AETNA BETTER HEALTH OF NEW JERSEY Formulary

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1 AETNA BETTER HEALTH OF NEW JERSEY Formulary NJ

2 FORMULARY What is the Aetna Better Health of New Jersey Formulary? This is a drug list created by Aetna Better Health of New Jersey ( plan ). Aetna Better Health of New Jersey will cover drugs on this list. Some drugs may have coverage rules. If the rules for that drug are met, Aetna Better Health of New Jersey will cover the drug. Drugs must also be filled at an Aetna Better Health of New Jersey network pharmacy. Can Aetna Better Health of New Jersey s Drug List change? The plan may add or remove drugs on the list. All drug removals from the formulary will be sent to the state for review before the change is made. Utilizing members and their providers will be notified at least 60 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 Aetna Better Health of New Jersey 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, Ear-Nose-Throat Medications. If you know what your drug is used for, please look for that section name on the drug list. Then look under that section for your drug. How much will I pay for covered drugs? Description 1-34 day supply GENERIC 1-34 day supply BRAND day supply GENERIC (mailorder only) day supply BRAND (mailorder only) FamilyCare Plan A No Copay No Copay No Copay No Copay FamilyCare Plan B No Copay No Copay No Copay No Copay FamilyCare Plan C $1 $5 $2 $10 FamilyCare Plan D $5 $5 $10 $10 FamilyCare Plan MLTSS No Copay No Copay No Copay No Copay American Indians and Alaska Native members will NOT have a copay. Page 1

3 FORMULARY What are some types of coverage rules? Prior Approval (): This means your doctor will need to get approval from the plan first before the drug can be filled at the pharmacy. If it is not approved, the plan will not cover the drug. Quantity Level Limits (QLL): This means there is a limit on the amount of drug the plan will cover. For example, the plan provides 60 pills in 30 days for some drugs. Step Therapy (ST): This means you may need to try certain drugs first to treat your condition. After the first drug is tried, the plan will then cover the other drug for that same condition. For example, Drug A and Drug B may treat your condition. The plan may not cover Drug B unless you try Drug A first. If Drug A does not work for you, then Drug B will be covered. What if my drug is not on Aetna Better Health of New Jersey s formulary? First, please call your doctor and ask if your drug is covered. If the plan does not cover the drug, then: Ask your doctor for a similar drug that is covered. Your doctor can ask the plan to cover your drug through the prior approval process. What are generic drugs? Aetna Better Health covers both brand and generic drugs. Generic drugs cost less and are approved by the Food and Drug Administration (FDA). Are Over-The-Counter () drugs covered? The plan will cover drugs on the formulary. Some drugs may have coverage rules. If the rules for that drug are met, the plan will cover the drug. Like other drugs, drugs need a prescription from a doctor if they are to be covered by the plan. Page 2

4 Qué es el formulario de Aetna Better Health of New Jersey? Es una lista de medicamentos creada por Aetna Better Health of New Jersey (el plan ). Aetna Better Health of New Jersey ofrece cobertura para los medicamentos de esta lista. Es posible que para algunos medicamentos se apliquen reglas de cobertura. Si se cumplen las reglas para esos medicamentos, Aetna Better Health of New Jersey los cubrirá. Además, los medicamentos deben adquirirse en una farmacia de la red de Aetna Better Health of New Jersey. Puede cambiar la lista de medicamentos de Aetna Better Health of New Jersey? El plan puede agregar o quitar medicamentos de la lista. Todas las eliminaciones de medicamentos del formulario se enviarán al estado, donde se revisarán antes de que se realice el cambio. Los miembros y proveedores que utilizan el formulario recibirán un aviso como mínimo 60 días antes de que se elimine un medicamento del formulario. Encontrará todos los cambios del formulario en el sitio en Internet del plan. Cómo utilizo el formulario de Aetna Better Health of New Jersey? Columna Nº 1: enumera los medicamentos cubiertos. Los medicamentos de marca aparecen en mayúscula (por ejemplo, MEDICAMENTO); los genéricos aparecen en minúscula (por ejemplo, medicamento). Columna Nº 2: enumera los medicamentos de marca cuando una opción genérica está cubierta. Columna Nº 3: muestra las reglas de cobertura de los medicamentos. Los medicamentos también están agrupados según el tipo de condición que tratan. Por ejemplo, los medicamentos que se usan para tratar un dolor de oído figuran en la sección, Ear Nose-Throat Medications. Si sabe para qué se usa el medicamento que usted toma, busque el nombre de esa sección en la lista de medicamentos y luego busque el medicamento en esa sección. Cuánto pagaré por los medicamentos cubiertos? Descripción Suministro para 1-34 días (GENÉRICOS) Suministro para 1-34 días (DE MARCA) Suministro para días (GENÉRICOS) Suministro para días (DE MARCA) FamilyCare Plan A Sin copago Sin copago Sin copago Sin copago FamilyCare Plan B Sin copago Sin copago Sin copago Sin copago FamilyCare Plan C $1 $5 $2 $10 FamilyCare Plan D $5 $5 $10 $10 FamilyCare Plan MLTSS Sin copago Sin copago Sin copago Sin copago Page 3

5 Los miembros que sean indígenas americanos o nativos de Alaska NO tienen copago. Cuáles son algunos de los tipos de reglas de cobertura? Aprobación previa (): significa que su médico primero deberá obtener la aprobación del plan antes de que se pueda adquirir el medicamento en la farmacia. Si no se aprueba, el plan no cubrirá el medicamento. Límites de cantidad (QLL): significa que el plan cubre hasta una cierta cantidad del medicamento. Por ejemplo, en el caso de algunos medicamentos, el plan cubre 60 píldoras en 30 días. Terapia escalonada (ST): significa que posiblemente primero deba probar ciertos medicamentos para tratar su condición. Después de probar el primer medicamento, el plan cubrirá el otro medicamento para la misma condición. Por ejemplo, el Medicamento A y el Medicamento B pueden tratar su condición. Es posible que el plan no cubra el Medicamento B a menos que usted primero pruebe el Medicamento A. Si el Medicamento A no funciona en su caso, entonces se cubrirá el Medicamento B. Qué sucede si el medicamento que tomo no está incluido en el formulario de Aetna Better Health of New Jersey? Primero, llame a su médico y pregúntele si su medicamento está cubierto. Si el plan no lo cubre, usted tiene dos opciones: Pida a su médico un medicamento similar que esté cubierto. Su médico puede solicitar que el plan cubra el medicamento a través del proceso de aprobación previa. Qué son los medicamentos genéricos? Aetna Better Health of New Jersey cubre tanto medicamentos de marca como genéricos. Los medicamentos genéricos cuestan menos y están aprobados por la Administración de Drogas y Alimentos (FDA). Los medicamentos de venta libre están cubiertos? El plan cubrirá los medicamentos de venta libre que figuren en el formulario. Es posible que para algunos medicamentos de venta libre se apliquen reglas de cobertura. Si se cumplen las reglas para esos medicamentos de venta libre, el plan los cubrirá. Al igual que con otros medicamentos, se requiere una receta del médico para que el plan brinde cobertura para los medicamentos de venta libre. Page 4

