AETNA BETTER HEALTH Formulary Guide Aetna Better Health of Kentucky Formulary Guide March 2018

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1 AETNA BETTER HEALTH Formulary Guide Aetna Better Health of Kentucky Formulary Guide March

2 AETNA BETTER HEALTH Formulary Guide What is the Aetna Better Health of Kentucky Formulary? This is a drug list created by Aetna Better Health ( plan ). The plan will cover drugs on this list. Some drugs may have coverage rules. If the rules for that drug are met, the plan will cover the drug. Drugs must also be filled at a plan network pharmacy. Can the Plan s Drug List change? The plan may add or remove drugs on the list. All drug removals from the formulary will be sent to the state for review before the change is made. Utilizing members and their providers will be notified at least 30 days before a drug is removed from the formulary. All changes to the formulary will be posted on the plan s website. How do I use the Plan s Formulary? Column #1: lists the covered drug. Brand drugs are in upper case letters (e.g., DRUG). Generics are in lower case letters (e.g., drug). Column #2: shows brand drug for the generic; brand drugs are not covered if generic equivalent is available. Column #3: tells you if drug has a need for prior authorization or other restrictions Drugs are also grouped by drug class. If you know what class your drug is in, please look for that class name in the table of contents. Then look under that page for your drug. What are generic drugs? The plan covers both brand and generic drugs. Generic drugs cost less and are approved by the Food and Drug Administration (FDA). Are Over-The-Counter (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. Are there Medication Copays? Refer to member handbook for copay information. Updated: 3/1/2018 P a g e 2

3 AETNA BETTER HEALTH Formulary Guide What are some types of coverage rules? Prior Approval (): This means your doctor will need to get approval from the plan first before the drug can be filled at the pharmacy. If it is not approved, the plan will not cover the drug. Quantity Level Limits (QLL): This means there is a limit on the amount of drug the plan will cover. For example, the plan provides 60 pills in 30 days for some drugs. Step Therapy (ST): This means you may need to try certain drugs first to treat your condition. After the first drug is tried, the plan will then cover the other drug for that same condition. For example, Drug A and Drug B may treat your condition. The plan may not cover Drug B unless you try Drug A first. If Drug A does not work for you, then Drug B will be covered. What if my drug is not on the plan s Formulary? First, please call your doctor and ask if your drug is covered. If the plan does not cover the drug, then: Ask your doctor for a similar drug that is covered. Your doctor can ask the plan to cover your drug through the prior approval process. Updated: 3/1/2018 P a g e 3

4 Aetna Better Health Kentucky Table of Contents *ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS*...4 *AMINOGLYCOSIDES*... 6 *ANALGESICS - ANTI-INFLAMMATORY*...6 *ANALGESICS - NONNARCOTIC*...8 *ANALGESICS - OPIOID*... 9 *ANDROGENS-ANABOLIC*...11 *ANORECTAL AGENTS* *ANTHELMINTICS* *ANTIANGINAL AGENTS* *ANTIANXIETY AGENTS* *ANTIARRHYTHMICS* *ANTIASTHMATIC AND BRONCHODILATOR AGENTS*...15 *ANTICOAGULANTS* *ANTICONVULSANTS* *ANTIDEPRESSANTS* *ANTIDIABETICS* *ANTIDIARRHEALS* *ANTIDOTES* *ANTIEMETICS* *ANTIFUNGALS* *ANTIHISTAMINES* *ANTIHYPERLIPIDEMICS* *ANTIHYPERTENSIVES* *ANTI-INFECTIVE AGENTS - MISC.*...30 *ANTIMALARIALS* *ANTIMYASTHENIC AGENTS*...31 *ANTIMYASTHENIC/CHOLINERGIC AGENTS*...31 *ANTIMYCOBACTERIAL AGENTS*...31 *ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES*...32 *ANTIRKINSON AGENTS*...34 *ANTIPSYCHOTICS/ANTIMANIC AGENTS*...35 *ANTIRETROVIRALS ADJUVANTS***

5 *ANTISEPTICS & DISINFECTANTS*...38 *ANTIVIRALS* *ASSORTED CLASSES* *BETA BLOCKERS* *CALCIUM CHANNEL BLOCKERS*...44 *CARDIOTONICS* *CARDIOVASCULAR AGENTS - MISC.*...46 *CEPHALOSPORINS* *CHEMICALS* *CONTRACEPTIVES* *CORTICOSTEROIDS* *COUGH/COLD/ALLERGY*...54 *DERMATOLOGICALS* *DIAGNOSTIC PRODUCTS*...61 *DIGESTIVE AIDS* *DIURETICS* *ENDOCRINE AND METABOLIC AGENTS - MISC.*...63 *ESTROGENS* *FLUOROQUINOLONES* *GASTROINTESTINAL AGENTS - MISC.*...65 *GENITOURINARY AGENTS - MISCELLANEOUS*...66 *GOUT AGENTS* *HEMATOLOGICAL AGENTS - MISC.*...67 *HEMATOPOIETIC AGENTS*...68 *HETITIS C AGENT - COMBINATIONS***...69 *HYPNOTICS* *LAXATIVES* *MACROLIDES* *MEDICAL DEVICES* *MIGRAINE PRODUCTS* *MINERALS & ELECTROLYTES*...76 *MOUTH/THROAT/DENTAL AGENTS*...77 *MULTIVITAMINS* *MUSCULOSKELETAL THERAPY AGENTS*...83 *NASAL AGENTS - SYSTEMIC AND TOPICAL*...83 *NEPRILYSIN INHIB (ARNI)-ANGIOTENSIN II RECEPT ANTAG COMB***...84 *NEUROMUSCULAR AGENTS*...84 *OPHTHALMIC AGENTS*

6 *OTIC AGENTS* *SSIVE IMMUNIZING AGENTS*...87 *PENICILLINS* *PHARMACEUTICAL ADJUVANTS*...89 *POTASSIUM REMOVING AGENTS***...95 *PROGESTINS* *PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.*...95 *RESPIRATORY AGENTS - MISC.* *SEROTONIN MODULATORS*** *SINUS NODE INHIBITORS** *SODIUM-GLUCOSE CO-TRANSPORTER 2 INHIBITOR-BIGUANIDE COMB*** *SULFONAMIDES* *TETRACYCLINES* *THYROID AGENTS* *ULCER DRUGS* *URINARY ANTI-INFECTIVES* *URINARY ANTISSMODICS* *VACCINES* *VAGINAL PRODUCTS* *VASOPRESSORS* *VITAMINS*

