AETNA BETTER HEALTH Formulary Guide Aetna Better Health of Kentucky Formulary Guide May 2017

Transcription

1 AETNA BETTER HEALTH Formulary Guide Aetna Better Health of Kentucky Formulary Guide May

2 AETNA BETTER HEALTH Formulary Guide What is the Aetna Better Health of Kentucky Formulary? This is a drug list created by Aetna Better Health ( plan ). The plan will cover drugs on this list. Some drugs may have coverage rules. If the rules for that drug are met, the plan will cover the drug. Drugs must also be filled at a plan network pharmacy. Can the Plan s Drug List change? The plan may add or remove drugs on the list. All drug removals from the formulary will be sent to the state for review before the change is made. Utilizing members and their providers will be notified at least 30 days before a drug is removed from the formulary. All changes to the formulary will be posted on the plan s website. How do I use the Plan s Formulary? Column #1: lists the covered drug. Brand drugs are in upper case letters (e.g., DRUG). Generics are in lower case letters (e.g., drug). Column #2: shows brand drug for the generic; brand drugs are not covered if generic equivalent is available. Column #3: tells you if drug has a need for prior authorization or other restrictions Drugs are also grouped by drug class. If you know what class your drug is in, please look for that class name in the table of contents. Then look under that page for your drug. What are generic drugs? The plan covers both brand and generic drugs. Generic drugs cost less and are approved by the Food and Drug Administration (FDA). Are Over-The-Counter (OTC) drugs covered? The plan will cover OTC drugs on the formulary. Some OTC drugs may have coverage rules. If the rules for that OTC drug are met, the plan will cover the OTC drug. Like other drugs, OTC drugs need a prescription from a doctor if they are to be covered by the plan. Are there Medication Copays? Refer to member handbook for copay information. Updated: May 1, 2017 Page 2

3 AETNA BETTER HEALTH Formulary Guide What are some types of coverage rules? Prior Approval (PA): This means your doctor will need to get approval from the plan first before the drug can be filled at the pharmacy. If it is not approved, the plan will not cover the drug. Quantity Level Limits (QLL): This means there is a limit on the amount of drug the plan will cover. For example, the plan provides 60 pills in 30 days for some drugs. Step Therapy (ST): This means you may need to try certain drugs first to treat your condition. After the first drug is tried, the plan will then cover the other drug for that same condition. For example, Drug A and Drug B may treat your condition. The plan may not cover Drug B unless you try Drug A first. If Drug A does not work for you, then Drug B will be covered. What if my drug is not on the plan s Formulary? First, please call your doctor and ask if your drug is covered. If the plan does not cover the drug, then: Ask your doctor for a similar drug that is covered. Your doctor can ask the plan to cover your drug through the prior approval process. Updated: May 1, 2017 Page 3

4 Aetna Better Health Kentucky Table of Contents *ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS*...3 *AMINOGLYCOSIDES*... 5 *ANALGESICS - ANTI-INFLAMMATORY*... 5 *ANALGESICS - NONNARCOTIC*...7 *ANALGESICS - OPIOID*... 7 *ANDROGENS-ANABOLIC* *ANORECTAL AGENTS*...10 *ANTHELMINTICS* *ANTIANGINAL AGENTS* *ANTIANXIETY AGENTS*...12 *ANTIARRHYTHMICS* *ANTIASTHMATIC AND BRONCHODILATOR AGENTS* *ANTICOAGULANTS* *ANTICONVULSANTS*...16 *ANTIDEPRESSANTS*...18 *ANTIDIABETICS* *ANTIDIARRHEALS*...22 *ANTIDOTES* *ANTIEMETICS* *ANTIFUNGALS*...23 *ANTIHISTAMINES* *ANTIHYPERLIPIDEMICS*...24 *ANTIHYPERTENSIVES* *ANTI-INFECTIVE AGENTS - MISC.* *ANTIMALARIALS*...29 *ANTIMYASTHENIC AGENTS* *ANTIMYCOBACTERIAL AGENTS* *ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES*...30 *ANTIPARKINSON AGENTS*...32 *ANTIPSYCHOTICS/ANTIMANIC AGENTS* *ANTIRETROVIRALS ADJUVANTS*** *ANTISEPTICS & DISINFECTANTS*...35 *ANTIVIRALS*...36 *ASSORTED CLASSES* *BETA BLOCKERS* *CALCIUM CHANNEL BLOCKERS* *CARDIOTONICS* *CARDIOVASCULAR AGENTS - MISC.* *CEPHALOSPORINS*...44 *CHEMICALS*...45 *CONTRACEPTIVES*...45 *CORTICOSTEROIDS* *COUGH/COLD/ALLERGY*...53 *DERMATOLOGICALS*

5 *DIAGNOSTIC PRODUCTS*...61 *DIGESTIVE AIDS*...62 *DIURETICS*...62 *ENDOCRINE AND METABOLIC AGENTS - MISC.*...63 *ESTROGENS*...64 *FLUOROQUINOLONES* *GASTROINTESTINAL AGENTS - MISC.*...65 *GENITOURINARY AGENTS - MISCELLANEOUS* *GOUT AGENTS*...67 *HEMATOLOGICAL AGENTS - MISC.* *HEMATOPOIETIC AGENTS*...68 *HEPATITIS C AGENT - COMBINATIONS*** *HYPNOTICS* *LAXATIVES* *MACROLIDES*...70 *MEDICAL DEVICES*...71 *MIGRAINE PRODUCTS*...75 *MINERALS & ELECTROLYTES*...76 *MOUTH/THROAT/DENTAL AGENTS*...78 *MULTIVITAMINS*...79 *MUSCULOSKELETAL THERAPY AGENTS*...83 *NASAL AGENTS - SYSTEMIC AND TOPICAL* *NEPRILYSIN INHIB (ARNI)-ANGIOTENSIN II RECEPT ANTAG COMB*** *NEUROMUSCULAR AGENTS* *OPHTHALMIC AGENTS*...85 *OTIC AGENTS*...88 *PASSIVE IMMUNIZING AGENTS*...88 *PENICILLINS*...89 *PHARMACEUTICAL ADJUVANTS* *POTASSIUM REMOVING AGENTS***...94 *PROGESTINS*...94 *PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.*...94 *SULFONAMIDES*...96 *TETRACYCLINES* *THYROID AGENTS* *ULCER DRUGS* *URINARY ANTI-INFECTIVES* *URINARY ANTISPASMODICS* *VACCINES* *VAGINAL PRODUCTS* *VASOPRESSORS* *VITAMINS*

6 Aetna Better Health Kentucky CURRENT AS OF 5/1/2017 Drug Name Reference Restrictions *ADHD/ANTI- NARCOLEPSY/ANTI- OBESITY/ANOREXIANTS* *Amphetamine Mixtures*** amphetamine-dextroamphet er oral capsule extended release 24 hour 10, 15, 20, 25, 5 amphetamine-dextroamphet er oral capsule extended release 24 hour 30 amphetamine-dextroamphetamine oral tablet 10, 12.5, 15, 20, 5, 7.5 amphetamine-dextroamphetamine oral tablet 30 *Amphetamines*** dextroamphetamine sulfate er oral capsule extended release 24 hour 10, 15 dextroamphetamine sulfate er oral capsule extended release 24 hour 5 dextroamphetamine sulfate oral tablet 10, 5 DEXEDRINE ORAL TABLET 10 MG, 5 MG ZENZEDI ORAL TABLET 10 MG, 5 MG Adderall XR Adderall XR Adderall Adderall Dexedrine Dexedrine Zenzedi Dextroamphetamine Sulfate Dextroamphetamine Sulfate QLL (30 EA per 30 days); AL (Min 6 Years and Max 18 Years) QLL: 1 capsule per day for under age 12 and 2 capsules per day for age 12 and older; AL (Min 6 Years and Max 18 Years) QLL (90 EA per 30 days); AL (Min 6 Years and Max 18 Years) QLL (60 EA per 30 days); AL (Min 6 Years and Max 18 Years) QLL (120 EA per 30 days); AL (Min 6 Years and Max 18 Years) QLL (90 EA per 30 days); AL (Min 6 Years and Max 18 Years) QLL (180 EA per 30 days); AL (Min 6 Years and Max 18 Years) QLL (180 EA per 30 days); AL (Min 6 Years and Max 18 Years) QLL (180 EA per 30 days); AL (Min 6 Years and Max 18 Years) 3

