COMMERCIAL FORMULARY Effective April 2018

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

2 Co-Pay Structure Generic Drug Brand Drug Generic Co-Pay Applies Brand Co-Pay Applies Requirements/Limits This field includes potential limitations to the formulary drug. It also may contain additional information about the coverage of the drug such as applicable quantity limits (QL). For certain agents within the Commercial Formulary, a recommended prescribing guideline may apply. Prescribing Guidelines Prescribing guidelines may apply to select drugs on the THC formulary. Prescribing guidelines may vary by benefit design but may include: Prior Authorization Required (PA) Over the Counter Drugs (OTC) Specialty Drugs (SP) Quantity Limit (QL) Age Limit (AL) Gender Restriction (GR) Step Therapy Required (ST) Custom (C) Drug requires prior authorization through a specific physician request process. Drug coverage is available for drugs that are available OTC with an authorized prescription from your provider. Drug requires processing through THC s contracted specialty pharmacy, Envision Specialty Pharmacy. Drug coverage may be limited to specific quantities per prescription and/or time period. Drug coverage may depend on patient age. Drug coverage may depend on patient gender. Drug coverage requires that an alternative or trial of another drug be used before the medication is covered. Drug coverage has unique restrictions. Benefit Coverage and Limitations This formulary does not define benefit coverage and limitations. Members may have specific benefit inclusions, exclusions, copayments, or a lack of coverage, which are not reflected in the Total Health Care Commercial Formulary. Members should contact Total Health Care at if they have questions regarding their coverage. Please note that the formulary process is evolutionary and changes can occur throughout the year. ii

3 Prior Authorization (PA) Drugs indicated with a PA require Prior Authorization for coverage. A prescriber may complete a Prior Authorization form that can be found on the Total Health Care website at You may also request a form by calling Total Health Care at Completed prior authorization forms should be faxed to Prior Authorization review of prescribing guidelines will be evaluated utilizing the established drug review criteria approved by Total Health Care. If the request does not meet the approved criteria, the request will not be approved and alternative therapy may be recommended along with the proper course of alternative action. The requesting provider will be provided written notification of Total Health Care review decisions. THC s website has a contact link where members can contact THC s Pharmacy Department to ask for an exception request. Non-Formulary Agents A Drug not located on the Total Health Care Commercial Formulary, or any updates published by Total Health Care, shall be considered a non-formulary drug. Requests for coverage of non-formulary agents may be requested by the health professional depending on specific coverage parameters. Review for nonformulary drug requests will require a Prior Authorization request with documentation of medical necessity. Generally, the following basic medical necessity guidelines are used in conducting a review: The patient has failed an appropriate trial of formulary or preferred agents. The use of preferred or formulary agent is contraindicated in the patient. The formulary drug or preferred agents are not suited for the present patient care need, and the drug selected is required for patient safety. If the request does not meet the established guidelines request, it will not be approved and alternative therapy may be recommended along with the proper course of alternative action. Common Drug Exclusions The member s plan design may exclude certain drug classes. Prior authorization is generally not available for drugs that are specifically excluded by benefit design. Common excluded coverages may include, but are not limited to: OTC medications or their equivalents unless otherwise specified in the Formulary listing. Drug products used for cosmetic purposes. Drug products for erectile dysfunction. Drug products for infertility treatment. Drug products for weight loss. Experimental drug products or any drug product used in an experimental manner. Foreign drugs or drugs not approved by the United States Food & Drug Administration (FDA). Mandated Generic Substitution Total Health Care advocates the use of cost-effective generic drugs where FDA-approved generic equivalent drugs are available. Generic products are listed in the Formulary and noted in lowercase lettering wherever an FDA-approved generic drug product is available. If a member or physician requests a brand-name product in lieu of an approved generic, the member, based upon their coverage, will typically be required to pay the difference in cost between the brand and the generic drug. iii

4 Total Health Care Pharmacy and Therapeutics (P&T) Committee Total Health Care s Pharmacy & Therapeutics Committee meets quarterly to review and recommend medications for formulary consideration. The Committee considers clinical information on drugs that are new to the market and drugs that are typically included in an outpatient pharmacy benefit. This assures that the formulary remains responsive to patient and physician needs. The Committee is composed of physicians, pharmacists, and health care professionals. The Committee also uses reference materials from our Pharmacy Benefits Manager's Pharmacy and Therapeutics Advisory Panel. Product Selection Criteria The primary goal of the THC Pharmacy & Therapeutics Committee is to maintain and update the formulary based upon an objective analysis of the safety, efficacy, approved indications, adverse effects, contraindications, patient administration/compliance considerations and cost effectiveness of available drugs. When a drug is considered for formulary inclusion, it will be reviewed relative to similar drugs including those currently in the THC Commercial Formulary. Physicians may request a copy of THC s drug criteria by calling the Pharmacy Department at Diabetic Testing Supplies Total Health Care works with J&B Medical Supply to provide diabetic testing supplies to our members. Covered diabetic testing supplies include Glucocard Vital glucometer, Glucocard Expression glucometer, and SD Biosensor GlucoNavii glucometer, Glucocard Vital test strips, Glucocard Expression test strips, SD Biosensor GlucoNavii test strips, lancets, insulin syringes, alcohol swabs and ketone strips. These supplies are to be filled through J&B Medical Supply. If you have any questions about our diabetic supply program, please contact J&B Medical Supply at Specialty Bio-Pharmaceutical Pharmacy Program Total Health Care works with Envision Specialty Pharmacy to provide Specialty Bio-Pharmaceutical Pharmacy products to our members. These medications are to be filled exclusively through Envision Specialty Pharmacy. A Specialty Drug Prior Authorization Request form must be completed and faxed to EnvisionRx at with supporting documentation and the prescription. A prescriber may obtain a Specialty Drug Prior Authorization Request form found on the Total Health Care website at Once the order is received, EnvisionRx obtains authorization from Total Health Care. If the specialty prior authorization is approved, Total Health Care notifies Envision Specialty Pharmacy. Then, the Envision Specialty Pharmacy staff ships the medication directly to the physician's office or the patient s home. All packages are individually marked for each patient and refrigerated items are shipped in insulated containers. Where appropriate, each shipment includes needles, syringes and alcohol swabs. If you have any questions about our Specialty Bio-Pharmaceutical Pharmacy program, please contact EnvisionRx at or Envision Specialty Pharmacy at Contact Information The Total Health Care Commercial Formulary is designed to assist physicians, members and other health care professionals in the selection of cost-effective agents. Total Health Care encourages your input and feedback on how we can assist in improving this document and the formulary management process. You may contact THC at iv

5 Medication Limitations Quantity Limitations Quantity Limitations are on medications throughout the formulary and are indicated with a "QL" notation. These are medications that have a daily dose restriction, quantity/days supply limitation, and/or a limitation on the duration of therapy. Age Limitations Age Limitations are on medications throughout the formulary and are indicated with an "AL" notation. Coverage for a medication is indicated by the age limitation. This could be a minimum age, maximum age, and/or the combination of a minimum and maximum age edit. Gender Restrictions Gender restrictions are indicated with a GR on the formulary and require the member to be a specific gender for coverage. Step Therapy Criteria Step Therapy medications are indicated with a ST on the formulary and require that an alternative, first line medication be tried and failed before the requested medication can be covered. The online claims adjudication system will automatically allow for the requested medication to be filled based on electronic claims history indicating that the first line medication was filled. Step Therapy Criteria Therapy Class First Line Second Line Third Line Step Therapy Criteria Attention Deficit/Hyperactivity Antimigraine Antipsychotic Agents amphetamine immediaterelease sumatriptan, rizatriptan risperidone, quetiapine immediaterelease, olanzapine amphetamine extendedrelease naratriptan, zolmitriptan, zolmitriptanodt ziprasidone, quetiapine extendedrelease v VYVANSE Second Line: Prior use of amphetamine immediate-release for 60 days within the last 90 days. Third Line: Prior use of amphetamine extendedrelease for 60 days within the last 90 days. Prior use of sumatriptan AND rizatriptan in the last 90 days. Prior use of one step 1 agent within the last 90 days. Osteoporosis alendronate risedronate Prior use of alendronate within the last 90 days.

