2018 Comprehensive Formulary. (List of Covered Drugs) COMMERCIAL

Transcription

1 08 Comprehensive Formulary (List of Covered Drugs) COMMERCIAL 6//08

2

3 0 8 D R U G F O R M U L A R Y & PHAR M A C Y BENEF I T GUID E L INE S PRESCRIPTION DRUG BENEFITS The following is a comprehensive listing by drug class of formulary medications approved under the SummaCare Prescription Drug Benefit. Brand name drugs are capitalized and generic drugs are listed in lower case. SummaCare tiered prescription drug benefits are generic-based. Prescription drug benefits vary, but in most cases, brand name medications that have a generic equivalent require the patient to pay a Tier copay or the difference in cost between the brand and generic medication. Some benefits may exclude certain drugs on this list. Refer to your Prescription Drug Benefit Rider or plan documents for more coverage information. ABOUT TIERS SummaCare members pay a Tier copay for most generic drugs and selected over-the-counter drugs. Members pay a Tier copay for higher cost generic drugs and preferred brand name drugs. Members pay a Tier copay for non-preferred brand name drugs. Note: Some benefits may require a deductible be met before copays apply and/or have a Tier 4 copay level. Refer to your plan documents for further information. OVER-THE-COUNTER (OTC) DRUG COVERAGE SummaCare s Prescription Drug Formulary includes selected OTC drugs that are covered when they are presented to a pharmacy with a written prescription. USING YOUR SUMMACARE ID CARD It is important to show your SummaCare ID card when filling prescriptions. By showing your SummaCare ID card, safety checks are performed such as drug-drug interactions, therapeutic duplications and dose checks, even if you use multiple pharmacies including mail order. MEDIMPACT MedImpact is SummaCare s Pharmacy Benefit Manager and is responsible for processing pharmacy claims for SummaCare members. MedImpact also handles pharmacy benefit customer service and utilization management requests on SummaCare s behalf. To reach MedImpact, members should call the SummaCare customer service number on the back of their ID card. PHARMACY UTILIZATION PROGRAMS SummaCare s Prescription Drug Benefit incorporates utilization management programs (prior authorization, step therapy and quantity limits). Drugs requiring utilization management are indicated in the Requirements/Limits column of the formulary document and will be indicated with PA, QL or ST. If you are prescribed one of these drugs, the prescriber may need to contact MedImpact to provide supporting medical information. PriorAuthorization= PA Prior authorization requirements are placed on medications when they have limited conditions for which they are prescribed, special monitoring or dispensing requirement or an extremely high cost. Guidelines for approving coverage for prior authorization drugs are developed and approved by a panel of practicing physicians and pharmacists. Step Therapy = ST Step Therapy is the practice of initiating drug therapy for a medical condition with the most cost-effective and safest drug and progressing to other more costly or risky therapy, only if necessary (i.e., you must try drug A before you can get drug B ). The goal is to control costs and minimize risks. Step therapy is an automated process. If you present a prescription for a step therapy drug (i.e., B ) to a pharmacy, an automated check of your prescription history will occur. If the system finds that you have received the qualifying drug(s) (i.e., A ), your prescription will be processed. If the system does not find that you received a qualifying drug (i.e., A ) in recent history, a prior authorization will be necessary. Quantity Limits= QL When a drug has a Quantity Limit, the amount of medication per prescription is limited to a specified amount per 0 days. These limitations are usually in place due to safety issues or because the use of a dose higher than what is recommended has been shown to result in minimal additional benefit to the patient. Specialty Drugs Specialty drugs are designated as such because they may require special handling, are expensive and/or special monitoring of the patient receiving the drug may be appropriate. Distribution is often restricted to a Specialty pharmacy. Some benefits may cover these drugs at a higher copay level. Refer to your plan documents for more information. These drugs are indicated by *May have Specialty Costshare. Employers and Members needing further information regarding the SummaCare prescription drug benefit please refer to the number on the back of your Member ID card or call Group Customer Service at Providers, please call Provider Services at TTY/TDD users should call TO VIEW THE MOST RECENT FORMULARY, PLEASE VISIT Revised 09/7

4 Table of Contents Analgesics... Anesthetics... 5 Anti-Addiction/Substance Abuse Treatment Agents... 6 Antianxiety Agents...7 Antibacterials... 9 Anticancer Agents... 9 Anticholinergic Agents... 7 Anticonvulsants...8 Antidementia Agents...44 Antidepressants Antidiabetic Agents... 5 Antifungals...59 Antigout Agents... 6 Antihistamines...6 Anti-Infectives (Skin And Mucous Membrane)...66 Antimigraine Agents...67 Antimycobacterials...69 Antinausea Agents...70 Antiparasite Agents...7 Antiparkinsonian Agents...7 Antipsychotic Agents...76 Antivirals (Systemic)...79 Blood Products/Modifiers/Volume Expanders Cardiovascular Agents... 9 Central Nervous System Agents... Contraceptives...9 Cough And Cold Products...9 Dental And Oral Agents... 0 Dermatological Agents... Devices Enzyme Replacement/Modifiers... 5 Eye, Ear, Nose, Throat Agents... 5 Gastrointestinal Agents... 6 Genitourinary Agents Heavy Metal Antagonists... 7 Hormonal Agents, Stimulant/Replacement/Modifying...7

5 Immunological Agents...84 Inflammatory Bowel Disease Agents... 9 Metabolic Bone Disease Agents...9 Miscellaneous Therapeutic Agents...94 Ophthalmic Agents...96 Replacement Preparations Respiratory Tract Agents Skeletal Muscle Relaxants Sleep Disorder Agents Vasodilating Agents...0 Vitamins And Minerals...

6 Analgesics Analgesics, Miscellaneous ABSTRAL SUBLINGUAL TABLET 00 MCG, 00 MCG, 00 MCG, 400 MCG, 600 MCG, 800 MCG acetaminophen-caff-dihydrocod oral capsule mg acetaminophen-caff-dihydrocod oral tablet mg acetaminophen-codeine oral solution 0- mg/5 ml acetaminophen-codeine oral tablet 00-5 mg acetaminophen-codeine oral tablet 00-0 mg acetaminophen-codeine oral tablet mg ACTIQ BUCCAL LOZENGE ON A HANDLE,00 MCG,,600 MCG, 00 MCG, 400 MCG, 600 MCG, 800 MCG alagesic lq oral solution mg/5 ml ALLZITAL ORAL TABLET 5-5 ARYMO ER ORAL TABLET,ORAL ONLY,EXTND RELEASE 5, 0, 60 aspirin-caffeine-dihydrocodein oral capsule mg AVINZA ORAL CAPSULE, ER MULTIPHASE 4 HR 0, 0, 45, 60, 75, 90 BELBUCA BUCCAL FILM 50 MCG, 00 MCG, 450 MCG, 600 MCG, 75 MCG, 750 MCG, 900 MCG belladonna alkaloids-opium rectal suppository mg belladonna-opium rectal suppository 6.-0 mg PA; QL (0 per 0 days) (Trezix) QL (00 per 0 days) (Panlor(acetam-caffdihydrocod)) QL (00 per 0 days) QL (700 per 0 days) QL (60 per 0 days) (Tylenol-Codeine #) QL (60 per 0 days) (Tylenol-Codeine #4) QL (80 per 0 days) PA; QL (0 per 0 days) QL (60 per 0 days) QL (60 per 0 days) QL (0 per 0 days) ST; QL (60 per 0 days) BUPAP ORAL TABLET QL (80 per 0 days)

7 buprenorphine transdermal patch weekly (Butrans) QL (4 per 8 days) 0 mcg/hour, 5 mcg/hour, 0 mcg/hour, 5 mcg/hour, 7.5 mcg/hour butalbital compound w/codeine oral capsule mg butalbital-acetaminop-caf-cod oral capsule mg, mg butalbital-acetaminophen oral tablet 50- (Bupap) QL (80 per 0 days) 00 mg butalbital-acetaminophen oral tablet 50- (Tencon) 5 mg butalbital-acetaminophen-caff oral (Fioricet) capsule mg butalbital-acetaminophen-caff oral (Capacet) capsule mg butalbital-acetaminophen-caff oral tablet (Esgic) mg butalbital-aspirin-caffeine oral capsule (Fiorinal) mg butalbital-aspirin-caffeine oral tablet mg butorphanol tartrate nasal spray,nonaerosol 0 mg/ml BUTRANS TRANSDERMAL QL (4 per 8 days) PATCH WEEKLY 0 MCG/HOUR, 5 MCG/HOUR, 0 MCG/HOUR, 5 MCG/HOUR, 7.5 MCG/HOUR capacet oral capsule mg CAPITAL WITH CODEINE ORAL QL (700 per 0 days) SUSPENSION 0- /5 ML CODEINE SULFATE ORAL SOLUTION 0 /5 ML codeine sulfate oral tablet 5 mg, 0 mg, 60 mg CONZIP ORAL CAPSULE,ER ST; QL (0 per 0 days) BIPHASE 4 HR CONZIP ORAL CAPSULE,ER BIPHASE 4 HR , 00 ST; QL (0 per 0 days) 4

