HealthPartners PreferredRx

Transcription

1 HealthPartners PreferredRx 2018 Formulary (List of covered drugs) For current information on the PreferredRx Drug List, visit healthpartners.com/pharmacy. Effective: April 1, HealthPartners

2 What s the PreferredRx drug list? This is the list of medicines (sometimes called a formulary) covered by your health plan. The drug list is reviewed by a team of experts every three months for new medicines, safety alerts and other updates. Who decides what s on the drug list? The HealthPartners Pharmacy and Therapeutics Committee manages the list. This team of experts is focused on safety, effectiveness and affordability. Visit healthpartners.com/pharmacy for more information. How do you use the drug list? The medicines on the drug list are listed in alphabetical order by type of medicine starting on page 3. Generic medicines are in lowercase italics (e.g., cephalexin) and are just as safe and effective as brand medicines but cost you less. Some generic medicines are very low-cost. Brand medicines are in ALL CAPS (e.g., KEFLEX) and are more costly than generic medicines. The Status can be used to determine how much a medicine will cost you. For exact cost information, Find the status for your medicine. Review your Summary of Plan Benefits or contract for the copay or coinsurance for that Status. Or, Log on to your myhealthpartners account to check your pharmacy benefits. F $ Formulary Low Cost Generics F $$ Formulary High Cost Generics F $$$ Formulary Brands What s a Specialty Medicine? Specialty medicines are usually prescribed by doctors whose focus is on the treatment of chronic and complex diseases. These medicines usually require more management, have a high price and aren t always stocked at retail pharmacies. Prescriptions for these medicines must be filled at a specialty pharmacy and are often covered at a different benefit than non-specialty medicines. Log on to your myhealthpartners account and click on My plan benefits on the Medical Plan tab to check your benefits for specialty medicines. What do the abbreviations in the More details column mean? This column gives special information about the medicine you re searching for. The abbreviations let you know there might be a special program or rule for the medicine. Use this key to help you navigate the drug list: Prior Authorization Required PA Step Therapy Required ST Age Edit AE Gender Edit Female GE Female Gender Edit Male GE Male Quantity Limit QL Smoking Cessation Benefit SC Trial Drug Program TD Weight Loss Benefit WL Oncology Benefit ONC

3 Why do you need prior authorization (PA) for some medicines? Even though some medicines are on the drug list, they need to meet the HealthPartners prior authorization criteria in order for the medicine to be covered by your pharmacy benefits. What s Step Therapy (ST)? Some medicines are on the drug list, but you need to try one or more other medicines first. HealthPartners covers a medicine with step therapy, if you've already tried the other medicine(s). If you haven't, you or your doctor will need to get approval from HealthPartners before the medicine will be covered by your lowest brand, generic or specialty copay or coinsurance. What s an Age Edit (AE)? An age edit means some medicines are only covered if you re within a specific age range. If you're not in the approved age range, you or your doctor will need to request approval from HealthPartners for your medicine to be covered. What s a Gender Edit (GE)? A gender edit means some medicines are covered for males or females only. If you're not in the approved gender group, you or your doctor will need to request approval from HealthPartners for your medicine to be covered. What s a Quantity Limit (QL)? This means HealthPartners limits the amount of the medicine you'll get each time you fill your prescription. The quantity limit may be less than the days supply listed in your contract or Summary Plan Description. What s the Trial Drug Program (TD)? The trial drug program is for new prescriptions for certain medicines that may not be well tolerated due to: Side effects High cost High potential for waste Your first 6 fills of a trial drug may be limited to less than a month supply. If the medicine works well, you ll get the rest of your month supply. If a copay applies to the medicine, you ll pay no more than one copay for each one month supply. What s the Weight Loss Benefit (WL)? This type of medicine may have limits on the amount you get or may not be covered under all plans. Log on to your myhealthpartners account and click on My plan benefits on the Medical Plan tab to check your benefits for weight loss. Weight Loss medicines are listed on the drug list under the Weight Loss medicine category. What s the Oncology Benefit (ONC)? These are oncology (cancer) medicines that must be filled at a specialty pharmacy, but you re only responsible for your regular generic or brand pharmacy copay or coinsurance. The HealthPartners family of health plans is underwritten and/or administered by HealthPartners, Inc., Group Health, Inc., HealthPartners Insurance Company or HealthPartners Administrators, Inc. Fully insured Wisconsin plans are underwritten by HealthPartners Insurance Company. (9/15) 2015 HealthPartners

4 Table of Contents Alcohol Dependency... 6 Allergy... 6 Alpha-1 Antitrypsin Deficiency...6 Anti-Addiction/Substance Abuse Treatment Agents... 7 Anti-Infective... 7 Arthritis Asthma & Copd Behavioral Health Birth Control...17 Bleeding Disorders...20 Blood Modifier Blood Thinner...22 Bone Health Cancer...23 Corticosteroids...25 Cough & Cold Cystic Fibrosis...26 Dementia...26 Diabetes Ear Conditions...28 Enzyme Replacement Eye Conditions Gout...31 Heart Health...31 Hereditary Angioedema Idiopathic Pulmonary Fibrosis...36 Immune Deficiency Immune Suppressant...36 Kidney Failure Men's Health...37 Migraine Mouth & Throat Multiple Sclerosis...38 Muscle Relaxant...39 Other Conditions...39 Pain...40 Parkinson's Pulmonary Hypertension...43 Seizures / Epilepsy Skin Conditions Sleep Disorders Smoking Cessation...49 Stomach / Gastrointestinal Thyroid Urinary & Bladder Health Vaccines Vitamins And Minerals Weight Loss Women's Health

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6 Alcohol Dependency Alcohol Dependency acamprosate oral disulfiram oral naltrexone oral Allergy Allergy, Eye azelastine ophthalmic (eye) cromolyn ophthalmic (eye) epinastine ophthalmic (eye) olopatadine ophthalmic (eye) drops 0.1 % Allergy, Injection epinephrine injection auto-injector Allergy, Other Nasal azelastine nasal aerosol,spray ipratropium bromide nasal Allergy, Other Oral GRASTEK SUBLINGUAL $ PA ODACTRA SUBLINGUAL $ PA RAGWITEK SUBLINGUAL $ PA Antihistamines, Oral cyproheptadine oral hydroxyzine hcl oral solution 10 mg/5 ml QL; AE hydroxyzine hcl oral tablet F$ QL; AE hydroxyzine pamoate oral QL; AE promethazine oral syrup QL; AE promethazine oral tablet QL; AE Corticosteroids, Nasal flunisolide nasal spray,non-aerosol 25 mcg (0.025 %) fluticasone nasal F$ QNASL NASAL $ Alpha-1 Antitrypsin Deficiency Alpha-1 Antitrypsin Deficiency ARALAST NP INTRAVENOUS $ PA; Specialty GLASSIA INTRAVENOUS $ PA; Specialty PROLASTIN-C INTRAVENOUS $ PA; Specialty ZEMAIRA INTRAVENOUS $ PA; Specialty 6

7 Anti-Addiction/Substance Abuse Treatment Agents Anti-Addiction/Substance Abuse Treatment Agents naloxone injection syringe 1 mg/ml NARCAN NASAL Anti-Infective Antibiotics, Cephalosporins $ cefadroxil oral capsule cefadroxil oral suspension for reconstitution 250 mg/5 ml, 500 mg/5 ml cefadroxil oral tablet cefdinir oral cefprozil oral CEFTIN ORAL SUSPENSION FOR RECONSTITUTION cefuroxime axetil oral tablet $ cephalexin oral capsule 250 mg, 500 mg F$ cephalexin oral suspension for reconstitution SUPRAX ORAL CAPSULE $ QL Antibiotics, Macrolides azithromycin oral suspension for reconstitution azithromycin oral tablet 250 mg, 500 mg F$ azithromycin oral tablet 600 mg clarithromycin oral suspension for reconstitution clarithromycin oral tablet DIFICID ORAL $ PA Antibiotics, Other clindamycin hcl oral capsule 150 mg, 300 mg F$ clindamycin hcl oral capsule 75 mg clindamycin palmitate hcl oral linezolid oral PA neomycin oral sulfamethoxazole-trimethoprim oral suspension sulfamethoxazole-trimethoprim oral tablet F$ trimethoprim oral vancomycin intravenous recon soln 1,000 mg, 10 gram, 5 gram, 500 mg vancomycin oral capsule XIFAXAN ORAL $ PA 7