7 *Stimulants - Misc.*** dexmethylphenidate hcl er oral capsule extended release 24 hour 10, 15, 20, 25, 30, 35, 40, 5 dexmethylphenidate hcl oral tablet 10, 2.5, 5 methylphenidate hcl er (cd) oral capsule extended release 10, 20, 30, 40, 50, 60 methylphenidate hcl er (la) oral capsule extended release 24 hour 20, 40 methylphenidate hcl er (la) oral capsule extended release 24 hour 30 methylphenidate hcl er (la) oral capsule extended release 24 hour 60 methylphenidate hcl er oral tablet extended release 10 methylphenidate hcl er oral tablet extended release 18, 27, 54 methylphenidate hcl er oral tablet extended release 20 methylphenidate hcl er oral tablet extended release 24 hour 18, 27, 36, 54 methylphenidate hcl er oral tablet extended release 36 methylphenidate hcl oral solution 10 /5ml, 5 /5ml methylphenidate hcl oral tablet 10, 20, 5 methylphenidate hcl oral tablet chewable 10 methylphenidate hcl oral tablet chewable 2.5, 5 Focalin XR Focalin Metadate CD Ritalin LA Ritalin LA Concerta Metadate ER Concerta Methylin Ritalin QLL (30 EA per 30 days); AL (Min 6 Years and Max 18 Years) QLL (60 EA per 30 days); AL (Min 6 Years and Max 18 Years) QLL (30 EA per 30 days); AL (Min 6 Years and Max 18 Years) QLL (30 EA per 30 days); AL (Min 6 Years and Max 18 Years) QLL (60 EA per 30 days); AL (Min 6 Years and Max 18 Years) QLL (30 EA per 30 days); AL (Min 6 Years and Max 18 Years) QLL (90 EA per 30 days); AL (Min 6 Years and Max 18 Years) QLL (30 EA per 30 days); AL (Min 5 Years and Max 18 Years) QLL (90 EA per 30 days); AL (Min 6 Years and Max 18 Years) QLL (30 EA per 30 days) QLL (60 EA per 30 days); AL (Min 5 Years and Max 18 Years) QLL (900 ML per 30 days); AL (Min 6 Years and Max 18 Years) QLL (90 EA per 30 days); AL (Min 6 Years and Max 18 Years) QLL (180 EA per 30 days); AL (Min 5 Years and Max 18 Years) QLL (150 EA per 30 days); AL (Min 5 Years and Max 18 Years) 4

8 modafinil oral tablet 100, 200 Provigil PA; QLL (30 EA per 30 days) METADATE ER ORAL TABLET EXTENDED RELEASE 20 MG *AMINOGLYCOSIDES* *Aminoglycosides*** neomycin sulfate oral tablet 500 paromomycin sulfate oral capsule 250 tobramycin inhalation nebulization solution Tobi 300 /5ml *ANALGESICS - ANTI- INFLAMMATORY* *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, 40 MG/0.8ML *Cyclooxygenase 2 (Cox-2) Inhibitors*** celecoxib oral capsule 100, 200, 400 CeleBREX, 50 *Gold Compounds*** RIDAURA ORAL CAPSULE 3 MG *Nonsteroidal Anti-Inflammatory Agents (Nsaids)*** diclofenac potassium oral tablet 50 diclofenac sodium er oral tablet extended release 24 hour 100 diclofenac sodium oral tablet delayed release 25, 50, 75 Methylphenidate HCl ER QLL (90 EA per 30 days); AL (Min 6 Years and Max 18 Years) PA PA PA PA PA ST; AL (Min 65 Years) 5

9 etodolac er oral tablet extended release 24 hour 400, 500, 600 etodolac oral capsule 200, 300 etodolac oral tablet 400 Lodine etodolac oral tablet 500 fenoprofen calcium oral tablet 600 flurbiprofen oral tablet 100, 50 ibuprofen oral tablet 400, 600, 800 indomethacin er oral capsule extended release 75 indomethacin oral capsule 25, 50 ketoprofen oral capsule 50, 75 ketorolac tromethamine oral tablet 10 QLL (2 Claims per 180 days) meclofenamate sodium oral capsule 100, 50 meloxicam oral tablet 15, 7.5 Mobic nabumetone oral tablet 500, 750 naproxen dr oral tablet delayed release 375, 500 EC-Naprosyn naproxen oral suspension 125 /5ml Naprosyn naproxen oral tablet 250, 500 Naprosyn naproxen oral tablet 375 naproxen sodium oral tablet 275 oxaprozin oral tablet 600 Daypro piroxicam oral capsule 10, 20 Feldene sulindac oral tablet 150, 200 tolmetin sodium oral capsule 400 tolmetin sodium oral tablet 200, 600 *Pyrimidine Synthesis Inhibitors*** leflunomide oral tablet 10, 20 Arava *Soluble Tumor Necrosis Factor Receptor Agents*** ENBREL SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 25 MG/0.5ML, 50 PA MG/ML ENBREL SURECLICK SUBCUTANEOUS SOLUTION AUTO-INJECTOR 50 MG/ML PA 6

10 *ANALGESICS - NONNARCOTIC* *Analgesics-Sedatives*** butalbital-acetaminophen oral tablet Tencon butalbital-apap-caffeine oral capsule Fioricet butalbital-apap-caffeine oral capsule Esgic QLL (180 EA per 30 days) butalbital-apap-caffeine oral tablet Esgic QLL (180 EA per 30 days) butalbital-aspirin-caffeine oral capsule Fiorinal QLL (180 EA per 30 days) marten-tab oral tablet Tencon CAPACET ORAL CAPSULE MG Butalbital-APAP-Caffeine QLL (180 EA per 30 days) ESGIC ORAL CAPSULE MG Butalbital-APAP-Caffeine QLL (180 EA per 30 days) TENCON ORAL TABLET MG Marten-Tab ZEBUTAL ORAL CAPSULE MG Butalbital-APAP-Caffeine QLL (180 EA per 30 days) *Salicylate Combinations*** choline & mag trisalicylate oral tablet 1000 choline-mag trisalicylate oral liquid 500 /5ml *Salicylates*** diflunisal oral tablet 500 salsalate oral tablet 500, 750 Disalcid *ANALGESICS - OPIOID* *Codeine Combinations*** acetaminophen-codeine #2 oral tablet acetaminophen-codeine #3 oral tablet Tylenol with Codeine #3 acetaminophen-codeine #4 oral tablet Tylenol with Codeine #4 acetaminophen-codeine oral solution /5ml acetaminophen-codeine oral tablet acetaminophen-codeine oral tablet Tylenol with Codeine #4 butalbital-apap-caff-cod oral capsule Fioricet/Codeine 7

11 butalbital-apap-caff-cod oral capsule QLL (30 EA per 30 days) butalbital-asa-caff-codeine oral capsule Ascomp-Codeine QLL (180 EA per 30 days) ASCOMP-CODEINE ORAL CAPSULE MG Butalbital-ASA-Caff-Codeine QLL (180 EA per 30 days) *Hydrocodone Combinations*** hydrocodone-acetaminophen oral solution /5ml, /10ml, Hycet /15ml hydrocodone-acetaminophen oral tablet Norco hydrocodone-acetaminophen oral tablet Verdrocet hydrocodone-acetaminophen oral tablet Lortab, hydrocodone-ibuprofen oral tablet LORCET HD ORAL TABLET MG Hydrocodone-Acetaminophen LORCET ORAL TABLET MG Hydrocodone-Acetaminophen LORCET PLUS ORAL TABLET MG Hydrocodone-Acetaminophen LORTAB ORAL TABLET MG, MG, MG Hydrocodone-Acetaminophen ZAMICET ORAL SOLUTION MG/15ML Hydrocodone-Acetaminophen *Opioid Agonists*** codeine sulfate oral tablet 15, 30, 60 QLL (120 EA per 30 days) fentanyl citrate buccal lozenge on a handle 1200 mcg, 1600 mcg, 200 mcg, 400 mcg, 600 mcg, 800 mcg Actiq ST; QLL (90 EA per 30 days) fentanyl transdermal patch 72 hour 100 mcg/hr 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 fentanyl transdermal patch 72 hour 75 mcg/hr Duragesic-75 PA; QLL (10 Patches per 30 days) PA; QLL (10 Patches per 30 days) PA; QLL (10 Patches per 30 days) PA; QLL (10 Patches per 30 days) PA; QLL (10 Patches per 30 days) hydromorphone hcl oral tablet 2 Dilaudid hydromorphone hcl oral tablet 4, 8 Dilaudid QLL (180 EA per 30 days) 8