8 DEMEROL (PF) INJECTION SYRINGE 00 /ML, 5 /ML, 50 /ML DEMEROL ORAL TABLET 00, QL (80 per 0 days) 50 DILAUDID ORAL LIQUID /ML DILAUDID ORAL TABLET, 4, 8 DISKETS ORAL TABLET,SOLUBLE QL (0 per 0 days) 40 DOLOPHINE ORAL TABLET 0 QL (0 per 0 days) DOLOPHINE ORAL TABLET 5 QL (40 per 0 days) DURAGESIC TRANSDERMAL QL (0 per 0 days) PATCH 7 HOUR 00 MCG/HR, MCG/HR, 5 MCG/HR, 50 MCG/HR, 75 MCG/HR EMBEDA ORAL CAPSULE,ORAL QL (0 per 0 days) ONLY,EXT.REL PELL 00-4 EMBEDA ORAL CAPSULE,ORAL QL (60 per 0 days) ONLY,EXT.REL PELL 0-0.8, 0-., 50-, 60-.4, 80-. endocet oral tablet 0-5 mg,.5-5 QL (60 per 0 days) mg, 5-5 mg, mg endodan oral tablet mg QL (60 per 0 days) ESGIC ORAL CAPSULE ESGIC ORAL TABLET EXALGO ER ORAL TABLET EXTENDED RELEASE 4 HR, 6,, 8 QL (0 per 0 days) fentanyl citrate buccal lozenge on a handle,00 mcg,,600 mcg, 00 mcg, 400 mcg, 600 mcg, 800 mcg fentanyl transdermal patch 7 hour 00 mcg/hr, mcg/hr, 50 mcg/hr, 75 mcg/hr fentanyl transdermal patch 7 hour 5 mcg/hr fentanyl transdermal patch 7 hour 7.5 mcg/hour, 6.5 mcg/hour, 87.5 mcg/hour (Actiq) PA; QL (0 per 0 days) (Duragesic) QL (0 per 0 days) (Duragesic) QL (0 per 0 days) QL (0 per 0 days) 5

9 FENTORA BUCCAL TABLET, EFFERVESCENT 00 MCG, 00 MCG, 400 MCG, 600 MCG, 800 MCG PA; QL ( per 0 days) fioricet oral capsule mg FIORICET WITH CODEINE ORAL CAPSULE FIORINAL ORAL CAPSULE FIORINAL-CODEINE # ORAL CAPSULE HYCET ORAL SOLUTION QL (700 per 0 days) /5 ML hydrocodone-acetaminophen oral solution QL (700 per 0 days).5-67 mg/5 ml, 5-6 mg/7.5ml(7.5ml) hydrocodone-acetaminophen oral solution (Hycet) QL (700 per 0 days) mg/5 ml hydrocodone-acetaminophen oral tablet (Vicodin HP) QL (90 per 0 days) 0-00 mg hydrocodone-acetaminophen oral tablet (Lorcet HD) QL (60 per 0 days) 0-5 mg hydrocodone-acetaminophen oral tablet (Verdrocet) QL (60 per 0 days).5-5 mg hydrocodone-acetaminophen oral tablet (Vicodin) QL (90 per 0 days) 5-00 mg hydrocodone-acetaminophen oral tablet (Lorcet (hydrocodone)) QL (60 per 0 days) 5-5 mg hydrocodone-acetaminophen oral tablet (Vicodin ES) QL (90 per 0 days) mg hydrocodone-acetaminophen oral tablet (Lorcet Plus) QL (60 per 0 days) mg hydrocodone-ibuprofen oral tablet 0-00 (Ibudone) mg, 5-00 mg hydrocodone-ibuprofen oral tablet.5-00 mg hydrocodone-ibuprofen oral tablet mg hydromorphone oral liquid mg/ml (Dilaudid) hydromorphone oral tablet mg, 4 mg, 8 (Dilaudid) mg hydromorphone oral tablet extended release 4 hr mg, 6 mg, 8 mg (Exalgo ER) QL (0 per 0 days) 6

10 hydromorphone oral tablet extended (Exalgo ER) QL (60 per 0 days) release 4 hr mg hydromorphone rectal suppository mg HYSINGLA ER ORAL QL (0 per 0 days) TABLET,ORAL ONLY,EXT.REL.4 HR 00, 0, 0, 0, 40, 60, 80 IBUDONE ORAL TABLET 0-00, 5-00 ibuprofen-oxycodone oral tablet mg KADIAN ORAL QL (60 per 0 days) CAPSULE,EXTEND.RELEASE PELLETS 0, 00, 0, 50, 0, 00, 0, 40, 50, 60, 70, 80 LAZANDA NASAL SPRAY,NON- AEROSOL 00 MCG/SPRAY, 00 PA; QL (5 per 0 days) MCG/SPRAY, 400 MCG/SPRAY levorphanol tartrate oral tablet mg lorcet (hydrocodone) oral tablet 5-5 QL (60 per 0 days) mg lorcet hd oral tablet 0-5 mg QL (60 per 0 days) lorcet plus oral tablet mg QL (60 per 0 days) LORTAB 0-5 ORAL TABLET 0- QL (60 per 0 days) 5 LORTAB 5-5 ORAL TABLET 5-5 QL (60 per 0 days) LORTAB ORAL TABLET 7.5- QL (60 per 0 days) 5 LORTAB ELIXIR ORAL SOLUTION QL (05 per 0 days) 0-00 /5 ML margesic oral capsule mg marten-tab oral tablet 50-5 mg meperidine (pf) injection solution 00 (Demerol (PF)) mg/ml, 50 mg/ml meperidine injection cartridge 0 mg/ml meperidine oral solution 50 mg/5 ml QL (900 per 0 days) meperidine oral tablet 00 mg (Demerol) QL (80 per 0 days) meperidine oral tablet 50 mg QL (80 per 0 days) methadone oral concentrate 0 mg/ml (Methadone Intensol) QL (0 per 0 days) methadone oral solution 0 mg/5 ml QL (600 per 0 days) 7

11 methadone oral solution 5 mg/5 ml QL (00 per 0 days) methadone oral tablet 0 mg (Dolophine) QL (0 per 0 days) methadone oral tablet 5 mg (Dolophine) QL (40 per 0 days) methadone oral tablet,soluble 40 mg (Diskets) QL (0 per 0 days) METHADOSE ORAL QL (0 per 0 days) CONCENTRATE 0 /ML methadose oral tablet,soluble 40 mg QL (0 per 0 days) MORPHABOND ER ORAL QL (60 per 0 days) TABLET,ORAL ONLY,EXT.REL. HR 00, 5, 0, 60 morphine concentrate oral solution 00 mg/5 ml (0 mg/ml) morphine intravenous cartridge 5 mg/ml morphine oral capsule, er multiphase 4 QL (0 per 0 days) hr 0 mg, 45 mg, 75 mg, 90 mg morphine oral capsule, er multiphase 4 QL (60 per 0 days) hr 0 mg, 60 mg morphine oral capsule,extend.release (Kadian) QL (60 per 0 days) pellets 0 mg, 00 mg, 0 mg, 0 mg, 50 mg, 60 mg, 80 mg morphine oral solution 0 mg/5 ml, 0 mg/5 ml (4 mg/ml) MORPHINE ORAL TABLET 5, 0 morphine oral tablet extended release 00 (MS Contin) QL (90 per 0 days) mg, 5 mg, 00 mg, 0 mg, 60 mg morphine rectal suppository 0 mg, 0 mg, 0 mg, 5 mg MS CONTIN ORAL TABLET QL (90 per 0 days) EXTENDED RELEASE 00, 5, 00, 0, 60 NORCO ORAL TABLET 0-5, QL (60 per 0 days) 5-5, NUCYNTA ER ORAL TABLET QL (60 per 0 days) EXTENDED RELEASE HR 00, 50, 00, 50, 50 NUCYNTA ORAL TABLET 00, 50, 75 QL (80 per 0 days) 8

12 OPANA ER ORAL TABLET,ORAL QL (60 per 0 days) ONLY,EXT.REL. HR 0, 5, 0, 0, 40, 5, 7.5 OPANA ORAL TABLET 0, 5 QL (0 per 0 days) OXAYDO ORAL TABLET, ORAL ONLY 5, 7.5 OXECTA ORAL TABLET, ORAL ONLY 5, 7.5 oxycodone oral capsule 5 mg oxycodone oral concentrate 0 mg/ml oxycodone oral solution 5 mg/5 ml oxycodone oral tablet 0 mg, 0 mg oxycodone oral tablet 5 mg, 0 mg, 5 (Roxicodone) mg oxycodone oral tablet,oral only,ext.rel. (OxyContin) QL (60 per 0 days) hr 0 mg, 5 mg, 0 mg, 0 mg, 40 mg, 60 mg oxycodone oral tablet,oral only,ext.rel. (OxyContin) QL (0 per 0 days) hr 80 mg oxycodone-acetaminophen oral solution QL (800 per 0 days) 5-5 mg/5 ml oxycodone-acetaminophen oral tablet 0- (Primlev) QL (60 per 0 days) 00 mg, 5-00 mg, mg oxycodone-acetaminophen oral tablet 0- (Endocet) QL (60 per 0 days) 5 mg,.5-5 mg, 5-5 mg, mg oxycodone-aspirin oral tablet QL (60 per 0 days) mg OXYCONTIN ORAL QL (60 per 0 days) TABLET,ORAL ONLY,EXT.REL. HR 0, 5, 0, 0, 40, 60 OXYCONTIN ORAL QL (0 per 0 days) TABLET,ORAL ONLY,EXT.REL. HR 80 oxymorphone oral tablet 0 mg, 5 mg (Opana) QL (0 per 0 days) oxymorphone oral tablet extended release hr 0 mg, 0 mg, 0 mg, 40 mg, 5 mg, 7.5 mg QL (60 per 0 days) 9

