AETNA BETTER HEALTH Formulary Guide Aetna Better Health Pennsylvania Formulary Guide April 2018

Transcription

1 AETNA BETTER HEALTH Formulary Guide 2018 Aetna Better Health Pennsylvania Formulary Guide April 2018

2 AETNA BETTER HEALTH Formulary Guide 2018 What is the Aetna Better Health in Pennsylvania Formulary? This is a drug list created by Aetna Better Health in Pennsylvania ( plan ). The plan will cover drugs on this list. Some drugs may have coverage rules. If the rules for that drug are met, the plan will cover the drug. Drugs must also be filled at a plan s network pharmacy. This list is for drugs covered under you prescription benefit. Drugs may not be listed here if they are covered under your medical benefit. Drugs covered under your medical benefit are usually those a health care professional gives to you, like an IV infusion or other injection, and not typically a medication you would take on your own. Can the Plan s Drug List change? The plan may add or remove drugs on the list. All drug removals from the formulary will be sent to the state for review at least 30 days before the change is made. Utilizing members will be notified at least PA A 2

3 AETNA BETTER HEALTH Formulary Guide days before a drug is removed from the formulary. All changes to the formulary will be posted on the plan s website. How do I use the Plan s Formulary? Column #1: lists the covered drug. Brand drugs are in upper case letters (e.g., DRUG). Generics are in lower case letters (e.g., drug). Column #2: lists the brand name of the drug when a generic is covered Column #3: shows coverage rules for the drug Drugs are also grouped by the type of condition they treat. Drugs used to treat an earache are listed under the section, Otic. If you know what your drug is used for, please look for that section name on the drug list. Then look under that section for your drug. What are generic drugs? Generic drugs are copies of brand name drugs. They are the same as those brand name drugs in dosage form, safety, strength, route of administration, quality, and intended use. When a drug is available as a generic, you will be required to use the generic version for your prescription. If your provider feels it is medically necessary that you take only the brand, then your provider must request a prior authorization from the plan before the brand will be covered. Are Over The Counter (OTC) drugs covered? The plan will cover OTC drugs on the formulary. Some OTC drugs may have coverage rules. If the rules for that OTC drug are met, the plan will cover the OTC drug. Like other drugs, OTC drugs need a prescription from a doctor if they are to be covered by the plan. A list of covered OTC products can be found on our website. How much will I pay for covered drugs? s There are no copays for: Pregnant women Children under 21 years of age Members in a nursing home or other facility (Intermediate Care Facility for Mental Retardation) 3 PA A

4 AETNA BETTER HEALTH Formulary Guide 2018 Family planning drugs Emergency situation (condition in which emergency medical care is needed to prevent death or serious injury of a member) Certain drug groups listed below do not have copays. For those drug groups that will not require a copay the drug group will be marked with a no copay on the formulary. High blood pressure drugs Cancer drugs Diabetes drugs Epilepsy drugs Heart disease drugs Antipsychotic drugs (except for those anti anxiety drugs that are controlled substances, like alprazolam or diazepam) Anti Parkinson drugs Anti glaucoma drugs Drugs used only to treat HIV/AIDS Drugs, including immunizations, which you get in a health care provider s office. Naloxone injection/nasal spray for drug overdose Copays Members 21 years of age and older: generic drugs on formulary are $1; brand drugs on formulary are $3 per prescription. Services cannot be denied if the member cannot afford the copay. What are some types of coverage rules? Prior Approval (PA): This means your doctor will need to get approval from the plan first before the drug can be filled at the pharmacy. If it is not approved, the plan will not cover the drug. Quantity Level Limits (QLL): This means there is a limit on the amount of drug the plan will cover. For example, the plan provides 60 pills in 30 days for some drugs. Your doctor will need to get approval from the plan first before the drug can be filled for more than the plans limits. Step Therapy (ST): This means you may need to try certain drugs first to treat your condition. After the first drug is tried, the plan will then cover the other drug for that same condition. For example, Drug A and Drug B may treat your condition. The plan may not cover Drug B unless you try Drug A first. If Drug A does not work for you or you cannot take Drug A, then Drug B will be covered. What if my drug is not on the plan s Formulary? First, please call your doctor and ask if your drug is on the formulary. If the drug is not listed on the formulary then: 4 PA A

5 AETNA BETTER HEALTH Formulary Guide 2018 Ask your doctor for a similar drug that is on the formulary. Your doctor can ask the plan to cover your drug through the prior approval process. Where can I fill my prescriptions? You can fill your prescriptions at any network pharmacy. You can find the location of an in network pharmacy by visiting the CVS Caremark pharmacy locator. This allows you to search for a pharmacy by zip code so you can find a location close to you. F AL Definition of Symbols Formulary Age Restriction: We require that the appropriate dose of medication based on age (e.g., pediatric and elderly populations) and indication AND Dosage requested must be based on national established/ recognized guidelines pertaining to the treatment and management of the diagnosis and age for which the medication is being used to treat. OR FDA-approved age limitations. Names in Italics PA QLL SP Generic Drug - The plan covers both brand and generic drugs. Generic drugs have the same active ingredient formula as a brand name drug. Generic drugs usually cost less than brand name drugs and are rated by the Food and Drug Administration (FDA) to be as safe and effective as brand name drugs. This means your doctor will need to get approval from the plan first before the drug can be filled at the pharmacy. If it is not approved, the plan will not cover the drug. This means there is a limit on the amount of drug the plan will cover. For example, the plan provides 60 pills in 30 days for some drugs. Specialty Pharmacy - All specialty medications require Prior Authorization. For a list of specialty medications, click on the following - Penn.pdf ST This means you may need to try certain drugs first to treat your condition. After the first drug is tried, the plan will then cover the other drug for that same condition. For example, Drug A and Drug B may treat your condition. The plan may not cover Drug B unless you try Drug A first. If Drug A does not work for you or you cannot take Drug A, then Drug B will be covered. For a complete list of all drugs requiring step therapy; click on the Following PA A

6 Aetna Better Health Pennsylvania Table of Contents *ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS*...3 *AMINOGLYCOSIDES*... 4 *ANALGESICS - ANTI-INFLAMMATORY*... 4 *ANALGESICS - NONNARCOTIC*...6 *ANALGESICS - OPIOID*... 7 *ANDROGENS-ANABOLIC* *ANORECTAL AGENTS*...13 *ANTHELMINTICS* *ANTIANGINAL AGENTS* *ANTIANXIETY AGENTS*...15 *ANTIARRHYTHMICS* *ANTIASTHMATIC AND BRONCHODILATOR AGENTS* *ANTICOAGULANTS* *ANTICONVULSANTS*...19 *ANTIDEPRESSANTS*...21 *ANTIDIABETICS* *ANTIDIARRHEALS*...27 *ANTIDOTES* *ANTIEMETICS* *ANTIFUNGALS*...27 *ANTIHISTAMINES* *ANTIHYPERLIPIDEMICS*...28 *ANTIHYPERTENSIVES* *ANTI-INFECTIVE AGENTS - MISC.* *ANTIMALARIALS*...33 *ANTIMYASTHENIC AGENTS* *ANTIMYCOBACTERIAL AGENTS* *ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES*...34 *ANTIPARKINSON AGENTS*...36 *ANTIPSYCHOTICS/ANTIMANIC AGENTS* *ANTIRETROVIRALS ADJUVANTS*** *ANTISEPTICS & DISINFECTANTS*...39 *ANTIVIRALS*...39 *ASSORTED CLASSES* *BETA BLOCKERS* *CALCIUM CHANNEL BLOCKERS* *CARDIOTONICS* *CARDIOVASCULAR AGENTS - MISC.* *CEPHALOSPORINS*...47 *CONTRACEPTIVES*...48 *CORTICOSTEROIDS* *COUGH/COLD/ALLERGY*...55 *DERMATOLOGICALS* *DIAGNOSTIC PRODUCTS*...61 *DIGESTIVE AIDS*...61 *DIURETICS*...61 *ENDOCRINE AND METABOLIC AGENTS - MISC.*