12 hydromorphone hcl rectal suppository 3 methadone hcl oral concentrate 10 /ml Methadose Sugar-Free PA methadone hcl oral solution 10 /5ml, 5 /5ml PA methadone hcl oral tablet 10, 5 Dolophine PA; QLL (240 EA per 30 days) methadone hcl oral tablet soluble 40 Methadose PA; QLL (240 EA per 30 days) morphine sulfate (concentrate) oral solution 100 /5ml morphine sulfate er oral capsule extended release 24 hour 10, 100, 20, 30, Kadian PA; QLL (60 EA per 30 days) 50, 60, 80 morphine sulfate er oral tablet extended release 100, 15, 200, 30, 60 morphine sulfate oral solution 10 /5ml, 20 /5ml morphine sulfate oral tablet 15, 30 morphine sulfate rectal suppository 10, 20, 30, 5 oxycodone hcl oral capsule 5 oxycodone hcl oral concentrate 100 /5ml oxycodone hcl oral solution 5 /5ml oxycodone hcl oral tablet 10 MS Contin PA; QLL (60 EA per 30 days) QLL (180 EA per 30 days) QLL (180 EA per 30 days) QLL (180 EA per 30 days) oxycodone hcl oral tablet 15, 5 Roxicodone QLL (180 EA per 30 days) oxycodone hcl oral tablet 20 QLL (240 EA per 30 days) oxycodone hcl oral tablet 30 Roxicodone QLL (240 EA per 30 days) oxymorphone hcl er oral tablet extended release 12 hour 10, 15, 20, 30, PA; QLL (60 EA per 30 days) 40, 5, 7.5 oxymorphone hcl oral tablet 10, 5 Opana tramadol hcl oral tablet 50 Ultram PA; QLL (240 EA per 30 days) METHADONE HCL INTENSOL ORAL CONCENTRATE 10 MG/ML Methadone HCl PA METHADOSE ORAL TABLET SOLUBLE 40 MG Methadone HCl PA; QLL (240 EA per 30 days) *Opioid Combinations*** oxycodone-acetaminophen oral tablet , , 5-325, Endocet oxycodone-aspirin oral tablet QLL (240 EA per 30 days) ENDOCET ORAL TABLET MG, MG, MG, MG Oxycodone-Acetaminophen 9

13 *Opioid Partial Agonists*** buprenorphine hcl sublingual tablet sublingual 2, 8 PA buprenorphine hcl-naloxone hcl sublingual tablet sublingual 2-0.5, 8-2 PA butorphanol tartrate nasal solution 10 /ml QLL (1 Bottle per 30 days) pentazocine-naloxone hcl oral tablet *Tramadol Combinations*** tramadol-acetaminophen oral tablet Ultracet PA; QLL (240 EA per 30 days) *ANDROGENS-ANABOLIC* *Androgens*** danazol oral capsule 100, 200, 50 methyltestosterone oral capsule 10 Android testosterone cypionate intramuscular solution 100 /ml Depo-Testosterone PA; QLL (10 ML per 90 days) testosterone cypionate intramuscular solution 200 /ml Depo-Testosterone PA testosterone transdermal gel 10 /act (2%) Fortesta PA; QLL (2 canisters per 30 days) testosterone transdermal gel 12.5 /act (1%) Vogelxo Pump PA; QLL (4 canisters per 30 days) testosterone transdermal gel 25 /2.5gm (1%) AndroGel PA; QLL (2.5 GM per 1 day) testosterone transdermal gel 50 /5gm (1%) AndroGel PA; QLL (10 GM per 1 day) ANDROGEL PUMP TRANSDERMAL GEL MG/ACT (1.62%) *ANORECTAL AGENTS* *Intrarectal Steroids*** hydrocortisone rectal enema 100 /60ml Colocort COLOCORT RECTAL ENEMA 100 MG/60ML Hydrocortisone CORTIFOAM RECTAL FOAM 10 % *Rectal Anesthetic/Steroids*** lidocaine-hydrocortisone ace rectal cream % LidaZone HC lidocaine-hydrocortisone ace rectal kit %, 3-1 % LIDAZONE HC RECTAL CREAM % Lidocaine-Hydrocortisone Ace 10

14 PROCTOFOAM HC RECTAL FOAM 1-1 % *Rectal Steroids*** PROCTO-PAK RECTAL CREAM 1 % Hydrocortisone PROCTOSOL HC RECTAL CREAM 2.5 % Hydrocortisone PROCTOZONE-HC RECTAL CREAM 2.5 % Hydrocortisone *ANTHELMINTICS* *Anthelmintics*** ivermectin oral tablet 3 Stromectol reeses pinworm medicine oral suspension 144 /ml OTC reeses pinworm medicine oral tablet 180 OTC ALBENZA ORAL TABLET 200 MG *ANTIANGINAL AGENTS* *Nitrates*** isosorbide dinitrate er oral tablet extended release 40 isosorbide dinitrate oral tablet 10, 20, 30 isosorbide dinitrate oral tablet 5 Isordil Titradose isosorbide mononitrate er oral tablet extended release 24 hour 120, 30, 60 isosorbide mononitrate oral tablet 10, 20 nitroglycerin er oral capsule extended release Nitro-Time 2.5, 6.5, 9 nitroglycerin sublingual tablet sublingual 0.3, 0.4, 0.6 Nitrostat nitroglycerin transdermal patch 24 hour 0.1 /hr, 0.4 /hr Nitro-Dur nitroglycerin transdermal patch 24 hour 0.2 /hr, 0.6 /hr Minitran nitroglycerin translingual solution 0.4 /spray Nitrolingual MINITRAN TRANSDERMAL PATCH 24 HOUR 0.1 MG/HR, 0.2 MG/HR, 0.4 Nitroglycerin MG/HR, 0.6 MG/HR NITRO-BID TRANSDERMAL OINTMENT 2 % 11

15 NITRO-TIME ORAL CAPSULE EXTENDED RELEASE 2.5 MG, 6.5 MG, 9 Nitroglycerin ER MG *ANTIANXIETY AGENTS* *Antianxiety Agents - Misc.*** buspirone hcl oral tablet 10, 5, 7.5 QLL (90 EA per 30 days) buspirone hcl oral tablet 15 QLL (120 EA per 30 days) hydroxyzine hcl oral syrup 10 /5ml hydroxyzine hcl oral tablet 10, 25, 50 hydroxyzine pamoate oral capsule 100 hydroxyzine pamoate oral capsule 25, 50 Vistaril meprobamate oral tablet 200, 400 *Benzodiazepines*** alprazolam er oral tablet extended release 24 hour 0.5, 1, 2, 3 Xanax XR alprazolam oral tablet 0.25, 0.5, 1, 2 Xanax alprazolam oral tablet dispersible 0.25, 0.5, 1, 2 alprazolam xr oral tablet extended release 24 hour 0.5, 1, 2, 3 Xanax XR chlordiazepoxide hcl oral capsule 10, 25, 5 clorazepate dipotassium oral tablet 15, 3.75 clorazepate dipotassium oral tablet 7.5 Tranxene-T diazepam oral concentrate 5 /ml Diazepam Intensol diazepam oral solution 1 /ml diazepam oral tablet 10, 2, 5 Valium lorazepam oral concentrate 2 /ml LORazepam Intensol lorazepam oral tablet 0.5, 1, 2 Ativan oxazepam oral capsule 10, 15, 30 ALPRAZOLAM INTENSOL ORAL CONCENTRATE 1 MG/ML DIAZEPAM INTENSOL ORAL CONCENTRATE 5 MG/ML Diazepam LORAZEPAM INTENSOL ORAL CONCENTRATE 2 MG/ML LORazepam 12

