Blue Cross of Idaho s Multi-Tier Prescription Drug Formulary for Qualified Health Plans

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1 Blue Cross of Idaho s Multi-Tier Prescription Drug Formulary for Qualified Health Plans This document is a searchable PDF. On your keyboard press Ctrl+F (Command+F for Mac) and a search field will open. Type in the name of the drug you are looking for in the search field, press enter and it will locate the name of the drug in the document. 201 Blue Cross of Idaho is an Independent Licensee of the Blue Cross and Blue Shield Association

2 Things to know about Blue Cross of Idaho s Multi-Tier Prescription Drug Formulary The Blue Cross of Idaho formulary is a list of drugs approved by Blue Cross of Idaho s Pharmacy and Therapeutics Committee for coverage under your pharmacy benefit. The formulary includes brand name as well as generic drugs that have undergone rigorous testing and are approved by the Food and Drug Administration (FDA). Not all drugs approved by the FDA are covered under the Blue Cross of Idaho formulary. The Multi-Tier Formulary In most cases you will be responsible for a portion of the cost of each prescription you have filled, and depending on the drug prescribed, your cost can vary. The Blue Cross of Idaho formulary for qualified health plans has six tiers, with the first tier costing you the least and the sixth tier costing you the most. Asking your doctor to prescribe drugs listed in the first, second or third tier of the formulary can save you money. Tier Description 1 Preferred Generic Drugs are equivalent to brand-name drugs in dosage, safety, strength, method of administration, performance characteristics and intended use and Blue Cross of Idaho has rated as preferred due to their quality and costeffectiveness. 2 Non-Preferred Generic Drugs are equivalent to brand-name drugs in dosage, safety, strength, method of administration, performance characteristics and intended use but come with an excessive cost compared to other alternatives within the same drug class. 3 Preferred Brand-Name Drugs are drugs that Blue Cross of Idaho has rated as preferred due to their quality and costeffectiveness. 4 Non-Preferred Brand-Name Drugs are clinically effective medications, but come with an excessive cost compared to other alternatives within the same drug class. 5 Preferred Specialty Drugs are medications used to treat complex conditions and Blue Cross of Idaho has rated as preferred due to their quality and cost-effectiveness. 6 Non-Preferred Specialty Drugs are medications used to treat complex conditions, but come with an excessive cost compared to other alternatives within the same drug class. ACA Affordable Care Act Drugs are drugs prescribed for covered preventive services that are available at no cost to members of Qualified Health Plans.

3 Reading the Formulary On the following pages, you ll find a list of prescription drugs and columns that list the tier they each belong to and any specific requirements or limitations. Column Name Drug Reference Tier Notes What you will find in each column: Name of covered prescription drugs Brand name of the covered generic drug listed in the Drug column. *Please see information below regarding Mandatory Generic Substitution The tier assignment for the prescription drug listed in the Drug column Requirements and limitations, as well as indicating if drugs are part of the Preventive Drug List for HSA Plans. See Abbreviation Dictionary on the next page for definitions and more information about the abbreviations. Mandatory Generic Substitution Your plan includes a mandatory generic substitution requirement. When a drug has both brand and generic forms available, the generic drug is listed under the Drug column as the covered option with the brand or trademark name listed under the Reference column. When you or your physician choose the brand name drug, in addition to any applicable cost share (deductible/coinsurance/copayments) for the brand name medication, you will pay the cost difference between the contracted cost of the generic drug and brand name drug. These cost difference amounts do not apply to your annual out of pocket maximum. Reference Specialty Drugs, designated by an SP in the Notes column, will apply a Tier 5 and 6 cost hare prior to the cost difference calculation This formulary is subject to change as new products and information become available. Please refer to your contract for more information about the terms and conditions of your prescription drug benefit. If you have questions about any of your medications, please discuss them with your doctor or pharmacist.

4 Abbreviation Dictionary PA - Prior authorization Medications that list PA need prior authorization from Blue Cross of Idaho before we will cover the drug. Your provider must provide documentation showing that the prescription is medically necessary. If prior authorization is not obtained, you may be held responsible for the entire cost of the drug. Please refer to your policy (also called a member contract) for more information about prior authorization. You can find a copy of your policy and detailed information on the prior authorization process online by logging into members.bcidaho.com. PR- Preventive Drugs for HSA Plans Some preventive drugs may be available at no cost to members of High Deductible Health Plans, also known as HSA plans. Preventive medications are prescribed for the prevention of conditions or illnesses when individuals may be at high risk. QL - Quantity Limits Some formulary drugs can only be filled in limited quantities. These prescriptions have been found to be less effective or even dangerous when taken at higher than normal doses. The limits on QL drugs are in line with manufacturer s recommendations regarding safety and effectiveness. SP Specialty Drug Program Specialty medications are generally prescribed for treatment of complex, on-going medical conditions. These medications are generally high cost, and have specific handling requirements. All specialty drugs are limited to a 30 day supply per fill. ST - Step Therapy You may need to use one or more alternative medications before Blue Cross of Idaho can authorize benefits for the use of another medication. Blue Cross of Idaho wants to ensure providers are trying equally or more effective, low-cost options before recommending effective, but higher cost treatments. AL - Age Limitation Some drugs may be only be safe or recommended for certain age groups. Blue Cross of Idaho places age limitations to ensure drugs are not prescribed to individuals who are not of the recommended age.

5 *Adhd/Anti-Narcolepsy/Anti-Obesity/Anorexiants* *Adhd Agent - Selective Alpha Adrenergic Agonists*** guanfacine hcl er oral tablet extended release 24 hour Intuniv 1 *Adhd Agent - Selective Norepinephrine Reuptake Inhibitor*** atomoxetine hcl oral capsule 10 mg, 100 mg, 18 mg, 25 mg, 40 mg, 60 mg, 80 mg *Amphetamine Mixtures*** amphetamine-dextroamphet er oral capsule extended release 24 hour 10 mg, 15 mg, 20 mg, 25 mg, 30 mg, 5 mg amphetamine-dextroamphetamine oral tablet *Amphetamines*** Strattera 2 QL Adderall XR 2 QL Adderall 2 QL DEXEDRINE ORAL TABLET Zenzedi 2 QL dextroamphetamine sulfate er oral capsule extended release 24 hour 10 mg, 15 mg, 5 mg dextroamphetamine sulfate oral solution Dexedrine 2 QL ProCentra 2 dextroamphetamine sulfate oral tablet Zenzedi 2 QL DYANAVEL XR ORAL SUSPENSION EXTENDED RELEASE 4 QL methamphetamine hcl oral tablet Desoxyn 2 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 3 QL 3 QL 1

6 ZENZEDI ORAL TABLET 10 MG, 5 MG ZENZEDI ORAL TABLET 15 MG, 2.5 MG, 20 MG, 30 MG, 7.5 MG *Stimulants - Misc.*** Zenzedi 2 QL 2 QL armodafinil oral tablet Nuvigil 2 PA DAYTRANA TRANSDERMAL PATCH 4 QL dexmethylphenidate hcl er oral capsule extended release 24 hour 10 mg, 15 mg, 20 mg, 25 mg, 30 mg, 35 mg, 40 mg, 5 mg dexmethylphenidate hcl oral tablet 10 mg, 2.5 mg, 5 mg METADATE ER ORAL TABLET EXTENDED RELEASE 20 MG methylphenidate hcl er (cd) oral capsule extended release 10 mg, 20 mg, 30 mg, 40 mg, 50 mg, 60 mg methylphenidate hcl er (la) oral capsule extended release 24 hour 20 mg, 30 mg, 40 mg methylphenidate hcl er (la) oral capsule extended release 24 hour 60 mg methylphenidate hcl er oral tablet extended release 10 mg methylphenidate hcl er oral tablet extended release 18 mg, 27 mg, 36 mg, 54 mg methylphenidate hcl er oral tablet extended release 20 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 10 mg, 20 mg, 5 mg methylphenidate hcl oral tablet chewable Focalin XR 2 QL Focalin 2 QL Metadate ER 2 QL 2 QL Ritalin LA 2 QL 2 QL 2 QL Concerta 2 QL Metadate ER 2 QL 2 QL Methylin 2 QL Ritalin 2 QL 2 QL 2