7 *ESTROGENS*...63 *FLUOROQUINOLONES* *GASTROINTESTINAL AGENTS - MISC.*...64 *GENITOURINARY AGENTS - MISCELLANEOUS* *GOUT AGENTS*...66 *HEMATOLOGICAL AGENTS - MISC.* *HEMATOPOIETIC AGENTS*...67 *HEPATITIS C AGENT - COMBINATIONS*** *HYPNOTICS* *LAXATIVES* *MACROLIDES*...69 *MEDICAL DEVICES*...69 *MIGRAINE PRODUCTS*...73 *MINERALS & ELECTROLYTES*...73 *MOUTH/THROAT/DENTAL AGENTS*...74 *MULTIVITAMINS*...75 *MUSCULOSKELETAL THERAPY AGENTS*...77 *NASAL AGENTS - SYSTEMIC AND TOPICAL* *NEPRILYSIN INHIB (ARNI)-ANGIOTENSIN II RECEPT ANTAG COMB*** *NEUROMUSCULAR AGENTS* *OPHTHALMIC AGENTS*...79 *OTIC AGENTS*...82 *PASSIVE IMMUNIZING AGENTS*...82 *PENICILLINS*...82 *PHARMACEUTICAL ADJUVANTS* *POTASSIUM REMOVING AGENTS***...83 *PROGESTINS*...84 *PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.*...84 *RESPIRATORY AGENTS - MISC.*...86 *SINUS NODE INHIBITORS**...86 *SODIUM-GLUCOSE CO-TRANSPORTER 2 INHIBITOR-BIGUANIDE COMB*** *SULFONAMIDES*...87 *TETRACYCLINES* *THYROID AGENTS* *ULCER DRUGS* *URINARY ANTI-INFECTIVES*...90 *URINARY ANTISPASMODICS*...90 *VACCINES*...91 *VAGINAL PRODUCTS*...91 *VASOPRESSORS* *VITAMINS*

8 Aetna Better Health Pennsylvania 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, 4 *Amphetamine Mixtures*** amphetamine-dextroamphet er oral capsule extended release 24 hour 10, 15, 20, 25, 30, 5 amphetamine-dextroamphetamine oral tablet 10, 12.5, 15, 20, 5, 7.5 amphetamine-dextroamphetamine oral tablet 30 *Amphetamines*** dextroamphetamine sulfate er oral capsule extended release 24 hour 10, 15 dextroamphetamine sulfate er oral capsule extended release 24 hour 5 dextroamphetamine sulfate oral solution 5 /5ml dextroamphetamine sulfate oral tablet 10, 5 Intuniv Adderall XR Adderall Adderall Dexedrine Dexedrine ProCentra Zenzedi QLL (30 Tablets per 30 ; AL (Min 6 Years) PA; QLL (30 EA per 30 PA; QLL (90 EA per 30 PA; QLL (60 EA per 30 PA; QLL (120 EA per 30 PA; QLL (90 EA per 30 PA; QLL (1800 ML per 30 PA; QLL (180 EA per 30 methamphetamine hcl oral tablet 5 Desoxyn PA; QLL (150 EA per 30 *Analeptics*** caffeine citrate oral solution 20 /ml, 60 /3ml *Stimulants - Misc.*** armodafinil oral tablet 150, 200, 250 Nuvigil PA; QLL (30 EA per 30 armodafinil oral tablet 50 Nuvigil PA; QLL (60 EA per 30 dexmethylphenidate hcl er oral capsule extended release 24 hour 10, 15, 20 Focalin XR PA; QLL (30 EA per 30, 25, 30, 35, 5 dexmethylphenidate hcl er oral capsule extended release 24 hour 40 Focalin XR QLL (30 EA per 30 dexmethylphenidate hcl oral tablet 10, 2.5, 5 Focalin PA; QLL (60 EA per 30 3

9 methylphenidate hcl er (cd) oral capsule extended release 10, 20, 30, 40, PA; QLL (30 EA per 30 50, 60 methylphenidate hcl er (la) oral capsule extended release 24 hour 20, 40 Ritalin LA PA; QLL (30 EA per 30 methylphenidate hcl er (la) oral capsule extended release 24 hour 30 Ritalin LA PA; QLL (60 EA per 30 methylphenidate hcl er (la) oral capsule extended release 24 hour 60 PA; QLL (30 EA per 30 methylphenidate hcl er oral tablet extended release 10 PA; QLL (90 EA per 30 methylphenidate hcl er oral tablet extended release 18, 27, 54 Concerta PA; QLL (30 EA per 30 methylphenidate hcl er oral tablet extended release 20 Metadate ER PA; QLL (90 EA per 30 methylphenidate hcl er oral tablet extended release 24 hour 18, 27, 36, 54 methylphenidate hcl er oral tablet extended release 36 Concerta PA; QLL (60 EA per 30 methylphenidate hcl oral solution 10 /5ml, 5 /5ml Methylin PA; QLL (900 ML per 30 methylphenidate hcl oral tablet 10, 20, Ritalin 5 PA; QLL (90 EA per 30 methylphenidate hcl oral tablet chewable 10 PA; QLL (180 EA per 30 methylphenidate hcl oral tablet chewable 2.5, 5 PA; QLL (150 EA per 30 *AMINOGLYCOSIDES* *Aminoglycosides*** neomycin sulfate oral tablet 500 paromomycin sulfate oral capsule 250 tobramycin inhalation nebulization solution 300 /5ml Kitabis Pak KITABIS PAK INHALATION NEBULIZATION SOLUTION 300 Kitabis Pak PA MG/5ML *ANALGESICS - ANTI- INFLAMMATORY* *Anti-Tnf-Alpha - Monoclonal Antibodies*** HUMIRA PEN-CROHNS STARTER SUBCUTANEOUS PEN-INJECTOR KIT 40 MG/0.8ML PA 4

10 *Anti-Tnf-Alpha - Monoclonoal Antibodies*** HUMIRA PEN-CROHNS STARTER SUBCUTANEOUS PEN-INJECTOR KIT PA 40 MG/0.8ML HUMIRA SUBCUTANEOUS PREFILLED SYRINGE KIT 10 MG/0.2ML, 20 PA MG/0.4ML, 40 MG/0.8ML *Cyclooxygenase 2 (Cox-2) Inhibitors*** celecoxib oral capsule 100, 200, 400, 50 CeleBREX ST *Gold Compounds*** RIDAURA ORAL CAPSULE 3 MG *Nonsteroidal Anti-Inflammatory Agents (Nsaids)*** diclofenac potassium oral tablet 50 diclofenac sodium er oral tablet extended release 24 hour 100 diclofenac sodium oral tablet delayed release 25, 50, 75 etodolac er oral tablet extended release 24 hour 400, 500, 600 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 oral tablet 400, 600, 800 IBU indomethacin er oral capsule extended release 75 indomethacin oral capsule 25, 50 ketoprofen oral capsule 75 ketorolac tromethamine oral tablet 10 QLL (20 Tablets per 30 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 5