6 Aetna Better Health New Jersey Table of Contents *ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS*...3 *AMINOGLYCOSIDES*... 5 *ANALGESICS - ANTI-INFLAMMATORY*... 5 *ANALGESICS - NONNARCOTIC*...7 *ANALGESICS - OPIOID*... 8 *ANDROGENS-ANABOLIC* *ANORECTAL AGENTS*...11 *ANTACIDS*...11 *ANTHELMINTICS* *ANTIANGINAL AGENTS* *ANTIANXIETY AGENTS*...13 *ANTIARRHYTHMICS* *ANTIASTHMATIC AND BRONCHODILATOR AGENTS* *ANTICOAGULANTS* *ANTICONVULSANTS*...17 *ANTIDEPRESSANTS*...19 *ANTIDIABETICS* *ANTIDIARRHEALS*...24 *ANTIDOTES AND SPECIFIC ANTAGONISTS*...25 *ANTIDOTES* *ANTIEMETICS* *ANTIFUNGALS*...25 *ANTIHISTAMINES* *ANTIHYPERLIPIDEMICS*...27 *ANTIHYPERTENSIVES* *ANTI-INFECTIVE AGENTS - MISC.* *ANTIMALARIALS*...32 *ANTIMYASTHENIC AGENTS* *ANTIMYCOBACTERIAL AGENTS* *ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES*...32 *ANTIRKINSON AGENTS*...35 *ANTIPSYCHOTICS/ANTIMANIC AGENTS* *ANTISEPTICS & DISINFECTANTS*...38 *ANTIVIRALS*...38 *ASSORTED CLASSES* *BETA BLOCKERS* *CALCIUM CHANNEL BLOCKERS* *CARDIOTONICS* *CARDIOVASCULAR AGENTS - MISC.* *CEPHALOSPORINS*...45 *CHEMICALS*...46 *CONTRACEPTIVES*...46 *CORTICOSTEROIDS* *COUGH/COLD/ALLERGY*...53 *DERMATOLOGICALS* *DIAGNOSTIC PRODUCTS*...63 *DIGESTIVE AIDS*

7 *DIURETICS*...64 *ENDOCRINE AND METABOLIC AGENTS - MISC.*...65 *ESTROGENS*...66 *FLUOROQUINOLONES* *GASTROINTESTINAL AGENTS - MISC.*...67 *GENITOURINARY AGENTS - MISCELLANEOUS* *GOUT AGENTS*...69 *HEMATOLOGICAL AGENTS - MISC.* *HEMATOPOIETIC AGENTS*...70 *HEMOSTATICS*...72 *HETITIS C AGENT - COMBINATIONS*** *HYPNOTICS* *LAXATIVES* *MACROLIDES*...74 *MEDICAL DEVICES*...75 *MIGRAINE PRODUCTS*...82 *MINERALS & ELECTROLYTES*...82 *MOUTH/THROAT/DENTAL AGENTS*...85 *MULTIVITAMINS*...86 *MUSCULOSKELETAL THERAPY AGENTS*...90 *NASAL AGENTS - SYSTEMIC AND TOPICAL* *NEPRILYSIN INHIB (ARNI)-ANGIOTENSIN II RECEPT ANTAG COMB*** *NEUROMUSCULAR AGENTS* *NUTRIENTS*...92 *OPHTHALMIC AGENTS*...92 *OTIC AGENTS*...96 *PENICILLINS*...96 *PHARMACEUTICAL ADJUVANTS* *POTASSIUM REMOVING AGENTS***...98 *PROGESTINS*...98 *PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.*...98 *RESPIRATORY AGENTS - MISC.* *SINUS NODE INHIBITORS** *SODIUM-GLUCOSE CO-TRANSPORTER 2 INHIBITOR-BIGUANIDE COMB*** *SULFONAMIDES* *TETRACYCLINES* *THYROID AGENTS* *ULCER DRUGS* *URINARY ANTI-INFECTIVES* *URINARY ANTISSMODICS* *VAGINAL PRODUCTS* *VASOPRESSORS* *VITAMINS*

8 Aetna Better Health New Jersey lowercase italics = Generic drugs UPPERCASE BOLD = Brand name drugs Restrictions = QLL: 1 capsule per day for under age 12 and 2 capsules per day for age 12 and older = Maximum qty of 360 tablets per 365 days (6 months of therapy per year) = QLL AL = Age Limit Applies F = Female Only M = Male Only = Over the Counter = Prior Authorization Required QLL = Quantity Level Limit Applies ST = Step Therapy Required Drug Name Reference Restrictions *ADHD/ANTI- NARCOLEPSY/ANTI- OBESITY/ANOREXIANTS* *Adhd Agent - Selective Alpha Adrenergic Agonists*** guanfacine hcl er oral tablet extended release 24 hour 1, 2, 3 guanfacine hcl er oral tablet extended release 24 hour 4 *Adhd Agent - Selective Norepinephrine Reuptake Inhibitor*** atomoxetine hcl oral capsule 10, 100, 18, 25, 40, 60, 80 *Amphetamine Mixtures*** amphetamine-dextroamphet er oral capsule extended release 24 hour 10, 15, 20, 25, 5 amphetamine-dextroamphet er oral capsule extended release 24 hour 30 Intuniv Intuniv Strattera Adderall XR Adderall XR QLL (30 EA per 30 days); AL (Min 6 Years) QLL (30 Tablets per 30 days); AL (Min 6 Years) ST; QLL (30 EA per 30 days) QLL (30 Capsules per 30 days); AL (Min 6 Years and Max 18 Years) QLL: 1 capsule per day for under age 12 and 2 capsules per day for age 12 and older; QLL (60 EA per 30 days); AL (Min 6 Years and Max 18 Years) 3

9 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 Adderall Adderall Dexedrine Dexedrine Zenzedi QLL (90 Tablets per 30 days); AL (Min 6 Years and Max 18 Years) QLL (60 Tablets per 30 days); AL (Min 6 Years and Max 18 Years) QLL (120 EA per 30 days); AL (Min 6 Years and Max 18 Years) QLL (90 EA per 30 days); AL (Min 6 Years) QLL (180 EA per 30 days); AL (Min 6 Years and Max 18 Years) *Analeptics*** caffeine citrate oral solution 20 /ml, 60 /3ml *Stimulants - Misc.*** armodafinil oral tablet 150, 200, 250 Nuvigil ; QLL (30 EA per 30 days) armodafinil oral tablet 50 Nuvigil ; QLL (60 EA per 30 days) 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 METADATE ER ORAL TABLET EXTENDED RELEASE 20 MG 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 methylphenidate hcl er (la) oral capsule extended release 24 hour 30 methylphenidate hcl er (la) oral capsule extended release 24 hour 60 Focalin XR Focalin Metadate ER Ritalin LA Ritalin LA QLL (30 EA per 30 days); AL (Min 6 Years and Max 18 Years) QLL (60 Tablets per 30 days); AL (Min 6 Years and Max 18 Years) QLL (90 EA per 30 days); AL (Min 6 Years and Max 18 Years) QLL (30 Capsules per 30 days); AL (Min 6 Years and Max 18 Years) QLL (30 EA per 30 days); AL (Min 6 Years and Max 18 Years) QLL (60 EA per 30 days); AL (Min 6 Years and Max 18 Years) QLL (30 EA per 30 days); AL (Min 6 Years and Max 18 Years) 4