13 oxymorphone oral tablet extended release QL (0 per 0 days) hr 5 mg panlor(acetam-caff-dihydrocod) oral QL (00 per 0 days) tablet mg pentazocine-naloxone oral tablet mg PERCOCET ORAL TABLET 0-5 QL (60 per 0 days),.5-5, 5-5, PERCODAN ORAL TABLET QL (60 per 0 days) 5 phrenilin forte(with caffeine) oral capsule mg PRIMLEV ORAL TABLET 0-00 QL (60 per 0 days), 5-00, reprexain oral tablet 0-00 mg,.5-00 mg, 5-00 mg roxicet oral solution 5-5 mg/5 ml QL (800 per 0 days) ROXICODONE ORAL TABLET 5, 0, 5 SUBLOCADE SUBCUTANEOUS SOLUTION, EXTENDED REL SYRINGE 00 /0.5 ML, 00 /.5 ML SUBSYS SUBLINGUAL SPRAY,NON-AEROSOL,00 MCG PA; QL (0 per 0 days) (600 MCG/SPRAY X ),,600 MCG (800 MCG/SPRAY X ), 00 MCG/SPRAY, 00 MCG/SPRAY, 400 MCG/SPRAY, 600 MCG/SPRAY, 800 MCG/SPRAY SYNALGOS-DC ORAL CAPSULE QL (60 per 0 days) tencon oral tablet 50-5 mg tramadol oral capsule,er biphase 4 hr (ConZip) ST; QL (0 per 0 days) mg tramadol oral capsule,er biphase 4 hr (ConZip) ST; QL (0 per 0 days) mg, 00 mg tramadol oral capsule,er biphase 4 hr QL (0 per 0 days) mg tramadol oral tablet 50 mg (Ultram) 0

14 tramadol oral tablet extended release 4 hr 00 mg, 00 mg, 00 mg tramadol oral tablet, er multiphase 4 hr 00 mg, 00 mg, 00 mg tramadol-acetaminophen oral tablet mg (Ultracet) TREZIX ORAL CAPSULE QL (00 per 0 days) 6 TYLENOL-CODEINE # ORAL QL (60 per 0 days) TABLET 00-0 TYLENOL-CODEINE #4 ORAL QL (80 per 0 days) TABLET ULTRACET ORAL TABLET ULTRAM ER ORAL TABLET EXTENDED RELEASE 4 HR 00, 00, 00 ULTRAM ORAL TABLET 50 VANATOL LQ ORAL SOLUTION /5 ML VERDROCET ORAL TABLET.5- QL (60 per 0 days) 5 vicodin es oral tablet mg QL (90 per 0 days) vicodin hp oral tablet 0-00 mg QL (90 per 0 days) vicodin oral tablet 5-00 mg QL (90 per 0 days) VICOPROFEN ORAL TABLET XARTEMIS XR ORAL TAB,ORAL QL (60 per 0 days) ONLY,IR - ER, BIPHASE XODOL 0/00 ORAL TABLET 0- QL (90 per 0 days) 00 XODOL 5/00 ORAL TABLET 5-00 QL (90 per 0 days) XODOL 7.5/00 ORAL TABLET 7.5- QL (90 per 0 days) 00 XTAMPZA ER ORAL QL (60 per 0 days) CAPSULE,SPRINKLE,ER HR TMPRR.5, 8, 9 XTAMPZA ER ORAL CAPSULE,SPRINKLE,ER HR TMPRR 7 QL (0 per 0 days)

15 XTAMPZA ER ORAL QL (40 per 0 days) CAPSULE,SPRINKLE,ER HR TMPRR 6 xylon 0 oral tablet 0-00 mg ZAMICET ORAL SOLUTION 0-5 QL (700 per 0 days) /5 ML zebutal oral capsule mg ZOHYDRO ER ORAL CAPSULE, QL (60 per 0 days) ORAL ONLY, ER HR 0, 5, 0, 0, 40, 50 Nonsteroidal Anti-Inflammatory Agents ANAPROX DS ORAL TABLET 550 ANAPROX ORAL TABLET 75 ARTHROTEC 50 ORAL TABLET,IR,DELAYED REL,BIPHASIC MCG ARTHROTEC 75 ORAL TABLET,IR,DELAYED REL,BIPHASIC MCG aspirin oral tablet,delayed release (dr/ec) 650 mg CAMBIA ORAL POWDER IN ST; QL (9 per 0 days) PACKET 50 CATAFLAM ORAL TABLET 50 CELEBREX ORAL CAPSULE 00, 50 PA; QL (60 per 0 days) CELEBREX ORAL CAPSULE 00, 400 PA; QL (0 per 0 days) celecoxib oral capsule 00 mg, 50 mg (Celebrex) PA; QL (60 per 0 days) celecoxib oral capsule 00 mg, 400 mg (Celebrex) PA; QL (0 per 0 days) choline,magnesium salicylate oral liquid 500 mg/5 ml DAYPRO ORAL TABLET 600 diclofenac potassium oral tablet 50 mg diclofenac sodium oral tablet extended (Voltaren-XR) release 4 hr 00 mg diclofenac sodium oral tablet,delayed release (dr/ec) 5 mg, 50 mg, 75 mg

16 diclofenac-misoprostol oral (Arthrotec 50) tablet,ir,delayed rel,biphasic mgmcg diclofenac-misoprostol oral (Arthrotec 75) tablet,ir,delayed rel,biphasic mgmcg diflunisal oral tablet 500 mg DISALCID ORAL TABLET 500, 750 DUEXIS ORAL TABLET ST; QL (90 per 0 days) DURLAZA ORAL CAPSULE,EXTENDED RELEASE 4HR 6.5 EC-NAPROSYN ORAL TABLET,DELAYED RELEASE (DR/EC) 75, 500 etodolac oral capsule 00 mg, 00 mg etodolac oral tablet 400 mg (Lodine) etodolac oral tablet 500 mg etodolac oral tablet extended release 4 hr 400 mg, 500 mg, 600 mg FELDENE ORAL CAPSULE 0, 0 fenoprofen oral capsule 00 mg (Fenortho) fenoprofen oral capsule 400 mg (Nalfon) fenoprofen oral tablet 600 mg (ProFeno) flurbiprofen oral tablet 00 mg, 50 mg ibu oral tablet 400 mg, 600 mg, 800 mg ibuprofen oral suspension 00 mg/5 ml (Child Ibuprofen) ibuprofen oral tablet 400 mg, 600 mg, (IBU) 800 mg INDOCIN ORAL SUSPENSION 5 /5 ML INDOCIN RECTAL SUPPOSITORY 50 indomethacin oral capsule 5 mg, 50 mg indomethacin oral capsule, extended release 75 mg ketoprofen oral capsule 50 mg, 75 mg ketoprofen oral capsule,ext rel. pellets 4 hr 00 mg PA; QL (0 per 0 days)

17 ketorolac oral tablet 0 mg LODINE ORAL TABLET 400 meclofenamate oral capsule 00 mg, 50 mg mefenamic acid oral capsule 50 mg meloxicam oral suspension 7.5 mg/5 ml meloxicam oral tablet 5 mg, 7.5 mg (Mobic) MOBIC ORAL SUSPENSION 7.5 /5 ML MOBIC ORAL TABLET 5, 7.5 nabumetone oral tablet 500 mg, 750 mg NALFON ORAL CAPSULE 400 NAPRELAN CR ORAL TABLET, ER MULTIPHASE 4 HR 75, 500, 750 NAPROSYN ORAL SUSPENSION 5 /5 ML NAPROSYN ORAL TABLET 50, 75, 500 naproxen oral suspension 5 mg/5 ml (Naprosyn) naproxen oral tablet 50 mg, 75 mg naproxen oral tablet 500 mg (Naprosyn) naproxen oral tablet,delayed release (EC-Naprosyn) (dr/ec) 75 mg, 500 mg naproxen sodium oral tablet 75 mg naproxen sodium oral tablet 550 mg (Anaprox DS) naproxen sodium oral tablet, er (Naprelan CR) multiphase 4 hr 75 mg, 500 mg oxaprozin oral tablet 600 mg (Daypro) piroxicam oral capsule 0 mg, 0 mg (Feldene) PONSTEL ORAL CAPSULE 50 PROFENO ORAL TABLET 600 salsalate oral tablet 500 mg, 750 mg (Disalcid) SPRIX NASAL SPRAY,NON- QL (5 per 0 days) AEROSOL 5.75 /SPRAY sulindac oral tablet 50 mg, 00 mg TIVORBEX ORAL CAPSULE 0 ST; QL (90 per 0 days), 40 tolmetin oral capsule 400 mg tolmetin oral tablet 00 mg 4