8 Antibiotics, Penicillins amoxicillin oral capsule F$ amoxicillin oral suspension for reconstitution F$ amoxicillin oral tablet F$ amoxicillin oral tablet,chewable 125 mg, 250 mg F$ amoxicillin-pot clavulanate oral suspension for reconstitution amoxicillin-pot clavulanate oral tablet amoxicillin-pot clavulanate oral tablet,chewable ampicillin oral F$ dicloxacillin oral penicillin v potassium oral recon soln penicillin v potassium oral tablet F$ Antibiotics, Quinolones CIPRO ORAL SUSPENSION,MICROCAPSULE RECON $ ciprofloxacin hcl oral F$ ciprofloxacin oral levofloxacin oral solution levofloxacin oral tablet F$ moxifloxacin oral Antibiotics, Tetracyclines demeclocycline oral doxycycline hyclate oral capsule doxycycline hyclate oral tablet 100 mg, 20 mg doxycycline monohydrate oral capsule 100 mg, 50 mg doxycycline monohydrate oral tablet 100 mg, 50 mg minocycline oral capsule tetracycline oral Antifungals clotrimazole mucous membrane CRESEMBA ORAL $ PA fluconazole oral suspension for reconstitution fluconazole oral tablet 100 mg, 200 mg fluconazole oral tablet 150 mg, 50 mg F$ griseofulvin microsize oral griseofulvin ultramicrosize oral itraconazole oral PA ketoconazole oral 8

9 NOXAFIL ORAL $ PA nystatin oral suspension nystatin oral tablet terbinafine hcl oral F$ voriconazole oral PA Anti-Infective, Other ALBENZA ORAL $ PA atovaquone oral BILTRICIDE ORAL $ dapsone oral ivermectin oral rifabutin oral SIVEXTRO ORAL $ PA Antiprotozoals ALINIA ORAL $ ST atovaquone-proguanil oral chloroquine phosphate oral hydroxychloroquine oral mefloquine oral metronidazole oral tablet Antiviral, Hepatitis B adefovir oral BARACLUDE ORAL SOLUTION entecavir oral EPIVIR HBV ORAL SOLUTION lamivudine oral tablet 100 mg TYZEKA ORAL VEMLIDY ORAL Antiviral, Hepatitis C $ $ $ $ EPCLUSA ORAL $ PA; Specialty HARVONI ORAL $ PA; Specialty INTRON A INJECTION $ Specialty MAVYRET ORAL $ PA; Specialty OLYSIO ORAL $ PA; Specialty PEGASYS PROCLICK SUBCUTANEOUS $ PA; Specialty PEGASYS SUBCUTANEOUS $ PA; Specialty PEGINTRON REDIPEN SUBCUTANEOUS $ PA; Specialty PEGINTRON SUBCUTANEOUS $ PA; Specialty 9

10 REBETOL ORAL SOLUTION $ Specialty ribavirin oral capsule Specialty ribavirin oral tablet 200 mg Specialty SOVALDI ORAL $ PA; Specialty VOSEVI ORAL $ PA; Specialty ZEPATIER ORAL $ PA; Specialty Antiviral, Hiv abacavir oral abacavir-lamivudine oral abacavir-lamivudine-zidovudine oral APTIVUS ORAL atazanavir oral ATRIPLA ORAL COMPLERA ORAL CRIXIVAN ORAL CAPSULE 200 MG, 400 MG DESCOVY ORAL didanosine oral EDURANT ORAL efavirenz oral EMTRIVA ORAL EVOTAZ ORAL fosamprenavir oral $ $ $ $ $ $ $ $ FUZEON SUBCUTANEOUS RECON SOLN $ Specialty GENVOYA ORAL INTELENCE ORAL INVIRASE ORAL ISENTRESS HD ORAL ISENTRESS ORAL JULUCA ORAL KALETRA ORAL TABLET lamivudine oral solution lamivudine oral tablet 150 mg, 300 mg lamivudine-zidovudine oral LEXIVA ORAL SUSPENSION lopinavir-ritonavir oral nevirapine oral NORVIR ORAL SOLUTION NORVIR ORAL TABLET 10 $ $ $ $ $ $ $ $ $ $

11 ODEFSEY ORAL PREZCOBIX ORAL PREZISTA ORAL RESCRIPTOR ORAL REYATAZ ORAL POWDER IN PACKET SELZENTRY ORAL stavudine oral STRIBILD ORAL tenofovir disoproxil fumarate oral TIVICAY ORAL TRIUMEQ ORAL TRUVADA ORAL TYBOST ORAL VIDEX 2 GRAM PEDIATRIC ORAL VIDEX 4 GRAM PEDIATRIC ORAL VIRACEPT ORAL TABLET VIREAD ORAL POWDER VIREAD ORAL TABLET 150 MG, 200 MG, 250 MG VITEKTA ORAL ZERIT ORAL RECON SOLN zidovudine oral Antiviral, Other $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ acyclovir oral capsule acyclovir oral suspension 200 mg/5 ml acyclovir oral tablet amantadine hcl oral famciclovir oral oseltamivir oral capsule 30 mg, 45 mg, 75 mg QL oseltamivir oral suspension for reconstitution QL PREVYMIS ORAL $ RELENZA DISKHALER INHALATION $ QL rimantadine oral TAMIFLU ORAL CAPSULE 30 MG, 45 MG, 75 MG $ QL TAMIFLU ORAL SUSPENSION FOR RECONSTITUTION $ QL valacyclovir oral valganciclovir oral Tuberculosis cycloserine oral PA 11

12 ethambutol oral isoniazid oral F$ PRIFTIN ORAL $ pyrazinamide oral rifampin oral SIRTURO ORAL $ PA TRECATOR ORAL $ PA Urinary Anti-Infectives MONUROL ORAL $ nitrofurantoin macrocrystal oral QL; AE nitrofurantoin monohyd/m-cryst oral QL; AE nitrofurantoin oral QL; AE Arthritis Arthritis, Other DEPEN TITRATABS ORAL Disease Modifying Agents $ ACTEMRA SUBCUTANEOUS $ PA; Specialty ENBREL SUBCUTANEOUS $ PA; Specialty ENBREL SURECLICK SUBCUTANEOUS $ PA; Specialty HUMIRA PEN SUBCUTANEOUS $ PA; Specialty HUMIRA SUBCUTANEOUS $ PA; Specialty KINERET SUBCUTANEOUS $ PA; Specialty leflunomide oral methotrexate sodium (pf) injection solution methotrexate sodium injection methotrexate sodium oral ORENCIA CLICKJECT SUBCUTANEOUS $ PA; Specialty ORENCIA SUBCUTANEOUS $ PA; Specialty OTEZLA ORAL $ PA; Specialty OTEZLA STARTER ORAL $ PA; Specialty RASUVO (PF) SUBCUTANEOUS $ PA RIDAURA ORAL Asthma & Copd Asthma & Copd, Other ATROVENT HFA INHALATION cromolyn inhalation $ $ DALIRESP ORAL TABLET 500 MCG $ PA ipratropium bromide inhalation 12

13 montelukast oral granules in packet montelukast oral tablet F$ montelukast oral tablet,chewable Bronchodilators, Inhaled albuterol sulfate inhalation solution for nebulization 0.63 mg/3 ml, 1.25 mg/3 ml, 2.5 mg /3 ml (0.083 %), 5 mg/ml INCRUSE ELLIPTA INHALATION SEREVENT DISKUS INHALATION STRIVERDI RESPIMAT INHALATION VENTOLIN HFA INHALATION Bronchodilators, Oral albuterol sulfate oral theophylline oral tablet extended release 12 hr theophylline oral tablet extended release 600 mg Combination Agents, Inhaled $ $ $ $ ADVAIR DISKUS INHALATION $ ADVAIR HFA INHALATION $ ANORO ELLIPTA INHALATION $ BREO ELLIPTA INHALATION $ COMBIVENT RESPIMAT INHALATION $ DULERA INHALATION $ PA fluticasone-salmeterol inhalation ipratropium-albuterol inhalation TRELEGY ELLIPTA INHALATION $ Corticosteroids, Inhaled ARNUITY ELLIPTA INHALATION ASMANEX HFA INHALATION ASMANEX TWISTHALER INHALATION AEROSOL POWDR BREATH ACTIVATED 110 MCG (30 DOSES), 220 MCG (120 DOSES), 220 MCG (30 DOSES), 220 MCG (60 DOSES) budesonide inhalation FLOVENT DISKUS INHALATION FLOVENT HFA INHALATION PULMICORT FLEXHALER INHALATION QVAR INHALATION QVAR REDIHALER INHALATION $ $ $ $ $ $ $ $ 13

