caffeine oral capsule Fioricet QLL (60 EA per 30 butalbital-apap-caffeine oral capsule Esgic QLL (60 EA per 30 butalbital-apap-caffeine oral tablet Esgic QLL (60 EA per 30 butalbital-asa-caffeine oral capsule Fiorinal QLL (60 EA per 30 *Salicylate Combinations*** choline-mag trisalicylate oral liquid 500 /5ml *Salicylates*** diflunisal oral tablet 500 salsalate oral tablet 500, 750 *ANALGESICS - OPIOID* *Codeine Combinations*** acetaminophen-codeine #2 oral tablet QLL (13 EA per 1 acetaminophen-codeine #3 oral tablet Tylenol with Codeine #3 QLL (11 EA per 1 acetaminophen-codeine #4 oral tablet Tylenol with Codeine #4 QLL (5 EA per 1 acetaminophen-codeine oral solution /5ml PA; QLL (137.5 ML per 1 butalbital-apap-caff-cod oral capsule Fioricet/Codeine QLL (6 EA per 1 butalbital-apap-caff-cod oral capsule QLL (6 EA per 1 butalbital-asa-caff-codeine oral capsule Ascomp-Codeine QLL (6 EA per 1 *Hydrocodone Combinations*** hydrocodone-acetaminophen oral solution /15ml QLL (100 ML per 1 hydrocodone-acetaminophen oral tablet Lorcet HD QLL (5 EA per 1 hydrocodone-acetaminophen oral tablet Verdrocet QLL (8 EA per 1 hydrocodone-acetaminophen oral tablet Lorcet QLL (8 EA per 1 hydrocodone-acetaminophen oral tablet Lorcet Plus QLL (6 EA per 1 hydrocodone-ibuprofen oral tablet Ibudone PA 7

14 hydrocodone-ibuprofen oral tablet hydrocodone-ibuprofen oral tablet QLL (5 EA per 1 *Opioid Agonists*** codeine sulfate oral tablet 30 QLL (11 EA per 1 codeine sulfate oral tablet 60 QLL (5 EA per 1 fentanyl citrate buccal lozenge on a handle 1200 mcg, 1600 mcg, 200 mcg, 400 mcg, 600 Actiq QLL (4 EA per 1 mcg, 800 mcg fentanyl transdermal patch 72 hour 100 mcg/hr Duragesic-100 PA; QLL (10 EA per 30 fentanyl transdermal patch 72 hour 12 mcg/hr Duragesic-12 PA; QLL (10 EA per 30 fentanyl transdermal patch 72 hour 25 mcg/hr Duragesic-25 PA; QLL (10 EA per 30 fentanyl transdermal patch 72 hour 50 mcg/hr Duragesic-50 PA; QLL (10 EA per 30 fentanyl transdermal patch 72 hour 75 mcg/hr Duragesic-75 PA; QLL (10 EA per 30 hydromorphone hcl injection solution 2 /ml Dilaudid hydromorphone hcl oral tablet 2 Dilaudid QLL (6 EA per 1 hydromorphone hcl oral tablet 4 Dilaudid QLL (3 EA per 1 hydromorphone hcl oral tablet 8 Dilaudid QLL (1 EA per 1 hydromorphone hcl pf injection solution 10 /ml, 50 /5ml, 500 /50ml hydromorphone hcl rectal suppository 3 QLL (4 EA per 1 methadone hcl oral concentrate 10 /ml Methadone HCl Intensol PA; QLL (1.25 ML per 1 methadone hcl oral solution 10 /5ml PA; QLL (6.25 ML per 1 methadone hcl oral solution 5 /5ml PA; QLL (12.5 ML per 1 methadone hcl oral tablet 10 Dolophine PA; QLL (1 EA per 1 methadone hcl oral tablet 5 Dolophine PA; QLL (2 EA per 1 methadone hcl oral tablet soluble 40 Methadose PA; QLL (1 EA per 1 morphine sulfate (concentrate) oral solution 10 /0.5ml QLL (2.5 ML per 1 morphine sulfate er oral tablet extended release 100, 200, 30 MS Contin PA; QLL (1 EA per 1 morphine sulfate er oral tablet extended release 15 MS Contin PA; QLL (3 EA per 1 morphine sulfate er oral tablet extended release 60 MS Contin PA; QLL (2 EA per 1 morphine sulfate oral solution 10 /5ml QLL (15 ML per 1 morphine sulfate oral solution 20 /5ml QLL (12.5 ML per 1 morphine sulfate oral tablet 15 QLL (3 EA per 1 morphine sulfate oral tablet 30 QLL (1 EA per 1 morphine sulfate rectal suppository 10 QLL (4 EA per 1 8

15 morphine sulfate rectal suppository 20 QLL (2 EA per 1 morphine sulfate rectal suppository 30 QLL (1 EA per 1 morphine sulfate rectal suppository 5 QLL (5 EA per 1 oxycodone hcl oral solution 5 /5ml QLL (30 ML per 1 oxycodone hcl oral tablet 10 QLL (3 EA per 1 oxycodone hcl oral tablet 15 Roxicodone QLL (4 EA per 1 oxycodone hcl oral tablet 20 QLL (1 EA per 1 oxycodone hcl oral tablet 30 Roxicodone QLL (1 EA per 1 oxycodone hcl oral tablet 5 Roxicodone QLL (6 EA per 1 oxymorphone hcl er oral tablet extended release 12 hour 10, 15, 20, 30, PA; ST; QLL (1 EA per 1 40 oxymorphone hcl er oral tablet extended release 12 hour 5 PA; ST; QLL (3 EA per 1 oxymorphone hcl er oral tablet extended release 12 hour 7.5 PA; ST; QLL (2 EA per 1 tramadol hcl oral tablet 50 Ultram QLL (8 EA per 1 *Opioid Combinations*** oxycodone-acetaminophen oral tablet Endocet QLL (3 EA per 1 oxycodone-acetaminophen oral tablet Endocet QLL (12 EA per 1 oxycodone-acetaminophen oral tablet Endocet QLL (6 EA per 1 oxycodone-acetaminophen oral tablet Endocet QLL (4 EA per 1 oxycodone-aspirin oral tablet QLL (6 EA per 1 *Opioid Partial Agonists*** buprenorphine hcl sublingual tablet sublingual 2, 8 buprenorphine hcl-naloxone hcl sublingual tablet sublingual 2-0.5, 8-2 pentazocine-naloxone hcl oral tablet *Tramadol Combinations*** tramadol-acetaminophen oral tablet *ANDROGENS-ANABOLIC* *Androgens*** danazol oral capsule 100, 200, 50 Ultracet PA; QLL (60 EA per 30 ; AL (Min 18 Years) QLL (3 EA per 1 QLL (2 EA per 1 QLL (8 EA per 1 9

