Aetna Better Health Virginia. Table of Contents

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1 Aetna Better Health Virginia Table of Contents *ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS*...4 *ALTERNATIVE MEDICINES*...6 *AMINOGLYCOSIDES*... 6 *ANALGESICS - ANTI-INFLAMMATORY*...7 *ANALGESICS - NONNARCOTIC*...9 *ANALGESICS - OPIOID* *ANDROGENS-ANABOLIC*...21 *ANORECTAL AGENTS* *ANTACIDS* *ANTHELMINTICS* *ANTIANGINAL AGENTS* *ANTIANXIETY AGENTS* *ANTIARRHYTHMICS* *ANTIASTHMATIC AND BRONCHODILATOR AGENTS*...24 *ANTICOAGULANTS* *ANTICONVULSANTS* *ANTIDEPRESSANTS* *ANTIDIABETICS* *ANTIDIARRHEALS* *ANTIDOTES* *ANTIEMETICS* *ANTIFUNGALS* *ANTIHISTAMINES* *ANTIHYPERLIPIDEMICS* *ANTIHYPERTENSIVES* *ANTI-INFECTIVE AGENTS - MISC.*...41 *ANTIMALARIALS* *ANTIMYASTHENIC AGENTS*...42 *ANTIMYASTHENIC/CHOLINERGIC AGENTS*...42 *ANTIMYCOBACTERIAL AGENTS*...42 *ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES*...43 *ANTI-OBESITY AGENT COMBINATIONS**

2 *ANTIPARKINSON AGENTS*...45 *ANTIPSYCHOTICS/ANTIMANIC AGENTS*...46 *ANTIRETROVIRALS ADJUVANTS***...49 *ANTISEPTICS & DISINFECTANTS*...49 *ANTIVIRALS* *ASSORTED CLASSES* *BETA BLOCKERS* *CALCIUM CHANNEL BLOCKERS*...56 *CARDIOTONICS* *CARDIOVASCULAR AGENTS - MISC.*...58 *CEPHALOSPORINS* *CHEMICALS* *CONTRACEPTIVES* *CORTICOSTEROIDS* *COUGH/COLD/ALLERGY*...66 *DERMATOLOGICALS* *DIAGNOSTIC PRODUCTS*...76 *DIGESTIVE AIDS* *DIURETICS* *ENDOCRINE AND METABOLIC AGENTS - MISC.*...78 *ESTROGENS* *FLUOROQUINOLONES* *GASTROINTESTINAL AGENTS - MISC.*...81 *GENITOURINARY AGENTS - MISCELLANEOUS*...82 *GOUT AGENTS* *HEMATOLOGICAL AGENTS - MISC.*...83 *HEMATOPOIETIC AGENTS*...83 *HEPATITIS C AGENT - COMBINATIONS***...85 *HYPNOTICS* *LAXATIVES* *MACROLIDES* *MEDICAL DEVICES* *MIGRAINE PRODUCTS* *MINERALS & ELECTROLYTES*...91 *MOUTH/THROAT/DENTAL AGENTS*...93 *MULTIVITAMINS* *MUSCULOSKELETAL THERAPY AGENTS*...97 *NASAL AGENTS - SYSTEMIC AND TOPICAL*

3 *NEPRILYSIN INHIB (ARNI)-ANGIOTENSIN II RECEPT ANTAG COMB***...98 *NEUROMUSCULAR AGENTS*...98 *OPHTHALMIC AGENTS* *OTIC AGENTS* *PASSIVE IMMUNIZING AGENTS* *PENICILLINS* *PHARMACEUTICAL ADJUVANTS* *POTASSIUM REMOVING AGENTS*** *PROGESTINS* *PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.* *RESPIRATORY AGENTS - MISC.* *SEROTONIN MODULATORS*** *SINUS NODE INHIBITORS** *SODIUM-GLUCOSE CO-TRANSPORTER 2 INHIBITOR-BIGUANIDE COMB*** *SULFONAMIDES* *TETRACYCLINES* *THYROID AGENTS* *ULCER DRUGS* *URINARY ANTI-INFECTIVES* *URINARY ANTISPASMODICS* *VAGINAL PRODUCTS* *VASOPRESSORS* *VITAMINS*

4 Aetna Better Health Virginia CURRENT AS OF 2/1/2018 Formulary Drug Name Reference Restrictions *ADHD/ANTI- NARCOLEPSY/ANTI- OBESITY/ANOREXIANTS* *Adhd Agent - Selective Alpha Adrenergic Agonists*** guanfacine hcl er oral tablet extended release 24 hour 1 mg, 2 mg, 3 mg, 4 mg *Amphetamine Mixtures*** amphetamine-dextroamphet er oral capsule extended release 24 hour 10 mg, 15 mg, 20 mg, 25 mg, 5 mg amphetamine-dextroamphet er oral capsule extended release 24 hour 30 mg amphetamine-dextroamphetamine oral tablet 10 mg, 12.5 mg, 15 mg, 20 mg, 5 mg, 7.5 mg amphetamine-dextroamphetamine oral tablet 30 mg *Amphetamines*** dextroamphetamine sulfate er oral capsule extended release 24 hour 10 mg, 15 mg dextroamphetamine sulfate er oral capsule extended release 24 hour 5 mg dextroamphetamine sulfate oral solution 5 mg/5ml dextroamphetamine sulfate oral tablet 10 mg, 5 mg *Analeptics*** caffeine citrate oral solution 20 mg/ml, 60 mg/3ml CAFFEINE ANHYDROUS POWDER CAFFEINE CITRATED POWDER *Anorexiant Combinations*** QSYMIA ORAL CAPSULE EXTENDED RELEASE 24 HOUR MG, MG, MG, MG *Anorexiants Non-Amphetamine*** Intuniv Adderall XR Adderall XR Adderall Adderall Dexedrine Dexedrine ProCentra Zenzedi ; AL (Min 6 Years) PA; PA PA; QLL (90 EA per 30 days) PA; QLL (60 EA per 30 days) PA; QLL (120 EA per 30 days) PA; QLL (90 EA per 30 days) PA; QLL (1800 ML per 30 days) PA; QLL (180 EA per 30 days) PA; ; AL (Min 18 Years) 4

5 benzphetamine hcl oral tablet 25 mg benzphetamine hcl oral tablet 50 mg diethylpropion hcl er oral tablet extended release 24 hour 75 mg diethylpropion hcl oral tablet 25 mg phendimetrazine tartrate er oral capsule extended release 24 hour 105 mg phendimetrazine tartrate oral tablet 35 mg phentermine hcl oral capsule 15 mg phentermine hcl oral capsule 30 mg phentermine hcl oral capsule 37.5 mg phentermine hcl oral tablet 37.5 mg DIDREX ORAL TABLET 50 MG REGIMEX ORAL TABLET 25 MG *Lipase Inhibitors*** ALLI ORAL CAPSULE 60 MG *Serotonin 2C Receptor Agonists*** BELVIQ ORAL TABLET 10 MG Regimex Didrex Adipex-P Adipex-P Didrex Regimex *Stimulants - Misc.*** dexmethylphenidate hcl er oral capsule extended release 24 hour 10 mg, 15 mg, 20 Focalin XR mg, 25 mg, 30 mg, 35 mg, 40 mg, 5 mg dexmethylphenidate hcl oral tablet 10 mg, 2.5 Focalin mg, 5 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 Ritalin LA extended release 24 hour 20 mg, 40 mg PA; QLL (90 EA per 30 days); AL (Min 12 Years) PA; QLL (90 EA per 30 days); AL (Min 12 Years) PA; ; AL (Min 17 Years) PA; QLL (90 EA per 30 days); AL (Min 17 Years) PA; ; AL (Min 17 Years) PA; QLL (90 EA per 30 days); AL (Min 17 Years) PA; QLL (60 EA per 30 days); AL (Min 16 Years) PA; ; AL (Min 16 Years) PA; ; AL (Min 16 Years) PA; ; AL (Min 16 Years) PA; QLL (90 EA per 30 days); AL (Min 12 Years) PA; QLL (90 EA per 30 days); AL (Min 12 Years) PA; OTC; QLL (180 EA per 30 days); AL (Min 12 Years) PA; QLL (60 EA per 30 days); AL (Min 18 Years) PA; PA; QLL (60 EA per 30 days) PA; PA; 5