6 Urinary Antispasmodics oxybutynin, oxybutynin er, oxybutynin syrup, OXYTROL OTC tolterodine, tolterodine er, trospium darifenacin er, trospium er, VESICARE Second Line: Prior use of OXYTROL OTC, oxybutynin, oxybutynin er, or oxybutynin syrup in the last 90 days. Third Line: Prior use of tolterodine, tolterodine er, or trospium in the last 90 days. *Formulary Disclaimer: Coverage for some drugs may be limited to specific dosage forms and/or strengths. The benefit design determines what is covered and the applicable co-payment. The medications listed on this formulary are subject to change pursuant to the formulary management activities of EnvisionRx. The presence of a medication on this formulary list does not guarantee coverage. vi

7 lowercase italics = Generic drugs UPPERCASE BOLD = Brand name drugs CURRENT AS OF 4/1/2018 Status = Covered Drug Status Notes *Adhd/Anti-Narcolepsy/Anti- Obesity/Anorexiants* amphetamine-dextroamphet er oral capsule extended release 24 hour 10, 15, 20, 25, 30, 5 amphetamine-dextroamphetamine oral tablet 10, 12.5, 15, 20, 30, 5, 7.5 dexmethylphenidate hcl oral tablet 10, 2.5, 5 dextroamphetamine sulfate er oral capsule extended release 24 hour 10, 15, 5 dextroamphetamine sulfate oral tablet 10, 5 guanfacine hcl er oral tablet extended release 24 hour 1, 2, 3, 4 METADATE ER ORAL TABLET EXTENDED RELEASE 20 MG methylphenidate hcl er (cd) oral capsule extended release 10, 20, 30, 40, 50, 60 methylphenidate hcl er oral tablet extended release 10 methylphenidate hcl er oral tablet extended release 20 methylphenidate hcl oral tablet 10 methylphenidate hcl oral tablet 20, 5 modafinil oral tablet 100, 200 PA VYVANSE ORAL CAPSULE 10 MG, 20 MG, 30 MG, 40 MG, 50 MG, 60 MG, 70 MG *Aminoglycosides* neomycin sulfate oral tablet 500 Notes AL = Age Limit C = Custom Restriction GR-F = Female Only GR-M = Male Only PA = Prior Authorization QL = Quantity Limit ST = Step Therapy ST; QL (30 EA per 30 days); AL (Min 6 Years and Max 17 Years) AL (Min 6 Years and Max 17 Years) AL (Min 6 Years and Max 17 Years) AL (Min 6 Years and Max 17 Years) AL (Min 6 Years and Max 17 Years) QL (30 EA per 30 days); AL (Min 6 Years and Max 17 Years) QL (90 EA per 30 days); AL (Min 6 Years and Max 17 Years) QL (30 EA per 30 days); AL (Min 6 Years and Max 17 Years) QL (30 EA per 30 days); AL (Min 6 Years and Max 17 Years) QL (90 EA per 30 days); AL (Min 6 Years and Max 17 Years) QL (180 EA per 30 days); AL (Min 6 Years and Max 17 Years) QL (90 EA per 30 days); AL (Min 6 Years and Max 17 Years) ST; QL (30 EA per 30 days); AL (Min 6 Years and Max 17 Years) 1

8 *Analgesics - Anti-Inflammatory* celecoxib oral capsule 100, 200, 400, 50 diclofenac potassium oral tablet 50 diclofenac sodium er oral tablet extended release 24 hour 100 diclofenac sodium oral tablet delayed release 25, 50, 75 ENBREL SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 25 MG/0.5ML, 50 MG/ML ENBREL SUBCUTANEOUS SOLUTION RECONSTITUTED 25 MG ENBREL SURECLICK SUBCUTANEOUS SOLUTION AUTO-INJECTOR 50 MG/ML fenoprofen calcium oral tablet 600 flurbiprofen oral tablet 100, 50 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 10 MG/0.2ML, 20 MG/0.4ML, 40 MG/0.8ML ibuprofen oral capsule 200 ibuprofen oral suspension 100 /5ml ibuprofen oral tablet 200, 400, 600, 800 INDOCIN ORAL SUSPENSION 25 MG/5ML indomethacin oral capsule 25, 50 QL (30 EA per 30 days) ketoprofen oral capsule 50 QL (360 EA per 30 days) ketoprofen oral capsule 75 QL (120 EA per 30 days) ketorolac tromethamine oral tablet 10 leflunomide oral tablet 10, 20 PA PA PA PA PA PA PA PA C (Max of 5 day supply); QL (20 EA per 5 days) 2

9 meloxicam oral tablet 15, 7.5 nabumetone oral tablet 500 QL (120 EA per 30 days) nabumetone oral tablet 750 QL (60 EA per 30 days) NAPROXEN COMFORT PAC COMBINATION KIT 500 MG naproxen dr oral tablet delayed release 375, 500 naproxen oral tablet 250, 375, 500 naproxen powder naproxen sodium oral capsule 220 naproxen sodium oral tablet 220 oxaprozin oral tablet 600 piroxicam oral capsule 10, 20 sulindac oral tablet 150, 200 *Analgesics - Nonnarcotic* ACEPHEN RECTAL SUPPOSITORY 325 MG acetaminophen er oral tablet extended release 650 acetaminophen oral capsule 500 acetaminophen oral elixir 160 /5ml acetaminophen oral suspension 160 /5ml acetaminophen oral tablet 325, 500 acetaminophen rectal suppository 120 adult aspirin low strength oral tablet dispersible 81 apap oral tablet chewable 80 ASCRIPTIN ORAL TABLET 325 MG aspirin adult low strength oral tablet delayed release 81 aspirin low dose oral tablet chewable 81 aspirin oral tablet 325 aspirin oral tablet 81 aspirin oral tablet delayed release 325 aspirin rectal suppository 300, 600 aspirtab maximum strength oral tablet 500 QL (30 EA per 30 days); AL (Min 40 Years and Max 79 Years) QL (60 EA per 30 days); AL (Min 40 Years and Max 79 Years) QL (60 EA per 30 days); AL (Min 40 Years and Max 79 Years) QL (30 EA per 30 days); AL (Min 40 Years and Max 79 Years) QL (60 EA per 30 days); AL (Min 40 Years and Max 79 Years) QL (30 EA per 30 days); AL (Min 40 Years and Max 79 Years) 3