11 naproxen oral tablet 250, 500 Naprosyn naproxen oral tablet 375 naproxen sodium oral tablet 275 oxaprozin oral tablet 600 Daypro piroxicam oral capsule 10, 20 Feldene sulindac oral tablet 150, 200 tolmetin sodium oral capsule 400 tolmetin sodium oral tablet 200, 600 *Pyrimidine Synthesis Inhibitors*** leflunomide oral tablet 10, 20 Arava *Soluble Tumor Necrosis Factor Receptor Agents*** ENBREL MINI SUBCUTANEOUS SOLUTION CARTRIDGE 50 MG/ML PA ENBREL SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 25 MG/0.5ML, 50 PA MG/ML ENBREL SURECLICK SUBCUTANEOUS SOLUTION AUTO-INJECTOR 50 PA MG/ML *ANALGESICS - NONNARCOTIC* *Analgesics-Sedatives*** butalbital-acetaminophen oral tablet Tencon butalbital-apap-caffeine oral capsule Fioricet butalbital-apap-caffeine oral capsule Esgic butalbital-apap-caffeine oral tablet Esgic butalbital-asa-caffeine oral capsule Fiorinal *Salicylate Combinations*** choline-mag trisalicylate oral liquid 500 /5ml *Salicylates*** diflunisal oral tablet 500 salsalate oral tablet 500, 750 6

12 *ANALGESICS - OPIOID* *Codeine Combinations*** acetaminophen-codeine #2 oral tablet acetaminophen-codeine #3 oral tablet acetaminophen-codeine #4 oral tablet acetaminophen-codeine oral solution /5ml butalbital-apap-caff-cod oral capsule butalbital-apap-caff-cod oral capsule butalbital-asa-caff-codeine oral capsule Tylenol with Codeine #3 Tylenol with Codeine #4 Fioricet/Codeine Ascomp-Codeine Ages 18yrs and older: 7 day supply per 90 days. Max 7 day supply per fill. Ages 17 yrs and younger: 3 day supply per 90 days. Max 3 day supply per fill.; QLL (10 EA per 1 day) Ages 18yrs and older: 7 day supply per 90 days. Max 7 day supply per fill. Ages 17 yrs and younger: 3 day supply per 90 days. Max 3 day supply per fill.; QLL (10 EA per 1 day) Ages 18yrs and older: 7 day supply per 90 days. Max 7 day supply per fill. Ages 17 yrs and younger: 3 day supply per 90 days. Max 3 day supply per fill.; QLL (10 EA per 1 day) PA; Ages 18yrs and older: 7 day supply per 90 days. Max 7 day supply per fill. Ages 17 yrs and younger: 3 day supply per 90 days. Max 3 day supply per fill.; QLL (150 ML per 1 day) Ages 18yrs and older: 7 day supply per 90 days. Max 7 day supply per fill. Ages 17 yrs and younger: 3 day supply per 90 days. Max 3 day supply per fill.; QLL (6 EA per 1 day) Ages 18yrs and older: 7 day supply per 90 days. Max 7 day supply per fill. Ages 17 yrs and younger: 3 day supply per 90 days. Max 3 day supply per fill.; QLL (6 EA per 1 day) PA; Ages 18yrs and older: 7 day supply per 90 days. Max 7 day supply per fill. Ages 17 yrs and younger: 3 day supply per 90 days. Max 3 day supply per fill.; QLL (6 EA per 1 day) 7

13 *Hydrocodone Combinations*** hydrocodone-acetaminophen oral solution /15ml hydrocodone-acetaminophen oral tablet hydrocodone-acetaminophen oral tablet hydrocodone-acetaminophen oral tablet hydrocodone-acetaminophen oral tablet Hycet Lorcet HD Verdrocet Lorcet Lorcet Plus hydrocodone-ibuprofen oral tablet Ibudone hydrocodone-ibuprofen oral tablet hydrocodone-ibuprofen oral tablet Ibudone Ages 18yrs and older: 7 day supply per 90 days. Max 7 day supply per fill. Ages 17 yrs and younger: 3 day supply per 90 days. Max 3 day supply per fill.; QLL (180 ML per 1 day) Ages 18yrs and older: 7 day supply per 90 days. Max 7 day supply per fill. Ages 17 yrs and younger: 3 day supply per 90 days. Max 3 day supply per fill.; QLL (8 EA per 1 day) Ages 18yrs and older: 7 day supply per 90 days. Max 7 day supply per fill. Ages 17 yrs and younger: 3 day supply per 90 days. Max 3 day supply per fill.; QLL (12 EA per 1 day) Ages 18yrs and older: 7 day supply per 90 days. Max 7 day supply per fill. Ages 17 yrs and younger: 3 day supply per 90 days. Max 3 day supply per fill.; QLL (12 EA per 1 day) Ages 18yrs and older: 7 day supply per 90 days. Max 7 day supply per fill. Ages 17 yrs and younger: 3 day supply per 90 days. Max 3 day supply per fill.; QLL (12 EA per 1 day) PA; 30 days supply allowed per 180 days. Maximum 15 days supply per fill. 30 days supply allowed per 180 days. Maximum 15 days supply per fill. PA; Ages 18yrs and older: 7 day supply per 90 days. Max 7 day supply per fill. Ages 17 yrs and younger: 3 day supply per 90 days. Max 3 day supply per fill.; QLL (5 EA per 1 day) 8

14 *Opioid Agonists*** codeine sulfate oral tablet 15 Ages 18yrs and older: 7 day supply per 90 days. Max 7 day supply per fill. Ages 17 yrs and younger: 3 day supply per 90 days. Max 3 day supply per fill.; QLL (24 EA per 1 day) codeine sulfate oral tablet 30 Ages 18yrs and older: 7 day supply per 90 days. Max 7 day supply per fill. Ages 17 yrs and younger: 3 day supply per 90 days. Max 3 day supply per fill.; QLL (12 EA per 1 day) codeine sulfate oral tablet 60 Ages 18yrs and older: 7 day supply per 90 days. Max 7 day supply per fill. Ages 17 yrs and younger: 3 day supply per 90 days. Max 3 day supply per fill.; QLL (6 EA 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 hydromorphone hcl injection solution 2 /ml Dilaudid hydromorphone hcl oral tablet 2 Dilaudid Ages 18yrs and older: 7 day supply per 90 days. Max 7 day supply per fill. Ages 17 yrs and younger: 3 day supply per 90 days. Max 3 day supply per fill.; QLL (4 EA per 1 day) PA; QLL (10 Patches per 30 PA; QLL (10 Patches per 30 PA; QLL (10 Patches per 30 PA; QLL (10 Patches per 30 PA; QLL (10 Patches per 30 Ages 18yrs and older: 7 day supply per 90 days. Max 7 day supply per fill. Ages 17 yrs and younger: 3 day supply per 90 days. Max 3 day supply per fill; QLL (11 EA per 1 day) 9