6 methylphenidate hcl er (la) oral capsule extended release 24 hour 30 mg Ritalin LA PA; QLL (60 EA per 30 days) methylphenidate hcl er (la) oral capsule extended release 24 hour 60 mg PA; methylphenidate hcl er oral tablet extended release 10 mg PA; QLL (90 EA per 30 days) methylphenidate hcl er oral tablet extended release 18 mg, 27 mg, 54 mg Concerta PA; methylphenidate hcl er oral tablet extended release 20 mg Metadate ER PA; QLL (90 EA per 30 days) methylphenidate hcl er oral tablet extended release 24 hour 18 mg, 27 mg, 54 mg PA; methylphenidate hcl er oral tablet extended release 24 hour 36 mg PA; QLL (60 EA per 30 days) methylphenidate hcl er oral tablet extended release 36 mg Concerta PA; QLL (60 EA per 30 days) methylphenidate hcl oral solution 10 mg/5ml Methylin PA; QLL (900 ml per 30 days) methylphenidate hcl oral solution 5 mg/5ml Methylin PA; QLL (900 ML per 30 days) methylphenidate hcl oral tablet 10 mg, 20 mg, Ritalin 5 mg PA; QLL (90 EA per 30 days) methylphenidate hcl oral tablet chewable 10 mg PA; QLL (180 EA per 30 days) methylphenidate hcl oral tablet chewable 2.5 mg, 5 mg PA; QLL (150 EA per 30 days) ARMODAFINIL ORAL TABLET 150 MG, Nuvigil 200 MG, 250 MG PA; ARMODAFINIL ORAL TABLET 50 MG Nuvigil PA; QLL (60 EA per 30 days) *ALTERNATIVE MEDICINES* *Alternative Medicine - St's*** STEVIA ORAL PACKET 100 MG OTC *AMINOGLYCOSIDES* *Aminoglycosides*** neomycin sulfate oral tablet 500 mg paromomycin sulfate oral capsule 250 mg tobramycin inhalation nebulization solution 300 mg/5ml KITABIS PAK INHALATION NEBULIZATION SOLUTION 300 MG/5ML Kitabis Pak Kitabis Pak PA; QLL (280 ml Max Qty Per Fill Retail) PA; QLL (280 ML Max Qty Per Fill Retail) 6

7 *ANALGESICS - ANTI- INFLAMMATORY* *Anti-Tnf-Alpha - Monoclonal Antibodies*** HUMIRA PEDIATRIC CROHNS START SUBCUTANEOUS PREFILLED SYRINGE KIT 40 MG/0.8ML HUMIRA PEN SUBCUTANEOUS PEN- INJECTOR KIT 40 MG/0.8ML HUMIRA PEN-CROHNS STARTER SUBCUTANEOUS PEN-INJECTOR KIT 40 MG/0.8ML HUMIRA PEN-PSORIASIS STARTER SUBCUTANEOUS PEN-INJECTOR KIT 40 MG/0.8ML HUMIRA SUBCUTANEOUS PREFILLED SYRINGE KIT 20 MG/0.4ML HUMIRA SUBCUTANEOUS PREFILLED SYRINGE KIT 40 MG/0.8ML *Anti-Tnf-Alpha - Monoclonoal Antibodies*** HUMIRA PEDIATRIC CROHNS START SUBCUTANEOUS PREFILLED SYRINGE KIT 40 MG/0.8ML HUMIRA PEN SUBCUTANEOUS PEN- INJECTOR KIT 40 MG/0.8ML HUMIRA PEN-CROHNS STARTER SUBCUTANEOUS PEN-INJECTOR KIT 40 MG/0.8ML HUMIRA PEN-PSORIASIS STARTER SUBCUTANEOUS PEN-INJECTOR KIT 40 MG/0.8ML HUMIRA SUBCUTANEOUS PREFILLED SYRINGE KIT 20 MG/0.4ML HUMIRA SUBCUTANEOUS PREFILLED SYRINGE KIT 40 MG/0.8ML *Cyclooxygenase 2 (Cox-2) Inhibitors*** celecoxib oral capsule 100 mg, 200 mg, 400 mg, 50 mg *Gold Compounds*** CeleBREX PA; QLL (1 Kit per 28 days) PA; QLL (1 Kit per 28 days) PA; QLL (1 Kit per 28 days) PA; QLL (1 Kit per 28 days) PA; QLL (2 Syringes per 28 days) PA; QLL (1 Kit per 28 days) PA; QLL (1 Kit per 28 days) PA; QLL (1 Kit per 28 days) PA; QLL (1 Kit per 28 days) PA; QLL (1 Kit per 28 days) PA; QLL (2 Syringes per 28 days) PA; QLL (1 Kit per 28 days) ST; 7

8 RIDAURA ORAL CAPSULE 3 MG *Nonsteroidal Anti-Inflammatory Agents (Nsaids)*** diclofenac potassium oral tablet 50 mg diclofenac sodium er oral tablet extended release 24 hour 100 mg diclofenac sodium oral tablet delayed release 25 mg, 50 mg, 75 mg etodolac er oral tablet extended release 24 hour 400 mg, 500 mg, 600 mg etodolac oral capsule 200 mg, 300 mg etodolac oral tablet 400 mg Lodine etodolac oral tablet 500 mg fenoprofen calcium oral tablet 600 mg ProFeno flurbiprofen oral tablet 100 mg, 50 mg ibuprofen oral tablet 400 mg, 600 mg, 800 mg indomethacin er oral capsule extended release 75 mg indomethacin oral capsule 25 mg, 50 mg ketoprofen oral capsule 50 mg, 75 mg ketorolac tromethamine oral tablet 10 mg Max Limit (Max 2 fills/90 days.); QLL (20 Tablets per 30 days); AL (Min 16 Years) meclofenamate sodium oral capsule 100 mg, 50 mg meloxicam oral tablet 15 mg, 7.5 mg Mobic nabumetone oral tablet 500 mg, 750 mg QLL (120 EA per 30 days) naproxen dr oral tablet delayed release 375 mg, 500 mg EC-Naprosyn naproxen oral suspension 125 mg/5ml Naprosyn naproxen oral tablet 250 mg, 500 mg Naprosyn naproxen oral tablet 375 mg naproxen sodium oral tablet 275 mg oxaprozin oral tablet 600 mg Daypro QLL (90 EA per 30 days) piroxicam oral capsule 10 mg, 20 mg Feldene sulindac oral tablet 150 mg, 200 mg tolmetin sodium oral capsule 400 mg QLL (90 EA per 30 days) tolmetin sodium oral tablet 200 mg, 600 mg QLL (90 EA per 30 days) 8

9 *Pyrimidine Synthesis Inhibitors*** leflunomide oral tablet 10 mg, 20 mg Arava *Selective Costimulation Modulators*** ORENCIA INTRAVENOUS SOLUTION RECONSTITUTED 250 MG *Soluble Tumor Necrosis Factor Receptor Agents*** ENBREL MINI SUBCUTANEOUS SOLUTION CARTRIDGE 50 MG/ML ENBREL SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 25 MG/0.5ML, 50 MG/ML ENBREL SURECLICK SUBCUTANEOUS SOLUTION AUTO-INJECTOR 50 MG/ML *ANALGESICS - NONNARCOTIC* *Analgesics-Sedatives*** butalbital-acetaminophen oral tablet mg butalbital-apap-caffeine oral capsule mg butalbital-apap-caffeine oral capsule mg butalbital-apap-caffeine oral tablet mg butalbital-aspirin-caffeine oral capsule mg Tencon Fioricet Capacet Esgic Fiorinal PA; QLL (4 Vials per 30 days) PA; QLL (3.92 ML per 28 days) PA; QLL (204 Mgs per 28 days) PA; QLL (204 Mgs per 28 days) QLL (180 EA per 30 days) QLL (180 EA per 30 days) QLL (180 EA per 30 days) Max Limit (Max 240 tabs or caps/year.); QLL (180 EA per 30 days) Max Limit (Max 240 tabs or caps/year.); QLL (180 EA per 30 days) capacet oral capsule mg Capacet QLL (180 EA per 30 days) esgic oral capsule mg Capacet QLL (180 EA per 30 days) tencon oral tablet mg Tencon zebutal oral capsule mg Capacet QLL (180 EA per 30 days) *Salicylate Combinations*** choline-mag trisalicylate oral liquid 500 mg/5ml *Salicylates*** diflunisal oral tablet 500 mg 9