14 Behavioral Health Antipsychotic aripiprazole oral solution AE aripiprazole oral tablet AE aripiprazole oral tablet,disintegrating PA; AE clozapine oral tablet AE clozapine oral tablet,disintegrating PA; AE FANAPT ORAL $ PA fluphenazine hcl oral concentrate F$ AE fluphenazine hcl oral elixir F$ AE fluphenazine hcl oral tablet AE haloperidol lactate oral AE haloperidol oral AE LATUDA ORAL TABLET 120 MG, 40 MG, 60 MG, 80 MG $ LATUDA ORAL TABLET 20 MG $ PA loxapine succinate oral AE PA; QL NUPLAZID ORAL $ PA; Specialty olanzapine oral tablet AE olanzapine oral tablet,disintegrating PA; AE paliperidone oral PA perphenazine oral AE quetiapine oral tablet AE quetiapine oral tablet extended release 24 hr PA; AE REXULTI ORAL $ PA risperidone oral solution AE risperidone oral tablet AE risperidone oral tablet,disintegrating PA; AE SAPHRIS (BLACK CHERRY) SUBLINGUAL $ PA thioridazine oral AE thiothixene oral AE trifluoperazine oral AE VERSACLOZ ORAL $ PA; AE ziprasidone hcl oral AE Anxiety alprazolam oral tablet 0.25 mg, 0.5 mg, 1 mg, 2 mg F$ QL alprazolam oral tablet extended release 24 hr 0.5 mg, 1 mg, 2 mg, 3 mg QL 14

15 buspirone oral chlordiazepoxide hcl oral capsule 10 mg, 25 mg F$ QL chlordiazepoxide hcl oral capsule 5 mg QL clonazepam oral tablet 0.5 mg, 1 mg, 2 mg F$ QL clonazepam oral tablet,disintegrating mg, 0.25 mg, 0.5 mg, 1 mg, 2 mg diazepam intensol oral QL diazepam oral solution 5 mg/5 ml (1 mg/ml) QL diazepam oral tablet 10 mg, 2 mg, 5 mg F$ QL diazepam rectal QL lorazepam oral concentrate QL lorazepam oral tablet 0.5 mg, 1 mg, 2 mg F$ QL Attention Deficit/Hyperactivity Disorder (Adhd) adderall xr oral capsule,extended release 24hr 10 mg, 15 mg, 20 mg, 25 mg, 30 mg, 5 mg atomoxetine oral capsule 10 mg, 100 mg, 18 mg, 25 mg, 40 mg, 60 mg, 80 mg clonidine hcl oral tablet extended release 12 hr PA; QL dexmethylphenidate oral capsule,er biphasic mg, 15 mg, 20 mg, 25 mg, 30 mg, 35 mg, 40 mg, 5 mg dexmethylphenidate oral tablet 10 mg, 2.5 mg, 5 mg QL dextroamphetamine oral capsule, extended release 10 mg, 15 mg, 5 mg dextroamphetamine oral tablet QL dextroamphetamine-amphetamine oral tablet 10 mg, 12.5 mg, 15 mg, 20 mg, 30 mg, 5 mg, 7.5 mg guanfacine oral tablet extended release 24 hr 1 mg, 2 mg, 3 mg, 4 mg metadate er oral QL methylphenidate hcl oral capsule, er biphasic mg, 20 mg, 30 mg, 40 mg, 50 mg, 60 mg methylphenidate hcl oral capsule,er biphasic mg, 20 mg, 30 mg, 40 mg, 60 mg methylphenidate hcl oral tablet 10 mg, 20 mg, 5 mg QL methylphenidate hcl oral tablet extended release 10 mg, 20 mg methylphenidate hcl oral tablet extended release 24hr 18 mg, 27 mg, 36 mg, 54 mg QUILLICHEW ER ORAL TABLET,CHEW,IR- ER.BIPHASIC24HR 20 MG, 30 MG, 40 MG $ QUILLIVANT XR 25 MG/5 ML SUSP 300 MG $ QL QL QL QL QL QL QL QL QL QL QL QL QL 15

16 QUILLIVANT XR 25 MG/5 ML SUSP 600 MG $ QL QUILLIVANT XR 25 MG/5 ML SUSP 750 MG $ QL QUILLIVANT XR 25 MG/5 ML SUSP 900 MG $ QL VYVANSE ORAL CAPSULE 10 MG, 20 MG, 30 MG, 40 MG, 50 MG, 60 MG, 70 MG VYVANSE ORAL TABLET,CHEWABLE 10 MG, 20 MG, 30 MG, 40 MG, 50 MG, 60 MG Bipolar Disorder $ $ QL QL divalproex oral lithium carbonate oral lithium citrate oral solution 8 meq/5 ml Depression, Atypical Antidepressants bupropion hcl oral mirtazapine oral tablet Depression, Maois EMSAM TRANSDERMAL $ PA phenelzine oral tranylcypromine oral Depression, Serotonin Modulators nefazodone oral trazodone oral F$ Depression, Snris desvenlafaxine succinate oral duloxetine oral capsule,delayed release(dr/ec) 20 mg, 30 mg, 60 mg venlafaxine oral capsule,extended release 24hr venlafaxine oral tablet Depression, Ssris citalopram oral solution citalopram oral tablet F$ escitalopram oxalate oral solution escitalopram oxalate oral tablet F$ fluoxetine oral capsule F$ fluoxetine oral solution fluvoxamine oral tablet paroxetine hcl oral tablet F$ PAXIL ORAL SUSPENSION sertraline oral concentrate $ sertraline oral tablet F$ 16

17 Depression, Tricyclic & Tetracyclic Antidepressants amitriptyline oral AE clomipramine oral AE desipramine oral doxepin oral AE imipramine hcl oral AE nortriptyline oral Birth Control Contraceptives, Other NUVARING VAGINAL xulane transdermal Emergency Contraception ELLA ORAL levonorgestrel oral tablet 1.5 mg my way oral next choice one dose oral Oral Contraceptives altavera (28) oral alyacen 1/35 (28) oral alyacen 7/7/7 (28) oral apri oral aranelle (28) oral aubra oral aviane oral azurette (28) oral balziva (28) oral blisovi fe 1.5/30 (28) oral blisovi fe 1/20 (28) oral brevicon (28) oral briellyn oral camila oral caziant (28) oral chateal oral cryselle (28) oral cyclafem 1/35 (28) oral cyclafem 7/7/7 (28) oral dasetta 1/35 (28) oral $ $ 17

18 dasetta 7/7/7 (28) oral desogestrel-ethinyl estradiol oral drospirenone-ethinyl estradiol oral tablet mg elinest oral emoquette oral enpresse oral enskyce oral errin oral estarylla oral falmina (28) oral gianvi (28) oral gildagia oral gildess 1.5/30 (21) oral gildess 1/20 (21) oral gildess fe 1.5/30 (28) oral gildess fe 1/20 (28) oral heather oral introvale oral jencycla oral jolessa oral jolivette oral junel 1.5/30 (21) oral junel 1/20 (21) oral junel fe 1.5/30 (28) oral junel fe 1/20 (28) oral kariva (28) oral kelnor 1/35 (28) oral kurvelo oral larin 1/20 (21) oral larin fe 1.5/30 (28) oral larin fe 1/20 (28) oral leena 28 oral lessina oral levonest (28) oral levonorgestrel-ethinyl estrad oral tablet mgmcg, mg levonorgestrel-ethinyl estrad oral tablets,dose pack,3 month levora-28 oral 18

19 loryna (28) oral low-ogestrel (28) oral lutera (28) oral lyza oral marlissa oral microgestin 1.5/30 (21) oral microgestin 1/20 (21) oral microgestin fe 1.5/30 (28) oral microgestin fe 1/20 (28) oral mono-linyah oral mononessa (28) oral myzilra oral necon 0.5/35 (28) oral necon 1/35 (28) oral necon 1/50 (28) oral necon 10/11 (28) oral necon 7/7/7 (28) oral nora-be oral norethindrone (contraceptive) oral norethindrone ac-eth estradiol oral tablet 1-20 mgmcg norgestimate-ethinyl estradiol oral norinyl 1/35 (28) oral nortrel 0.5/35 (28) oral nortrel 1/35 (21) oral nortrel 1/35 (28) oral nortrel 7/7/7 (28) oral ocella oral ogestrel (28) oral orsythia oral philith oral pimtrea (28) oral pirmella oral portia oral previfem oral quasense oral reclipsen (28) oral sprintec (28) oral 19