15 hydromorphone hcl oral tablet 4 Dilaudid Ages 18yrs and older: 7 day supply per 90 days. Max 7 day supply per fill. Ages 17 yrs and younger: 3 day supply per 90 days. Max 3 day supply per fill.; QLL (5 EA per 1 day) hydromorphone hcl oral tablet 8 Dilaudid Ages 18yrs and older: 7 day supply per 90 days. Max 7 day supply per fill. Ages 17 yrs and younger: 3 day supply per 90 days. Max 3 day supply per fill.; QLL (2 EA per 1 day) hydromorphone hcl pf injection solution 10 /ml, 50 /5ml, 500 /50ml Ages 18yrs and older: 7 day supply per 90 days. Max 7 day hydromorphone hcl rectal suppository 3 supply per fill. Ages 17 yrs and younger: 3 day supply per 90 days. Max 3 day supply per fill.; QLL (4 EA per 1 day) methadone hcl oral concentrate 10 /ml Methadone HCl Intensol PA; QLL (3 ML per 1 day) methadone hcl oral solution 10 /5ml PA; QLL (15 ML per 1 day) methadone hcl oral solution 5 /5ml PA; QLL (30 ML per 1 day) methadone hcl oral tablet 10 Dolophine PA; QLL (3 EA per 1 day) methadone hcl oral tablet 5 Dolophine PA; QLL (6 EA per 1 day) methadone hcl oral tablet soluble 40 Methadose PA; QLL (1 EA per 1 day) morphine sulfate (concentrate) oral solution 10 /0.5ml morphine sulfate er oral tablet extended release 100, 200 morphine sulfate er oral tablet extended release 15 morphine sulfate er oral tablet extended release 30 morphine sulfate er oral tablet extended release 60 morphine sulfate oral solution 10 /5ml 10 MS Contin MS Contin MS Contin MS Contin Ages 18yrs and older: 7 day supply per 90 days. Max 7 day supply per fill. Ages 17 yrs and younger: 3 day supply per 90 days. Max 3 day supply per fill.; QLL (4 ML per 1 day) PA; QLL (1 EA per 1 day) PA; QLL (6 EA per 1 day) PA; QLL (3 EA per 1 day) PA; QLL (2 EA per 1 day) Ages 18yrs and older: 7 day supply per 90 days. Max 7 day supply per fill. Ages 17 yrs and younger: 3 day supply per 90 days. Max 3 day supply per fill.; QLL (30 ML per 1 day)

16 morphine sulfate oral solution 20 /5ml morphine sulfate oral tablet 15 morphine sulfate oral tablet 30 morphine sulfate rectal suppository 10, 20, 30, 5 oxycodone hcl oral solution 5 /5ml oxycodone hcl oral tablet 10 oxycodone hcl oral tablet 15 oxycodone hcl oral tablet 20 Roxicodone Ages 18yrs and older: 7 day supply per 90 days. Max 7 day supply per fill. Ages 17 yrs and younger: 3 day supply per 90 days. Max 3 day supply per fill.; QLL (22 ML per 1 day) Ages 18yrs and older: 7 day supply per 90 days. Max 7 day supply per fill. Ages 17 yrs and younger: 3 day supply per 90 days. Max 3 day supply per fill.; QLL (6 EA per 1 day) Ages 18yrs and older: 7 day supply per 90 days. Max 7 day supply per fill. Ages 17 yrs and younger: 3 day supply per 90 days. Max 3 day supply per fill.; QLL (3 EA per 1 day) Ages 18yrs and older: 7 day supply per 90 days. Max 7 day supply per fill. Ages 17 yrs and younger: 3 day supply per 90 days. Max 3 day supply per fill.; QLL (1 EA per 1 day) Ages 18yrs and older: 7 day supply per 90 days. Max 7 day supply per fill. Ages 17 yrs and younger: 3 day supply per 90 days. Max 3 day supply per fill.; QLL (30 ML per 1 day) Ages 18yrs and older: 7 day supply per 90 days. Max 7 day supply per fill. Ages 17 yrs and younger: 3 day supply per 90 days. Max 3 day supply per fill.; QLL (6 EA per 1 day) Ages 18yrs and older: 7 day supply per 90 days. Max 7 day supply per fill. Ages 17 yrs and younger: 3 day supply per 90 days. Max 3 day supply per fill.; QLL (4 EA per 1 day) Ages 18yrs and older: 7 day supply per 90 days. Max 7 day supply per fill. Ages 17 yrs and younger: 3 day supply per 90 days. Max 3 day supply per fill.; QLL (3 EA per 1 day) 11

17 oxycodone hcl oral tablet 30 oxycodone hcl oral tablet 5 oxymorphone hcl er oral tablet extended release 12 hour 10 oxymorphone hcl er oral tablet extended release 12 hour 15, 20 oxymorphone hcl er oral tablet extended release 12 hour 30, 40 oxymorphone hcl er oral tablet extended release 12 hour 5 oxymorphone hcl er oral tablet extended release 12 hour 7.5 tramadol hcl oral tablet 50 *Opioid Combinations*** oxycodone-acetaminophen oral tablet oxycodone-acetaminophen oral tablet , oxycodone-acetaminophen oral tablet Roxicodone Roxicodone Ultram Endocet Endocet Endocet Ages 18yrs and older: 7 day supply per 90 days. Max 7 day supply per fill. Ages 17 yrs and younger: 3 day supply per 90 days. Max 3 day supply per fill.; QLL (2 EA per 1 day) Ages 18yrs and older: 7 day supply per 90 days. Max 7 day supply per fill. Ages 17 yrs and younger: 3 day supply per 90 days. Max 3 day supply per fill.; QLL (6 EA per 1 day) PA; ST; QLL (3 EA per 1 day) PA; ST; QLL (2 EA per 1 day) PA; ST; QLL (1 EA per 1 day) PA; ST; QLL (6 EA per 1 day) PA; ST; QLL (4 EA per 1 day) Ages 18yrs and older: 7 day supply per 90 days. Max 7 day supply per fill. Ages 17 yrs and younger: 3 day supply per 90 days. Max 3 day supply per fill.; QLL (8 EA per 1 day) Ages 18yrs and older: 7 day supply per 90 days. Max 7 day supply per fill. Ages 17 yrs and younger: 3 day supply per 90 days. Max 3 day supply per fill.; QLL (6 EA per 1 day) Ages 18yrs and older: 7 day supply per 90 days. Max 7 day supply per fill. Ages 17 yrs and younger: 3 day supply per 90 days. Max 3 day supply per fill.; QLL (12 EA per 1 day) Ages 18yrs and older: 7 day supply per 90 days. Max 7 day supply per fill. Ages 17 yrs and younger: 3 day supply per 90 days. Max 3 day supply per fill.; QLL (8 EA per 1 day)

