QUALIFIED HEALTH PLAN FORMULARY Effective January 2018

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1 QUALIFIED HEALTH PLAN FORMULARY Effective January 2018 Provided by EnvisionRx Introduction The Total Health Care (THC) Qualified Health Plan Formulary was developed to serve as a guide for physicians, pharmacists, health care professionals and members in the selection of cost-effective drug therapy. Total Health Care recognizes that drug therapy is an integral part of effective health management. Total Health Care continually reviews new and existing medications to ensure the Formulary remains responsive to the needs of our members and health professionals. Criteria used to evaluate drug selection for the formulary includes, but is not limited to: safety, efficacy and cost-effectiveness data, as well as comparison of relevant benefits of similar prescription or over-the counter (OTC) agents while minimizing potential duplications. Notice The information contained in this formulary is provided by THC & EnvisionRx, solely for the convenience of medical providers and members. THC does not warrant or assure accuracy of this information, nor is it intended to be comprehensive in nature. This formulary is not intended to be a substitute for the knowledge, expertise, skill or judgment of the medical provider in their choice of prescription drugs. Total Health Care assumes no responsibility for the actions or omissions of any medical provider based upon reliance, in whole or in part, on the information contained herein. The medical provider should consult the drug manufacturer s product literature or standard references for more detailed information. How to Read the Formulary All formulary drugs are listed either by their generic names (in lowercase) or by their brand names (in uppercase). Drugs are grouped together by their therapeutic drug category. Specific drug listings may be accessed by using the index, using the covered generic name or the covered brand name of the drug. Any drug not found in this Formulary listing shall be considered a non-formulary drug. i

2 Tier Guidelines Generic Tier 1 Preferred Brand Tier 2 Non-Preferred Brand Tier 3 Non- Preferred Generic Specialty Tier 4 Preventive Tier 5 $0 co-pay at in-network pharmacies The Certificate of Coverage provided upon enrollment has specific information regarding co-payments, coinsurance, annual deductible requirements and maximum out of pocket limits associated with the corresponding pharmacy benefit. Prescribing Guidelines Prescribing guidelines may apply to select drugs on the THC formulary. Prescribing guidelines may vary by benefit design but may include: Prior Authorization Required () Over the Counter Drugs (OTC) Specialty Drugs (SP) Quantity Limit (QL) Age Limit (AL) Gender Restriction (GR) Step Therapy Required (ST) Custom (C) Drug requires prior authorization through a specific physician request process. Drug coverage is available for drugs that are available OTC with an authorized prescription from your provider. Drug requires processing through THC s contracted specialty pharmacy, Envision Specialty Pharmacy. Drug coverage may be limited to specific quantities per prescription and/or time period. Drug coverage may depend on patient age. Drug coverage may depend on patient gender. Drug coverage requires that an alternative or trial of another drug be used before the medication is covered. Drug coverage has unique restrictions. ii

3 Saving on Out-Of-Pocket Costs Total Health Care has designed its prescription drug plan to encourage the use of generic and preferred brand name drugs. Choosing non-preferred drugs may mean paying higher out-of-pocket expenses (such as coinsurance and co-payments) or not receiving coverage at all. Members may also pay less for generic drugs or they may be asked to pay the cost difference between brand name drugs and their generic alternatives, which are preferred by the plan. Benefit Coverage and Limitations This formulary does not define benefit coverage and limitations. Many members have specific benefit inclusions, exclusions, copayments, coinsurance or a lack of coverage, which are not reflected in the THC Qualified Health Plan Formulary. Members should contact Total Health Care at if they have questions regarding their coverage. Please note that the formulary process is evolutionary and changes can occur throughout the year. Preventive Medications Total Health Care covers certain preventive services for $0 co-pay when delivered by in-network pharmacies. These drugs are indicated on the THC Qualified Health Plan Formulary under Drug Tier 5. Examples of preventive medications include aspirin, contraceptives, iron supplementations, smoking cessation products and Vitamin D drugs. These drugs are available with standard drug coverage recommendations and are only available for certain populations. Prior Authorization () Drugs indicated with a require Prior Authorization for coverage. A prescriber may complete a Prior Authorization form that can be found on the Total Health Care website at You may also request a form by calling Total Health Care at Completed prior authorization forms should be faxed to Prior Authorization review of prescribing guidelines will be evaluated utilizing the established drug review criteria approved by Total Health Care. If the request does not meet the approved criteria, the request will not be approved and alternative therapy may be recommended along with the proper course of alternative action. The requesting provider will be provided written notification of Total Health Care review decisions. THC s website has a contact link where members can contact THC s Pharmacy Department to ask for an exception request. Non-Formulary Agents Drugs not located on the Total Health Care Qualified Health Plan Formulary, or any updates published by Total Health Care, shall be considered a non-formulary drug. Requests for coverage of non-formulary agents may be requested by the health professional depending on specific coverage parameters. Review for nonformulary drug requests will require a Prior Authorization request with documentation of medical necessity. Generally, the following basic medical necessity guidelines are used in conducting a review: The patient has failed an appropriate trial of formulary or preferred agents. The use of preferred or formulary agent is contraindicated in the patient. iii

4 The formulary drug or preferred agents are not suited for the present patient care need, and the drug selected is required for patient safety. If the request does not meet the established guidelines request, it will not be approved and alternative therapy may be recommended along with the proper course of alternative action. Common Drug Exclusions The member s plan design may exclude certain drug classes. Prior authorization is generally not available for drugs that are specifically excluded by benefit design. Common excluded coverages may include, but are not limited to: OTC medications or their equivalents unless otherwise specified in the Formulary listing. Drug products used for cosmetic purposes. Experimental drug products, or any drug product used in an experimental manner. Foreign drugs or drugs not approved by the United States Food & Drug Administration (FDA). Mandated Generic Substitution Total Health Care advocates the use of cost-effective generic drugs where FDA-approved generic equivalent drugs are available. Generic products are listed in the Formulary and noted in lowercase lettering wherever an FDA-approved generic drug product is available. If a member or physician requests a brand name product in lieu of an approved generic, the member, based upon their coverage, will be required to pay the difference in cost between the brand/non-preferred brand and the generic drug, plus the brand/non-preferred brand copay. Total Health Care Pharmacy and Therapeutics (P&T) Committee Total Health Care s Pharmacy & Therapeutics Committee meets quarterly to review and recommend medications for formulary consideration. The Committee considers clinical information on drugs that are new to the market and drugs that are typically included in an outpatient pharmacy benefit. This assures that the formulary remains responsive to patient and physician needs. The Committee is composed of physicians, pharmacists, and health care professionals. The Committee also uses reference materials from our Pharmacy Benefits Manager's Pharmacy and Therapeutics Advisory Panel. Product Selection Criteria The primary goal of the THC Pharmacy & Therapeutics Committee is to maintain and update the formulary based upon an objective analysis of the safety, efficacy, approved indications, adverse effects, contraindications, patient administration/compliance considerations and cost effectiveness of available drugs. When a drug is considered for formulary inclusion, it will be reviewed relative to similar drugs including those currently in the THC Formulary. Physicians may request a copy of THC s drug criteria by calling the Pharmacy Department at Diabetic Testing Supplies Total Health Care works with J&B Medical Supply to provide diabetic testing supplies to our members. Covered diabetic testing supplies include Glucocard Vital glucometer, Glucocard Expression glucometer, and SD Biosensor GlucoNavii glucometer, Glucocard Vital test strips, Glucocard Expression test strips, SD Biosensor GlucoNavii test strips, lancets, insulin syringes, alcohol swabs and ketone strips. These supplies iv