16 testosterone cypionate intramuscular solution 100 /ml, 200 /ml Depo-Testosterone PA; QLL (1 ML per 28 testosterone enanthate intramuscular solution 200 /ml QLL (5 ML per 30 testosterone transdermal gel 10 /act (2%) Fortesta PA; QLL (2 canisters per 30 Days) testosterone transdermal gel 12.5 /act (1%) Vogelxo Pump PA; QLL (4 canisters per 30 testosterone transdermal gel 25 /2.5gm (1%) AndroGel PA testosterone transdermal gel 50 /5gm (1%) AndroGel PA; QLL (60 PACKETS per 30 *ANORECTAL AGENTS* *Intrarectal Steroids*** hydrocortisone rectal enema 100 /60ml Colocort *Nitrate Vasodilating Agents*** RECTIV RECTAL OINTMENT 0.4 % PA; QLL (30 gm per 30 *Rectal Anesthetic/Steroids*** lidocaine-hydrocortisone ace rectal cream % PROCTOFOAM HC RECTAL FOAM 1-1 % *Rectal Steroids*** PROCTO-PAK RECTAL CREAM 1 % Hydrocortisone PROCTOSOL HC RECTAL CREAM 2.5 % Hydrocortisone PROCTOZONE-HC RECTAL CREAM 2.5 % Hydrocortisone *ANTHELMINTICS* *Anthelmintics*** albendazole oral tablet 200 Albenza ST ivermectin oral tablet 3 Stromectol praziquantel oral tablet 600 Biltricide PA reeses pinworm medicine oral suspension 144 (50 base) /ml reeses pinworm medicine oral tablet 180 *ANTIANGINAL AGENTS* *Nitrates*** isosorbide dinitrate er oral tablet extended release 40 10

17 isosorbide dinitrate oral tablet 10, 20, 30 isosorbide dinitrate oral tablet 5 Isordil Titradose isosorbide mononitrate er oral tablet extended release 24 hour 120, 30, 60 isosorbide mononitrate oral tablet 10, 20 nitroglycerin er oral capsule extended release Nitro-Time 2.5, 6.5, 9 nitroglycerin sublingual tablet sublingual 0.3, 0.4, 0.6 Nitrostat nitroglycerin transdermal patch 24 hour 0.1 /hr, 0.2 /hr, 0.4 /hr, 0.6 /hr Minitran NITRO-BID TRANSDERMAL OINTMENT 2 % *ANTIANXIETY AGENTS* *Antianxiety Agents - Misc.*** buspirone hcl oral tablet 10, 15, 5, 7.5 QLL (2 EA per 1 hydroxyzine hcl oral syrup 10 /5ml hydroxyzine hcl oral tablet 10, 25, 50 QLL (4 EA per 1 hydroxyzine pamoate oral capsule 100 hydroxyzine pamoate oral capsule 25, 50 Vistaril *Benzodiazepines*** alprazolam er oral tablet extended release 24 hour 0.5, 1, 2, 3 Xanax XR AL (Min 18 Years) alprazolam oral tablet 0.25, 0.5 Xanax QLL (4 EA per 1 alprazolam oral tablet 1 Xanax QLL (6 EA per 1 alprazolam oral tablet 2 Xanax QLL (5 EA per 1 alprazolam xr oral tablet extended release 24 hour 0.5, 1, 2, 3 Xanax XR AL (Min 18 Years) chlordiazepoxide hcl oral capsule 10, 5 QLL (4 EA per 1 chlordiazepoxide hcl oral capsule 25 QLL (12 EA per 1 diazepam oral concentrate 5 /ml Diazepam Intensol diazepam oral solution 5 /5ml diazepam oral tablet 10, 2, 5 Valium lorazepam oral tablet 0.5 Ativan QLL (4 EA per 1 lorazepam oral tablet 1 Ativan QLL (6 EA per 1 lorazepam oral tablet 2 Ativan QLL (5 EA per 1 11

