Plan for your best health

Transcription

1 Plan for your best health 2018 Aetna Pharmacy Drug Guide Aetna Performance Plan A (1/18) aetna.com

2 How to use this guide Your guide includes a list of drugs covered on your pharmacy plan. The amount you pay depends on the drug your doctor prescribes. It s either a flat fee or a percentage of the prescription s price after you meet your deductible, if applicable. Preferred generic drugs cost less. Preferred brand drugs will have a higher cost. Your plan includes Brand and generic drugs that are hand-picked for their quality and effectiveness Aetna Specialty Pharmacy fills specialty drug prescriptions (ones that are injected, infused or taken by mouth) and provides services that include personal support, helpful resources and training, and free secure home delivery Aetna Rx Home Delivery pharmacy that delivers maintenance drugs to your home or wherever you choose (for drugs that are taken regularly to treat conditions like arthritis, diabetes or asthma) What you can expect to pay With your pharmacy plan, the amount you pay depends on the drug your doctor prescribes. It s either a flat fee or a percentage of the drug s/medicine s price. Each drug is grouped as a generic, a brand or a specialty drug. The preferred drugs within these groups will generally save you money compared to a non-preferred drug. Generic drugs are less expensive than brands. Specialty prescription drugs typically include higher-cost drugs that require special handling, special storage or monitoring. These types of drugs may include, but are not limited to, drugs that are injected, infused, inhaled or taken by mouth. You re covered for all types of medicine some more expensive, and some less. Preferred generic: the lowest cost Preferred brand: a slightly higher cost Non-preferred brand and generic: a higher cost Preferred Specialty: lower cost for specialty drugs Non-preferred specialty: higher cost for non-preferred specialty drugs Your pharmacy plan may not have all the coverage levels listed above so check your plan documents to see how much you will pay. For your exact coverage and cost, and to learn more about your plan Visit the website that s on your member ID card. Then log in to your account, where you can: Find out the coverage and estimate of cost for specific drugs View your deductibles and plan limits Order medications Check your pharmacy order status Get a member ID card View your claims, Explanation of Benefits and more Aetna is the brand name used for products and services provided by one or more of the Aetna group of subsidiary companies, including Aetna Life Insurance Company and its affiliates (Aetna). Aetna Pharmacy Management refers to an internal business unit of Aetna Health Management, LLC. Aetna Pharmacy Management administers, but does not offer, insure or otherwise underwrite the prescription drug benefits portion of your health plan and has no financial responsibility therefor. Aetna Specialty Pharmacy refers to Aetna Specialty Pharmacy, LLC, a subsidiary of Aetna Inc., which is a licensed pharmacy that operates through specialty pharmacy prescription fulfillment. 2

3 Have more questions about your pharmacy benefits? We re here to help. There are several ways you can learn more about your benefits: Check your Plan Design and Benefits Summary in your enrollment kit. Call the toll-free number on your member ID card. Review our pharmacy frequently asked questions (FAQs) and answers. Just visit the website that s on your member ID card to search for the Pharmacy FAQ. Aetna Specialty Pharmacy Aetna Specialty Pharmacy medicine and support services is our in-house specialty pharmacy that can fill your prescriptions for specialty drugs. These are the types of drugs that may be injected, infused or taken by mouth. They often need special storage and handling. And they need to be delivered quickly. A nurse or pharmacist may monitor you during your treatment, if needed. With Aetna Specialty Pharmacy, you can get this medicine sent right to your mailbox. How to get started with Aetna Specialty Pharmacy Ordering your prescription through Aetna Specialty Pharmacy is easy. And we typically offer a 30-day medicine supply. To transfer your prescription, just call us toll-free at For a new prescription, your doctor can send it to us in one of four ways: 1. Electronically: Through e-prescribe Aetna Rx Home Delivery You can have maintenance drugs sent right to your home or anywhere else you choose with Aetna Rx Home Delivery pharmacy. These are drugs that are taken regularly for chronic conditions like arthritis, diabetes or asthma. Depending on your plan, you can get up to a 90-day supply of medicine for less cost. It s fast and convenient, and standard shipping is always free. Get started right away You can submit your order using one of these options: 1. Online Visit your secure member website and sign in to your account. There you can add or remove your prescriptions. 2. Phone Call us toll-free, 24/7 at If you need the help of a telephone device for the deaf, call Mail Get a new prescription from your doctor. Then mail it to us with a completed order form. You can find the form on your secure member website. The mailing address is on the form. Your doctor can submit your order using one of these options: 1. Online They can submit your prescriptions using the e-prescribe services on our provider website. 2. Fax They can fax your prescription to Make sure they include your member ID number, date of birth and mailing address on the fax cover sheet. Only a doctor may fax a prescription. 2. Fax: FAX-ASRX ( ) 3. Mail: Aetna Specialty Pharmacy 503 Sunport Lane Orlando, FL Phone: ASRX ( ), option 2 If you mail in your own prescription, please send it with a completed Patient Profile Form. To find this form, just visit the website that s on your member ID card, to search for the Patient Profile Form. 3

4 Frequently asked questions How can I save on prescriptions? Here are some tips to pay less out of pocket for your prescription drugs: Ask your doctor to consider prescribing drugs that are on the Pharmacy Drug Guide (formulary). Ask your doctor to consider prescribing generic drugs instead of brand-name drugs. Check to see if your plan includes our home delivery pharmacy service. Depending upon your plan, our home delivery service may save you money. For more information, visit the website on your member ID card and log in to your account. Remind your doctor to check your plan to make sure you get maximum coverage. What are generic drugs? Generic drugs are proven to be just as safe and effective as brand-name drugs. They contain the same active ingredients in the same amounts as the brand-name drugs and work the same way. So they have the same risks and benefits as brand-name drugs. However, they typically cost less. When appropriate, your doctor may decide to prescribe a generic drug or allow the pharmacist to substitute a generic drug. What is precertification? Precertification is one way that we can help you and your doctor find safe, appropriate drugs and keep costs down. Precertification means that you or your doctor need to get approval from the plan before certain drugs will be covered. Generally, precertification applies to drugs that: Are often taken in the wrong way Should only be used for certain conditions Often cost more than other drugs that are proven to be just as effective Keep in mind that your doctor must contact us to request approval of coverage for these drugs. What is step therapy? Some drugs require step therapy. This means that you must try one or more prerequisite drug(s) before a step therapy drug is covered. The prerequisite drugs are equally effective, have U.S. Food and Drug Administration (FDA) approval and may cost less. They treat the same condition as the step therapy drug. If you don t try the appropriate alternative drug first, you may need to pay full cost for the brand-name version. What are quantity limits? Quantity limits help your doctor and pharmacist make sure that you use your drug correctly and safely. We use medical guidelines and FDA-approved recommendations from drug makers to set these coverage limits. The quantity limit program includes: Dose efficiency edits Limits prescription coverage to one dose per day for drugs that have approval for once-daily dosing Maximum daily dose If a prescription is lower than the minimum or higher than the maximum allowed dose, a message is sent to the pharmacy Quantity limits over time Limits prescription coverage to a specific number of units over a specific amount of time What if I need a drug that requires an exception to the precertification, step therapy or quantity limits requirements? Or what if I need a drug that s not covered under my plan? In certain cases, you or your prescriber can request a medical exception to the precertification, step therapy or quantity limits requirements. And also for a drug that s not covered in your plan. If you ask for your request to be expedited, a coverage determination will be made within 24 hours of receiving it. We ll then contact you or your prescriber with our decision. All medically necessary outpatient prescription drugs will be covered. If a medical exception is approved, you only need to pay the copay after the deductible. This amount is based on your pharmacy plan design. 4