5 are to be filled through J&B Medical Supply. If you have any questions about our diabetic supply program, please contact J&B Medical Supply at Specialty Bio-Pharmaceutical Pharmacy Program Total Health Care works with Envision Specialty Pharmacy to provide Specialty Bio-Pharmaceutical Pharmacy products to our members. These medications are to be filled exclusively through Envision Specialty Pharmacy. A Specialty Drug Prior Authorization Request form must be completed and faxed to EnvisionRx at with supporting documentation and the prescription. A prescriber may obtain a Specialty Drug Prior Authorization Request form found on the Total Health Care website at Once the order is received, EnvisionRx obtains authorization from Total Health Care. If the specialty prior authorization is approved, Total Health Care notifies Envision Specialty Pharmacy. Then, Envision Specialty Pharmacy staff ships the medication directly to the physician's office or the patient s home. All packages are individually marked for each patient and refrigerated items are shipped in insulated containers. Where appropriate, each shipment includes needles, syringes and alcohol swabs. If you have any questions about our Specialty Bio-Pharmaceutical Pharmacy program, please contact EnvisionRx at or Envision Specialty Pharmacy at Contact Information The Total Health Care Qualified Health Plan Formulary is designed to assist physicians, members and other health care professionals in the selection of cost-effective agents. Total Health Care encourages your input and feedback on how we can assist in improving this document and the formulary management process. You may contact THC at Medication Limitations Quantity Limitations Quantity Limitations are on medications throughout the formulary and are indicated with a "QL" notation. These are medications that have a daily dose restriction, quantity/days supply limitation, and/or a limitation on the duration of therapy. Age Limitations Age Limitations are on medications throughout the formulary and are indicated with an "AL" notation. Coverage for a medication is indicated by the age limitation. This could be a minimum age, maximum age, and/or the combination of a minimum and maximum age edit. Gender Restrictions Gender restrictions are indicated with a GR on the formulary and require the member to be a specific gender for coverage. Step Therapy Criteria v

6 Step Therapy medications are indicated with a ST on the formulary and require that an alternative, first line medication be tried and failed before the requested medication can be covered. The online claims adjudication system will automatically allow for the requested medication to be filled based on electronic claims history indicating that the first line medication was filled. Step Therapy Criteria Therapy Class First Line Second Line Step Therapy Criteria Aminosalicylic Acid Derivative Agents APRISO, DELZICOL PENTASA, ASACOL HD Prior use of APRISO or DELZICOL in the last 90 days. Angiotensin Receptor Blocker and Calcium Channel Blocker amlodipinevalsartan amlodipineolmesartan Prior use of amlodipinevalsartan in the last 90 days. Antidiabetic Agents DPP4 alogliptin, alogliptin-metformin alogliptinpioglitazone JANUVIA, JANUMET, JANUMET XR, ONGLYZA, TRADJENTA Prior use of alogliptin, alogliptin-metformin, or alogliptin-pioglitazone in the last 90 days. Antidiabetic Agents SGLT-2 Antiemetic Agents INVOKANA, INVOKAMET, INVOKAMET XR, JARDIANCE, SYNJARDY, SYNJARDY XR ondansetron, granisetron FARXIGA, XIGDUO XR ANZEMET, aprepitant Prior use of TWO of the following: INVOKANA, INVOKAMET, JARDIANCE, SYNJARDY in the last 180 days. Prior use of ondansetron AND granisetron in the last 90 days. Antiglaucoma Agents latanoprost, bimatoprost, travoprost Antimigraine sumatriptan, rizatriptan, naratriptan, zolmitriptan LUMIGAN, TRAVATAN-Z, ZIOPTAN almotriptan, RELX, eletriptan, frovatriptan Prior use of TWO of the following: latanoprost, bimatoprost or travoprost in the last 90 days. Prior use of TWO of the following: sumatriptan, rizatriptan, zolmitriptan, naratriptan in the last 90 days. Anti-Parkinson's Agents MAO-B inhibitors Anti-Parkinson's Agents selegiline tablet EMSAM Prior use of selegiline tablet in the last 90 days. ropinirole immediate-release, pramipexole immediate-release ropinirole extended-release, pramipexole extended-release Prior use of ropinirole immediate-release AND pramipexole immediate-release in the last 90 days. Anti-platelet Agents clopidogrel EFFIENT Prior use of clopidogrel in the last 90 days. vi

7 Antiprotozoal Antibiotic metronidazole immediate- release FLAGYL ER Prior use of metronidazole immediate-release in the last 90 days. Beta2 Agonist (nebulizer) albuterol nebulizer solution levalbuterol nebulizer solution Prior use of albuterol nebulizer solution in the last 90 days. Coreg CR carvedilol immediate-release COREG CR Prior use of carvedilol immediate-release in the last 90 days. H-CoA Reductase Inhibitor atorvastatin, simvastatin, rosuvastatin LIVALO, ezetimibesimvastatin Prior use of TWO of the following: atorvastatin, rosuvastatin, simvastatin in the last 90 days. Hypnotic Agents temazepam, zaleplon, zolpidem immediaterelease, zolpidem extendedrelease, eszopiclone ROZEREM, BELSOMRA Prior use of TWO of the following: temazepam, zaleplon, zolpidem, zolpidem ER, eszopiclone in the last 90 days. Nasal Corticosteroids flunisolide, fluticasone, NASACORT OTC, budesonide OTC azelastine, BECONASE AQ, mometasone, QNASL Pediculicides malathion 0.5% ULESFIA, NATROBA Pleuromutilin Antibiotic Prior use of TWO of the following: flunisolide, fluticasone, NASACORT OTC or budesonide OTC nasal in the last 180 days. Prior use of malathion 0.5% within the last 90 days. mupirocin ALTABAX Prior use of mupirocin in the last 90 days. Propranolol ER propranolol immediate-release propranolol extended-release Prior use of propranolol immediate-release in the last 90 days. Retinoic Acid Derivatives tretinoin 0.025%, tretinoin 0.05%, tretinoin 0.1%, tretinoin 0.01%, DIFFERIN OTC 0.1% GEL tretinoin 0.04% gel adapalene-benz peroxide gel, EPIDUO, CLINDAP-T, ZIANA Prior use of tretinoin 0.025%, tretinoin 0.05%, tretinoin 0.01%, tretinoin 0.1%, or DIFFERIN OTC 0.1% GEL in the last 90 days. Topical Scalp Corticosteroids ketoconazole 2% shampoo CAPEX SHAMPOO Prior use of ketoconazole 2% shampoo in the last 90 days. vii

8 Topical Corticosteroids Urinary Antispasmodics clobetasol, desonide, betamethasone, flucinolone, flucinonide, hydrocortisone, triamcinolone oxybutynin, oxybutynin er, OXYTROL OTC, oxybutynin syrup, GELNIQUE calcip-beta, TACLONEX SUSP tolterodine, tolterodine er, trospium, trospium er, darifenacin, TOVIAZ, VESICARE Prior use of TWO of the following: clobetasol, desonide, betamethasone, flucinolone, flucinonide, hydrocortisone, or triamcinolone in the last 90 days. Prior use of OXYTROL OTC, oxybutynin, oxybutynin er, oxybutynin syrup, or GELNIQUE in the last 90 days. Vascepa omega-3-acid VASCE Prior use of omega-3 acid capsule in the last 90 days. Vyvanse amphetamine ER VYVANSE Prior use of amphetamine ER capsule in the last 90 days. *Formulary Disclaimer: Coverage for some drugs may be limited to specific dosage forms and/or strengths. The benefit design determines what is covered and the applicable co-payment. The medications listed on this formulary are subject to change pursuant to the formulary management activities of EnvisionRx. The presence of a medication on this formulary list does not guarantee coverage. viii