7 modafinil oral tablet Provigil 2 PA QUILLIVANT XR ORAL SUSPENSION RECONSTITUTED *Amebicides* *Amebicides*** YODOXIN ORAL TABLET 650 MG 3 *Aminoglycosides* *Aminoglycosides*** neomycin sulfate oral tablet 1 TOBI PODHALER INHALATION CAPSULE tobramycin inhalation nebulization solution tobramycin pak inhalation nebulization solution *Analgesics - Anti-Inflammatory* *Antirheumatic - Janus Kinase (Jak) Inhibitors*** 4 QL 6 PA; SP Kitabis Pak 5 PA; SP Kitabis Pak 5 PA; SP XELJANZ ORAL TABLET 6 PA; SP XELJANZ XR ORAL TABLET EXTENDED RELEASE 24 HOUR *Antirheumatic Antimetabolites*** RHEUMATREX ORAL TABLET 2.5 MG *Anti-Tnf-Alpha - Monoclonal Antibodies*** 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 SIMPONI SUBCUTANEOUS SOLUTION AUTO-INJECTOR 6 PA; SP 4 5 PA; SP 5 PA; SP 5 PA; SP 5 PA; SP 5 PA; SP 6 PA; SP 3

8 SIMPONI SUBCUTANEOUS SOLUTION PREFILLED SYRINGE *Anti-Tnf-Alpha - Monoclonoal Antibodies*** 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 SIMPONI SUBCUTANEOUS SOLUTION AUTO-INJECTOR SIMPONI SUBCUTANEOUS SOLUTION PREFILLED SYRINGE *Cyclooxygenase 2 (Cox-2) Inhibitors*** celecoxib oral capsule 100 mg, 200 mg, 400 mg, 50 mg *Gold Compounds*** 6 PA; SP 5 PA; SP 5 PA; SP 5 PA; SP 5 PA; SP 5 PA; SP 6 PA; SP 6 PA; SP CeleBREX 2 QL RIDAURA ORAL CAPSULE 3 *Interleukin-1 Receptor Antagonist (Il-1Ra)*** KINERET SUBCUTANEOUS SOLUTION PREFILLED SYRINGE *Interleukin-1Beta Blockers*** ILARIS (150MG DELIVERED) SUBCUTANEOUS SOLUTION RECONSTITUTED 6 PA; SP 6 PA; SP ILARIS SUBCUTANEOUS SOLUTION 6 PA; SP *Interleukin-6 Receptor Inhibitors*** ACTEMRA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE KEVZARA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 6 PA; SP 6 PA; SP 4

9 *Nonsteroidal Anti-Inflammatory Agent Combinations*** diclofenac-misoprostol oral tablet delayed release Arthrotec 2 *Nonsteroidal Anti-Inflammatory Agents (Nsaids)*** diclofenac potassium oral tablet 2 diclofenac sodium er oral tablet extended release 24 hour diclofenac sodium oral tablet delayed release etodolac er oral tablet extended release 24 hour etodolac oral capsule 2 etodolac oral tablet Lodine 2 fenoprofen calcium oral capsule 400 mg Fenortho 2 fenoprofen calcium oral tablet ProFeno 2 flurbiprofen oral tablet 2 ibuprofen oral suspension Childrens Advil 1 ibuprofen oral tablet 400 mg, 600 mg, 800 mg INDOCIN ORAL SUSPENSION 4 indomethacin er oral capsule extended release indomethacin oral capsule 2 ketoprofen er oral capsule extended release 24 hour ketoprofen oral capsule 2 ketorolac tromethamine oral tablet 2 QL meclofenamate sodium oral capsule 2 mefenamic acid oral capsule Ponstel 2 meloxicam oral suspension 2 meloxicam oral tablet Mobic 2 nabumetone oral tablet 1 naproxen dr oral tablet delayed release EC-Naprosyn 1 naproxen kit oral tablet Naprosyn 1 naproxen oral suspension Naprosyn 1 naproxen oral tablet Naprosyn

10 naproxen sodium oral tablet 275 mg 1 naproxen sodium oral tablet 550 mg Anaprox DS 1 oxaprozin oral tablet Daypro 2 piroxicam oral capsule Feldene 2 sulindac oral tablet 1 tolmetin sodium oral capsule 2 tolmetin sodium oral tablet 2 *Pyrimidine Synthesis Inhibitors*** leflunomide oral tablet Arava 2 QL *Selective Costimulation Modulators*** ORENCIA CLICKJECT SUBCUTANEOUS SOLUTION AUTO- INJECTOR ORENCIA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE *Soluble Tumor Necrosis Factor Receptor Agents*** ENBREL MINI SUBCUTANEOUS SOLUTION CARTRIDGE ENBREL SUBCUTANEOUS SOLUTION PREFILLED SYRINGE ENBREL SUBCUTANEOUS SOLUTION RECONSTITUTED ENBREL SURECLICK SUBCUTANEOUS SOLUTION AUTO- INJECTOR *Analgesics - Nonnarcotic* *Analgesics-Sedatives*** ALAGESIC LQ ORAL SOLUTION 2 butalbital-acetaminophen oral tablet mg Tencon 2 butalbital-apap-caffeine oral capsule Fioricet 2 butalbital-apap-caffeine oral tablet mg Esgic 2 butalbital-asa-caffeine oral capsule Fiorinal 2 butalbital-aspirin-caffeine oral capsule Fiorinal 2 CAPACET ORAL CAPSULE Capacet 2 6 PA; SP 6 PA; SP 5 PA; SP 5 PA; SP 5 PA; SP 5 PA; SP 6

11 ESGIC ORAL CAPSULE Capacet 2 margesic oral capsule Capacet 2 marten-tab oral tablet Tencon 2 TENCON ORAL TABLET MG Tencon 2 ZEBUTAL ORAL CAPSULE MG *Salicylate Combinations*** choline & mag trisalicylate oral tablet 1000 mg Capacet 2 choline-mag trisalicylate oral liquid 1 *Salicylates*** adult aspirin ec low strength oral tablet delayed release Aspir-Low ACA AL; QL aspir-81 oral tablet delayed release Aspir-Low ACA AL; QL aspirin adult low dose oral tablet delayed release aspirin adult low strength oral tablet chewable aspirin adult low strength oral tablet delayed release Aspir-Low ACA AL; QL Bayer Low Dose ACA AL; QL Aspir-Low ACA AL; QL aspirin childrens oral tablet chewable Bayer Low Dose ACA AL; QL aspirin ec low dose oral tablet delayed release aspirin ec low strength oral tablet delayed release Aspir-Low ACA AL; QL Aspir-Low ACA AL; QL aspirin ec oral tablet delayed release Aspir-Low ACA AL; QL aspirin low dose oral tablet chewable Bayer Low Dose ACA AL; QL aspirin low dose oral tablet delayed release aspirin low strength oral tablet chewable aspirin oral tablet 325 mg Aspir-Low ACA AL; QL Bayer Low Dose ACA AL; QL Bayer Advanced Aspirin Reg St 1 ACA AL; QL aspirin oral tablet chewable Bayer Low Dose ACA AL; QL aspirin oral tablet delayed release 325 mg Bayer Aspirin Regimen ACA AL; QL 7

12 aspirin oral tablet delayed release 81 mg ASPIR-LOW ORAL TABLET DELAYED RELEASE Aspir-Low ACA AL; QL Aspir-Low ACA AL; QL aspirtab oral tablet delayed release Bayer Aspirin Regimen ACA AL; QL BAYER ADVANCED ASPIRIN REG ST ORAL TABLET BAYER ASPIRIN EC LOW DOSE ORAL TABLET DELAYED RELEASE BAYER ASPIRIN ORAL TABLET BAYER ASPIRIN REGIMEN ORAL TABLET DELAYED RELEASE BAYER LOW DOSE ORAL TABLET CHEWABLE BAYER LOW DOSE ORAL TABLET DELAYED RELEASE childrens aspirin low strength oral tablet chewable Bayer Advanced Aspirin Reg St ACA AL; QL Aspir-Low ACA AL; QL Bayer Advanced Aspirin Reg St ACA AL; QL Bayer Aspirin Regimen ACA AL; QL Bayer Low Dose ACA AL; QL Aspir-Low ACA AL; QL Bayer Low Dose ACA AL; QL childrens aspirin oral tablet chewable Bayer Low Dose ACA AL; QL cvs aspirin adult low dose oral tablet chewable cvs aspirin adult low strength oral tablet delayed release Bayer Low Dose ACA AL; QL Aspir-Low ACA AL; QL cvs aspirin child oral tablet chewable Bayer Low Dose ACA AL; QL cvs aspirin ec oral tablet delayed release Aspir-Low ACA AL; QL cvs aspirin low dose oral tablet delayed release cvs aspirin oral tablet 325 mg cvs aspirin oral tablet delayed release 81 mg cvs childrens aspirin oral tablet chewable Aspir-Low ACA AL; QL Bayer Advanced Aspirin Reg St ACA AL; QL Aspir-Low ACA AL; QL Bayer Low Dose ACA AL; QL diflunisal oral tablet 1 ec-81 aspirin oral tablet delayed release Aspir-Low ACA AL; QL ECOTRIN LOW STRENGTH ORAL TABLET DELAYED RELEASE Aspir-Low ACA AL; QL 8