5 How can your provider request a medical exception? Submit their request through our secure provider website on NaviNet. Call the Aetna Pharmacy Precertification Unit at Fax the completed request form to Mail the completed request form to: Aetna Pharmacy Management 1300 East Campbell Road Richardson, TX How is the formulary (drug list) developed? Our Pharmacy and Therapeutics Committee meets regularly to review new drugs and new information about current drugs. We review them for their safety, effectiveness and current use in therapy. Can the formulary change during the year? The formulary can change throughout the year. Some reasons why they can change include: New drugs are approved. Existing drugs are removed from the market. Prescription drugs may become available over the counter (without a prescription). Over-the-counter drugs are not generally covered in a formulary. Brand-name drugs lose patent protection and generic versions become available. When this happens, the brand-name drug is likely to be covered at a higher cost. And the generic versions cost less. See the What are generic drugs? section above for more information. This committee includes licensed pharmacists and doctors. They are currently in practice or are Aetna employees. Once we complete our clinical review, we also consider overall value before adding or removing a drug from the formulary. We may recommend moving a drug to a different coverage level. Or that it be placed on our Formulary Exclusions List and no longer be covered. 5

6 Commercial 1557 Nondiscrimination Notice Aetna complies with applicable Federal civil rights laws and does not discriminate, exclude or treat people differently based on their race, color, national origin, sex, age, or disability. Aetna provides free aids/services to people with disabilities and to people who need language assistance. If you need a qualified interpreter, written information in other formats, translation or other services, call the number on your ID card. If you believe we have failed to provide these services or otherwise discriminated based on a protected class noted above, you can also file a grievance with the Civil Rights Coordinator by contacting: Civil Rights Coordinator, P.O. Box 14462, Lexington, KY (CA HMO customers: PO Box Fresno, CA 93779), , TTY: 711, Fax: (CA HMO customers: ), CRCoordinator@aetna.com. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights Complaint Portal, available at or at: U.S. Department of Health and Human Services, 200 Independence Avenue SW., Room 509F, HHH Building, Washington, DC 20201, or at , (TDD). Aetna is the brand name used for products and services provided by one or more of the Aetna group of subsidiary companies, including Aetna Life Insurance Company, Coventry Health Care plans and their affiliates (Aetna). 6

7 TTY: 711 To access language services at no cost to you, call the number on your ID card. Para acceder a los servicios de idiomas sin costo, llame al número que figura en su tarjeta de identificación. (Spanish) 如欲使用免費語言服務, 請致電您 ID 卡上的電話號碼 (Chinese) Afin d'accéder aux services langagiers sans frais, veuillez composer le numéro inscrit sur votre carte d'identité. (French) Para ma-access ang mga serbisyo sa wika nang wala kayong babayaran, tawagan ang numero sa inyong ID card. (Tagalog) (Navajo) Um auf für Sie kostenlose Sprachdienstleistungen zuzugreifen, rufen Sie die Nummer auf Ihrer ID-Karte an. (German) Për shërbime përkthimi falas për ju, telefononi në numrin që gjendet në kartën tuaj të identitetit. (Albanian) የቋንቋ አገልግሎቶችን ያለክፍያ ለማግኘት በመታወቂያዎት ላይ ያለውን ቁጥር ይደውሉ (Amharic) للحصول على الخدمات اللغوية دون أي تكلفة الرجاء االتصال على الرقم الموجود على بطاقتك الشخصية. Arabic( ) Անվճար լեզվական ծառայություններից օգտվելու համար զանգահարեք ձեր ինքնության (ID) քարտի վրա նշված հեռախոսահամարով: (Armenian) Kugira uronke serivisi z indimi atakiguzi, Hamagara inumero iri kuri karangamuntu kawe. (Bantu) আপন ক ব ন ম কয ভ ষ পব কষ পপক হকয আপন পব চয পক প ওয নম ক প বযক ন র ন (Bengali) Ngadto maakses ang mga serbisyo sa pinulongan alang libre, tawagan sa numero sa nimong ID card. (Bisayan-Visayan) သင အ န ဖင အခ ၾက င မ ပ ရပ ဘ သ စက ၀န ဆ င မ မ ရရ ငရန သင ID ကတ ပၚတ င ရ သ ဖ န န ပတအ ခၚဆ ပ (Burmese) Per accedir a serveis lingüístics sense cap cost per vostè, telefoni al número indicat a la seva targeta d identificació. (Catalan) Para un hago' i setbision lengguåhi ni dibåtde para hågu, ågang i numiru gi iyo-mu kard aidentifikasion. (Chamorro) 7

8 ᏩᎩᏍᏗ ᎦᏬᏂᎯᏍᏗ ᎢᏅᎾᏓᏛᏁᏗ Ꮭ ᎪᎱᏍᏗ ᏗᏣᎬᏩᎳᏁᏗ ᏱᎩ, ᏫᎨᎯᏏᎳᏛᏏ ᎾᏍᎩ ᏗᏎᏍᏗ ᏥᏕᎪᏪᎵ ᎤᎾᎢ ID ᏆᏂᏲᏍᏗ ᏣᏤᎵᎢ. (Cherokee) Anumpa tohsholi I toksvli ya peh pilla ho ish I paya hinla kvt chi holisso iskitini holhtena takanli ma I paya. (Choctaw) Tajaajiiloota afaanii gatii bilisaa ati argaachuuf,lakkoofsa duugda waraaqaa eenyummaa (ID) kee irraa jiruun bilbili. (Cushite-Oromo) Voor gratis toegang tot taaldiensten, bel het nummer op uw ID-kaart. (Dutch) Pou jwenn sèvis lang gratis, rele nimewo telefòn ki sou kat idantite ou a. (French Creole-Haitian) Για να επικοινωνήσετε χωρίς χρέωση με το κέντρο υποστήριξης πελατών στη γλώσσα σας, τηλεφωνήστε στον αριθμό που αναγράφεται στην κάρτα σας προνομίων μέλους. (Greek) તમ ર ક ઇ જ તન ખર ચ વ ન ભ ષ ન સ ઓન પહ ર મ ટ, તમ ર આઇડ ક ડચ ઉપરન ન બરન ક લ કર. (Gujarati) No ka walaʻau ʻana me ka lawelawe ʻōlelo e kahea aku i ka helu kelepona ma kāu kāleka ID. Kāki ʻole ʻia kēia kōkua nei. (Hawaiian) आपक ल ए ब न ककस क मत क भ ष सव ओ क उपय ग करन क ल ए, अपन आईड क ड ड पर द य नम र पर क कर (Hindi) Xav tau kev pab txhais lus tsis muaj nqi them rau koj, hu tus naj npawb ntawm koj daim npav ID. (Hmong) Iji nwetaòhèrè na ọrụ gasị asụsụ n'efu, kpọọ nọmba no na kaadị ID gị. (Ibo) Tapno maaksesyo dagiti serbisio maipapan iti pagsasao nga awan ti bayadanyo, tawagan ti numero idiay ID cardyo. (Ilocano) Untuk mengakses layanan bahasa tanpa dikenakan biaya, hubungi nomor telepon di kartu identitas Anda. (Indonesian) Per accedere ai servizi linguistici, senza alcun costo per lei, chiami il numero sulla tessera identificativa. (Italian) 言語サービスを無料でご利用いただくには ID カードに記載の番号にお電話ください (Japanese) v>w>furreh>fusd.ftw>frrp>rtw>fzh;w>frrwz.fv>wtd.f'd;tyshrv>eub.f[h.ftdrb.feh.f ud;b.fvdwjpded>f*h>fv>td.fv>ew>f*drcd.f (ID) tc;vdreh.fwuh>ff (Karen) 무료언어서비스를이용하려면보험 ID 카드에수록된번호로전화해주십시오. (Korean) 8