20 sronyx oral syeda oral tilia fe oral tri-estarylla oral tri-legest fe oral tri-linyah oral tri-lo-estarylla oral tri-lo-sprintec oral trinessa (28) oral trinessa lo oral tri-previfem (28) oral tri-sprintec (28) oral trivora (28) oral velivet triphasic regimen (28) oral vestura (28) oral viorele (28) oral vyfemla (28) oral wera (28) oral zarah oral zenchent (28) oral zovia 1/35e (28) oral zovia 1/50e (28) oral Bleeding Disorders Bleeding Disorders, Hemophilia STIMATE NASAL $ PA Bleeding Disorders, Other AMICAR ORAL SOLUTION AMICAR ORAL TABLET 500 MG Blood Modifier Blood Modifiers $ $ ARANESP (IN POLYSORBATE) INJECTION $ Specialty GRANIX SUBCUTANEOUS $ Specialty; ONC LEUKINE INJECTION RECON SOLN $ Specialty NEULASTA SUBCUTANEOUS $ Specialty NEUPOGEN INJECTION $ Specialty PROCRIT INJECTION SOLUTION 10,000 UNIT/ML, 2,000 UNIT/ML, 20,000 UNIT/2 ML, 20,000 UNIT/ML, 3,000 UNIT/ML, 4,000 UNIT/ML $ Specialty 20

21 PROMACTA ORAL $ PA; Specialty REBINYN INTRAVENOUS $ Specialty ZARXIO INJECTION $ Specialty Clotting Disorders ADVATE INTRAVENOUS $ Specialty ADYNOVATE INTRAVENOUS $ Specialty AFSTYLA INTRAVENOUS $ Specialty ALPHANATE INTRAVENOUS $ Specialty ALPHANINE SD INTRAVENOUS $ Specialty ALPROLIX INTRAVENOUS $ Specialty BEBULIN INTRAVENOUS $ Specialty BENEFIX INTRAVENOUS $ Specialty COAGADEX INTRAVENOUS $ Specialty CORIFACT INTRAVENOUS $ Specialty ELOCTATE INTRAVENOUS $ Specialty FEIBA NF INTRAVENOUS $ Specialty HELIXATE FS INTRAVENOUS $ Specialty HEMOFIL M HIGH INTRAVENOUS $ Specialty HEMOFIL M LOW INTRAVENOUS $ Specialty HEMOFIL M MID INTRAVENOUS $ Specialty HEMOFIL M SUPER HIGH INTRAVENOUS $ Specialty HUMATE-P INTRAVENOUS $ Specialty IDELVION INTRAVENOUS $ Specialty IXINITY INTRAVENOUS $ Specialty KOATE-DVI INTRAVENOUS RECON SOLN $ Specialty KOGENATE FS INTRAVENOUS $ Specialty KOVALTRY INTRAVENOUS $ Specialty MONOCLATE-P INTRAVENOUS $ Specialty NOVOEIGHT INTRAVENOUS $ Specialty NOVOSEVEN RT INTRAVENOUS $ Specialty NUWIQ INTRAVENOUS $ Specialty OBIZUR INTRAVENOUS $ Specialty PLASMANATE INTRAVENOUS $ Specialty PROFILNINE INTRAVENOUS $ Specialty RECOMBINATE INTRAVENOUS $ Specialty RIXUBIS INTRAVENOUS $ Specialty THROMBATE III INTRAVENOUS $ Specialty TRETTEN INTRAVENOUS $ Specialty 21

22 VONVENDI INTRAVENOUS $ Specialty WILATE INTRAVENOUS $ Specialty XYNTHA INTRAVENOUS $ Specialty XYNTHA SOLOFUSE INTRAVENOUS $ Specialty Blood Thinner Anticoagulants ELIQUIS ORAL $ enoxaparin subcutaneous QL fondaparinux subcutaneous PA heparin (porcine) injection cartridge heparin (porcine) injection solution heparin (porcine) injection syringe 5,000 unit/ml heparin, porcine (pf) injection syringe jantoven oral F$ PRADAXA ORAL $ PA warfarin oral F$ XARELTO ORAL $ Platelet Inhibitors anagrelide oral aspirin-dipyridamole oral BRILINTA ORAL $ cilostazol oral clopidogrel oral tablet 75 mg F$ dipyridamole oral pentoxifylline oral prasugrel oral ZONTIVITY ORAL $ PA Bone Health Bone Health, Other etidronate disodium oral Osteoporosis alendronate oral solution alendronate oral tablet 10 mg, 35 mg, 5 mg, 70 mg F$ alendronate oral tablet 40 mg calcitonin (salmon) nasal FORTEO SUBCUTANEOUS $ PA; Specialty FORTICAL NASAL ibandronate oral 22 $

23 raloxifene oral risedronate oral tablet ST TYMLOS SUBCUTANEOUS $ PA; Specialty Cancer Cancer, Alkylating Agents EMCYT ORAL $ GLEOSTINE ORAL $ HEXALEN ORAL $ Specialty; ONC LEUKERAN ORAL $ MATULANE ORAL $ PA; Specialty; ONC melphalan oral MYLERAN ORAL $ temozolomide oral Specialty; ONC VALCHLOR TOPICAL $ PA; Specialty; ONC; QL Cancer, Antiandrogens bicalutamide oral flutamide oral XTANDI ORAL $ PA; Specialty; TD; ONC ZYTIGA ORAL $ PA; Specialty; TD; ONC Cancer, Antimetabolites capecitabine oral Specialty; ONC hydroxyurea oral LONSURF ORAL $ PA; Specialty; ONC mercaptopurine oral TABLOID ORAL $ Cancer, Aromatase Inhibitors anastrozole oral F$ exemestane oral letrozole oral Cancer, Hdac Inhibitors ZOLINZA ORAL $ PA; Specialty; TD; ONC Cancer, Immunosuppressives AFINITOR DISPERZ ORAL $ Specialty; TD; ONC AFINITOR ORAL $ Specialty; TD; ONC CYCLOPHOSPHAMIDE ORAL CAPSULE $ methotrexate sodium (pf) injection solution methotrexate sodium injection methotrexate sodium oral 23

24 POMALYST ORAL $ PA; Specialty; ONC REVLIMID ORAL $ Specialty; ONC THALOMID ORAL $ Specialty; ONC Cancer, Interferons SYLATRON SUBCUTANEOUS $ Specialty; ONC Cancer, Natural And Semi-Synthetic etoposide oral HYCAMTIN INTRAVENOUS $ Specialty; ONC HYCAMTIN ORAL $ Specialty; ONC Cancer, Other Agents megestrol oral tablet ODOMZO ORAL $ PA; Specialty; ONC ZEJULA ORAL $ PA; Specialty; ONC Cancer, Retinoids tretinoin (chemotherapy) oral Specialty; ONC Cancer, Serms SOLTAMOX ORAL tamoxifen oral Cancer, Signal Transduction Inhibitors $ ALECENSA ORAL $ PA; Specialty BOSULIF ORAL $ PA; Specialty; TD; ONC CABOMETYX ORAL $ PA; Specialty; TD; ONC CAPRELSA ORAL $ Specialty; ONC COMETRIQ ORAL $ PA; Specialty; ONC COTELLIC ORAL $ PA; Specialty; ONC ERIVEDGE ORAL $ PA; Specialty; TD; ONC GILOTRIF ORAL $ PA; Specialty; ONC IBRANCE ORAL $ PA; Specialty; ONC ICLUSIG ORAL $ PA; Specialty; ONC IDHIFA ORAL $ PA; Specialty; ONC imatinib oral Specialty; TD; ONC IMBRUVICA ORAL $ PA; Specialty; ONC INLYTA ORAL $ PA; Specialty; TD; ONC IRESSA ORAL $ PA; Specialty; TD; ONC JAKAFI ORAL $ PA; Specialty; TD; ONC KISQALI FEMARA CO-PACK ORAL $ PA; Specialty; ONC KISQALI ORAL $ PA; Specialty; ONC MEKINIST ORAL $ PA; Specialty; ONC 24