7 Aetna Better Health Kentucky CURRENT AS OF 3/1/2018 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, 5 amphetamine-dextroamphet er oral capsule extended release 24 hour 30 amphetamine-dextroamphetamine oral tablet 10, 12.5, 15, 20, 5, 7.5 amphetamine-dextroamphetamine oral tablet 30 *Amphetamines*** dextroamphetamine sulfate er oral capsule extended release 24 hour 10, 15 dextroamphetamine sulfate er oral capsule extended release 24 hour 5 dextroamphetamine sulfate oral tablet 10, 5 zenzedi oral tablet 10, 5 Intuniv Adderall XR Adderall XR Adderall Adderall Dexedrine Dexedrine Zenzedi Zenzedi QLL (30 EA per 30 days); AL (Min 6 Years) QLL (30 EA 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; AL (Min 6 Years and Max 18 Years) QLL (90 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 (120 EA 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 (180 EA per 30 days); AL (Min 6 Years and Max 18 Years) QLL (180 EA per 30 days); AL (Min 6 Years and Max 18 Years) *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) 4

8 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 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 methylphenidate hcl er oral tablet extended release 10 methylphenidate hcl er oral tablet extended release 18, 27, 54 methylphenidate hcl er oral tablet extended release 20 methylphenidate hcl er oral tablet extended release 24 hour 18, 27, 54 methylphenidate hcl er oral tablet extended release 24 hour 36 methylphenidate hcl er oral tablet extended release 36 methylphenidate hcl oral solution 10 /5ml, 5 /5ml Focalin XR Focalin Metadate ER Ritalin LA Ritalin LA Concerta Metadate ER Concerta Methylin 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 (90 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) 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) QLL (90 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) QLL (90 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) QLL (60 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 (900 ML per 30 days); AL (Min 6 Years and Max 18 Years) 5

9 methylphenidate hcl oral tablet 10, 20, 5 methylphenidate hcl oral tablet chewable 10 methylphenidate hcl oral tablet chewable 2.5, 5 Ritalin *AMINOGLYCOSIDES* *Aminoglycosides*** neomycin sulfate oral tablet 500 paromomycin sulfate oral capsule 250 tobramycin inhalation nebulization solution Kitabis Pak 300 /5ml KITABIS K INHALATION NEBULIZATION SOLUTION 300 Kitabis Pak MG/5ML *ANALGESICS - ANTI- INFLAMMATORY* *Anti-Tnf-Alpha - Monoclonal Antibodies*** HUMIRA PEDIATRIC CROHNS START SUBCUTANEOUS PREFILLED SYRINGE KIT 40 MG/0.8ML HUMIRA PEN SUBCUTANEOUS PEN- INJECTOR KIT 40 MG/0.8ML HUMIRA PEN-CROHNS STARTER SUBCUTANEOUS PEN-INJECTOR KIT 40 MG/0.8ML HUMIRA PEN-PSORIASIS STARTER SUBCUTANEOUS PEN-INJECTOR KIT 40 MG/0.8ML HUMIRA SUBCUTANEOUS PREFILLED SYRINGE KIT 20 MG/0.4ML, 40 MG/0.8ML *Anti-Tnf-Alpha - Monoclonoal Antibodies*** HUMIRA PEDIATRIC CROHNS START SUBCUTANEOUS PREFILLED SYRINGE KIT 40 MG/0.8ML QLL (90 EA per 30 days); AL (Min 6 Years and Max 18 Years) QLL (180 EA per 30 days); AL (Min 5 Years and Max 18 Years) QLL (150 EA per 30 days); AL (Min 5 Years and Max 18 Years) 6

10 HUMIRA PEN SUBCUTANEOUS PEN- INJECTOR KIT 40 MG/0.8ML HUMIRA PEN-CROHNS STARTER SUBCUTANEOUS PEN-INJECTOR KIT 40 MG/0.8ML HUMIRA PEN-PSORIASIS STARTER SUBCUTANEOUS PEN-INJECTOR KIT 40 MG/0.8ML HUMIRA SUBCUTANEOUS PREFILLED SYRINGE KIT 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 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 meclofenamate sodium oral capsule 100, 50 ST; AL (Min 65 Years) QLL (2 Claims per 180 days) 7

11 meloxicam oral tablet 15, 7.5 nabumetone oral tablet 500, 750 naproxen dr oral tablet delayed release 375, 500 Mobic EC-Naprosyn naproxen oral suspension 125 /5ml Naprosyn ST naproxen oral tablet 250, 500 naproxen oral tablet 375 naproxen sodium oral tablet 275 oxaprozin oral tablet 600 piroxicam oral capsule 10, 20 Naprosyn Daypro 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 ENBREL SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 25 MG/0.5ML, 50 MG/ML ENBREL SURECLICK SUBCUTANEOUS SOLUTION AUTO-INJECTOR 50 MG/ML *ANALGESICS - NONNARCOTIC* *Analgesics-Sedatives*** butalbital-acetaminophen oral tablet Tencon QLL (90 EA per 15 Days) butalbital-apap oral tablet Tencon QLL (90 EA per 15 Days) butalbital-apap-caffeine oral capsule Fioricet QLL (90 EA per 15 Days) butalbital-apap-caffeine oral capsule Esgic QLL (90 EA per 15 Days) butalbital-apap-caffeine oral tablet Esgic QLL (90 EA per 15 Days) butalbital-asa-caffeine oral capsule Fiorinal QLL (90 EA per 15 Days) 8