18 oxazepam oral capsule 10, 15, 30 QLL (4 EA per 1 DIAZEPAM INTENSOL ORAL CONCENTRATE 5 MG/ML Diazepam Intensol LORAZEPAM INTENSOL ORAL CONCENTRATE 2 MG/ML LORazepam *ANTIARRHYTHMICS* *Antiarrhythmics Type I-A*** disopyramide phosphate oral capsule 100, Norpace 150 procainamide hcl injection solution 100 /ml quinidine gluconate er oral tablet extended release 324 quinidine sulfate oral tablet 200, 300 *Antiarrhythmics Type I-B*** mexiletine hcl oral capsule 150, 200, 250 *Antiarrhythmics Type I-C*** flecainide acetate oral tablet 100, 150, 50 propafenone hcl er oral capsule extended release 12 hour 225, 325, 425 Rythmol SR propafenone hcl oral tablet 150, 225, 300 *Antiarrhythmics Type Iii*** amiodarone hcl oral tablet 100, 200, 400 Pacerone MULTAQ ORAL TABLET 400 MG PA; *ANTIASTHMATIC AND BRONCHODILATOR AGENTS* *Adrenergic Combinations*** fluticasone-salmeterol inhalation aerosol powder breath activated mcg/act AirDuo RespiClick 113/14 QLL (1 Inhaler per 30 fluticasone-salmeterol inhalation aerosol powder breath activated mcg/act AirDuo RespiClick 232/14 QLL (1 Inhaler per 30 fluticasone-salmeterol inhalation aerosol powder breath activated mcg/act AirDuo RespiClick 55/14 QLL (1 Inhaler per 30 ipratropium-albuterol inhalation solution (3) /3ml ANORO ELLIPTA INHALATION AEROSOL POWDER BREATH ACTIVATED MCG/INH QLL (1 inhaler per 30 Days) 12

19 BREO ELLIPTA INHALATION AEROSOL POWDER BREATH ACTIVATED MCG/INH, MCG/INH COMBIVENT RESPIMAT INHALATION AEROSOL SOLUTION MCG/ACT STIOLTO RESPIMAT INHALATION AEROSOL SOLUTION MCG/ACT *Anti-Inflammatory Agents*** cromolyn sodium inhalation nebulization solution 20 /2ml *Beta Adrenergics*** albuterol sulfate hfa inhalation aerosol solution 108 (90 base) mcg/act albuterol sulfate inhalation nebulization solution (2.5 /3ml) 0.083% albuterol sulfate inhalation nebulization solution (5 /ml) 0.5% albuterol sulfate inhalation nebulization solution 0.63 /3ml, 1.25 /3ml albuterol sulfate oral syrup 2 /5ml levalbuterol tartrate inhalation aerosol 45 mcg/act metaproterenol sulfate oral syrup 10 /5ml metaproterenol sulfate oral tablet 10, 20 ARCAPTA NEOHALER INHALATION CAPSULE 75 MCG STRIVERDI RESPIMAT INHALATION AEROSOL SOLUTION 2.5 MCG/ACT VENTOLIN HFA INHALATION AEROSOL SOLUTION 108 (90 BASE) MCG/ACT *Bronchodilators - Anticholinergics*** ipratropium bromide inhalation solution 0.02 % ATROVENT HFA INHALATION AEROSOL SOLUTION 17 MCG/ACT INCRUSE ELLIPTA INHALATION AEROSOL POWDER BREATH ACTIVATED 62.5 MCG/INH ProAir HFA Xopenex HFA ProAir HFA QLL (1 EA per 30 ; AL (Min 18 Years) ST; QLL (1 inhaler per 30 QLL (36 GM per 30 QLL (15 ML per 1 QLL (15 EA per 1 ST; AL (Max 17 Years) ST; QLL (2 INH per 30 QLL (1 Inhaler per 30 QLL (1 Respimat per 30 QLL (36 GM per 30 QLL (1 Inhaler per 30 13

20 *Leukotriene Receptor Antagonists*** montelukast sodium oral packet 4 Singulair AL (Max 1 Years) montelukast sodium oral tablet 10 Singulair montelukast sodium oral tablet chewable 4, 5 Singulair zafirlukast oral tablet 10, 20 Accolate ST *Steroid Inhalants*** budesonide inhalation suspension 0.25 /2ml, 0.5 /2ml Pulmicort QLL (120 ML per 30 budesonide inhalation suspension 1 /2ml Pulmicort ARNUITY ELLIPTA INHALATION AEROSOL POWDER BREATH ACTIVATED 100 MCG/ACT, 200 MCG/ACT, 50 MCG/ACT FLOVENT HFA INHALATION AEROSOL 110 MCG/ACT, 220 MCG/ACT FLOVENT HFA INHALATION AEROSOL 44 MCG/ACT QVAR REDIHALER INHALATION AEROSOL BREATH ACTIVATED 40 MCG/ACT QVAR REDIHALER INHALATION AEROSOL BREATH ACTIVATED 80 MCG/ACT *Xanthines*** theophylline er oral tablet extended release 12 hour 100, 200, 300 theophylline er oral tablet extended release 12 hour 450 theophylline er oral tablet extended release 24 hour 400, 600 theophylline oral solution 80 /15ml *ANTICOAGULANTS* *Coumarin Anticoagulants*** warfarin sodium oral tablet 1, 10, 2, 2.5, 3, 4, 5, 6, 7.5 JANTOVEN ORAL TABLET 1 MG, 10 MG, 2 MG, 2.5 MG, 3 MG, 4 MG, 5 MG, 6 MG, 7.5 MG *Direct Factor Xa Inhibitors*** ELIQUIS ORAL TABLET 2.5 MG, 5 MG 14 Theochron Coumadin Coumadin QLL (0.4 GM per 1 ; AL (Max 12 Years) QLL (0.35 GM per 1 ; AL (Max 12 Years) QLL (10.6 GM per 30 QLL (21.2 GM per 30 PA; QLL (60 EA per 30