10 buffasal oral tablet 324 buffered aspirin oral tablet 325 butalbital-acetaminophen oral tablet butalbital-apap-caffeine oral tablet butalbital-aspirin-caffeine oral capsule choline & mag trisalicylate oral tablet 1000 choline-mag trisalicylate oral liquid 500 /5ml diflunisal oral tablet 500 infants pain relief oral suspension 80 /0.8ml migraine relief oral tablet q-pap infants oral solution 80 /0.8ml q-pap oral liquid 160 /5ml salsalate oral tablet 500, 750 *Analgesics - Opioid* QL (30 EA per 30 days); AL (Min 40 Years and Max 79 Years) QL (30 EA per 30 days); AL (Min 40 Years and Max 79 Years) acetaminophen-codeine #2 oral tablet QL (390 EA per 30 days) acetaminophen-codeine #3 oral tablet QL (390 EA per 30 days) acetaminophen-codeine #4 oral tablet QL (390 EA per 30 days) acetaminophen-codeine oral solution /5ml butalbital-apap-caff-cod oral capsule butalbital-asa-caff-codeine oral capsule codeine sulfate oral tablet 15, 30, 60 fentanyl transdermal patch 72 hour 100 mcg/hr, 12 mcg/hr, 25 mcg/hr, 50 mcg/hr, 75 mcg/hr hydrocodone-acetaminophen oral solution /15ml, /15ml hydrocodone-acetaminophen oral tablet , PA; QL (10 EA per 30 days) QL (900 ML per 90 days) QL (180 EA per 30 days) hydrocodone-acetaminophen oral tablet QL (360 EA per 30 days) hydromorphone hcl oral tablet 2, 4, 8 QL (240 EA per 30 days) LORTAB ORAL ELIXIR MG/15ML QL (900 ML per 90 days) meperidine hcl oral tablet 100, 50 methadone hcl oral concentrate 10 /ml methadone hcl oral solution 10 /5ml, 5 /5ml methadone hcl oral tablet 10 QL (240 EA per 30 days) 4

11 methadone hcl oral tablet 5 QL (120 EA per 30 days) methadone hcl oral tablet soluble 40 morphine sulfate (concentrate) oral solution 100 /5ml morphine sulfate er oral tablet extended release 100, 15, 30, 60 morphine sulfate oral solution 10 /5ml, 20 /5ml QL (90 EA per 30 days) morphine sulfate oral tablet 15, 30 QL (180 EA per 30 days) oxycodone hcl oral concentrate 100 /5ml oxycodone hcl oral solution 5 /5ml oxycodone hcl oral tablet 10, 15, 20, 30, 5 oxycodone-acetaminophen oral tablet , QL (180 EA per 30 days) QL (180 EA per 30 days) oxycodone-acetaminophen oral tablet QL (360 EA per 30 days) oxycodone-aspirin oral tablet tramadol hcl oral tablet 50 QL (240 EA per 30 days) *Androgens-Anabolic* testosterone cypionate intramuscular solution 100 /ml, 200 /ml testosterone enanthate intramuscular solution 200 /ml *Anorectal Agents* GR-M GR-M anucort-hc suppository 25 rectal 25 QL (28 EA per 14 days) FLEET NATURALS CLEANSING ENEMA RECTAL ENEMA hemorrhoidal rectal cream % hemorrhoidal rectal suppository 51 % hydrocortisone acetate rectal suppository 30 QL (28 EA per 14 days) hydrocortisone acetate suppository 25 rectal 25 QL (28 EA per 14 days) hydrocortisone rectal cream 1 % QL (120 GM per 30 days) hydrocortisone rectal enema 100 /60ml PROCTOZONE-HC RECTAL CREAM 2.5 % *Antacids* ALKA-SELTZER HEARTBURN ORAL TABLET EFFERVESCENT MG ALMACONE ORAL TABLET CHEWABLE MG 5

12 antacid & antigas oral suspension /5ml, /5ml antacid extra strength oral tablet chewable antacid multi-symptom oral tablet chewable antacid oral tablet chewable 1177, , 420, calcium antacid ultra oral tablet chewable 1000 calcium carbonate antacid oral tablet 648 calcium carbonate antacid oral tablet chewable 500, 750 CHILDRENS SOOTHE ORAL TABLET CHEWABLE 400 MG CITROCARBONATE ORAL GRANULES EFFERVESCENT GM/DOSE cvs antacid & anti-gas oral tablet chewable cvs antacid supreme oral suspension /5ml cvs heartburn relief ex st oral suspension /5ml DEWEES CARMINATIVE ORAL LIQUID E-Z-GAS II ORAL PACKET GM GAVISCON ORAL TABLET CHEWABLE MG gnp foaming antacid oral suspension /15ml gnp foaming antacid oral tablet chewable heartburn antacid ex st oral tablet chewable mag-al oral liquid /5ml magnesium oxide oral capsule 400 magnesium oxide oral tablet 250, 400, 420 magnesium oxide powder MI-ACID ORAL TABLET CHEWABLE MG sodium bicarbonate oral powder 6

13 sodium bicarbonate oral tablet 325, 650 URO-MAG ORAL CAPSULE 140 MG *Anthelmintics* ivermectin oral tablet 3 QL (20 EA per 90 days) PIN-X ORAL SUSPENSION 50 MG/ML PIN-X ORAL TABLET CHEWABLE MG reeses pinworm medicine oral suspension 144 /ml *Antianginal Agents* isosorbide dinitrate er oral tablet extended release 40 isosorbide dinitrate oral tablet 10, 20, 30, 5 isosorbide mononitrate er oral tablet extended release 24 hour 120, 30, 60 isosorbide mononitrate oral tablet 20 NITRO-BID TRANSDERMAL OINTMENT 2 % nitroglycerin er oral capsule extended release 2.5, 6.5, 9 nitroglycerin sublingual tablet sublingual 0.3, 0.4, 0.6 nitroglycerin transdermal patch 24 hour 0.1 /hr, 0.2 /hr, 0.4 /hr, 0.6 /hr *Antianxiety Agents* alprazolam oral tablet 0.25, 0.5, 1, 2 buspirone hcl oral tablet 10, 15, 30, 5, 7.5 chlordiazepoxide hcl oral capsule 10, 25, 5 clorazepate dipotassium oral tablet 15, 3.75, 7.5 diazepam injection solution 5 /ml AL (Max 64 Years) diazepam oral solution 1 /ml AL (Max 64 Years) diazepam oral tablet 10, 2, 5 AL (Max 64 Years) hydroxyzine hcl oral syrup 10 /5ml hydroxyzine hcl oral tablet 10, 25, 50 hydroxyzine pamoate oral capsule 100, 25, 50 7

14 lorazepam oral tablet 0.5, 1, 2 oxazepam oral capsule 10, 15, 30 *Antiarrhythmics* amiodarone hcl oral tablet 200 disopyramide phosphate oral capsule 100, 150 flecainide acetate oral tablet 100, 150, 50 NORPACE CR ORAL CAPSULE EXTENDED RELEASE 12 HOUR 100 MG NORPACE CR ORAL CAPSULE EXTENDED RELEASE 12 HOUR 150 MG propafenone hcl oral tablet 150, 225, 300 quinidine gluconate er oral tablet extended release 324 quinidine sulfate oral tablet 200, 300 *Antiasthmatic And Bronchodilator Agents* ADVAIR DISKUS INHALATION AEROSOL POWDER BREATH ACTIVATED MCG/DOSE AEROSPAN INHALATION AEROSOL SOLUTION 80 MCG/ACT albuterol sulfate inhalation nebulization solution (2.5 /3ml) 0.083%, (5 /ml) 0.5% albuterol sulfate oral syrup 2 /5ml ANORO ELLIPTA INHALATION AEROSOL POWDER BREATH ACTIVATED MCG/INH ATROVENT HFA INHALATION AEROSOL SOLUTION 17 MCG/ACT BREO ELLIPTA INHALATION AEROSOL POWDER BREATH ACTIVATED MCG/INH, MCG/INH budesonide inhalation suspension 0.25 /2ml, 0.5 /2ml DULERA INHALATION AEROSOL MCG/ACT, MCG/ACT FLOVENT DISKUS INHALATION AEROSOL POWDER BREATH ACTIVATED 100 MCG/BLIST, 50 MCG/BLIST 8 QL (60 EA per 30 days) QL (120 EA per 30 days) QL (60 EA per 30 days); AL (Max 11 Years) QL (8.9 GM per 30 days) PA; QL (60 EA per 30 days) QL (12.9 GM per 30 days) QL (60 EA per 30 days) AL (Max 6 Years) QL (13 GM per 30 days) QL (60 EA per 30 days); AL (Min 4 Years and Max 11 Years)