10 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 36 methylphenidate hcl oral solution 10 /5ml, 5 /5ml methylphenidate hcl oral tablet 10, 20, 5 Concerta Metadate ER Concerta Methylin Ritalin *AMINOGLYCOSIDES* *Aminoglycosides*** KITABIS K INHALATION NEBULIZATION SOLUTION 300 Tobramycin MG/5ML neomycin sulfate oral tablet 500 paromomycin sulfate oral capsule 250 *ANALGESICS - ANTI- INFLAMMATORY* *Anti-Tnf-Alpha - Monoclonoal Antibodies*** HUMIRA PEN-CROHNS STARTER SUBCUTANEOUS PEN-INJECTOR KIT 40 MG/0.8ML HUMIRA SUBCUTANEOUS PREFILLED SYRINGE KIT 10 MG/0.2ML, 20 MG/0.4ML, 40 MG/0.8ML *Cyclooxygenase 2 (Cox-2) Inhibitors*** celecoxib oral capsule 100, 200, 400 CeleBREX, 50 *Gold Compounds*** RIDAURA ORAL CAPSULE 3 MG QLL (90 EA per 30 days); AL (Min 6 Years and Max 18 Years) QLL (30 Tablets per 30 days); AL (Min 6 Years and Max 18 Years) QLL (90 EA per 30 days); AL (Min 6 Years and Max 18 Years) QLL (60 Tablets per 30 days); AL (Min 6 Years and Max 18 Years) QLL (900 ML per 30 days); AL (Min 6 Years and Max 18 Years) QLL (90 Tablets per 30 days); AL (Min 6 Years and Max 18 Years) ST 5

11 *Nonsteroidal Anti-Inflammatory Agents (Nsaids)*** childrens ibuprofen 100 oral suspension 100 /5ml Childrens Advil childrens ibuprofen oral suspension 40 /ml Infants Advil cvs naproxen sodium oral tablet 220 Aleve 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 etodolac oral capsule 200, 300 etodolac oral tablet 400 Lodine etodolac oral tablet 500 fenoprofen calcium oral tablet 600 ProFeno flurbiprofen oral tablet 100, 50 ibuprofen junior strength oral tablet chewable Advil Junior Strength 100 ibuprofen oral capsule 200 Advil ibuprofen oral tablet 200 Advil ibuprofen oral tablet 400, 600, 800 indomethacin er oral capsule extended release 75 indomethacin oral capsule 25, 50 ketoprofen er oral capsule extended release 24 hour 200 ketoprofen oral capsule 50, 75 ketorolac tromethamine oral tablet 10 QLL (20 EA per 30 days) meclofenamate sodium oral capsule 100, 50 meloxicam oral tablet 15, 7.5 Mobic nabumetone oral tablet 500, 750 naproxen dr oral tablet delayed release 375, 500 EC-Naprosyn naproxen oral suspension 125 /5ml Naprosyn ST naproxen oral tablet 250, 500 Naprosyn naproxen oral tablet 375 naproxen sodium oral capsule 220 Aleve 6

12 naproxen sodium oral tablet 275 oxaprozin oral tablet 600 Daypro piroxicam oral capsule 10, 20 Feldene sm ibuprofen jr oral tablet 100 Advil Junior Strength 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 ENBREL SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 25 MG/0.5ML, 50 MG/ML ENBREL SURECLICK SUBCUTANEOUS SOLUTION AUTO-INJECTOR 50 MG/ML *ANALGESICS - NONNARCOTIC* *Analgesics Other*** ACEPHEN RECTAL SUPPOSITORY 325 MG acetaminophen er oral tablet extended release Midol 650 acetaminophen extra strength oral liquid 500 /15ml Chloraseptic Sore Throat acetaminophen oral liquid 160 /5ml Little Remedies for Fever acetaminophen oral solution 160 /5ml acetaminophen oral suspension 160 /5ml Mapap Childrens acetaminophen oral tablet 325 Pharbetol acetaminophen oral tablet 500 Healthy Mama Shake That Ache acetaminophen oral tablet chewable 80 Childrens Medi-Tabs acetaminophen rectal suppository 120, 650 Acephen childrens acetaminophen oral tablet dispersible 80 Mapap Childrens non-aspirin jr strength oral tablet chewable 160 Mapap Childrens 7

13 TRIAMINIC FEVER REDUCER ORAL SYRUP 160 MG/5ML *Analgesics-Sedatives*** butalbital-apap-caffeine oral capsule Capacet QLL (180 Capsules per 30 days) butalbital-apap-caffeine oral tablet Esgic QLL (180 Tablets per 30 days) butalbital-aspirin-caffeine oral capsule Fiorinal QLL (180 Tablets per 30 days) ZEBUTAL ORAL CAPSULE MG Capacet QLL (180 Capsules per 30 days) *Salicylate Combinations*** choline-mag trisalicylate oral liquid 500 /5ml effervescent pain relief oral tablet effervescent Alka-Seltzer 325 *Salicylates*** aspirin ec oral tablet delayed release 325 Bayer Aspirin Regimen aspirin oral tablet 325 Bayer Advanced Aspirin Reg St aspirin oral tablet chewable 81 Bayer Low Dose aspirin oral tablet delayed release 81 Aspir-Low aspirtab maximum strength oral tablet 500 Bayer Advanced Aspirin Ex St diflunisal oral tablet 500 salsalate oral tablet 500, 750 *ANALGESICS - OPIOID* *Codeine Combinations*** acetaminophen-codeine #2 oral tablet QLL (4 EA per 1 day) acetaminophen-codeine #3 oral tablet Tylenol with Codeine #3 QLL (4 EA per 1 day) acetaminophen-codeine #4 oral tablet Tylenol with Codeine #4 QLL (4 EA per 1 day) acetaminophen-codeine oral solution /5ml QLL (90 ML per 1 day) acetaminophen-codeine oral tablet QLL (4 EA per 1 day) acetaminophen-codeine oral tablet Tylenol with Codeine #4 QLL (4 EA per 1 day) ASCOMP-CODEINE ORAL CAPSULE MG Ascomp-Codeine QLL (4 Capsules per 1 day) butalbital-apap-caff-cod oral capsule QLL (4 Capsules per 1 day) 8

14 butalbital-asa-caff-codeine oral capsule Ascomp-Codeine QLL (4 Capsules per 1 day) *Hydrocodone Combinations*** hydrocodone-acetaminophen oral solution /5ml, /10ml, Hycet QLL (60 ML per 1 day) /15ml hydrocodone-acetaminophen oral tablet Lorcet HD QLL (4 EA per 1 day) hydrocodone-acetaminophen oral tablet Lorcet QLL (4 EA per 1 day) hydrocodone-acetaminophen oral tablet Lorcet Plus QLL (4 EA per 1 day) hydrocodone-ibuprofen oral tablet , Ibudone QLL (4 Tablets per 1 day) hydrocodone-ibuprofen oral tablet QLL (4 Tablets per 1 day) *Opioid Agonists*** codeine sulfate oral tablet 15, 30, 60 QLL (4 Tablets per 1 day) fentanyl citrate buccal lozenge on a handle 1200 mcg, 1600 mcg, 200 mcg, 400 mcg, 600 mcg, 800 mcg fentanyl transdermal patch 72 hour 100 mcg/hr Actiq Duragesic-100 fentanyl transdermal patch 72 hour 12 mcg/hr Duragesic-12 fentanyl transdermal patch 72 hour 25 mcg/hr Duragesic-25 fentanyl transdermal patch 72 hour 50 mcg/hr Duragesic-50 fentanyl transdermal patch 72 hour 75 mcg/hr Duragesic-75 ; QLL (4 Lozenges per 1 day) ; QLL (10 Patches per 30 days) ; QLL (10 Patches per 30 days) ; QLL (10 Patches per 30 days) ; QLL (10 Patches per 30 days) ; QLL (10 Patches per 30 days) hydromorphone hcl oral tablet 2, 4 Dilaudid QLL (4 Tablets per 1 day) hydromorphone hcl oral tablet 8 Dilaudid QLL (2 Tablets per 1 day) hydromorphone hcl rectal suppository 3 QLL (4 EA per 1 day) methadone hcl oral concentrate 10 /ml Methadone HCl Intensol ; QLL (3 ML per 1 day) methadone hcl oral solution 10 /5ml ; QLL (15 ML per 1 day) methadone hcl oral solution 5 /5ml ; QLL (30 ML per 1 day) methadone hcl oral tablet 10 Dolophine ; QLL (3 Tablets per 1 day) methadone hcl oral tablet 5 Dolophine ; QLL (6 Tablets per 1 day) methadone hcl oral tablet soluble 40 Methadose ; QLL (22 Tablets per 30 days) 9