21 XARELTO ORAL TABLET 10 MG, 15 MG, 20 MG PA; QLL (1 EA per 1 XARELTO ORAL TABLET 2.5 MG PA; QLL (2 EA per 1 XARELTO STARTER PACK ORAL TABLET THERAPY PACK 15 & 20 MG PA; QLL (1 FILL per 90 *Heparins And Heparinoid-Like Agents*** heparin sodium (porcine) injection solution 1000 unit/ml, unit/ml, unit/ml, 5000 unit/ml heparin sodium (porcine) pf injection solution 5000 unit/0.5ml *Low Molecular Weight Heparins*** enoxaparin sodium injection solution 300 /3ml Lovenox QLL (21 days per 180 enoxaparin sodium subcutaneous solution 100 /ml, 120 /0.8ml, 150 /ml, 30 /0.3ml, 40 /0.4ml, 60 /0.6ml, 80 Lovenox QLL (21 days per 180 /0.8ml *ANTICONVULSANTS* *Anticonvulsants - Benzodiazepines*** clonazepam oral tablet 0.5, 1, 2 KlonoPIN clonazepam oral tablet dispersible 0.125, 0.25, 0.5, 1, 2 diazepam rectal gel 10, 20 Diastat AcuDial ; QLL (2 EA per 1 Fill) diazepam rectal gel 2.5 Diastat Pediatric ; QLL (2 EA per 1 Fill) *Anticonvulsants - Misc.*** carbamazepine er oral capsule extended release 12 hour 100, 200, 300 Carbatrol carbamazepine er oral tablet extended release TEGretol-XR 12 hour 100 carbamazepine er oral tablet extended release 12 hour 200, 400 TEGretol-XR carbamazepine oral suspension 100 /5ml TEGretol carbamazepine oral tablet 200 Epitol carbamazepine oral tablet chewable 100 gabapentin oral capsule 100, 300, 400 Neurontin ; QLL (120 EA per 30 ; QLL (3600 MG (cumulative) per 1 15

22 gabapentin oral solution 250 /5ml Neurontin ; QLL (3600 MG (cumulative) per 1 gabapentin oral tablet 600, 800 Neurontin ; QLL (3600 MG (cumulative) per 1 lamotrigine oral tablet 100, 150, 200, 25 LaMICtal lamotrigine oral tablet chewable 25, 5 LaMICtal levetiracetam er oral tablet extended release 24 hour 500, 750 Keppra XR levetiracetam oral solution 100 /ml Keppra levetiracetam oral tablet 1000, 250, 500, 750 Keppra oxcarbazepine oral suspension 300 /5ml Trileptal oxcarbazepine oral tablet 150, 300, 600 Trileptal primidone oral tablet 250, 50 Mysoline topiramate oral capsule sprinkle 15, 25 Topamax Sprinkle ; QLL (120 EA per 30 topiramate oral tablet 100, 200, 25, 50 Topamax ; QLL (120 EA per 30 zonisamide oral capsule 100, 25 Zonegran zonisamide oral capsule 50 ; QLL (6 EA per 1 *Carbamates*** felbamate oral suspension 600 /5ml Felbatol felbamate oral tablet 400, 600 Felbatol *Gaba Modulators*** tiagabine hcl oral tablet 2 Gabitril tiagabine hcl oral tablet 4 Gabitril ; QLL (60 EA per 30 GABITRIL ORAL TABLET 12 MG, 16 MG TiaGABine HCl *Hydantoins*** phenytoin oral suspension 125 /5ml Dilantin phenytoin oral tablet chewable 50 Dilantin Infatabs phenytoin sodium extended oral capsule 100 Dilantin phenytoin sodium extended oral capsule 200, 300 Phenytek DILANTIN ORAL CAPSULE 100 MG Dilantin 16

23 *Succinimides*** ethosuximide oral capsule 250 Zarontin ethosuximide oral solution 250 /5ml Zarontin *Valproic Acid*** divalproex sodium er oral tablet extended release 24 hour 250, 500 Depakote ER divalproex sodium oral capsule delayed release sprinkle 125 Depakote Sprinkles divalproex sodium oral tablet delayed release 125, 250, 500 Depakote valproic acid oral capsule 250 Depakene valproic acid oral solution 250 /5ml Depakene *ANTIDEPRESSANTS* *Alpha-2 Receptor Antagonists (Tetracyclics)*** mirtazapine oral tablet 15 Remeron QLL (30 EA per 30 mirtazapine oral tablet 30 Remeron QLL (60 EA per 30 mirtazapine oral tablet 45 QLL (45 EA per 30 mirtazapine oral tablet 7.5 QLL (30 EA per 30 mirtazapine oral tablet dispersible 15, 45 Remeron SolTab QLL (30 EA per 30 mirtazapine oral tablet dispersible 30 Remeron SolTab QLL (60 EA per 30 *Antidepressants - Misc.*** bupropion hcl er (sr) oral tablet extended release 12 hour 100 Wellbutrin SR QLL (120 EA per 30 bupropion hcl er (sr) oral tablet extended release 12 hour 150 Wellbutrin SR QLL (2 EA per 1 bupropion hcl er (sr) oral tablet extended release 12 hour 200 Wellbutrin SR QLL (30 EA per 30 bupropion hcl er (xl) oral tablet extended release 24 hour 150 Wellbutrin XL QLL (90 EA per 30 bupropion hcl er (xl) oral tablet extended release 24 hour 300 Wellbutrin XL QLL (30 EA per 30 bupropion hcl oral tablet 100 QLL (135 EA per 30 bupropion hcl oral tablet 75 QLL (180 EA per 30 maprotiline hcl oral tablet 25 QLL (9 EA per 1 maprotiline hcl oral tablet 50 QLL (5 EA per 1 maprotiline hcl oral tablet 75 QLL (3 EA per 1 *Modified Cyclics*** trazodone hcl oral tablet 100, 50 QLL (6 EA per 1 17