9 lowercase italics = Generic drugs UPPERCASE BOLD = Brand name drugs CURRENT AS OF 1/1/2018 Status = Tier 1 = Tier 2 = Tier 3 = Tier 4 T5 = Tier 5 Drug Status Notes *Adhd/Anti-Narcolepsy/Anti- Obesity/Anorexiants* amphetamine-dextroamphet er capsule extended release 24 hour 10 mg oral 10 mg amphetamine-dextroamphet er capsule extended release 24 hour 15 mg oral 15 mg amphetamine-dextroamphet er capsule extended release 24 hour 20 mg oral 20 mg amphetamine-dextroamphet er capsule extended release 24 hour 25 mg oral 25 mg amphetamine-dextroamphet er capsule extended release 24 hour 30 mg oral 30 mg amphetamine-dextroamphet er capsule extended release 24 hour 5 mg oral 5 mg amphetamine-dextroamphetamine tablet 10 mg oral 10 mg amphetamine-dextroamphetamine tablet 12.5 mg oral 12.5 mg amphetamine-dextroamphetamine tablet 15 mg oral 15 mg amphetamine-dextroamphetamine tablet 20 mg oral 20 mg amphetamine-dextroamphetamine tablet 30 mg oral 30 mg amphetamine-dextroamphetamine tablet 5 mg oral 5 mg amphetamine-dextroamphetamine tablet 7.5 mg oral 7.5 mg armodafinil tablet 150 mg oral 150 mg armodafinil tablet 200 mg oral 200 mg armodafinil tablet 50 mg oral 50 mg atomoxetine hcl capsule 10 mg oral 10 mg Notes AL = Age Limit C = Custom Restriction GR-F = Female Only GR-M = Male Only = Prior Authorization QL = Quantity Limit ST = Step Therapy ; AL (Min 6 Years and Max 17 Years) ; AL (Min 6 Years and Max 17 Years) ; AL (Min 6 Years and Max 17 Years) ; AL (Min 6 Years and Max 17 Years) ; AL (Min 6 Years and Max 17 Years) ; AL (Min 6 Years and Max 17 Years) AL (Min 6 Years and Max 17 Years) AL (Min 6 Years and Max 17 Years) AL (Min 6 Years and Max 17 Years) AL (Min 6 Years and Max 17 Years) AL (Min 6 Years and Max 17 Years) AL (Min 6 Years and Max 17 Years) AL (Min 6 Years and Max 17 Years) ; AL (Min 6 Years and Max 17 Years) 1

10 atomoxetine hcl capsule 100 mg oral 100 mg atomoxetine hcl capsule 18 mg oral 18 mg atomoxetine hcl capsule 25 mg oral 25 mg atomoxetine hcl capsule 40 mg oral 40 mg atomoxetine hcl capsule 60 mg oral 60 mg atomoxetine hcl capsule 80 mg oral 80 mg caffeine citrate solution 20 mg/ml oral 20 mg/ml caffeine citrate solution 60 mg/3ml intravenous 60 mg/3ml caffeine-sodium benzoate solution mg/ml injection mg/ml DAYTRANA TCH 10 /9HR TRANSDERMAL 10 /9HR DAYTRANA TCH 15 /9HR TRANSDERMAL 15 /9HR DAYTRANA TCH 20 /9HR TRANSDERMAL 20 /9HR DAYTRANA TCH 30 /9HR TRANSDERMAL 30 /9HR dexmethylphenidate hcl er capsule extended release 24 hour 10 mg oral 10 mg dexmethylphenidate hcl er capsule extended release 24 hour 15 mg oral 15 mg dexmethylphenidate hcl er capsule extended release 24 hour 20 mg oral 20 mg dexmethylphenidate hcl er capsule extended release 24 hour 25 mg oral 25 mg dexmethylphenidate hcl er capsule extended release 24 hour 30 mg oral 30 mg dexmethylphenidate hcl er capsule extended release 24 hour 35 mg oral 35 mg dexmethylphenidate hcl er capsule extended release 24 hour 40 mg oral 40 mg dexmethylphenidate hcl tablet 10 mg oral 10 mg dexmethylphenidate hcl tablet 2.5 mg oral 2.5 mg 2 ; AL (Min 6 Years and Max 17 Years) ; AL (Min 6 Years and Max 17 Years) ; AL (Min 6 Years and Max 17 Years) ; AL (Min 6 Years and Max 17 Years) ; AL (Min 6 Years and Max 17 Years) ; AL (Min 6 Years and Max 17 Years) ; ; AL (Min 6 Years and Max 17 Years) ; ; AL (Min 6 Years and Max 17 Years) ; ; AL (Min 6 Years and Max 17 Years) ; ; AL (Min 6 Years and Max 17 Years) ; ; AL (Min 6 Years and Max 17 Years) ; ; AL (Min 6 Years and Max 17 Years) ; ; AL (Min 6 Years and Max 17 Years) ; ; AL (Min 6 Years and Max 17 Years) ; ; AL (Min 6 Years and Max 17 Years) ; ; AL (Min 6 Years and Max 17 Years) ; ; AL (Min 6 Years and Max 17 Years) AL (Min 6 Years and Max 17 Years) AL (Min 6 Years and Max 17 Years)

11 dexmethylphenidate hcl tablet 5 mg oral 5 mg dextroamphetamine sulfate er capsule extended release 24 hour 10 mg oral 10 mg dextroamphetamine sulfate er capsule extended release 24 hour 15 mg oral 15 mg dextroamphetamine sulfate er capsule extended release 24 hour 5 mg oral 5 mg dextroamphetamine sulfate tablet 10 mg oral 10 mg dextroamphetamine sulfate tablet 5 mg oral 5 mg diethylpropion hcl er tablet extended release 24 hour 75 mg oral 75 mg diethylpropion hcl tablet 25 mg oral 25 mg doxapram hcl solution 20 mg/ml intravenous 20 mg/ml FOCALIN XR CAPSULE EXTENDED RELEASE 24 HOUR 25 ORAL 25 FOCALIN XR CAPSULE EXTENDED RELEASE 24 HOUR 35 ORAL 35 guanfacine hcl er tablet extended release 24 hour 1 mg oral 1 mg guanfacine hcl er tablet extended release 24 hour 2 mg oral 2 mg guanfacine hcl er tablet extended release 24 hour 3 mg oral 3 mg guanfacine hcl er tablet extended release 24 hour 4 mg oral 4 mg methamphetamine hcl tablet 5 mg oral 5 mg methylphenidate hcl er (cd) capsule extended release 10 mg oral 10 mg methylphenidate hcl er (cd) capsule extended release 20 mg oral 20 mg methylphenidate hcl er (cd) capsule extended release 30 mg oral 30 mg methylphenidate hcl er (cd) capsule extended release 40 mg oral 40 mg methylphenidate hcl er (cd) capsule extended release 50 mg oral 50 mg methylphenidate hcl er (cd) capsule extended release 60 mg oral 60 mg AL (Min 6 Years and Max 17 Years) AL (Min 6 Years and Max 17 Years) AL (Min 6 Years and Max 17 Years) AL (Min 6 Years and Max 17 Years) AL (Min 6 Years and Max 17 Years) AL (Min 6 Years and Max 17 Years) ; ; AL (Min 6 Years and Max 17 Years) ; ; AL (Min 6 Years and Max 17 Years) ; AL (Min 6 Years and Max 17 Years) ; AL (Min 6 Years and Max 17 Years) ; AL (Min 6 Years and Max 17 Years) ; AL (Min 6 Years and Max 17 Years) AL (Min 6 Years and Max 17 Years) ; AL (Min 6 Years and Max 17 Years) ; AL (Min 6 Years and Max 17 Years) ; AL (Min 6 Years and Max 17 Years) ; AL (Min 6 Years and Max 17 Years) ; AL (Min 6 Years and Max 17 Years) ; AL (Min 6 Years and Max 17 Years) 3