18 tolmetin oral tablet 600 mg VIMOVO ORAL ST; QL (60 per 0 days) TABLET,IR,DELAYED REL,BIPHASIC 75-0, VIVLODEX ORAL CAPSULE 0 ST; QL (0 per 0 days), 5 VOLTAREN-XR ORAL TABLET EXTENDED RELEASE 4 HR 00 ZIPSOR ORAL CAPSULE 5 ST; QL (0 per 0 days) ZORVOLEX ORAL CAPSULE 8 ST; QL (90 per 0 days), 5 Anesthetics Local Anesthetics ana-lex kit rectal kit - % ASTERO TOPICAL GEL WITH PUMP 4 % CIDALEAZE TOPICAL CREAM % EMLA TOPICAL CREAM.5-.5 % glydo mucous membrane jelly in applicator % lidocaine hcl mucous membrane jelly % lidocaine hcl mucous membrane solution 4 % (40 mg/ml) lidocaine hcl topical cream % (Lidopin) lidocaine hcl-hydrocortison ac rectal kit - % (7 gram) lidocaine hcl-hydrocortison ac topical cream -0.5 % lidocaine topical adhesive (Lidoderm) patch,medicated 5 % lidocaine topical ointment 5 % lidocaine viscous mucous membrane solution % lidocaine-hydrocortisone-aloe rectal kit (Ana-Lex Kit) - % lidocaine-hydrocortisone-aloe rectal kit -.5 % (7 gram) lidocaine-prilocaine topical cream.5-.5 % 5

19 lidocaine-prilocaine topical kit.5-.5 % (AgonEaze) lidocaine-tetracaine topical cream 7-7 % (Pliaglis) LIDODERM TOPICAL ADHESIVE PATCH,MEDICATED 5 % LIDO-K TOPICAL LOTION % LIDOPIN TOPICAL CREAM.5 % LIDORX TOPICAL GEL WITH PUMP % PLIAGLIS TOPICAL CREAM 7-7 % SYNERA TOPICAL PATCH, MEDICATED SELF-HEATING Anti-Addiction/Substance Abuse Treatment Agents Anti-Addiction/Substance Abuse Treatment Agents acamprosate oral tablet,delayed release (dr/ec) mg ANTABUSE ORAL TABLET 50, 500 BUNAVAIL BUCCAL FILM.-0. PA; QL (0 per 0 days) BUNAVAIL BUCCAL FILM , 6.- PA; QL (60 per 0 days) buprenorphine hcl sublingual tablet mg, 8 mg PA; QL (90 per 0 days) buprenorphine-naloxone sublingual tablet -0.5 mg, 8- mg PA; QL (90 per 0 days) buproban oral tablet extended release QL (60 per 0 days) hr 50 mg bupropion hcl (smoking deter) oral tablet (Zyban) QL (60 per 0 days) extended release hr 50 mg CAMPRAL ORAL TABLET,DELAYED RELEASE (DR/EC) CHANTIX CONTINUING MONTH 0 QL (6 per 65 days) BOX ORAL TABLET CHANTIX ORAL TABLET QL (67 per 65 days) CHANTIX ORAL TABLET 0 QL (6 per 65 days) 6

20 CHANTIX STARTING MONTH BOX ORAL TABLETS,DOSE PACK 0.5 ()- (4) 0 QL (06 per 65 days) disulfiram oral tablet 50 mg, 500 mg (Antabuse) EVZIO INJECTION AUTO- QL (0.8 per 65 days) INJECTOR 0.4 /0.4 ML, /0.4 ML naloxone injection solution 0.4 mg/ml naloxone injection syringe mg/ml naltrexone oral tablet 50 mg NARCAN NASAL SPRAY,NON- QL ( per 0 days) AEROSOL /ACTUATION, 4 /ACTUATION REVIA ORAL TABLET 50 SUBOXONE SUBLINGUAL FILM -, 8- PA; QL (60 per 0 days) SUBOXONE SUBLINGUAL FILM - 0.5, 4- PA; QL (0 per 0 days) ZUBSOLV SUBLINGUAL TABLET ,.4-0.6,.4-.9,.9-0.7, ZUBSOLV SUBLINGUAL TABLET ZYBAN ORAL TABLET EXTENDED RELEASE HR 50 Antianxiety Agents Benzodiazepines ALPRAZOLAM INTENSOL ORAL CONCENTRATE /ML alprazolam oral tablet 0.5 mg, 0.5 mg, mg, mg alprazolam oral tablet extended release 4 hr 0.5 mg, mg, mg, mg alprazolam oral tablet,disintegrating 0.5 mg, 0.5 mg, mg, mg ATIVAN ORAL TABLET 0.5,, buspirone oral tablet 0 mg, 5 mg, 0 mg, 5 mg, 7.5 mg chlordiazepoxide hcl oral capsule 0 mg, 5 mg, 5 mg (Xanax) (Xanax XR) PA; QL (0 per 0 days) PA; QL (60 per 0 days) 0 QL (60 per 0 days) 7

21 clonazepam oral tablet 0.5 mg, mg, (Klonopin) mg clonazepam oral tablet,disintegrating 0.5 mg, 0.5 mg, 0.5 mg, mg, mg clorazepate dipotassium oral tablet 5 mg,.75 mg clorazepate dipotassium oral tablet 7.5 mg (Tranxene T-Tab) DIASTAT ACUDIAL RECTAL KIT QL ( per day) , DIASTAT RECTAL KIT.5 QL ( per day) diazepam intensol oral concentrate 5 mg/ml diazepam oral solution 5 mg/5 ml ( mg/ml) diazepam oral tablet 0 mg, mg, 5 mg (Valium) diazepam rectal kit mg, (Diastat AcuDial) QL ( per day) mg diazepam rectal kit.5 mg (Diastat) QL ( per day) DORAL ORAL TABLET 5 estazolam oral tablet mg, mg flurazepam oral capsule 5 mg, 0 mg HALCION ORAL TABLET 0.5 KLONOPIN ORAL TABLET 0.5,, lorazepam oral concentrate mg/ml (Lorazepam Intensol) lorazepam oral tablet 0.5 mg, mg, mg (Ativan) meprobamate oral tablet 00 mg, 400 mg midazolam oral syrup mg/ml ONFI ORAL SUSPENSION.5 /ML PA; QL (480 per 0 days) ONFI ORAL TABLET 0, 0 PA; QL (60 per 0 days) oxazepam oral capsule 0 mg, 5 mg, 0 mg quazepam oral tablet 5 mg (Doral) RESTORIL ORAL CAPSULE 5,.5, 0, 7.5 temazepam oral capsule 5 mg,.5 mg, 0 mg, 7.5 mg (Restoril) 8

22 TRANXENE T-TAB ORAL TABLET 5,.75, 7.5 triazolam oral tablet 0.5 mg triazolam oral tablet 0.5 mg (Halcion) VALIUM ORAL TABLET 0,, 5 XANAX ORAL TABLET 0.5, 0.5,, XANAX XR ORAL TABLET EXTENDED RELEASE 4 HR 0.5,,, Antibacterials Aminoglycosides BETHKIS INHALATION SOLUTION FOR NEBULIZATION 00 /4 ML *May have Specialty Costshare neomycin oral tablet 500 mg TOBI INHALATION SOLUTION FOR NEBULIZATION 00 /5 ML *May have Specialty Costshare TOBI PODHALER INHALATION CAPSULE, W/INHALATION *May have Specialty Costshare DEVICE 8 tobramycin in 0.5 % nacl inhalation solution for nebulization 00 mg/5 ml (Tobi) *May have Specialty Costshare Antibacterials, Miscellaneous CLEOCIN HCL ORAL CAPSULE 50, 00, 75 CLEOCIN PEDIATRIC ORAL RECON SOLN 75 /5 ML clindamycin hcl oral capsule 50 mg, 00 (Cleocin HCl) mg, 75 mg clindamycin palmitate hcl oral recon soln (Cleocin Pediatric) 75 mg/5 ml FLAGYL ER ORAL TABLET EXTENDED RELEASE 750 FLAGYL ORAL CAPSULE 75 FLAGYL ORAL TABLET 50, 500 FURADANTIN ORAL SUSPENSION 5 /5 ML HIPREX ORAL TABLET GRAM hyolev mb oral tablet mg 9

23 linezolid oral suspension for (Zyvox) PA reconstitution 00 mg/5 ml linezolid oral tablet 600 mg (Zyvox) PA MACROBID ORAL CAPSULE 00 MACRODANTIN ORAL CAPSULE 00, 5, 50 methenamine hippurate oral tablet (Hiprex) gram methenamine mandelate oral tablet 0.5 g, gram methen-sod phos-meth blue-hyos oral (Urogesic-Blue) tablet mg metronidazole oral capsule 75 mg (Flagyl) metronidazole oral tablet 50 mg, 500 mg (Flagyl) MONUROL ORAL PACKET GRAM nitrofurantoin macrocrystal oral capsule (Macrodantin) 00 mg, 5 mg, 50 mg nitrofurantoin monohyd/m-cryst oral capsule 00 mg (Macrobid) nitrofurantoin oral suspension 5 mg/5 ml (Furadantin) PHOSPHASAL ORAL TABLET PRIMSOL ORAL SOLUTION 50 /5 ML SIVEXTRO ORAL TABLET 00 *May have Specialty Costshare SOLOSEC ORAL GRANULES DEL RELEASE IN PACKET GRAM trimethoprim oral tablet 00 mg TRIMPEX ORAL SOLUTION 50 /5 ML ur n-c oral tablet mg URELLE ORAL TABLET uretron d-s oral tablet mg URETRON D-S ORAL TABLET urimar-t oral tablet mg URIN DS ORAL TABLET