24 trazodone hcl oral tablet 150 QLL (4 EA per 1 *Monoamine Oxidase Inhibitors (Maois)*** phenelzine sulfate oral tablet 15 Nardil QLL (6 EA per 1 *Selective Serotonin Reuptake Inhibitors (Ssris)*** citalopram hydrobromide oral solution 10 /5ml citalopram hydrobromide oral tablet 10, 20, 40 CeleXA QLL (600 ML per 30 ; AL (Max 10 Years) QLL (30 EA per 30 escitalopram oxalate oral solution 5 /5ml QLL (600 ML per 30 ; AL (Max 10 Years) escitalopram oxalate oral tablet 10, 20, Lexapro 5 QLL (30 EA per 30 fluoxetine hcl oral capsule 10 PROzac QLL (30 EA per 30 fluoxetine hcl oral capsule 20 PROzac QLL (120 EA per 30 fluoxetine hcl oral capsule 40 PROzac QLL (60 EA per 30 fluoxetine hcl oral solution 20 /5ml QLL (600 ML per 30 fluvoxamine maleate oral tablet 100 QLL (3 EA per 1 fluvoxamine maleate oral tablet 25 QLL (1 EA per 1 fluvoxamine maleate oral tablet 50 QLL (2 EA per 1 paroxetine hcl oral tablet 10, 20, 30, 40 Paxil QLL (1 EA per 1 sertraline hcl oral concentrate 20 /ml QLL (300 ML per 30 sertraline hcl oral tablet 100 Zoloft QLL (75 EA per 30 sertraline hcl oral tablet 25 Zoloft QLL (30 Tablet per 30 sertraline hcl oral tablet 50 Zoloft QLL (60 Tablet per 30 *Serotonin-Norepinephrine Reuptake Inhibitors (Snris)*** duloxetine hcl oral capsule delayed release particles 20, 30, 60 Cymbalta QLL (30 EA per 30 duloxetine hcl oral capsule delayed release particles 40 QLL (30 EA per 30 venlafaxine hcl er oral capsule extended release 24 hour 150 Effexor XR QLL (60 EA per 30 venlafaxine hcl er oral capsule extended release 24 hour 37.5, 75 Effexor XR QLL (1 EA per 1 venlafaxine hcl oral tablet 100 QLL (3 EA per 1 venlafaxine hcl oral tablet 25 QLL (9 EA per 1 venlafaxine hcl oral tablet 37.5 QLL (10 EA per 1 18

25 venlafaxine hcl oral tablet 50 QLL (7 EA per 1 venlafaxine hcl oral tablet 75 QLL (5 EA per 1 *Tricyclic Agents*** amitriptyline hcl oral tablet 10 QLL (30 Tablets per 1 amitriptyline hcl oral tablet 100 QLL (3 Tablets per 1 amitriptyline hcl oral tablet 150, 75 QLL (2 Tablets per 1 amitriptyline hcl oral tablet 25 QLL (12 Tablets per 1 amitriptyline hcl oral tablet 50 QLL (6 Tablets per 1 amoxapine oral tablet 100 QLL (6 EA per 1 amoxapine oral tablet 150 QLL (4 EA per 1 amoxapine oral tablet 25 QLL (24 EA per 1 amoxapine oral tablet 50 QLL (12 EA per 1 doxepin hcl oral capsule 10 QLL (30 EA per 1 doxepin hcl oral capsule 100 QLL (3 EA per 1 doxepin hcl oral capsule 150 QLL (2 EA per 1 doxepin hcl oral capsule 25 QLL (12 EA per 1 doxepin hcl oral capsule 50 QLL (6 EA per 1 doxepin hcl oral capsule 75 QLL (4 EA per 1 doxepin hcl oral concentrate 10 /ml imipramine hcl oral tablet 10, 25 Tofranil imipramine hcl oral tablet 50 Tofranil QLL (180 EA per 30 nortriptyline hcl oral capsule 10 Pamelor nortriptyline hcl oral capsule 25 Pamelor QLL (180 EA per 30 nortriptyline hcl oral capsule 50 Pamelor QLL (90 EA per 30 nortriptyline hcl oral capsule 75 Pamelor QLL (60 EA per 30 nortriptyline hcl oral solution 10 /5ml AL (Max 10 Years) *ANTIDIABETICS* *Alpha-Glucosidase Inhibitors*** acarbose oral tablet 100, 25, 50 Precose *Biguanides*** metformin hcl er oral tablet extended release 24 hour 500, 750 Glucophage XR metformin hcl oral tablet 1000, 500, 850 Glucophage *Diabetic Other*** GLUCAGEN HYPOKIT INJECTION SOLUTION RECONSTITUTED 1 MG 19

26 *Dipeptidyl Peptidase-4 (Dpp-4) Inhibitors*** alogliptin benzoate oral tablet 12.5, 25, 6.25 Nesina JANUVIA ORAL TABLET 100 MG, 25 MG, 50 MG *Dipeptidyl Peptidase-4 Inhibitor- Biguanide Combinations*** alogliptin-metformin hcl oral tablet , JANUMET ORAL TABLET MG, MG JANUMET XR ORAL TABLET EXTENDED RELEASE 24 HOUR MG, MG, MG *Dpp-4 Inhibitor-Thiazolidinedione Combinations*** alogliptin-pioglitazone oral tablet , , , 25-15, 25-30, *Human Insulin*** ADMELOG SOLOSTAR SUBCUTANEOUS SOLUTION PEN- INJECTOR 100 UNIT/ML ADMELOG SUBCUTANEOUS SOLUTION 100 UNIT/ML BASAGLAR KWIKPEN SUBCUTANEOUS SOLUTION PEN- INJECTOR 100 UNIT/ML HUMALOG MIX 50/50 KWIKPEN SUBCUTANEOUS SUSPENSION PEN- INJECTOR (50-50) 100 UNIT/ML HUMALOG MIX 50/50 SUBCUTANEOUS SUSPENSION (50-50) 100 UNIT/ML HUMALOG MIX 75/25 KWIKPEN SUBCUTANEOUS SUSPENSION PEN- INJECTOR (75-25) 100 UNIT/ML HUMALOG MIX 75/25 SUBCUTANEOUS SUSPENSION (75-25) 100 UNIT/ML HUMULIN 70/30 SUBCUTANEOUS SUSPENSION (70-30) 100 UNIT/ML HUMULIN R INJECTION SOLUTION 100 UNIT/ML Kazano Oseni ST; ; QLL (30 EA per 30 ST; ; QLL (60 EA per 30 ST; ; QLL (30 EA per 30 ; ; 20