12 butalbital-aspirin-caffeine oral capsule Fiorinal QLL (90 EA per 15 Days) esgic oral capsule Esgic QLL (90 EA per 15 Days) phrenilin forte oral capsule Fioricet QLL (90 EA per 15 Days) tencon oral tablet Tencon QLL (90 EA per 15 Days) zebutal oral capsule Esgic QLL (90 EA per 15 Days) *Salicylate Combinations*** choline-mag trisalicylate oral liquid 500 /5ml *Salicylates*** diflunisal oral tablet 500 salsalate oral tablet 500, 750 *ANALGESICS - OPIOID* *Codeine Combinations*** acetaminophen-codeine #2 oral tablet acetaminophen-codeine #3 oral tablet Tylenol with Codeine #3 acetaminophen-codeine #4 oral tablet Tylenol with Codeine #4 acetaminophen-codeine oral solution /5ml acetaminophen-codeine oral tablet acetaminophen-codeine oral tablet Tylenol with Codeine #4 ascomp-codeine oral capsule Ascomp-Codeine butalbital-apap-caff-cod oral capsule Fioricet/Codeine butalbital-apap-caff-cod oral capsule butalbital-asa-caff-codeine oral capsule 50- Ascomp-Codeine *Hydrocodone Combinations*** hydrocodone-acetaminophen oral solution /5ml, /10ml, Hycet /15ml hydrocodone-acetaminophen oral tablet 10- Lorcet HD 325 QLL (4 EA per 1 day) QLL (4 EA per 1 day) QLL (4 EA per 1 day) QLL (90 ML per 1 day) QLL (4 EA per 1 day) QLL (4 EA per 1 day) QLL (4 EA per 1 day) QLL (4 EA per 1 day) QLL (4 EA per 1 day) QLL (4 EA per 1 day) QLL (60 ML per 1 day) QLL (4 EA per 1 day) 9

13 hydrocodone-acetaminophen oral tablet hydrocodone-acetaminophen oral tablet hydrocodone-acetaminophen oral tablet hydrocodone-ibuprofen oral tablet *Opioid Agonists*** codeine sulfate oral tablet 15, 30, 60 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 Verdrocet Lorcet Lorcet Plus 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 EA per 1 day) QLL (4 EA per 1 day) QLL (4 EA per 1 day) QLL (4 EA per 1 day) QLL (4 EA per 1 day) ST; QLL (4 EA 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 EA per 1 day) hydromorphone hcl oral tablet 8 Dilaudid QLL (2 EA per 1 day) methadone hcl intensol oral concentrate 10 /ml Methadone HCl Intensol ; QLL (2 ML per 1 day) methadone hcl oral concentrate 10 /ml Methadone HCl Intensol ; QLL (2 ML per 1 day) methadone hcl oral solution 10 /5ml ; QLL (11 ML per 1 day) methadone hcl oral solution 5 /5ml ; QLL (22 ML per 1 day) methadone hcl oral tablet 10 Dolophine ; QLL (2 EA per 1 day) methadone hcl oral tablet 5 Dolophine ; QLL (4 EA per 1 day) methadone hcl oral tablet soluble 40 Methadose ; QLL (22 EA per 30 days) methadose oral tablet soluble 40 Methadose ; QLL (22 EA per 30 days) morphine sulfate (concentrate) oral solution 100 /5ml QLL (4 ML per 1 day) morphine sulfate er oral tablet extended release 100, 200, 60 MS Contin ; QLL (1 EA per 1 day) morphine sulfate er oral tablet extended release 15 MS Contin ; QLL (6 EA per 1 day) 10

14 morphine sulfate er oral tablet extended release 30 MS Contin ; QLL (3 EA per 1 day) morphine sulfate oral solution 10 /5ml, 20 /5ml QLL (20 ML per 1 day) morphine sulfate oral tablet 15 QLL (4 EA per 1 day) morphine sulfate oral tablet 30 QLL (3 EA per 1 day) morphine sulfate rectal suppository 10, 20, 5 QLL (4 EA per 1 day) oxycodone hcl oral solution 5 /5ml QLL (20 ML per 1 day) oxycodone hcl oral tablet 10 QLL (4 EA per 1 day) oxycodone hcl oral tablet 15, 5 Roxicodone QLL (4 EA per 1 day) oxycodone hcl oral tablet 20 QLL (3 EA per 1 day) oxycodone hcl oral tablet 30 Roxicodone QLL (2 EA per 1 day) tramadol hcl oral tablet 50 Ultram ; QLL (4 EA per 1 day); AL (Min 16 Years) HYDROMORPHONE HCL RECTAL SUPPOSITORY 3 MG QLL (4 EA per 1 day) MORPHINE SULFATE RECTAL SUPPOSITORY 30 MG QLL (3 EA per 1 day) *Opioid Combinations*** oxycodone-acetaminophen oral tablet , , 5-325, Endocet QLL (4 EA per 1 day) oxycodone-aspirin oral tablet QLL (4 EA per 2 days) *Opioid Partial Agonists*** buprenorphine hcl sublingual tablet sublingual 2, 8 buprenorphine hcl-naloxone hcl sublingual tablet sublingual 2-0.5, 8-2 butorphanol tartrate nasal solution 10 /ml QLL (1 Bottle per 30 days) pentazocine-naloxone hcl oral tablet QLL (4 EA per 1 day) *Tramadol Combinations*** tramadol-acetaminophen oral tablet *ANDROGENS-ANABOLIC* *Androgens*** danazol oral capsule 100, 200, 50 methyltestosterone oral capsule 10 Ultracet Android ; QLL (4 EA per 1 day); AL (Min 16 Years) 11

15 testosterone cypionate intramuscular solution 100 /ml testosterone cypionate intramuscular solution 200 /ml testosterone transdermal gel 10 /act (2%) Depo-Testosterone Depo-Testosterone Fortesta testosterone transdermal gel 12.5 /act (1%) Vogelxo Pump testosterone transdermal gel 25 /2.5gm AndroGel (1%) testosterone transdermal gel 50 /5gm (1%) AndroGel ANDROGEL PUMP TRANSDERMAL GEL MG/ACT (1.62%) *ANORECTAL AGENTS* *Intrarectal Steroids*** colocort rectal enema 100 /60ml Colocort hydrocortisone rectal enema 100 /60ml Colocort CORTIFOAM RECTAL FOAM 10 % *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 ALBENZA ORAL TABLET 200 MG BILTRICIDE ORAL TABLET 600 MG REESES PINWORM MEDICINE ORAL TABLET 180 MG ; QLL (10 ML per 90 days) ; QLL (2 canisters per 30 days) ; QLL (4 canisters per 30 days) ; QLL (2.5 GM per 1 day) ; QLL (10 GM per 1 day) OTC ST OTC 12