10 salsalate oral tablet 500 mg, 750 mg *ANALGESICS - OPIOID* *Codeine Combinations*** acetaminophen-codeine #2 oral tablet mg acetaminophen-codeine #3 oral tablet mg acetaminophen-codeine #4 oral tablet mg acetaminophen-codeine oral solution mg/5ml acetaminophen-codeine oral tablet mg Tylenol with Codeine #3 Tylenol with Codeine #4 acetaminophen-codeine oral tablet mg Tylenol with Codeine #4 Prior authorization is required if the days supply exceeds 7 days, or a max of 14 days in the past 60. Drug may also be subject to 120 cumulative morphine equivalents per day.; QLL (300 EA per 30 days) Prior authorization is required if the days supply exceeds 7 days, or a max of 14 days in the past 60. Drug may also be subject to 120 cumulative morphine equivalents per day.; QLL (300 EA per 30 days) Prior authorization is required if the days supply exceeds 7 days, or a max of 14 days in the past 60. Drug may also be subject to 120 cumulative morphine equivalents per day.; QLL (300 EA per 30 days) Prior authorization is required if the days supply exceeds 7 days, or a max of 14 days in the past 60. Drug may also be subject to 120 cumulative morphine equivalents per day.; QLL (4500 ML per 30 days) Prior authorization is required if the days supply exceeds 7 days, or a max of 14 days in the past 60. Drug may also be subject to 120 cumulative morphine equivalents per day.; QLL (300 EA per 30 days) Prior authorization is required if the days supply exceeds 7 days, or a max of 14 days in the past 60. Drug may also be subject to 120 cumulative morphine equivalents per day.; QLL (300 EA per 30 days) 10

11 ascomp-codeine oral capsule mg butalbital-apap-caff-cod oral capsule mg butalbital-apap-caff-cod oral capsule mg butalbital-asa-caff-codeine oral capsule mg *Hydrocodone Combinations*** hydrocodone-acetaminophen oral solution mg/5ml, mg/10ml, mg/15ml hydrocodone-acetaminophen oral tablet mg Ascomp-Codeine Fioricet/Codeine Ascomp-Codeine Hycet Lorcet HD Prior authorization is required if the days supply exceeds 14 days, or a max of 28 days in the past 60. Drug may also be subject to 120 cumulative morphine equivalents per day.; QLL (180 EA per 30 days) Prior authorization is required if the days supply exceeds 7 days, or a max of 14 days in the past 60. Drug may also be subject to 120 cumulative morphine equivalents per day.; QLL (180 EA per 30 days) Prior authorization is required if the days supply exceeds 7 days, or a max of 14 days in the past 60. Drug may also be subject to 120 cumulative morphine equivalents per day.; QLL (180 EA per 30 days) Prior authorization is required if the days supply exceeds 14 days, or a max of 28 days in the past 60. Drug may also be subject to 120 cumulative morphine equivalents per day.; QLL (180 EA per 30 days) Prior authorization is required if the days supply exceeds 7 days, or a max of 14 days in the past 60. Drug may also be subject to 120 cumulative morphine equivalents per day.; QLL (5400 ML per 30 days) Prior authorization is required if the days supply exceeds 7 days, or a max of 14 days in the past 60. Drug may also be subject to 120 cumulative morphine equivalents per day.; QLL (270 EA per 30 days) 11

12 hydrocodone-acetaminophen oral tablet mg hydrocodone-acetaminophen oral tablet mg hydrocodone-acetaminophen oral tablet mg hydrocodone-ibuprofen oral tablet mg lorcet hd oral tablet mg lorcet oral tablet mg Verdrocet Lorcet Lorcet Plus Lorcet HD Lorcet Prior authorization is required if the days supply exceeds 7 days, or a max of 14 days in the past 60. Drug may also be subject to 120 cumulative morphine equivalents per day.; QLL (360 EA per 30 days) Prior authorization is required if the days supply exceeds 7 days, or a max of 14 days in the past 60. Drug may also be subject to 120 cumulative morphine equivalents per day.; QLL (360 EA per 30 days) Prior authorization is required if the days supply exceeds 7 days, or a max of 14 days in the past 60. Drug may also be subject to 120 cumulative morphine equivalents per day.; QLL (360 EA per 30 days) Prior authorization is required if the days supply exceeds 7 days, or a max of 14 days in the past 60. Drug may also be subject to 120 cumulative morphine equivalents per day.; QLL (150 EA per 30 days) Prior authorization is required if the days supply exceeds 14 days, or a max of 28 days in the past 60. Drug may also be subject to 120 cumulative morphine equivalents per day.; QLL (270 EA per 30 days) Prior authorization is required if the days supply exceeds 7 days, or a max of 14 days in the past 60. Drug may also be subject to 120 cumulative morphine equivalents per day.; QLL (360 EA per 30 days) 12

13 lorcet plus oral tablet mg *Opioid Agonists*** codeine sulfate oral tablet 15 mg codeine sulfate oral tablet 30 mg codeine sulfate oral tablet 60 mg fentanyl transdermal patch 72 hour 100 mcg/hr Lorcet Plus Duragesic-100 fentanyl transdermal patch 72 hour 12 mcg/hr Duragesic-12 fentanyl transdermal patch 72 hour 25 mcg/hr Duragesic-25 fentanyl transdermal patch 72 hour 50 mcg/hr Duragesic-50 Prior authorization is required if the days supply exceeds 7 days, or a max of 14 days in the past 60. Drug may also be subject to 120 cumulative morphine equivalents per day.; QLL (360 EA per 30 days) Prior authorization is required if the days supply exceeds 7 days, or a max of 14 days in the past 60. Drug may also be subject to 120 cumulative morphine equivalents per day.; QLL (720 EA per 30 days) Prior authorization is required if the days supply exceeds 7 days, or a max of 14 days in the past 60. Drug may also be subject to 120 cumulative morphine equivalents per day.; QLL (360 EA per 30 days) Prior authorization is required if the days supply exceeds 7 days, or a max of 14 days in the past 60. Drug may also be subject to 120 cumulative morphine equivalents per day.; QLL (180 EA per 30 days) PA; Drug may be subject to 120 cumulative morphine equivalents per day.; QLL (10 EA per 30 days) PA; Drug may be subject to 120 cumulative morphine equivalents per day.; QLL (10 EA per 30 days) PA; Drug may be subject to 120 cumulative morphine equivalents per day.; QLL (10 EA per 30 days) PA; Drug may be subject to 120 cumulative morphine equivalents per day.; QLL (10 EA per 30 days) 13

14 PA; Drug may be subject to 120 fentanyl transdermal patch 72 hour 75 mcg/hr Duragesic-75 cumulative morphine equivalents per day.; QLL (10 EA per 30 days) hydromorphone hcl oral tablet 2 mg Dilaudid Prior authorization is required if the days supply exceeds 7 days, or a max of 14 days in the past 60. Drug may also be subject to 120 cumulative morphine equivalents per day.; QLL (330 EA per 30 days) hydromorphone hcl oral tablet 4 mg Dilaudid Prior authorization is required if the days supply exceeds 7 days, or a max of 14 days in the past 60. Drug may also be subject to 120 cumulative morphine equivalents per day.; QLL (150 EA per 30 days) hydromorphone hcl oral tablet 8 mg Dilaudid Prior authorization is required if the days supply exceeds 7 days, or a max of 14 days in the past 60. Drug may also be subject to 120 cumulative morphine equivalents per day.; QLL (60 EA per 30 days) methadone hcl intensol oral concentrate 10 mg/ml Methadone HCl Intensol PA; QLL (90 ML per 30 days) methadone hcl oral concentrate 10 mg/ml Methadone HCl Intensol PA; QLL (90 ML per 30 days) methadone hcl oral solution 10 mg/5ml PA; Drug may be subject to 120 cumulative morphine equivalents per day.; QLL (450 ML per 30 days); AL (Max 1 Years) methadone hcl oral solution 5 mg/5ml PA; Drug may be subject to 120 cumulative morphine equivalents per day.; QLL (900 ML per 30 days); AL (Max 1 Years) methadone hcl oral tablet 10 mg Dolophine PA; Drug may be subject to 120 cumulative morphine equivalents per day.; QLL (90 EA per 30 days) 14