24 uro-458 oral tablet mg uro-blue oral tablet mg urogesic-blue oral tablet mg urolet mb oral tablet mg UROQID-ACID NO. ORAL TABLET UTIRA-C ORAL TABLET VANCOCIN ORAL CAPSULE 5 QL (56 per 0 days) VANCOCIN ORAL CAPSULE 50 QL ( per 0 days) vancomycin oral capsule 5 mg (Vancocin) QL (56 per 0 days) vancomycin oral capsule 50 mg (Vancocin) QL ( per 0 days) XIFAXAN ORAL TABLET 00 QL (6 per days) XIFAXAN ORAL TABLET 550 PA ZYVOX ORAL SUSPENSION FOR PA RECONSTITUTION 00 /5 ML ZYVOX ORAL TABLET 600 PA Cephalosporins CEDAX ORAL CAPSULE 400 CEDAX ORAL SUSPENSION FOR RECONSTITUTION 80 /5 ML cefaclor oral capsule 50 mg, 500 mg cefaclor oral suspension for reconstitution 5 mg/5 ml, 50 mg/5 ml, 75 mg/5 ml cefaclor oral tablet extended release hr 500 mg cefadroxil oral capsule 500 mg cefadroxil oral suspension for reconstitution 50 mg/5 ml, 500 mg/5 ml cefadroxil oral tablet gram cefdinir oral capsule 00 mg cefdinir oral suspension for reconstitution 5 mg/5 ml, 50 mg/5 ml cefditoren pivoxil oral tablet 00 mg cefditoren pivoxil oral tablet 400 mg (Spectracef) cefixime oral suspension for reconstitution 00 mg/5 ml, 00 mg/5 ml (Suprax)

25 cefpodoxime oral suspension for reconstitution 00 mg/5 ml, 50 mg/5 ml cefpodoxime oral tablet 00 mg, 00 mg cefprozil oral suspension for reconstitution 5 mg/5 ml, 50 mg/5 ml cefprozil oral tablet 50 mg, 500 mg ceftibuten oral capsule 400 mg ceftibuten oral suspension for reconstitution 80 mg/5 ml CEFTIN ORAL SUSPENSION FOR RECONSTITUTION 5 /5 ML, 50 /5 ML CEFTIN ORAL TABLET 50, 500 cefuroxime axetil oral tablet 50 mg, 500 mg cephalexin oral capsule 50 mg, 500 mg, (Keflex) 750 mg cephalexin oral suspension for reconstitution 5 mg/5 ml, 50 mg/5 ml cephalexin oral tablet 50 mg, 500 mg DAXBIA ORAL CAPSULE KEFLEX ORAL CAPSULE 50, 500, 750 SPECTRACEF ORAL TABLET 400 SUPRAX ORAL CAPSULE 400 SUPRAX ORAL SUSPENSION FOR RECONSTITUTION 00 /5 ML, 00 /5 ML SUPRAX ORAL SUSPENSION FOR RECONSTITUTION 500 /5 ML SUPRAX ORAL TABLET,CHEWABLE 00, 00 Macrolides azithromycin oral packet gram (Zithromax) azithromycin oral suspension for (Zithromax) reconstitution 00 mg/5 ml, 00 mg/5 ml azithromycin oral tablet 50 mg, 500 mg, 600 mg (Zithromax)

26 BIAXIN ORAL SUSPENSION FOR RECONSTITUTION 50 /5 ML BIAXIN ORAL TABLET 50, 500 BIAXIN XL ORAL TABLET EXTENDED RELEASE 4 HR 500 BIAXIN XL PAK ORAL TABLET EXTENDED RELEASE 4 HR 500 clarithromycin oral suspension for reconstitution 5 mg/5 ml, 50 mg/5 ml clarithromycin oral tablet 50 mg, 500 mg clarithromycin oral tablet extended release 4 hr 500 mg DIFICID ORAL TABLET 00 ST; QL (0 per 0 days) e.e.s. 400 oral tablet 400 mg E.E.S. GRANULES ORAL SUSPENSION FOR RECONSTITUTION 00 /5 ML ERYPED 00 ORAL SUSPENSION FOR RECONSTITUTION 00 /5 ML ERYPED 400 ORAL SUSPENSION FOR RECONSTITUTION 400 /5 ML ery-tab oral tablet,delayed release (dr/ec) 50 mg ERY-TAB ORAL TABLET,DELAYED RELEASE (DR/EC) ery-tab oral tablet,delayed release (dr/ec) 500 mg erythrocin (as stearate) oral tablet 50 mg erythromycin ethylsuccinate oral (E.E.S. Granules) suspension for reconstitution 00 mg/5 ml erythromycin ethylsuccinate oral tablet (E.E.S. 400) 400 mg erythromycin oral capsule,delayed release(dr/ec) 50 mg

27 erythromycin oral tablet 50 mg, 500 mg erythromycin-sulfisoxazole oral suspension for reconstitution mg/5 ml KETEK ORAL TABLET 00, 400 PCE ORAL TABLET, PARTICLES/CRYSTALS, 500 ZITHROMAX ORAL PACKET GRAM ZITHROMAX ORAL SUSPENSION FOR RECONSTITUTION 00 /5 ML, 00 /5 ML ZITHROMAX ORAL TABLET 50, 500, 600 ZITHROMAX TRI-PAK ORAL TABLET 500 ZITHROMAX Z-PAK ORAL TABLET 50 ZMAX ORAL SUSPENSION,EXTENDED REL RECON GRAM/60 ML Miscellaneous B-Lactam Antibiotics CAYSTON INHALATION SOLUTION FOR NEBULIZATION 75 /ML PA; *May have QL (84 per 56 days) Penicillins amoxicillin oral capsule 50 mg, 500 mg amoxicillin oral suspension for reconstitution 5 mg/5 ml, 00 mg/5 ml, 50 mg/5 ml, 400 mg/5 ml amoxicillin oral tablet 500 mg, 875 mg amoxicillin oral tablet, er multiphase 4 (Moxatag) hr 775 mg amoxicillin oral tablet,chewable 5 mg, 50 mg amoxicillin-pot clavulanate oral suspension for reconstitution mg/5 ml, mg/5 ml 4

28 amoxicillin-pot clavulanate oral (Augmentin) suspension for reconstitution mg/5 ml amoxicillin-pot clavulanate oral (Augmentin ES-600) suspension for reconstitution mg/5 ml amoxicillin-pot clavulanate oral tablet 50-5 mg amoxicillin-pot clavulanate oral tablet (Augmentin) mg, mg amoxicillin-pot clavulanate oral tablet (Augmentin XR) extended release hr, mg amoxicillin-pot clavulanate oral tablet,chewable mg, mg ampicillin oral capsule 50 mg, 500 mg ampicillin oral suspension for reconstitution 5 mg/5 ml, 50 mg/5 ml AUGMENTIN ES-600 ORAL SUSPENSION FOR RECONSTITUTION /5 ML AUGMENTIN ORAL SUSPENSION FOR RECONSTITUTION 5-.5 /5 ML AUGMENTIN ORAL SUSPENSION FOR RECONSTITUTION /5 ML AUGMENTIN ORAL TABLET 500-5, AUGMENTIN XR ORAL TABLET EXTENDED RELEASE HR, dicloxacillin oral capsule 50 mg, 500 mg MOXATAG ORAL TABLET, ER MULTIPHASE 4 HR 775 penicillin v potassium oral recon soln 5 mg/5 ml, 50 mg/5 ml penicillin v potassium oral tablet 50 mg, 500 mg Quinolones AVELOX ABC PACK ORAL TABLET 400 5

29 AVELOX ORAL TABLET 400 BAXDELA ORAL TABLET 450 CIPRO ORAL SUSPENSION,MICROCAPSULE RECON 50 /5 ML, 500 /5 ML CIPRO ORAL TABLET 50, 500 CIPRO XR ORAL TABLET, ER MULTIPHASE 4 HR,000, 500 ciprofloxacin (mixture) oral tablet, er (Cipro XR) multiphase 4 hr,000 mg, 500 mg ciprofloxacin hcl oral tablet 00 mg, 750 mg ciprofloxacin hcl oral tablet 50 mg, 500 (Cipro) mg ciprofloxacin oral (Cipro) suspension,microcapsule recon 50 mg/5 ml, 500 mg/5 ml FACTIVE ORAL TABLET 0 LEVAQUIN ORAL SOLUTION 50 /0 ML LEVAQUIN ORAL TABLET 50, 500, 750 levofloxacin oral solution 50 mg/0 ml levofloxacin oral tablet 50 mg, 500 mg, (Levaquin) 750 mg moxifloxacin oral tablet 400 mg (Avelox) NOROXIN ORAL TABLET 400 ofloxacin oral tablet 00 mg, 400 mg Sulfonamides BACTRIM DS ORAL TABLET BACTRIM ORAL TABLET sulfadiazine oral tablet 500 mg sulfamethoxazole-trimethoprim oral (Sulfatrim) suspension mg/5 ml sulfamethoxazole-trimethoprim oral (Bactrim) tablet mg sulfamethoxazole-trimethoprim oral tablet mg (Bactrim DS) 6