16 *ANTIARRHYTHMICS* *Antiarrhythmics Type I-A*** disopyramide phosphate oral capsule 100, Norpace 150 quinidine gluconate er oral tablet extended release 324 quinidine sulfate oral tablet 200, 300 *Antiarrhythmics Type I-B*** mexiletine hcl oral capsule 150, 200, 250 *Antiarrhythmics Type I-C*** flecainide acetate oral tablet 100, 150, 50 propafenone hcl oral tablet 150, 225, 300 *Antiarrhythmics Type Iii*** amiodarone hcl oral tablet 100, 200, Pacerone 400 MULTAQ ORAL TABLET 400 MG PACERONE ORAL TABLET 100 MG, 200 Amiodarone HCl MG, 400 MG *ANTIASTHMATIC AND BRONCHODILATOR AGENTS* *Adrenergic Combinations*** ipratropium-albuterol inhalation solution (3) /3ml ANORO ELLIPTA INHALATION AEROSOL POWDER BREATH QLL (1 EA 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 AEROSOL SOLUTION MCG/ACT DULERA INHALATION AEROSOL MCG/ACT, MCG/ACT STIOLTO RESPIMAT INHALATION ST; QLL (1 canister per 30 AEROSOL SOLUTION MCG/ACT Days) 13

17 *Anti-Inflammatory Agents*** cromolyn sodium inhalation nebulization solution 20 /2ml *Beta Adrenergics*** albuterol sulfate er oral tablet extended release 12 hour 4, 8 VoSpire ER albuterol sulfate inhalation nebulization solution (2.5 /3ml) 0.083%, (5 /ml) 0.5% QLL (130 vials per 30 days) albuterol sulfate inhalation nebulization solution 0.63 /3ml, 1.25 /3ml albuterol sulfate oral syrup 2 /5ml albuterol sulfate oral tablet 2, 4 levalbuterol tartrate inhalation aerosol 45 mcg/act metaproterenol sulfate oral syrup 10 /5ml metaproterenol sulfate oral tablet 10, 20 terbutaline sulfate oral tablet 2.5, 5 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 ST; QLL (130 vials per 30 days); AL (Min 18 Years) ST; QLL (2 INH per 30 days) QLL (2 Inhalers per 30 days) montelukast sodium oral packet 4 Singulair PA; QLL (30 packet per 30 days); AL (Max 2 Years) montelukast sodium oral tablet 10 Singulair QLL (30 EA per 30 days) montelukast sodium oral tablet chewable 4, 5 Singulair QLL (30 EA per 30 days) zafirlukast oral tablet 10, 20 Accolate ST; QLL (60 EA per 30 days) *Steroid Inhalants*** budesonide inhalation suspension 0.25 /2ml, 0.5 /2ml, 1 /2ml Pulmicort QLL (527 ML per 30 days); AL (Max 5 Years) 14

18 FLOVENT DISKUS INHALATION AEROSOL POWDER BREATH ACTIVATED 100 MCG/BLIST, 250 MCG/BLIST, 50 MCG/BLIST PULMICORT FLEXHALER INHALATION AEROSOL POWDER BREATH ACTIVATED 180 MCG/ACT, 90 QLL (1 Inhaler per 30 days) MCG/ACT QVAR INHALATION AEROSOL SOLUTION 40 MCG/ACT, 80 MCG/ACT *Xanthines*** theophylline er oral tablet extended release 12 Theochron hour 100, 200, 300 theophylline er oral tablet extended release 12 hour 450 theophylline er oral tablet extended release 24 hour 400, 600 theophylline oral solution 80 /15ml THEOCHRON ORAL TABLET EXTENDED RELEASE 12 HOUR 100 Theophylline ER MG, 200 MG, 300 MG *ANTICOAGULANTS* *Coumarin Anticoagulants*** warfarin sodium oral tablet 1, 10, 2.5, 4, 5, 7.5 Jantoven warfarin sodium oral tablet 2, 3, 6 Coumadin JANTOVEN ORAL TABLET 1 MG, 10 MG, 2 MG, 2.5 MG, 3 MG, 4 MG, 5 MG, 6 Warfarin Sodium MG, 7.5 MG *Direct Factor Xa Inhibitors*** XARELTO ORAL TABLET 10 MG, 15 MG, 20 MG PA; QLL (30 EA per 30 days) XARELTO STARTER PACK ORAL TABLET THERAPY PACK 15 & 20 MG PA; QLL (1 EA per 90 days) *Heparins And Heparinoid-Like Agents*** heparin sodium (porcine) injection solution 1000 unit/ml, unit/ml, unit/ml, 5000 unit/ml heparin sodium (porcine) pf injection solution 5000 unit/0.5ml 15

19 *Low Molecular Weight Heparins*** enoxaparin sodium injection solution 300 /3ml Lovenox enoxaparin sodium subcutaneous solution 100 /ml, 120 /0.8ml, 150 /ml, 30 /0.3ml, 40 /0.4ml, 60 /0.6ml, 80 Lovenox QLL (20 Syringes per 10 days) /0.8ml FRAGMIN SUBCUTANEOUS SOLUTION UNIT/ML, UNIT/0.5ML, UNIT/0.6ML, QLL (10 Syringes per 10 days) UNT/0.72ML, 2500 UNIT/0.2ML, 5000 UNIT/0.2ML, 7500 UNIT/0.3ML *Synthetic Heparinoid-Like Agents*** fondaparinux sodium subcutaneous solution 10 /0.8ml, 2.5 /0.5ml, 5 /0.4ml, 7.5 Arixtra /0.6ml *ANTICONVULSANTS* *Anticonvulsants - Benzodiazepines*** clonazepam oral tablet 0.5, 1, 2 KlonoPIN clonazepam oral tablet dispersible 0.125, 0.25, 0.5, 1, 2 diazepam rectal gel 10, 20 Diastat AcuDial QLL (2 EA per 30 days) diazepam rectal gel 2.5 Diastat Pediatric QLL (2 EA per 30 days) *Anticonvulsants - Misc.*** carbamazepine er oral capsule extended release 12 hour 100, 200, 300 carbamazepine er oral tablet extended release 12 hour 100 carbamazepine er oral tablet extended release 12 hour 200, 400 carbamazepine oral suspension 100 /5ml carbamazepine oral tablet 200 carbamazepine oral tablet chewable 100 Carbatrol TEGretol-XR TEGretol-XR TEGretol Epitol QLL (400 EA per 100 days); AL (Min 6 Years) QLL 6-15 yrs old QL = 1000 /day > 15 and adults QL = 1200 /day; QLL (12 EA per 1 Day) QLL (400 EA per 100 days); AL (Min 6 Years) gabapentin oral capsule 100 Neurontin QLL (36 EA per 1 day) gabapentin oral capsule 300 Neurontin QLL (12 EA per 1 day) gabapentin oral capsule 400 Neurontin QLL (9 EA per 1 day) gabapentin oral solution 250 /5ml Neurontin gabapentin oral tablet 600 Neurontin QLL (6 EA per 1 day) 16