15 methadone hcl oral tablet 5 mg Dolophine PA; Drug may be subject to 120 cumulative morphine equivalents per day.; QLL (180 EA per 30 days) methadone hcl oral tablet soluble 40 mg Methadose PA; QLL (22 EA per 30 days) morphine sulfate (concentrate) oral solution 100 mg/5ml morphine sulfate er oral capsule extended release 24 hour 10 mg, 20 mg morphine sulfate er oral capsule extended release 24 hour 100 mg, 50 mg, 60 mg, 80 mg morphine sulfate er oral capsule extended release 24 hour 30 mg morphine sulfate er oral tablet extended release 100 mg, 200 mg morphine sulfate er oral tablet extended release 15 mg, 30 mg, 60 mg morphine sulfate oral solution 10 mg/5ml Kadian Kadian Kadian MS Contin MS Contin Prior authorization is required if the days supply exceeds 7 days, or a max of 14 days in the past 60. Drug may also be subject to 120 cumulative morphine equivalents per day.; QLL (120 ML per 30 days) PA; Drug may be subject to 120 cumulative morphine equivalents per day.; QLL (60 EA per 30 days) PA; Drug may be subject to 120 cumulative morphine equivalents per day.; QLL (30 EA per 30 days) PA; Drug may be subject to 120 cumulative morphine equivalents per day.; QLL (90 EA per 30 days) PA; Drug may be subject to 120 cumulative morphine equivalents per day.; QLL (60 EA per 30 days) PA; Drug may be subject to 120 cumulative morphine equivalents per day.; QLL (90 EA per 30 days) Prior authorization is required if the days supply exceeds 7 days, or a max of 14 days in the past 60. Drug may also be subject to 120 cumulative morphine equivalents per day.; QLL (900 ML per 30 days) 15

16 morphine sulfate oral solution 20 mg/5ml morphine sulfate oral tablet 15 mg morphine sulfate oral tablet 30 mg morphine sulfate rectal suppository 10 mg, 20 mg, 5 mg oxycodone hcl oral capsule 5 mg oxycodone hcl oral concentrate 100 mg/5ml Prior authorization is required if the days supply exceeds 7 days, or a max of 14 days in the past 60. Drug may also be subject to 120 cumulative morphine equivalents per day.; QLL (660 ML per 30 days) Prior authorization is required if the days supply exceeds 7 days, or a max of 14 days in the past 60. Drug may also be subject to 120 cumulative morphine equivalents per day.; QLL (180 EA per 30 days) Prior authorization is required if the days supply exceeds 7 days, or a max of 14 days in the past 60. Drug may also be subject to 120 cumulative morphine equivalents per day.; QLL (90 EA per 30 days) Prior authorization is required if the days supply exceeds 7 days, or a max of 14 days in the past 60. Drug may also be subject to 120 cumulative morphine equivalents per day. Prior authorization is required if the days supply exceeds 7 days, or a max of 14 days in the past 60. Drug may also be subject to 120 cumulative morphine equivalents per day.; QLL (180 EA per 30 days) Prior authorization is required if the days supply exceeds 7 days, or a max of 14 days in the past 60. Drug may also be subject to 120 cumulative morphine equivalents per day.; QLL (90 ML per 30 days) 16

17 oxycodone hcl oral solution 5 mg/5ml oxycodone hcl oral tablet 10 mg oxycodone hcl oral tablet 15 mg oxycodone hcl oral tablet 20 mg oxycodone hcl oral tablet 30 mg oxycodone hcl oral tablet 5 mg oxymorphone hcl er oral tablet extended release 12 hour 10 mg, 15 mg, 20 mg, 30 mg, 40 mg, 5 mg, 7.5 mg Roxicodone Roxicodone Roxicodone Prior authorization is required if the days supply exceeds 7 days, or a max of 14 days in the past 60. Drug may also be subject to 120 cumulative morphine equivalents per day.; QLL (900 ML per 30 days) Prior authorization is required if the days supply exceeds 7 days, or a max of 14 days in the past 60. Drug may also be subject to 120 cumulative morphine equivalents per day.; QLL (180 EA per 30 days) Prior authorization is required if the days supply exceeds 7 days, or a max of 14 days in the past 60. Drug may also be subject to 120 cumulative morphine equivalents per day.; QLL (120 EA per 30 days) Prior authorization is required if the days supply exceeds 7 days, or a max of 14 days in the past 60. Drug may also be subject to 120 cumulative morphine equivalents per day.; QLL (90 EA per 30 days) Prior authorization is required if the days supply exceeds 7 days, or a max of 14 days in the past 60. Drug may also be subject to 120 cumulative morphine equivalents per day.; QLL (60 EA per 30 days) Prior authorization is required if the days supply exceeds 7 days, or a max of 14 days in the past 60. Drug may also be subject to 120 cumulative morphine equivalents per day.; QLL (180 EA per 30 days) PA; Drug may be subject to 120 cumulative morphine equivalents per day.; QLL (60 EA per 30 days) 17

18 oxymorphone hcl oral tablet 10 mg oxymorphone hcl oral tablet 5 mg tramadol hcl oral tablet 50 mg HYDROMORPHONE HCL RECTAL SUPPOSITORY 3 MG MORPHINE SULFATE RECTAL SUPPOSITORY 30 MG *Opioid Combinations*** endocet oral tablet mg Opana Opana Ultram Endocet Prior authorization is required if the days supply exceeds 7 days, or a max of 14 days in the past 60. Drug may also be subject to 120 cumulative morphine equivalents per day.; QLL (90 EA per 30 days) Prior authorization is required if the days supply exceeds 7 days, or a max of 14 days in the past 60. Drug may also be subject to 120 cumulative morphine equivalents per day.; QLL (180 EA per 30 days) Prior authorization is required if the days supply exceeds 7 days, or a max of 14 days in the past 60. Drug may also be subject to 120 cumulative morphine equivalents per day.; QLL (240 EA per 30 days); AL (Min 16 Years) Prior authorization is required if the days supply exceeds 7 days, or a max of 14 days in the past 60. Drug may also be subject to 120 cumulative morphine equivalents per day.; QLL (120 EA per 30 days) Prior authorization is required if the days supply exceeds 7 days, or a max of 14 days in the past 60. Drug may also be subject to 120 cumulative morphine equivalents per day. Prior authorization is required if the days supply exceeds 7 days, or a max of 14 days in the past 60. Drug may also be subject to 120 cumulative morphine equivalents per day.; QLL (180 EA per 30 days) 18

19 endocet oral tablet mg, mg endocet oral tablet mg oxycodone-acetaminophen oral tablet mg oxycodone-acetaminophen oral tablet mg, mg oxycodone-acetaminophen oral tablet mg oxycodone-aspirin oral tablet mg *Opioid Partial Agonists*** Endocet Endocet Endocet Endocet Endocet Prior authorization is required if the days supply exceeds 7 days, or a max of 14 days in the past 60. Drug may also be subject to 120 cumulative morphine equivalents per day.; QLL (360 EA per 30 days) Prior authorization is required if the days supply exceeds 7 days, or a max of 14 days in the past 60. Drug may also be subject to 120 cumulative morphine equivalents per day.; QLL (240 EA per 30 days) Prior authorization is required if the days supply exceeds 7 days, or a max of 14 days in the past 60. Drug may also be subject to 120 cumulative morphine equivalents per day.; QLL (180 EA per 30 days) Prior authorization is required if the days supply exceeds 7 days, or a max of 14 days in the past 60. Drug may also be subject to 120 cumulative morphine equivalents per day.; QLL (360 EA per 30 days) Prior authorization is required if the days supply exceeds 7 days, or a max of 14 days in the past 60. Drug may also be subject to 120 cumulative morphine equivalents per day.; QLL (240 EA per 30 days) Prior authorization is required if the days supply exceeds 7 days, or a max of 14 days in the past 60. Drug may also be subject to 120 cumulative morphine equivalents per day.; QLL (360 EA per 30 days) 19