25 NERLYNX ORAL $ PA; Specialty; ONC NEXAVAR ORAL $ Specialty; TD; ONC NINLARO ORAL $ PA; Specialty; ONC RYDAPT ORAL $ PA; Specialty; ONC SPRYCEL ORAL $ Specialty; TD; ONC STIVARGA ORAL $ PA; Specialty; ONC SUTENT ORAL $ Specialty; TD; ONC TAFINLAR ORAL $ PA; Specialty; ONC TARCEVA ORAL $ Specialty; TD; ONC TASIGNA ORAL $ Specialty; TD; ONC TYKERB ORAL $ Specialty; ONC VERZENIO ORAL $ PA; Specialty; ONC VOTRIENT ORAL $ Specialty; TD; ONC XALKORI ORAL $ PA; Specialty; TD; ONC ZELBORAF ORAL $ PA; Specialty; ONC ZYKADIA ORAL $ PA; Specialty; TD; ONC Corticosteroids Corticosteroids, Injectable dexamethasone sodium phosphate injection solution 4 mg/ml Corticosteroids, Oral DEXAMETHASONE INTENSOL ORAL dexamethasone oral elixir dexamethasone oral solution dexamethasone oral tablet 0.5 mg, 0.75 mg, 1 mg, 1.5 mg, 4 mg, 6 mg dexamethasone oral tablet 2 mg fludrocortisone oral hydrocortisone oral MEDROL ORAL TABLET 2 MG methylprednisolone oral MILLIPRED ORAL TABLET prednisolone oral solution 15 mg/5 ml prednisolone sodium phosphate oral solution 15 mg/5 ml (3 mg/ml), 25 mg/5 ml (5 mg/ml), 5 mg base/5 ml (6.7 mg/5 ml) PREDNISONE INTENSOL ORAL prednisone oral solution $ F$ $ $ $ prednisone oral tablet F$ 25

26 prednisone oral tablets,dose pack F$ Cough & Cold Cough & Cold benzonatate oral capsule 100 mg, 200 mg codeine-guaifenesin oral QL; AE promethazine vc oral F$ promethazine-dm oral F$ Cystic Fibrosis Cystic Fibrosis acetylcysteine CAYSTON INHALATION $ PA; Specialty KALYDECO ORAL $ PA; Specialty ORKAMBI ORAL $ PA; Specialty PULMOZYME INHALATION $ PA; Specialty; QL tobramycin in % nacl inhalation PA; Specialty Dementia Dementia donepezil oral tablet 10 mg, 5 mg donepezil oral tablet,disintegrating galantamine oral memantine oral solution memantine oral tablet memantine oral tablets,dose pack rivastigmine tartrate oral rivastigmine transdermal Diabetes Diabetes, Alpha-Glucosidase Inhibitors acarbose oral miglitol oral Diabetes, Biguanides metformin oral tablet F$ metformin oral tablet extended release 24 hr F$ Diabetes, Dpp-4 Inhibitor / Biguanide Combinations JENTADUETO ORAL JENTADUETO XR ORAL Diabetes, Dpp-4 Inhibitors TRADJENTA ORAL 26 $ $ $

27 Diabetes, Glp-1 Agonists BYDUREON BCISE SUBCUTANEOUS $ QL BYDUREON SUBCUTANEOUS $ QL BYETTA SUBCUTANEOUS PEN INJECTOR 10 MCG/DOSE(250 MCG/ML) 2.4 ML, 5 MCG/DOSE (250 MCG/ML) 1.2 ML $ TRULICITY SUBCUTANEOUS $ QL VICTOZA 2-PAK SUBCUTANEOUS $ QL VICTOZA 3-PAK SUBCUTANEOUS $ QL Diabetes, Intermediate-Acting Insulins QL HUMULIN N NPH INSULIN KWIKPEN SUBCUTANEOUS HUMULIN N NPH U-100 INSULIN SUBCUTANEOUS Diabetes, Long-Acting Insulins $ $ BASAGLAR KWIKPEN U-100 INSULIN SUBCUTANEOUS LEVEMIR FLEXTOUCH U-100 INSULN SUBCUTANEOUS $ $ LEVEMIR U-100 INSULIN SUBCUTANEOUS $ ST Diabetes, Meglitinides ST nateglinide oral repaglinide oral Diabetes, Other Oral Agents CYCLOSET ORAL $ PA Diabetes, Pre-Mixed Insulins HUMALOG MIX INSULN U-100 SUBCUTANEOUS HUMALOG MIX KWIKPEN SUBCUTANEOUS HUMALOG MIX KWIKPEN SUBCUTANEOUS HUMALOG MIX 75-25(U-100)INSULN SUBCUTANEOUS HUMULIN 70/30 U-100 INSULIN SUBCUTANEOUS HUMULIN 70/30 U-100 KWIKPEN SUBCUTANEOUS Diabetes, Rapid-Acting Insulins HUMALOG JUNIOR KWIKPEN U-100 SUBCUTANEOUS HUMALOG KWIKPEN INSULIN SUBCUTANEOUS HUMALOG U-100 INSULIN SUBCUTANEOUS Diabetes, Rescue Agents GLUCAGEN HYPOKIT INJECTION $ $ $ $ $ $ $ $ $ $ 27

28 GLUCAGEN INJECTION GLUCAGON EMERGENCY KIT (HUMAN) INJECTION Diabetes, Sglt2 Inhibitor / Biguanide Combinations $ $ INVOKAMET ORAL $ ST INVOKAMET XR ORAL $ ST SYNJARDY ORAL $ ST SYNJARDY XR ORAL $ ST Diabetes, Sglt2 Inhibitors INVOKANA ORAL $ ST JARDIANCE ORAL $ ST Diabetes, Short-Acting Insulins HUMULIN R REGULAR U-100 INSULN INJECTION HUMULIN R U-500 (CONC) INSULIN SUBCUTANEOUS HUMULIN R U-500 (CONC) KWIKPEN SUBCUTANEOUS Diabetes, Sulfonylurea / Biguanide Combination glipizide-metformin oral Diabetes, Sulfonylureas $ $ $ glimepiride oral F$ glipizide oral tablet F$ glipizide oral tablet extended release 24hr glyburide micronized oral GE Female; AE glyburide oral GE Female; AE Diabetes, Thiazolidinedione / Biguanide Combinations pioglitazone-metformin oral Diabetes, Thiazolidinedione / Sulfonylurea Combinations pioglitazone-glimepiride oral Diabetes, Thiazolidinediones pioglitazone oral F$ Ear Conditions Anti-Infectives, Ear acetic acid otic (ear) CIPRO HC OTIC (EAR) CIPRODEX OTIC (EAR) neomycin-polymyxin-hc otic (ear) $ $ 28

29 ofloxacin otic (ear) Ear Conditions, Other fluocinolone acetonide oil otic (ear) Enzyme Replacement Enzyme Replacement CERDELGA ORAL $ PA; Specialty CREON ORAL $ STRENSIQ SUBCUTANEOUS $ PA; Specialty SUCRAID ORAL $ PA; Specialty ZAVESCA ORAL $ PA; Specialty Eye Conditions Anti-Infectives, Eye AZASITE OPHTHALMIC (EYE) $ bacitracin ophthalmic (eye) bacitracin-polymyxin b ophthalmic (eye) BESIVANCE OPHTHALMIC (EYE) $ PA BLEPHAMIDE S.O.P. OPHTHALMIC (EYE) $ CILOXAN OPHTHALMIC (EYE) OINTMENT $ ciprofloxacin hcl ophthalmic (eye) erythromycin ophthalmic (eye) gatifloxacin ophthalmic (eye) gentamicin ophthalmic (eye) ointment moxifloxacin ophthalmic (eye) neomycin-bacitracin-polymyxin ophthalmic (eye) neomycin-polymyxin b-dexameth ophthalmic (eye) neomycin-polymyxin-gramicidin ophthalmic (eye) ofloxacin ophthalmic (eye) polymyxin b sulf-trimethoprim ophthalmic (eye) sulfacetamide sodium ophthalmic (eye) sulfacetamide-prednisolone ophthalmic (eye) TOBRADEX OPHTHALMIC (EYE) OINTMENT $ tobramycin ophthalmic (eye) tobramycin-dexamethasone ophthalmic (eye) TOBREX OPHTHALMIC (EYE) OINTMENT $ trifluridine ophthalmic (eye) ZIRGAN OPHTHALMIC (EYE) $ Anti-Inflammatories, Eye ACUVAIL (PF) OPHTHALMIC (EYE) $ PA 29