20 gabapentin oral tablet 800 Neurontin QLL (4 EA per 1 day) lamotrigine oral tablet 100, 150, 200, 25 LaMICtal lamotrigine oral tablet chewable 25, 5 LaMICtal levetiracetam er oral tablet extended release 24 hour 500, 750 Keppra XR levetiracetam oral solution 100 /ml Keppra levetiracetam oral tablet 1000, 250, 500, 750 Keppra oxcarbazepine oral suspension 300 /5ml Trileptal oxcarbazepine oral tablet 150, 300, 600 Trileptal primidone oral tablet 250, 50 Mysoline topiramate oral capsule sprinkle 15, 25 Topamax Sprinkle QLL (120 EA per 30 days) topiramate oral tablet 100, 200, 25, Topamax 50 QLL (120 EA per 30 days) zonisamide oral capsule 100, 25 Zonegran QLL (180 EA per 30 days) zonisamide oral capsule 50 QLL (180 EA per 30 days) EPITOL ORAL TABLET 200 MG CarBAMazepine TEGRETOL-XR ORAL TABLET CarBAMazepine ER EXTENDED RELEASE 12 HOUR 100 MG *Carbamates*** felbamate oral suspension 600 /5ml Felbatol felbamate oral tablet 400, 600 Felbatol *Gaba Modulators*** tiagabine hcl oral tablet 2, 4 Gabitril QLL (60 EA per 30 days) GABITRIL ORAL TABLET 12 MG, 16 MG QLL (60 EA per 30 days) *Hydantoins*** phenytoin oral suspension 125 /5ml Dilantin phenytoin oral tablet chewable 50 Dilantin Infatabs phenytoin sodium extended oral capsule 100 Dilantin phenytoin sodium extended oral capsule 200, 300 Phenytek DILANTIN ORAL CAPSULE 30 MG PHENYTEK ORAL CAPSULE 200 MG, 300 MG Phenytoin Sodium Extended PHENYTOIN INFATABS ORAL TABLET Phenytoin CHEWABLE 50 MG 17

21 *Succinimides*** ethosuximide oral capsule 250 Zarontin ethosuximide oral solution 250 /5ml Zarontin CELONTIN ORAL CAPSULE 300 MG *Valproic Acid*** divalproex sodium er oral tablet extended release 24 hour 250, 500 Depakote ER divalproex sodium oral tablet delayed release 125, 250, 500 Depakote valproic acid oral capsule 250 Depakene valproic acid oral solution 250 /5ml Depakene *ANTIDEPRESSANTS* *Alpha-2 Receptor Antagonists (Tetracyclics)*** mirtazapine oral tablet 15, 30, 45 Remeron QLL (30 EA per 30 days) mirtazapine oral tablet 7.5 QLL (30 EA per 30 days) mirtazapine oral tablet dispersible 15, 30, 45 Remeron SolTab QLL (30 EA per 30 days) *Antidepressants - Misc.*** bupropion hcl er (sr) oral tablet extended release 12 hour 100, 150, 200 Wellbutrin SR QLL (60 EA per 30 days) bupropion hcl er (xl) oral tablet extended release 24 hour 150, 300 Wellbutrin XL QLL (30 EA per 30 days) bupropion hcl oral tablet 100, 75 QLL (90 EA per 30 days) maprotiline hcl oral tablet 25, 50, 75 *Modified Cyclics*** trazodone hcl oral tablet 100, 150, 50 *Monoamine Oxidase Inhibitors (Maois)*** phenelzine sulfate oral tablet 15 Nardil tranylcypromine sulfate oral tablet 10 Parnate MARPLAN ORAL TABLET 10 MG *Selective Serotonin Reuptake Inhibitors (Ssris)*** citalopram hydrobromide oral solution 10 /5ml QLL (300 ML per 30 days) citalopram hydrobromide oral tablet 10, 20, 40 CeleXA QLL (30 EA per 30 days) 18

22 escitalopram oxalate oral solution 5 /5ml QLL (300 ML per 30 days) escitalopram oxalate oral tablet 10, 20, Lexapro 5 QLL (30 EA per 30 days) fluoxetine hcl oral capsule 10 PROzac QLL (30 EA per 30 days) fluoxetine hcl oral capsule 20, 40 PROzac QLL (60 EA per 30 days) fluoxetine hcl oral solution 20 /5ml QLL (150 ML per 30 days) fluoxetine hcl oral tablet 10 QLL (30 EA per 30 days) fluvoxamine maleate oral tablet 100 QLL (90 EA per 30 days) fluvoxamine maleate oral tablet 25 QLL (30 EA per 30 days) fluvoxamine maleate oral tablet 50 QLL (60 EA per 30 days) paroxetine hcl oral tablet 10, 20, 40 Paxil QLL (30 EA per 30 days) paroxetine hcl oral tablet 30 Paxil QLL (60 EA per 30 days) sertraline hcl oral concentrate 20 /ml Zoloft QLL (75 ML per 30 days) sertraline hcl oral tablet 100, 50 Zoloft QLL (60 EA per 30 days) sertraline hcl oral tablet 25 Zoloft QLL (30 EA per 30 days) *Serotonin-Norepinephrine Reuptake Inhibitors (Snris)*** duloxetine hcl oral capsule delayed release particles 20, 30, 60 Cymbalta QLL (60 EA per 30 days) venlafaxine hcl er oral capsule extended release 24 hour 150, 37.5, 75 Effexor XR QLL (30 EA per 30 days) venlafaxine hcl oral tablet 100, 25, 37.5, 50, 75 *Tricyclic Agents*** amitriptyline hcl oral tablet 10, 100, 150, 50, 75 amitriptyline hcl oral tablet 25 Elavil amoxapine oral tablet 100, 150, 25, 50 desipramine hcl oral tablet 10, 25 Norpramin desipramine hcl oral tablet 100, 150, 50, 75 doxepin hcl oral capsule 10, 100, 150, 25, 50, 75 doxepin hcl oral concentrate 10 /ml imipramine hcl oral tablet 10, 25, 50 Tofranil nortriptyline hcl oral capsule 10, 25, 50, 75 Pamelor nortriptyline hcl oral solution 10 /5ml 19

23 protriptyline hcl oral tablet 10, 5 *ANTIDIABETICS* *Alpha-Glucosidase Inhibitors*** acarbose oral tablet 100, 25, 50 Precose *Biguanides*** metformin hcl er oral tablet extended release Glucophage XR 24 hour 500, 750 metformin hcl oral tablet 1000, 500, Glucophage 850 *Diabetic Other*** 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, 25 Nesina, 6.25 *Dipeptidyl Peptidase-4 Inhibitor- Biguanide Combinations*** alogliptin-metformin hcl oral tablet Kazano, JENTADUETO XR ORAL TABLET EXTENDED RELEASE 24 HOUR MG JENTADUETO XR ORAL TABLET EXTENDED RELEASE 24 HOUR MG *Dpp-4 Inhibitor-Thiazolidinedione Combinations*** alogliptin-pioglitazone oral tablet , , , 25-15, 25-30, Oseni *Human Insulin*** BASAGLAR KWIKPEN SUBCUTANEOUS SOLUTION PEN- INJECTOR 100 UNIT/ML HUMALOG KWIKPEN SUBCUTANEOUS SOLUTION PEN- INJECTOR 100 UNIT/ML, 200 UNIT/ML QLL (30 EA per 30 Days) QLL (60 EA per 30 Days) ST; QLL (60 EA per 30 days) ST; QLL (30 EA per 30 days) QLL (30 EA per 30 Days) PA; AL (Max 18 Years) 20

24 HUMALOG MIX 50/50 KWIKPEN SUBCUTANEOUS SUSPENSION PEN- PA; AL (Max 18 Years) INJECTOR (50-50) 100 UNIT/ML HUMALOG MIX 50/50 SUBCUTANEOUS SUSPENSION (50-50) 100 UNIT/ML HUMALOG MIX 75/25 KWIKPEN SUBCUTANEOUS SUSPENSION PEN- PA; 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 R U-500 (CONCENTRATED) SUBCUTANEOUS SOLUTION 500 UNIT/ML LANTUS SOLOSTAR SUBCUTANEOUS SOLUTION PEN-INJECTOR 100 UNIT/ML LANTUS SUBCUTANEOUS SOLUTION 100 UNIT/ML LEVEMIR FLEXTOUCH SUBCUTANEOUS SOLUTION PEN- INJECTOR 100 UNIT/ML LEVEMIR SUBCUTANEOUS SOLUTION 100 UNIT/ML NOVOLOG MIX 70/30 SUBCUTANEOUS SUSPENSION (70-30) 100 UNIT/ML NOVOLOG PENFILL SUBCUTANEOUS SOLUTION CARTRIDGE 100 UNIT/ML NOVOLOG SUBCUTANEOUS SOLUTION 100 UNIT/ML *Incretin Mimetic Agents (Glp-1 Receptor Agonists)*** TRULICITY SUBCUTANEOUS SOLUTION PEN-INJECTOR 0.75 ST MG/0.5ML, 1.5 MG/0.5ML *Meglitinide Analogues*** nateglinide oral tablet 120, 60 Starlix repaglinide oral tablet 0.5 repaglinide oral tablet 1, 2 Prandin 21