20 buprenorphine hcl sublingual tablet sublingual 2 mg buprenorphine hcl sublingual tablet sublingual 8 mg buprenorphine hcl-naloxone hcl sublingual tablet sublingual mg buprenorphine hcl-naloxone hcl sublingual tablet sublingual 8-2 mg buprenorphine transdermal patch weekly 10 mcg/hr, 5 mcg/hr buprenorphine transdermal patch weekly 15 mcg/hr, 20 mcg/hr butorphanol tartrate nasal solution 10 mg/ml pentazocine-naloxone hcl oral tablet mg BUTRANS TRANSDERMAL PATCH WEEKLY 7.5 MCG/HR *Tramadol Combinations*** Butrans Butrans Buprenorphine PA; Three 7 day induction periods are permitted without prior authorization in 365 days, the induction periods must be at least 90 days apart.; QLL (90 EA per 30 days) PA; Three 7 day induction periods are permitted without prior authorization in 365 days, the induction periods must be at least 90 days apart.; QLL (60 EA per 30 days) PA; Three 7 day induction periods are permitted without prior authorization in 365 days, the induction periods must be at least 90 days apart.; QLL (90 EA per 30 days) PA; Three 7 day induction periods are permitted without prior authorization in 365 days, the induction periods must be at least 90 days apart.; QLL (60 EA per 30 days) PA; QLL (8 EA per 28 days) PA; QLL (4 EA per 28 days) QLL (1 Bottle per 30 days) Prior authorization is required if the days supply exceeds 7 days, or a max of 14 days in the past 60. Drug may also be subject to 120 cumulative morphine equivalents per day.; QLL (120 EA per 30 days) PA; Drug may be subject to 120 cumulative morphine equivalents per day.; QLL (8 EA per 28 days) 20

21 tramadol-acetaminophen oral tablet mg *ANDROGENS-ANABOLIC* *Androgens*** danazol oral capsule 100 mg, 200 mg, 50 mg methyltestosterone oral capsule 10 mg testosterone cypionate intramuscular solution 100 mg/ml, 200 mg/ml testosterone enanthate intramuscular solution 200 mg/ml testosterone transdermal gel 10 mg/act (2%) Ultracet Android Depo-Testosterone Fortesta testosterone transdermal gel 12.5 mg/act (1%) Vogelxo Pump testosterone transdermal gel 25 mg/2.5gm AndroGel (1%) testosterone transdermal gel 50 mg/5gm (1%) AndroGel *ANORECTAL AGENTS* *Intrarectal Steroids*** colocort rectal enema 100 mg/60ml Colocort hydrocortisone rectal enema 100 mg/60ml Colocort CORTIFOAM RECTAL FOAM 10 % *Nitrate Vasodilating Agents*** RECTIV RECTAL OINTMENT 0.4 % *Rectal Anesthetic/Steroids*** lidocaine-hydrocortisone ace rectal cream % lidocaine-hydrocortisone ace rectal kit %, 3-1 % PROCTOFOAM HC RECTAL FOAM 1-1 % *Rectal Steroids*** hemmorex-hc rectal suppository 30 mg Hemmorex-HC Prior authorization is required if the days supply exceeds 7 days, or a max of 14 days in the past 60. Drug may also be subject to 120 cumulative morphine equivalents per day.; QLL (240 EA per 30 days); AL (Min 16 Years) PA PA PA; QLL (2 canisters per 30 days) PA; QLL (300 GM per 30 days) PA; QLL (30 pak per 30 days) PA; QLL (300 GM per 30 days) PA 21

22 hydrocortisone acetate rectal suppository 30 mg Hemmorex-HC procto-pak rectal cream 1 % Hydrocortisone proctosol hc rectal cream 2.5 % Hydrocortisone proctozone-hc rectal cream 2.5 % Hydrocortisone *ANTACIDS* *Antacids - Bicarbonate*** SODIUM BICARBONATE ORAL POWDER *ANTHELMINTICS* *Anthelmintics*** ivermectin oral tablet 3 mg Stromectol ALBENZA ORAL TABLET 200 MG ST BILTRICIDE ORAL TABLET 600 MG PA REESES PINWORM MEDICINE ORAL TABLET 180 MG OTC *ANTIANGINAL AGENTS* *Nitrates*** isosorbide dinitrate er oral tablet extended release 40 mg isosorbide dinitrate oral tablet 10 mg, 20 mg, 30 mg isosorbide dinitrate oral tablet 5 mg Isordil Titradose isosorbide mononitrate er oral tablet extended release 24 hour 120 mg QLL (60 EA per 30 days) isosorbide mononitrate er oral tablet extended release 24 hour 30 mg, 60 mg isosorbide mononitrate oral tablet 10 mg, 20 mg minitran transdermal patch 24 hour 0.1 mg/hr, 0.2 mg/hr, 0.4 mg/hr, 0.6 mg/hr Minitran nitroglycerin er oral capsule extended release Nitro-Time 2.5 mg, 6.5 mg, 9 mg nitroglycerin sublingual tablet sublingual 0.3 mg, 0.4 mg, 0.6 mg Nitrostat nitroglycerin transdermal patch 24 hour 0.1 mg/hr, 0.2 mg/hr, 0.4 mg/hr, 0.6 mg/hr Minitran nitro-time oral capsule extended release 2.5 mg, 6.5 mg, 9 mg Nitro-Time 22

23 NITRO-BID TRANSDERMAL OINTMENT 2 % *ANTIANXIETY AGENTS* *Antianxiety Agents - Misc.*** buspirone hcl oral tablet 10 mg, 5 mg, 7.5 mg buspirone hcl oral tablet 15 mg hydroxyzine hcl oral syrup 10 mg/5ml hydroxyzine hcl oral tablet 10 mg, 25 mg, 50 mg hydroxyzine pamoate oral capsule 100 mg hydroxyzine pamoate oral capsule 25 mg, 50 mg meprobamate oral tablet 200 mg, 400 mg *Benzodiazepines*** alprazolam er oral tablet extended release 24 hour 0.5 mg, 1 mg, 2 mg, 3 mg 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 alprazolam xr oral tablet extended release 24 hour 0.5 mg, 1 mg, 2 mg, 3 mg chlordiazepoxide hcl oral capsule 10 mg, 25 mg, 5 mg clorazepate dipotassium oral tablet 15 mg, 3.75 mg clorazepate dipotassium oral tablet 7.5 mg Vistaril Xanax XR Xanax Xanax XR Tranxene-T QLL (90 EA per 30 days) QLL (120 EA per 30 days) QLL (60 EA per 30 days); AL (Min 18 Years) QLL (90 EA per 30 days); AL (Min 18 Years) QLL (90 EA per 30 days); AL (Min 18 Years) QLL (60 EA per 30 days); AL (Min 18 Years) QLL (120 EA per 30 days); AL (Min 6 Years) QLL (120 EA per 30 days); AL (Min 9 Years) QLL (120 EA per 30 days); AL (Min 9 Years) QLL (300 ML per 30 days) diazepam oral solution 1 mg/ml diazepam oral tablet 10 mg, 2 mg, 5 mg Valium QLL (120 EA per 30 days) lorazepam intensol oral concentrate 2 mg/ml LORazepam Intensol QLL (180 ML per 30 days) lorazepam oral concentrate 2 mg/ml LORazepam Intensol QLL (180 ML per 30 days) lorazepam oral tablet 0.5 mg, 1 mg, 2 mg Ativan QLL (90 EA per 30 days) oxazepam oral capsule 10 mg, 15 mg, 30 mg ALPRAZOLAM INTENSOL ORAL CONCENTRATE 1 MG/ML *ANTIARRHYTHMICS* *Antiarrhythmics Type I-A*** QLL (120 EA per 30 days); AL (Min 6 Years) QLL (180 ML per 30 days); AL (Min 18 Years) 23