15 morphine sulfate (concentrate) oral solution 100 /5ml QLL (4 ML per 1 day) morphine sulfate er oral tablet extended release 100, 200 MS Contin ; QLL (2 Tablets per 1 day) morphine sulfate er oral tablet extended release 15, 30, 60 MS Contin ; QLL (3 Tablets per 1 day) morphine sulfate oral solution 10 /5ml, 20 /5ml QLL (20 ML per 1 day) morphine sulfate oral tablet 15 QLL (4 Tablets per 1 day) morphine sulfate oral tablet 30 QLL (3 Tablets per 1 day) morphine sulfate rectal suppository 10, 20, 5 QLL (4 EA per 1 day) morphine sulfate rectal suppository 30 QLL (3 EA per 1 day) oxycodone hcl oral solution 5 /5ml QLL (20 ML per 1 day) oxycodone hcl oral tablet 10 QLL (4 Tablets per 1 day) oxycodone hcl oral tablet 15, 5 Roxicodone QLL (4 Tablets per 1 day) oxycodone hcl oral tablet 20 QLL (3 Tablets per 1 day) oxycodone hcl oral tablet 30 Roxicodone QLL (2 Tablets per 1 day) tramadol hcl oral tablet 50 Ultram ; QLL (4 Tablets per 1 day) *Opioid Combinations*** oxycodone-acetaminophen oral solution /5ml QLL (20 ML per 1 day) oxycodone-acetaminophen oral tablet , , 5-325, Endocet QLL (4 Tablets per 1 day) oxycodone-aspirin oral tablet QLL (4 Tablets per 1 day) *Opioid Partial Agonists*** buprenorphine hcl sublingual tablet sublingual 2 ; QLL (240 EA per 30 days) buprenorphine hcl sublingual tablet sublingual 8 ; QLL (60 EA per 30 days) buprenorphine hcl-naloxone hcl sublingual tablet sublingual ; QLL (240 EA per 30 days) buprenorphine hcl-naloxone hcl sublingual tablet sublingual 8-2 ; QLL (60 EA per 30 days) butorphanol tartrate nasal solution 10 /ml QLL (1 Bottle per 30 days) SUBOXONE SUBLINGUAL FILM 12-3 MG, MG, 4-1 MG, 8-2 MG *Tramadol Combinations*** tramadol-acetaminophen oral tablet Ultracet ; QLL (4 Tablets per 1 day) 10

16 *ANDROGENS-ANABOLIC* *Androgens*** danazol oral capsule 100, 200, 50 testosterone cypionate intramuscular solution 100 /ml, 200 /ml Depo-Testosterone ; QLL (10 ML per 90 days) testosterone enanthate intramuscular solution 200 /ml testosterone transdermal gel 10 /act (2%) Fortesta ; QLL (2 canisters per 30 days) testosterone transdermal gel 12.5 /act (1%) Vogelxo Pump ; QLL (4 canisters per 30 days) testosterone transdermal gel 25 /2.5gm (1%), 50 /5gm (1%) AndroGel *ANORECTAL AGENTS* *Intrarectal Steroids*** CORTIFOAM RECTAL FOAM 10 % hydrocortisone rectal enema 100 /60ml Colocort *Nitrate Vasodilating Agents*** RECTIV RECTAL OINTMENT 0.4 % ; QLL (30 GM per 30 days) *Rectal Anesthetic/Steroids*** lidocaine-hydrocortisone ace rectal cream % lidocaine-hydrocortisone ace rectal kit %, 3-1 % PROCTOFOAM HC RECTAL FOAM 1-1 % *Rectal Steroids*** PROCTOSOL HC RECTAL CREAM 2.5 % Hydrocortisone PROCTOZONE-HC RECTAL CREAM 2.5 % Hydrocortisone *ANTACIDS* *Antacid & Simethicone*** aluminum-magnesium-simethicone oral suspension /5ml Almacone antacid/simethicone ds oral suspension /5ml Almacone Double Strength cvs antacid & anti-gas oral tablet chewable Maalox Advanced Max St 11

17 DI-GEL ORAL SUSPENSION MG/5ML *Antacid Combinations*** ACID GONE ORAL SUSPENSION GNP Foaming Antacid MG/15ML heartburn antacid ex st oral tablet chewable Acid Gone *Antacids - Bicarbonate*** sodium bicarbonate oral tablet 325, 650 *Antacids - Calcium Salts*** calcium antacid ultra strength oral tablet chewable 1000 Tums Ultra 1000 calcium carbonate antacid oral tablet chewable 500 Cal-Gest Antacid calcium carbonate antacid oral tablet chewable 750 Antacid Flavor Chews childrens pepto oral tablet chewable 400 Childrens Soothe *Antacids - Magnesium Salts*** magnesium oxide oral tablet 250, 400 magnesium oxide oral tablet 420 Maox *ANTHELMINTICS* *Anthelmintics*** ALBENZA ORAL TABLET 200 MG ST BILTRICIDE ORAL TABLET 600 MG reeses pinworm medicine oral suspension 144 /ml reeses pinworm medicine oral tablet 180 *ANTIANGINAL AGENTS* *Nitrates*** isosorbide dinitrate er oral tablet extended release 40 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 12

18 MINITRAN TRANSDERMAL TCH 24 HOUR 0.1 MG/HR, 0.2 MG/HR, 0.4 Minitran MG/HR, 0.6 MG/HR NITRO-BID TRANSDERMAL OINTMENT 2 % 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-TIME ORAL CAPSULE EXTENDED RELEASE 2.5 MG, 6.5 MG, 9 Nitro-Time MG *ANTIANXIETY AGENTS* *Antianxiety Agents - Misc.*** buspirone hcl oral tablet 10, 15, 5, 7.5 QLL (90 Tablets per 30 days) hydroxyzine hcl oral syrup 10 /5ml hydroxyzine hcl oral tablet 10, 25, 50 hydroxyzine pamoate oral capsule 100 hydroxyzine pamoate oral capsule 25, 50 Vistaril meprobamate oral tablet 200, 400 *Benzodiazepines*** alprazolam er oral tablet extended release 24 hour 0.5, 1, 2, 3 Xanax XR ALPRAZOLAM INTENSOL ORAL CONCENTRATE 1 MG/ML alprazolam oral tablet 0.25, 0.5, 1, 2 Xanax alprazolam oral tablet dispersible 0.25, 0.5, 1, 2 alprazolam xr oral tablet extended release 24 hour 0.5, 1, 2, 3 Xanax XR chlordiazepoxide hcl oral capsule 10, 25, 5 clorazepate dipotassium oral tablet 15, 3.75 clorazepate dipotassium oral tablet 7.5 Tranxene-T 13