25 *Meglitinide-Biguanide Combinations*** repaglinide-metformin hcl oral tablet 1-500, *Sulfonylurea-Biguanide Combinations*** glipizide-metformin hcl oral tablet , , glyburide-metformin oral tablet glyburide-metformin oral tablet , Glucovance *Sulfonylureas*** chlorpropamide oral tablet 100, 250 glimepiride oral tablet 1, 2, 4 Amaryl glipizide er oral tablet extended release 24 hour 10, 2.5, 5 Glucotrol XL glipizide oral tablet 10, 5 Glucotrol glipizide xl oral tablet extended release 24 hour 10, 2.5, 5 Glucotrol XL glyburide micronized oral tablet 1.5, 3, Glynase 6 glyburide oral tablet 1.25, 2.5, 5 tolazamide oral tablet 250, 500 tolbutamide oral tablet 500 *Sulfonylurea-Thiazolidinedione Combinations*** pioglitazone hcl-glimepiride oral tablet 30-2, 30-4 Duetact QLL (30 EA per 30 days) *Thiazolidinedione-Biguanide Combinations*** pioglitazone hcl-metformin hcl oral tablet , Actoplus Met QLL (90 EA per 30 days) *Thiazolidinediones*** pioglitazone hcl oral tablet 15, 30, 45 Actos QLL (30 EA per 30 days) AVANDIA ORAL TABLET 2 MG, 4 MG ST; QLL (30 EA per 30 days) *ANTIDIARRHEALS* *Antiperistaltic Agents*** diphenoxylate-atropine oral liquid /5ml 22

26 diphenoxylate-atropine oral tablet Lomotil lofene oral tablet Lomotil loperamide hcl oral capsule 2 Imodium A-D *ANTIDOTES* *Antidotes - Chelating Agents*** CHEMET ORAL CAPSULE 100 MG *Opioid Antagonists*** naloxone hcl injection solution 0.4 /ml naloxone hcl injection solution prefilled syringe 2 /2ml naltrexone hcl oral tablet 50 NARCAN NASAL LIQUID 4 MG/0.1ML QLL (2 EA per 30 days) *ANTIEMETICS* *5-Ht3 Receptor Antagonists*** granisetron hcl oral tablet 1 ondansetron hcl oral solution 4 /5ml Zofran ondansetron hcl oral tablet 24 ondansetron hcl oral tablet 4, 8 Zofran ondansetron oral tablet dispersible 4, 8 Zofran ODT *Antiemetics - Anticholinergic*** meclizine hcl oral tablet 12.5 meclizine hcl oral tablet 25 Wal-Dram II trimethobenzamide hcl oral capsule 300 Tigan *Substance P/Neurokinin 1 (Nk1) Receptor Antagonists*** EMEND ORAL CAPSULE 125 MG, 40 MG, 80 & 125 MG, 80 MG Aprepitant *ANTIFUNGALS* *Antifungals*** bio-statin oral powder griseofulvin microsize oral suspension 125 /5ml griseofulvin microsize oral tablet 500 griseofulvin ultramicrosize oral tablet 125, Gris-PEG 250 nystatin oral tablet unit terbinafine hcl oral tablet 250 LamISIL QLL (84 EA per 365 days) 23

27 *Imidazoles*** ketoconazole oral tablet 200 *Triazoles*** fluconazole oral suspension reconstituted 10 /ml, 40 /ml Diflucan fluconazole oral tablet 100, 150, 200, 50 Diflucan itraconazole oral capsule 100 Sporanox SPORANOX ORAL SOLUTION 10 MG/ML *ANTIHISTAMINES* *Antihistamines - Alkylamines*** brompheniramine tannate oral tablet chewable 12 *Antihistamines - Ethanolamines*** carbinoxamine maleate oral tablet 4 clemastine fumarate oral tablet 2.68 *Antihistamines - Non-Sedating*** cetirizine hcl oral solution 1 /ml ZyrTEC Childrens Allergy QLL (150 ML per 30 days) cetirizine hcl oral syrup 1 /ml ZyrTEC Childrens Allergy QLL (150 ML per 30 days) *Antihistamines - Phenothiazines*** promethazine hcl oral solution 6.25 /5ml promethazine hcl oral syrup 6.25 /5ml promethazine hcl oral tablet 12.5, 25, 50 promethazine hcl rectal suppository 12.5, 25, 50 Phenergan PHENADOZ RECTAL SUPPOSITORY 12.5 MG, 25 MG Promethazine HCl PHENERGAN RECTAL SUPPOSITORY 12.5 MG, 25 MG, 50 MG Promethazine HCl PROMETHEGAN RECTAL SUPPOSITORY 12.5 MG, 25 MG, 50 MG Promethazine HCl *Antihistamines - Piperidines*** cyproheptadine hcl oral syrup 2 /5ml cyproheptadine hcl oral tablet 4 *ANTIHYPERLIPIDEMICS* *Bile Acid Sequestrants*** cholestyramine light oral packet 4 gm Prevalite 24

28 cholestyramine light oral powder 4 gm/dose Prevalite cholestyramine oral packet 4 gm Questran cholestyramine oral powder 4 gm/dose Questran colestipol hcl oral granules 5 gm Colestid Flavored colestipol hcl oral packet 5 gm Colestid colestipol hcl oral tablet 1 gm Colestid PREVALITE ORAL PACKET 4 GM Cholestyramine Light PREVALITE ORAL POWDER 4 GM/DOSE Cholestyramine Light *Fibric Acid Derivatives*** fenofibrate micronized oral capsule 134, 200, 67 Lofibra fenofibrate oral tablet 145, 48 Tricor fenofibrate oral tablet 160, 54 Lofibra fenofibric acid oral capsule delayed release 135, 45 Trilipix gemfibrozil oral tablet 600 Lopid QLL (60 EA per 30 days) *H Coa Reductase Inhibitors*** atorvastatin calcium oral tablet 10, 20, Lipitor 40, 80 QLL (30 EA per 30 days) fluvastatin sodium er oral tablet extended release 24 hour 80 Lescol XL QLL (30 EA per 30 days) fluvastatin sodium oral capsule 20 Lescol QLL (30 EA per 30 days) fluvastatin sodium oral capsule 40 QLL (30 EA per 30 days) lovastatin oral tablet 10, 20 QLL (30 EA per 30 days) lovastatin oral tablet 40 Mevacor QLL (60 EA per 30 days) pravastatin sodium oral tablet 10 QLL (30 EA per 30 days) pravastatin sodium oral tablet 20, 40, 80 Pravachol QLL (30 EA per 30 days) rosuvastatin calcium oral tablet 10, 20, Crestor 40, 5 PA; QLL (1 EA per 1 Day) simvastatin oral tablet 10, 20, 40, 5 Zocor, 80 QLL (30 EA per 30 days) *Intestinal Cholesterol Absorption Inhibitors*** ezetimibe oral tablet 10 Zetia ST *Nicotinic Acid Derivatives*** niacin er (antihyperlipidemic) oral tablet extended release 1000, 500, 750 Niaspan 25