24 disopyramide phosphate oral capsule 100 mg, Norpace 150 mg quinidine gluconate er oral tablet extended release 324 mg quinidine sulfate oral tablet 200 mg, 300 mg *Antiarrhythmics Type I-B*** mexiletine hcl oral capsule 150 mg, 200 mg, 250 mg *Antiarrhythmics Type I-C*** flecainide acetate oral tablet 100 mg, 150 mg, 50 mg propafenone hcl oral tablet 150 mg, 225 mg, 300 mg *Antiarrhythmics Type Iii*** amiodarone hcl oral tablet 100 mg, 200 mg, Pacerone 400 mg pacerone oral tablet 100 mg, 200 mg, 400 mg Pacerone MULTAQ ORAL TABLET 400 MG PA; QLL (60 EA per 30 days) *ANTIASTHMATIC AND BRONCHODILATOR AGENTS* *Adrenergic Combinations*** ipratropium-albuterol inhalation solution 0.5- QLL (180 Nebules per 30 days) 2.5 (3) mg/3ml ANORO ELLIPTA INHALATION AEROSOL POWDER BREATH QLL (1 inhaler per 30 days) ACTIVATED MCG/INH BREO ELLIPTA INHALATION AEROSOL POWDER BREATH QLL (1 EA per 30 days) ACTIVATED MCG/INH, MCG/INH COMBIVENT RESPIMAT INHALATION QLL (2 Inhaler per 30 days) AEROSOL SOLUTION MCG/ACT DULERA INHALATION AEROSOL QLL (1 Inhaler per 30 days) MCG/ACT, MCG/ACT STIOLTO RESPIMAT INHALATION ST; QLL (1 ea per 30 days) AEROSOL SOLUTION MCG/ACT *Anti-Inflammatory Agents*** cromolyn sodium inhalation nebulization solution 20 mg/2ml *Beta Adrenergics*** 24

25 albuterol sulfate inhalation nebulization solution (2.5 mg/3ml) 0.083%, (5 mg/ml) 0.5% albuterol sulfate inhalation nebulization solution 0.63 mg/3ml, 1.25 mg/3ml albuterol sulfate oral syrup 2 mg/5ml levalbuterol tartrate inhalation aerosol 45 mcg/act metaproterenol sulfate oral syrup 10 mg/5ml metaproterenol sulfate oral tablet 10 mg, 20 mg ARCAPTA NEOHALER INHALATION CAPSULE 75 MCG STRIVERDI RESPIMAT INHALATION AEROSOL SOLUTION 2.5 MCG/ACT VENTOLIN HFA INHALATION AEROSOL SOLUTION 108 (90 BASE) MCG/ACT *Bronchodilators - Anticholinergics*** ipratropium bromide inhalation solution 0.02 % ATROVENT HFA INHALATION AEROSOL SOLUTION 17 MCG/ACT INCRUSE ELLIPTA INHALATION AEROSOL POWDER BREATH ACTIVATED 62.5 MCG/INH *Leukotriene Receptor Antagonists*** Xopenex HFA QLL (360 Nebules per 30 days) ST; QLL (360 Nebules per 30 days) ST; QLL (2 INH per 30 days) QLL (1 Inhaler per 30 days) QLL (2 Inhaler per 30 days) QLL (2 Inhaler per 30 days) montelukast sodium oral packet 4 mg Singulair PA; ; AL (Max 2 Years) montelukast sodium oral tablet 10 mg Singulair montelukast sodium oral tablet chewable 4 mg, 5 mg Singulair zafirlukast oral tablet 10 mg, 20 mg Accolate ST; QLL (60 EA per 30 days) *Steroid Inhalants*** budesonide inhalation suspension 0.25 mg/2ml, 0.5 mg/2ml FLOVENT DISKUS INHALATION AEROSOL POWDER BREATH ACTIVATED 100 MCG/BLIST, 250 MCG/BLIST, 50 MCG/BLIST Pulmicort QLL (120 ML per 30 days); AL (Max 5 Years) QLL (60 Blisters per 30 days) 25

26 PULMICORT FLEXHALER INHALATION AEROSOL POWDER BREATH ACTIVATED 180 MCG/ACT, 90 MCG/ACT QLL (1 Inhaler per 30 days) PULMICORT INHALATION SUSPENSION 1 MG/2ML QVAR INHALATION AEROSOL SOLUTION 40 MCG/ACT QVAR INHALATION AEROSOL SOLUTION 80 MCG/ACT QVAR REDIHALER INHALATION AEROSOL BREATH ACTIVATED 40 MCG/ACT QVAR REDIHALER INHALATION AEROSOL BREATH ACTIVATED 80 MCG/ACT *Xanthines*** theochron oral tablet extended release 12 hour 100 mg, 200 mg, 300 mg theophylline er oral tablet extended release 12 hour 100 mg, 200 mg, 300 mg theophylline er oral tablet extended release 12 hour 450 mg theophylline er oral tablet extended release 24 hour 400 mg, 600 mg theophylline oral solution 80 mg/15ml *ANTICOAGULANTS* *Coumarin Anticoagulants*** jantoven oral tablet 1 mg, 10 mg, 2 mg, 2.5 mg, 3 mg, 4 mg, 5 mg, 6 mg, 7.5 mg warfarin sodium oral tablet 1 mg, 10 mg, 2 mg, 2.5 mg, 3 mg, 4 mg, 5 mg, 6 mg, 7.5 mg *Direct Factor Xa Inhibitors*** ELIQUIS ORAL TABLET 2.5 MG, 5 MG XARELTO ORAL TABLET 10 MG, 15 MG, 20 MG XARELTO STARTER PACK ORAL TABLET THERAPY PACK 15 & 20 MG *Heparins And Heparinoid-Like Agents*** Budesonide Theochron Theochron Coumadin Coumadin QLL (120 ML per 30 days); AL (Max 5 Years) QLL (1 Inhaler per 30 days) QLL (2 Inhaler per 30 days) QLL (0.35 gm per 1 day) QLL (0.71 gm per 1 day) PA; QLL (60 EA per 30 days) PA; PA; QLL (1 FILL per 90 days) 26

27 heparin sodium (porcine) injection solution 1000 unit/ml, unit/ml, unit/ml, 5000 unit/ml heparin sodium (porcine) pf injection solution 5000 unit/0.5ml *Low Molecular Weight Heparins*** enoxaparin sodium injection solution 300 mg/3ml enoxaparin sodium subcutaneous solution 100 mg/ml, 120 mg/0.8ml, 150 mg/ml, 30 mg/0.3ml, 40 mg/0.4ml, 60 mg/0.6ml, 80 mg/0.8ml Lovenox Lovenox Max Limit (Total quantities are limited to a 21 days supply every 90 days. Quantities above this amount will require a Prior Authorization) Max Limit (Total quantities are limited to a 21 days supply every 90 days. Quantities above this amount will require a Prior Authorization) *ANTICONVULSANTS* *Anticonvulsants - Benzodiazepines*** clonazepam oral tablet 0.5 mg, 1 mg KlonoPIN QLL (90 EA per 30 days) clonazepam oral tablet 2 mg KlonoPIN QLL (45 EA per 30 days) clonazepam oral tablet dispersible mg, 0.25 mg, 0.5 mg, 1 mg QLL (90 EA per 30 days) clonazepam oral tablet dispersible 2 mg QLL (45 EA per 30 days) *Anticonvulsants - Misc.*** carbamazepine er oral capsule extended release 12 hour 100 mg, 200 mg, 300 mg Carbatrol QLL (120 EA per 30 days) carbamazepine er oral tablet extended release 12 hour 100 mg carbamazepine er oral tablet extended release 12 hour 200 mg carbamazepine er oral tablet extended release 12 hour 400 mg carbamazepine oral suspension 100 mg/5ml carbamazepine oral tablet 200 mg carbamazepine oral tablet chewable 100 mg epitol oral tablet 200 mg gabapentin oral capsule 100 mg, 300 mg, 400 mg gabapentin oral solution 250 mg/5ml TEGretol-XR TEGretol-XR TEGretol-XR TEGretol Epitol Epitol Neurontin Neurontin QLL (300 EA per 30 days); AL (Min 6 Years) QLL (150 EA per 30 days); AL (Min 6 Years) QLL (2.5 EA per 1 day); AL (Min 6 Years) QLL (180 EA per 30 days) 27