16 *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 minitran transdermal patch 24 hour 0.1 /hr, 0.2 /hr, 0.4 /hr, 0.6 /hr Minitran 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, 6.5, 9 Nitro-Time NITRO-BID TRANSDERMAL OINTMENT 2 % *ANTIANXIETY AGENTS* *Antianxiety Agents - Misc.*** buspirone hcl oral tablet 10, 5, 7.5 QLL (90 EA per 30 days) buspirone hcl oral tablet 15 QLL (120 EA 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 oral tablet 0.25, 0.5, 1, 2 Xanax 13

17 alprazolam oral tablet dispersible 0.25, 0.5, 1, 2 alprazolam xr oral tablet extended release 24 Xanax XR hour 0.5, 1, 2, 3 chlordiazepoxide hcl oral capsule 10, 25, 5 clorazepate dipotassium oral tablet 15, 3.75 clorazepate dipotassium oral tablet 7.5 Tranxene-T diazepam intensol oral concentrate 5 /ml Diazepam Intensol diazepam oral concentrate 5 /ml Diazepam Intensol diazepam oral solution 1 /ml diazepam oral tablet 10, 2, 5 Valium lorazepam intensol oral concentrate 2 /ml LORazepam Intensol lorazepam oral concentrate 2 /ml LORazepam Intensol lorazepam oral tablet 0.5, 1, 2 Ativan oxazepam oral capsule 10, 15, 30 ALPRAZOLAM INTENSOL ORAL CONCENTRATE 1 MG/ML *ANTIARRHYTHMICS* *Antiarrhythmics Type I-A*** disopyramide phosphate oral capsule 100, Norpace 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 oral tablet 150, 225, 300 *Antiarrhythmics Type Iii*** amiodarone hcl oral tablet 100, 200, Pacerone 400 pacerone oral tablet 100, 200, 400 Pacerone 14

18 MULTAQ ORAL TABLET 400 MG *ANTIASTHMATIC AND BRONCHODILATOR AGENTS* *Adrenergic Combinations*** ipratropium-albuterol inhalation solution (3) /3ml ANORO ELLIPTA INHALATION AEROSOL POWDER BREATH ACTIVATED MCG/INH BREO ELLIPTA INHALATION AEROSOL POWDER BREATH ACTIVATED MCG/INH, MCG/INH COMBIVENT RESPIMAT INHALATION AEROSOL SOLUTION MCG/ACT DULERA INHALATION AEROSOL MCG/ACT, MCG/ACT 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 levalbuterol tartrate inhalation aerosol 45 mcg/act metaproterenol sulfate oral syrup 10 /5ml metaproterenol sulfate oral tablet 10, 20 VENTOLIN HFA INHALATION AEROSOL SOLUTION 108 (90 BASE) MCG/ACT *Bronchodilators - Anticholinergics*** ipratropium bromide inhalation solution 0.02 % Xopenex HFA ; QLL (60 EA per 30 days) QLL (1 EA per 30 Days) QLL (1 EA per 30 days) ST; QLL (1 canister per 30 days) QLL (130 vials per 30 days) ST; QLL (130 ML per 1 day); AL (Max 18 Years) ST; QLL (2 INH per 30 days) QLL (2 Inhalers per 30 days) 15

19 ATROVENT HFA INHALATION AEROSOL SOLUTION 17 MCG/ACT INCRUSE ELLIPTA INHALATION AEROSOL POWDER BREATH ACTIVATED 62.5 MCG/INH *Leukotriene Receptor Antagonists*** montelukast sodium oral packet 4 Singulair ; QLL (30 packet per 30 days); AL (Max 1 Years) montelukast sodium oral tablet 10 Singulair QLL (30 EA per 30 days) montelukast sodium oral tablet chewable 4, 5 Singulair QLL (30 EA per 30 days) zafirlukast oral tablet 10, 20 Accolate ST; QLL (60 EA per 30 days) *Steroid Inhalants*** budesonide inhalation suspension 0.25 /2ml, 0.5 /2ml, 1 /2ml 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 MCG/ACT QVAR INHALATION AEROSOL SOLUTION 40 MCG/ACT, 80 MCG/ACT QVAR REDIHALER INHALATION AEROSOL BREATH ACTIVATED 40 MCG/ACT QVAR REDIHALER INHALATION AEROSOL BREATH ACTIVATED 80 MCG/ACT *Xanthines*** theochron oral tablet extended release 12 hour 100, 200, 300 theophylline er oral tablet extended release 12 hour 100, 200, 300 theophylline er oral tablet extended release 12 hour 450 theophylline er oral tablet extended release 24 hour 400, 600 Pulmicort Theochron Theochron QLL (527 ML per 30 days); AL (Max 5 Years) QLL (1 Inhaler per 30 days) QLL (10.6 GM per 30 days) QLL (21.2 GM per 30 days) 16

20 theophylline oral solution 80 /15ml *ANTICOAGULANTS* *Coumarin Anticoagulants*** jantoven oral tablet 1, 10, 2, 2.5, 3, 4, 5, 6, 7.5 Coumadin warfarin sodium oral tablet 1, 10, 2, 2.5, 3, 4, 5, 6, 7.5 Coumadin *Direct Factor Xa Inhibitors*** ELIQUIS ORAL TABLET 2.5 MG, 5 MG ; QLL (60 EA per 30 days) XARELTO ORAL TABLET 10 MG, 15 MG, 20 MG ; QLL (30 EA per 30 days) XARELTO STARTER CK ORAL TABLET THERAPY CK 15 & 20 MG ; QLL (1 EA per 90 days) *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 enoxaparin sodium subcutaneous solution 100 /ml, 120 /0.8ml, 150 /ml, 30 /0.3ml, 40 /0.4ml, 60 /0.6ml, 80 Lovenox QLL (20 Syringes per 10 days) /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 QLL (400 EA per 100 days); AL Carbatrol release 12 hour 100, 200, 300 (Min 6 Years) carbamazepine er oral tablet extended release TEGretol-XR 12 hour 100 QLL (12 EA per 1 Day) 17