18 oxycodone-aspirin oral tablet *Opioid Partial Agonists*** buprenorphine hcl sublingual tablet sublingual 2, 8 buprenorphine hcl-naloxone hcl sublingual tablet sublingual 2-0.5, 8-2 pentazocine-naloxone hcl oral tablet *Tramadol Combinations*** tramadol-acetaminophen oral tablet *ANDROGENS-ANABOLIC* *Androgens*** danazol oral capsule 100, 200, 50 methyltestosterone oral capsule 10 testosterone cypionate intramuscular solution 100 /ml, 200 /ml testosterone enanthate intramuscular solution 200 /ml testosterone transdermal gel 10 /act (2%) Ultracet Android Depo-Testosterone Fortesta testosterone transdermal gel 12.5 /act (1%) Vogelxo Pump testosterone transdermal gel 25 /2.5gm (1%) AndroGel testosterone transdermal gel 50 /5gm (1%) AndroGel *ANORECTAL AGENTS* *Intrarectal Steroids*** hydrocortisone rectal enema 100 /60ml Colocort Ages 18yrs and older: 7 day supply per 90 days. Max 7 day supply per fill. Ages 17 yrs and younger: 3 day supply per 90 days. Max 3 day supply per fill.; QLL (12 EA per 1 day) PA; QLL (60 EA per 30 ; AL (Min 18 Years) PA; QLL (60 EA per 30 ; AL (Min 18 Years) Ages 18yrs and older: 7 day supply per 90 days. Max 7 day supply per fill. Ages 17 yrs and younger: 3 day supply per 90 days. Max 3 day supply per fill.; QLL (4 EA per 1 day) Ages 18yrs and older: 7 day supply per 90 days. Max 7 day supply per fill. Ages 17 yrs and younger: 3 day supply per 90 days. Max 3 day supply per fill.; QLL (8 EA per 1 day) PA; QLL (1 ML per 28 QLL (5 ML per 30 PA; QLL (2 canisters per 30 Days) PA; QLL (4 canisters per 30 PA PA; QLL (60 PACKETS per 30 13

19 CORTIFOAM RECTAL FOAM 10 % *Nitrate Vasodilating Agents*** RECTIV RECTAL OINTMENT 0.4 % PA; QLL (30 gm per 30 *Rectal Anesthetic/Steroids*** lidocaine-hydrocortisone ace rectal cream % lidocaine-hydrocortisone ace rectal kit %, 3-1 % PROCTOFOAM HC RECTAL FOAM 1-1 % *Rectal Steroids*** PROCTO-PAK RECTAL CREAM 1 % Hydrocortisone PROCTOSOL HC RECTAL CREAM 2.5 % Hydrocortisone PROCTOZONE-HC RECTAL CREAM 2.5 % Hydrocortisone *ANTHELMINTICS* *Anthelmintics*** ivermectin oral tablet 3 Stromectol reeses pinworm medicine oral suspension 144 /ml OTC reeses pinworm medicine oral tablet 180 OTC ALBENZA ORAL TABLET 200 MG ST BILTRICIDE ORAL TABLET 600 MG PA *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 nitroglycerin er oral capsule extended release Nitro-Time 2.5, 6.5, 9 nitroglycerin sublingual tablet sublingual 0.3, 0.4, 0.6 Nitrostat 14

20 nitroglycerin transdermal patch 24 hour 0.1 /hr, 0.2 /hr, 0.4 /hr, 0.6 /hr Minitran NITRO-BID TRANSDERMAL OINTMENT 2 % 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 (2 EA per 1 day) 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 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 diazepam injection solution 5 /ml diazepam oral solution 1 /ml diazepam oral tablet 10, 2, 5 Valium lorazepam oral tablet 0.5, 1, 2 Ativan oxazepam oral capsule 10, 15, 30 LORAZEPAM INTENSOL ORAL CONCENTRATE 2 MG/ML LORazepam 15

21 *ANTIARRHYTHMICS* *Antiarrhythmics Type I-A*** disopyramide phosphate oral capsule 100, Norpace 150 procainamide hcl injection solution 100 /ml quinidine gluconate er oral tablet extended release 324 quinidine sulfate oral tablet 200, 300 *Antiarrhythmics Type I-B*** mexiletine hcl oral capsule 150, 200, 250 *Antiarrhythmics Type I-C*** flecainide acetate oral tablet 100, 150, 50 propafenone hcl er oral capsule extended release 12 hour 225, 325, 425 Rythmol SR propafenone hcl oral tablet 150, 225, 300 *Antiarrhythmics Type Iii*** amiodarone hcl oral tablet 100, 200, 400 Pacerone MULTAQ ORAL TABLET 400 MG PA *ANTIASTHMATIC AND BRONCHODILATOR AGENTS* *Adrenergic Combinations*** fluticasone-salmeterol inhalation aerosol powder breath activated mcg/act AirDuo RespiClick 113/14 QLL (1 Inhaler per 30 fluticasone-salmeterol inhalation aerosol powder breath activated mcg/act AirDuo RespiClick 232/14 QLL (1 Inhaler per 30 fluticasone-salmeterol inhalation aerosol powder breath activated mcg/act AirDuo RespiClick 55/14 QLL (1 Inhaler per 30 ipratropium-albuterol inhalation solution (3) /3ml ANORO ELLIPTA INHALATION AEROSOL POWDER BREATH QLL (1 inhaler per 30 Days) ACTIVATED MCG/INH BREO ELLIPTA INHALATION AEROSOL POWDER BREATH ACTIVATED MCG/INH, QLL (1 EA per 30 MCG/INH COMBIVENT RESPIMAT INHALATION AEROSOL SOLUTION MCG/ACT 16

22 DULERA INHALATION AEROSOL MCG/ACT, MCG/ACT QLL (1 EA per 30 STIOLTO RESPIMAT INHALATION AEROSOL SOLUTION MCG/ACT ST; QLL (1 inhaler per 30 *Anti-Inflammatory Agents*** cromolyn sodium inhalation nebulization solution 20 /2ml *Beta Adrenergics*** albuterol sulfate inhalation nebulization solution (2.5 /3ml) 0.083% QLL (15 ML per 1 day) albuterol sulfate inhalation nebulization solution (5 /ml) 0.5% QLL (15 EA per 1 day) albuterol sulfate inhalation nebulization solution 0.63 /3ml, 1.25 /3ml ST; AL (Max 17 Years) albuterol sulfate oral syrup 2 /5ml levalbuterol tartrate inhalation aerosol 45 mcg/act Xopenex HFA ST; QLL (2 INH per 30 metaproterenol sulfate oral syrup 10 /5ml metaproterenol sulfate oral tablet 10, 20 ARCAPTA NEOHALER INHALATION CAPSULE 75 MCG QLL (1 Inhaler per 30 STRIVERDI RESPIMAT INHALATION AEROSOL SOLUTION 2.5 MCG/ACT QLL (1 Respimat per 30 VENTOLIN HFA INHALATION AEROSOL SOLUTION 108 (90 BASE) QLL (2 Inhaler per 30 MCG/ACT *Bronchodilators - Anticholinergics*** ipratropium bromide inhalation solution 0.02 % ATROVENT HFA INHALATION AEROSOL SOLUTION 17 MCG/ACT INCRUSE ELLIPTA INHALATION AEROSOL POWDER BREATH QLL (1 Inhaler per 30 ACTIVATED 62.5 MCG/INH *Leukotriene Receptor Antagonists*** montelukast sodium oral packet 4 Singulair AL (Max 2 Years) montelukast sodium oral tablet 10 Singulair montelukast sodium oral tablet chewable 4, 5 Singulair 17