28 gabapentin oral tablet 600 mg Neurontin QLL (180 EA per 30 days) gabapentin oral tablet 800 mg Neurontin QLL (135 EA per 30 days) lamotrigine oral tablet 100 mg, 200 mg LaMICtal QLL (60 EA per 30 days) lamotrigine oral tablet 150 mg LaMICtal QLL (90 EA per 30 days) lamotrigine oral tablet 25 mg LaMICtal QLL (180 EA per 30 days) lamotrigine oral tablet chewable 25 mg LaMICtal QLL (180 EA per 30 days) lamotrigine oral tablet chewable 5 mg LaMICtal QLL (240 EA per 30 days) levetiracetam er oral tablet extended release 24 hour 500 mg Keppra XR QLL (180 EA per 30 days) levetiracetam er oral tablet extended release 24 hour 750 mg Keppra XR QLL (120 EA per 30 days) levetiracetam oral solution 100 mg/ml Keppra levetiracetam oral tablet 1000 mg Keppra QLL (90 EA per 30 days) levetiracetam oral tablet 250 mg Keppra QLL (60 EA per 30 days) levetiracetam oral tablet 500 mg Keppra QLL (180 EA per 30 days) levetiracetam oral tablet 750 mg Keppra QLL (120 EA per 30 days) oxcarbazepine oral suspension 300 mg/5ml Trileptal oxcarbazepine oral tablet 150 mg, 300 mg, 600 mg Trileptal primidone oral tablet 250 mg, 50 mg Mysoline topiramate oral capsule sprinkle 15 mg, 25 mg Topamax Sprinkle QLL (120 EA per 30 days) topiramate oral tablet 100 mg Topamax QLL (90 EA per 30 days) topiramate oral tablet 200 mg Topamax QLL (60 EA per 30 days) topiramate oral tablet 25 mg, 50 mg Topamax QLL (120 EA per 30 days) zonisamide oral capsule 100 mg, 25 mg Zonegran QLL (180 EA per 30 days) zonisamide oral capsule 50 mg QLL (180 EA per 30 days) LYRICA ORAL CAPSULE 100 MG, 150 MG, 200 MG, 225 MG, 25 MG, 300 MG, 50 ST MG, 75 MG LYRICA ORAL SOLUTION 20 MG/ML ST *Carbamates*** felbamate oral suspension 600 mg/5ml Felbatol felbamate oral tablet 400 mg, 600 mg Felbatol *Gaba Modulators*** tiagabine hcl oral tablet 2 mg Gabitril tiagabine hcl oral tablet 4 mg Gabitril QLL (120 EA per 30 days) GABITRIL ORAL TABLET 12 MG QLL (120 EA per 30 days) 28

29 GABITRIL ORAL TABLET 16 MG QLL (90 EA per 30 days) *Hydantoins*** phenytoin infatabs oral tablet chewable 50 mg Dilantin Infatabs phenytoin oral suspension 125 mg/5ml Dilantin phenytoin oral tablet chewable 50 mg Dilantin Infatabs phenytoin sodium extended oral capsule 100 mg Dilantin phenytoin sodium extended oral capsule 200 mg, 300 mg Phenytek DILANTIN ORAL CAPSULE 30 MG *Succinimides*** ethosuximide oral capsule 250 mg Zarontin ethosuximide oral solution 250 mg/5ml Zarontin CELONTIN ORAL CAPSULE 300 MG *Valproic Acid*** divalproex sodium er oral tablet extended release 24 hour 250 mg, 500 mg Depakote ER divalproex sodium oral tablet delayed release 125 mg, 250 mg, 500 mg Depakote valproic acid oral capsule 250 mg Depakene valproic acid oral solution 250 mg/5ml Depakene *ANTIDEPRESSANTS* *Alpha-2 Receptor Antagonists (Tetracyclics)*** mirtazapine oral tablet 15 mg Remeron mirtazapine oral tablet 30 mg Remeron QLL (60 EA per 30 days) mirtazapine oral tablet 45 mg Remeron QLL (45 EA per 30 days) mirtazapine oral tablet 7.5 mg mirtazapine oral tablet dispersible 15 mg, 45 mg Remeron SolTab mirtazapine oral tablet dispersible 30 mg Remeron SolTab QLL (60 EA per 30 days) *Antidepressants - Misc.*** bupropion hcl er (sr) oral tablet extended release 12 hour 100 mg Wellbutrin SR QLL (120 EA per 30 days) bupropion hcl er (sr) oral tablet extended release 12 hour 150 mg, 200 mg Wellbutrin SR QLL (60 EA per 30 days) bupropion hcl er (xl) oral tablet extended release 24 hour 150 mg Wellbutrin XL QLL (90 EA per 30 days) 29

30 bupropion hcl er (xl) oral tablet extended release 24 hour 300 mg Wellbutrin XL bupropion hcl oral tablet 100 mg QLL (135 EA per 30 days) bupropion hcl oral tablet 75 mg QLL (180 EA per 30 days) maprotiline hcl oral tablet 25 mg, 50 mg, 75 mg *Modified Cyclics*** trazodone hcl oral tablet 100 mg, 150 mg, 300 mg, 50 mg *Monoamine Oxidase Inhibitors (Maois)*** phenelzine sulfate oral tablet 15 mg Nardil tranylcypromine sulfate oral tablet 10 mg Parnate MARPLAN ORAL TABLET 10 MG *Selective Serotonin Reuptake Inhibitors (Ssris)*** citalopram hydrobromide oral solution 10 mg/5ml QLL (600 ML per 30 days) citalopram hydrobromide oral tablet 10 mg, 20 mg CeleXA QLL (45 EA per 30 days) citalopram hydrobromide oral tablet 40 mg CeleXA escitalopram oxalate oral solution 5 mg/5ml QLL (600 ML per 30 days) escitalopram oxalate oral tablet 10 mg, 20 mg, Lexapro 5 mg fluoxetine hcl oral capsule 10 mg PROzac fluoxetine hcl oral capsule 20 mg PROzac QLL (120 EA per 30 days) fluoxetine hcl oral capsule 40 mg PROzac QLL (60 EA per 30 days) fluoxetine hcl oral solution 20 mg/5ml QLL (600 ML per 30 days) fluvoxamine maleate oral tablet 100 mg QLL (90 EA per 30 days) fluvoxamine maleate oral tablet 25 mg, 50 mg paroxetine hcl oral tablet 10 mg, 20 mg Paxil paroxetine hcl oral tablet 30 mg Paxil QLL (60 EA per 30 days) paroxetine hcl oral tablet 40 mg Paxil QLL (45 EA per 30 days) sertraline hcl oral concentrate 20 mg/ml Zoloft QLL (300 ML per 30 days) sertraline hcl oral tablet 100 mg Zoloft QLL (75 EA per 30 days) sertraline hcl oral tablet 25 mg, 50 mg Zoloft QLL (45 EA per 30 days) *Serotonin-Norepinephrine Reuptake Inhibitors (Snris)*** 30