9 ड ន M dyi wuɖu-dù kà kò ɖò ɓě dyi mɔúń nì pídyi ní, nìí, ɖá nɔ ɓà nìà nì ID káàɔ kɔ ɛ. (Kru-Bassa) بۆ دەسپێڕاگەيشتن بە خزمەتگوزاری زمان بەبێ تێچوون بۆ تۆ پەيوەندی بکە بە ژمارەی سەر ئای دی) ID ( کارتی خۆت. )Kurdish( ເພອເຂາໃຊການບລການພາສາໂດຍບເສຍຄາຕກບທານ, ໃຫໂທຫາເບໂທທບອກໄວໃນບດປະຈາຕວຂອງທານ. (Laotian) क णत य ह शल क लशव य भ ष स व प प त करण य स ठ, तमच य ID क ड डवर क म क वर फ न कर. (Marathi) Nan etal nan jikin jiban ko ikijen kajin ilo an ejelok onen nan kwe, kirlok nomba eo ilo ID kaat eo am. (Marshallese) Pwehn alehdi sawas en lokaia kan ni sohte pweipwei, koahlih nempe nan amhw doaropwe en ID. (Micronesian-Pohnpeian) ដ ម ប ទទលប នដ វ កម ភ ស ដ ម លឥតគ តថ ល ម រ ប ដ កអ ក ន ម ដ ទរ ព ដ ក ន ទ ដលខដ ល នដ ដលប ណ ណ ល ខល ន រប ដ កអ ក (Mon-Khmer, Cambodian) नन शल क भ ष स व प प त गन आफ न पररचयपत म भएक नम रम टल फ न गनह स ड (Nepali) Të kɔɔr yïn wɛ ɛ r de thokic ke cïn wëu kɔr keek tënɔŋ yïn. Ke cɔl kɔc ye kɔc kuɔny në nɔmba de abac tɔ në ID kard du kɔü. (Nilotic-Dinka) For tilgang til kostnadsfri språktjenester, ring nummeret på ID-kortet ditt. (Norwegian) Um Schprooch Services zu griege mitaus Koscht, ruff die Nummer uff dei ID Kaart. (Pennsylvania Dutch) برای دسترسی بە خدمات زبان بە طور رايگان با شماره قيد شده روی کارت شناسايی خود تماس بگيريد. ( Persian-Farsi ) Aby uzyskać dostęp do bezpłatnych usług językowych proszę zadzwonić numer telefonu na Twojej Karcie Identykującej (Polish) Para acessar os serviços de idiomas sem custo para você, ligue para o número que consta na sua identidade. (Portuguese) ਤ ਹ ਡ ਲਈ ਬ ਨ ਬ ਸ ਮਤ ਵ ਲ ਆ ਭ ਸ਼ ਸ ਵ ਵ ਦ ਵਰਤ ਰਨ ਲਈ, ਆਪਣ ਆਈਡ ਰਡ ਤ ਬਦ ਤ ਨ ਰ ਤ ਫ਼ ਨ ਰ (Punjabi) Pentru a accesa gratuit serviciile de limbă, apelați numărul de pe cardul dvs. de identificare. (Romanian) Для того чтобы бесплатно получить помощь переводчика, позвоните по телефону, приведенному на вашей карточке участника плана. (Russian) 9

10 Mo le mauaina o auaunaga tau gagana e aunoa ma se totogi, vala au le numera I luga o lau pepa ID. (Samoan) Za besplatne prevodilačke usluge pozovite broj naveden na Vašoj identifikacionoj kartici. (Serbo- Croatian) Heeba a nasta jangirde djey wolde, apelou lamba djey do windi ha dereji Maada. (Sudanic-Fulfulde) Kupata huduma za lugha bila malipo kwako, piga nambari iliyo kwenye kadi yako ya kitambulisho. (Swahili) ܐܢ ܣܢܝܩܐ ܝܬܘܢ ܥܠ ܚܠܡܬܐ ܕܗܝܪܬܐ ܒܠܫܢܐ ܡܓܢܐܝܬ ܩܪܝܡܘܢ ܡܢܝܢܐ ܥܠ ܦܬܩܐ ܗܕܡܝܘܬܐ ܕܝܘܟܘܢ. Syriac-( )Assyrian మ ర భ ష స వలన ఉచ త గ అ ద క న ద క, మ ID క ర ప ఉనన న బర క క ల చ య డ (Telugu) หากท านตองการเขาถงการบรการทางดานภาษาโดยไม ม ค าใชจ าย โปรดโทรหมายเลขท แสดงอย บนบตรประจาตวของท าน (Thai) Kapau oku ke fiema u ta etōtōngi a e ngaahi sēvesi kotoa pē he ngaahi lea kotoa, telefoni ki he fika oku hā atu i ho o ID kaati. (Tongan) Ren omw kopwe angei aninisin eman chon awewei (ese kamo), kopwe kori ewe nampa mei mak won noum ena katen ID (Trukese) Sizin için ücretsiz dil hizmetlerine erişebilmek için, kartınızdaki numarayı arayın. (Turkish) Щоб отримати безкоштовний доступ до мовних послуг, задзвоніть за номером, вказаним на Вашій ідентифікайній картці. (Ukrainian) بالقیمت زبان سے متعلقہ خدمات حاصل کرنے کے لیے اپنے شناختی کارڈ پر درج نمبرپر بات کریں )Urdu( Nếu quý vị muốn sử dụng miễn phí các dịch vụ ngôn ngữ, hãy gọi tới số điện thoại ghi trên thẻ ID (Nhận dạng) của quý vị. (Vietnamese) צוטריט ש פר אך ב אדינונגען אין קיין פרייז צו איר, רופן די נומער אויף דיין שיין ק ארט. )Yiddish( Lati wọnú awọn isẹ èdè l ọfẹ fun ọ, pe nọmba ori káádi idánimọ rẹ. (Yoruba) 10

11 Remember to visit the website on your member ID card. Then sign in to your account for the most up-to-date information. Please note that if your prescription drug benefits plan changes, the information here may no longer apply. A copayment is a flat fee. Coinsurance is a percentage of the rate that Aetna negotiates with the plan sponsor for covered prescriptions except as required by law to be otherwise. Some drugs on the Preferred Drug List are subject to manufacturer rebates. Coinsurance is calculated before any rebates are subtracted. That means it may be possible for your cost of a preferred drug to be higher than your cost of a non-preferred drug. Not all health services are covered. See plan documents for a complete description of benefits, exclusions, limitations and conditions of coverage. Plan features and availability may vary by location and are subject to change. Aetna receives rebates from drug manufacturers that may be taken into account in determining Aetna s Pharmacy Drug (formulary) Guide. Rebates do not reduce the amount a member pays the pharmacy for covered prescriptions. Information is subject to change. The drugs on the Pharmacy Drug (formulary) Guide, Formulary Exclusions, Precertification, and Quantity Limit Lists are subject to change. The quantity limits and drug coverage review programs are not available in all service areas. In accordance with state law, commercial fully insured members in Louisiana and Texas (except Federal Employee Health Benefit Plan members) who are receiving coverage for medications that are added or removed from the Pharmacy Drug (formulary) Guide, Precertification, Quantity Limits or Step-Therapy Lists during the plan year will continue to have those medications covered at the same benefit level until their plan s renewal date. In Texas, precertification approval is known as pre-service utilization review. It is not verification as defined by Texas law. In accordance with state law, fully insured Commercial California health maintenance organization (HMO) members (except Federal Employee Health Benefit Plan members) who are receiving coverage for medications that are added to the Precertification or Step-Therapy Lists will continue to have those medications covered, for as long as the treating physician continues prescribing them, provided that the drug is appropriately prescribed and is considered safe and effective for treating the enrollee s medical condition. In accordance with state law, fully insured Commercial Connecticut preferred provider organization (PPO) members (except Federal Employee Health Benefit Plan members) who are receiving coverage for medications that are added to the Precertification or Step-Therapy Lists will continue to have those medications covered for as long as the treating physician prescribes them, provided the drug is medically necessary and more medically beneficial than other covered drugs. Nothing in this section shall preclude the prescribing provider from prescribing another drug covered by the plan that is medically appropriate for the enrollee, nor shall anything in this section be construed to prohibit generic drug substitutions. This material is for information only. It contains only a partial, general description of plan benefits or programs and does not constitute a contract. See plan documents for a complete description of benefits, exclusions, limitations and conditions of coverage. Plan features and availability may vary by location and are subject to change. Providers are independent contractors and are not agents of Aetna. Provider participation may change without notice. Aetna does not provide care or guarantee access to health services. Information is subject to change Aetna Inc A (1/18) aetna.com