19 DIAZEM INTENSOL ORAL CONCENTRATE 5 MG/ML diazepam oral solution 1 /ml diazepam oral tablet 10, 2, 5 lorazepam injection solution 2 /ml LORAZEM INTENSOL ORAL CONCENTRATE 2 MG/ML lorazepam oral concentrate 2 /ml lorazepam oral tablet 0.5, 1, 2 oxazepam oral capsule 10, 15, 30 *ANTIARRHYTHMICS* *Antiarrhythmics Type I-A*** disopyramide phosphate oral capsule 100, 150 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 propafenone hcl oral tablet 150, 225, 300 *Antiarrhythmics Type Iii*** amiodarone hcl oral tablet 200, 400 MULTAQ ORAL TABLET 400 MG *ANTIASTHMATIC AND BRONCHODILATOR AGENTS* *Adrenergic Combinations*** ANORO ELLIPTA INHALATION AEROSOL POWDER BREATH ACTIVATED MCG/INH BREO ELLIPTA INHALATION AEROSOL POWDER BREATH ACTIVATED MCG/INH, MCG/INH Diazepam Valium Ativan LORazepam Intensol LORazepam Intensol Ativan Norpace Rythmol SR Pacerone ; QLL (60 EA per 30 days) QLL (1 EA per 30 days) QLL (1 EA per 30 days) 14

20 COMBIVENT RESPIMAT INHALATION AEROSOL SOLUTION MCG/ACT DULERA INHALATION AEROSOL MCG/ACT, MCG/ACT fluticasone-salmeterol inhalation aerosol powder breath activated mcg/act fluticasone-salmeterol inhalation aerosol powder breath activated mcg/act fluticasone-salmeterol inhalation aerosol powder breath activated mcg/act ipratropium-albuterol inhalation solution (3) /3ml STIOLTO RESPIMAT INHALATION AEROSOL SOLUTION MCG/ACT *Anti-Inflammatory Agents*** cromolyn sodium inhalation nebulization solution 20 /2ml *Beta Adrenergics*** albuterol sulfate inhalation nebulization solution (2.5 /3ml) 0.083%, (5 /ml) 0.5% albuterol sulfate inhalation nebulization solution 0.63 /3ml, 1.25 /3ml albuterol sulfate oral syrup 2 /5ml ARCAPTA NEOHALER INHALATION CAPSULE 75 MCG levalbuterol tartrate inhalation aerosol 45 mcg/act metaproterenol sulfate oral syrup 10 /5ml metaproterenol sulfate oral tablet 10, 20 STRIVERDI RESPIMAT INHALATION AEROSOL SOLUTION 2.5 MCG/ACT VENTOLIN HFA INHALATION AEROSOL SOLUTION 108 (90 BASE) MCG/ACT *Bronchodilators - Anticholinergics*** ATROVENT HFA INHALATION AEROSOL SOLUTION 17 MCG/ACT INCRUSE ELLIPTA INHALATION AEROSOL POWDER BREATH ACTIVATED 62.5 MCG/INH AirDuo RespiClick 113/14 AirDuo RespiClick 232/14 AirDuo RespiClick 55/14 Xopenex HFA QLL (1 EA per 30 days) QLL (1 EA per 30 days) QLL (1 EA per 30 days) ST; QLL (1 ea per 30 days) QLL (375 ml per 30 days) ST; QLL (375 ML per 30 days); AL (Max 18 Years) ST; QLL (2 INH per 30 days) QLL (2 Inhalers per 30 days) 15

21 ipratropium bromide inhalation solution 0.02 % *Leukotriene Receptor Antagonists*** montelukast sodium oral packet 4 Singulair ; QLL (30 Packets per 30 days); AL (Max 2 Years) montelukast sodium oral tablet 10 Singulair QLL (30 Tablets per 30 days) montelukast sodium oral tablet chewable 4, 5 Singulair QLL (30 Tablets per 30 days) zafirlukast oral tablet 10, 20 Accolate ST; QLL (60 Tablets per 30 days) *Steroid Inhalants*** budesonide inhalation suspension 0.25 /2ml, 0.5 /2ml Pulmicort ; QLL (120 ml per 30 days) FLOVENT DISKUS INHALATION AEROSOL POWDER BREATH ACTIVATED 100 MCG/BLIST, 250 MCG/BLIST, 50 MCG/BLIST PULMICORT FLEXHALER INHALATION AEROSOL POWDER BREATH ACTIVATED 180 MCG/ACT, 90 QLL (1 Inhaler per 30 days) MCG/ACT QVAR INHALATION AEROSOL SOLUTION 40 MCG/ACT, 80 MCG/ACT QLL (8.7 GM per 30 days) QVAR REDIHALER INHALATION AEROSOL BREATH ACTIVATED 40 QLL (10.6 GM per 30 days) MCG/ACT QVAR REDIHALER INHALATION AEROSOL BREATH ACTIVATED 80 QLL (21.2 GM per 30 days) MCG/ACT *Xanthines*** theophylline er oral tablet extended release 12 Theochron 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*** JANTOVEN ORAL TABLET 1 MG, 10 MG, 2 MG, 2.5 MG, 3 MG, 4 MG, 5 MG, 6 Coumadin MG, 7.5 MG 16

22 warfarin sodium oral tablet 1, 10, 2, 2.5, 3, 4, 5, 6, 7.5 *Direct Factor Xa Inhibitors*** ELIQUIS ORAL TABLET 2.5 MG, 5 MG XARELTO ORAL TABLET 10 MG, 15 MG, 20 MG XARELTO STARTER CK ORAL TABLET THERAPY CK 15 & 20 MG *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 subcutaneous solution 100 /ml, 120 /0.8ml, 150 /ml, 30 /0.3ml, 40 /0.4ml, 60 /0.6ml, 80 /0.8ml *Thrombin Inhibitors - Selective Direct & Reversible*** PRADAXA ORAL CAPSULE 150 MG, 75 MG *ANTICONVULSANTS* *Anticonvulsants - Benzodiazepines*** clonazepam oral tablet 0.5, 1, 2 clonazepam oral tablet dispersible 0.125, 0.25, 0.5, 1, 2 *Anticonvulsants - Misc.*** carbamazepine er oral capsule extended release 12 hour 100, 200, 300 carbamazepine er oral tablet extended release 12 hour 100 carbamazepine er oral tablet extended release 12 hour 200, 400 carbamazepine oral suspension 100 /5ml carbamazepine oral tablet 200 carbamazepine oral tablet chewable 100 Coumadin Lovenox KlonoPIN Carbatrol TEGretol-XR TEGretol-XR TEGretol Epitol QLL (42 syringes per 180 days) QLL (120 Tablets per 30 days) ; QLL: 300ea per 30 days for ages 6-15, 360ea per 30 days for age 16 and older QLL (120 Tablets per 30 days) 17