15 FLOVENT HFA INHALATION AEROSOL 44 MCG/ACT fluticasone-salmeterol aerosol powder breath activated mcg/act inhalation mcg/act fluticasone-salmeterol aerosol powder breath activated mcg/act inhalation mcg/act fluticasone-salmeterol aerosol powder breath activated mcg/act inhalation mcg/act FORADIL AEROLIZER INHALATION CAPSULE 12 MCG INCRUSE ELLIPTA INHALATION AEROSOL POWDER BREATH ACTIVATED 62.5 MCG/INH ipratropium bromide inhalation solution 0.02 % LUFYLLIN ORAL TABLET 200 MG, 400 MG metaproterenol sulfate oral syrup 10 /5ml metaproterenol sulfate oral tablet 10, 20 montelukast sodium oral tablet 10 montelukast sodium oral tablet chewable 4, 5 QVAR INHALATION AEROSOL SOLUTION 40 MCG/ACT, 80 MCG/ACT QVAR REDIHALER INHALATION AEROSOL BREATH ACTIVATED 40 MCG/ACT, 80 MCG/ACT SEREVENT DISKUS INHALATION AEROSOL POWDER BREATH ACTIVATED 50 MCG/DOSE STRIVERDI RESPIMAT INHALATION AEROSOL SOLUTION 2.5 MCG/ACT SYMBICORT INHALATION AEROSOL MCG/ACT, MCG/ACT terbutaline sulfate oral tablet 2.5, 5 THEO-24 ORAL CAPSULE EXTENDED RELEASE 24 HOUR 100 MG, 200 MG, 300 MG theophylline er oral tablet extended release 12 hour 100, 200, 300, 450 theophylline er oral tablet extended release 24 hour 400 theophylline oral solution 80 /15ml QL (10.6 GM per 30 days); AL (Min 4 Years and Max 11 Years) QL (1 EA per 30 days) QL (1 EA per 30 days) QL (1 EA per 30 days) QL (60 EA per 30 days) QL (30 EA per 30 days) QL (8.7 GM per 30 days) QL (10.6 GM per 30 days) QL (120 EA per 30 days) QL (4 GM per 30 days) QL (10.2 GM per 30 days) 9

16 TUDORZA PRESSAIR INHALATION AEROSOL POWDER BREATH ACTIVATED 400 MCG/ACT VENTOLIN HFA INHALATION AEROSOL SOLUTION 108 (90 BASE) MCG/ACT *Anticoagulants* QL (1 EA per 30 days) QL (36 GM per 30 days) enoxaparin sodium injection solution 300 /3ml PA; C (7 day supply then PA) enoxaparin sodium subcutaneous solution 100 /ml, 120 /0.8ml, 150 /ml, 30 /0.3ml, 40 /0.4ml, 60 /0.6ml, 80 /0.8ml heparin sodium (porcine) injection solution 1000 unit/ml, unit/ml, unit/ml, 5000 unit/ml heparin sodium (porcine) intravenous solution 2000 unit/ml heparin sodium (porcine) pf injection solution 5000 unit/0.5ml JANTOVEN ORAL TABLET 1 MG, 10 MG, 2 MG, 2.5 MG, 3 MG, 4 MG, 5 MG, 6 MG, 7.5 MG warfarin sodium oral tablet 1, 10, 2, 2.5, 3, 4, 5, 6, 7.5 PA; C (7 day supply then PA) XARELTO ORAL TABLET 10 MG PA; QL (35 EA per 35 days) *Anticonvulsants* carbamazepine er oral capsule extended release 12 hour 300 carbamazepine er oral tablet extended release 12 hour 200, 400 carbamazepine oral suspension 100 /5ml carbamazepine oral tablet 200 carbamazepine oral tablet chewable 100 clonazepam oral tablet 0.5, 1, 2 DIASTAT ACUDIAL RECTAL GEL 10 MG, 20 MG QL (2 EA per 30 days) diazepam rectal gel 10, 2.5, 20 QL (2 EA per 30 days) DILANTIN ORAL CAPSULE 100 MG, 30 MG divalproex sodium er oral tablet extended release 24 hour 250, 500 divalproex sodium oral capsule delayed release sprinkle 125 divalproex sodium oral tablet delayed release 125, 250,

17 EPITOL ORAL TABLET 200 MG ethosuximide oral capsule 250 ethosuximide oral solution 250 /5ml fosphenytoin sodium injection solution 100 pe/2ml, 500 pe/10ml gabapentin oral capsule 100, 300, 400 gabapentin oral solution 250 /5ml gabapentin oral tablet 600, 800 lamotrigine oral tablet 100, 150, 200, 25 lamotrigine oral tablet chewable 25, 5 levetiracetam oral solution 100 /ml levetiracetam oral tablet 1000 QL (90 EA per 30 days) levetiracetam oral tablet 250 QL (360 EA per 30 days) levetiracetam oral tablet 500 QL (180 EA per 30 days) levetiracetam oral tablet 750 QL (120 EA per 30 days) oxcarbazepine oral tablet 150, 300, 600 phenytoin oral suspension 125 /5ml QL (750 ML per 30 days) phenytoin oral tablet chewable 50 phenytoin sodium extended oral capsule 100 phenytoin sodium injection solution 50 /ml primidone oral tablet 250, 50 topiramate oral capsule sprinkle 15, 25 topiramate oral tablet 100, 200, 25, 50 valproic acid oral capsule 250 valproic acid oral solution 250 /5ml zonisamide oral capsule 100 QL (180 EA per 30 days) zonisamide oral capsule 25, 50 QL (30 EA per 30 days) *Antidepressants* amitriptyline hcl oral tablet 10, 100, 150, 25, 50, 75 amoxapine oral tablet 100, 150, 25, 50 bupropion hcl er (sr) oral tablet extended release 12 hour 100, 150, 200 bupropion hcl er (xl) oral tablet extended release 24 hour 150, 300 bupropion hcl oral tablet 100, 75 AL (Max 64 Years) AL (Max 64 Years) 11