27 HUMULIN R U-500 (CONCENTRATED) SUBCUTANEOUS SOLUTION 500 UNIT/ML NOVOLIN 70/30 RELION SUBCUTANEOUS SUSPENSION (70-30) ; 100 UNIT/ML NOVOLIN 70/30 SUBCUTANEOUS SUSPENSION (70-30) 100 UNIT/ML ; NOVOLIN N RELION SUBCUTANEOUS SUSPENSION 100 UNIT/ML ; NOVOLIN N SUBCUTANEOUS SUSPENSION 100 UNIT/ML ; NOVOLIN R INJECTION SOLUTION 100 UNIT/ML ; NOVOLIN R RELION INJECTION SOLUTION 100 UNIT/ML ; NOVOLOG MIX 70/30 FLEXPEN SUBCUTANEOUS SUSPENSION PEN- INJECTOR (70-30) 100 UNIT/ML NOVOLOG MIX 70/30 SUBCUTANEOUS SUSPENSION (70-30) 100 UNIT/ML *Incretin Mimetic Agents (Glp-1 Receptor Agonists)*** OZEMPIC SUBCUTANEOUS SOLUTION PEN-INJECTOR 0.25 OR 0.5 MG/DOSE OZEMPIC SUBCUTANEOUS SOLUTION PEN-INJECTOR 1 MG/DOSE VICTOZA SUBCUTANEOUS SOLUTION PEN-INJECTOR 18 MG/3ML *Meglitinide Analogues*** nateglinide oral tablet 120, 60 Starlix repaglinide oral tablet 0.5 repaglinide oral tablet 1, 2 Prandin *Meglitinide-Biguanide Combinations*** repaglinide-metformin hcl oral tablet 1-500, *Sodium-Glucose Co-Transporter 2 (Sglt2) Inhibitors*** JARDIANCE ORAL TABLET 10 MG, 25 MG ST; ; QLL (0.05 ML per 1 ST; ; QLL (0.11 ML per 1 ST; ; QLL (0.6 ML per 1 PA; ; QLL (1 EA per 1 21

28 STEGLATRO ORAL TABLET 15 MG, 5 MG *Sulfonylurea-Biguanide Combinations*** glipizide-metformin hcl oral tablet , , glyburide-metformin oral tablet , , *Sulfonylureas*** ST; ; QLL (1 EA per 1 glimepiride oral tablet 1, 2, 4 Amaryl glipizide er oral tablet extended release 24 hour 10, 2.5, 5 Glucotrol XL glipizide oral tablet 10, 5 Glucotrol glyburide micronized oral tablet 1.5, 3, Glynase 6 glyburide oral tablet 1.25, 2.5, 5 *Thiazolidinediones*** pioglitazone hcl oral tablet 15, 30, 45 Actos AVANDIA ORAL TABLET 2 MG, 4 MG ST; *ANTIDIARRHEALS* *Antiperistaltic Agents*** diphenoxylate-atropine oral liquid /5ml diphenoxylate-atropine oral tablet Lomotil loperamide hcl oral capsule 2 Imodium A-D *ANTIDOTES* *Antidotes - Chelating Agents*** CHEMET ORAL CAPSULE 100 MG *Opioid Antagonists*** naloxone hcl injection solution 0.4 /ml ; QLL (2 ML Max Qty Per Fill Retail) naltrexone hcl oral tablet 50 NARCAN NASAL LIQUID 4 MG/0.1ML VIVITROL INTRAMUSCULAR SUSPENSION RECONSTITUTED 380 MG 22

29 *ANTIEMETICS* *5-Ht3 Receptor Antagonists*** granisetron hcl oral tablet 1 ondansetron hcl oral tablet 24 ondansetron hcl oral tablet 4, 8 Zofran QLL (3 EA per 1 ondansetron oral tablet dispersible 4, 8 *Substance P/Neurokinin 1 (Nk1) Receptor Antagonists*** EMEND ORAL CAPSULE 125 MG, 40 MG, 80 MG Aprepitant *ANTIFUNGALS* *Antifungals*** griseofulvin microsize oral suspension 125 /5ml ST griseofulvin microsize oral tablet 500 ST griseofulvin ultramicrosize oral tablet 125, 250 ST nystatin oral tablet unit terbinafine hcl oral tablet 250 LamISIL QLL (84 EA per 365 *Imidazoles*** ketoconazole oral tablet 200 *Triazoles*** fluconazole oral suspension reconstituted 10 /ml, 40 /ml Diflucan fluconazole oral tablet 100, 150, 200, 50 Diflucan itraconazole oral capsule 100 Sporanox itraconazole oral solution 10 /ml Sporanox *ANTIHISTAMINES* *Antihistamines - Alkylamines*** brompheniramine tannate oral tablet chewable 12 *Antihistamines - Ethanolamines*** carbinoxamine maleate oral tablet 4 clemastine fumarate oral tablet 2.68 diphenhydramine hcl oral liquid 6.25 /ml Vanamine PD *Antihistamines - Non-Sedating*** allergy relief oral tablet dispersible 10 Alavert ; QLL (1 EA per 1 23