23 gabapentin oral capsule 100, 300, 400 Neurontin QLL (6 EA per 1 day) gabapentin oral solution 250 /5ml Neurontin QLL (180 ML per 30 days) gabapentin oral tablet 600 Neurontin QLL (6 EA per 1 day) gabapentin oral tablet 800 Neurontin QLL (4.5 tablet per 1 day) lamotrigine oral tablet 100, 150, 200, 25 LaMICtal lamotrigine oral tablet chewable 25, 5 LaMICtal 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 Capsules per 30 days) topiramate oral tablet 100, 200, 25, Topamax 50 QLL (120 Tablets per 30 days) zonisamide oral capsule 100, 25 Zonegran QLL (180 Capsules per 30 days) zonisamide oral capsule 50 QLL (180 Capsules per 30 days) *Carbamates*** felbamate oral suspension 600 /5ml Felbatol felbamate oral tablet 400, 600 Felbatol *Gaba Modulators*** GABITRIL ORAL TABLET 12 MG, 16 MG QLL (60 Tablets per 30 days) tiagabine hcl oral tablet 2, 4 Gabitril QLL (60 Tablets per 30 days) *Hydantoins*** PHENYTOIN INFATABS ORAL TABLET Dilantin Infatabs CHEWABLE 50 MG phenytoin oral suspension 125 /5ml Dilantin phenytoin oral tablet chewable 50 Dilantin Infatabs phenytoin sodium extended oral capsule 100 Dilantin *Succinimides*** CELONTIN ORAL CAPSULE 300 MG ethosuximide oral capsule 250 Zarontin ethosuximide oral solution 250 /5ml Zarontin 18

24 *Valproic Acid*** divalproex sodium er oral tablet extended release 24 hour 250, 500 Depakote ER 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 Tablets per 30 days) mirtazapine oral tablet 30 Remeron QLL (60 Tablets per 30 days) mirtazapine oral tablet 45 Remeron QLL (45 Tablets per 30 days) mirtazapine oral tablet 7.5 QLL (30 Tablets per 30 days) mirtazapine oral tablet dispersible 15, 45 Remeron SolTab QLL (30 Tablets per 30 days) mirtazapine oral tablet dispersible 30 Remeron SolTab QLL (60 Tablets per 30 days) *Antidepressants - Misc.*** bupropion hcl er (sr) oral tablet extended release 12 hour 100 Wellbutrin SR QLL (120 Tablets per 30 days) bupropion hcl er (sr) oral tablet extended release 12 hour 150, 200 Wellbutrin SR QLL (60 Tablets per 30 days) bupropion hcl er (xl) oral tablet extended release 24 hour 150 Wellbutrin XL QLL (90 Tablets per 30 days) bupropion hcl er (xl) oral tablet extended release 24 hour 300 Wellbutrin XL QLL (30 Tablets per 30 days) bupropion hcl oral tablet 100 QLL (135 Tablets per 30 days) bupropion hcl oral tablet 75 QLL (180 Tablets per 30 days) maprotiline hcl oral tablet 25, 50, 75 *Modified Cyclics*** trazodone hcl oral tablet 100, 150, 50 *Monoamine Oxidase Inhibitors (Maois)*** MARPLAN ORAL TABLET 10 MG phenelzine sulfate oral tablet 15 Nardil tranylcypromine sulfate oral tablet 10 Parnate 19

25 *Selective Serotonin Reuptake Inhibitors (Ssris)*** citalopram hydrobromide oral solution 10 /5ml QLL (600 ML per 30 days) citalopram hydrobromide oral tablet 10, 20, 40 CeleXA QLL (30 Tablets per 30 days) escitalopram oxalate oral solution 5 /5ml QLL (30 Tablets per 30 days) escitalopram oxalate oral tablet 10, 20, Lexapro 5 QLL (30 Tablets per 30 days) fluoxetine hcl oral capsule 10 PROzac QLL (30 Capsules per 30 days) fluoxetine hcl oral capsule 20 PROzac QLL (120 Capsules per 30 days) fluoxetine hcl oral capsule 40 PROzac QLL (60 Capsules per 30 days) fluoxetine hcl oral solution 20 /5ml QLL (600 ML per 30 days) fluvoxamine maleate oral tablet 100 QLL (90 Tablets per 30 days) fluvoxamine maleate oral tablet 25 QLL (30 Tablets per 30 days) fluvoxamine maleate oral tablet 50 QLL (60 Tablets per 30 days) paroxetine hcl oral tablet 10, 20 Paxil QLL (30 Tablets per 30 days) paroxetine hcl oral tablet 30 Paxil QLL (60 Tablets per 30 days) paroxetine hcl oral tablet 40 Paxil QLL (45 Tablets per 30 days) sertraline hcl oral concentrate 20 /ml Zoloft QLL (300 ML per 30 days) sertraline hcl oral tablet 100 Zoloft QLL (75 Tablets per 30 days) sertraline hcl oral tablet 25 Zoloft QLL (30 Tablets per 30 days) sertraline hcl oral tablet 50 Zoloft QLL (60 Tablets per 30 days) *Serotonin-Norepinephrine Reuptake Inhibitors (Snris)*** duloxetine hcl oral capsule delayed release particles 20, 30, 60 Cymbalta QLL (30 Capsules per 30 days) duloxetine hcl oral capsule delayed release particles 40 QLL (30 Capsules per 30 days) venlafaxine hcl er oral capsule extended release 24 hour 150 Effexor XR QLL (60 Capsules per 30 days) venlafaxine hcl er oral capsule extended release 24 hour 37.5, 75 Effexor XR QLL (30 Capsules per 30 days) venlafaxine hcl oral tablet 100, 25, 37.5, 50, 75 *Tricyclic Agents*** amitriptyline hcl oral tablet 10, 100, 150, 50, 75 amitriptyline hcl oral tablet 25 Elavil desipramine hcl oral tablet 10, 25 Norpramin 20

26 desipramine hcl oral tablet 100, 150, 50, 75 doxepin hcl oral capsule 10, 100, 150, 25, 50, 75 doxepin hcl oral concentrate 10 /ml imipramine hcl oral tablet 10, 25, 50 nortriptyline hcl oral capsule 10, 25, 50, 75 nortriptyline hcl oral solution 10 /5ml protriptyline hcl oral tablet 10, 5 *ANTIDIABETICS* *Alpha-Glucosidase Inhibitors*** acarbose oral tablet 100, 25, 50 *Biguanides*** metformin hcl er oral tablet extended release 24 hour 500, 750 metformin hcl oral tablet 1000, 500, 850 *Diabetic Other*** BD GLUCOSE ORAL TABLET CHEWABLE 5 GM cvs glucose bits oral tablet chewable 1 gm GLUCAGEN HYPOKIT INJECTION SOLUTION RECONSTITUTED 1 MG GLUCAGON EMERGENCY INJECTION KIT 1 MG glucose oral tablet chewable 4 gm *Dipeptidyl Peptidase-4 (Dpp-4) Inhibitors*** alogliptin benzoate oral tablet 12.5, 25, 6.25 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 Tofranil Pamelor Precose Glucophage XR Glucophage Dex4 Quick Dissolve Glucose Nesina Kazano ST; QLL (30 EA per 30 days) ST; QLL (60 EA per 30 days) 21