18 citalopram hydrobromide oral tablet 10, 20, 40 doxepin hcl oral capsule 10, 100, 150, 25, 50, 75 AL (Max 64 Years) doxepin hcl oral concentrate 10 /ml AL (Max 64 Years) duloxetine hcl oral capsule delayed release particles 20 duloxetine hcl oral capsule delayed release particles 30, 60 QL (60 EA per 30 days) QL (30 EA per 30 days) escitalopram oxalate oral tablet 10, 5 QL (45 EA per 30 days) escitalopram oxalate oral tablet 20 QL (30 EA per 30 days) fluoxetine hcl oral capsule 10, 20, 40 fluoxetine hcl oral solution 20 /5ml fluvoxamine maleate oral tablet 100, 25, 50 imipramine hcl oral tablet 10, 25, 50 AL (Max 64 Years) mirtazapine oral tablet 15, 30, 45 nortriptyline hcl oral capsule 10, 25, 50, 75 nortriptyline hcl oral solution 10 /5ml paroxetine hcl oral tablet 10, 20, 30, 40 phenelzine sulfate oral tablet 15 sertraline hcl oral tablet 100, 25, 50 tranylcypromine sulfate oral tablet 10 PA trazodone hcl oral tablet 100, 150, 50 venlafaxine hcl er oral capsule extended release 24 hour 150, 37.5, 75 venlafaxine hcl oral tablet 100, 25, 37.5, 50, 75 *Antidiabetics* acarbose oral tablet 100, 25, 50 alogliptin benzoate oral tablet 12.5, 25, 6.25 QL (30 EA per 30 days) alogliptin-metformin hcl oral tablet QL (60 EA per 30 days) alogliptin-metformin hcl oral tablet QL (30 EA per 30 days) alogliptin-pioglitazone oral tablet , , , 25-15, 25-30, chlorpropamide oral tablet 100, 250 glimepiride oral tablet 1, 2, 4 12 QL (30 EA per 30 days)

19 glipizide oral tablet 10, 5 glipizide xl oral tablet extended release 24 hour 10, 2.5, 5 glipizide-metformin hcl oral tablet , , GLUCAGON EMERGENCY INJECTION KIT 1 MG glyburide micronized oral tablet 1.5, 3, 6 glyburide oral tablet 1.25, 2.5, 5 glyburide-metformin oral tablet , , INVOKANA ORAL TABLET 100 MG, 300 MG JANUMET ORAL TABLET MG, MG JANUMET XR ORAL TABLET EXTENDED RELEASE 24 HOUR MG, MG, MG JANUVIA ORAL TABLET 100 MG, 25 MG, 50 MG QL (60 EA per 30 days) QL (2 EA per 365 days) QL (30 EA per 30 days) QL (60 EA per 30 days) QL (30 EA per 30 days) QL (30 EA per 30 days) JARDIANCE ORAL TABLET 10 MG, 25 MG QL (30 EA per 30 days) LANTUS SOLOSTAR SUBCUTANEOUS SOLUTION PEN-INJECTOR 100 UNIT/ML LANTUS SUBCUTANEOUS SOLUTION 100 UNIT/ML LEVEMIR FLEXTOUCH SUBCUTANEOUS SOLUTION PEN-INJECTOR 100 UNIT/ML LEVEMIR SUBCUTANEOUS SOLUTION 100 UNIT/ML metformin hcl er oral tablet extended release 24 hour 500, 750 metformin hcl oral tablet 1000, 500, 850 nateglinide oral tablet 120, 60 QL (90 EA per 30 days) NOVOLIN 70/30 RELION SUBCUTANEOUS SUSPENSION (70-30) 100 UNIT/ML NOVOLIN 70/30 SUBCUTANEOUS SUSPENSION (70-30) 100 UNIT/ML NOVOLIN N RELION SUBCUTANEOUS SUSPENSION 100 UNIT/ML NOVOLIN N SUBCUTANEOUS SUSPENSION 100 UNIT/ML 13

20 NOVOLIN R INJECTION SOLUTION 100 UNIT/ML NOVOLIN R RELION INJECTION SOLUTION 100 UNIT/ML NOVOLOG FLEXPEN SUBCUTANEOUS SOLUTION PEN-INJECTOR 100 UNIT/ML NOVOLOG MIX 70/30 FLEXPEN SUBCUTANEOUS SUSPENSION PEN- INJECTOR (70-30) 100 UNIT/ML NOVOLOG MIX 70/30 SUBCUTANEOUS SUSPENSION (70-30) 100 UNIT/ML NOVOLOG SUBCUTANEOUS SOLUTION 100 UNIT/ML pioglitazone hcl oral tablet 15, 30, 45 QL (30 EA per 30 days) pioglitazone hcl-metformin hcl oral tablet , TANZEUM SUBCUTANEOUS PEN- INJECTOR 30 MG, 50 MG TOUJEO SOLOSTAR SUBCUTANEOUS SOLUTION PEN-INJECTOR 300 UNIT/ML TRESIBA FLEXTOUCH SUBCUTANEOUS SOLUTION PEN-INJECTOR 100 UNIT/ML, 200 UNIT/ML *Antidiarrheals* acidophilus/citrus pectin oral tablet acidophilus/pectin oral capsule bismuth oral tablet chewable 262 CULTURELLE DIGESTIVE HEALTH ORAL CAPSULE CULTURELLE DIGESTIVE HEALTH ORAL TABLET CHEWABLE diphenoxylate-atropine oral liquid /5ml diphenoxylate-atropine oral tablet IMODIUM A-D ORAL TABLET CHEWABLE 2 MG loperamide hcl oral capsule 2 loperamide hcl oral liquid 1 /5ml loperamide hcl oral suspension 1 /7.5ml loperamide hcl oral tablet 2 pink bismuth maximum strength oral suspension 525 /15ml 14 QL (60 EA per 30 days) PA

21 pink bismuth oral suspension 262 /15ml probiotic-prebiotic oral capsule billion- ra pink bismuth oral tablet 262 ra probiotic digestive care oral capsule *Antidotes* CHEMET ORAL CAPSULE 100 MG naloxone hcl injection solution 0.4 /ml, 1 /ml naloxone hcl injection solution cartridge 0.4 /ml QL (2 ML per 90 days) QL (2 ML per 90 days) naltrexone hcl oral tablet 50 QL (40 EA per 30 days) *Antiemetics* dimenhydrinate injection solution 50 /ml dimenhydrinate oral tablet 50 DRAMAMINE ORAL TABLET CHEWABLE 50 MG dronabinol oral capsule 10, 2.5, 5 PA meclizine hcl oral tablet 12.5, 25 meclizine hcl oral tablet chewable 25 meclizine hcl powder ondansetron hcl oral solution 4 /5ml QL (50 ML per 30 days) ondansetron hcl oral tablet 4, 8 ondansetron oral tablet dispersible 4, 8 trimethobenzamide hcl oral capsule 300 *Antifungals* fluconazole oral suspension reconstituted 10 /ml, 40 /ml fluconazole oral tablet 100, 200, 50 fluconazole oral tablet 150 QL (4 EA per 30 days) griseofulvin microsize oral suspension 125 /5ml griseofulvin microsize oral tablet 500 griseofulvin ultramicrosize oral tablet 125, 250 ketoconazole oral tablet 200 nystatin oral powder nystatin oral tablet unit terbinafine hcl oral tablet