30 bromfenac ophthalmic (eye) dexamethasone sodium phosphate ophthalmic (eye) diclofenac sodium ophthalmic (eye) fluorometholone ophthalmic (eye) flurbiprofen sodium ophthalmic (eye) F$ FML S.O.P. OPHTHALMIC (EYE) ILEVRO OPHTHALMIC (EYE) ketorolac ophthalmic (eye) LOTEMAX OPHTHALMIC (EYE) NEVANAC OPHTHALMIC (EYE) PRED FORTE OPHTHALMIC (EYE) PRED MILD OPHTHALMIC (EYE) prednisolone acetate ophthalmic (eye) prednisolone sodium phosphate ophthalmic (eye) PROLENSA OPHTHALMIC (EYE) Eye Conditions, Other atropine ophthalmic (eye) cyclopentolate ophthalmic (eye) drops 1 %, 2 % $ $ $ $ $ $ $ CYSTARAN OPHTHALMIC (EYE) $ PA; Specialty homatropaire ophthalmic (eye) LACRISERT OPHTHALMIC (EYE) phenylephrine hcl ophthalmic (eye) RESTASIS MULTIDOSE OPHTHALMIC (EYE) RESTASIS OPHTHALMIC (EYE) Glaucoma acetazolamide oral ALPHAGAN P OPHTHALMIC (EYE) DROPS 0.1 % AZOPT OPHTHALMIC (EYE) betaxolol ophthalmic (eye) BETOPTIC S OPHTHALMIC (EYE) bimatoprost ophthalmic (eye) brimonidine ophthalmic (eye) $ $ $ $ $ $ carteolol ophthalmic (eye) F$ COMBIGAN OPHTHALMIC (EYE) $ COSOPT (PF) OPHTHALMIC (EYE) $ PA dorzolamide ophthalmic (eye) dorzolamide-timolol ophthalmic (eye) latanoprost ophthalmic (eye) 30

31 levobunolol ophthalmic (eye) drops 0.5 % LUMIGAN OPHTHALMIC (EYE) DROPS 0.01 % methazolamide oral PHOSPHOLINE IODIDE OPHTHALMIC (EYE) pilocarpine hcl ophthalmic (eye) drops 1 %, 2 %, 4 % SIMBRINZA OPHTHALMIC (EYE) $ $ $ timolol maleate ophthalmic (eye) drops F$ timolol maleate ophthalmic (eye) gel forming solution TRAVATAN Z OPHTHALMIC (EYE) travoprost (benzalkonium) ophthalmic (eye) $ ZIOPTAN (PF) OPHTHALMIC (EYE) $ PA Gout Gout allopurinol oral colchicine oral probenecid oral probenecid-colchicine oral ULORIC ORAL $ ST Heart Health Angina ISORDIL ORAL isosorbide dinitrate oral $ isosorbide mononitrate oral tablet F$ isosorbide mononitrate oral tablet extended release 24 hr NITRO-BID TRANSDERMAL NITRO-DUR TRANSDERMAL PATCH 24 HOUR 0.3 MG/HR, 0.8 MG/HR nitroglycerin sublingual nitroglycerin transdermal patch 24 hour Antiarrhythmics amiodarone oral disopyramide phosphate oral capsule dofetilide oral flecainide oral mexiletine oral $ $ MULTAQ ORAL $ PA NORPACE CR ORAL $ 31

32 propafenone oral tablet quinidine gluconate oral quinidine sulfate oral sotalol af oral sotalol oral Blood Pressure, Acei & Arb amlodipine-benazepril oral amlodipine-valsartan oral amlodipine-valsartan-hcthiazid oral ST benazepril oral F$ benazepril-hydrochlorothiazide oral captopril oral captopril-hydrochlorothiazide oral enalapril maleate oral enalapril-hydrochlorothiazide oral F$ fosinopril oral F$ fosinopril-hydrochlorothiazide oral irbesartan oral irbesartan-hydrochlorothiazide oral lisinopril oral F$ lisinopril-hydrochlorothiazide oral F$ losartan oral F$ losartan-hydrochlorothiazide oral F$ moexipril oral moexipril-hydrochlorothiazide oral olmesartan oral olmesartan-hydrochlorothiazide oral perindopril erbumine oral quinapril oral F$ quinapril-hydrochlorothiazide oral ramipril oral F$ trandolapril oral valsartan oral valsartan-hydrochlorothiazide oral Blood Pressure, Beta Blockers atenolol oral F$ atenolol-chlorthalidone oral bisoprolol fumarate oral 32

33 bisoprolol-hydrochlorothiazide oral F$ carvedilol oral F$ carvedilol phosphate oral ST labetalol oral metoprolol succinate oral metoprolol ta-hydrochlorothiaz oral metoprolol tartrate oral tablet 100 mg, 25 mg, 50 mg F$ nadolol oral propranolol oral propranolol-hydrochlorothiazid oral Blood Pressure, Calcium Channel Blockers amlodipine oral F$ amlodipine-benazepril oral amlodipine-valsartan oral amlodipine-valsartan-hcthiazid oral ST cartia xt oral diltiazem hcl oral capsule,ext.rel 24h degradable diltiazem hcl oral capsule,extended release 24 hr diltiazem hcl oral capsule,extended release 24hr 120 mg, 180 mg, 240 mg, 300 mg diltiazem hcl oral tablet dilt-xr oral capsule,ext.rel 24h degradable 120 mg, 180 mg nifedipine oral tablet extended release nifedipine oral tablet extended release 24hr nimodipine oral taztia xt oral verapamil oral capsule,ext rel. pellets 24 hr verapamil oral tablet F$ verapamil oral tablet extended release Blood Pressure, Other clonidine hcl oral tablet F$ clonidine transdermal doxazosin oral guanfacine oral tablet F$ hydralazine oral methyldopa oral midodrine oral minoxidil oral 33

34 phenoxybenzamine oral PA prazosin oral reserpine oral terazosin oral F$ Cholesterol Lowering, Bile Acid Resins cholestyramine (with sugar) oral cholestyramine light oral colestipol oral tablet prevalite oral Cholesterol Lowering, Other ezetimibe oral JUXTAPID ORAL $ PA; Specialty KYNAMRO SUBCUTANEOUS $ PA; Specialty REPATHA PUSHTRONEX SUBCUTANEOUS $ PA; Specialty REPATHA SURECLICK SUBCUTANEOUS $ PA; Specialty REPATHA SYRINGE SUBCUTANEOUS $ PA; Specialty Cholesterol Lowering, Statins atorvastatin oral F$ ezetimibe-simvastatin oral lovastatin oral F$ pravastatin oral F$ rosuvastatin oral simvastatin oral tablet 10 mg, 20 mg, 5 mg F$ simvastatin oral tablet 40 mg F$ QL simvastatin oral tablet 80 mg F$ PA Diuretics acetazolamide oral ALDACTAZIDE ORAL TABLET MG amiloride oral amiloride-hydrochlorothiazide oral bumetanide oral chlorothiazide oral chlorthalidone oral tablet 25 mg, 50 mg DIURIL ORAL eplerenone oral furosemide oral solution 10 mg/ml, 40 mg/5 ml (8 mg/ml) $ $ furosemide oral tablet F$ 34 F$

35 hydrochlorothiazide oral F$ indapamide oral metolazone oral spironolactone oral spironolacton-hydrochlorothiaz oral torsemide oral triamterene-hydrochlorothiazid oral F$ Heart Health, Other DIGOXIN ORAL SOLUTION 50 MCG/ML digoxin oral tablet 125 mcg $ digoxin oral tablet 250 mcg AE ENTRESTO ORAL klor-con m10 oral klor-con m15 oral KLOR-CON/25 ORAL potassium chloride oral capsule, extended release potassium chloride oral liquid potassium chloride oral packet potassium chloride oral tablet extended release 10 meq, 8 meq potassium chloride oral tablet,er particles/crystals potassium cl er 20 meq tablet Triglyceride Lowering fenofibrate micronized oral capsule 134 mg, 200 mg, 67 mg fenofibrate nanocrystallized oral fenofibrate oral tablet 160 mg, 54 mg $ $ gemfibrozil oral F$ omega-3 acid ethyl esters oral ST Hereditary Angioedema Hereditary Angioedema BERINERT INTRAVENOUS $ PA; Specialty CINRYZE INTRAVENOUS $ PA; Specialty FIRAZYR SUBCUTANEOUS $ PA; Specialty; QL HAEGARDA SUBCUTANEOUS $ PA; Specialty KALBITOR SUBCUTANEOUS $ PA; Specialty RUCONEST INTRAVENOUS $ PA; Specialty 35