12 methylphenidate hcl er (la) capsule extended release 24 hour 20 mg oral 20 mg methylphenidate hcl er (la) capsule extended release 24 hour 30 mg oral 30 mg methylphenidate hcl er (la) capsule extended release 24 hour 40 mg oral 40 mg methylphenidate hcl er tablet extended release 10 mg oral 10 mg methylphenidate hcl er tablet extended release 18 mg oral 18 mg methylphenidate hcl er tablet extended release 20 mg oral 20 mg methylphenidate hcl er tablet extended release 24 hour 18 mg oral 18 mg methylphenidate hcl er tablet extended release 24 hour 27 mg oral 27 mg methylphenidate hcl er tablet extended release 24 hour 36 mg oral 36 mg methylphenidate hcl er tablet extended release 24 hour 54 mg oral 54 mg methylphenidate hcl er tablet extended release 27 mg oral 27 mg methylphenidate hcl er tablet extended release 36 mg oral 36 mg methylphenidate hcl er tablet extended release 54 mg oral 54 mg methylphenidate hcl solution 10 mg/5ml oral 10 mg/5ml methylphenidate hcl solution 5 mg/5ml oral 5 mg/5ml methylphenidate hcl tablet 10 mg oral 10 mg methylphenidate hcl tablet 20 mg oral 20 mg methylphenidate hcl tablet 5 mg oral 5 mg modafinil tablet 100 mg oral 100 mg modafinil tablet 200 mg oral 200 mg phendimetrazine tartrate er capsule extended release 24 hour 105 mg oral 105 mg phendimetrazine tartrate tablet 35 mg oral 35 mg phentermine hcl capsule 15 mg oral 15 mg phentermine hcl capsule 30 mg oral 30 mg 4 ; AL (Min 6 Years and Max 17 Years) ; AL (Min 6 Years and Max 17 Years) ; AL (Min 6 Years and Max 17 Years) ; AL (Min 6 Years and Max 17 Years) ; AL (Min 6 Years and Max 17 Years) ; AL (Min 6 Years and Max 17 Years) ; AL (Min 6 Years and Max 17 Years) ; AL (Min 6 Years and Max 17 Years) ; AL (Min 6 Years and Max 17 Years) ; AL (Min 6 Years and Max 17 Years) ; AL (Min 6 Years and Max 17 Years) ; AL (Min 6 Years and Max 17 Years) ; AL (Min 6 Years and Max 17 Years) ; AL (Min 6 Years and Max 17 Years) ; AL (Min 6 Years and Max 17 Years) AL (Min 6 Years and Max 17 Years) AL (Min 6 Years and Max 17 Years) AL (Min 6 Years and Max 17 Years)

13 phentermine hcl capsule 37.5 mg oral 37.5 mg phentermine hcl tablet 37.5 mg oral 37.5 mg STRATTERA CAPSULE 10 ORAL 10 STRATTERA CAPSULE 100 ORAL 100 STRATTERA CAPSULE 18 ORAL 18 STRATTERA CAPSULE 25 ORAL 25 STRATTERA CAPSULE 40 ORAL 40 STRATTERA CAPSULE 60 ORAL 60 STRATTERA CAPSULE 80 ORAL 80 VYVANSE CAPSULE 10 ORAL 10 VYVANSE CAPSULE 20 ORAL 20 VYVANSE CAPSULE 30 ORAL 30 VYVANSE CAPSULE 40 ORAL 40 VYVANSE CAPSULE 50 ORAL 50 VYVANSE CAPSULE 60 ORAL 60 VYVANSE CAPSULE 70 ORAL 70 *Aminoglycosides* neomycin sulfate tablet 500 mg oral 500 mg paromomycin sulfate capsule 250 mg oral 250 mg tobramycin nebulization solution 300 mg/5ml inhalation 300 mg/5ml *Analgesics - Anti-Inflammatory* ACTEMRA SOLUTION PREFILLED SYRINGE 162 /0.9ML SUBCUTANEOUS 162 /0.9ML ARCALYST SOLUTION RECONSTITUTED 220 SUBCUTANEOUS 220 ; AL (Min 6 Years and Max 17 Years) ; AL (Min 6 Years and Max 17 Years) ; AL (Min 6 Years and Max 17 Years) ; AL (Min 6 Years and Max 17 Years) ; AL (Min 6 Years and Max 17 Years) ; AL (Min 6 Years and Max 17 Years) ; AL (Min 6 Years and Max 17 Years) ST; ; AL (Min 6 Years and Max 17 Years) ST; ; AL (Min 6 Years and Max 17 Years) ST; ; AL (Min 6 Years and Max 17 Years) ST; ; AL (Min 6 Years and Max 17 Years) ST; ; AL (Min 6 Years and Max 17 Years) ST; ; AL (Min 6 Years and Max 17 Years) ST; ; AL (Min 6 Years and Max 17 Years) celecoxib capsule 100 mg oral 100 mg 5

14 celecoxib capsule 200 mg oral 200 mg celecoxib capsule 50 mg oral 50 mg diclofenac potassium tablet 50 mg oral 50 mg diclofenac sodium er tablet extended release 24 hour 100 mg oral 100 mg diclofenac sodium tablet delayed release 25 mg oral 25 mg diclofenac sodium tablet delayed release 50 mg oral 50 mg diclofenac sodium tablet delayed release 75 mg oral 75 mg diclofenac-misoprostol tablet delayed release mg oral mg diclofenac-misoprostol tablet delayed release mg oral mg ENBREL SOLUTION PREFILLED SYRINGE 50 /ML SUBCUTANEOUS 50 /ML ENBREL SOLUTION RECONSTITUTED 25 SUBCUTANEOUS 25 ENBREL SURECLICK SOLUTION AUTO- INJECTOR 50 /ML SUBCUTANEOUS 50 /ML etodolac capsule 200 mg oral 200 mg etodolac capsule 300 mg oral 300 mg etodolac er tablet extended release 24 hour 400 mg oral 400 mg etodolac er tablet extended release 24 hour 500 mg oral 500 mg etodolac er tablet extended release 24 hour 600 mg oral 600 mg etodolac tablet 400 mg oral 400 mg etodolac tablet 500 mg oral 500 mg flurbiprofen tablet 100 mg oral 100 mg flurbiprofen tablet 50 mg oral 50 mg HUMIRA PEN PEN-INJECTOR KIT 40 /0.8ML SUBCUTANEOUS 40 /0.8ML HUMIRA PREFILLED SYRINGE KIT 20 /0.4ML SUBCUTANEOUS 20 /0.4ML HUMIRA PREFILLED SYRINGE KIT 40 /0.8ML SUBCUTANEOUS 40 /0.8ML ibuprofen oral suspension 100 mg/5ml 6

15 ibuprofen tablet 400 mg oral 400 mg ibuprofen tablet 600 mg oral 600 mg ibuprofen tablet 800 mg oral 800 mg indomethacin capsule 25 mg oral 25 mg AL (Max 64 Years) indomethacin capsule 50 mg oral 50 mg AL (Max 64 Years) indomethacin er capsule extended release 75 mg oral 75 mg AL (Max 64 Years) ketoprofen capsule 50 mg oral 50 mg QL (180 EA per 30 days) ketoprofen capsule 75 mg oral 75 mg QL (120 EA per 30 days) ketoprofen er capsule extended release 24 hour 200 mg oral 200 mg ketorolac tromethamine tablet 10 mg oral 10 mg QL (20 EA per 5 days) KINERET SOLUTION PREFILLED SYRINGE 100 /0.67ML SUBCUTANEOUS 100 /0.67ML leflunomide tablet 10 mg oral 10 mg leflunomide tablet 20 mg oral 20 mg meclofenamate sodium capsule 100 mg oral 100 mg meclofenamate sodium capsule 50 mg oral 50 mg meloxicam tablet 15 mg oral 15 mg meloxicam tablet 7.5 mg oral 7.5 mg MOBIC SUSPENSION 7.5 /5ML ORAL 7.5 /5ML nabumetone tablet 500 mg oral 500 mg QL (120 EA per 30 days) nabumetone tablet 750 mg oral 750 mg QL (60 EA per 30 days) naproxen dr tablet delayed release 375 mg oral 375 mg naproxen dr tablet delayed release 500 mg oral 500 mg naproxen sodium tablet 275 mg oral 275 mg naproxen sodium tablet 550 mg oral 550 mg naproxen suspension 125 mg/5ml oral 125 mg/5ml naproxen tablet 250 mg oral 250 mg naproxen tablet 375 mg oral 375 mg naproxen tablet 500 mg oral 500 mg ORENCIA SOLUTION PREFILLED SYRINGE 125 /ML SUBCUTANEOUS 125 /ML oxaprozin tablet 600 mg oral 600 mg QL (300 ML per 30 days); AL (Max 12 Years) 7