22 *Antihistamines* aler-dryl oral tablet 50 aller-chlor oral syrup 2 /5ml cetirizine hcl oral syrup 5 /5ml cetirizine hcl oral tablet 10, 5 chlorpheniramine maleate er oral tablet extended release 12 chlorpheniramine maleate oral tablet 4 chlorpheniramine maleate powder clemastine fumarate oral syrup 0.67 /5ml clemastine fumarate oral tablet 1.34, 2.68 cvs allergy childrens oral tablet chewable 12.5 cyproheptadine hcl oral syrup 2 /5ml cyproheptadine hcl oral tablet 4 dexchlorpheniramine maleate oral syrup 2 /5ml diphenhist oral liquid 12.5 /5ml diphenhydramine hcl oral capsule 25, 50 diphenhydramine hcl oral elixir 12.5 /5ml diphenhydramine hcl oral tablet 25 ED CHLORPED ORAL LIQUID 2 MG/ML fexofenadine hcl childrens oral suspension 30 /5ml fexofenadine hcl oral tablet 180 PA; C (covered up to age 65, then PA required) PA; C (covered up to age 65, then PA required) PA; C (covered up to age 65, then PA required) PA; C (covered up to age 65, then PA required) PA; C (covered up to age 65, then PA required) PA; C (covered up to age 65, then PA required) levocetirizine dihydrochloride oral tablet 5 QL (30 EA per 30 days) loratadine allergy relief oral tablet dispersible 10 loratadine childrens oral solution 5 /5ml loratadine oral tablet 10 promethazine hcl oral solution 6.25 /5ml promethazine hcl oral tablet 12.5, 25, 50 promethazine hcl rectal suppository 12.5, 25, 50 QL (12 EA per 30 days) 16

23 ra allergy relief childrens oral tablet dispersible 12.5 silphen cough oral syrup 12.5 /5ml TRIAMINIC COUGH/RUNNY NOSE ORAL STRIP 12.5 MG *Antihyperlipidemics* atorvastatin calcium oral tablet 10, 20, 40, 80 cholestyramine light oral powder 4 gm/dose cholestyramine oral powder 4 gm/dose colestipol hcl oral granules 5 gm colestipol hcl oral tablet 1 gm PA; C (covered up to age 65, then PA required) PA; C (covered up to age 65, then PA required) QL (30 EA per 30 days) ezetimibe oral tablet 10 QL (30 EA per 30 days) fenofibrate micronized oral capsule 134, 200, 67 fenofibrate oral tablet 145, 48 fenofibrate oral tablet 160, 54 QL (30 EA per 30 days) gemfibrozil oral tablet 600 lovastatin oral tablet 10, 20, 40 NIACOR ORAL TABLET 500 MG pravastatin sodium oral tablet 10, 20, 40, 80 rosuvastatin calcium oral tablet 10, 20, 40, 5 simvastatin oral tablet 10, 20, 40, 5 simvastatin oral tablet 80 QL (30 EA per 30 days) *Antihypertensives* amlodipine besy-benazepril hcl oral capsule 10-20, 10-40, , 5-10, 5-20, 5-40 amlodipine besylate-valsartan oral tablet , , 5-160, amlodipine-olmesartan oral tablet 10-20, 10-40, 5-20, 5-40 atenolol-chlorthalidone oral tablet , benazepril hcl oral tablet 10, 20, 40, 5 benazepril-hydrochlorothiazide oral tablet , , 20-25, QL (30 EA per 30 days) PA; QL (30 EA per 30 days) 17

24 bisoprolol-hydrochlorothiazide oral tablet , , captopril oral tablet 100 captopril oral tablet 12.5, 25, 50 QL (90 EA per 30 days) captopril-hydrochlorothiazide oral tablet 25-15, 25-25, 50-15, clonidine hcl oral tablet 0.1, 0.2, 0.3 doxazosin mesylate oral tablet 1, 2, 4, 8 enalapril maleate oral tablet 10, 2.5, 20, 5 enalapril-hydrochlorothiazide oral tablet 10-25, fosinopril sodium oral tablet 10, 20, 40 fosinopril sodium-hctz oral tablet , guanfacine hcl oral tablet 1, 2 hydralazine hcl oral tablet 10, 100, 25, 50 irbesartan oral tablet 150, 300, 75 QL (30 EA per 30 days) irbesartan-hydrochlorothiazide oral tablet , lisinopril oral tablet 10, 2.5, 20, 30, 40, 5 lisinopril-hydrochlorothiazide oral tablet , , losartan potassium oral tablet 100, 25, 50 losartan potassium-hctz oral tablet , , methyldopa oral tablet 250, 500 metoprolol-hydrochlorothiazide oral tablet , , minoxidil oral tablet 10, 2.5 moexipril hcl oral tablet 15, 7.5 olmesartan medoxomil oral tablet 20, 40, 5 prazosin hcl oral capsule 1, 2, 5 QL (30 EA per 30 days) propranolol-hctz oral tablet 40-25, QL (60 EA per 30 days) quinapril hcl oral tablet 10, 20, 40, 5 18

25 quinapril-hydrochlorothiazide oral tablet , , ramipril oral capsule 1.25, 10, 2.5, 5 telmisartan oral tablet 20, 40, 80 terazosin hcl oral capsule 1, 10, 2, 5 trandolapril oral tablet 1, 2, 4 valsartan oral tablet 160, 320, 40, 80 valsartan-hydrochlorothiazide oral tablet , , , , *Anti-Infective Agents - Misc.* QL (30 EA per 30 days) atovaquone oral suspension 750 /5ml QL (210 ML per 18 days) clindamycin hcl oral capsule 150, 300, 75 clindamycin palmitate hcl oral solution reconstituted 75 /5ml dapsone oral tablet 100, 25 DORIBAX INTRAVENOUS SOLUTION RECONSTITUTED 250 MG, 500 MG FIRST-VANCOMYCIN 25 ORAL SOLUTION 25 MG/ML FIRST-VANCOMYCIN 50 ORAL SOLUTION 50 MG/ML metronidazole oral tablet 250, 500 PRIMSOL ORAL SOLUTION 50 MG/5ML QL (600 ML per 30 days) sulfamethoxazole-trimethoprim oral suspension /5ml sulfamethoxazole-trimethoprim oral tablet , tinidazole oral tablet 500 trimethoprim oral tablet 100 QL (60 EA per 30 days) vancomycin hcl intravenous solution reconstituted 10 gm, 1000, 500, 5000, 750 *Antimalarials* chloroquine phosphate oral tablet 250 PA DARAPRIM ORAL TABLET 25 MG PA hydroxychloroquine sulfate oral tablet 200 mefloquine hcl oral tablet 250 QL (5 EA per 30 days) 19

26 primaquine phosphate oral tablet 26.3 QL (14 EA per 30 days) quinine sulfate oral capsule 324 *Antimyasthenic Agents* pyridostigmine bromide oral tablet 60 *Antimycobacterial Agents* ethambutol hcl oral tablet 100, 400 isoniazid oral syrup 50 /5ml isoniazid oral tablet 100, 300 pyrazinamide oral tablet 500 rifampin oral capsule 150, 300 RIFATER ORAL TABLET MG TRECATOR ORAL TABLET 250 MG *Antineoplastics And Adjunctive Therapies* anastrozole oral tablet 1 GR-F bicalutamide oral tablet 50 capecitabine oral tablet 150, 500 PA cyclophosphamide oral capsule 25, 50 cyclophosphamide oral tablet 25, 50 ELIGARD SUBCUTANEOUS KIT 22.5 MG, 30 MG, 45 MG, 7.5 MG flutamide oral capsule 125 PA GLEOSTINE ORAL CAPSULE 10 MG, 100 MG, 40 MG HEXALEN ORAL CAPSULE 50 MG PA hydroxyurea oral capsule 500 imatinib mesylate oral tablet 100, 400 PA INTRON A INJECTION SOLUTION UNIT/ML, UNIT/ML INTRON A INJECTION SOLUTION RECONSTITUTED UNIT, UNIT, UNIT letrozole oral tablet 2.5 QL (30 EA per 30 days) leucovorin calcium oral tablet 15, 25, 5 LEUKERAN ORAL TABLET 2 MG LUPRON DEPOT (1-MONTH) INTRAMUSCULAR KIT 3.75 MG, 7.5 MG LUPRON DEPOT (3-MONTH) INTRAMUSCULAR KIT MG, 22.5 MG 20 PA PA PA PA PA