36 Idiopathic Pulmonary Fibrosis Idiopathic Pulmonary Fibrosis ESBRIET ORAL $ PA; Specialty OFEV ORAL $ PA; Specialty Immune Deficiency Immune Deficiency BIVIGAM INTRAVENOUS $ PA; Specialty CARIMUNE NF NANOFILTERED INTRAVENOUS RECON SOLN 12 GRAM, 6 GRAM $ PA; Specialty CUVITRU SUBCUTANEOUS $ PA; Specialty FLEBOGAMMA DIF INTRAVENOUS $ PA; Specialty GAMASTAN S/D INTRAMUSCULAR $ PA; Specialty GAMMAGARD LIQUID INJECTION $ PA; Specialty GAMMAGARD S-D (IGA < 1 MCG/ML) INTRAVENOUS $ PA; Specialty GAMMAKED INJECTION $ PA; Specialty GAMMAPLEX (WITH SORBITOL) INTRAVENOUS $ PA; Specialty GAMMAPLEX INTRAVENOUS $ PA; Specialty GAMUNEX-C INJECTION $ PA; Specialty HIZENTRA SUBCUTANEOUS $ PA; Specialty HYQVIA HY COMPONENT SUBCUTANEOUS $ PA; Specialty HYQVIA IG COMPONENT SUBCUTANEOUS $ PA; Specialty HYQVIA SUBCUTANEOUS $ PA; Specialty OCTAGAM INTRAVENOUS $ PA; Specialty PRIVIGEN INTRAVENOUS $ PA; Specialty Immune Suppressant Immune Suppressant azathioprine oral cyclosporine modified oral cyclosporine oral capsule gengraf oral capsule 100 mg, 25 mg gengraf oral solution methotrexate sodium (pf) injection solution methotrexate sodium injection methotrexate sodium oral mycophenolate mofetil oral RAPAMUNE ORAL SOLUTION sirolimus oral tacrolimus oral $ 36

37 Kidney Failure Kidney Failure calcium acetate oral capsule PHOSLYRA ORAL SENSIPAR ORAL sevelamer carbonate oral Men's Health Benign Prostatic Hypertrophy $ $ alfuzosin oral doxazosin oral dutasteride oral dutasteride-tamsulosin oral finasteride oral tablet 5 mg F$ prazosin oral tamsulosin oral terazosin oral F$ Sexual Dysfunction sildenafil (antihypertensive) oral QL Testosterone Deficiency ANDROGEL TRANSDERMAL GEL IN METERED-DOSE PUMP MG/1.25 GRAM (1.62 %) ANDROGEL TRANSDERMAL GEL IN PACKET 1.62 % (20.25 MG/1.25 GRAM), 1.62 % (40.5 MG/2.5 GRAM) $ $ androxy oral QL PA; GE Male PA; GE Male testosterone cypionate intramuscular PA; GE Male testosterone enanthate intramuscular PA; GE Male testosterone transdermal gel PA; GE Male testosterone transdermal gel in metered-dose pump PA; GE Male testosterone transdermal gel in packet PA; GE Male Migraine Migraine, Other ERGOMAR SUBLINGUAL $ QL ergotamine-caffeine oral QL isometh-dichloral-acetaminophn oral QL nodolor oral QL Migraine, Preventives divalproex oral propranolol oral 37

38 Migraine, Triptans naratriptan oral QL rizatriptan oral QL sumatriptan nasal QL sumatriptan succinate oral QL sumatriptan succinate subcutaneous cartridge QL sumatriptan succinate subcutaneous pen injector QL sumatriptan succinate subcutaneous solution QL Mouth & Throat Dental Health chlorhexidine gluconate mucous membrane F$ periogard mucous membrane triamcinolone acetonide dental Dry Mouth cevimeline oral pilocarpine hcl oral Pain lidocaine hcl mucous membrane jelly lidocaine hcl mucous membrane jelly in applicator lidocaine hcl mucous membrane solution 4 % (40 mg/ml) lidocaine viscous mucous membrane Multiple Sclerosis Multiple Sclerosis, Injection AVONEX (WITH ALBUMIN) INTRAMUSCULAR $ Specialty; QL AVONEX INTRAMUSCULAR PEN INJECTOR KIT $ Specialty; QL AVONEX INTRAMUSCULAR SYRINGE KIT $ Specialty; QL EXTAVIA SUBCUTANEOUS KIT $ Specialty; QL glatiramer subcutaneous syringe 40 mg/ml Specialty; QL glatopa subcutaneous syringe 20 mg/ml Specialty; QL PLEGRIDY SUBCUTANEOUS $ Specialty; QL REBIF (WITH ALBUMIN) SUBCUTANEOUS $ Specialty; QL REBIF REBIDOSE SUBCUTANEOUS PEN INJECTOR 22 MCG/0.5 ML, 44 MCG/0.5 ML, 8.8MCG/0.2ML-22 MCG/0.5ML (6) $ Specialty; QL REBIF TITRATION PACK SUBCUTANEOUS $ Specialty; QL Multiple Sclerosis, Oral AMPYRA ORAL $ PA; Specialty 38

39 AUBAGIO ORAL $ Specialty; QL GILENYA ORAL $ Specialty; QL TECFIDERA ORAL $ Specialty; QL Muscle Relaxant Muscle Relaxants baclofen oral chlorzoxazone oral tablet 500 mg AE cyclobenzaprine oral tablet 10 mg, 5 mg F$ AE dantrolene oral methocarbamol oral AE tizanidine oral tablet Other Conditions Other Agents ACTHAR H.P. INJECTION $ PA; Specialty ALFERON N INJECTION $ Specialty ARCALYST SUBCUTANEOUS $ PA; Specialty AUSTEDO ORAL $ PA; Specialty CARNITOR (SUGAR-FREE) ORAL $ CHEMET ORAL $ CYSTAGON ORAL $ desmopressin nasal PA desmopressin oral AE EXJADE ORAL $ PA; Specialty; TD FERRIPROX ORAL $ PA; Specialty ILARIS (PF) SUBCUTANEOUS $ PA; Specialty INGREZZA ORAL $ PA; Specialty JADENU ORAL $ PA; Specialty; TD JADENU SPRINKLE ORAL $ PA; Specialty; TD kionex oral KUVAN ORAL $ PA; Specialty leucovorin calcium oral levocarnitine (with sugar) oral levocarnitine oral tablet megestrol oral suspension 400 mg/10 ml (40 mg/ml) nifedipine oral capsule GE Female; AE octreotide acetate injection Specialty pyridostigmine bromide oral riluzole oral 39

40 SANDOSTATIN LAR DEPOT INTRAMUSCULAR SUSPENSION,EXTENDED REL RECON $ Specialty SIGNIFOR SUBCUTANEOUS $ PA; Specialty sodium phenylbutyrate oral powder PA sodium polystyrene (sorb free) oral sodium polystyrene sulfonate oral tetrabenazine oral PA; Specialty VISTOGARD ORAL $ PA; Specialty Pain Fibromyalgia / Neuropathic Pain gabapentin oral capsule 100 mg, 300 mg, 400 mg QL gabapentin oral solution QL gabapentin oral tablet 600 mg, 800 mg QL lidocaine topical adhesive patch,medicated PA; QL LYRICA ORAL CAPSULE 100 MG, 150 MG, 200 MG, 225 MG, 25 MG, 300 MG, 50 MG, 75 MG $ ST; QL LYRICA ORAL SOLUTION $ ST; QL SAVELLA ORAL $ ST Non-Steroidal Anti-Inflammatories celecoxib oral diclofenac potassium oral diclofenac sodium oral etodolac oral flurbiprofen oral ibuprofen oral tablet 400 mg, 600 mg, 800 mg F$ INDOCIN ORAL $ QL; AE indomethacin oral capsule F$ QL; AE ketorolac oral QL meloxicam oral F$ nabumetone oral naproxen oral suspension naproxen oral tablet F$ naproxen oral tablet,delayed release (dr/ec) piroxicam oral salsalate oral sulindac oral Pain, Opioids acetaminophen-codeine oral solution mg/5 ml F$ QL; AE 40