13 ECOTRIN ORAL TABLET DELAYED RELEASE ECPIRIN ORAL TABLET DELAYED RELEASE eq adult aspirin low strength oral tablet delayed release eq aspirin adult low dose oral tablet delayed release Bayer Aspirin Regimen ACA AL; QL Bayer Aspirin Regimen ACA AL; QL Aspir-Low ACA AL; QL Aspir-Low ACA AL; QL eq aspirin low dose oral tablet chewable Bayer Low Dose ACA AL; QL eq aspirin low dose oral tablet delayed release eq aspirin oral tablet eq aspirin oral tablet delayed release 325 mg eq childrens aspirin oral tablet chewable eql aspirin ec oral tablet delayed release 325 mg eql aspirin low dose oral tablet chewable eql aspirin low dose oral tablet delayed release gnp adult aspirin low strength oral tablet chewable gnp adult aspirin low strength oral tablet delayed release gnp aspirin low dose oral tablet delayed release gnp aspirin oral tablet 325 mg Aspir-Low ACA AL; QL Bayer Advanced Aspirin Reg St ACA AL; QL Bayer Aspirin Regimen ACA AL; QL Bayer Low Dose ACA AL; QL Bayer Aspirin Regimen ACA AL; QL Bayer Low Dose ACA AL; QL Aspir-Low ACA AL; QL Bayer Low Dose ACA AL; QL Aspir-Low ACA AL; QL Aspir-Low ACA AL; QL Bayer Advanced Aspirin Reg St ACA AL; QL gnp aspirin oral tablet delayed release Aspir-Low ACA AL; QL goodsense aspirin low dose oral tablet delayed release goodsense aspirin oral tablet Aspir-Low ACA AL; QL Bayer Advanced Aspirin Reg St ACA AL; QL goodsense aspirin oral tablet chewable Bayer Low Dose ACA AL; QL hm aspirin ec low dose oral tablet delayed release Aspir-Low ACA AL; QL 9

14 hm aspirin ec oral tablet delayed release Bayer Aspirin Regimen ACA AL; QL hm aspirin oral tablet Bayer Advanced Aspirin Reg St ACA AL; QL hm aspirin oral tablet chewable Bayer Low Dose ACA AL; QL kls aspirin ec oral tablet delayed release Bayer Aspirin Regimen ACA AL; QL kls aspirin low dose oral tablet delayed release Aspir-Low ACA AL; QL kp aspirin oral tablet delayed release Aspir-Low ACA AL; QL meijer aspirin ec oral tablet delayed release MINIPRIN LOW DOSE ORAL TABLET DELAYED RELEASE mm aspirin oral tablet NORWICH ASPIRIN ORAL TABLET 325 MG px aspirin oral tablet Bayer Aspirin Regimen ACA AL; QL Aspir-Low ACA AL; QL Bayer Advanced Aspirin Reg St Bayer Advanced Aspirin Reg St Bayer Advanced Aspirin Reg St ACA ACA ACA AL; QL AL; QL AL; QL px aspirin oral tablet chewable Bayer Low Dose ACA AL; QL px enteric aspirin oral tablet delayed release Aspir-Low ACA AL; QL qc aspirin low dose oral tablet chewable Bayer Low Dose ACA AL; QL qc aspirin low dose oral tablet delayed release qc aspirin oral tablet Aspir-Low ACA AL; QL Bayer Advanced Aspirin Reg St ACA AL; QL qc aspirin oral tablet delayed release Bayer Aspirin Regimen ACA AL; QL qc childrens aspirin oral tablet chewable ra aspirin adult low dose oral tablet chewable ra aspirin adult low strength oral tablet chewable ra aspirin adult low strength oral tablet delayed release ra aspirin childrens oral tablet chewable Bayer Low Dose ACA AL; QL Bayer Low Dose ACA AL; QL Bayer Low Dose ACA AL; QL Aspir-Low ACA AL; QL Bayer Low Dose ACA AL; QL 10

15 ra aspirin ec adult low st oral tablet delayed release Aspir-Low ACA AL; QL ra aspirin ec oral tablet delayed release Aspir-Low ACA AL; QL ra aspirin oral tablet 325 mg ra childrens aspirin oral tablet chewable Bayer Advanced Aspirin Reg St ACA AL; QL Bayer Low Dose ACA AL; QL salsalate oral tablet 1 sb aspirin ec oral tablet delayed release Bayer Aspirin Regimen ACA AL; QL sb aspirin oral tablet Bayer Advanced Aspirin Reg St ACA AL; QL sb aspirin oral tablet delayed release Aspir-Low ACA AL; QL sb childrens aspirin oral tablet chewable sb low dose asa ec oral tablet delayed release sm aspirin adult low strength oral tablet chewable sm aspirin adult low strength oral tablet delayed release sm aspirin ec low strength oral tablet delayed release Bayer Low Dose ACA AL; QL Aspir-Low ACA AL; QL Bayer Low Dose ACA AL; QL Aspir-Low ACA AL; QL Aspir-Low ACA AL; QL sm aspirin ec oral tablet delayed release Bayer Aspirin Regimen ACA AL; QL sm aspirin oral tablet sm childrens aspirin oral tablet chewable ST JOSEPH ASPIRIN ORAL TABLET CHEWABLE ST JOSEPH ASPIRIN ORAL TABLET DELAYED RELEASE ST JOSEPH LOW DOSE ORAL TABLET CHEWABLE Bayer Advanced Aspirin Reg St ACA AL; QL Bayer Low Dose ACA AL; QL Bayer Low Dose ACA AL; QL Aspir-Low ACA AL; QL Bayer Low Dose ACA AL; QL tgt aspirin ec oral tablet delayed release Bayer Aspirin Regimen ACA AL; QL tgt aspirin low dose oral tablet delayed release tgt aspirin oral tablet Aspir-Low ACA AL; QL Bayer Advanced Aspirin Reg St ACA AL; QL 11

16 tgt aspirin oral tablet chewable Bayer Low Dose ACA AL; QL tgt aspirin oral tablet delayed release Aspir-Low ACA AL; QL tgt childrens aspirin oral tablet chewable th aspirin low dose oral tablet delayed release *Analgesics - Opioid* *Codeine Combinations*** Bayer Low Dose ACA AL; QL Aspir-Low ACA AL; QL acetaminophen-codeine #2 oral tablet 1 QL acetaminophen-codeine #3 oral tablet Tylenol with Codeine #3 1 QL acetaminophen-codeine #4 oral tablet Tylenol with Codeine #4 1 QL acetaminophen-codeine oral solution 1 QL acetaminophen-codeine oral tablet mg acetaminophen-codeine oral tablet mg 1 QL Tylenol with Codeine #4 1 QL ASCOMP-CODEINE ORAL CAPSULE Ascomp-Codeine 2 butalbital-apap-caff-cod oral capsule Fioricet/Codeine 2 butalbital-asa-caff-codeine oral capsule Ascomp-Codeine 2 *Hydrocodone Combinations*** hydrocodone-acetaminophen oral solution hydrocodone-acetaminophen oral tablet mg hydrocodone-acetaminophen oral tablet mg hydrocodone-acetaminophen oral tablet mg hydrocodone-acetaminophen oral tablet mg hydrocodone-acetaminophen oral tablet mg hydrocodone-acetaminophen oral tablet mg hydrocodone-acetaminophen oral tablet mg Hycet 2 Vicodin HP 2 QL Lorcet HD 2 QL Verdrocet 2 QL Vicodin 2 QL Lorcet 2 QL Vicodin ES 2 QL Lorcet Plus 2 QL hydrocodone-ibuprofen oral tablet 2 QL 12