21 carbamazepine er oral tablet extended release 12 hour 200, 400 carbamazepine oral suspension 100 /5ml carbamazepine oral tablet 200 carbamazepine oral tablet chewable 100 epitol oral tablet 200 gabapentin oral capsule 100, 300, 400 gabapentin oral solution 250 /5ml gabapentin oral tablet 600, 800 TEGretol-XR TEGretol Epitol Epitol Neurontin Neurontin Neurontin QLL (400 EA per 100 days); AL (Min 6 Years) Gabapentin has a maximum cumulative dose of 3600/day Gabapentin has a maximum cumulative dose of 3600/day Gabapentin has a maximum cumulative dose of 3600/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 days) topiramate oral tablet 100, 200, 25, Topamax 50 QLL (120 EA per 30 days) zonisamide oral capsule 100, 25 Zonegran QLL (180 EA per 30 days) zonisamide oral capsule 50 QLL (180 EA per 30 days) TEGRETOL-XR ORAL TABLET EXTENDED RELEASE 12 HOUR 100 MG TEGretol-XR *Carbamates*** felbamate oral suspension 600 /5ml Felbatol felbamate oral tablet 400, 600 Felbatol *Gaba Modulators*** tiagabine hcl oral tablet 2, 4 Gabitril QLL (60 EA per 30 days) GABITRIL ORAL TABLET 12 MG, 16 MG QLL (60 EA per 30 days) *Hydantoins*** 18

22 phenytoin infatabs oral tablet chewable 50 Dilantin Infatabs phenytoin oral suspension 125 /5ml phenytoin oral tablet chewable 50 phenytoin sodium extended oral capsule 100 phenytoin sodium extended oral capsule 200, 300 Dilantin Dilantin Infatabs Dilantin Phenytek DILANTIN ORAL 30 MG PHENYTEK ORAL 200 MG, 300 MG Phenytek *Succinimides*** ethosuximide oral capsule 250 Zarontin ethosuximide oral solution 250 /5ml Zarontin CELONTIN ORAL 300 MG *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, 30, 45 Remeron QLL (30 EA per 30 days) mirtazapine oral tablet 7.5 QLL (30 EA per 30 days) mirtazapine oral tablet dispersible 15, 30, 45 Remeron SolTab QLL (30 EA per 30 days) *Antidepressants - Misc.*** bupropion hcl er (sr) oral tablet extended release 12 hour 100, 150, 200 Wellbutrin SR QLL (60 EA per 30 days) bupropion hcl er (xl) oral tablet extended release 24 hour 150, 300 Wellbutrin XL QLL (30 EA per 30 days) bupropion hcl oral tablet 100, 75 QLL (90 EA per 30 days) maprotiline hcl oral tablet 25, 50, 75 *Modified Cyclics*** 19

23 trazodone hcl oral tablet 100, 150, 50 *Monoamine Oxidase Inhibitors (Maois)*** phenelzine sulfate oral tablet 15 Nardil tranylcypromine sulfate oral tablet 10 Parnate MARPLAN ORAL TABLET 10 MG *Selective Serotonin Reuptake Inhibitors (Ssris)*** citalopram hydrobromide oral solution 10 /5ml QLL (300 ML per 30 days) citalopram hydrobromide oral tablet 10, 20, 40 CeleXA QLL (30 EA per 30 days) escitalopram oxalate oral solution 5 /5ml QLL (300 ML per 30 days) escitalopram oxalate oral tablet 10, 20, Lexapro 5 QLL (30 EA per 30 days) fluoxetine hcl oral capsule 10 PROzac QLL (30 EA per 30 days) fluoxetine hcl oral capsule 20, 40 PROzac QLL (60 EA per 30 days) fluoxetine hcl oral solution 20 /5ml QLL (150 ML per 30 days) fluvoxamine maleate oral tablet 100 QLL (90 EA per 30 days) fluvoxamine maleate oral tablet 25 QLL (30 EA per 30 days) fluvoxamine maleate oral tablet 50 QLL (60 EA per 30 days) paroxetine hcl oral tablet 10, 20, 40 Paxil QLL (30 EA per 30 days) paroxetine hcl oral tablet 30 Paxil QLL (60 EA per 30 days) sertraline hcl oral concentrate 20 /ml Zoloft QLL (75 ML per 30 days) sertraline hcl oral tablet 100, 50 Zoloft QLL (60 EA per 30 days) sertraline hcl oral tablet 25 Zoloft QLL (30 EA per 30 days) *Serotonin-Norepinephrine Reuptake Inhibitors (Snris)*** duloxetine hcl oral capsule delayed release particles 20, 30, 60 Cymbalta QLL (30 EA per 30 days) duloxetine hcl oral capsule delayed release particles 40 QLL (30 EA per 30 days) venlafaxine hcl er oral capsule extended release 24 hour 150, 37.5, 75 Effexor XR QLL (30 EA per 30 days) venlafaxine hcl oral tablet 100, 25, 37.5, 50, 75 20

24 *Tricyclic Agents*** amitriptyline hcl oral tablet 10, 100, 150, 25, 50, 75 amoxapine oral tablet 100, 150, 25, 50 desipramine hcl oral tablet 10, 25 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*** GLUCAGEN HYPOKIT INJECTION SOLUTION RECONSTITUTED 1 MG GLUCAGON EMERGENCY INJECTION KIT 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*** Norpramin Tofranil Pamelor Precose Glucophage XR Glucophage Nesina QLL (30 EA per 30 Days) ST; QLL (30 EA per 30 days) 21

25 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 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 R U-500 (CONCENTRATED) SUBCUTANEOUS SOLUTION 500 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 Kazano Oseni QLL (60 EA per 30 Days) ST; QLL (60 EA per 30 days) ST; QLL (30 EA per 30 days) QLL (30 EA per 30 Days) ; AL (Max 18 Years) ; AL (Max 18 Years) ; AL (Max 18 Years) ; AL (Max 18 Years) 22

26 *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 *Meglitinide Analogues*** nateglinide oral tablet 120, 60 repaglinide oral tablet 0.5 repaglinide oral tablet 1, 2 *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 glimepiride oral tablet 1, 2, 4 glipizide er oral tablet extended release 24 hour 10, 2.5, 5 glipizide oral tablet 10, 5 glipizide xl oral tablet extended release 24 hour 10, 2.5, 5 glyburide micronized oral tablet 1.5, 3, 6 glyburide oral tablet 1.25, 2.5, 5 tolazamide oral tablet 250, 500 tolbutamide oral tablet 500 Starlix Prandin Glucovance Amaryl Glucotrol XL Glucotrol Glucotrol XL Glynase ST; QLL (4 EA per 28 days) ST ST; QLL (31 EA per 31 days) 23