41 acetaminophen-codeine oral solution 300 mg-30 mg /12.5 ml QL; AE acetaminophen-codeine oral tablet QL; AE buprenorphine-naloxone sublingual tablet mg, 8-2 mg codeine sulfate oral tablet QL; AE endocet oral tablet mg, mg, mg QL fentanyl transdermal patch 72 hour 100 mcg/hr, 62.5 mcg/hour, 75 mcg/hr, 87.5 mcg/hour fentanyl transdermal patch 72 hour 12 mcg/hr, 25 mcg/hr, 37.5 mcg/hour, 50 mcg/hr hydrocodone-acetaminophen oral solution mg/15 ml hydrocodone-acetaminophen oral tablet mg, mg, mg hydrocodone-ibuprofen oral tablet mg QL hydromorphone oral liquid QL hydromorphone oral tablet 2 mg, 4 mg, 8 mg QL hydromorphone rectal QL methadone oral concentrate QL methadone oral solution 10 mg/5 ml, 5 mg/5 ml QL methadone oral tablet 10 mg, 5 mg QL methadone oral tablet,soluble PA morphine concentrate oral solution QL morphine oral solution 10 mg/5 ml, 20 mg/5 ml (4 mg/ml) MORPHINE ORAL TABLET 15 MG, 30 MG $ QL morphine oral tablet extended release 100 mg, 200 mg, 60 mg morphine oral tablet extended release 15 mg, 30 mg QL morphine rectal QL oxycodone oral capsule QL oxycodone oral concentrate QL oxycodone oral solution QL oxycodone oral tablet 10 mg, 15 mg, 20 mg, 5 mg QL oxycodone oral tablet 30 mg PA oxycodone oral tablet,oral only,ext.rel.12 hr 10 mg, 15 mg, 20 mg, 30 mg oxycodone oral tablet,oral only,ext.rel.12 hr 40 mg, 60 mg, 80 mg QL PA QL QL QL QL PA QL PA 41

42 oxycodone-acetaminophen oral tablet mg, mg, mg oxycodone-aspirin oral QL OXYCONTIN ORAL TABLET,ORAL ONLY,EXT.REL.12 HR 10 MG, 15 MG, 20 MG, 30 MG OXYCONTIN ORAL TABLET,ORAL ONLY,EXT.REL.12 HR 40 MG, 60 MG, 80 MG SUBOXONE SUBLINGUAL FILM 12-3 MG, MG, 4-1 MG, 8-2 MG Pain, Other $ $ $ butalbital-acetaminophen oral tablet mg QL butalbital-acetaminophen-caff oral capsule mg butalbital-acetaminophen-caff oral tablet mg butalbital-aspirin-caffeine oral capsule QL tramadol oral tablet F$ QL Pain, Topical diclofenac sodium topical gel 1 % lidocaine-prilocaine topical cream QL Parkinson's Parkinson's amantadine hcl oral benztropine oral bromocriptine oral carbidopa oral carbidopa-levodopa oral carbidopa-levodopa-entacapone oral entacapone oral NEUPRO TRANSDERMAL $ PA pramipexole oral tablet pramipexole oral tablet extended release 24 hr PA rasagiline oral PA ropinirole oral tablet ropinirole oral tablet extended release 24 hr PA RYTARY ORAL $ PA selegiline hcl oral trihexyphenidyl oral QL QL PA QL QL QL 42

43 Pulmonary Hypertension Pulmonary Hypertension ADEMPAS ORAL $ PA; Specialty epoprostenol (glycine) intravenous recon soln 1.5 mg PA; Specialty FLOLAN INTRAVENOUS RECON SOLN 1.5 MG $ PA; Specialty LETAIRIS ORAL $ PA; Specialty OPSUMIT ORAL $ PA; Specialty REMODULIN INJECTION $ PA; Specialty sildenafil (antihypertensive) oral PA; QL TRACLEER ORAL $ PA; Specialty TYVASO INHALATION $ PA; Specialty TYVASO REFILL KIT INHALATION $ PA; Specialty TYVASO STARTER KIT INHALATION $ PA; Specialty UPTRAVI ORAL $ PA; Specialty VELETRI INTRAVENOUS $ PA; Specialty VENTAVIS INHALATION $ PA; Specialty Seizures / Epilepsy Seizures / Epilepsy acetazolamide oral APTIOM ORAL $ PA BANZEL ORAL SUSPENSION $ PA; QL BANZEL ORAL TABLET 200 MG, 400 MG $ PA; QL BRIVIACT ORAL $ PA carbamazepine oral capsule, er multiphase 12 hr carbamazepine oral suspension 100 mg/5 ml, 100 mg/5 ml (5 ml) carbamazepine oral tablet carbamazepine oral tablet extended release 12 hr carbamazepine oral tablet,chewable clonazepam oral tablet 0.5 mg, 1 mg, 2 mg F$ QL clonazepam oral tablet,disintegrating mg, 0.25 mg, 0.5 mg, 1 mg, 2 mg diazepam intensol oral QL diazepam oral solution 5 mg/5 ml (1 mg/ml) QL diazepam oral tablet 10 mg, 2 mg, 5 mg F$ QL diazepam rectal QL DILANTIN KAPSEAL ORAL CAPSULE 30 MG DILANTIN ORAL $ $ QL 43

44 divalproex oral ethosuximide oral felbamate oral FYCOMPA ORAL SUSPENSION $ PA FYCOMPA ORAL TABLET $ PA gabapentin oral capsule 100 mg, 300 mg, 400 mg QL gabapentin oral solution QL gabapentin oral tablet 600 mg, 800 mg QL GABITRIL ORAL TABLET 12 MG, 16 MG lamotrigine oral tablet $ lamotrigine oral tablet disintegrating, dose pk PA lamotrigine oral tablet, chewable dispersible lamotrigine oral tablet,disintegrating PA levetiracetam oral solution 100 mg/ml levetiracetam oral tablet levetiracetam oral tablet extended release 24 hr LYRICA ORAL CAPSULE 100 MG, 150 MG, 200 MG, 225 MG, 25 MG, 300 MG, 50 MG, 75 MG $ ST; QL LYRICA ORAL SOLUTION $ ST; QL ONFI ORAL SUSPENSION $ QL ONFI ORAL TABLET 10 MG, 20 MG $ QL oxcarbazepine oral phenobarbital oral elixir phenobarbital oral tablet 100 mg, 15 mg, 16.2 mg, 30 mg, 60 mg phenytoin oral suspension 125 mg/5 ml phenytoin oral tablet,chewable phenytoin sodium extended oral POTIGA ORAL TABLET 200 MG, 300 MG, 400 MG, 50 MG primidone oral $ SABRIL ORAL TABLET $ PA; Specialty tiagabine oral tablet 2 mg, 4 mg topiramate oral capsule, sprinkle topiramate oral tablet F$ valproic acid (as sodium salt) oral solution 250 mg/5 ml, 500 mg/10 ml (10 ml) valproic acid oral VIGABATRIN ORAL $ PA; Specialty 44 QL

45 VIMPAT ORAL SOLUTION $ QL VIMPAT ORAL TABLET 100 MG, 150 MG, 200 MG, 50 MG zonisamide oral Skin Conditions Acne, Oral $ QL amnesteem oral claravis oral myorisan oral capsule 10 mg, 20 mg, 40 mg zenatane oral capsule 10 mg, 20 mg, 40 mg Acne, Topical ACZONE TOPICAL GEL WITH PUMP $ PA adapalene topical cream adapalene topical gel 0.3 % adapalene topical gel with pump avita topical clindamycin phosphate topical gel clindamycin phosphate topical lotion clindamycin phosphate topical solution clindamycin phosphate topical swab DAPSONE TOPICAL $ PA DIFFERIN 0.1% GEL (OTC) erythromycin with ethanol topical gel erythromycin with ethanol topical solution sulfacetamide sodium (acne) topical sulfacetamide sodium-sulfur topical cleanser 10-5 % (w/w) sulfacetamide sodium-sulfur topical cream 10-5 % (w/w) sulfacetamide sodium-sulfur topical lotion 10-5 % (w/v), 10-5 % (w/w) sulfacetamide sod-sulfur-urea topical cleanser tretinoin topical cream tretinoin topical gel 0.01 %, % Antifungals, Topical $ ciclopirox topical cream ciclopirox topical gel ciclopirox topical solution ciclopirox topical suspension 45