16 piroxicam capsule 10 mg oral 10 mg piroxicam capsule 20 mg oral 20 mg RIDAURA CAPSULE 3 ORAL 3 sulindac tablet 150 mg oral 150 mg sulindac tablet 200 mg oral 200 mg tolmetin sodium capsule 400 mg oral 400 mg tolmetin sodium tablet 200 mg oral 200 mg tolmetin sodium tablet 600 mg oral 600 mg XELJANZ TABLET 5 ORAL 5 *Analgesics - Nonnarcotic* aspirin 81 oral tablet chewable 81 mg aspirin ec low dose oral tablet delayed release 81 mg aspirin ec oral tablet delayed release 325 mg aspirin oral tablet 325 mg butalbital-apap-caffeine capsule mg oral mg butalbital-apap-caffeine capsule mg oral mg butalbital-apap-caffeine tablet mg oral mg butalbital-aspirin-caffeine capsule mg oral mg choline-mag trisalicylate liquid 500 mg/5ml oral 500 mg/5ml diflunisal tablet 500 mg oral 500 mg marten-tab tablet mg oral mg salsalate tablet 500 mg oral 500 mg salsalate tablet 750 mg oral 750 mg TENCON TABLET ORAL *Analgesics - Opioid* acetaminophen-codeine #2 tablet mg oral mg acetaminophen-codeine #3 tablet mg oral mg acetaminophen-codeine #4 tablet mg oral mg 8 T5 T5 T5 T5 QL (60 EA per 30 days); AL (Min 40 Years and Max 79 Years) QL (60 EA per 30 days); AL (Min 40 Years and Max 79 Years) ; AL (Min 40 Years and Max 79 Years) ; AL (Min 40 Years and Max 79 Years) QL (390 EA per 30 days) QL (390 EA per 30 days) QL (390 EA per 30 days)

17 acetaminophen-codeine solution mg/5ml oral mg/5ml buprenorphine hcl solution 0.3 mg/ml injection 0.3 mg/ml buprenorphine hcl tablet sublingual 2 mg sublingual 2 mg buprenorphine hcl tablet sublingual 8 mg sublingual 8 mg buprenorphine hcl-naloxone hcl tablet sublingual mg sublingual mg buprenorphine hcl-naloxone hcl tablet sublingual 8-2 mg sublingual 8-2 mg butalbital-apap-caff-cod capsule mg oral mg butalbital-apap-caff-cod capsule mg oral mg butalbital-asa-caff-codeine capsule mg oral mg butorphanol tartrate solution 1 mg/ml injection 1 mg/ml butorphanol tartrate solution 10 mg/ml nasal 10 mg/ml butorphanol tartrate solution 2 mg/ml injection 2 mg/ml BUTRANS TCH WEEKLY 10 MCG/HR TRANSDERMAL 10 MCG/HR BUTRANS TCH WEEKLY 20 MCG/HR TRANSDERMAL 20 MCG/HR BUTRANS TCH WEEKLY 5 MCG/HR TRANSDERMAL 5 MCG/HR codeine sulfate solution 30 mg/5ml oral 30 mg/5ml codeine sulfate tablet 15 mg oral 15 mg codeine sulfate tablet 30 mg oral 30 mg ENDOCET TABLET ORAL fentanyl patch 72 hour 100 mcg/hr transdermal 100 mcg/hr fentanyl patch 72 hour 12 mcg/hr transdermal 12 mcg/hr fentanyl patch 72 hour 25 mcg/hr transdermal 25 mcg/hr ; QL (90 EA per 30 days) ; QL (90 EA per 30 days) QL (360 EA per 30 days) ; QL (10 EA per 30 days) ; QL (10 EA per 30 days) ; QL (10 EA per 30 days) 9

18 fentanyl patch 72 hour 50 mcg/hr transdermal 50 mcg/hr fentanyl patch 72 hour 75 mcg/hr transdermal 75 mcg/hr hydrocodone-acetaminophen solution mg/15ml oral mg/15ml hydrocodone-acetaminophen solution mg/15ml oral mg/15ml hydrocodone-acetaminophen tablet mg oral mg hydrocodone-acetaminophen tablet mg oral mg hydrocodone-acetaminophen tablet mg oral mg hydrocodone-ibuprofen tablet mg oral mg hydrocodone-ibuprofen tablet mg oral mg hydrocodone-ibuprofen tablet mg oral mg hydrocodone-ibuprofen tablet mg oral mg hydromorphone hcl er tablet er 24 hour abusedeterrent 12 mg oral 12 mg hydromorphone hcl er tablet er 24 hour abusedeterrent 16 mg oral 16 mg hydromorphone hcl er tablet er 24 hour abusedeterrent 32 mg oral 32 mg hydromorphone hcl er tablet er 24 hour abusedeterrent 8 mg oral 8 mg hydromorphone hcl liquid 1 mg/ml oral 1 mg/ml hydromorphone hcl suppository 3 mg rectal 3 mg ; QL (10 EA per 30 days) ; QL (10 EA per 30 days) QL (180 EA per 30 days) QL (180 EA per 30 days) QL (180 EA per 30 days) QL (180 EA per 30 days) QL (180 EA per 30 days) QL (180 EA per 30 days) QL (180 EA per 30 days) hydromorphone hcl tablet 2 mg oral 2 mg QL (240 EA per 30 days) hydromorphone hcl tablet 4 mg oral 4 mg QL (240 EA per 30 days) hydromorphone hcl tablet 8 mg oral 8 mg QL (240 EA per 30 days) levorphanol tartrate tablet 2 mg oral 2 mg meperidine hcl solution 10 mg/ml injection 10 mg/ml meperidine hcl solution 100 mg/ml injection 100 mg/ml meperidine hcl solution 25 mg/ml injection 25 mg/ml 10

19 meperidine hcl solution 50 mg/5ml oral 50 mg/5ml meperidine hcl solution 50 mg/ml injection 50 mg/ml meperidine hcl tablet 100 mg oral 100 mg meperidine hcl tablet 50 mg oral 50 mg METHADONE HCL INTENSOL CONCENTRATE 10 /ML ORAL 10 /ML methadone hcl solution 10 mg/5ml oral 10 mg/5ml methadone hcl solution 10 mg/ml injection 10 mg/ml methadone hcl solution 5 mg/5ml oral 5 mg/5ml methadone hcl tablet 10 mg oral 10 mg QL (240 EA per 30 days) methadone hcl tablet 5 mg oral 5 mg METHADOSE TABLET SOLUBLE 40 ORAL 40 morphine sulfate (concentrate) solution 100 mg/5ml oral 100 mg/5ml morphine sulfate (pf) solution 0.5 mg/ml injection 0.5 mg/ml morphine sulfate (pf) solution 1 mg/ml injection 1 mg/ml morphine sulfate (pf) solution 10 mg/ml intravenous 10 mg/ml morphine sulfate (pf) solution 15 mg/ml intravenous 15 mg/ml morphine sulfate (pf) solution 2 mg/ml intravenous 2 mg/ml morphine sulfate (pf) solution 4 mg/ml intravenous 4 mg/ml morphine sulfate (pf) solution 8 mg/ml intravenous 8 mg/ml morphine sulfate device 10 mg/0.7ml intramuscular 10 mg/0.7ml morphine sulfate er tablet extended release 100 mg oral 100 mg morphine sulfate er tablet extended release 15 mg oral 15 mg morphine sulfate er tablet extended release 30 mg oral 30 mg QL (90 EA per 30 days) QL (90 EA per 30 days) QL (90 EA per 30 days) 11