12 Table of Contents *ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS*...16 *AMINOGLYCOSIDES*...17 *ANALGESICS - ANTI-INFLAMMATORY* *ANALGESICS - NONNARCOTIC*...19 *ANALGESICS - OPIOID*...23 *ANDROGENS-ANABOLIC* *ANORECTAL AGENTS* *ANTHELMINTICS* *ANTIANGINAL AGENTS* *ANTIANXIETY AGENTS*...27 *ANTIARRHYTHMICS*...27 *ANTIASTHMATIC AND BRONCHODILATOR AGENTS*...28 *ANTICOAGULANTS* *ANTICONVULSANTS* *ANTIDEPRESSANTS* *ANTIDIABETICS*...32 *ANTIDIARRHEALS*...34 *ANTIDOTES AND SPECIFIC ANTAGONISTS*...34 *ANTIDOTES*...34 *ANTIEMETICS* *ANTIFUNGALS*...35 *ANTIHISTAMINES* *ANTIHYPERLIPIDEMICS* *ANTIHYPERTENSIVES*...36 *ANTI-INFECTIVE AGENTS - MISC.*...38 *ANTIMALARIALS* *ANTIMYASTHENIC AGENTS* *ANTIMYASTHENIC/CHOLINERGIC AGENTS* *ANTIMYCOBACTERIAL AGENTS* *ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES* *ANTI-OBESITY AGENT COMBINATIONS**...41 *ANTIPARKINSON AGENTS* *ANTIPSYCHOTICS/ANTIMANIC AGENTS* *ANTIVIRALS* *ASSORTED CLASSES* *BETA BLOCKERS* *CALCIUM CHANNEL BLOCKERS* *CARDIOTONICS* *CARDIOVASCULAR AGENTS - MISC.*...48 *PHALOSPORINS* *CIC AGENTS - GUANYLATE CYCLASE-C (GC-C) AGONISTS***...49 *CONTRAPTIVES* *CORTICOSTEROIDS* *COUGH/COLD/ALLERGY*...55 *CYCLIN-DEPENDENT KINASES (CDK) INHIBITORS*** *DERMATOLOGICALS* *DIAGNOSTIC PRODUCTS*

13 *DIGESTIVE AIDS* *DIRECT-ACTING P2Y12 INHIBITORS***...63 *DIURETICS*...63 *ENDOCRINE AND METABOLIC AGENTS - MISC.*...63 *ESTROGENS* *ESTROGEN-SELECTIVE ESTROGEN REPTOR MODULATOR COMB***...65 *FLUOROQUINOLONES*...65 *GASTROINTESTINAL AGENTS - MISC.* *GENITOURINARY AGENTS - MISLLANEOUS*...66 *GOUT AGENTS* *HEMATOLOGICAL AGENTS - MISC.*...67 *HEMATOPOIETIC AGENTS*...67 *HEMOSTATICS* *HEPATITIS C AGENT - COMBINATIONS*** *HYPNOTICS*...74 *IBS AGENT - MU-OPIOID REPTOR AGONISTS***...74 *INSULIN-INCRETIN MIMETIC COMBINATIONS*** *INTEGRIN REPTOR ANTAGONISTS*** *LAXATIVES* *MACROLIDES* *MEDICAL DEVIS* *MIGRAINE PRODUCTS*...79 *MINERALS & ELECTROLYTES* *MOUTH/THROAT/DENTAL AGENTS*...81 *MULTIVITAMINS*...83 *MUSCULOSKELETAL THERAPY AGENTS*...88 *NASAL AGENTS - SYSTEMIC AND TOPICAL* *NEPRILYSIN INHIB (ARNI)-ANGIOTENSIN II REPT ANTAG COMB***...89 *NEUROMUSCULAR AGENTS*...89 *OPHTHALMIC AGENTS*...89 *OTIC AGENTS* *OXYTOCICS*...92 *PASSIVE IMMUNIZING AGENTS*...92 *PENICILLINS*...93 *PHOSPHATIDYLINOSITOL 3-KINASE (PI3K) INHIBITORS*** *POLY (ADP-RIBOSE) POLYMERASE (PARP) INHIBITORS** *POLY (ADP-RIBOSE) POLYMERASE (PARP) INHIBITORS*** *POTASSIUM REMOVING AGENTS*** *PROGESTINS*...94 *PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.* *SEROTONIN 1A REPT AGONIST/SEROTONIN 2A REPT ANTAG***...97 *SEROTONIN MODULATORS***...97 *SODIUM-GLUCOSE CO-TRANSPORTER 2 INHIBITOR-BIGUANIDE COMB*** *SULFONAMIDES* *TETRACYCLINES*...97 *THYROID AGENTS* *ULR DRUGS*...98 *URINARY ANTI-INFECTIVES* *URINARY ANTISPASMODICS* *VAGINAL PRODUCTS*

14 *VASOPRESSORS* *VITAMINS*

15 15

16 lowercase italics = Generic drugs UPPERCASE = Brand name drugs CURRENT AS OF 1/1/2018 Drug Details # = Brand-name drug expected to become available generically in the near future. After the generic drug becomes available, the brandname drug may be covered at a higher non-preferred copay and/or added to the Formulary Exclusion List. The brand-name drug may also be subject to precertification and/or step-therapy. LGC = Lowest Generic Copay Applies Drug Status PA = Prior Authorization = Copay Exception: Available = Quantity Limit to some members at no cost with a SP Pharmacy = You may pay prescription from your provider higher out of pocket costs and when obtained at an in-network may be required to get these pharmacy. Certain limitations may products at an Aetna Specialty apply. Pharmacy network provider, like = Preferred Brand Aetna Specialty Pharmacy. S = Preferred Brand Specialty Specialty products are limited to a = Preferred Generic 30 day supply. Drug Name Drug Status Drug Details *ADHD/ANTI-NARCOLEPSY/ANTI- OBESITY/ANOREXIANTS* amphetamine-dextroamphet er PA; amphetamine-dextroamphetamine oral tablet 10 mg, 12.5 mg, 15 mg, 20 mg, 30 mg, 5 mg, 7.5 mg armodafinil oral tablet 150 mg, 200 mg, 250 mg, 50 mg atomoxetine hcl oral capsule 10 mg, 100 mg, 18 mg, 25 mg, 40 mg, 60 mg, 80 mg benzphetamine hcl oral tablet 50 mg PA; clonidine hcl er PA; DEXEDRINE ORAL TABLET dexmethylphenidate hcl dexmethylphenidate hcl er dextroamphetamine sulfate er dextroamphetamine sulfate oral solution 16