30 cetirizine hcl allergy child oral solution 5 /5ml KLS Aller-Tec Childrens QLL (150 ML per 30 cetirizine hcl oral tablet 10 KLS Aller-Tec ; QLL (60 EA per 30 cetirizine hcl oral tablet 5 loradamed oral tablet 10 Claritin ; QLL (1 EA per 1 loratadine childrens oral solution 5 /5ml Claritin loratadine childrens oral tablet chewable 5 Claritin ; QLL (2 EA per 1 *Antihistamines - Phenothiazines*** promethazine hcl oral solution 6.25 /5ml promethazine hcl oral syrup 6.25 /5ml promethazine hcl oral tablet 12.5, 25, 50 promethazine hcl rectal suppository 12.5, 25 Phenadoz *Antihistamines - Piperidines*** cyproheptadine hcl oral syrup 2 /5ml cyproheptadine hcl oral tablet 4 *ANTIHYPERLIPIDEMICS* *Antihyperlipidemics - Misc.*** omega-3-acid ethyl esters oral capsule 1 gm Lovaza ST; QLL (4 EA per 1 *Bile Acid Sequestrants*** cholestyramine light oral packet 4 gm Prevalite cholestyramine oral packet 4 gm Questran colesevelam hcl oral packet 3.75 gm Welchol colestipol hcl oral granules 5 gm Colestid colestipol hcl oral packet 5 gm Colestid colestipol hcl oral tablet 1 gm Colestid *Fibric Acid Derivatives*** fenofibrate micronized oral capsule 134, 200, 67 fenofibrate oral tablet 160 Triglide fenofibrate oral tablet 54 gemfibrozil oral tablet 600 Lopid ; QLL (60 EA per 30 *H Coa Reductase Inhibitors*** atorvastatin calcium oral tablet 10, 20, 40, 80 fluvastatin sodium er oral tablet extended release 24 hour Lipitor Lescol XL ; QLL (30 EA per 30 ; QLL (30 EA per 30

31 fluvastatin sodium oral capsule 20 Lescol ; QLL (2 EA per 1 fluvastatin sodium oral capsule 40 ; QLL (2 EA per 1 lovastatin oral tablet 10, 20 ; QLL (1 EA per 1 lovastatin oral tablet 40 ; QLL (2 EA per 1 pravastatin sodium oral tablet 10 ; QLL (60 EA per 30 pravastatin sodium oral tablet 20, 40, 80 rosuvastatin calcium oral tablet 10, 20, 40, 5 simvastatin oral tablet 10, 20, 40, 5 simvastatin oral tablet 80 Pravachol Crestor Zocor Zocor *Intestinal Cholesterol Absorption Inhibitors*** ezetimibe oral tablet 10 Zetia ST; *ANTIHYPERTENSIVES* *Ace Inhibitor & Calcium Channel Blocker Combinations*** amlodipine besy-benazepril hcl oral capsule 10-20, 10-40, 5-10, 5-20 Lotrel amlodipine besy-benazepril hcl oral capsule , 5-40 *Ace Inhibitors & Thiazide/Thiazide- Like*** benazepril-hydrochlorothiazide oral tablet 10- Lotensin HCT 12.5, , benazepril-hydrochlorothiazide oral tablet enalapril-hydrochlorothiazide oral tablet Vaseretic enalapril-hydrochlorothiazide oral tablet fosinopril sodium-hctz oral tablet , lisinopril-hydrochlorothiazide oral tablet , , Zestoretic ; QLL (1 EA per 1 ST; ; QLL (1 EA per 1 ; QLL (1 EA per 1 ; QLL (30 EA per 30 25

32 quinapril-hydrochlorothiazide oral tablet , , Accuretic *Ace Inhibitors*** benazepril hcl oral tablet 10, 20 Lotensin ; QLL (2 EA per 1 benazepril hcl oral tablet 40 Lotensin benazepril hcl oral tablet 5 ; QLL (2 EA per 1 enalapril maleate oral tablet 10, 2.5, 5 Vasotec ; QLL (2 EA per 1 enalapril maleate oral tablet 20 Vasotec fosinopril sodium oral tablet 10, 20 ; QLL (2 EA per 1 fosinopril sodium oral tablet 40 lisinopril oral tablet 10, 20, 5 Prinivil ; QLL (2 EA per 1 lisinopril oral tablet 2.5, 30 Zestril ; QLL (2 EA per 1 lisinopril oral tablet 40 Zestril ; QLL (60 EA per 30 moexipril hcl oral tablet 15, 7.5 perindopril erbumine oral tablet 2, 4, 8 quinapril hcl oral tablet 10, 20, 5 Accupril ; QLL (2 EA per 1 quinapril hcl oral tablet 40 Accupril ramipril oral capsule 1.25, 2.5, 5 Altace ; QLL (2 EA per 1 ramipril oral capsule 10 Altace trandolapril oral tablet 1, 2 trandolapril oral tablet 4 Mavik *Adrenolytics-Central & Thiazide/Thiazide-Like Comb*** methyldopa-hydrochlorothiazide oral tablet , *Angiotensin Ii Receptor Antag & Ca Channel Blocker Comb*** amlodipine besylate-valsartan oral tablet , , 5-160, Exforge ; QLL (30 EA per 30 Days) 26