31 duloxetine hcl oral capsule delayed release particles 20 mg, 30 mg, 60 mg Cymbalta QLL (60 EA per 30 days) duloxetine hcl oral capsule delayed release particles 40 mg QLL (60 EA per 30 days) venlafaxine hcl er oral capsule extended release 24 hour 150 mg Effexor XR QLL (60 EA per 30 days) venlafaxine hcl er oral capsule extended release 24 hour 37.5 mg, 75 mg Effexor XR venlafaxine hcl oral tablet 100 mg, 25 mg, 37.5 mg, 50 mg, 75 mg *Tricyclic Agents*** amitriptyline hcl oral tablet 10 mg, 100 mg, 150 mg, 50 mg, 75 mg amitriptyline hcl oral tablet 25 mg Elavil amoxapine oral tablet 100 mg, 150 mg, 25 mg, 50 mg desipramine hcl oral tablet 10 mg, 25 mg Norpramin desipramine hcl oral tablet 100 mg, 150 mg, 50 mg, 75 mg doxepin hcl oral capsule 10 mg, 100 mg, 150 mg, 25 mg, 50 mg, 75 mg doxepin hcl oral concentrate 10 mg/ml imipramine hcl oral tablet 10 mg, 25 mg, 50 mg Tofranil nortriptyline hcl oral capsule 10 mg, 25 mg, 50 mg, 75 mg Pamelor nortriptyline hcl oral solution 10 mg/5ml protriptyline hcl oral tablet 10 mg, 5 mg *ANTIDIABETICS* *Alpha-Glucosidase Inhibitors*** acarbose oral tablet 100 mg, 25 mg, 50 mg Precose QLL (90 EA per 30 days) *Biguanides*** metformin hcl er oral tablet extended release 24 hour 500 mg Glucophage XR QLL (120 EA per 30 days) metformin hcl er oral tablet extended release 24 hour 750 mg Glucophage XR QLL (60 EA per 30 days) metformin hcl oral tablet 1000 mg, 500 mg, 850 mg Glucophage *Diabetic Other*** 31

32 GLUCAGEN HYPOKIT INJECTION SOLUTION RECONSTITUTED 1 MG GLUCAGON EMERGENCY INJECTION KIT 1 MG *Dipeptidyl Peptidase-4 (Dpp-4) Inhibitors*** alogliptin benzoate oral tablet 12.5 mg, 25 mg, 6.25 mg JANUVIA ORAL TABLET 100 MG, 25 MG, 50 MG *Dipeptidyl Peptidase-4 Inhibitor- Biguanide Combinations*** alogliptin-metformin hcl oral tablet mg, mg JANUMET ORAL TABLET MG, MG JANUMET XR ORAL TABLET EXTENDED RELEASE 24 HOUR MG, MG, MG *Dpp-4 Inhibitor-Thiazolidinedione Combinations*** alogliptin-pioglitazone oral tablet mg, mg, mg, mg, mg, mg *Human Insulin*** BASAGLAR KWIKPEN SUBCUTANEOUS SOLUTION PEN- INJECTOR 100 UNIT/ML FIASP FLEXTOUCH SUBCUTANEOUS SOLUTION PEN-INJECTOR 100 UNIT/ML FIASP SUBCUTANEOUS SOLUTION 100 UNIT/ML HUMALOG KWIKPEN SUBCUTANEOUS SOLUTION PEN- INJECTOR 100 UNIT/ML, 200 UNIT/ML HUMALOG MIX 50/50 KWIKPEN SUBCUTANEOUS SUSPENSION PEN- INJECTOR (50-50) 100 UNIT/ML HUMALOG MIX 50/50 SUBCUTANEOUS SUSPENSION (50-50) 100 UNIT/ML Nesina Kazano Oseni QLL (1 Unit Max Qty Per Fill Retail) QLL (1 Unit Max Qty Per Fill Retail) ST; ST; QLL (1 EA per 1 day) QLL (60 EA per 30 days) ST; QLL (2 EA per 1 day) ST; QLL (1 EA per 1 day) AL (Max 18 Years) AL (Max 18 Years) AL (Max 18 Years) 32

33 HUMALOG MIX 75/25 KWIKPEN SUBCUTANEOUS SUSPENSION PEN- AL (Max 18 Years) INJECTOR (75-25) 100 UNIT/ML HUMALOG MIX 75/25 SUBCUTANEOUS SUSPENSION (75-25) 100 UNIT/ML HUMALOG SUBCUTANEOUS SOLUTION 100 UNIT/ML HUMALOG SUBCUTANEOUS SOLUTION CARTRIDGE 100 UNIT/ML HUMULIN 70/30 KWIKPEN SUBCUTANEOUS SUSPENSION PEN- OTC; AL (Max 18 Years) INJECTOR (70-30) 100 UNIT/ML HUMULIN N KWIKPEN SUBCUTANEOUS SUSPENSION PEN- OTC; AL (Max 18 Years) INJECTOR 100 UNIT/ML HUMULIN R U-500 (CONCENTRATED) SUBCUTANEOUS SOLUTION 500 UNIT/ML HUMULIN R U-500 KWIKPEN SUBCUTANEOUS SOLUTION PEN- AL (Max 18 Years) INJECTOR 500 UNIT/ML NOVOLOG FLEXPEN SUBCUTANEOUS SOLUTION PEN-INJECTOR 100 AL (Max 18 Years) UNIT/ML NOVOLOG MIX 70/30 FLEXPEN SUBCUTANEOUS SUSPENSION PEN- AL (Max 18 Years) INJECTOR (70-30) 100 UNIT/ML NOVOLOG MIX 70/30 SUBCUTANEOUS SUSPENSION (70-30) 100 UNIT/ML NOVOLOG SUBCUTANEOUS SOLUTION 100 UNIT/ML *Incretin Mimetic Agents (Glp-1 Receptor Agonists)*** TANZEUM SUBCUTANEOUS PEN- ST; QLL (4 EA per 28 days) INJECTOR 30 MG, 50 MG TRULICITY SUBCUTANEOUS SOLUTION PEN-INJECTOR 0.75 ST; QLL (4 ea per 28 days) MG/0.5ML, 1.5 MG/0.5ML *Meglitinide Analogues*** nateglinide oral tablet 120 mg, 60 mg Starlix QLL (90 EA per 30 days) repaglinide oral tablet 0.5 mg QLL (120 EA per 30 days) repaglinide oral tablet 1 mg Prandin QLL (120 EA per 30 days) 33

34 repaglinide oral tablet 2 mg Prandin QLL (240 EA per 30 days) *Meglitinide-Biguanide Combinations*** repaglinide-metformin hcl oral tablet mg, mg *Sodium-Glucose Co-Transporter 2 (Sglt2) Inhibitors*** INVOKANA ORAL TABLET 100 MG, 300 MG ST; *Sulfonylurea-Biguanide Combinations*** glipizide-metformin hcl oral tablet mg, mg QLL (60 EA per 30 days) glipizide-metformin hcl oral tablet mg QLL (120 EA per 30 days) glyburide-metformin oral tablet mg QLL (60 EA per 30 days) glyburide-metformin oral tablet mg Glucovance QLL (60 EA per 30 days) glyburide-metformin oral tablet mg Glucovance QLL (120 EA per 30 days) *Sulfonylureas*** chlorpropamide oral tablet 100 mg, 250 mg glimepiride oral tablet 1 mg, 2 mg Amaryl glimepiride oral tablet 4 mg Amaryl QLL (60 EA per 30 days) glipizide er oral tablet extended release 24 hour 10 mg Glucotrol XL QLL (60 EA per 30 days) glipizide er oral tablet extended release 24 hour 2.5 mg, 5 mg Glucotrol XL glipizide oral tablet 10 mg, 5 mg Glucotrol glipizide xl oral tablet extended release 24 hour 10 mg Glucotrol XL QLL (60 EA per 30 days) glipizide xl oral tablet extended release 24 hour 2.5 mg, 5 mg Glucotrol XL glyburide micronized oral tablet 1.5 mg, 3 mg Glynase glyburide micronized oral tablet 6 mg Glynase QLL (60 EA per 30 days) glyburide oral tablet 1.25 mg, 2.5 mg, 5 mg tolazamide oral tablet 250 mg, 500 mg tolbutamide oral tablet 500 mg *Sulfonylurea-Thiazolidinedione Combinations*** 34

AETNA BETTER HEALTH Formulary Guide Aetna Better Health Of Virginia Formulary Guide March 2018

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