17 dextroamphetamine sulfate oral tablet diethylpropion hcl er diethylpropion hcl oral METADATE ER ORAL TABLET EXTENDED RELEASE 20 MG methamphetamine hcl PA; methylphenidate hcl er (cd) methylphenidate hcl er (la) methylphenidate hcl er oral tablet extended release 10 mg methylphenidate hcl er oral tablet extended release 18 mg, 20 mg, 27 mg, 36 mg, 54 mg methylphenidate hcl er oral tablet extended release 24 hour 18 mg, 27 mg, 36 mg, 54 mg methylphenidate hcl oral solution 10 mg/5ml, 5 mg/5ml methylphenidate hcl oral tablet methylphenidate hcl oral tablet chewable PA; modafinil PA; phendimetrazine tartrate phendimetrazine tartrate er phentermine hcl oral VYVANSE ZENZEDI ORAL TABLET 10 MG, 5 MG *AMINOGLYCOSIDES* neomycin sulfate oral paromomycin sulfate oral tobramycin inhalation SP Pharmacy; tobramycin pak *ANALGESICS - ANTI-INFLAMMATORY* celecoxib oral diclofenac potassium diclofenac sodium er diclofenac sodium oral tablet delayed release 25 mg, 50 mg diclofenac sodium oral tablet delayed release 75 mg LGC 17

18 diclofenac-misoprostol oral tablet delayed release ENBREL SUBCUTANEOUS KIT S PA; SP Pharmacy; ENBREL SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 25 MG/0.5ML, 50 MG/ML etodolac er etodolac oral fenoprofen calcium oral capsule 400 mg fenoprofen calcium oral tablet flurbiprofen oral HUMIRA PEDIATRIC CROHNS START SUBCUTANEOUS PREFILLED SYRINGE KIT 40 MG/0.8ML HUMIRA PEN SUBCUTANEOUS PEN- INJECTOR KIT HUMIRA PEN-CROHNS STARTER SUBCUTANEOUS PEN-INJECTOR KIT HUMIRA PEN-PSORIASIS STARTER SUBCUTANEOUS PEN-INJECTOR KIT HUMIRA SUBCUTANEOUS PREFILLED SYRINGE KIT 10 MG/0.2ML, 20 MG/0.4ML, 40 MG/0.8ML S S S S S S ibuprofen oral tablet 400 mg, 600 mg, 800 mg LGC indomethacin er indomethacin oral ketoprofen oral ketorolac tromethamine oral leflunomide oral meclofenamate sodium oral mefenamic acid oral meloxicam oral suspension meloxicam oral tablet LGC nabumetone oral naproxen dr oral tablet delayed release 375 mg LGC naproxen dr oral tablet delayed release 500 mg naproxen kit LGC 18 PA; SP Pharmacy; PA; SP Pharmacy; PA; SP Pharmacy; PA; SP Pharmacy; PA; SP Pharmacy; PA; SP Pharmacy;

19 naproxen oral suspension naproxen oral tablet LGC naproxen sodium er naproxen sodium oral tablet oxaprozin piroxicam oral SIMPONI SUBCUTANEOUS SOLUTION AUTO-INJECTOR SIMPONI SUBCUTANEOUS SOLUTION PREFILLED SYRINGE sulindac oral tolmetin sodium S S PA; SP Pharmacy; PA; SP Pharmacy; XELJANZ S PA; SP Pharmacy; XELJANZ XR S PA; SP Pharmacy; *ANALGESICS - NONNARCOTIC* adult aspirin ec low strength adult aspirin low strength ALKA-SELTZER ANACIN ORAL TABLET DELAYED RELEASE aspir-81 aspirin adult low dose aspirin adult low strength aspirin childrens aspirin ec aspirin ec lo-dose aspirin ec low dose aspirin ec low strength aspirin low dose aspirin low strength aspirin oral tablet aspirin oral tablet chewable aspirin oral tablet delayed release 325 mg, 81 mg aspirin rectal suppository 120 mg, 200 mg, 300 mg aspirin suppository 19

20 ASPIR-LOW aspirtab BAYER ADVAND ASPIRIN REG ST BAYER ASPIRIN EC LOW DOSE BAYER ASPIRIN ORAL TABLET BAYER ASPIRIN ORAL TABLET DELAYED RELEASE BAYER ASPIRIN REGIMEN BAYER LOW DOSE buffered aspirin BUFFERIN BUFFERIN LOW DOSE ORAL TABLET butalbital-acetaminophen oral tablet mg butalbital-apap-caffeine butalbital-asa-caffeine butalbital-aspirin-caffeine oral capsule CAPAT cephadyn childrens aspirin childrens aspirin low strength choline & mag trisalicylate choline-mag trisalicylate cvs aspirin adult low dose cvs aspirin adult low strength cvs aspirin child cvs aspirin ec cvs aspirin low dose cvs aspirin low strength oral tablet chewable cvs aspirin oral tablet 325 mg cvs aspirin oral tablet delayed release 81 mg cvs buffered aspirin cvs childrens aspirin cvs effervescent antacid diflunisal oral duraxin 20

21 ec-81 aspirin ECOTRIN ECOTRIN LOW STRENGTH ECPIRIN ED-FLEX effervescent antacid/pain rel effervescent pain relief eq adult aspirin low strength eq antacid & pain relief eq aspirin adult low dose eq aspirin low dose oral tablet chewable eq aspirin low dose oral tablet delayed release eq aspirin oral tablet eq aspirin oral tablet delayed release 325 mg eq buffered aspirin eq childrens aspirin eq effervescent pain relief eql adult aspirin low strength eql antacid/pain relief eql aspirin eql aspirin ec eql aspirin low dose eql buffered aspirin eql childrens aspirin ESGIC ORAL CAPSULE gnp adult aspirin low strength gnp aspirin low dose gnp aspirin oral tablet 325 mg gnp aspirin oral tablet delayed release gnp effervescent antacid/pain goodsense aspirin low dose HALFPRIN hm aspirin hm aspirin ec hm aspirin ec low dose 21

22 kls aspirin ec kls aspirin low dose kp aspirin margesic marten-tab medi-seltzer oral tablet effervescent 325 mg meijer aspirin ec MINIPRIN LOW DOSE mm aspirin neutralin NORWICH ASPIRIN ORAL TABLET 325 MG promacet px aspirin px effervescent px enteric aspirin qc aspirin qc aspirin low dose oral tablet delayed release qc childrens aspirin qc effervescent antacid/pain ra antacid pain relief ra aspirin adult low dose ra aspirin adult low strength ra aspirin childrens ra aspirin ec ra aspirin ec adult low st ra aspirin oral tablet 325 mg ra childrens aspirin ra tri-buffered aspirin repan salsalate oral sb aspirin sb aspirin ec sb childrens aspirin sb effervescent pain relief 22

23 sb low dose asa ec sm aspirin sm aspirin adult low strength sm aspirin ec sm aspirin ec low strength sm aspirin low dose sm aspirin tri-buffered sm childrens aspirin sm effervescent pain relief ST JOSEPH ASPIRIN TENCON ORAL TABLET MG tgt aspirin tgt aspirin ec tgt aspirin low dose oral tablet delayed release tgt childrens aspirin th aspirin th aspirin low dose th enteric aspirin tri-buffered aspirin oral tablet 325 mg ZEBUTAL *ANALGESICS - OPIOID* acetaminophen-codeine #2 PA; acetaminophen-codeine #3 PA; acetaminophen-codeine #4 PA; acetaminophen-codeine oral solution PA; acetaminophen-codeine oral tablet mg, mg acetaminophen-codeine oral tablet mg PA; apap-caff-dihydrocodeine oral capsule PA; ASCOMP-CODEINE PA; aspirin-caff-dihydrocodeine PA; buprenorphine PA; buprenorphine hcl sublingual buprenorphine hcl-naloxone hcl butalbital compound/codeine 23