17 IBUDONE ORAL TABLET Ibudone 2 QL LORCET HD ORAL TABLET Lorcet HD 2 QL LORCET ORAL TABLET Lorcet 2 QL LORCET PLUS ORAL TABLET MG Lorcet Plus 2 QL LORTAB ORAL TABLET MG Lorcet HD 2 QL LORTAB ORAL TABLET MG Lorcet 2 QL LORTAB ORAL TABLET MG Lorcet Plus 2 QL REPREXAIN ORAL TABLET MG Ibudone 2 QL VERDROCET ORAL TABLET Verdrocet 2 QL VICODIN ES ORAL TABLET MG VICODIN HP ORAL TABLET MG Vicodin ES 2 QL Vicodin HP 2 QL VICODIN ORAL TABLET MG Vicodin 2 QL XYLON ORAL TABLET Ibudone 2 QL ZAMICET ORAL SOLUTION Zamicet 2 *Opioid Agonists*** ABSTRAL SUBLINGUAL TABLET SUBLINGUAL 4 PA codeine sulfate oral tablet 2 QL fentanyl citrate buccal lozenge on a handle fentanyl transdermal patch 72 hour 100 mcg/hr fentanyl transdermal patch 72 hour 12 mcg/hr fentanyl transdermal patch 72 hour 25 mcg/hr fentanyl transdermal patch 72 hour 50 mcg/hr fentanyl transdermal patch 72 hour 75 mcg/hr FENTORA BUCCAL TABLET 100 MCG, 200 MCG, 400 MCG, 600 MCG, 800 MCG Actiq 2 PA Duragesic QL Duragesic-12 2 QL Duragesic-25 2 QL Duragesic-50 2 QL Duragesic-75 2 QL 4 PA 13

18 hydromorphone hcl er oral tablet er 24 hour abuse-deterrent Exalgo 2 PA; QL hydromorphone hcl oral liquid Dilaudid 2 QL hydromorphone hcl oral tablet Dilaudid 2 QL KADIAN ORAL CAPSULE EXTENDED RELEASE 24 HOUR 200 MG, 40 MG 4 QL meperidine hcl oral solution 2 QL meperidine hcl oral tablet Demerol 2 QL METHADONE HCL INTENSOL ORAL CONCENTRATE Methadone HCl Intensol 2 QL methadone hcl oral concentrate Methadone HCl Intensol 2 QL methadone hcl oral solution 10 mg/5ml, 5 mg/5ml 2 QL methadone hcl oral tablet Dolophine 2 QL methadone hcl oral tablet soluble Methadose 2 QL METHADOSE ORAL TABLET SOLUBLE morphine sulfate (concentrate) oral solution 100 mg/5ml morphine sulfate er beads oral capsule extended release 24 hour morphine sulfate er oral capsule extended release 24 hour morphine sulfate er oral tablet extended release 100 mg, 15 mg, 200 mg, 30 mg, 60 mg Methadose 2 QL 2 QL 2 PA; QL Kadian 2 QL MS Contin 2 QL morphine sulfate oral solution 2 QL morphine sulfate oral tablet 2 QL morphine sulfate rectal suppository 10 mg, 20 mg, 5 mg NUCYNTA ER ORAL TABLET EXTENDED RELEASE 12 HOUR 100 MG, 150 MG, 200 MG, 250 MG, 50 MG NUCYNTA ORAL TABLET 100 MG, 50 MG, 75 MG oxycodone hcl er oral tablet er 12 hour abuse-deterrent 2 QL 4 QL 4 QL OxyCONTIN 2 QL 14

19 oxycodone hcl oral capsule 2 QL oxycodone hcl oral concentrate 100 mg/5ml oxycodone hcl oral solution 2 oxycodone hcl oral tablet Roxicodone 2 QL OXYCONTIN ORAL TABLET ER 12 HOUR ABUSE-DETERRENT oxymorphone hcl er oral tablet extended release 12 hour OxyCONTIN 3 QL 2 2 QL oxymorphone hcl oral tablet Opana 2 QL tramadol hcl er oral tablet extended release 24 hour 1 QL tramadol hcl oral tablet Ultram 1 QL *Opioid Combinations*** ENDOCET ORAL TABLET MG, MG, MG, MG Endocet 2 QL ENDODAN ORAL TABLET 2 oxycodone-acetaminophen oral solution 2 oxycodone-acetaminophen oral tablet mg, mg, mg, mg oxycodone-aspirin oral tablet mg Endocet 2 QL oxycodone-ibuprofen oral tablet 2 ROXICET ORAL TABLET MG Endocet 2 QL *Opioid Partial Agonists*** buprenorphine hcl sublingual tablet sublingual buprenorphine hcl-naloxone hcl sublingual tablet sublingual buprenorphine transdermal patch weekly 10 mcg/hr, 15 mcg/hr, 20 mcg/hr, 5 mcg/hr 2 2 QL 2 QL Butrans 2 PA; QL butorphanol tartrate nasal solution 2 QL BUTRANS TRANSDERMAL PATCH WEEKLY Butrans 4 PA; QL pentazocine-naloxone hcl oral tablet 1 15

20 SUBOXONE SUBLINGUAL FILM 12-3 MG, MG, 4-1 MG, 8-2 MG *Tramadol Combinations*** 4 PA; QL tramadol-acetaminophen oral tablet Ultracet 1 QL *Androgens-Anabolic* *Anabolic Steroids*** ANADROL-50 ORAL TABLET 4 PA oxandrolone oral tablet Oxandrin 2 PA *Androgens*** ANDRODERM TRANSDERMAL PATCH 24 HOUR danazol oral capsule 2 methitest oral tablet 4 methyltestosterone oral capsule Android 2 testosterone cypionate intramuscular solution 100 mg/ml, 200 mg/ml testosterone enanthate intramuscular solution testosterone transdermal gel 10 mg/act (2%) testosterone transdermal gel 12.5 mg/act (1%) testosterone transdermal gel 25 mg/2.5gm (1%), 50 mg/5gm (1%) Depo-Testosterone 2 3 PA Fortesta 2 PA Vogelxo Pump 2 PA AndroGel 2 PA testosterone transdermal solution 2 PA *Anorectal Agents* *Intrarectal Steroids*** COLOCORT RECTAL ENEMA Colocort 2 CORTIFOAM RECTAL FOAM 3 hydrocortisone rectal enema Colocort 2 *Nitrate Vasodilating Agents*** RECTIV RECTAL OINTMENT 4 *Rectal Anesthetic/Steroids*** ANALPRAM-HC RECTAL LOTION

21 hydrocortisone ace-pramoxine rectal cream Analpram-HC 2 pramcort rectal cream Analpram-HC 2 PROCORT RECTAL CREAM 3 PROCTOFOAM HC RECTAL FOAM 3 *Rectal Steroids*** anucort-hc rectal suppository Anusol-HC 2 ANUSOL-HC RECTAL SUPPOSITORY Anusol-HC 2 grx hicort 25 rectal suppository Anusol-HC 2 HEMMOREX-HC RECTAL SUPPOSITORY hydrocortisone acetate rectal suppository Anusol-HC 2 Anusol-HC 2 hydrocortisone rectal cream Procto-Pak 2 PROCTO-MED HC RECTAL CREAM Anusol-HC 2 PROCTO-PAK RECTAL CREAM Procto-Pak 2 PROCTOSOL HC RECTAL CREAM Anusol-HC 2 PROCTOZONE-HC RECTAL CREAM Anusol-HC 2 rectacort-hc rectal suppository Anusol-HC 2 *Anthelmintics* *Anthelmintics*** ALBENZA ORAL TABLET 4 BILTRICIDE ORAL TABLET 4 ivermectin oral tablet Stromectol 2 *Antianginal Agents* *Antianginals-Other*** RANEXA ORAL TABLET EXTENDED RELEASE 12 HOUR *Nitrates*** DILATRATE-SR ORAL CAPSULE EXTENDED RELEASE ISORDIL TITRADOSE ORAL TABLET 40 MG isosorbide dinitrate er oral tablet extended release