23 zafirlukast oral tablet 10, 20 Accolate ST *Steroid Inhalants*** budesonide inhalation suspension 0.25 /2ml, 0.5 /2ml Pulmicort QLL (120 ML per 30 budesonide inhalation suspension 1 /2ml Pulmicort FLOVENT DISKUS INHALATION AEROSOL POWDER BREATH ACTIVATED 100 MCG/BLIST, 250 MCG/BLIST, 50 MCG/BLIST FLOVENT HFA INHALATION AEROSOL 110 MCG/ACT, 220 MCG/ACT QLL (0.4 GM per 1 day) FLOVENT HFA INHALATION AEROSOL 44 MCG/ACT QLL (0.35 GM per 1 day) PULMICORT FLEXHALER INHALATION AEROSOL POWDER BREATH ACTIVATED 180 MCG/ACT, 90 QLL (1 Bottle per 30 MCG/ACT QVAR INHALATION AEROSOL SOLUTION 40 MCG/ACT, 80 MCG/ACT QLL (1 Inhaler per 30 QVAR REDIHALER INHALATION AEROSOL BREATH ACTIVATED 40 QLL (10.6 GM per 30 MCG/ACT QVAR REDIHALER INHALATION AEROSOL BREATH ACTIVATED 80 QLL (21.2 GM per 30 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 THEOCHRON ORAL TABLET EXTENDED RELEASE 12 HOUR 100 Theochron MG, 200 MG, 300 MG *ANTICOAGULANTS* *Coumarin Anticoagulants*** warfarin sodium oral tablet 1, 10, 2, 2.5, 3, 4, 5, 6, 7.5 Coumadin JANTOVEN ORAL TABLET 1 MG, 10 MG, 2 MG, 2.5 MG, 3 MG, 4 MG, 5 MG, 6 Coumadin MG, 7.5 MG 18

24 *Direct Factor Xa Inhibitors*** ELIQUIS ORAL TABLET 2.5 MG, 5 MG PA; QLL (60 EA per 30 XARELTO ORAL TABLET 10 MG, 15 MG, 20 MG PA; QLL (30 EA per 30 XARELTO STARTER PACK ORAL TABLET THERAPY PACK 15 & 20 MG PA; QLL (1 FILL per 90 *Heparins And Heparinoid-Like Agents*** heparin sodium (porcine) injection solution 1000 unit/ml, unit/ml, unit/ml, 5000 unit/ml heparin sodium (porcine) pf injection solution 5000 unit/0.5ml *Low Molecular Weight Heparins*** enoxaparin sodium injection solution 300 /3ml Lovenox QLL (21 days per 180 enoxaparin sodium subcutaneous solution 100 /ml, 120 /0.8ml, 150 /ml, 30 /0.3ml, 40 /0.4ml, 60 /0.6ml, 80 Lovenox QLL (21 days per 180 /0.8ml *ANTICONVULSANTS* *Anticonvulsants - Benzodiazepines*** clonazepam oral tablet 0.5, 1, 2 KlonoPIN clonazepam oral tablet dispersible 0.125, 0.25, 0.5, 1, 2 *Anticonvulsants - Misc.*** carbamazepine er oral capsule extended release 12 hour 100, 200, 300 Carbatrol carbamazepine er oral tablet extended release TEGretol-XR 12 hour 100 carbamazepine er oral tablet extended release 12 hour 200, 400 TEGretol-XR carbamazepine oral suspension 100 /5ml TEGretol carbamazepine oral tablet 200 Epitol carbamazepine oral tablet chewable 100 gabapentin oral capsule 100, 300, 400 Neurontin ; QLL (120 EA per 30 ; QLL (6 EA per 1 day) gabapentin oral solution 250 /5ml Neurontin gabapentin oral tablet 600 Neurontin ; QLL (6 EA per 1 day) 19

25 gabapentin oral tablet 800 Neurontin ; QLL (4.5 EA per 1 day) lamotrigine oral tablet 100, 150, 200, 25 LaMICtal lamotrigine oral tablet chewable 25, 5 LaMICtal levetiracetam er oral tablet extended release 24 hour 500, 750 Keppra XR levetiracetam oral solution 100 /ml Keppra levetiracetam oral tablet 1000, 250, 500, 750 Keppra oxcarbazepine oral suspension 300 /5ml Trileptal oxcarbazepine oral tablet 150, 300, 600 Trileptal primidone oral tablet 250, 50 Mysoline topiramate oral capsule sprinkle 15, 25 Topamax Sprinkle ; QLL (120 EA per 30 topiramate oral tablet 100, 200, 25, 50 Topamax ; QLL (120 EA per 30 zonisamide oral capsule 100, 25 Zonegran zonisamide oral capsule 50 ; QLL (6 EA per 1 day) *Carbamates*** felbamate oral suspension 600 /5ml Felbatol felbamate oral tablet 400, 600 Felbatol *Gaba Modulators*** tiagabine hcl oral tablet 2 Gabitril tiagabine hcl oral tablet 4 Gabitril ; QLL (60 EA per 30 GABITRIL ORAL TABLET 12 MG, 16 MG *Hydantoins*** phenytoin oral suspension 125 /5ml Dilantin phenytoin oral tablet chewable 50 Dilantin Infatabs phenytoin sodium extended oral capsule 100 Dilantin phenytoin sodium extended oral capsule 200, 300 Phenytek DILANTIN ORAL CAPSULE 100 MG Dilantin *Succinimides*** ethosuximide oral capsule 250 Zarontin ethosuximide oral solution 250 /5ml Zarontin 20

26 *Valproic Acid*** divalproex sodium er oral tablet extended release 24 hour 250, 500 Depakote ER divalproex sodium oral capsule delayed release sprinkle 125 Depakote Sprinkles divalproex sodium oral tablet delayed release 125, 250, 500 Depakote valproic acid oral capsule 250 Depakene valproic acid oral solution 250 /5ml Depakene *ANTIDEPRESSANTS* *Alpha-2 Receptor Antagonists (Tetracyclics)*** mirtazapine oral tablet 15 Remeron QLL (30 EA per 30 mirtazapine oral tablet 30 Remeron QLL (60 EA per 30 mirtazapine oral tablet 45 Remeron QLL (45 EA per 30 mirtazapine oral tablet 7.5 QLL (30 EA per 30 mirtazapine oral tablet dispersible 15, 45 Remeron SolTab QLL (30 EA per 30 mirtazapine oral tablet dispersible 30 Remeron SolTab QLL (60 EA per 30 *Antidepressants - Misc.*** bupropion hcl er (sr) oral tablet extended release 12 hour 100 Wellbutrin SR QLL (120 EA per 30 bupropion hcl er (sr) oral tablet extended release 12 hour 150 Wellbutrin SR QLL (2 EA per 1 day) bupropion hcl er (sr) oral tablet extended release 12 hour 200 Wellbutrin SR QLL (30 EA per 30 bupropion hcl er (xl) oral tablet extended release 24 hour 150 Wellbutrin XL QLL (90 EA per 30 bupropion hcl er (xl) oral tablet extended release 24 hour 300 Wellbutrin XL QLL (30 EA per 30 bupropion hcl oral tablet 100 QLL (135 EA per 30 bupropion hcl oral tablet 75 QLL (180 EA per 30 maprotiline hcl oral tablet 25 QLL (9 EA per 1 day) maprotiline hcl oral tablet 50 QLL (5 EA per 1 day) maprotiline hcl oral tablet 75 QLL (3 EA per 1 day) *Modified Cyclics*** trazodone hcl oral tablet 100 QLL (6 EA per 1 day) trazodone hcl oral tablet 150 QLL (4 EA per 1 day) trazodone hcl oral tablet 50 QLL (12 EA per 1 day) 21