24 butalbital-apap-caff-cod PA; butalbital-asa-caff-codeine PA; butorphanol tartrate injection butorphanol tartrate nasal PA; BUTRANS PA; codeine sulfate oral tablet PA; CO-GESIC EMBEDA PA; ENDOT ORAL TABLET MG, MG, MG, MG ENDOT ORAL TABLET MG, MG ENDODAN PA; fentanyl PA; fentanyl citrate buccal PA; hydrocodone-acetaminophen oral solution mg/15ml, mg/5ml, mg/10ml, mg/15ml hydrocodone-acetaminophen oral solution mg/15ml hydrocodone-acetaminophen oral tablet mg, mg, mg, mg, mg, mg, mg hydrocodone-acetaminophen oral tablet mg, mg, mg, mg, mg, mg, mg, mg, mg PA; PA; hydrocodone-ibuprofen PA; hydromorphone hcl er PA; hydromorphone hcl oral tablet PA; hydromorphone hcl rectal PA; HYSINGLA ER PA; #; IBUDONE ORAL TABLET MG PA; levorphanol tartrate oral PA; LORT PA; LORT HD PA; LORT PLUS ORAL TABLET MG PA; 24

25 LORTAB ORAL TABLET MG, MG, MG PA; meperidine hcl oral tablet PA; meperitab oral tablet 50 mg METHADONE HCL INTENSOL PA; methadone hcl oral concentrate PA; methadone hcl oral tablet PA; methadone hcl oral tablet soluble PA; METHADOSE ORAL TABLET 10 MG morphine sulfate er beads PA; morphine sulfate er oral capsule extended release 24 hour PA; morphine sulfate er oral tablet extended release PA; morphine sulfate oral tablet PA; morphine sulfate rectal PA; oxycodone hcl er oral tablet er 12 hour abusedeterrent PA; oxycodone hcl oral capsule PA; oxycodone hcl oral concentrate 100 mg/5ml, 20 mg/ml PA; oxycodone hcl oral solution PA; oxycodone hcl oral tablet PA; oxycodone-acetaminophen oral tablet mg, mg, mg, mg oxycodone-acetaminophen oral tablet mg, mg PA; oxycodone-aspirin oral tablet mg PA; oxycodone-ibuprofen PA; OXYCONTIN ORAL TABLET ER 12 HOUR ABUSE-DETERRENT PA; oxymorphone hcl PA; oxymorphone hcl er PA; pentazocine-naloxone hcl PA; REPREXAIN ORAL TABLET MG PA; ROXIT ORAL TABLET MG SUBOXONE SUBLINGUAL FILM #; tramadol hcl er (biphasic) PA; 25

26 tramadol hcl er oral tablet extended release 24 hour PA; tramadol hcl oral PA; tramadol-acetaminophen PA; VERDROT PA; VICODIN ES ORAL TABLET MG PA; VICODIN HP ORAL TABLET MG PA; VICODIN HP ORAL TABLET MG VICODIN ORAL TABLET MG PA; ZAMIT PA; *ANDROGENS-ANABOLIC* ANDROGEL PUMP TRANSDERMAL GEL MG/ACT (1.62%) ANDROGEL TRANSDERMAL GEL MG/1.25GM (1.62%), 40.5 MG/2.5GM (1.62%) danazol oral oxandrolone oral testosterone cypionate intramuscular solution testosterone enanthate intramuscular solution testosterone transdermal gel 10 mg/act (2%), 12.5 mg/act (1%), 25 mg/2.5gm (1%), 50 mg/5gm (1%) *ANORECTAL AGENTS* COLOCORT hemorrhoidal-hc rectal cream hydrocortisone rectal PROCTOCARE-HC PROCTOCREAM HC PROCTO-PAK PROCTOSOL HC PROCTOZONE-HC RECTAL *ANTHELMINTICS* EMVERM *ANTIANGINAL AGENTS* ISOCHRON 26 PA; #; PA; #; PA;

27 isoditrate er isosorbide dinitrate er isosorbide dinitrate oral isosorbide mononitrate isosorbide mononitrate er MINITRAN nitroglycerin sublingual nitroglycerin transdermal patch 24 hour nitroglycerin translingual *ANTIANXIETY AGENTS* alprazolam er ; AL (Min 18 Years) alprazolam oral AL (Min 18 Years) alprazolam xr ; AL (Min 18 Years) buspirone hcl oral tablet 10 mg, 5 mg LGC buspirone hcl oral tablet 15 mg, 30 mg, 7.5 mg chlordiazepoxide hcl AL (Min 5 Years) clorazepate dipotassium AL (Min 8 Years) diazepam injection diazepam oral solution diazepam oral tablet hydroxyzine hcl oral hydroxyzine pamoate oral lorazepam oral tablet meprobamate oxazepam AL (Min 5 Years) *ANTIARRHYTHMICS* amiodarone hcl oral disopyramide phosphate oral dofetilide flecainide acetate mexiletine hcl oral MULTAQ PARONE ORAL TABLET 100 MG, 200 MG, 400 MG propafenone hcl 27

28 propafenone hcl er quinidine gluconate er quinidine sulfate er quinidine sulfate oral *ANTIASTHMATIC AND BRONCHODILATOR AGENTS* ADVAIR HFA #; albuterol sulfate er albuterol sulfate inhalation albuterol sulfate oral ANORO ELLIPTA ASMANEX 120 METERED DOSES #; ASMANEX 14 METERED DOSES #; ASMANEX 30 METERED DOSES #; ASMANEX 60 METERED DOSES #; ASMANEX 7 METERED DOSES #; ASMANEX HFA BREO ELLIPTA budesonide inhalation PA; cromolyn sodium inhalation fluticasone-salmeterol INCRUSE ELLIPTA ipratropium bromide inhalation ipratropium-albuterol levalbuterol hcl inhalation nebulization solution 0.31 mg/3ml, 0.63 mg/3ml, 1.25 mg/0.5ml, 1.25 mg/3ml metaproterenol sulfate oral montelukast sodium oral QVAR INHALATION AEROSOL SOLUTION SEREVENT DISKUS SPIRIVA HANDIHALER SPIRIVA RESPIMAT STIOLTO RESPIMAT SYMBICORT 28

29 terbutaline sulfate oral THEOCHRON ORAL TABLET EXTENDED RELEASE 12 HOUR 100 MG, 200 MG, 300 MG theophylline theophylline er VENTOLIN HFA zafirlukast *ANTICOAGULANTS* ELIQUIS enoxaparin sodium fondaparinux sodium heparin sodium (porcine) injection heparin sodium (porcine) intravenous solution heparin sodium (porcine) pf JANTOVEN LGC warfarin sodium oral LGC XARELTO XARELTO STARTER PACK *ANTICONVULSANTS* carbamazepine er carbamazepine oral clonazepam oral diazepam rectal divalproex sodium er oral tablet extended release 24 hour divalproex sodium oral capsule sprinkle divalproex sodium oral tablet delayed release EPITOL ethosuximide oral felbamate gabapentin oral capsule gabapentin oral solution 250 mg/5ml gabapentin oral tablet 29

30 lamotrigine er oral tablet extended release 24 hour 100 mg, 200 mg, 25 mg, 250 mg, 300 mg, 50 mg lamotrigine oral kit 25 & 50 & 100 mg, 25 (21)- 50 (7) mg, 50 (42)-100(14) mg lamotrigine oral tablet lamotrigine oral tablet chewable lamotrigine oral tablet dispersible 100 mg, 200 mg, 25 mg, 50 mg levetiracetam er oral tablet extended release 24 hour 500 mg, 750 mg levetiracetam intravenous levetiracetam oral LYRICA oxcarbazepine PHENYTOIN INFATABS phenytoin oral phenytoin sodium extended primidone oral tiagabine hcl oral tablet 2 mg, 4 mg TOPIRAGEN topiramate oral capsule sprinkle topiramate oral tablet valproic acid oral zonisamide oral *ANTIDEPRESSANTS* amitriptyline hcl oral tablet 10 mg, 100 mg, 25 mg, 50 mg, 75 mg amitriptyline hcl oral tablet 150 mg amoxapine BUDEPRION SR BUDEPRION XL ORAL TABLET EXTENDED RELEASE 24 HOUR 300 MG bupropion hcl er (sr) bupropion hcl er (xl) bupropion hcl oral citalopram hydrobromide oral solution 30 PA; PA PA; LGC