22 isosorbide dinitrate oral tablet Isordil Titradose 1 isosorbide mononitrate er oral tablet extended release 24 hour isosorbide mononitrate oral tablet 1 MINITRAN TRANSDERMAL PATCH 24 HOUR NITRO-BID TRANSDERMAL OINTMENT NITRO-DUR TRANSDERMAL PATCH 24 HOUR 0.3 MG/HR, 0.8 MG/HR nitroglycerin er oral capsule extended release nitroglycerin sublingual tablet sublingual nitroglycerin transdermal patch 24 hour nitroglycerin translingual aerosol solution Minitran 2 Nitro-Time 2 Nitrostat 2 Minitran 2 NitroMist 2 nitroglycerin translingual solution Nitrolingual 2 NITRO-TIME ORAL CAPSULE EXTENDED RELEASE *Antianxiety Agents* *Antianxiety Agents - Misc.*** Nitro-Time 2 buspirone hcl oral tablet 2 hydroxyzine hcl oral solution 1 hydroxyzine hcl oral syrup 1 hydroxyzine hcl oral tablet 1 hydroxyzine pamoate oral capsule Vistaril 1 meprobamate oral tablet 2 *Benzodiazepines*** ALPRAZOLAM INTENSOL ORAL CONCENTRATE alprazolam oral tablet 0.25 mg, 0.5 mg, 1 mg, 2 mg alprazolam oral tablet dispersible 0.25 mg, 0.5 mg, 1 mg, 2 mg QL Xanax 2 QL 2 QL chlordiazepoxide hcl oral capsule 1 QL 18

23 clorazepate dipotassium oral tablet 2 QL DIAZEPAM INTENSOL ORAL CONCENTRATE Diazepam Intensol 2 QL diazepam oral concentrate Diazepam Intensol 2 QL diazepam oral solution 1 mg/ml 2 QL diazepam oral tablet Valium 2 QL LORAZEPAM INTENSOL ORAL CONCENTRATE LORazepam Intensol 2 QL lorazepam oral concentrate LORazepam Intensol 2 QL lorazepam oral tablet Ativan 2 QL oxazepam oral capsule 2 QL *Antiarrhythmics* *Antiarrhythmics Type I-A*** disopyramide phosphate oral capsule Norpace 2 NORPACE CR ORAL CAPSULE EXTENDED RELEASE 12 HOUR quinidine gluconate er oral tablet extended release quinidine sulfate er oral tablet extended release quinidine sulfate oral tablet 1 *Antiarrhythmics Type I-B*** mexiletine hcl oral capsule 2 *Antiarrhythmics Type I-C*** flecainide acetate oral tablet 2 propafenone hcl er oral capsule extended release 12 hour Rythmol SR 2 propafenone hcl oral tablet 2 *Antiarrhythmics Type Iii*** amiodarone hcl oral tablet Pacerone 2 dofetilide oral capsule Tikosyn 2 MULTAQ ORAL TABLET 4 PACERONE ORAL TABLET 100 MG, 200 MG, 400 MG Pacerone

24 *Antiasthmatic And Bronchodilator Agents* *5-Lipoxygenase Inhibitors*** zileuton er oral tablet extended release 12 hour Zyflo CR 2 ZYFLO ORAL TABLET 4 *Adrenergic Combinations*** ADVAIR DISKUS INHALATION AEROSOL POWDER BREATH ACTIVATED ADVAIR HFA INHALATION AEROSOL ANORO ELLIPTA INHALATION AEROSOL POWDER BREATH ACTIVATED BREO ELLIPTA INHALATION AEROSOL POWDER BREATH ACTIVATED COMBIVENT RESPIMAT INHALATION AEROSOL SOLUTION DULERA INHALATION AEROSOL 4 fluticasone-salmeterol inhalation aerosol powder breath activated ipratropium-albuterol inhalation solution STIOLTO RESPIMAT INHALATION AEROSOL SOLUTION AirDuo RespiClick 55/ PR 3 PR PR 2 PR SYMBICORT INHALATION AEROSOL 3 PR *Anti-Ige Monoclonal Antibodies*** XOLAIR SUBCUTANEOUS SOLUTION RECONSTITUTED *Anti-Inflammatory Agents*** cromolyn sodium inhalation nebulization solution *Beta Adrenergics*** albuterol sulfate er oral tablet extended release 12 hour VoSpire ER PA; SP 2 PR albuterol sulfate inhalation nebulization 2 solution 20

25 albuterol sulfate oral syrup 2 albuterol sulfate oral tablet 2 ARCAPTA NEOHALER INHALATION CAPSULE BROVANA INHALATION NEBULIZATION SOLUTION levalbuterol hcl inhalation nebulization solution 0.31 mg/3ml, 0.63 mg/3ml, 1.25 mg/3ml levalbuterol hcl inhalation nebulization solution 1.25 mg/0.5ml Xopenex 1 PR Xopenex Concentrate 1 PR levalbuterol tartrate inhalation aerosol Xopenex HFA 2 metaproterenol sulfate oral syrup 1 PR metaproterenol sulfate oral tablet 1 PR PERFOROMIST INHALATION NEBULIZATION SOLUTION PROAIR HFA INHALATION AEROSOL SOLUTION PROAIR RESPICLICK INHALATION AEROSOL POWDER BREATH ACTIVATED PROVENTIL HFA INHALATION AEROSOL SOLUTION SEREVENT DISKUS INHALATION AEROSOL POWDER BREATH ACTIVATED PR terbutaline sulfate oral tablet 1 PR VENTOLIN HFA INHALATION AEROSOL SOLUTION *Bronchodilators - Anticholinergics*** ATROVENT HFA INHALATION AEROSOL SOLUTION ipratropium bromide inhalation solution SPIRIVA HANDIHALER INHALATION CAPSULE SPIRIVA RESPIMAT INHALATION AEROSOL SOLUTION PR 3 PR 3 PR 21

26 TUDORZA PRESSAIR INHALATION AEROSOL POWDER BREATH ACTIVATED *Leukotriene Receptor Antagonists*** montelukast sodium oral packet Singulair 1 PR montelukast sodium oral tablet Singulair 1 PR montelukast sodium oral tablet chewable Singulair 1 PR zafirlukast oral tablet Accolate 2 PR *Selective Phosphodiesterase 4 (Pde4) Inhibitors*** DALIRESP ORAL TABLET 4 PA *Steroid Inhalants*** ALVESCO INHALATION AEROSOL SOLUTION ASMANEX 120 METERED DOSES INHALATION AEROSOL POWDER BREATH ACTIVATED ASMANEX 14 METERED DOSES INHALATION AEROSOL POWDER BREATH ACTIVATED ASMANEX 30 METERED DOSES INHALATION AEROSOL POWDER BREATH ACTIVATED 110 MCG/INH, 220 MCG/INH ASMANEX 60 METERED DOSES INHALATION AEROSOL POWDER BREATH ACTIVATED ASMANEX 7 METERED DOSES INHALATION AEROSOL POWDER BREATH ACTIVATED ASMANEX HFA INHALATION AEROSOL budesonide inhalation suspension 0.25 mg/2ml, 0.5 mg/2ml, 1 mg/2ml FLOVENT DISKUS INHALATION AEROSOL POWDER BREATH ACTIVATED FLOVENT HFA INHALATION AEROSOL 4 4 QL 3 PR; QL 3 PR; QL 3 PR; QL 3 PR; QL 3 PR; QL 3 PR; QL Pulmicort 2 PR; QL 3 PR; QL 3 PR; QL 22