29 *ANTIHYPERTENSIVES* *Ace Inhibitor & Calcium Channel Blocker Combinations*** amlodipine besy-benazepril hcl oral capsule 10-20, 10-40, 5-10, 5-20 Lotrel amlodipine besy-benazepril hcl oral capsule , 5-40 *Ace Inhibitors & Thiazide/Thiazide- Like*** benazepril-hydrochlorothiazide oral tablet 10 Lotensin HCT 12.5, , benazepril-hydrochlorothiazide oral tablet captopril-hydrochlorothiazide oral tablet 25 15, 25-25, 50-15, enalapril-hydrochlorothiazide oral tablet Vaseretic enalapril-hydrochlorothiazide oral tablet fosinopril sodium-hctz oral tablet , lisinopril-hydrochlorothiazide oral tablet , , Zestoretic moexipril-hydrochlorothiazide oral tablet , 15-25, quinapril-hydrochlorothiazide oral tablet , , Accuretic *Ace Inhibitors*** benazepril hcl oral tablet 10, 20, 40 Lotensin benazepril hcl oral tablet 5 captopril oral tablet 100, 12.5, 25, 50 enalapril maleate oral tablet 10, 2.5, 20, 5 Vasotec fosinopril sodium oral tablet 10, 20, 40 lisinopril oral tablet 10, 2.5, 20, 30 Zestril, 5 QLL (30 EA per 30 days) lisinopril oral tablet 40 Zestril QLL (60 EA per 30 days) moexipril hcl oral tablet 15, 7.5 perindopril erbumine oral tablet 2 perindopril erbumine oral tablet 4, 8 Aceon 26

30 quinapril hcl oral tablet 10, 20, 40, Accupril 5 ramipril oral capsule 1.25, 10, 2.5, Altace 5 trandolapril oral tablet 1, 2, 4 Mavik *Adrenolytics-Central & Thiazide/Thiazide-Like Comb*** methyldopa-hydrochlorothiazide oral tablet , *Angiotensin Ii Receptor Antag & Thiazide/Thiazide-Like*** candesartan cilexetil-hctz oral tablet , , Atacand HCT irbesartan-hydrochlorothiazide oral tablet , Avalide losartan potassium-hctz oral tablet , , Hyzaar valsartan-hydrochlorothiazide oral tablet , , , , Diovan HCT QLL (30 EA per 30 days) *Angiotensin Ii Receptor Antagonists*** candesartan cilexetil oral tablet 16, 32, Atacand 4, 8 irbesartan oral tablet 150, 300, 75 Avapro losartan potassium oral tablet 100, 25, Cozaar 50 valsartan oral tablet 160, 320, 40, 80 Diovan QLL (60 EA per 30 days) *Angiotensin Ii Receptor Ant-Ca Channel Blocker-Thiazides*** amlodipine-valsartan-hctz oral tablet , , , Exforge HCT QLL (30 EA per 30 days) 12.5, *Antiadrenergics - Centrally Acting*** clonidine hcl oral tablet 0.1, 0.2, 0.3 Catapres clonidine hcl transdermal patch weekly 0.1 /24hr Catapres-TTS-1 clonidine hcl transdermal patch weekly 0.2 /24hr Catapres-TTS-2 27

31 clonidine hcl transdermal patch weekly 0.3 /24hr Catapres-TTS-3 guanfacine hcl oral tablet 1 QLL (240 EA per 30 days) guanfacine hcl oral tablet 2 QLL (120 EA per 30 days) methyldopa oral tablet 250, 500 *Antiadrenergics - Peripherally Acting*** doxazosin mesylate oral tablet 1, 2, 4, 8 Cardura QLL (30 EA per 30 days) prazosin hcl oral capsule 1, 2, 5 Minipress terazosin hcl oral capsule 1, 10, 2, 5 QLL (30 EA per 30 days) *Beta Blocker & Diuretic Combinations*** atenolol-chlorthalidone oral tablet Tenoretic 100 atenolol-chlorthalidone oral tablet Tenoretic 50 bisoprolol-hydrochlorothiazide oral tablet , , Ziac metoprolol-hydrochlorothiazide oral tablet , metoprolol-hydrochlorothiazide oral tablet Lopressor HCT nadolol-bendroflumethiazide oral tablet 40-5, 80-5 Corzide propranolol-hctz oral tablet 40-25, *Vasodilators*** hydralazine hcl oral tablet 10, 100, 25, 50 minoxidil oral tablet 10, 2.5 *ANTI-INFECTIVE AGENTS - MISC.* *Anti-Infective Agents - Misc.*** metronidazole oral capsule 375 Flagyl metronidazole oral tablet 250, 500 Flagyl trimethoprim oral tablet 100 vancomycin hcl intravenous solution reconstituted 10 gm, 1000, 500, 5000 vancomycin hcl oral capsule 125, 250 Vancocin HCl 28

32 FIRST-VANCOMYCIN 25 ORAL SOLUTION 25 MG/ML FIRST-VANCOMYCIN 50 ORAL SOLUTION 50 MG/ML *Anti-Infective Misc. - Combinations*** sulfamethoxazole-trimethoprim oral suspension /5ml Sulfatrim Pediatric sulfamethoxazole-trimethoprim oral tablet Bactrim sulfamethoxazole-trimethoprim oral tablet Bactrim DS SULFATRIM PEDIATRIC ORAL SUSPENSION MG/5ML *Leprostatics*** dapsone oral tablet 100, 25 *Lincosamides*** clindamycin hcl oral capsule 150, 300, 75 clindamycin palmitate hcl oral solution reconstituted 75 /5ml *ANTIMALARIALS* *Antimalarials*** chloroquine phosphate oral tablet 250, 500 Sulfamethoxazole- Trimethoprim Cleocin Cleocin hydroxychloroquine sulfate oral tablet 200 Plaquenil mefloquine hcl oral tablet 250 DARAPRIM ORAL TABLET 25 MG *ANTIMYASTHENIC AGENTS* *Antimyasthenic Agents*** pyridostigmine bromide oral tablet 60 Mestinon *ANTIMYCOBACTERIAL AGENTS* *Anti Tb Combinations*** RIFAMATE ORAL CAPSULE MG *Antimycobacterial Agents*** ethambutol hcl oral tablet 100, 400 Myambutol isoniazid oral syrup 50 /5ml isoniazid oral tablet 100,

33 pyrazinamide oral tablet 500 rifabutin oral capsule 150 Mycobutin rifampin oral capsule 150, 300 Rifadin PRIFTIN ORAL TABLET 150 MG *ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES* *Alkylating Agents*** HEXALEN ORAL CAPSULE 50 MG MYLERAN ORAL TABLET 2 MG *Antiadrenals*** LYSODREN ORAL TABLET 500 MG *Antiandrogens*** bicalutamide oral tablet 50 Casodex flutamide oral capsule 125 nilutamide oral tablet 150 Nilandron QLL (60 EA per 30 days) *Antiestrogens*** tamoxifen citrate oral tablet 10, 20 FARESTON ORAL TABLET 60 MG SOLTAMOX ORAL SOLUTION 10 MG/5ML *Antimetabolites*** capecitabine oral tablet 150 Xeloda PA; QLL (140 EA per 21 days) capecitabine oral tablet 500 Xeloda PA; QLL (154 EA per 21 days) mercaptopurine oral tablet 50 methotrexate oral tablet 2.5 TABLOID ORAL TABLET 40 MG *Antineoplastic - Histone Deacetylase Inhibitors*** ZOLINZA ORAL CAPSULE 100 MG PA *Antineoplastic - Mtor Kinase Inhibitors*** AFINITOR ORAL TABLET 10 MG, 2.5 MG, 5 MG, 7.5 MG PA *Antineoplastic - Multikinase Inhibitors*** NEXAVAR ORAL TABLET 200 MG PA; QLL (120 EA per 30 days) SUTENT ORAL CAPSULE 12.5 MG, 25 MG PA 30

34 SUTENT ORAL CAPSULE 37.5 MG PA; QLL (30 EA per 30 days) SUTENT ORAL CAPSULE 50 MG PA; QLL (28 EA per 42 days) *Antineoplastic - Tyrosine Kinase Inhibitors*** CABOMETYX ORAL TABLET 20 MG, 40 MG, 60 MG PA; QLL (30 EA per 30 Days) GLEEVEC ORAL TABLET 400 MG Imatinib Mesylate PA IMBRUVICA ORAL CAPSULE 140 MG PA; QLL (120 EA per 30 days) SPRYCEL ORAL TABLET 100 MG, 140 MG, 20 MG, 50 MG, 70 MG, 80 MG PA TARCEVA ORAL TABLET 100 MG, 150 MG PA TARCEVA ORAL TABLET 25 MG TASIGNA ORAL CAPSULE 150 MG, 200 MG PA TYKERB ORAL TABLET 250 MG PA; QLL (180 EA per 30 days) VOTRIENT ORAL TABLET 200 MG PA *Antineoplastics Misc.*** hydroxyurea oral capsule 500 Hydrea MATULANE ORAL CAPSULE 50 MG PA *Aromatase Inhibitors*** anastrozole oral tablet 1 Arimidex exemestane oral tablet 25 Aromasin letrozole oral tablet 2.5 Femara *Estrogens-Antineoplastic*** EMCYT ORAL CAPSULE 140 MG *Folic Acid Antagonists Rescue Agents*** leucovorin calcium oral tablet 10, 15, 25, 5 *Imidazotetrazines*** temozolomide oral capsule 100, 140, 180, 20, 250, 5 Temodar *Lhrh Analogs*** ELIGARD SUBCUTANEOUS KIT 22.5 MG, 30 MG, 45 MG, 7.5 MG PA TRELSTAR INTRAMUSCULAR SUSPENSION RECONSTITUTED MG, 3.75 MG PA 31