31 citalopram hydrobromide oral tablet LGC; clomipramine hcl oral desipramine hcl oral doxepin hcl oral duloxetine hcl oral capsule delayed release particles 20 mg, 30 mg, 40 mg, 60 mg escitalopram oxalate oral solution escitalopram oxalate oral tablet fluoxetine hcl oral capsule 10 mg, 20 mg, 40 mg LGC; fluoxetine hcl oral capsule delayed release fluoxetine hcl oral solution fluoxetine hcl oral tablet 10 mg, 20 mg fluvoxamine maleate oral tablet 100 mg, 25 mg, 50 mg imipramine hcl oral imipramine pamoate maprotiline hcl oral tablet 25 mg, 50 mg, 75 mg mirtazapine oral nefazodone hcl nortriptyline hcl oral capsule 10 mg, 25 mg LGC nortriptyline hcl oral capsule 50 mg, 75 mg nortriptyline hcl oral solution paroxetine hcl er paroxetine hcl oral tablet 10 mg, 20 mg, 30 mg, 40 mg phenelzine sulfate oral protriptyline hcl sertraline hcl oral concentrate LGC; sertraline hcl oral tablet 100 mg, 25 mg, 50 mg LGC; tranylcypromine sulfate trazodone hcl oral tablet 100 mg, 150 mg, 50 mg LGC trazodone hcl oral tablet 300 mg trimipramine maleate oral venlafaxine hcl er oral capsule extended release 24 hour 150 mg, 37.5 mg, 75 mg 31

32 venlafaxine hcl er oral tablet extended release 24 hour 150 mg, 225 mg, 37.5 mg, 75 mg venlafaxine hcl oral tablet 100 mg, 25 mg, 37.5 mg, 50 mg, 75 mg *ANTIDIABETICS* acarbose chlorpropamide cvs glucose oral gel cvs glucose shot oral liquid 15 gm/59ml DEX4 GLUCOSE ORAL GEL 15 GM/38GM glimepiride LGC glipizide er oral tablet extended release 24 hour 10 mg, 5 mg glipizide er oral tablet extended release 24 hour 2.5 mg LGC glipizide oral LGC glipizide xl oral tablet extended release 24 hour 10 mg, 5 mg glipizide xl oral tablet extended release 24 hour 2.5 mg glipizide-metformin hcl GLUCO BURST ORAL GEL glucose oral gel 40 % glucose oral liquid 15 gm/59ml glucose oral tablet chewable GLUTOSE 15 GLUTOSE 45 glyburide micronized oral tablet 1.5 mg LGC glyburide micronized oral tablet 3 mg, 6 mg LGC glyburide oral tablet 1.25 mg glyburide oral tablet 2.5 mg, 5 mg LGC glyburide-metformin HUMALOG HUMALOG KWIKPEN SUBCUTANEOUS SOLUTION PEN-INJECTOR 100 UNIT/ML, 200 UNIT/ML HUMALOG MIX 50/50 32

33 HUMALOG MIX 50/50 KWIKPEN SUBCUTANEOUS SUSPENSION PEN- INJECTOR HUMALOG MIX 75/25 HUMALOG MIX 75/25 KWIKPEN SUBCUTANEOUS SUSPENSION PEN- INJECTOR HUMULIN 70/30 HUMULIN 70/30 KWIKPEN SUBCUTANEOUS SUSPENSION PEN- INJECTOR HUMULIN 70/30 PEN SUBCUTANEOUS SUSPENSION PEN-INJECTOR HUMULIN N HUMULIN N KWIKPEN SUBCUTANEOUS SUSPENSION PEN- INJECTOR HUMULIN N PEN SUBCUTANEOUS SUSPENSION PEN-INJECTOR HUMULIN R HUMULIN R U-500 (CONNTRATED) HUMULIN R U-500 KWIKPEN INVOKANA JANUMET JANUMET XR ORAL TABLET EXTENDED RELEASE 24 HOUR MG, MG, MG JANUVIA JARDIAN JENTADUETO JENTADUETO XR ORAL TABLET EXTENDED RELEASE 24 HOUR MG, MG LEVEMIR LEVEMIR FLEXPEN LEVEMIR FLEXTOUCH metformin hcl er oral tablet extended release 24 hour 500 mg LGC 33

34 metformin hcl er oral tablet extended release 24 hour 750 mg metformin hcl oral LGC nateglinide pioglitazone hcl pioglitazone hcl-glimepiride pioglitazone hcl-metformin hcl ra glucose oral gel RELION GLUCOSE DRINK RELION GLUCOSE ORAL GEL repaglinide repaglinide-metformin hcl SYMLINPEN 120 SUBCUTANEOUS SOLUTION PEN-INJECTOR SYMLINPEN 60 SUBCUTANEOUS SOLUTION PEN-INJECTOR tolazamide tolbutamide TRADJENTA TRESIBA FLEXTOUCH PA; TRULICITY PA; value plus glucose oral gel *ANTIDIARRHEALS* diphenatol diphenoxylate-atropine lofene LONOX opium tincture (paregoric) *ANTIDOTES AND SPECIFIC ANTAGONISTS* VISTOGARD S SP Pharmacy; *ANTIDOTES* naltrexone hcl oral NARCAN VISTOGARD S SP Pharmacy; PA 34

35 *ANTIEMETICS* aprepitant oral capsule 125 mg, 40 mg, 80 & 125 mg, 80 mg DICLEGIS PA; dronabinol PA; EMEND ORAL SUSPENSION RECONSTITUTED granisetron hcl oral ondansetron ondansetron hcl oral tablet trimethobenzamide hcl oral *ANTIFUNGALS* fluconazole oral flucytosine oral griseofulvin microsize oral griseofulvin ultramicrosize itraconazole oral ketoconazole oral nystatin oral tablet terbinafine hcl oral voriconazole oral tablet *ANTIHISTAMINES* ARBINOXA ORAL SOLUTION ARBINOXA ORAL TABLET carbinoxamine maleate oral solution carbinoxamine maleate oral tablet cyproheptadine hcl oral desloratadine oral tablet desloratadine oral tablet dispersible 2.5 mg desloratadine oral tablet dispersible 5 mg PHENADOZ PHENERGAN RECTAL promethazine hcl oral promethazine hcl rectal PROMETHEGAN 35

36 *ANTIHYPERLIPIDEMICS* atorvastatin calcium oral cholestyramine light cholestyramine oral colestipol hcl ezetimibe ezetimibe-simvastatin fenofibrate micronized fenofibrate oral fenofibric acid oral tablet fluvastatin sodium fluvastatin sodium er gemfibrozil oral LGC lovastatin LGC; micronized colestipol hcl omega-3-acid ethyl esters pravastatin sodium PREVALITE rosuvastatin calcium simvastatin oral LGC; VASPA ORAL CAPSULE 1 GM *ANTIHYPERTENSIVES* amlodipine besy-benazepril hcl amlodipine besylate-valsartan atenolol-chlorthalidone benazepril hcl oral LGC benazepril-hydrochlorothiazide bisoprolol-hydrochlorothiazide LGC candesartan cilexetil candesartan cilexetil-hctz captopril oral captopril-hydrochlorothiazide clonidine hcl oral LGC clonidine hcl transdermal doxazosin mesylate 36