30 sulfatrim oral suspension mg/5 ml Tetracyclines ACTICLATE ORAL TABLET 50, 75 ADOXA ORAL CAPSULE 50 PA AVIDOXY ORAL TABLET 00 PA BENZODOX 0 KIT, CLEANSER ER AND TABLET % BENZODOX 60 KIT, CLEANSER ER AND TABLET % demeclocycline oral tablet 50 mg, 00 mg DORYX MPC ORAL PA TABLET,DELAYED RELEASE (DR/EC) 0 DORYX ORAL TABLET,DELAYED RELEASE (DR/EC) 50, 00, 50 PA doxycycline hyclate oral capsule 00 mg, (Morgidox) 50 mg doxycycline hyclate oral tablet 00 mg, 0 mg doxycycline hyclate oral tablet 50 mg, (Acticlate) 75 mg doxycycline hyclate oral tablet 50 mg (Targadox) doxycycline hyclate oral tablet,delayed release (dr/ec) 00 mg, 75 mg doxycycline hyclate oral tablet,delayed (Soloxide) release (dr/ec) 50 mg doxycycline hyclate oral tablet,delayed (Doryx) PA release (dr/ec) 00 mg, 50 mg doxycycline monohydrate oral capsule (Mondoxyne NL) 00 mg, 50 mg doxycycline monohydrate oral capsule 50 mg doxycycline monohydrate oral capsule,ir (Oracea) - delay rel,biphase 40 mg doxycycline monohydrate oral suspension (Vibramycin) for reconstitution 5 mg/5 ml doxycycline monohydrate oral tablet 00 mg (Avidoxy) 7

31 doxycycline monohydrate oral tablet 50 mg, 50 mg, 75 mg MINOCIN KIT WITH WIPES COMBO PACK 00, 50 MINOCIN ORAL CAPSULE 00, 50, 75 minocycline oral capsule 00 mg, 50 mg, (Minocin) 75 mg minocycline oral tablet 00 mg, 50 mg, 75 mg minocycline oral tablet extended release (Solodyn) PA 4 hr 5 mg, 65 mg minocycline oral tablet extended release (CoreMino) PA 4 hr 5 mg, 45 mg, 90 mg mondoxyne nl oral capsule 00 mg, 50 PA mg, 75 mg MONODOX ORAL CAPSULE 00 PA, 50, 75 MORGIDOX ORAL CAPSULE 00, 50 ORACEA ORAL CAPSULE,IR - PA DELAY REL,BIPHASE 40 SOLODYN ORAL TABLET PA EXTENDED RELEASE 4 HR 05, 5, 55, 65, 80 TARGADOX ORAL TABLET 50 PA; QL (0 per 0 days) tetracycline oral capsule 50 mg, 500 mg VIBRAMYCIN ORAL CAPSULE 00 VIBRAMYCIN ORAL SUSPENSION FOR RECONSTITUTION 5 /5 ML VIBRAMYCIN ORAL SYRUP 50 /5 ML XIMINO ORAL CAPSULE,EXTENDED RELEASE 4HR 5, 45, 90 PA 8

32 Anticancer Agents Anticancer Agents AFINITOR DISPERZ ORAL TABLET FOR SUSPENSION,, 5 AFINITOR ORAL TABLET 0, 7.5 AFINITOR ORAL TABLET.5, 5 ALECENSA ORAL CAPSULE 50 PA; *May have QL ( per 8 days) PA; *May have QL (60 per 0 days) PA; *May have QL (0 per 0 days) PA; *May have QL (40 per 0 days) ALKERAN ORAL TABLET ALUNBRIG ORAL TABLET 80, 90 PA; *May have QL (0 per 0 days) ALUNBRIG ORAL TABLET 0 PA; *May have QL (0 per 0 days) ALUNBRIG ORAL TABLETS,DOSE PACK 90 (7)- 80 () PA; *May have QL (0 per 0 days) anastrozole oral tablet mg (Arimidex) ARIMIDEX ORAL TABLET AROMASIN ORAL TABLET 5 ST bexarotene oral capsule 75 mg (Targretin) PA NSO; *May have QL (40 per 0 days) bicalutamide oral tablet 50 mg (Casodex) BOSULIF ORAL TABLET 00 PA; *May have QL (0 per 0 days) BOSULIF ORAL TABLET 400, 500 CABOMETYX ORAL TABLET 0, 60 PA; *May have QL (0 per 0 days) PA; *May have QL (0 per 0 days) 9

33 CABOMETYX ORAL TABLET 40 CALQUENCE ORAL CAPSULE 00 PA; *May have QL (60 per 0 days) PA; *May have QL (60 per 0 days) capecitabine oral tablet 50 mg, 500 mg (Xeloda) *May have Specialty Costshare CAPRELSA ORAL TABLET 00 PA; *May have QL (60 per 0 days) CAPRELSA ORAL TABLET 00 PA; *May have QL (0 per 0 days) CASODEX ORAL TABLET 50 COMETRIQ ORAL CAPSULE 00 /DAY(80 X-0 X), 40 /DAY(80 X-0 X), 60 /DAY (0 X /DAY) PA; *May have QL ( per 8 days) COTELLIC ORAL TABLET 0 PA; *May have QL (6 per 8 days) CYCLOPHOSPHAMIDE ORAL CAPSULE 5, 50 *May have Specialty Costshare cyclophosphamide oral tablet 5 mg, 50 mg *May have Specialty Costshare DROXIA ORAL CAPSULE 00, 00, 400 EMCYT ORAL CAPSULE 40 *May have Specialty Costshare ERIVEDGE ORAL CAPSULE 50 PA; *May have QL (0 per 0 days) ERLEADA ORAL TABLET 60 PA; *May have QL (0 per 0 days) etoposide oral capsule 50 mg exemestane oral tablet 5 mg (Aromasin) ST FARESTON ORAL TABLET 60 *May have Specialty Costshare 0

34 FARYDAK ORAL CAPSULE 0, 5, 0 PA; *May have QL (6 per days) FEMARA ORAL TABLET.5 flutamide oral capsule 5 mg GILOTRIF ORAL TABLET 0, 0, 40 PA; *May have QL (0 per 0 days) GLEEVEC ORAL TABLET 00 PA; *May have QL (60 per 0 days) GLEEVEC ORAL TABLET 400 PA; *May have QL (0 per 0 days) GLEOSTINE ORAL CAPSULE 0, 00, 40, 5 *May have Specialty Costshare HEXALEN ORAL CAPSULE 50 *May have Specialty Costshare HYCAMTIN ORAL CAPSULE 0.5, *May have Specialty Costshare HYDREA ORAL CAPSULE 500 hydroxyurea oral capsule 500 mg (Hydrea) IBRANCE ORAL CAPSULE 00, 5, 75 PA; *May have QL ( per 8 days) ICLUSIG ORAL TABLET 5 PA; *May have QL (60 per 0 days) ICLUSIG ORAL TABLET 45 PA; *May have QL (0 per 0 days) IDHIFA ORAL TABLET 00, 50 PA; *May have QL (0 per 0 days) imatinib oral tablet 00 mg (Gleevec) PA; *May have QL (60 per 0 days) imatinib oral tablet 400 mg (Gleevec) PA; *May have QL (0 per 0 days)

35 IMBRUVICA ORAL CAPSULE 40 PA; *May have QL (0 per 0 days) PA; QL (0 per 0 days) PA; QL (0 per 0 days) IMBRUVICA ORAL CAPSULE 70 IMBRUVICA ORAL TABLET 40, 80, 40, 560 INLYTA ORAL TABLET PA; *May have QL (80 per 0 days) INLYTA ORAL TABLET 5 PA; *May have QL (0 per 0 days) IRESSA ORAL TABLET 50 PA; *May have QL (60 per 0 days) JAKAFI ORAL TABLET 0, 5, 0, 5, 5 KISQALI FEMARA CO-PACK ORAL TABLET 00 /DAY(00 X )-.5 KISQALI FEMARA CO-PACK ORAL TABLET 400 /DAY(00 X )-.5 KISQALI FEMARA CO-PACK ORAL TABLET 600 /DAY(00 X )-.5 KISQALI ORAL TABLET 00 /DAY (00 X ) KISQALI ORAL TABLET 400 /DAY (00 X ) KISQALI ORAL TABLET 600 /DAY (00 X ) LENVIMA ORAL CAPSULE 0 /DAY (0 X /DAY) PA; *May have QL (60 per 0 days) PA; *May have QL (49 per 8 days) PA; *May have QL (70 per 8 days) PA; *May have QL (9 per 8 days) PA; *May have QL ( per 8 days) PA; *May have QL (4 per 8 days) PA; *May have QL (6 per 8 days) PA; *May have QL (0 per 0 days)