27 *Monoamine Oxidase Inhibitors (Maois)*** phenelzine sulfate oral tablet 15 Nardil QLL (6 EA per 1 day) tranylcypromine sulfate oral tablet 10 Parnate QLL (6 EA per 1 day) MARPLAN ORAL TABLET 10 MG QLL (180 EA per 30 *Selective Serotonin Reuptake Inhibitors (Ssris)*** citalopram hydrobromide oral solution 10 /5ml QLL (600 ML per 30 citalopram hydrobromide oral tablet 10, 20, 40 CeleXA QLL (30 EA per 30 escitalopram oxalate oral solution 5 /5ml QLL (600 ML per 30 escitalopram oxalate oral tablet 10, 20, Lexapro 5 QLL (30 EA per 30 fluoxetine hcl oral capsule 10 PROzac QLL (30 EA per 30 fluoxetine hcl oral capsule 20 PROzac QLL (120 EA per 30 fluoxetine hcl oral capsule 40 PROzac QLL (60 EA per 30 fluoxetine hcl oral solution 20 /5ml QLL (600 ML per 30 fluvoxamine maleate oral tablet 100 QLL (3 EA per 1 day) fluvoxamine maleate oral tablet 25 QLL (1 EA per 1 day) fluvoxamine maleate oral tablet 50 QLL (2 EA per 1 day) paroxetine hcl oral tablet 10, 20, 30, 40 Paxil QLL (1 EA per 1 day) sertraline hcl oral concentrate 20 /ml Zoloft QLL (300 ML per 30 sertraline hcl oral tablet 100 Zoloft QLL (75 EA per 30 sertraline hcl oral tablet 25 Zoloft QLL (30 Tablet per 30 sertraline hcl oral tablet 50 Zoloft QLL (60 Tablet per 30 *Serotonin-Norepinephrine Reuptake Inhibitors (Snris)*** duloxetine hcl oral capsule delayed release particles 20, 30, 60 Cymbalta QLL (30 EA per 30 duloxetine hcl oral capsule delayed release particles 40 QLL (30 EA per 30 venlafaxine hcl er oral capsule extended release 24 hour 150 Effexor XR QLL (60 EA per 30 venlafaxine hcl er oral capsule extended release 24 hour 37.5, 75 Effexor XR QLL (1 EA per 1 day) venlafaxine hcl oral tablet 100 QLL (3 EA per 1 day) venlafaxine hcl oral tablet 25 QLL (9 EA per 1 day) venlafaxine hcl oral tablet 37.5 QLL (10 EA per 1 day) 22

28 venlafaxine hcl oral tablet 50 QLL (7 EA per 1 day) venlafaxine hcl oral tablet 75 QLL (5 EA per 1 day) *Tricyclic Agents*** amitriptyline hcl oral tablet 10 QLL (30 Tablets per 1 day) amitriptyline hcl oral tablet 100 QLL (3 Tablets per 1 day) amitriptyline hcl oral tablet 150, 75 QLL (2 Tablets per 1 day) amitriptyline hcl oral tablet 25 QLL (12 Tablets per 1 day) amitriptyline hcl oral tablet 50 QLL (6 Tablets per 1 day) amoxapine oral tablet 100 QLL (6 EA per 1 day) amoxapine oral tablet 150 QLL (4 EA per 1 day) amoxapine oral tablet 25 QLL (24 EA per 1 day) amoxapine oral tablet 50 QLL (12 EA per 1 day) desipramine hcl oral tablet 10, 25 Norpramin desipramine hcl oral tablet 100 QLL (90 EA per 30 desipramine hcl oral tablet 150 QLL (60 EA per 30 desipramine hcl oral tablet 50 QLL (180 EA per 30 desipramine hcl oral tablet 75 QLL (120 EA per 30 doxepin hcl oral capsule 10 QLL (30 EA per 1 day) doxepin hcl oral capsule 100 QLL (3 EA per 1 day) doxepin hcl oral capsule 150 QLL (2 EA per 1 day) doxepin hcl oral capsule 25 QLL (12 EA per 1 day) doxepin hcl oral capsule 50 QLL (6 EA per 1 day) doxepin hcl oral capsule 75 QLL (4 EA per 1 day) doxepin hcl oral concentrate 10 /ml imipramine hcl oral tablet 10, 25 Tofranil imipramine hcl oral tablet 50 Tofranil QLL (180 EA per 30 nortriptyline hcl oral capsule 10 Pamelor nortriptyline hcl oral capsule 25 Pamelor QLL (180 EA per 30 nortriptyline hcl oral capsule 50 Pamelor QLL (90 EA per 30 nortriptyline hcl oral capsule 75 Pamelor QLL (60 EA per 30 nortriptyline hcl oral solution 10 /5ml protriptyline hcl oral tablet 10 QLL (6 EA per 1 day) protriptyline hcl oral tablet 5 QLL (12 EA per 1 day) *ANTIDIABETICS* *Alpha-Glucosidase Inhibitors*** acarbose oral tablet 100, 25, 50 Precose 23

29 *Biguanides*** metformin hcl er oral tablet extended release 24 hour 500, 750 metformin hcl oral tablet 1000, 500, 850 *Diabetic Other*** GLUCAGEN HYPOKIT INJECTION SOLUTION RECONSTITUTED 1 MG *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 JANUMET XR ORAL TABLET EXTENDED RELEASE 24 HOUR MG, MG, MG *Dpp-4 Inhibitor-Thiazolidinedione Combinations*** alogliptin-pioglitazone oral tablet , , , 25-15, 25-30, *Human Insulin*** BASAGLAR KWIKPEN SUBCUTANEOUS SOLUTION PEN- INJECTOR 100 UNIT/ML HUMALOG KWIKPEN SUBCUTANEOUS SOLUTION PEN- INJECTOR 100 UNIT/ML, 200 UNIT/ML HUMALOG MIX 50/50 KWIKPEN SUBCUTANEOUS SUSPENSION PEN- INJECTOR (50-50) 100 UNIT/ML HUMALOG MIX 50/50 SUBCUTANEOUS SUSPENSION (50-50) 100 UNIT/ML HUMALOG MIX 75/25 KWIKPEN SUBCUTANEOUS SUSPENSION PEN- INJECTOR (75-25) 100 UNIT/ML 24 Glucophage XR Glucophage Nesina Kazano Oseni ST; QLL (30 EA per 30 ST; QLL (60 EA per 30 ST; QLL (30 EA per 30 PA; PA;