20 morphine sulfate er tablet extended release 60 mg oral 60 mg morphine sulfate solution 1 mg/ml intravenous 1 mg/ml morphine sulfate solution 10 mg/5ml oral 10 mg/5ml morphine sulfate solution 10 mg/ml injection 10 mg/ml morphine sulfate solution 15 mg/ml injection 15 mg/ml morphine sulfate solution 150 mg/30ml intravenous 150 mg/30ml morphine sulfate solution 20 mg/5ml oral 20 mg/5ml morphine sulfate solution 25 mg/ml intravenous 25 mg/ml morphine sulfate solution 50 mg/ml intravenous 50 mg/ml morphine sulfate solution 8 mg/ml injection 8 mg/ml morphine sulfate suppository 10 mg rectal 10 mg morphine sulfate suppository 20 mg rectal 20 mg morphine sulfate suppository 30 mg rectal 30 mg morphine sulfate suppository 5 mg rectal 5 mg QL (90 EA per 30 days) morphine sulfate tablet 15 mg oral 15 mg QL (180 EA per 30 days) morphine sulfate tablet 30 mg oral 30 mg QL (180 EA per 30 days) nalbuphine hcl solution 10 mg/ml injection 10 mg/ml nalbuphine hcl solution 20 mg/ml injection 20 mg/ml NUCYNTA ER TABLET EXTENDED RELEASE 12 HOUR 100 ORAL 100 NUCYNTA ER TABLET EXTENDED RELEASE 12 HOUR 150 ORAL 150 NUCYNTA ER TABLET EXTENDED RELEASE 12 HOUR 200 ORAL 200 NUCYNTA ER TABLET EXTENDED RELEASE 12 HOUR 250 ORAL 250 NUCYNTA ER TABLET EXTENDED RELEASE 12 HOUR 50 ORAL 50 ONA ER TABLET ER 12 HOUR ABUSE- DETERRENT 10 ORAL 10 12

21 ONA ER TABLET ER 12 HOUR ABUSE- DETERRENT 15 ORAL 15 ONA ER TABLET ER 12 HOUR ABUSE- DETERRENT 20 ORAL 20 ONA ER TABLET ER 12 HOUR ABUSE- DETERRENT 30 ORAL 30 ONA ER TABLET ER 12 HOUR ABUSE- DETERRENT 40 ORAL 40 ONA ER TABLET ER 12 HOUR ABUSE- DETERRENT 5 ORAL 5 ONA ER TABLET ER 12 HOUR ABUSE- DETERRENT 7.5 ORAL 7.5 OXAYDO TABLET ABUSE-DETERRENT 5 ORAL 5 OXAYDO TABLET ABUSE-DETERRENT 7.5 ORAL 7.5 ; QL (180 EA per 30 days) ; QL (180 EA per 30 days) oxycodone hcl capsule 5 mg oral 5 mg QL (180 EA per 30 days) oxycodone hcl concentrate 100 mg/5ml oral 100 mg/5ml oxycodone hcl solution 5 mg/5ml oral 5 mg/5ml oxycodone hcl tablet 10 mg oral 10 mg QL (180 EA per 30 days) oxycodone hcl tablet 15 mg oral 15 mg QL (180 EA per 30 days) oxycodone hcl tablet 20 mg oral 20 mg QL (180 EA per 30 days) oxycodone hcl tablet 30 mg oral 30 mg QL (180 EA per 30 days) oxycodone hcl tablet 5 mg oral 5 mg QL (180 EA per 30 days) oxycodone-acetaminophen tablet mg oral mg oxycodone-acetaminophen tablet mg oral mg oxycodone-acetaminophen tablet mg oral mg oxycodone-aspirin tablet mg oral mg oxycodone-ibuprofen tablet mg oral mg oxymorphone hcl er tablet extended release 12 hour 10 mg oral 10 mg oxymorphone hcl er tablet extended release 12 hour 15 mg oral 15 mg oxymorphone hcl er tablet extended release 12 hour 20 mg oral 20 mg oxymorphone hcl er tablet extended release 12 hour 30 mg oral 30 mg QL (180 EA per 30 days) QL (180 EA per 30 days) QL (240 EA per 30 days) 13

22 oxymorphone hcl er tablet extended release 12 hour 40 mg oral 40 mg oxymorphone hcl er tablet extended release 12 hour 5 mg oral 5 mg oxymorphone hcl er tablet extended release 12 hour 7.5 mg oral 7.5 mg pentazocine-naloxone hcl tablet mg oral mg SUBOXONE FILM 12-3 SUBLINGUAL 12-3 SUBOXONE FILM SUBLINGUAL SUBOXONE FILM 4-1 SUBLINGUAL 4-1 SUBOXONE FILM 8-2 SUBLINGUAL 8-2 tramadol hcl er (biphasic) tablet extended release 24 hour 300 mg oral 300 mg tramadol hcl er capsule extended release 24 hour 150 mg oral 150 mg tramadol hcl er tablet extended release 24 hour 100 mg oral 100 mg tramadol hcl er tablet extended release 24 hour 200 mg oral 200 mg ; ; QL (90 EA per 30 days) ; QL (90 EA per 30 days) ; QL (60 EA per 30 days) tramadol hcl tablet 50 mg oral 50 mg QL (240 EA per 30 days) tramadol-acetaminophen tablet mg oral mg VERDROCET TABLET ORAL VICODIN ES TABLET ORAL VICODIN HP TABLET ORAL VICODIN TABLET ORAL XARTEMIS XR TABLET EXTENDED RELEASE ORAL *Androgens-Anabolic* ANADROL-50 TABLET 50 ORAL 50 ANDRODERM TCH 24 HOUR 2 /24HR TRANSDERMAL 2 /24HR QL (180 EA per 30 days) QL (180 EA per 30 days) QL (180 EA per 30 days) QL (180 EA per 30 days) 14

23 ANDRODERM TCH 24 HOUR 4 /24HR TRANSDERMAL 4 /24HR ANDROGEL GEL /1.25GM (1.62%) TRANSDERMAL /1.25GM (1.62%) ANDROGEL GEL 40.5 /2.5GM (1.62%) TRANSDERMAL 40.5 /2.5GM (1.62%) ANDROGEL PUMP GEL /ACT (1.62%) TRANSDERMAL /ACT (1.62%) ANDROXY TABLET 10 ORAL 10 AXIRON SOLUTION 30 /ACT TRANSDERMAL 30 /ACT methitest tablet 10 mg oral 10 mg oxandrolone tablet 10 mg oral 10 mg oxandrolone tablet 2.5 mg oral 2.5 mg testosterone cypionate solution 100 mg/ml intramuscular 100 mg/ml testosterone cypionate solution 200 mg/ml intramuscular 200 mg/ml testosterone gel 25 mg/2.5gm (1%) transdermal 25 mg/2.5gm (1%) testosterone solution 30 mg/act transdermal 30 mg/act *Anorectal Agents* ANALPRAM-HC LOTION % RECTAL % anucort-hc suppository 25 mg rectal 25 mg QL (12 EA per 30 days) COLOCORT ENEMA 100 /60ML RECTAL 100 /60ML CORTIFOAM FOAM 10 % RECTAL 10 % hydrocortisone ace-pramoxine cream % rectal % hydrocortisone ace-pramoxine kit & 1 % rectal & 1 % hydrocortisone acetate suppository 30 mg rectal 30 mg lidocaine-hydrocortisone ace gel % rectal % lidocaine-hydrocortisone ace kit 2-2 % rectal 2-2 % lidocaine-hydrocortisone ace kit % rectal % QL (12 EA per 30 days) 15