36 LENVIMA ORAL CAPSULE 4 /DAY(0 X -4 X ), 0 /DAY (0 X ), 8 /DAY (4 X ) LENVIMA ORAL CAPSULE 8 /DAY (0 X -4 X), 4 /DAY(0 X -4 X ) PA; *May have QL (60 per 0 days) PA; *May have QL (90 per 0 days) letrozole oral tablet.5 mg (Femara) LEUKERAN ORAL TABLET *May have Specialty Costshare leuprolide subcutaneous kit mg/0. ml PA; *May have Specialty Costshare lomustine oral capsule 0 mg, 00 mg, 40 mg (Gleostine) *May have Specialty Costshare LONSURF ORAL TABLET LONSURF ORAL TABLET LYNPARZA ORAL CAPSULE 50 LYNPARZA ORAL TABLET 00, 50 PA; *May have QL (00 per 8 days) PA; *May have QL (80 per 8 days) PA; *May have QL (480 per 0 days) PA; *May have QL (0 per 0 days) LYSODREN ORAL TABLET 500 *May have Specialty Costshare MATULANE ORAL CAPSULE 50 *May have Specialty Costshare megestrol oral tablet 0 mg, 40 mg MEKINIST ORAL TABLET 0.5 PA; *May have QL (90 per 0 days) MEKINIST ORAL TABLET PA; *May have QL (0 per 0 days) melphalan oral tablet mg (Alkeran) mercaptopurine oral tablet 50 mg methotrexate sodium (pf) injection recon soln gram

37 methotrexate sodium (pf) injection solution 5 mg/ml methotrexate sodium injection solution 5 mg/ml methotrexate sodium oral tablet.5 mg MYLERAN ORAL TABLET *May have Specialty Costshare NERLYNX ORAL TABLET 40 PA; *May have QL (80 per 0 days) NEXAVAR ORAL TABLET 00 PA; *May have QL (0 per 0 days) NILANDRON ORAL TABLET 50 *May have Specialty Costshare; QL (50 per 0 days) nilutamide oral tablet 50 mg (Nilandron) *May have Specialty Costshare; QL (50 per 0 days) NINLARO ORAL CAPSULE.,, 4 PA; *May have QL ( per 8 days) ODOMZO ORAL CAPSULE 00 PA; *May have QL (0 per 0 days) POMALYST ORAL CAPSULE,,, 4 PURINETHOL ORAL TABLET 50 PURIXAN ORAL SUSPENSION 0 /ML REVLIMID ORAL CAPSULE 0, 5,.5, 0, 5, 5 RHEUMATREX ORAL TABLETS,DOSE PACK.5 RUBRACA ORAL TABLET 00, 50, 00 PA; *May have QL ( per 8 days) PA; *May have QL (8 per 8 days) PA; *May have QL (0 per 0 days) 4

38 RYDAPT ORAL CAPSULE 5 PA; *May have QL (4 per 8 days) SOLTAMOX ORAL SOLUTION 0 /5 ML SPRYCEL ORAL TABLET 00, 40, 50, 70, 80 PA; *May have QL (0 per 0 days) SPRYCEL ORAL TABLET 0 PA; *May have QL (60 per 0 days) STIVARGA ORAL TABLET 40 PA; *May have QL (84 per 8 days) SUTENT ORAL CAPSULE.5, 5, 7.5, 50 SYNRIBO SUBCUTANEOUS RECON SOLN.5 PA; *May have QL (0 per 0 days) PA; *May have QL (8 per 8 days) TABLOID ORAL TABLET 40 *May have Specialty Costshare TAFINLAR ORAL CAPSULE 50, 75 PA; *May have QL (0 per 0 days) TAGRISSO ORAL TABLET 40, 80 PA; *May have QL (0 per 0 days) tamoxifen oral tablet 0 mg, 0 mg 0 TARCEVA ORAL TABLET 00, 5 PA; *May have QL (60 per 0 days) TARCEVA ORAL TABLET 50 PA; *May have QL (90 per 0 days) TARGRETIN ORAL CAPSULE 75 PA NSO; *May have QL (40 per 0 days) TARGRETIN TOPICAL GEL % PA NSO; *May have QL (60 per 0 days) 5

39 TASIGNA ORAL CAPSULE 50, 00, 50 TEMODAR ORAL CAPSULE 00, 40, 80, 0, 50, 5 temozolomide oral capsule 00 mg, 40 mg, 80 mg, 0 mg, 50 mg, 5 mg tretinoin (chemotherapy) oral capsule 0 mg TREXALL ORAL TABLET 0, 5, 5, 7.5 PA; *May have QL (0 per 0 days) *May have Specialty Costshare (Temodar) *May have Specialty Costshare *May have Specialty Costshare TYKERB ORAL TABLET 50 PA; *May have QL (80 per 0 days) VENCLEXTA ORAL TABLET 0 VENCLEXTA ORAL TABLET 00 VENCLEXTA ORAL TABLET 50 VENCLEXTA STARTING PACK ORAL TABLETS,DOSE PACK VERZENIO ORAL TABLET 00, 50, 00, 50 PA; *May have QL (60 per 0 days) PA; *May have QL (0 per 0 days) PA; *May have QL (0 per 0 days) PA; *May have QL (4 per 8 days) PA; *May have QL (56 per 8 days) VOTRIENT ORAL TABLET 00 PA; *May have QL (0 per 0 days) XALKORI ORAL CAPSULE 00, 50 XATMEP ORAL SOLUTION.5 /ML XELODA ORAL TABLET 50, 500 PA; *May have QL (60 per 0 days) *May have Specialty Costshare *May have Specialty Costshare 6

40 XTANDI ORAL CAPSULE 40 PA; *May have QL (0 per 0 days) ZEJULA ORAL CAPSULE 00 PA; *May have QL (90 per 0 days) ZELBORAF ORAL TABLET 40 PA; *May have QL (40 per 0 days) ZOLINZA ORAL CAPSULE 00 *May have Specialty Costshare ZYDELIG ORAL TABLET 00, 50 *May have Specialty Costshare ZYKADIA ORAL CAPSULE 50 PA; *May have QL (40 per 8 days) ZYTIGA ORAL TABLET 50 PA; *May have QL (0 per 0 days) ZYTIGA ORAL TABLET 500 PA; *May have QL (60 per 0 days) Anticholinergic Agents Antimuscarinics/Antispasmodics B-DONNA ORAL TABLET chlordiazepoxide-clidinium oral capsule (Librax (with 5-.5 mg clidinium)) DONNATAL ORAL ELIXIR /5 ML DONNATAL ORAL TABLET LIBRAX (WITH CLIDINIUM) ORAL CAPSULE 5-.5 PHENOBARB-HYOSCY- (Donnatal) ATROPINE-SCOP ORAL ELIXIR /5 ML phenobarb-hyoscy-atropine-scop oral (Donnatal) tablet mg PHENOHYTRO ORAL TABLET propantheline oral tablet 5 mg 7

41 Anticonvulsants Anticonvulsants APTIOM ORAL TABLET 00, ST; QL (0 per 0 days) 400, 800 APTIOM ORAL TABLET 600 ST; QL (60 per 0 days) BANZEL ORAL SUSPENSION 40 /ML BANZEL ORAL TABLET 00, 400 BRIVIACT ORAL SOLUTION 0 /ML BRIVIACT ORAL TABLET 0, 00, 5, 50, 75 ST; *May have QL (600 per 0 days) ST; *May have QL (60 per 0 days) (Carbatrol) carbamazepine oral capsule, er multiphase hr 00 mg, 00 mg, 00 mg carbamazepine oral suspension 00 mg/5 (Tegretol) ml carbamazepine oral tablet 00 mg (Epitol) carbamazepine oral tablet extended (Tegretol XR) release hr 00 mg, 00 mg, 400 mg carbamazepine oral tablet,chewable 00 mg CARBATROL ORAL CAPSULE, ER MULTIPHASE HR 00, 00, 00 CELONTIN ORAL CAPSULE 00 DEPAKENE ORAL CAPSULE 50 DEPAKENE ORAL SOLUTION 50 /5 ML DEPAKOTE ER ORAL TABLET EXTENDED RELEASE 4 HR 50 DEPAKOTE ER ORAL TABLET EXTENDED RELEASE 4 HR 500 DEPAKOTE ORAL TABLET,DELAYED RELEASE (DR/EC) 5, 50, 500 8

42 DEPAKOTE SPRINKLES ORAL CAPSULE, DELAYED REL SPRINKLE 5 DILANTIN EXTENDED ORAL CAPSULE 00 DILANTIN INFATABS ORAL TABLET,CHEWABLE 50 DILANTIN ORAL CAPSULE 0 DILANTIN-5 ORAL SUSPENSION 5 /5 ML divalproex oral capsule, delayed rel sprinkle 5 mg (Depakote Sprinkles) divalproex oral tablet extended release 4 (Depakote ER) hr 50 mg, 500 mg divalproex oral tablet,delayed release (Depakote) (dr/ec) 5 mg, 50 mg, 500 mg epitol oral tablet 00 mg EQUETRO ORAL CAPSULE, ER MULTIPHASE HR 00, 00, 00 ethosuximide oral capsule 50 mg (Zarontin) ethosuximide oral solution 50 mg/5 ml (Zarontin) felbamate oral suspension 600 mg/5 ml (Felbatol) felbamate oral tablet 400 mg, 600 mg (Felbatol) FELBATOL ORAL SUSPENSION 600 /5 ML FELBATOL ORAL TABLET 400, 600 FYCOMPA ORAL SUSPENSION 0.5 /ML ST; QL (680 per 8 days) FYCOMPA ORAL TABLET 0, ST; QL (0 per 0 days), 8 FYCOMPA ORAL TABLET ST; QL (0 per 0 days) FYCOMPA ORAL TABLET 4, 6 ST; QL (60 per 0 days) gabapentin oral capsule 00 mg, 00 mg, (Neurontin) 400 mg gabapentin oral solution 50 mg/5 ml (Neurontin) gabapentin oral tablet 600 mg, 800 mg (Neurontin) GABITRIL ORAL TABLET, 6,, 4 9