27 PULMICORT FLEXHALER INHALATION AEROSOL POWDER BREATH ACTIVATED QVAR INHALATION AEROSOL SOLUTION 40 MCG/ACT, 80 MCG/ACT *Xanthine-Expectorants*** DIFIL-G FORTE ORAL LIQUID 2 *Xanthines*** ELIXOPHYLLIN ORAL ELIXIR 3 LUFYLLIN ORAL TABLET 4 THEO-24 ORAL CAPSULE EXTENDED RELEASE 24 HOUR THEOCHRON ORAL TABLET EXTENDED RELEASE 12 HOUR 100 MG, 200 MG, 300 MG theophylline er oral tablet extended release 12 hour theophylline er oral tablet extended release 24 hour 3 PR; QL 3 PR; QL Theochron 1 PR Theochron 1 PR 3 1 PR theophylline oral solution 1 PR *Anticoagulants* *Coumarin Anticoagulants*** JANTOVEN ORAL TABLET Coumadin 1 PR warfarin sodium oral tablet Coumadin 1 PR *Direct Factor Xa Inhibitors*** ELIQUIS ORAL TABLET 3 QL XARELTO ORAL TABLET 10 MG, 15 MG, 20 MG XARELTO STARTER PACK ORAL TABLET THERAPY PACK *Heparins And Heparinoid-Like Agents*** heparin sodium (porcine) injection solution 1000 unit/ml, unit/ml, unit/ml, 5000 unit/ml heparin sodium (porcine) pf injection solution 3 QL 3 QL

28 *Low Molecular Weight Heparins*** enoxaparin sodium injection solution Lovenox 5 QL enoxaparin sodium subcutaneous solution FRAGMIN SUBCUTANEOUS SOLUTION UNIT/ML, UNIT/0.5ML, UNIT/0.6ML, UNT/0.72ML, 2500 UNIT/0.2ML, 5000 UNIT/0.2ML, 7500 UNIT/0.3ML, UNIT/3.8ML *Synthetic Heparinoid-Like Agents*** fondaparinux sodium subcutaneous solution Lovenox 5 QL 6 QL Arixtra 5 QL *Thrombin Inhibitors - Selective Direct & Reversible*** PRADAXA ORAL CAPSULE 3 QL *Anticonvulsants* *Ampa Glutamate Receptor Antagonists*** FYCOMPA ORAL SUSPENSION 4 PA FYCOMPA ORAL TABLET 4 PA *Anticonvulsants - Benzodiazepines*** clonazepam oral tablet 0.5 mg, 1 mg, 2 mg KlonoPIN 2 QL diazepam rectal gel 10 mg, 20 mg Diastat AcuDial 2 QL diazepam rectal gel 2.5 mg Diastat Pediatric 2 QL ONFI ORAL SUSPENSION 4 PA ONFI ORAL TABLET 10 MG, 20 MG 4 PA *Anticonvulsants - Misc.*** APTIOM ORAL TABLET 4 PA BANZEL ORAL SUSPENSION 4 BANZEL ORAL TABLET 4 BRIVIACT ORAL SOLUTION 4 PA BRIVIACT ORAL TABLET 4 PA carbamazepine er oral capsule extended release 12 hour carbamazepine er oral tablet extended release 12 hour Carbatrol 2 TEGretol-XR 2 24

29 carbamazepine oral suspension TEGretol 2 carbamazepine oral tablet Epitol 2 carbamazepine oral tablet chewable 2 EPITOL ORAL TABLET Epitol 2 gabapentin oral capsule Neurontin 2 gabapentin oral solution Neurontin 2 gabapentin oral tablet Neurontin 2 LAMICTAL XR ORAL KIT 3 lamotrigine er oral tablet extended release 24 hour lamotrigine oral kit 25 & 50 & 100 mg, 25 (21)-50 (7) mg, 50 (42)-100(14) mg LaMICtal XR 2 LaMICtal ODT 2 lamotrigine oral tablet LaMICtal 2 lamotrigine oral tablet chewable LaMICtal 2 lamotrigine oral tablet dispersible LaMICtal ODT 2 lamotrigine starter kit-blue oral kit LaMICtal Starter 2 lamotrigine starter kit-green oral kit LaMICtal Starter 2 lamotrigine starter kit-orange oral kit LaMICtal Starter 2 levetiracetam er oral tablet extended release 24 hour Keppra XR 2 levetiracetam oral solution Keppra 2 levetiracetam oral tablet Keppra 2 LYRICA ORAL CAPSULE 3 LYRICA ORAL SOLUTION 3 oxcarbazepine oral suspension Trileptal 2 oxcarbazepine oral tablet Trileptal 2 POTIGA ORAL TABLET 4 primidone oral tablet Mysoline 2 ROWEEPRA ORAL TABLET 500 MG Keppra 2 TOPIRAGEN ORAL TABLET Topamax 2 topiramate oral capsule sprinkle Topamax Sprinkle 2 topiramate oral tablet Topamax 2 VIMPAT ORAL SOLUTION 4 VIMPAT ORAL TABLET 4 zonisamide oral capsule Zonegran 2 25

30 *Carbamates*** felbamate oral suspension Felbatol 2 felbamate oral tablet Felbatol 2 *Gaba Modulators*** GABITRIL ORAL TABLET 12 MG, 16 MG SABRIL ORAL TABLET 6 PA; SP tiagabine hcl oral tablet Gabitril 2 vigabatrin oral packet Sabril 5 PA; SP *Hydantoins*** DILANTIN ORAL CAPSULE 30 MG 3 PEGANONE ORAL TABLET 4 PHENYTOIN INFATABS ORAL TABLET CHEWABLE Dilantin Infatabs 2 phenytoin oral suspension 125 mg/5ml Dilantin 2 phenytoin oral tablet chewable Dilantin Infatabs 2 phenytoin sodium extended oral capsule Dilantin 2 *Succinimides*** CELONTIN ORAL CAPSULE 4 ethosuximide oral capsule Zarontin 2 ethosuximide oral solution Zarontin 2 *Valproic Acid*** divalproex sodium er oral tablet extended release 24 hour divalproex sodium oral capsule delayed release sprinkle divalproex sodium oral tablet delayed release STAVZOR ORAL CAPSULE DELAYED RELEASE Depakote ER 2 Depakote Sprinkles 2 Depakote 2 valproate sodium oral solution Depakene 2 valproic acid oral capsule Depakene 2 valproic acid oral solution Depakene

31 *Antidepressants* *Alpha-2 Receptor Antagonists (Tetracyclics)*** mirtazapine oral tablet 1 mirtazapine oral tablet dispersible Remeron SolTab 1 *Antidepressants - Misc.*** bupropion hcl er (sr) oral tablet extended release 12 hour bupropion hcl er (xl) oral tablet extended release 24 hour Wellbutrin SR 1 Wellbutrin XL 1 bupropion hcl oral tablet 1 FORFIVO XL ORAL TABLET EXTENDED RELEASE 24 HOUR maprotiline hcl oral tablet 1 *Modified Cyclics*** nefazodone hcl oral tablet 2 OLEPTRO ORAL TABLET EXTENDED RELEASE 24 HOUR trazodone hcl oral tablet 1 TRINTELLIX ORAL TABLET 4 PA VIIBRYD ORAL KIT 4 PA; QL VIIBRYD ORAL TABLET 4 PA; QL VIIBRYD STARTER PACK ORAL KIT 4 PA; QL *Monoamine Oxidase Inhibitors (Maois)*** EMSAM TRANSDERMAL PATCH 24 HOUR phenelzine sulfate oral tablet Nardil 1 tranylcypromine sulfate oral tablet Parnate 1 *Selective Serotonin Reuptake Inhibitors (Ssris)*** citalopram hydrobromide oral solution 1 citalopram hydrobromide oral tablet CeleXA 1 escitalopram oxalate oral solution 1 escitalopram oxalate oral tablet Lexapro 1 fluoxetine hcl oral capsule PROzac 1 fluoxetine hcl oral capsule delayed release