27 *Sulfonylurea-Thiazolidinedione Combinations*** pioglitazone hcl-glimepiride oral tablet 30-2 Duetact, 30-4 *Thiazolidinedione-Biguanide Combinations*** pioglitazone hcl-metformin hcl oral tablet 15- Actoplus Met 500, *Thiazolidinediones*** pioglitazone hcl oral tablet 15, 30, 45 Actos AVANDIA ORAL TABLET 2 MG, 4 MG *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 100 MG *Opioid Antagonists*** naloxone hcl injection solution 0.4 /ml naloxone hcl injection solution prefilled syringe 2 /2ml 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 ondansetron hcl oral tablet 24 ondansetron hcl oral tablet 4, 8 Zofran ondansetron oral tablet dispersible 4, 8 Zofran ODT *Antiemetics - Anticholinergic*** meclizine hcl oral tablet 12.5 QLL (30 EA per 30 days) QLL (90 EA per 30 days) QLL (30 EA per 30 days) ST; QLL (30 EA per 30 days) QLL (2 EA per 30 days) 24

28 meclizine hcl oral tablet 25 trimethobenzamide hcl oral capsule 300 Dramamine Less Drowsy Tigan *Substance P/Neurokinin 1 (Nk1) Receptor Antagonists*** EMEND ORAL 125 MG, 40 MG, 80 MG Aprepitant *ANTIFUNGALS* *Antifungals*** bio-statin oral powder griseofulvin microsize oral suspension 125 /5ml 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 EA per 365 days) *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 solution 1 /ml KLS Aller-Tec Childrens QLL (150 ML per 30 days) cetirizine hcl oral syrup 1 /ml KLS Aller-Tec Childrens QLL (150 ML per 30 days) *Antihistamines - Phenothiazines*** 25

29 phenadoz rectal suppository 12.5, 25 Phenadoz phenergan rectal suppository 12.5, 25 Phenadoz phenergan rectal suppository 50 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, 25 Phenadoz promethegan rectal suppository 50 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 light oral powder 4 gm/dose Prevalite cholestyramine oral packet 4 gm Questran cholestyramine oral powder 4 gm/dose Questran colestipol hcl oral granules 5 gm Colestid colestipol hcl oral packet 5 gm Colestid colestipol hcl oral tablet 1 gm Colestid prevalite oral packet 4 gm Prevalite prevalite oral powder 4 gm/dose Prevalite *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 days) 26

30 *H Coa Reductase Inhibitors*** atorvastatin calcium oral tablet 10, 20, 40, 80 fluvastatin sodium er oral tablet extended release 24 hour 80 Lipitor Lescol XL QLL (30 EA per 30 days) QLL (30 EA per 30 days) fluvastatin sodium oral capsule 20 Lescol QLL (30 EA per 30 days) fluvastatin sodium oral capsule 40 lovastatin oral tablet 10, 20 QLL (30 EA per 30 days) QLL (30 EA per 30 days) lovastatin oral tablet 40 Mevacor QLL (60 EA per 30 days) pravastatin sodium oral tablet 10 pravastatin sodium oral tablet 20, 40, 80 rosuvastatin calcium oral tablet 10, 20, 40, 5 Pravachol Crestor QLL (30 EA per 30 days) QLL (30 EA per 30 days) ; QLL (1 EA per 1 Day) simvastatin oral tablet 10, 20, 40, 5 Zocor, 80 QLL (30 EA 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 captopril-hydrochlorothiazide oral tablet 25-15, 25-25, 50-15, enalapril-hydrochlorothiazide oral tablet Vaseretic enalapril-hydrochlorothiazide oral tablet

31 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 days) lisinopril oral tablet 2.5, 30 Zestril QLL (30 EA per 30 days) lisinopril oral tablet 40 Zestril QLL (60 EA 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 , *Angiotensin Ii Receptor Antag & Thiazide/Thiazide-Like*** candesartan cilexetil-hctz oral tablet , , Atacand HCT irbesartan-hydrochlorothiazide oral tablet , Avalide 28

32 losartan potassium-hctz oral tablet , , Hyzaar valsartan-hydrochlorothiazide oral tablet , , , , Diovan HCT *Angiotensin Ii Receptor Antagonists*** candesartan cilexetil oral tablet 16, 32, Atacand 4, 8 irbesartan oral tablet 150, 300, 75 Avapro losartan potassium oral tablet 100, 25, Cozaar 50 valsartan oral tablet 160, 320, 40, Diovan 80 *Angiotensin Ii Receptor Ant-Ca Channel Blocker-Thiazides*** amlodipine-valsartan-hctz oral tablet , , , Exforge HCT 12.5, *Antiadrenergics - Centrally Acting*** clonidine hcl oral tablet 0.1, 0.2, 0.3 Catapres clonidine hcl transdermal patch weekly 0.1 Catapres-TTS-1 /24hr clonidine hcl transdermal patch weekly 0.2 Catapres-TTS-2 /24hr clonidine hcl transdermal patch weekly 0.3 Catapres-TTS-3 /24hr guanfacine hcl oral tablet 1 guanfacine hcl oral tablet 2 methyldopa oral tablet 250, 500 *Antiadrenergics - Peripherally Acting*** doxazosin mesylate oral tablet 1, 2, 4 Cardura, 8 prazosin hcl oral capsule 1, 2, 5 Minipress terazosin hcl oral capsule 1, 10, 2, 5 QLL (30 EA per 30 days) QLL (60 EA per 30 days) QLL (30 EA per 30 days) QLL (240 EA per 30 days) QLL (120 EA per 30 days) QLL (30 EA per 30 days) QLL (30 EA per 30 days) 29

33 *Beta Blocker & Diuretic Combinations*** atenolol-chlorthalidone oral tablet Tenoretic 100 atenolol-chlorthalidone oral tablet Tenoretic 50 bisoprolol-hydrochlorothiazide oral tablet 10- Ziac 6.25, , metoprolol-hydrochlorothiazide oral tablet , metoprolol-hydrochlorothiazide oral tablet Lopressor HCT nadolol-bendroflumethiazide oral tablet 40-5 Corzide, 80-5 propranolol-hctz oral tablet 40-25, *Vasodilators*** hydralazine hcl oral tablet 10, 100, 25, 50 minoxidil oral tablet 10, 2.5 *ANTI-INFECTIVE AGENTS - MISC.* *Anti-Infective Agents - Misc.*** metronidazole oral capsule 375 Flagyl metronidazole oral tablet 250, 500 Flagyl trimethoprim oral tablet 100 vancomycin hcl intravenous solution reconstituted 10 gm, 1000, 500, 5000 FIRST-VANCOMYCIN 25 ORAL SOLUTION 25 MG/ML FIRST-VANCOMYCIN 50 ORAL SOLUTION 50 MG/ML *Anti-Infective Misc. - Combinations*** sulfamethoxazole-trimethoprim oral Sulfatrim Pediatric suspension /5ml sulfamethoxazole-trimethoprim oral tablet Bactrim sulfamethoxazole-trimethoprim oral tablet Bactrim DS