43 GRALISE 0-DAY STARTER PACK ORAL TABLET EXTENDED RELEASE 4 HR 00 (9)- 600 (69) GRALISE ORAL TABLET EXTENDED RELEASE 4 HR 00, 600 HORIZANT ORAL TABLET EXTENDED RELEASE 00 HORIZANT ORAL TABLET EXTENDED RELEASE 600 KEPPRA ORAL SOLUTION 00 /ML KEPPRA ORAL TABLET,000, 50, 500, 750 KEPPRA XR ORAL TABLET EXTENDED RELEASE 4 HR 500, 750 LAMICTAL ODT ORAL TABLET,DISINTEGRATING 00, 00, 5, 50 LAMICTAL ODT STARTER (BLUE) ORAL TABLET DISINTEGRATING, DOSE PK 5 () -50 (7) LAMICTAL ODT STARTER (GREEN) ORAL TABLET DISINTEGRATING, DOSE PK 50 (4) -00 (4) LAMICTAL ODT STARTER (ORANGE) ORAL TABLET DISINTEGRATING, DOSE PK 5 (4)-50 (4)-00 (7) LAMICTAL ORAL TABLET 00, 50, 00, 5 LAMICTAL ORAL TABLET, CHEWABLE DISPERSIBLE, 5, 5 LAMICTAL STARTER (BLUE) KIT ORAL TABLETS,DOSE PACK 5 (5) LAMICTAL STARTER (GREEN) KIT ORAL TABLETS,DOSE PACK 5 (84) -00 (4) ST; QL (78 per 0 days) ST; QL (90 per 0 days) ST; QL (0 per 0 days) ST; QL (60 per 0 days) 40

44 LAMICTAL STARTER (ORANGE) KIT ORAL TABLETS,DOSE PACK 5 (4) -00 (7) LAMICTAL XR ORAL TABLET EXTENDED RELEASE 4HR 00, 00, 5, 50, 00, 50 LAMICTAL XR STARTER (BLUE) ORAL TABLET EXTENDED REL,DOSE PACK 5 () -50 (7) LAMICTAL XR STARTER (GREEN) ORAL TABLET EXTENDED REL,DOSE PACK 50 (4)-00 (4)-00 (7) LAMICTAL XR STARTER (ORANGE) ORAL TABLET EXTENDED REL,DOSE PACK 5 (4)-50 (4)-00 (7) lamotrigine oral tablet 00 mg, 50 mg, 00 mg, 5 mg lamotrigine oral tablet disintegrating, dose pk 5 mg () -50 mg (7) lamotrigine oral tablet disintegrating, dose pk 5 mg(4)-50 mg (4)-00 mg (7) lamotrigine oral tablet disintegrating, dose pk 50 mg (4) -00 mg (4) lamotrigine oral tablet extended release 4hr 00 mg, 00 mg, 5 mg, 50 mg, 00 mg, 50 mg lamotrigine oral tablet, chewable dispersible 5 mg, 5 mg lamotrigine oral tablet,disintegrating 00 mg, 00 mg, 5 mg, 50 mg lamotrigine oral tablets,dose pack 5 mg (5) lamotrigine oral tablets,dose pack 5 mg (4) -00 mg (7) lamotrigine oral tablets,dose pack 5 mg (84) -00 mg (4) (Lamictal) (Lamictal ODT Starter (Blue)) (Lamictal ODT Starter (Orange)) (Lamictal ODT Starter (Green)) (Lamictal XR) (Lamictal) (Lamictal ODT) (Lamictal Starter (Blue) Kit) (Lamictal Starter (Orange) Kit) (Lamictal Starter (Green) Kit) levetiracetam oral solution 00 mg/ml (Keppra) 4

45 levetiracetam oral tablet,000 mg, 50 (Keppra) mg, 500 mg, 750 mg levetiracetam oral tablet extended release (Keppra XR) 4 hr 500 mg, 750 mg LYRICA ORAL CAPSULE 00, 50, 00, 5, 5, 00, 50, 75 LYRICA ORAL SOLUTION 0 /ML MYSOLINE ORAL TABLET 50, 50 NEURONTIN ORAL CAPSULE 00, 00, 400 NEURONTIN ORAL SOLUTION 50 /5 ML NEURONTIN ORAL TABLET 600, 800 oxcarbazepine oral suspension 00 mg/5 (Trileptal) ml (60 mg/ml) oxcarbazepine oral tablet 50 mg, 00 mg, 600 mg (Trileptal) OXTELLAR XR ORAL TABLET ST; QL (0 per 0 days) EXTENDED RELEASE 4 HR 50, 00 OXTELLAR XR ORAL TABLET EXTENDED RELEASE 4 HR 600 ST; QL (0 per 0 days) PEGANONE ORAL TABLET 50 phenobarbital oral elixir 0 mg/5 ml (4 mg/ml) phenobarbital oral tablet 00 mg, 5 mg, 6. mg, 0 mg,.4 mg, 60 mg, 64.8 mg, 97. mg PHENYTEK ORAL CAPSULE 00, 00 phenytoin oral suspension 5 mg/5 ml (Dilantin-5) phenytoin oral tablet,chewable 50 mg (Dilantin Infatabs) phenytoin sodium extended oral capsule (Dilantin Extended) 00 mg phenytoin sodium extended oral capsule 00 mg, 00 mg (Phenytek) 4

46 POTIGA ORAL TABLET 00, ST; QL (90 per 0 days) 00, 400 POTIGA ORAL TABLET 50 ST; QL (70 per 0 days) primidone oral tablet 50 mg, 50 mg (Mysoline) QUDEXY XR ORAL ST; QL (0 per 0 days) CAPSULE,SPRINKLE,ER 4HR 00, 5, 50 QUDEXY XR ORAL ST; QL (60 per 0 days) CAPSULE,SPRINKLE,ER 4HR 50, 00 ROWEEPRA ORAL TABLET,000, 750 ROWEEPRA XR ORAL TABLET EXTENDED RELEASE 4 HR 500, 750 SABRIL ORAL POWDER IN QL (80 per 0 days) PACKET 500 SABRIL ORAL TABLET 500 QL (80 per 0 days) SPRITAM ORAL TABLET FOR ST; QL (60 per 0 days) SUSPENSION,000 SPRITAM ORAL TABLET FOR SUSPENSION 50, 500, 750 ST; QL (0 per 0 days) STAVZOR ORAL CAPSULE,DELAYED RELEASE(DR/EC) 5, 50, 500 TEGRETOL ORAL SUSPENSION 00 /5 ML TEGRETOL ORAL TABLET 00 TEGRETOL XR ORAL TABLET EXTENDED RELEASE HR 00, 00, 400 tiagabine oral tablet mg, 6 mg, mg, (Gabitril) 4 mg TOPAMAX ORAL CAPSULE, SPRINKLE 5, 5 TOPAMAX ORAL TABLET 00, 00, 5, 50 topiragen oral tablet 00 mg, 00 mg, 5 mg, 50 mg 4

47 topiramate oral capsule, sprinkle 5 mg, (Topamax) 5 mg topiramate oral capsule,sprinkle,er 4hr (Qudexy XR) 00 mg, 50 mg, 00 mg, 5 mg, 50 mg topiramate oral tablet 00 mg, 00 mg, (Topamax) 5 mg, 50 mg TRILEPTAL ORAL SUSPENSION 00 /5 ML (60 /ML) TRILEPTAL ORAL TABLET 50, 00, 600 TROKENDI XR ORAL ST; QL (0 per 0 days) CAPSULE,EXTENDED RELEASE 4HR 00, 5, 50 TROKENDI XR ORAL CAPSULE,EXTENDED RELEASE 4HR 00 ST; QL (60 per 0 days) valproic acid (as sodium salt) oral (Depakene) solution 50 mg/5 ml valproic acid oral capsule 50 mg (Depakene) vigabatrin oral powder in packet 500 mg (Sabril) QL (80 per 0 days) VIMPAT ORAL SOLUTION 0 /ML VIMPAT ORAL TABLET 00, 50, 00, 50 ZARONTIN ORAL CAPSULE 50 ZARONTIN ORAL SOLUTION 50 /5 ML ZONEGRAN ORAL CAPSULE 00, 5 zonisamide oral capsule 00 mg, 5 mg (Zonegran) zonisamide oral capsule 50 mg Antidementia Agents Antidementia Agents ARICEPT ODT ORAL TABLET,DISINTEGRATING 0, 5 ARICEPT ORAL TABLET 0,, 5 donepezil oral tablet 0 mg, 5 mg (Aricept) donepezil oral tablet mg (Aricept) 44