37 EDARBI EDARBYCLOR enalapril maleate oral LGC enalapril-hydrochlorothiazide LGC eplerenone eprosartan mesylate fosinopril sodium fosinopril sodium-hctz guanfacine hcl oral hydralazine hcl oral tablet 10 mg, 100 mg, 50 mg hydralazine hcl oral tablet 25 mg LGC irbesartan irbesartan-hydrochlorothiazide lisinopril oral tablet 10 mg, 2.5 mg, 20 mg, 5 mg LGC lisinopril oral tablet 30 mg, 40 mg lisinopril-hydrochlorothiazide LGC losartan potassium oral tablet 100 mg LGC losartan potassium oral tablet 25 mg, 50 mg LGC; losartan potassium-hctz LGC methyldopa oral methyldopa-hydrochlorothiazide metoprolol-hydrochlorothiazide minoxidil oral moexipril hcl moexipril-hydrochlorothiazide nadolol-bendroflumethiazide olmesartan medoxomil oral olmesartan medoxomil-hctz perindopril erbumine phenoxybenzamine hcl oral PA prazosin hcl oral propranolol-hctz quinapril hcl quinapril-hydrochlorothiazide ramipril 37

38 reserpine oral telmisartan telmisartan-amlodipine telmisartan-hctz terazosin hcl oral LGC trandolapril trandolapril-verapamil hcl er valsartan valsartan-hydrochlorothiazide *ANTI-INFECTIVE AGENTS - MISC.* atovaquone oral clindamycin hcl oral clindamycin palmitate hcl colistimethate sodium injection SP Pharmacy dapsone oral linezolid oral suspension reconstituted linezolid oral tablet metronidazole oral sulfamethoxazole-trimethoprim oral LGC SULFATRIM PEDIATRIC LGC tinidazole oral trimethoprim oral vancomycin hcl oral XIFAXAN ORAL TABLET 550 MG PA; *ANTIMALARIALS* atovaquone-proguanil hcl chloroquine phosphate oral hydroxychloroquine sulfate oral mefloquine hcl primaquine phosphate oral quinine sulfate oral *ANTIMYASTHENIC AGENTS* guanidine hcl oral pyridostigmine bromide er pyridostigmine bromide oral 38

39 *ANTIMYASTHENIC/CHOLINERGIC AGENTS* guanidine hcl oral pyridostigmine bromide er pyridostigmine bromide oral *ANTIMYCOBACTERIAL AGENTS* cycloserine oral ethambutol hcl oral ISONARIF isoniazid oral pyrazinamide oral rifabutin rifampin oral *ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES* anastrozole oral bexarotene PA; SP Pharmacy bicalutamide CABOMETYX S PA; SP Pharmacy; capecitabine PA; SP Pharmacy CAPRELSA ORAL TABLET 100 MG, 300 MG ENU S PA; SP Pharmacy; COMETRIQ (100 MG DAILY DOSE) S PA; SP Pharmacy; COMETRIQ (140 MG DAILY DOSE) S PA; SP Pharmacy; COMETRIQ (60 MG DAILY DOSE) S PA; SP Pharmacy; cyclophosphamide oral capsule ELIGARD SUBCUTANEOUS KIT 7.5 MG S PA; SP Pharmacy EMCYT ERIVEDGE S PA; SP Pharmacy; etoposide oral exemestane FARESTON flutamide GILOTRIF S PA; SP Pharmacy; GLEOSTINE 39

40 HEXALEN HYCAMTIN ORAL S PA; SP Pharmacy hydroxyurea oral imatinib mesylate oral tablet 100 mg, 400 mg SP Pharmacy; IMBRUVICA S PA; SP Pharmacy; INLYTA S PA; SP Pharmacy; INTRON A S PA; SP Pharmacy JAKAFI ORAL TABLET 10 MG S PA; SP Pharmacy JAKAFI ORAL TABLET 15 MG, 20 MG, 25 MG, 5 MG letrozole oral leucovorin calcium oral LEUKERAN S PA; SP Pharmacy; leuprolide acetate injection PA; SP Pharmacy LUPRON DEPOT (1-MONTH) S PA; #; SP Pharmacy LYSODREN MATULANE megestrol acetate oral suspension 40 mg/ml, 400 mg/10ml, 800 mg/20ml megestrol acetate oral tablet MEKINIST ORAL TABLET 0.5 MG, 2 MG S PA; SP Pharmacy; melphalan mercaptopurine oral methotrexate oral nilutamide POMALYST S PA; SP Pharmacy; SOLTAMOX SPRYL ORAL TABLET 100 MG, 140 MG, 20 MG, 50 MG, 70 MG, 80 MG S PA; SP Pharmacy; STIVARGA S PA; SP Pharmacy; SUTENT ORAL CAPSULE 12.5 MG, 25 MG, 37.5 MG, 50 MG SYLATRON SUBCUTANEOUS KIT 200 MCG, 300 MCG, 4 X 200 MCG, 4 X 300 MCG, 600 MCG SYLATRON SUBCUTANEOUS KIT 4 X 600 MCG 40 S S S PA; SP Pharmacy; PA; SP Pharmacy PA

41 TABLOID TAFINLAR S PA; SP Pharmacy; tamoxifen citrate oral TARVA S PA; SP Pharmacy; TARGRETIN ORAL PA; SP Pharmacy temozolomide PA; SP Pharmacy tretinoin oral SP Pharmacy TREXALL TYKERB S PA; SP Pharmacy vandetanib S PA XALKORI S PA; SP Pharmacy; XTANDI S PA; SP Pharmacy; ZELBORAF S PA; SP Pharmacy; ZYKADIA S PA; SP Pharmacy ZYTIGA ORAL TABLET 250 MG, 500 MG S PA; #; SP Pharmacy; *ANTI-OBESITY AGENT COMBINATIONS** CONTRAVE *ANTIPARKINSON AGENTS* amantadine hcl oral benztropine mesylate oral LGC bromocriptine mesylate oral carbidopa oral carbidopa-levodopa carbidopa-levodopa er oral tablet extended release mg, mg carbidopa-levodopa-entacapone entacapone pramipexole dihydrochloride pramipexole dihydrochloride er rasagiline mesylate oral ropinirole hcl ropinirole hcl er oral tablet extended release 24 hour 12 mg, 2 mg, 4 mg, 6 mg, 8 mg selegiline hcl oral tolcapone 41

42 trihexyphenidyl hcl oral elixir trihexyphenidyl hcl oral tablet 2 mg LGC trihexyphenidyl hcl oral tablet 5 mg *ANTIPSYCHOTICS/ANTIMANIC AGENTS* aripiprazole oral solution aripiprazole oral tablet chlorpromazine hcl oral clozapine oral tablet 100 mg, 200 mg, 25 mg, 50 mg clozapine oral tablet dispersible 100 mg, 12.5 mg, 150 mg, 200 mg, 25 mg COMPAZINE RECTAL COMPRO fluphenazine hcl oral haloperidol oral LATUDA ORAL TABLET 120 MG, 20 MG, 40 MG, 60 MG, 80 MG lithium lithium carbonate er lithium carbonate oral loxapine succinate oral molindone hcl olanzapine oral tablet 10 mg, 15 mg, 2.5 mg, 20 mg, 5 mg, 7.5 mg olanzapine oral tablet dispersible 10 mg olanzapine oral tablet dispersible 15 mg, 20 mg, 5 mg paliperidone er oral tablet extended release 24 hour 1.5 mg, 3 mg, 6 mg, 9 mg perphenazine oral prochlorperazine prochlorperazine maleate oral quetiapine fumarate er oral tablet extended release 24 hour 150 mg, 200 mg, 300 mg, 400 mg, 50 mg 42