33 *Angiotensin Ii Receptor Antag & Thiazide/Thiazide-Like*** candesartan cilexetil-hctz oral tablet , , Atacand HCT irbesartan-hydrochlorothiazide oral tablet , Avalide losartan potassium-hctz oral tablet , , Hyzaar valsartan-hydrochlorothiazide oral tablet , , , , Diovan HCT *Angiotensin Ii Receptor Antagonists*** candesartan cilexetil oral tablet 16, 32, Atacand 4, 8 irbesartan oral tablet 150, 300, 75 Avapro ; QLL (1 EA per 1 losartan potassium oral tablet 100 Cozaar losartan potassium oral tablet 25, 50 telmisartan oral tablet 20, 40, 80 valsartan oral tablet 160, 320, 40, 80 *Antiadrenergics - Centrally Acting*** clonidine hcl oral tablet 0.1, 0.2, 0.3 clonidine transdermal patch weekly 0.1 /24hr clonidine transdermal patch weekly 0.2 /24hr clonidine transdermal patch weekly 0.3 /24hr guanfacine hcl oral tablet 1 guanfacine hcl oral tablet 2 methyldopa oral tablet 250, 500 *Antiadrenergics - Peripherally Acting*** doxazosin mesylate oral tablet 1, 2, 4, 8 Cozaar Micardis Diovan Catapres Catapres-TTS-1 Catapres-TTS-2 Catapres-TTS-3 Cardura ; QLL (2 EA per 1 ; QLL (1 EA per 1 ; QLL (60 EA per 30 ST; ST; ST; ; QLL (240 EA per 30 ; QLL (120 EA per 30 ; QLL (1 EA per 1 27

34 prazosin hcl oral capsule 1, 2, 5 Minipress terazosin hcl oral capsule 1, 2, 5 ; QLL (1 EA per 1 terazosin hcl oral capsule 10 ; QLL (2 EA per 1 *Beta Blocker & Diuretic Combinations*** atenolol-chlorthalidone oral tablet Tenoretic 100 atenolol-chlorthalidone oral tablet Tenoretic 50 bisoprolol-hydrochlorothiazide oral tablet , , Ziac metoprolol-hydrochlorothiazide oral tablet , metoprolol-hydrochlorothiazide oral tablet Lopressor HCT nadolol-bendroflumethiazide oral tablet 40-5 propranolol-hctz oral tablet 40-25, *Vasodilators*** hydralazine hcl oral tablet 10, 100, 25, 50 minoxidil oral tablet 10, 2.5 *ANTI-INFECTIVE AGENTS - MISC.* *Anti-Infective Agents - Misc.*** metronidazole oral capsule 375 Flagyl metronidazole oral tablet 250, 500 Flagyl trimethoprim oral tablet 100 *Anti-Infective Misc. - Combinations*** sulfamethoxazole-trimethoprim oral suspension /5ml Sulfatrim Pediatric sulfamethoxazole-trimethoprim oral tablet Bactrim *Leprostatics*** dapsone oral tablet 100, 25 *Lincosamides*** clindamycin hcl oral capsule 150, 300, Cleocin 75 28

35 clindamycin palmitate hcl oral solution reconstituted 75 /5ml Cleocin *ANTIMALARIALS* *Antimalarials*** chloroquine phosphate oral tablet 250, 500 hydroxychloroquine sulfate oral tablet 200 Plaquenil mefloquine hcl oral tablet 250 primaquine phosphate oral tablet 26.3 DARAPRIM ORAL TABLET 25 MG PA *ANTIMYASTHENIC AGENTS* *Antimyasthenic Agents*** pyridostigmine bromide oral tablet 60 Mestinon *ANTIMYCOBACTERIAL AGENTS* *Antimycobacterial Agents*** ethambutol hcl oral tablet 100, 400 Myambutol isoniazid injection solution 100 /ml isoniazid oral syrup 50 /5ml isoniazid oral tablet 100, 300 pyrazinamide oral tablet 500 rifabutin oral capsule 150 Mycobutin rifampin oral capsule 150, 300 Rifadin PRIFTIN ORAL TABLET 150 MG *ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES* *Alkylating Agents*** MYLERAN ORAL TABLET 2 MG *Antiandrogens*** bicalutamide oral tablet 50 Casodex flutamide oral capsule 125 nilutamide oral tablet 150 Nilandron ; QLL (60 EA per 30 *Antiestrogens*** tamoxifen citrate oral tablet 10, 20 toremifene citrate oral tablet 60 Fareston SOLTAMOX ORAL SOLUTION 10 MG/5ML 29

36 *Antimetabolites*** capecitabine oral tablet 150 Xeloda PA; capecitabine oral tablet 500 floxuridine injection solution reconstituted 0.5 gm mercaptopurine oral tablet 50 methotrexate oral tablet 2.5 TABLOID ORAL TABLET 40 MG *Antineoplastic - Multikinase Inhibitors*** SUTENT ORAL CAPSULE 12.5 MG, 25 MG, 37.5 MG SUTENT ORAL CAPSULE 50 MG Xeloda PA; ; QLL (154 EA per 21 PA; ; QLL (1 EA per 1 PA; ; QLL (42 EA per 28 *Antineoplastic - Tyrosine Kinase Inhibitors*** imatinib mesylate oral tablet 100, 400 Gleevec PA; CABOMETYX ORAL TABLET 20 MG, 40 MG, 60 MG PA; ; QLL (30 EA per 30 Days) IMBRUVICA ORAL CAPSULE 70 MG PA; ; QLL (1 EA per 1 IMBRUVICA ORAL TABLET 140 MG PA; ; QLL (120 EA per 30 SPRYCEL ORAL TABLET 100 MG, 140 MG, 20 MG, 50 MG, 70 MG, 80 MG PA; ; QLL (30 EA per 30 TASIGNA ORAL CAPSULE 150 MG, 200 MG PA; ; QLL (2 EA per 1 TASIGNA ORAL CAPSULE 50 MG PA; ; QLL (4 EA per 1 TYKERB ORAL TABLET 250 MG PA; ; QLL (180 EA per 30 VOTRIENT ORAL TABLET 200 MG PA; ; QLL (120 EA per 30 Days) *Antineoplastics Misc.*** hydroxyurea oral capsule 500 Hydrea MATULANE ORAL CAPSULE 50 MG *Aromatase Inhibitors*** anastrozole oral tablet 1 Arimidex exemestane oral tablet 25 Aromasin letrozole oral tablet 2.5 Femara 30