34 sulfatrim pediatric oral suspension /5ml *Leprostatics*** dapsone oral tablet 100, 25 *Lincosamides*** clindamycin hcl oral capsule 150, 300, 75 Sulfatrim Pediatric Cleocin clindamycin palmitate hcl oral solution Cleocin reconstituted 75 /5ml *ANTIMALARIALS* *Antimalarials*** chloroquine phosphate oral tablet 250, 500 hydroxychloroquine sulfate oral tablet 200 Plaquenil mefloquine hcl oral tablet 250 DARAPRIM ORAL TABLET 25 MG *ANTIMYASTHENIC AGENTS* *Antimyasthenic Agents*** pyridostigmine bromide oral tablet 60 Mestinon *Antimyasthenic/Cholinergic Agents*** pyridostigmine bromide oral tablet 60 Mestinon *ANTIMYASTHENIC/CHOLINER GIC AGENTS* pyridostigmine bromide oral tablet 60 Mestinon *ANTIMYCOBACTERIAL AGENTS* *Anti Tb Combinations*** RIFAMATE ORAL MG *Antimycobacterial Agents*** ethambutol hcl oral tablet 100, 400 Myambutol isoniazid oral syrup 50 /5ml isoniazid oral tablet 100, 300 pyrazinamide oral tablet 500 rifabutin oral capsule 150 Mycobutin rifampin oral capsule 150, 300 Rifadin 31

35 PRIFTIN ORAL TABLET 150 MG *ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES* *Alkylating Agents*** HEXALEN ORAL 50 MG MYLERAN ORAL TABLET 2 MG *Antiadrenals*** LYSODREN ORAL TABLET 500 MG *Antiandrogens*** bicalutamide oral tablet 50 Casodex flutamide oral capsule 125 nilutamide oral tablet 150 Nilandron QLL (60 EA per 30 days) *Antiestrogens*** tamoxifen citrate oral tablet 10, 20 FARESTON ORAL TABLET 60 MG SOLTAMOX ORAL SOLUTION 10 MG/5ML *Antimetabolites*** capecitabine oral tablet 150 Xeloda ; QLL (140 EA per 21 days) capecitabine oral tablet 500 Xeloda ; QLL (154 EA per 21 days) mercaptopurine oral tablet 50 methotrexate oral tablet 2.5 TABLOID ORAL TABLET 40 MG *Antineoplastic - Histone Deacetylase Inhibitors*** ZOLINZA ORAL 100 MG *Antineoplastic - Mtor Kinase Inhibitors*** AFINITOR ORAL TABLET 10 MG, 2.5 MG, 5 MG, 7.5 MG *Antineoplastic - Multikinase Inhibitors*** NEXAVAR ORAL TABLET 200 MG ; QLL (120 EA per 30 days) SUTENT ORAL 12.5 MG, 25 MG SUTENT ORAL 37.5 MG ; QLL (30 EA per 30 days) 32

36 SUTENT ORAL 50 MG ; QLL (28 EA per 42 days) *Antineoplastic - Tyrosine Kinase Inhibitors*** CABOMETYX ORAL TABLET 20 MG, 40 MG, 60 MG ; QLL (30 EA per 30 Days) GLEEVEC ORAL TABLET 400 MG Imatinib Mesylate IMBRUVICA ORAL 140 MG ; QLL (120 EA per 30 days) SPRYCEL ORAL TABLET 100 MG, 140 MG, 20 MG, 50 MG, 70 MG, 80 MG ; QLL (30 EA per 30 days) TARCEVA ORAL TABLET 100 MG, 150 MG, 25 MG TASIGNA ORAL 150 MG, 200 MG TYKERB ORAL TABLET 250 MG ; QLL (180 EA per 30 days) VOTRIENT ORAL TABLET 200 MG *Antineoplastics Misc.*** hydroxyurea oral capsule 500 Hydrea MATULANE ORAL 50 MG *Aromatase Inhibitors*** anastrozole oral tablet 1 Arimidex exemestane oral tablet 25 Aromasin letrozole oral tablet 2.5 Femara *Estrogens-Antineoplastic*** EMCYT ORAL 140 MG *Folic Acid Antagonists Rescue Agents*** leucovorin calcium oral tablet 10, 15, 25, 5 *Imidazotetrazines*** temozolomide oral capsule 100, 140, 180, 20, 250, 5 Temodar *Lhrh Analogs*** ELIGARD SUBCUTANEOUS KIT 22.5 MG, 30 MG, 45 MG, 7.5 MG TRELSTAR MIXJECT INTRAMUSCULAR SUSPENSION RECONSTITUTED MG, 22.5 MG, 3.75 MG 33

37 VANTAS SUBCUTANEOUS KIT 50 MG ZOLADEX SUBCUTANEOUS IMPLANT 10.8 MG, 3.6 MG *Mitotic Inhibitors*** etoposide oral capsule 50 *Nitrogen Mustards*** melphalan oral tablet 2 LEUKERAN ORAL TABLET 2 MG *Nitrosoureas*** GLEOSTINE ORAL 10 MG, 100 MG, 40 MG *Progestins-Antineoplastic*** hydroxyprogesterone caproate intramuscular solution 1.25 gm/5ml megestrol acetate oral suspension 40 /ml, 400 /10ml megestrol acetate oral tablet 20, 40 *Retinoids*** tretinoin oral capsule 10 *Urinary Tract Protective Agents*** MESNEX ORAL TABLET 400 MG *ANTIRKINSON AGENTS* *Antiparkinson Anticholinergics*** benztropine mesylate oral tablet 0.5, 1, 2 trihexyphenidyl hcl oral elixir 0.4 /ml trihexyphenidyl hcl oral tablet 2, 5 *Antiparkinson Dopaminergics*** amantadine hcl oral capsule 100 amantadine hcl oral syrup 50 /5ml amantadine hcl oral tablet 100 bromocriptine mesylate oral capsule 5 bromocriptine mesylate oral tablet 2.5 *Antiparkinson Monoamine Oxidase Inhibitors*** selegiline hcl oral capsule 5 Alkeran Parlodel Parlodel Eldepryl 34