27 JANUMET XR ORAL TABLET EXTENDED RELEASE 24 HOUR 100- ST; QLL (30 EA per 30 days) 1000 MG, MG, MG *Dpp-4 Inhibitor-Thiazolidinedione Combinations*** alogliptin-pioglitazone oral tablet , , , 25-15, 25-30, Oseni *Human Insulin*** APIDRA INJECTION SOLUTION 100 UNIT/ML BASAGLAR KWIKPEN SUBCUTANEOUS SOLUTION PEN- INJECTOR 100 UNIT/ML HUMALOG KWIKPEN SUBCUTANEOUS SOLUTION PEN- AL (Max 18 Years) INJECTOR 100 UNIT/ML, 200 UNIT/ML HUMALOG MIX 50/50 KWIKPEN SUBCUTANEOUS SUSPENSION PEN- AL (Max 18 Years) 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- AL (Max 18 Years) INJECTOR (75-25) 100 UNIT/ML HUMALOG MIX 75/25 SUBCUTANEOUS SUSPENSION (75-25) 100 UNIT/ML HUMALOG SUBCUTANEOUS SOLUTION 100 UNIT/ML HUMALOG SUBCUTANEOUS SOLUTION CARTRIDGE 100 UNIT/ML HUMULIN 70/30 SUBCUTANEOUS SUSPENSION (70-30) 100 UNIT/ML HUMULIN N SUBCUTANEOUS SUSPENSION 100 UNIT/ML HUMULIN R INJECTION SOLUTION 100 UNIT/ML HUMULIN R U-500 (CONCENTRATED) SUBCUTANEOUS SOLUTION 500 UNIT/ML NOVOLIN 70/30 SUBCUTANEOUS SUSPENSION (70-30) 100 UNIT/ML NOVOLIN N SUBCUTANEOUS SUSPENSION 100 UNIT/ML 22

28 NOVOLIN R INJECTION SOLUTION 100 UNIT/ML NOVOLIN R RELION INJECTION SOLUTION 100 UNIT/ML NOVOLOG FLEXPEN SUBCUTANEOUS SOLUTION PEN-INJECTOR 100 AL (Max 18 Years) UNIT/ML NOVOLOG MIX 70/30 FLEXPEN SUBCUTANEOUS SUSPENSION PEN- AL (Max 18 Years) INJECTOR (70-30) 100 UNIT/ML NOVOLOG MIX 70/30 SUBCUTANEOUS SUSPENSION (70-30) 100 UNIT/ML NOVOLOG SUBCUTANEOUS SOLUTION 100 UNIT/ML *Incretin Mimetic Agents (Glp-1 Receptor Agonists)*** TANZEUM SUBCUTANEOUS PEN- INJECTOR 30 MG, 50 MG ST TRULICITY SUBCUTANEOUS SOLUTION PEN-INJECTOR 0.75 ST MG/0.5ML, 1.5 MG/0.5ML *Meglitinide Analogues*** nateglinide oral tablet 120, 60 Starlix repaglinide oral tablet 0.5 repaglinide oral tablet 1, 2 Prandin *Sodium-Glucose Co-Transporter 2 (Sglt2) Inhibitors*** INVOKANA ORAL TABLET 100 MG, 300 MG ST; QLL (30 EA per 30 days) *Sulfonylurea-Biguanide Combinations*** glipizide-metformin hcl oral tablet , , glyburide-metformin oral tablet glyburide-metformin oral tablet , Glucovance *Sulfonylureas*** chlorpropamide oral tablet 100, 250 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 23

29 glipizide xl oral tablet extended release 24 hour 10, 2.5, 5 Glucotrol XL glyburide oral tablet 1.25, 2.5, 5 tolazamide oral tablet 250, 500 tolbutamide oral tablet 500 *Sulfonylurea-Thiazolidinedione Combinations*** pioglitazone hcl-glimepiride oral tablet 30-2, 30-4 Duetact QLL (30 Tablets per 30 days) *Thiazolidinedione-Biguanide Combinations*** pioglitazone hcl-metformin hcl oral tablet , Actoplus Met QLL (90 Tablets per 30 days) *Thiazolidinediones*** AVANDIA ORAL TABLET 2 MG, 4 MG ST; QLL (30 Tablets per 30 days) pioglitazone hcl oral tablet 15, 30, 45 Actos QLL (30 Tablets per 30 days) *ANTIDIARRHEALS* *Antidiarrheal Agents - Misc.*** acidophilus probiotic oral tablet 10 Floranex bismuth subsalicylate oral tablet chewable 262 Pepto-Bismol cvs bismuth oral tablet 262 Kaopectate cvs probiotic (lactobacillus) oral capsule Culturelle lactobacillus extra strength oral capsule Abatinex PEDIA-LAX PROBIOTIC YUMS ORAL TABLET CHEWABLE pink bismuth maximum strength oral suspension 525 /15ml Kaopectate Extra Strength pink bismuth oral suspension 262 /15ml Kao-Tin *Antiperistaltic Agents*** anti-diarrheal oral capsule 2 Imodium A-D diphenoxylate-atropine oral liquid /5ml diphenoxylate-atropine oral tablet Lomotil loperamide hcl oral capsule 2 Imodium A-D loperamide hcl oral liquid 1 /5ml loperamide hcl oral suspension 1 /7.5ml Imodium A-D 24

30 loperamide hcl oral tablet 2 Imodium A-D *ANTIDOTES AND SPECIFIC ANTAGONISTS* *Antidotes And Specific Antagonists*** sm ipecac syrup oral syrup *ANTIDOTES* *Antidotes - Chelating Agents*** CHEMET ORAL CAPSULE 100 MG *Antidotes*** sm ipecac syrup oral syrup *Opioid Antagonists*** naloxone hcl injection solution 0.4 /ml naltrexone hcl oral tablet 50 NARCAN NASAL LIQUID 4 MG/0.1ML *ANTIEMETICS* *5-Ht3 Receptor Antagonists*** granisetron hcl oral tablet 1 ondansetron hcl oral solution 4 /5ml Zofran QLL (50 ml per 30 Dayss) ondansetron hcl oral tablet 24 QLL (8 Tablets per 30 days) ondansetron hcl oral tablet 4, 8 Zofran QLL (21 EA per 30 Dayss) ondansetron oral tablet dispersible 4, 8 Zofran ODT QLL (21 EA per 30 Dayss) *Antiemetic Combinations*** anti-nausea oral solution Emetrol *Antiemetics - Anticholinergic*** DRAMAMINE LESS DROWSY ORAL TABLET 25 MG Dramamine Less Drowsy meclizine hcl oral tablet 12.5 meclizine hcl oral tablet 25 Dramamine Less Drowsy travel sickness oral tablet chewable 25 *Substance P/Neurokinin 1 (Nk1) Receptor Antagonists*** EMEND ORAL CAPSULE 125 MG, 40 MG, 80 MG Aprepitant QLL (6 EA per 30 days) *ANTIFUNGALS* *Antifungals*** griseofulvin microsize oral suspension 125 /5ml 25