27 LUPRON DEPOT (4-MONTH) INTRAMUSCULAR KIT 30 MG MATULANE ORAL CAPSULE 50 MG PA megestrol acetate oral suspension 40 /ml, 400 /10ml megestrol acetate oral tablet 20, 40 mercaptopurine oral tablet 50 methotrexate oral tablet 2.5 MYLERAN ORAL TABLET 2 MG TABLOID ORAL TABLET 40 MG tamoxifen citrate oral tablet 10, 20 GR-F; AL (Min 35 Years) tretinoin oral capsule 10 PA *Antiparkinson Agents* amantadine hcl oral capsule 100 amantadine hcl oral syrup 50 /5ml benztropine mesylate oral tablet 0.5, 1, 2 bromocriptine mesylate oral capsule 5 bromocriptine mesylate oral tablet 2.5 carbidopa oral tablet 25 carbidopa-levodopa er oral tablet extended release , carbidopa-levodopa oral tablet , , entacapone oral tablet 200 pramipexole dihydrochloride oral tablet 0.125, 0.25, 0.5, 0.75, 1, 1.5 ropinirole hcl oral tablet 0.25, 0.5, 1, 2, 3, 4, 5 selegiline hcl oral capsule 5 trihexyphenidyl hcl oral elixir 0.4 /ml trihexyphenidyl hcl oral tablet 2, 5 *Antipsychotics/Antimanic Agents* aripiprazole oral tablet 10, 15, 2, 20, 30, 5 clozapine oral tablet 100, 200, 25, 50 fluphenazine hcl injection solution 2.5 /ml fluphenazine hcl oral concentrate 5 /ml fluphenazine hcl oral elixir 2.5 /5ml PA QL (30 EA per 30 days) 21

28 fluphenazine hcl oral tablet 1, 10, 2.5, 5 haloperidol decanoate intramuscular solution 100 /ml haloperidol oral tablet 0.5, 1, 10, 2, 20, 5 lithium carbonate er oral tablet extended release 300, 450 lithium carbonate oral capsule 150, 300, 600 lithium carbonate oral tablet 300 loxapine succinate oral capsule 10, 25, 5, 50 olanzapine oral tablet 10, 15, 2.5, 20, 5, 7.5 perphenazine oral tablet 16, 2, 4, 8 prochlorperazine maleate oral tablet 10, 5 prochlorperazine rectal suppository 25 QL (60 EA per 30 days) quetiapine fumarate er oral tablet extended release 24 hour 150, 200, 300, 400, 50 quetiapine fumarate oral tablet 100, 200, 25, 300, 400, 50 risperidone oral tablet 0.25, 0.5, 1, 2, 3, 4 thiothixene oral capsule 1, 10, 2, 5 trifluoperazine hcl oral tablet 1, 10, 2, 5 ziprasidone hcl oral capsule 20, 40, 60, 80 *Antiseptics & Disinfectants* povidone-iodine external pad 10 % povidone-iodine external solution 10 % *Antivirals* ST; QL (30 EA per 30 days) abacavir sulfate oral solution 20 /ml QL (900 ML per 30 days) abacavir sulfate oral tablet 300 QL (60 EA per 30 days) abacavir sulfate-lamivudine oral tablet abacavir-lamivudine-zidovudine oral tablet acyclovir oral capsule 200 ST QL (30 EA per 30 days) QL (60 EA per 30 days) acyclovir oral suspension 200 /5ml AL (Max 12 Years) 22

29 acyclovir oral tablet 400, 800 APTIVUS ORAL CAPSULE 250 MG QL (120 EA per 30 days) APTIVUS ORAL SOLUTION 100 MG/ML QL (300 ML per 30 days) atazanavir sulfate oral capsule 150, 200 QL (60 EA per 30 days) atazanavir sulfate oral capsule 300 QL (30 EA per 30 days) ATRIPLA ORAL TABLET MG QL (30 EA per 30 days) COMPLERA ORAL TABLET MG QL (30 EA per 30 days) CRIXIVAN ORAL CAPSULE 200 MG QL (360 EA per 30 days) CRIXIVAN ORAL CAPSULE 400 MG QL (180 EA per 30 days) didanosine oral capsule delayed release 125, 200 didanosine oral capsule delayed release 250, 400 QL (60 EA per 30 days) QL (30 EA per 30 days) EDURANT ORAL TABLET 25 MG QL (30 EA per 30 days) efavirenz oral capsule 200 QL (90 EA per 30 days) efavirenz oral capsule 50 QL (360 EA per 30 days) efavirenz oral tablet 600 QL (30 EA per 30 days) EMTRIVA ORAL CAPSULE 200 MG QL (30 EA per 30 days) EMTRIVA ORAL SOLUTION 10 MG/ML QL (600 ML per 30 days) EPIVIR HBV ORAL SOLUTION 5 MG/ML QL (1800 ML per 30 days) fosamprenavir calcium oral tablet 700 QL (120 EA per 30 days) INTELENCE ORAL TABLET 100 MG QL (120 EA per 30 days) INTELENCE ORAL TABLET 200 MG QL (60 EA per 30 days) INTELENCE ORAL TABLET 25 MG INVIRASE ORAL CAPSULE 200 MG QL (300 EA per 30 days) INVIRASE ORAL TABLET 500 MG QL (120 EA per 30 days) ISENTRESS ORAL TABLET 400 MG QL (60 EA per 30 days) ISENTRESS ORAL TABLET CHEWABLE 100 MG, 25 MG KALETRA ORAL TABLET MG QL (360 EA per 30 days) KALETRA ORAL TABLET MG QL (180 EA per 30 days) lamivudine oral solution 10 /ml QL (900 ML per 30 days) lamivudine oral tablet 100 lamivudine oral tablet 150 QL (60 EA per 30 days) lamivudine oral tablet 300 QL (30 EA per 30 days) lamivudine-zidovudine oral tablet QL (60 EA per 30 days) LEXIVA ORAL SUSPENSION 50 MG/ML QL (360 ML per 60 days) lopinavir-ritonavir oral solution /5ml QL (450 ML per 30 days) 23