30 HUMALOG MIX 75/25 SUBCUTANEOUS SUSPENSION (75-25) 100 UNIT/ML HUMALOG SUBCUTANEOUS SOLUTION 100 UNIT/ML HUMULIN 70/30 SUBCUTANEOUS SUSPENSION (70-30) 100 UNIT/ML ; OTC HUMULIN R INJECTION SOLUTION 100 UNIT/ML ; OTC HUMULIN R U-500 (CONCENTRATED) SUBCUTANEOUS SOLUTION 500 UNIT/ML NOVOLIN 70/30 RELION SUBCUTANEOUS SUSPENSION (70-30) ; OTC 100 UNIT/ML NOVOLIN 70/30 SUBCUTANEOUS SUSPENSION (70-30) 100 UNIT/ML ; OTC NOVOLIN N RELION SUBCUTANEOUS SUSPENSION 100 UNIT/ML ; OTC NOVOLIN N SUBCUTANEOUS SUSPENSION 100 UNIT/ML ; OTC NOVOLIN R INJECTION SOLUTION 100 UNIT/ML ; OTC NOVOLIN R RELION INJECTION SOLUTION 100 UNIT/ML ; OTC NOVOLOG FLEXPEN SUBCUTANEOUS SOLUTION PEN-INJECTOR 100 UNIT/ML NOVOLOG MIX 70/30 FLEXPEN SUBCUTANEOUS SUSPENSION PEN- PA; INJECTOR (70-30) 100 UNIT/ML NOVOLOG MIX 70/30 SUBCUTANEOUS SUSPENSION (70-30) 100 UNIT/ML NOVOLOG PENFILL SUBCUTANEOUS SOLUTION CARTRIDGE 100 UNIT/ML NOVOLOG SUBCUTANEOUS SOLUTION 100 UNIT/ML *Incretin Mimetic Agents (Glp-1 Receptor Agonists)*** TANZEUM SUBCUTANEOUS PEN- INJECTOR 30 MG, 50 MG TRULICITY SUBCUTANEOUS SOLUTION PEN-INJECTOR 0.75 MG/0.5ML, 1.5 MG/0.5ML ST; ; QLL (4 EA per 30 ST; 25

31 *Meglitinide Analogues*** nateglinide oral tablet 120, 60 Starlix repaglinide oral tablet 0.5 repaglinide oral tablet 1, 2 Prandin *Meglitinide-Biguanide Combinations*** repaglinide-metformin hcl oral tablet 1-500, *Sodium-Glucose Co-Transporter 2 (Sglt2) Inhibitors*** INVOKANA ORAL TABLET 100 MG, 300 MG *Sulfonylurea-Biguanide Combinations*** glipizide-metformin hcl oral tablet , , glyburide-metformin oral tablet glyburide-metformin oral tablet , *Sulfonylureas*** chlorpropamide oral tablet 100, 250 Glucovance ST; ; QLL (30 EA per 30 glimepiride oral tablet 1, 2, 4 Amaryl glipizide er oral tablet extended release 24 hour 10, 2.5, 5 Glucotrol XL glipizide oral tablet 10, 5 Glucotrol glyburide micronized oral tablet 1.5, 3, Glynase 6 glyburide oral tablet 1.25, 2.5, 5 tolazamide oral tablet 250, 500 tolbutamide oral tablet 500 *Sulfonylurea-Thiazolidinedione Combinations*** pioglitazone hcl-glimepiride oral tablet 30-2, 30-4 Duetact *Thiazolidinedione-Biguanide Combinations*** pioglitazone hcl-metformin hcl oral tablet , Actoplus Met 26

32 *Thiazolidinediones*** pioglitazone hcl oral tablet 15, 30, 45 Actos AVANDIA ORAL TABLET 2 MG, 4 MG ST; *ANTIDIARRHEALS* *Antiperistaltic Agents*** diphenoxylate-atropine oral liquid /5ml diphenoxylate-atropine oral tablet Lomotil loperamide hcl oral capsule 2 Imodium A-D *ANTIDOTES* *Antidotes - Chelating Agents*** CHEMET ORAL CAPSULE 100 MG *Opioid Antagonists*** naloxone hcl injection solution 0.4 /ml ; QLL (2 ML Max Qty Per Fill Retail) naltrexone hcl oral tablet 50 NARCAN NASAL LIQUID 4 MG/0.1ML ; QLL (4 EA Max Qty Per Fill Retail) *ANTIEMETICS* *5-Ht3 Receptor Antagonists*** granisetron hcl oral tablet 1 ondansetron hcl oral solution 4 /5ml Zofran ondansetron hcl oral tablet 24 ondansetron hcl oral tablet 4, 8 Zofran ondansetron oral tablet dispersible 4, 8 Zofran ODT *Antiemetics - Anticholinergic*** trimethobenzamide hcl oral capsule 300 Tigan *Substance P/Neurokinin 1 (Nk1) Receptor Antagonists*** EMEND ORAL CAPSULE 125 MG, 40 MG, 80 MG Aprepitant *ANTIFUNGALS* *Antifungals*** griseofulvin microsize oral suspension 125 /5ml griseofulvin microsize oral tablet

33 griseofulvin ultramicrosize oral tablet 125, Gris-PEG 250 nystatin oral tablet unit terbinafine hcl oral tablet 250 LamISIL QLL (84 EA per 365 *Imidazoles*** ketoconazole oral tablet 200 *Triazoles*** fluconazole oral suspension reconstituted 10 /ml, 40 /ml Diflucan fluconazole oral tablet 100, 150, 200, 50 Diflucan itraconazole oral capsule 100 Sporanox SPORANOX ORAL SOLUTION 10 MG/ML *ANTIHISTAMINES* *Antihistamines - Alkylamines*** brompheniramine tannate oral tablet chewable 12 *Antihistamines - Ethanolamines*** carbinoxamine maleate oral tablet 4 clemastine fumarate oral tablet 2.68 *Antihistamines - Non-Sedating*** cetirizine hcl oral syrup 1 /ml, 5 /5ml KLS Aller-Tec Childrens QLL (150 ML per 30 *Antihistamines - Phenothiazines*** promethazine hcl oral solution 6.25 /5ml promethazine hcl oral syrup 6.25 /5ml promethazine hcl oral tablet 12.5, 25, 50 promethazine hcl rectal suppository 12.5, 25 Phenadoz *Antihistamines - Piperidines*** cyproheptadine hcl oral syrup 2 /5ml cyproheptadine hcl oral tablet 4 *ANTIHYPERLIPIDEMICS* *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 28

34 colestipol hcl oral tablet 1 gm Colestid *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 EA per 30 *H Coa Reductase Inhibitors*** atorvastatin calcium oral tablet 10, 20, 40, 80 fluvastatin sodium er oral tablet extended release 24 hour 80 fluvastatin sodium oral capsule 20 fluvastatin sodium oral capsule 40 lovastatin oral tablet 10, 20 lovastatin oral tablet 40 pravastatin sodium oral tablet 10 pravastatin sodium oral tablet 20, 40, 80 rosuvastatin calcium oral tablet 10, 20, 40, 5 simvastatin oral tablet 10, 20, 40, 5 simvastatin oral tablet 80 Lipitor Lescol XL Lescol Mevacor Pravachol Crestor Zocor Zocor *Intestinal Cholesterol Absorption Inhibitors*** ezetimibe oral tablet 10 Zetia ST; ; QLL (30 EA per 30 ; QLL (30 EA per 30 ; QLL (2 EA per 1 day) ; QLL (2 EA per 1 day) ; QLL (1 EA per 1 day) ; QLL (2 EA per 1 day) ; QLL (60 EA per 30 ; QLL (1 EA per 1 day) PA; QLL (30 EA per 30 ; QLL (1 EA per 1 day) ; QLL (30 EA per 30 29

35 *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 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 EA per 30 lisinopril oral tablet 2.5, 30 Zestril ; QLL (30 EA per 30 lisinopril oral tablet 40 Zestril ; QLL (60 EA per 30 30