38 selegiline hcl oral tablet 5 *Levodopa Combinations*** carbidopa-levodopa er oral tablet extended release , Sinemet CR carbidopa-levodopa oral tablet , , Sinemet carbidopa-levodopa oral tablet dispersible , , carbidopa-levodopa-entacapone oral tablet Stalevo 50 QLL (270 EA per 30 days) carbidopa-levodopa-entacapone oral tablet Stalevo 75 QLL (270 EA per 30 days) carbidopa-levodopa-entacapone oral tablet Stalevo 100 QLL (270 EA per 30 days) carbidopa-levodopa-entacapone oral tablet Stalevo 125 QLL (270 EA per 30 days) carbidopa-levodopa-entacapone oral tablet Stalevo 150 QLL (270 EA per 30 days) carbidopa-levodopa-entacapone oral tablet Stalevo 200 QLL (270 EA per 30 days) *Nonergoline Dopamine Receptor Agonists*** pramipexole dihydrochloride oral tablet Mirapex, 0.25, 0.5, 0.75, 1, 1.5 ropinirole hcl er oral tablet extended release 24 hour 12, 2, 4, 6, 8 Requip XL ropinirole hcl oral tablet 0.25, 0.5, 1, 2, 3, 4, 5 Requip QLL (90 EA per 30 days) *Peripheral Comt Inhibitors*** entacapone oral tablet 200 Comtan QLL (120 EA per 30 days) *ANTIPSYCHOTICS/ANTIMANIC AGENTS* *Antimanic Agents*** lithium carbonate er oral tablet extended release 300 Lithobid lithium carbonate er oral tablet extended release 450 lithium carbonate oral capsule 150, 300, 600 lithium carbonate oral tablet

39 LITHIUM ORAL SOLUTION 8 MEQ/5ML *Antipsychotics - Misc.*** ziprasidone hcl oral capsule 20, 40, 60, 80 *Benzisoxazoles*** risperidone m-tab oral tablet dispersible 0.5, 1 Geodon RisperDAL M-TAB risperidone m-tab oral tablet dispersible 2 RisperiDONE M-TAB risperidone oral solution 1 /ml risperidone oral tablet 0.25, 0.5, 1, 2, 3, 4 risperidone oral tablet dispersible 0.25 risperidone oral tablet dispersible 0.5, 1, 3, 4 risperidone oral tablet dispersible 2 RisperDAL RisperDAL RisperDAL M-TAB RisperiDONE M-TAB QLL (60 EA per 30 days) QLL (60 EA per 30 days); AL (Min 5 Years) QLL (60 EA per 30 days); AL (Min 5 Years) QLL (240 ML per 30 days); AL (Min 5 Years) QLL (60 EA per 30 days); AL (Min 5 Years) QLL (60 EA per 30 days); AL (Min 5 Years) QLL (60 EA per 30 days); AL (Min 5 Years) QLL (60 EA per 30 days); AL (Min 5 Years) INVEGA SUSTENNA INTRAMUSCULAR SUSPENSION 117 MG/0.75ML, 156 MG/ML, 234 MG/1.5ML, 39 MG/0.25ML, 78 MG/0.5ML INVEGA TRINZA INTRAMUSCULAR SUSPENSION 273 MG/0.875ML, 410 MG/1.315ML, 546 MG/1.75ML, 819 MG/2.625ML RISPERDAL CONSTA INTRAMUSCULAR SUSPENSION RECONSTITUTED 12.5 MG, 25 MG, 37.5 MG, 50 MG *Butyrophenones*** haloperidol decanoate intramuscular solution 100 /ml, 50 /ml Haldol Decanoate AL (Min 3 Years) haloperidol lactate injection solution 5 /ml Haldol AL (Min 3 Years) haloperidol lactate oral concentrate 2 /ml AL (Min 3 Years) haloperidol oral tablet 0.5, 1, 10, 2, 20, 5 AL (Min 3 Years) *Dibenzodiazepines*** clozapine oral tablet 100, 25 Clozaril AL (Min 9 Years) 36

40 clozapine oral tablet 200, 50 *Dibenzothiazepines*** quetiapine fumarate oral tablet 100, 200, 25, 50 quetiapine fumarate oral tablet 300, 400 *Dibenzoxazepines*** loxapine succinate oral capsule 10, 25, 5, 50 *Phenothiazines*** compro rectal suppository 25 fluphenazine decanoate injection solution 25 /ml fluphenazine hcl injection solution 2.5 /ml fluphenazine hcl oral concentrate 5 /ml fluphenazine hcl oral elixir 2.5 /5ml perphenazine oral tablet 16, 2, 4, 8 prochlorperazine maleate oral tablet 10, 5 prochlorperazine rectal suppository 25 thioridazine hcl oral tablet 10, 100, 25, 50 trifluoperazine hcl oral tablet 1, 10, 2, 5 *Quinolinone Derivatives*** ABILIFY MAINTENA INTRAMUSCULAR PREFILLED SYRINGE 300 MG, 400 MG ABILIFY MAINTENA INTRAMUSCULAR SUSPENSION RECONSTITUTED ER 300 MG, 400 MG ARISTADA INTRAMUSCULAR PREFILLED SYRINGE 1064 MG/3.9ML, 441 MG/1.6ML, 662 MG/2.4ML, 882 MG/3.2ML *Thienbenzodiazepines*** olanzapine oral tablet 10, 15, 2.5, 20, 5, 7.5 SEROquel SEROquel Compro Compro ZyPREXA AL (Min 9 Years) QLL (90 EA per 30 days); AL (Min 10 Years) QLL (60 EA per 30 days); AL (Min 10 Years) AL (Min 5 Years) AL (Min 12 Years) AL (Min 12 Years) AL (Min 12 Years) AL (Min 12 Years) AL (Min 5 Years) AL (Min 2 Years) QLL (30 EA per 30 days) 37

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