32 fluoxetine hcl oral solution 1 fluoxetine hcl oral tablet 10 mg, 20 mg 1 fluoxetine hcl oral tablet 60 mg 2 fluvoxamine maleate er oral capsule extended release 24 hour fluvoxamine maleate oral tablet 1 paroxetine hcl er oral tablet extended release 24 hour Paxil CR 1 paroxetine hcl oral tablet Paxil 1 PAXIL ORAL SUSPENSION 4 sertraline hcl oral concentrate Zoloft 1 sertraline hcl oral tablet Zoloft 1 *Serotonin-Norepinephrine Reuptake Inhibitors (Snris)*** desvenlafaxine succinate er oral tablet extended release 24 hour duloxetine hcl oral capsule delayed release particles IRENKA ORAL CAPSULE DELAYED RELEASE PARTICLES venlafaxine hcl er oral capsule extended release 24 hour venlafaxine hcl er oral tablet extended release 24 hour Pristiq 2 ST Cymbalta 1 Effexor XR 1 venlafaxine hcl oral tablet 1 *Tricyclic Agents*** amitriptyline hcl oral tablet 10 mg, 100 mg, 150 mg, 50 mg, 75 mg QL amitriptyline hcl oral tablet 25 mg Elavil 1 QL amoxapine oral tablet 100 mg, 150 mg, 25 mg, 50 mg clomipramine hcl oral capsule 25 mg, 50 mg, 75 mg desipramine hcl oral tablet 10 mg, 25 mg desipramine hcl oral tablet 100 mg, 150 mg, 50 mg, 75 mg 1 QL Anafranil 1 QL Norpramin 1 QL 1 QL 28

33 doxepin hcl oral capsule 10 mg, 100 mg, 150 mg, 25 mg, 50 mg, 75 mg 1 QL doxepin hcl oral concentrate 1 QL imipramine hcl oral tablet Tofranil 1 QL imipramine pamoate oral capsule 1 QL nortriptyline hcl oral capsule 10 mg, 25 mg, 50 mg, 75 mg Pamelor 1 QL nortriptyline hcl oral solution 1 QL protriptyline hcl oral tablet 1 QL *Antidiabetics* *Alpha-Glucosidase Inhibitors*** acarbose oral tablet Precose 1 PR miglitol oral tablet Glyset 2 *Antidiabetic - Amylin Analogs*** SYMLINPEN 120 SUBCUTANEOUS SOLUTION PEN-INJECTOR SYMLINPEN 60 SUBCUTANEOUS SOLUTION PEN-INJECTOR *Biguanides*** metformin hcl er oral tablet extended release 24 hour 4 PR 4 PR Glucophage XR 1 PR metformin hcl oral tablet Glucophage 1 PR RIOMET ORAL SOLUTION 4 *Diabetic Other*** GLUCAGEN HYPOKIT INJECTION SOLUTION RECONSTITUTED GLUCAGON EMERGENCY INJECTION KIT PROGLYCEM ORAL SUSPENSION 3 *Dipeptidyl Peptidase-4 (Dpp-4) Inhibitors*** JANUVIA ORAL TABLET 3 TRADJENTA ORAL TABLET 3 *Dipeptidyl Peptidase-4 Inhibitor-Biguanide Combinations*** JANUMET ORAL TABLET

34 JANUMET XR ORAL TABLET EXTENDED RELEASE 24 HOUR JENTADUETO ORAL TABLET 3 JENTADUETO XR ORAL TABLET EXTENDED RELEASE 24 HOUR *Dopamine Receptor Agonists - Ergot Derivatives*** CYCLOSET ORAL TABLET 4 *Human Insulin*** HUMULIN R U-500 (CONCENTRATED) SUBCUTANEOUS SOLUTION HUMULIN R U-500 KWIKPEN SUBCUTANEOUS SOLUTION PEN- INJECTOR LANTUS SOLOSTAR SUBCUTANEOUS SOLUTION PEN- INJECTOR LANTUS SUBCUTANEOUS SOLUTION LEVEMIR FLEXTOUCH SUBCUTANEOUS SOLUTION PEN- INJECTOR LEVEMIR SUBCUTANEOUS SOLUTION NOVOLIN 70/30 SUBCUTANEOUS SUSPENSION NOVOLIN N SUBCUTANEOUS SUSPENSION PR 3 PR 3 PR 3 PR 3 PR 3 PR 3 PR 3 PR NOVOLIN R INJECTION SOLUTION 3 PR NOVOLOG FLEXPEN SUBCUTANEOUS SOLUTION PEN- INJECTOR NOVOLOG MIX 70/30 FLEXPEN SUBCUTANEOUS SUSPENSION PEN- INJECTOR NOVOLOG MIX 70/30 SUBCUTANEOUS SUSPENSION 3 PR 3 PR 3 PR 30

35 NOVOLOG PENFILL SUBCUTANEOUS SOLUTION CARTRIDGE NOVOLOG SUBCUTANEOUS SOLUTION TOUJEO SOLOSTAR SUBCUTANEOUS SOLUTION PEN- INJECTOR TRESIBA FLEXTOUCH SUBCUTANEOUS SOLUTION PEN- INJECTOR *Incretin Mimetic Agents (Glp-1 Receptor Agonists)*** BYDUREON SUBCUTANEOUS PEN- INJECTOR BYDUREON SUBCUTANEOUS SUSPENSION RECONSTITUTED ER BYETTA 10 MCG PEN SUBCUTANEOUS SOLUTION PEN- INJECTOR BYETTA 5 MCG PEN SUBCUTANEOUS SOLUTION PEN- INJECTOR TRULICITY SUBCUTANEOUS SOLUTION PEN-INJECTOR VICTOZA SUBCUTANEOUS SOLUTION PEN-INJECTOR *Meglitinide Analogues*** 3 PR 3 PR 3 PR 3 PR 4 PA; ST 4 PA; ST 4 PA; ST; QL 4 PA; ST; QL 3 PA; ST; PR; QL 3 PA; ST; PR nateglinide oral tablet Starlix 1 PR repaglinide oral tablet 1 PR *Sodium-Glucose Co-Transporter 2 (Sglt2) Inhibitors*** FARXIGA ORAL TABLET 3 PA JARDIANCE ORAL TABLET 3 PA *Sulfonylurea-Biguanide Combinations*** glipizide-metformin hcl oral tablet 1 PR glyburide-metformin oral tablet 1 PR *Sulfonylureas*** chlorpropamide oral tablet 1 PR 31

36 glimepiride oral tablet Amaryl 1 PR glipizide er oral tablet extended release 24 hour Glucotrol XL 1 PR glipizide oral tablet Glucotrol 1 PR glipizide xl oral tablet extended release 24 hour Glucotrol XL 1 PR glyburide micronized oral tablet Glynase 1 PR glyburide oral tablet 1 PR tolazamide oral tablet 1 PR tolbutamide oral tablet 1 *Sulfonylurea-Thiazolidinedione Combinations*** pioglitazone hcl-glimepiride oral tablet Duetact 1 PR *Thiazolidinedione-Biguanide Combinations*** pioglitazone hcl-metformin hcl oral tablet *Thiazolidinediones*** Actoplus Met 1 PR AVANDIA ORAL TABLET 4 pioglitazone hcl oral tablet Actos 1 PR *Antidiarrheals* *Antidiarrheal - Chloride Channel Antagonists*** FULYZAQ ORAL TABLET DELAYED RELEASE *Antiperistaltic Agents*** diphenoxylate-atropine oral liquid 1 diphenoxylate-atropine oral tablet Lomotil 1 LOPERAMIDE A-D ORAL TABLET 1 loperamide hcl oral capsule Imodium A-D 1 MOTOFEN ORAL TABLET 4 opium oral tincture 2 *Antidotes And Specific Antagonists* *Antidotes And Specific Antagonists*** 6 PA VISTOGARD ORAL PACKET 5 SP 32

37 *Antidotes* *Antidotes - Chelating Agents*** CHEMET ORAL CAPSULE 4 PA EXJADE ORAL TABLET SOLUBLE 6 PA; SP FERRIPROX ORAL SOLUTION 6 PA; SP FERRIPROX ORAL TABLET 6 PA; SP JADENU ORAL TABLET 6 PA; SP JADENU SPRINKLE ORAL PACKET 6 PA; SP *Antidotes*** VISTOGARD ORAL PACKET 5 SP *Opioid Antagonists*** naloxone hcl injection solution 0.4 mg/ml naloxone hcl injection solution cartridge naloxone hcl injection solution prefilled syringe naltrexone hcl oral tablet 2 2 QL 2 QL 2 QL NARCAN NASAL LIQUID 3 QL VIVITROL INTRAMUSCULAR SUSPENSION RECONSTITUTED *Antiemetics* *5-Ht3 Receptor Antagonists*** ANZEMET ORAL TABLET 4 6 PA; SP granisetron hcl oral tablet 2 QL ondansetron hcl oral solution Zofran 2 ondansetron hcl oral tablet Zofran 2 QL ondansetron oral tablet dispersible Zofran ODT 2 QL SANCUSO TRANSDERMAL PATCH 4 QL ZUPLENZ ORAL FILM 4 PA; QL *Antiemetics - Anticholinergic*** meclizine hcl oral tablet 1 meclizine hcl oral tablet chewable 1 trimethobenzamide hcl oral capsule Tigan 1 33