30 nevirapine er oral tablet extended release 24 hour 400 QL (30 EA per 30 days) nevirapine oral suspension 50 /5ml QL (1200 ML per 30 days) nevirapine oral tablet 200 QL (60 EA per 30 days) NORVIR ORAL CAPSULE 100 MG QL (360 EA per 30 days) NORVIR ORAL SOLUTION 80 MG/ML QL (450 ML per 30 days) oseltamivir phosphate oral capsule 30, 45, 75 oseltamivir phosphate oral suspension reconstituted 6 /ml PEG-INTRON REDIPEN PAK 4 SUBCUTANEOUS KIT 120 MCG/0.5ML, 150 MCG/0.5ML, 50 MCG/0.5ML, 80 MCG/0.5ML PEG-INTRON REDIPEN SUBCUTANEOUS KIT 120 MCG/0.5ML, 150 MCG/0.5ML, 50 MCG/0.5ML, 80 MCG/0.5ML PEGINTRON SUBCUTANEOUS KIT 120 MCG/0.5ML, 150 MCG/0.5ML, 50 MCG/0.5ML, 80 MCG/0.5ML PEG-INTRON SUBCUTANEOUS KIT 120 MCG/0.5ML, 150 MCG/0.5ML, 50 MCG/0.5ML, 80 MCG/0.5ML QL (10 EA per 5 days) QL (120 ML per 10 days); AL (Max 12 Years) PREZISTA ORAL TABLET 150 MG QL (240 EA per 30 days) PREZISTA ORAL TABLET 600 MG QL (60 EA per 30 days) PREZISTA ORAL TABLET 75 MG QL (480 EA per 30 days) PREZISTA ORAL TABLET 800 MG QL (30 EA per 30 days) RELENZA DISKHALER INHALATION AEROSOL POWDER BREATH ACTIVATED 5 MG/BLISTER PA PA PA PA QL (20 EA per 5 days) RESCRIPTOR ORAL TABLET 100 MG QL (360 EA per 30 days) RESCRIPTOR ORAL TABLET 200 MG RIBASPHERE ORAL CAPSULE 200 MG PA ribavirin oral capsule 200 PA rimantadine hcl oral tablet 100 ritonavir oral tablet 100 QL (360 EA per 30 days) SELZENTRY ORAL TABLET 150 MG, 300 MG stavudine oral capsule 15, 20, 30, 40 QL (60 EA per 30 days) stavudine oral solution reconstituted 1 /ml QL (1200 ML per 30 days) 24

31 STRIBILD ORAL TABLET MG QL (30 EA per 30 days) tenofovir disoproxil fumarate oral tablet 300 QL (30 EA per 30 days) TIVICAY ORAL TABLET 50 MG QL (30 EA per 30 days) TRIUMEQ ORAL TABLET MG QL (30 EA per 30 days) TRUVADA ORAL TABLET MG, MG, MG, MG valacyclovir hcl oral tablet 1 gm, 500 VIDEX ORAL SOLUTION RECONSTITUTED 2 GM, 4 GM QL (30 EA per 30 days) QL (603 ML per 30 days) VIRACEPT ORAL TABLET 250 MG QL (300 EA per 30 days) VIRACEPT ORAL TABLET 625 MG QL (120 EA per 30 days) VIRAMUNE ORAL SUSPENSION 50 MG/5ML VIREAD ORAL TABLET 150 MG, 200 MG, 250 MG QL (1200 ML per 30 days) QL (30 EA per 30 days) zidovudine oral capsule 100 QL (180 EA per 30 days) zidovudine oral syrup 50 /5ml QL (1800 ML per 30 days) zidovudine oral tablet 300 QL (60 EA per 30 days) *Assorted Classes* ARGYLE STERILE WATER IRRIGATION SOLUTION azathioprine oral tablet 50 CELLCEPT ORAL SUSPENSION RECONSTITUTED 200 MG/ML cyclosporine modified oral capsule 100, 25, 50 cyclosporine modified oral solution 100 /ml cyclosporine oral capsule 100, 25 GENGRAF ORAL CAPSULE 100 MG, 25 MG GENGRAF ORAL SOLUTION 100 MG/ML KIONEX ORAL POWDER mycophenolate mofetil oral capsule 250 mycophenolate mofetil oral suspension reconstituted 200 /ml mycophenolate mofetil oral tablet 500 sodium polystyrene sulfonate oral powder sterile water for irrigation irrigation solution tacrolimus oral capsule 0.5, 1, 5 PA PA 25

32 *Beta Blockers* acebutolol hcl oral capsule 200, 400 atenolol oral tablet 100, 25, 50 bisoprolol fumarate oral tablet 10, 5 BYSTOLIC ORAL TABLET 10 MG, 2.5 MG, 20 MG, 5 MG carvedilol oral tablet 12.5, 25, 3.125, 6.25 labetalol hcl oral tablet 100, 200, 300 metoprolol succinate er oral tablet extended release 24 hour 100, 25, 50 metoprolol succinate er oral tablet extended release 24 hour 200 metoprolol tartrate oral tablet 100, 25, 50 nadolol oral tablet 20, 40, 80 pindolol oral tablet 10, 5 propranolol hcl er oral capsule extended release 24 hour 120, 160, 60, 80 propranolol hcl oral solution 20 /5ml, 40 /5ml propranolol hcl oral tablet 10, 20, 40, 60, 80 sotalol hcl (af) oral tablet 120, 160, 80 sotalol hcl oral tablet 120, 160, 240, 80 timolol maleate oral tablet 10, 20, 5 *Calcium Channel Blockers* amlodipine besylate oral tablet 10, 2.5, 5 CARTIA XT ORAL CAPSULE EXTENDED RELEASE 24 HOUR 120 MG, 180 MG, 240 MG, 300 MG diltiazem cd oral capsule extended release 24 hour 120, 180 diltiazem hcl er beads oral capsule extended release 24 hour 420 diltiazem hcl er coated beads oral capsule extended release 24 hour 300 diltiazem hcl er oral capsule extended release 12 hour 120, 60, 90 QL (30 EA per 30 days) QL (45 EA per 30 days) QL (60 EA per 30 days) QL (30 EA per 30 days) QL (30 EA per 30 days) QL (30 EA per 30 days) QL (30 EA per 30 days) QL (30 EA per 30 days) QL (60 EA per 30 days) 26

33 diltiazem hcl er oral capsule extended release 24 hour 120, 180, 240 diltiazem hcl oral tablet 120, 30, 60, 90 dilt-xr oral capsule extended release 24 hour 120, 180, 240 felodipine er oral tablet extended release 24 hour 10, 2.5, 5 isradipine oral capsule 2.5, 5 nicardipine hcl oral capsule 20, 30 nifedipine er oral tablet extended release 24 hour 30, 60, 90 nifedipine er osmotic release oral tablet extended release 24 hour 30, 60, 90 nifedipine oral capsule 10, 20 nimodipine oral capsule 30 PA TAZTIA XT ORAL CAPSULE EXTENDED RELEASE 24 HOUR 120 MG, 180 MG, 240 MG, 300 MG, 360 MG verapamil hcl er oral capsule extended release 24 hour 100, 120, 180, 200, 240, 300, 360 verapamil hcl er oral tablet extended release 120, 180, 240 verapamil hcl oral tablet 120, 40, 80 *Cardiotonics* digoxin oral tablet 125 mcg, 250 mcg *Cephalosporins* cefaclor oral capsule 250, 500 cefaclor oral suspension reconstituted 125 /5ml, 250 /5ml, 375 /5ml QL (30 EA per 30 days) QL (30 EA per 30 days) QL (30 EA per 30 days) QL (30 EA per 30 days) QL (30 EA per 30 days) QL (30 EA per 30 days) QL (30 EA per 30 days) QL (30 EA per 30 days) AL (Max 11 Years) cefadroxil oral capsule 500 QL (40 EA per 10 days) cefadroxil oral suspension reconstituted 250 /5ml, 500 /5ml cefadroxil oral tablet 1 gm QL (20 EA per 10 days) cefdinir oral capsule 300 cefdinir oral suspension reconstituted 125 /5ml, 250 /5ml cefpodoxime proxetil oral suspension reconstituted 100 /5ml, 50 /5ml cefpodoxime proxetil oral tablet 100, 200 AL (Max 11 Years) 27

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