24 lidocaine-hydrocortisone ace kit 3-1 % rectal 3-1 % lidocaine-hydrocortisone ace kit % rectal % pramcort cream 1-1 % rectal 1-1 % QL (60 GM per 30 days) PROCTOFOAM HC FOAM 1-1 % RECTAL 1-1 % PROCTOZONE-HC CREAM 2.5 % RECTAL 2.5 % RECTIV OINTMENT 0.4 % RECTAL 0.4 % *Anthelmintics* ALBENZA TABLET 200 ORAL 200 ivermectin tablet 3 mg oral 3 mg QL (10 EA per 30 days) mebendazole tablet chewable 100 mg oral 100 mg PIN-X TABLET CHEWABLE ORAL reeses pinworm medicine suspension 144 mg/ml oral 144 mg/ml *Antianginal Agents* DILATRATE-SR CAPSULE EXTENDED RELEASE 40 ORAL 40 isosorbide dinitrate er tablet extended release 40 mg oral 40 mg isosorbide dinitrate tablet 10 mg oral 10 mg isosorbide dinitrate tablet 20 mg oral 20 mg isosorbide dinitrate tablet 30 mg oral 30 mg isosorbide dinitrate tablet 5 mg oral 5 mg isosorbide mononitrate er tablet extended release 24 hour 120 mg oral 120 mg isosorbide mononitrate er tablet extended release 24 hour 30 mg oral 30 mg isosorbide mononitrate er tablet extended release 24 hour 60 mg oral 60 mg isosorbide mononitrate tablet 10 mg oral 10 mg isosorbide mononitrate tablet 20 mg oral 20 mg NITRO-BID OINTMENT 2 % TRANSDERMAL 2 % NITRO-DUR TCH 24 HOUR 0.3 /HR TRANSDERMAL 0.3 /HR NITRO-DUR TCH 24 HOUR 0.8 /HR TRANSDERMAL 0.8 /HR 16

25 nitroglycerin er capsule extended release 2.5 mg oral 2.5 mg nitroglycerin patch 24 hour 0.1 mg/hr transdermal 0.1 mg/hr nitroglycerin patch 24 hour 0.2 mg/hr transdermal 0.2 mg/hr nitroglycerin patch 24 hour 0.4 mg/hr transdermal 0.4 mg/hr nitroglycerin patch 24 hour 0.6 mg/hr transdermal 0.6 mg/hr nitroglycerin solution 0.4 mg/spray translingual 0.4 mg/spray nitroglycerin sublingual tablet sublingual 0.3 mg, 0.4 mg, 0.6 mg NITRO-TIME CAPSULE EXTENDED RELEASE 6.5 ORAL 6.5 NITRO-TIME CAPSULE EXTENDED RELEASE 9 ORAL 9 RANEXA TABLET EXTENDED RELEASE 12 HOUR 1000 ORAL 1000 RANEXA TABLET EXTENDED RELEASE 12 HOUR 500 ORAL 500 *Antianxiety Agents* alprazolam er tablet extended release 24 hour 1 mg oral 1 mg alprazolam er tablet extended release 24 hour 2 mg oral 2 mg AL (Max 64 Years) AL (Max 64 Years) alprazolam tablet 0.25 mg oral 0.25 mg AL (Max 64 Years) alprazolam tablet 0.5 mg oral 0.5 mg AL (Max 64 Years) alprazolam tablet 1 mg oral 1 mg AL (Max 64 Years) alprazolam tablet 2 mg oral 2 mg AL (Max 64 Years) alprazolam tablet dispersible 0.25 mg oral 0.25 mg AL (Max 64 Years) alprazolam tablet dispersible 0.5 mg oral 0.5 mg AL (Max 64 Years) alprazolam tablet dispersible 1 mg oral 1 mg AL (Max 64 Years) alprazolam tablet dispersible 2 mg oral 2 mg AL (Max 64 Years) alprazolam xr tablet extended release 24 hour 0.5 mg oral 0.5 mg alprazolam xr tablet extended release 24 hour 3 mg oral 3 mg buspirone hcl tablet 10 mg oral 10 mg buspirone hcl tablet 15 mg oral 15 mg AL (Max 64 Years) AL (Max 64 Years) 17

26 buspirone hcl tablet 30 mg oral 30 mg buspirone hcl tablet 5 mg oral 5 mg buspirone hcl tablet 7.5 mg oral 7.5 mg chlordiazepoxide hcl capsule 10 mg oral 10 mg AL (Max 64 Years) chlordiazepoxide hcl capsule 25 mg oral 25 mg AL (Max 64 Years) chlordiazepoxide hcl capsule 5 mg oral 5 mg AL (Max 64 Years) clorazepate dipotassium tablet 15 mg oral 15 mg AL (Max 64 Years) clorazepate dipotassium tablet 3.75 mg oral 3.75 mg AL (Max 64 Years) clorazepate dipotassium tablet 7.5 mg oral 7.5 mg AL (Max 64 Years) diazepam solution 1 mg/ml oral 1 mg/ml AL (Max 64 Years) diazepam solution 5 mg/ml injection 5 mg/ml AL (Max 64 Years) diazepam tablet 10 mg oral 10 mg AL (Max 64 Years) diazepam tablet 2 mg oral 2 mg AL (Max 64 Years) diazepam tablet 5 mg oral 5 mg AL (Max 64 Years) droperidol solution 2.5 mg/ml injection 2.5 mg/ml hydroxyzine hcl solution 25 mg/ml intramuscular 25 mg/ml hydroxyzine hcl solution 50 mg/ml intramuscular 50 mg/ml AL (Max 64 Years) AL (Max 64 Years) hydroxyzine hcl syrup 10 mg/5ml oral 10 mg/5ml AL (Max 64 Years) hydroxyzine hcl tablet 10 mg oral 10 mg AL (Max 64 Years) hydroxyzine hcl tablet 25 mg oral 25 mg AL (Max 64 Years) hydroxyzine hcl tablet 50 mg oral 50 mg AL (Max 64 Years) hydroxyzine pamoate capsule 100 mg oral 100 mg AL (Max 64 Years) hydroxyzine pamoate capsule 25 mg oral 25 mg AL (Max 64 Years) hydroxyzine pamoate capsule 50 mg oral 50 mg AL (Max 64 Years) LORAZEM INTENSOL CONCENTRATE 2 /ML ORAL 2 /ML lorazepam solution 2 mg/ml injection 2 mg/ml lorazepam solution 4 mg/ml injection 4 mg/ml lorazepam tablet 0.5 mg oral 0.5 mg lorazepam tablet 1 mg oral 1 mg lorazepam tablet 2 mg oral 2 mg meprobamate tablet 200 mg oral 200 mg AL (Max 64 Years) meprobamate tablet 400 mg oral 400 mg AL (Max 64 Years) oxazepam capsule 10 mg oral 10 mg oxazepam capsule 15 mg oral 15 mg 18