31 griseofulvin microsize oral tablet 500 griseofulvin ultramicrosize oral tablet 125, Gris-PEG 250 nystatin oral tablet unit terbinafine hcl oral tablet 250 LamISIL QLL (84 Tablets per 1 Year) *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 SPORANOX ORAL SOLUTION 10 MG/ML *ANTIHISTAMINES* *Antihistamines - Alkylamines*** ALA-HIST IR ORAL TABLET 2 MG brompheniramine tannate oral tablet chewable 12 chlorpheniramine maleate er oral tablet extended release 12 Chlor-Trimeton Allergy chlorpheniramine maleate oral tablet 4 Chlor-Trimeton *Antihistamines - Ethanolamines*** allergy medication childrens oral liquid 12.5 /5ml Banophen allergy medication oral tablet 25 Alka-Seltzer Plus Allergy allergy relief childrens oral tablet dispersible 12.5 Wal-Dryl Allergy Rel Childrens allergy relief oral capsule 25 Banophen carbinoxamine maleate oral solution 4 /5ml carbinoxamine maleate oral tablet 4 clemastine fumarate oral tablet 1.34 Allerhist clemastine fumarate oral tablet 2.68 diphenhydramine hcl oral capsule 25, 50 Banophen diphenhydramine hcl oral elixir 12.5 /5ml silphen cough oral syrup 12.5 /5ml 26

32 *Antihistamines - Non-Sedating*** cetirizine hcl oral solution 1 /ml KLS Aller-Tec Childrens QLL (150 ML per 30 days); AL (Min 6 Years) cetirizine hcl oral syrup 1 /ml, 5 /5ml KLS Aller-Tec Childrens QLL (150 ML per 30 days); AL (Min 6 Years) cetirizine hcl oral tablet 10 KLS Aller-Tec cetirizine hcl oral tablet 5 fexofenadine hcl oral tablet 180, 60 Allegra Allergy loratadine oral tablet 10 Claritin *Antihistamines - Phenothiazines*** PHENADOZ RECTAL SUPPOSITORY 12.5 MG, 25 MG Phenadoz PHENERGAN RECTAL SUPPOSITORY 12.5 MG, 25 MG Phenadoz PHENERGAN RECTAL SUPPOSITORY 50 MG Phenergan 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 promethazine hcl rectal suppository 50 Phenergan PROMETHEGAN RECTAL SUPPOSITORY 12.5 MG, 25 MG Phenadoz PROMETHEGAN RECTAL SUPPOSITORY 50 MG Phenergan *Antihistamines - Piperidines*** cyproheptadine hcl oral syrup 2 /5ml cyproheptadine hcl oral tablet 4 *ANTIHYPERLIPIDEMICS* *Bile Acid Sequestrants*** cholestyramine light oral packet 4 gm Prevalite cholestyramine oral packet 4 gm Questran colestipol hcl oral granules 5 gm Colestid colestipol hcl oral packet 5 gm Colestid colestipol hcl oral tablet 1 gm Colestid PREVALITE ORAL CKET 4 GM Prevalite 27

33 *Fibric Acid Derivatives*** fenofibrate micronized oral capsule 134, 67 Lofibra fenofibrate micronized oral capsule 200 fenofibrate oral tablet 145, 48 Tricor fenofibrate oral tablet 160 Triglide fenofibrate oral tablet 54 Lofibra fenofibric acid oral capsule delayed release 135, 45 Trilipix gemfibrozil oral tablet 600 Lopid QLL (60 Tablets per 30 days) *H Coa Reductase Inhibitors*** atorvastatin calcium oral tablet 10, 20, Lipitor 40, 80 QLL (30 Tablets per 30 days) fluvastatin sodium oral capsule 20 Lescol QLL (30 Capsules per 30 days) fluvastatin sodium oral capsule 40 QLL (30 Capsules per 30 days) lovastatin oral tablet 10, 20 QLL (30 Tablets per 30 days) lovastatin oral tablet 40 Mevacor QLL (60 Tablets per 30 days) pravastatin sodium oral tablet 10 QLL (30 Tablets per 30 days) pravastatin sodium oral tablet 20, 40, 80 Pravachol QLL (30 Tablets per 30 days) rosuvastatin calcium oral tablet 10, 20, Crestor 40, 5 ; QLL (30 EA per 30 days) simvastatin oral tablet 10, 20, 40, 5 Zocor, 80 QLL (30 Tablets per 30 days) *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

34 captopril-hydrochlorothiazide oral tablet 25-15, 25-25, 50-15, enalapril-hydrochlorothiazide oral tablet Vaseretic enalapril-hydrochlorothiazide oral tablet fosinopril sodium-hctz oral tablet , lisinopril-hydrochlorothiazide oral tablet , , Zestoretic moexipril-hydrochlorothiazide oral tablet , 15-25, quinapril-hydrochlorothiazide oral tablet , , Accuretic *Ace Inhibitors*** benazepril hcl oral tablet 10, 20, 40 Lotensin benazepril hcl oral tablet 5 captopril oral tablet 100, 12.5, 25, 50 enalapril maleate oral tablet 10, 2.5, 20, 5 Vasotec fosinopril sodium oral tablet 10, 20, 40 lisinopril oral tablet 10, 20, 5 Prinivil QLL (30 Tablets per 30 days) lisinopril oral tablet 2.5, 30 Zestril QLL (30 Tablets per 30 days) lisinopril oral tablet 40 Zestril QLL (60 Tablets per 30 days) moexipril hcl oral tablet 15, 7.5 perindopril erbumine oral tablet 2, 4, 8 quinapril hcl oral tablet 10, 20, 40, Accupril 5 ramipril oral capsule 1.25, 10, 2.5, Altace 5 trandolapril oral tablet 1, 2 trandolapril oral tablet 4 Mavik *Adrenolytics-Central & Thiazide/Thiazide-Like Comb*** methyldopa-hydrochlorothiazide oral tablet ,

35 *Angiotensin Ii Receptor Antag & Ca Channel Blocker Comb*** amlodipine besylate-valsartan oral tablet , , 5-160, Exforge QLL (1 EA per 1 day) *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 QLL (30 Tablets per 30 days) *Angiotensin Ii Receptor Antagonists*** candesartan cilexetil oral tablet 16, 32, Atacand 4, 8 irbesartan oral tablet 150, 300, 75 Avapro losartan potassium oral tablet 100, 25, Cozaar 50 valsartan oral tablet 160, 320, 40, 80 Diovan QLL (60 Tablets per 30 days) *Angiotensin Ii Receptor Ant-Ca Channel Blocker-Thiazides*** amlodipine-valsartan-hctz oral tablet , , , Exforge HCT QLL (1 EA per 1 day) 12.5, *Antiadrenergics - Centrally Acting*** clonidine hcl oral tablet 0.1, 0.2, 0.3 Catapres clonidine hcl transdermal patch weekly 0.1 /24hr Catapres-TTS-1 clonidine hcl transdermal patch weekly 0.2 /24hr Catapres-TTS-2 clonidine hcl transdermal patch weekly 0.3 /24hr Catapres-TTS-3 guanfacine hcl oral tablet 1 QLL (240 EA per 30 days) guanfacine hcl oral tablet 2 QLL (120 EA per 30 days) methyldopa oral tablet 250,

36 *Antiadrenergics - Peripherally Acting*** doxazosin mesylate oral tablet 1, 2, 4, 8 Cardura QLL (30 Tablets per 30 days) prazosin hcl oral capsule 1, 2, 5 Minipress terazosin hcl oral capsule 1, 10, 2, 5 QLL (30 Capsules per 30 days) *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 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.*** FIRST-VANCOMYCIN 25 ORAL SOLUTION 25 MG/ML FIRST-VANCOMYCIN 50 ORAL SOLUTION 50 MG/ML 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 SULFATRIM PEDIATRIC ORAL SUSPENSION MG/5ML Sulfatrim Pediatric 31

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