38 *Antiemetics - Miscellaneous*** CESAMET ORAL CAPSULE 4 dronabinol oral capsule Marinol 2 QL SYNDROS ORAL SOLUTION 4 QL *Substance P/Neurokinin 1 (Nk1) Receptor Antagonists*** aprepitant oral capsule 125 mg, 40 mg, 80 mg Emend 2 QL aprepitant oral capsule 80 & 125 mg Emend Tri-Pack 2 QL EMEND ORAL SUSPENSION RECONSTITUTED 3 QL VARUBI ORAL TABLET 4 PA; ST; QL *Antifungals* *Antifungals*** bio-statin oral capsule 3 bio-statin oral powder 2 flucytosine oral capsule Ancobon 2 griseofulvin microsize oral suspension 2 griseofulvin microsize oral tablet 2 griseofulvin ultramicrosize oral tablet Gris-PEG 2 LAMISIL ORAL PACKET 4 nystatin oral powder 2 nystatin oral tablet 2 terbinafine hcl oral tablet LamISIL 2 *Imidazoles*** ketoconazole oral tablet 2 *Triazoles*** CRESEMBA ORAL CAPSULE 4 PA fluconazole oral suspension reconstituted Diflucan 2 fluconazole oral tablet Diflucan 2 itraconazole oral capsule Sporanox 2 NOXAFIL ORAL SUSPENSION 4 PA NOXAFIL ORAL TABLET DELAYED RELEASE SPORANOX ORAL SOLUTION PA

39 voriconazole oral suspension reconstituted Vfend 2 PA voriconazole oral tablet Vfend 2 PA *Antihistamines* *Antihistamines - Alkylamines*** brompheniramine tannate oral tablet chewable *Antihistamines - Ethanolamines*** ARBINOXA ORAL SOLUTION 1 ARBINOXA ORAL TABLET 1 carbinoxamine maleate oral solution 1 carbinoxamine maleate oral tablet 1 clemastine fumarate oral syrup 2 clemastine fumarate oral tablet *Antihistamines - Non-Sedating*** Dayhist Allergy 12 Hour Relief CLARINEX ORAL SYRUP 3 desloratadine oral tablet Clarinex 2 desloratadine oral tablet dispersible 2 levocetirizine dihydrochloride oral solution levocetirizine dihydrochloride oral tablet *Antihistamines - Phenothiazines*** Xyzal 2 Xyzal 2 PHENADOZ RECTAL SUPPOSITORY Phenadoz 2 PHENERGAN RECTAL SUPPOSITORY Phenadoz 2 promethazine hcl oral solution 2 promethazine hcl oral syrup 2 promethazine hcl oral tablet 2 promethazine hcl rectal suppository Phenadoz 2 PROMETHEGAN RECTAL SUPPOSITORY *Antihistamines - Piperidines*** Phenadoz 2 cyproheptadine hcl oral syrup

40 cyproheptadine hcl oral tablet 1 *Antihyperlipidemics* *Antihyperlipidemics - Misc.*** omega-3-acid ethyl esters oral capsule Lovaza 2 *Bile Acid Sequestrants*** cholestyramine light oral packet Prevalite 1 PR cholestyramine light oral powder Prevalite 1 PR cholestyramine oral packet Questran 1 PR cholestyramine oral powder Questran 1 PR colestipol hcl oral granules Colestid 2 PR colestipol hcl oral packet Colestid 2 PR colestipol hcl oral tablet Colestid 2 PR PREVALITE ORAL PACKET Prevalite 1 PR PREVALITE ORAL POWDER Prevalite 1 PR WELCHOL ORAL PACKET 4 WELCHOL ORAL TABLET 4 *Fibric Acid Derivatives*** fenofibrate micronized oral capsule 2 PR fenofibrate oral capsule Lipofen 2 PR fenofibrate oral tablet Fenoglide 2 PR fenofibric acid oral capsule delayed release Trilipix 2 PR fenofibric acid oral tablet Fibricor 2 PR gemfibrozil oral tablet Lopid 1 PR *Hmg Coa Reductase Inhibitors*** atorvastatin calcium oral tablet Lipitor 1 PR fluvastatin sodium oral capsule Lescol 1 PR lovastatin oral tablet 1 PR pravastatin sodium oral tablet 1 PR rosuvastatin calcium oral tablet Crestor 2 PR simvastatin oral tablet Zocor 1 PR *Intestinal Cholesterol Absorption Inhibitors*** ezetimibe oral tablet Zetia 2 36

41 *Nicotinic Acid Derivatives*** niacin er (antihyperlipidemic) oral tablet extended release *Antihypertensives* Niaspan 2 PR *Ace Inhibitor & Calcium Channel Blocker Combinations*** amlodipine besy-benazepril hcl oral capsule trandolapril-verapamil hcl er oral tablet extended release *Ace Inhibitors & Thiazide/Thiazide-Like*** benazepril-hydrochlorothiazide oral tablet captopril-hydrochlorothiazide oral tablet enalapril-hydrochlorothiazide oral tablet 1 PR Tarka 1 PR 1 PR 1 PR 1 PR fosinopril sodium-hctz oral tablet 1 PR lisinopril-hydrochlorothiazide oral tablet moexipril-hydrochlorothiazide oral tablet quinapril-hydrochlorothiazide oral tablet *Ace Inhibitors*** Zestoretic 1 PR 1 PR Accuretic 1 PR benazepril hcl oral tablet 1 PR captopril oral tablet 1 PR enalapril maleate oral tablet Vasotec 1 PR fosinopril sodium oral tablet 1 PR lisinopril oral tablet Zestril 1 PR moexipril hcl oral tablet 1 PR perindopril erbumine oral tablet 1 PR quinapril hcl oral tablet Accupril 1 PR ramipril oral capsule Altace 1 PR trandolapril oral tablet 1 PR *Adrenolytics-Central & Thiazide/Thiazide-Like Comb*** CLORPRES ORAL TABLET 2 PR 37

42 methyldopa-hydrochlorothiazide oral tablet *Agents For Pheochromocytoma*** 2 PR phenoxybenzamine hcl oral capsule Dibenzyline 2 PA *Angiotensin Ii Receptor Antag & Ca Channel Blocker Comb*** amlodipine besylate-valsartan oral tablet Exforge 1 PR amlodipine-olmesartan oral tablet Azor 2 telmisartan-amlodipine oral tablet Twynsta 1 PR *Angiotensin Ii Receptor Antag & Thiazide/Thiazide-Like*** candesartan cilexetil-hctz oral tablet Atacand HCT 1 PR EDARBYCLOR ORAL TABLET 4 irbesartan-hydrochlorothiazide oral tablet Avalide 1 PR losartan potassium-hctz oral tablet Hyzaar 1 PR olmesartan medoxomil-hctz oral tablet Benicar HCT 2 PR telmisartan-hctz oral tablet Micardis HCT 1 PR valsartan-hydrochlorothiazide oral tablet *Angiotensin Ii Receptor Antagonists*** Diovan HCT 1 PR candesartan cilexetil oral tablet Atacand 1 PR EDARBI ORAL TABLET 4 eprosartan mesylate oral tablet 1 PR irbesartan oral tablet Avapro 1 PR losartan potassium oral tablet Cozaar 1 PR olmesartan medoxomil oral tablet Benicar 2 PR telmisartan oral tablet Micardis 1 PR valsartan oral tablet Diovan 1 PR *Angiotensin Ii Receptor Ant-Ca Channel Blocker-Thiazides*** amlodipine-valsartan-hctz oral tablet Exforge HCT 1 PR olmesartan-amlodipine-hctz oral tablet Tribenzor 2 *Antiadrenergics - Centrally Acting*** clonidine hcl oral tablet Catapres 2 PR clonidine hcl transdermal patch weekly Catapres-TTS-1 2 PR guanfacine hcl oral tablet 1 PR 38

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