27 oxazepam capsule 30 mg oral 30 mg *Antiarrhythmics* amiodarone hcl tablet 200 mg oral 200 mg disopyramide phosphate capsule 100 mg oral 100 mg disopyramide phosphate capsule 150 mg oral 150 mg dofetilide capsule 125 mcg oral 125 mcg dofetilide capsule 250 mcg oral 250 mcg dofetilide capsule 500 mcg oral 500 mcg flecainide acetate tablet 100 mg oral 100 mg flecainide acetate tablet 150 mg oral 150 mg flecainide acetate tablet 50 mg oral 50 mg mexiletine hcl capsule 150 mg oral 150 mg mexiletine hcl capsule 200 mg oral 200 mg mexiletine hcl capsule 250 mg oral 250 mg MULTAQ TABLET 400 ORAL 400 NORCE CR CAPSULE EXTENDED RELEASE 12 HOUR 100 ORAL 100 CERONE TABLET 100 ORAL 100 CERONE TABLET 400 ORAL 400 propafenone hcl er capsule extended release 12 hour 225 mg oral 225 mg propafenone hcl er capsule extended release 12 hour 325 mg oral 325 mg propafenone hcl er capsule extended release 12 hour 425 mg oral 425 mg propafenone hcl tablet 150 mg oral 150 mg propafenone hcl tablet 225 mg oral 225 mg propafenone hcl tablet 300 mg oral 300 mg quinidine gluconate er tablet extended release 324 mg oral 324 mg quinidine sulfate er tablet extended release 300 mg oral 300 mg quinidine sulfate tablet 200 mg oral 200 mg quinidine sulfate tablet 300 mg oral 300 mg 19

28 *Antiasthmatic And Bronchodilator Agents* ADVAIR DISKUS AEROSOL POWDER BREATH ACTIVATED MCG/DOSE INHALATION MCG/DOSE ADVAIR DISKUS AEROSOL POWDER BREATH ACTIVATED MCG/DOSE INHALATION MCG/DOSE ADVAIR DISKUS AEROSOL POWDER BREATH ACTIVATED MCG/DOSE INHALATION MCG/DOSE ADVAIR HFA AEROSOL MCG/ACT INHALATION MCG/ACT ADVAIR HFA AEROSOL MCG/ACT INHALATION MCG/ACT ADVAIR HFA AEROSOL MCG/ACT INHALATION MCG/ACT AEROSN AEROSOL SOLUTION 80 MCG/ACT INHALATION 80 MCG/ACT albuterol sulfate er tablet extended release 12 hour 4 mg oral 4 mg albuterol sulfate er tablet extended release 12 hour 8 mg oral 8 mg albuterol sulfate nebulization solution (2.5 mg/3ml) 0.083% inhalation (2.5 mg/3ml) 0.083% albuterol sulfate nebulization solution (5 mg/ml) 0.5% inhalation (5 mg/ml) 0.5% albuterol sulfate nebulization solution 0.63 mg/3ml inhalation 0.63 mg/3ml albuterol sulfate nebulization solution 1.25 mg/3ml inhalation 1.25 mg/3ml albuterol sulfate syrup 2 mg/5ml oral 2 mg/5ml aminophylline solution 25 mg/ml intravenous 25 mg/ml ANORO ELLIPTA AEROSOL POWDER BREATH ACTIVATED MCG/INH INHALATION MCG/INH ARCAPTA NEOHALER CAPSULE 75 MCG INHALATION 75 MCG ARNUITY ELLIPTA AEROSOL POWDER BREATH ACTIVATED 100 MCG/ACT INHALATION 100 MCG/ACT QL (60 EA per 30 days) QL (60 EA per 30 days) QL (60 EA per 30 days) QL (12 GM per 30 days) QL (12 GM per 30 days) QL (12 GM per 30 days) QL (8.9 GM per 30 days) ; 20

29 ARNUITY ELLIPTA AEROSOL POWDER BREATH ACTIVATED 200 MCG/ACT INHALATION 200 MCG/ACT ASMANEX 120 METERED DOSES AEROSOL POWDER BREATH ACTIVATED 220 MCG/INH INHALATION 220 MCG/INH ASMANEX 7 METERED DOSES AEROSOL POWDER BREATH ACTIVATED 110 MCG/INH INHALATION 110 MCG/INH ATROVENT HFA AEROSOL SOLUTION 17 MCG/ACT INHALATION 17 MCG/ACT BREO ELLIPTA AEROSOL POWDER BREATH ACTIVATED MCG/INH INHALATION MCG/INH BREO ELLIPTA AEROSOL POWDER BREATH ACTIVATED MCG/INH INHALATION MCG/INH BROVANA NEBULIZATION SOLUTION 15 MCG/2ML INHALATION 15 MCG/2ML budesonide suspension 0.25 mg/2ml inhalation 0.25 mg/2ml budesonide suspension 0.5 mg/2ml inhalation 0.5 mg/2ml budesonide suspension 1 mg/2ml inhalation 1 mg/2ml COMBIVENT RESPIMAT AEROSOL SOLUTION MCG/ACT INHALATION MCG/ACT DALIRESP TABLET 500 MCG ORAL 500 MCG DULERA AEROSOL MCG/ACT INHALATION MCG/ACT DULERA AEROSOL MCG/ACT INHALATION MCG/ACT ELIXOPHYLLIN ELIXIR 80 /15ML ORAL 80 /15ML FLOVENT DISKUS AEROSOL POWDER BREATH ACTIVATED 100 MCG/BLIST INHALATION 100 MCG/BLIST FLOVENT DISKUS AEROSOL POWDER BREATH ACTIVATED 250 MCG/BLIST INHALATION 250 MCG/BLIST QL (1 EA per 30 days) QL (1 EA per 30 days) QL (12.9 GM per 30 days) QL (60 EA per 30 days) QL (60 EA per 30 days) ; QL (120 ML per 30 days) QL (120 ML per 30 days); AL (Max 6 Years) QL (120 ML per 30 days); AL (Max 6 Years) QL (120 ML per 30 days); AL (Max 6 Years) QL (4 GM per 30 days) QL (13 GM per 30 days) QL (13 GM per 30 days) QL (60 EA per 30 days) QL (60 EA per 30 days) 21

30 FLOVENT DISKUS AEROSOL POWDER BREATH ACTIVATED 50 MCG/BLIST INHALATION 50 MCG/BLIST FLOVENT HFA AEROSOL 110 MCG/ACT INHALATION 110 MCG/ACT FLOVENT HFA AEROSOL 220 MCG/ACT INHALATION 220 MCG/ACT FLOVENT HFA AEROSOL 44 MCG/ACT INHALATION 44 MCG/ACT fluticasone-salmeterol aerosol powder breath activated mcg/act inhalation mcg/act fluticasone-salmeterol aerosol powder breath activated mcg/act inhalation mcg/act fluticasone-salmeterol aerosol powder breath activated mcg/act inhalation mcg/act FORADIL AEROLIZER CAPSULE 12 MCG INHALATION 12 MCG INCRUSE ELLIPTA AEROSOL POWDER BREATH ACTIVATED 62.5 MCG/INH INHALATION 62.5 MCG/INH ipratropium bromide solution 0.02 % inhalation 0.02 % ipratropium-albuterol solution (3) mg/3ml inhalation (3) mg/3ml levalbuterol hcl nebulization solution 0.31 mg/3ml inhalation 0.31 mg/3ml levalbuterol hcl nebulization solution 0.63 mg/3ml inhalation 0.63 mg/3ml levalbuterol hcl nebulization solution 1.25 mg/0.5ml inhalation 1.25 mg/0.5ml levalbuterol tartrate aerosol 45 mcg/act inhalation 45 mcg/act metaproterenol sulfate syrup 10 mg/5ml oral 10 mg/5ml metaproterenol sulfate tablet 10 mg oral 10 mg metaproterenol sulfate tablet 20 mg oral 20 mg montelukast sodium packet 4 mg oral 4 mg montelukast sodium tablet 10 mg oral 10 mg montelukast sodium tablet chewable 4 mg oral 4 mg montelukast sodium tablet chewable 5 mg oral 5 mg 22 QL (60 EA per 30 days) QL (12 GM per 30 days) QL (12 GM per 30 days) QL (10.6 GM per 30 days) QL (1 EA per 30 days) QL (1 EA per 30 days) QL (1 EA per 30 days) QL (60 EA per 30 days) ST ST ST QL (15 GM per 30 days)

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