35 TRELSTAR MIXJECT INTRAMUSCULAR SUSPENSION RECONSTITUTED MG, 22.5 MG, 3.75 MG VANTAS SUBCUTANEOUS KIT 50 MG ZOLADEX SUBCUTANEOUS IMPLANT 10.8 MG, 3.6 MG *Mitotic Inhibitors*** etoposide oral capsule 50 *Nitrogen Mustards*** ALKERAN ORAL TABLET 2 MG LEUKERAN ORAL TABLET 2 MG *Nitrosoureas*** GLEOSTINE ORAL CAPSULE 10 MG, 100 MG, 40 MG *Progestins-Antineoplastic*** hydroxyprogesterone caproate intramuscular solution 1.25 gm/5ml megestrol acetate oral suspension 40 /ml, 400 /10ml megestrol acetate oral tablet 20, 40 *Retinoids*** tretinoin oral capsule 10 *Urinary Tract Protective Agents*** MESNEX ORAL TABLET 400 MG *ANTIPARKINSON AGENTS* *Antiparkinson Anticholinergics*** benztropine mesylate oral tablet 0.5, 1, 2 trihexyphenidyl hcl oral elixir 0.4 /ml trihexyphenidyl hcl oral tablet 2, 5 *Antiparkinson Dopaminergics*** amantadine hcl oral capsule 100 amantadine hcl oral syrup 50 /5ml amantadine hcl oral tablet 100 bromocriptine mesylate oral capsule 5 bromocriptine mesylate oral tablet 2.5 Megace Oral Parlodel Parlodel PA PA PA PA 32

36 *Antiparkinson Monoamine Oxidase Inhibitors*** selegiline hcl oral capsule 5 Eldepryl selegiline hcl oral tablet 5 *Levodopa Combinations*** carbidopa-levodopa er oral tablet extended release , Sinemet CR carbidopa-levodopa oral tablet , , Sinemet carbidopa-levodopa oral tablet dispersible , , carbidopa-levodopa-entacapone oral tablet Stalevo 50 QLL (270 EA per 30 days) carbidopa-levodopa-entacapone oral tablet Stalevo 75 QLL (270 EA per 30 days) carbidopa-levodopa-entacapone oral tablet Stalevo 100 QLL (270 EA per 30 days) carbidopa-levodopa-entacapone oral tablet Stalevo 125 QLL (270 EA per 30 days) carbidopa-levodopa-entacapone oral tablet Stalevo 150 QLL (270 EA per 30 days) carbidopa-levodopa-entacapone oral tablet Stalevo 200 QLL (270 EA per 30 days) *Nonergoline Dopamine Receptor Agonists*** pramipexole dihydrochloride oral tablet Mirapex, 0.25, 0.5, 0.75, 1, 1.5 ropinirole hcl er oral tablet extended release 24 hour 12, 2, 4, 6, 8 Requip XL ropinirole hcl oral tablet 0.25, 0.5, 1, 2, 3, 4, 5 Requip QLL (90 EA per 30 days) *Peripheral Comt Inhibitors*** entacapone oral tablet 200 Comtan QLL (120 EA per 30 days) *ANTIPSYCHOTICS/ANTIMANIC AGENTS* *Antimanic Agents*** lithium carbonate er oral tablet extended release 300 Lithobid lithium carbonate er oral tablet extended release

37 lithium carbonate oral capsule 150, 300, 600 lithium carbonate oral tablet 300 lithium oral solution 8 meq/5ml *Antipsychotics - Misc.*** ziprasidone hcl oral capsule 20, 40, 60 Geodon, 80 QLL (60 EA per 30 days) *Benzisoxazoles*** risperidone oral solution 1 /ml RisperDAL QLL (240 ML per 30 days); AL (Min 5 Years) risperidone oral tablet 0.25, 0.5, 1, 2, 3, 4 risperidone oral tablet dispersible 0.25 risperidone oral tablet dispersible 0.5, 1, 2 RisperDAL RisperiDONE M-TAB risperidone oral tablet dispersible 3, 4 RisperDAL M-TAB RISPERIDONE M-TAB ORAL TABLET DISPERSIBLE 0.5 MG, 1 MG, 2 MG, 3 RisperiDONE MG, 4 MG *Butyrophenones*** haloperidol decanoate intramuscular solution Haldol Decanoate 100 /ml, 50 /ml haloperidol lactate injection solution 5 /ml Haldol haloperidol lactate oral concentrate 2 /ml haloperidol oral tablet 0.5, 1, 10, 2, 20, 5 *Dibenzodiazepines*** QLL (60 EA per 30 days); AL (Min 5 Years) QLL (60 EA per 30 days); AL (Min 5 Years) QLL (60 EA per 30 days); AL (Min 5 Years) QLL (60 EA per 30 days); AL (Min 5 Years) QLL (60 EA per 30 days); AL (Min 5 Years) AL (Min 3 Years) AL (Min 3 Years) AL (Min 3 Years) AL (Min 3 Years) clozapine oral tablet 100, 25 Clozaril AL (Min 9 Years) clozapine oral tablet 200, 50 AL (Min 9 Years) *Dibenzothiazepines*** quetiapine fumarate oral tablet 100, 200, 25, 50 quetiapine fumarate oral tablet 300, 400 *Dibenzoxazepines*** loxapine succinate oral capsule 10, 25, 5, 50 SEROquel SEROquel QLL (90 EA per 30 days); AL (Min 10 Years) QLL (60 EA per 30 days); AL (Min 10 Years) AL (Min 5 Years) 34

38 *Phenothiazines*** chlorpromazine hcl oral tablet 10, 100, 200, 25, 50 fluphenazine decanoate injection solution 25 /ml fluphenazine hcl injection solution 2.5 /ml fluphenazine hcl oral concentrate 5 /ml fluphenazine hcl oral elixir 2.5 /5ml fluphenazine hcl oral tablet 1, 10, 2.5, 5 perphenazine oral tablet 16, 2, 4, 8 prochlorperazine maleate oral tablet 10, 5 prochlorperazine rectal suppository 25 thioridazine hcl oral tablet 10, 100, 25, 50 trifluoperazine hcl oral tablet 1, 10, 2, 5 COMPRO RECTAL SUPPOSITORY 25 MG *Thienbenzodiazepines*** olanzapine oral tablet 10, 15, 2.5, 20, 5, 7.5 olanzapine oral tablet dispersible 10, 15, 20, 5 *Thioxanthenes*** thiothixene oral capsule 1, 10, 2, 5 *ANTIRETROVIRALS ADJUVANTS*** *Antiretrovirals Adjuvants*** TYBOST ORAL TABLET 150 MG *ANTISEPTICS & DISINFECTANTS* *Chlorine Antiseptics*** chlorhexidine gluconate solution 20 % Compro Prochlorperazine ZyPREXA ZyPREXA Zydis AL (Min 5 Years) AL (Min 12 Years) AL (Min 12 Years) AL (Min 12 Years) AL (Min 12 Years) AL (Min 12 Years) AL (Min 5 Years) AL (Min 2 Years) QLL (30 EA per 30 days) QLL (30 EA per 30 days) AL (Min 13 Years) 35

39 *ANTIVIRALS* *Antiretroviral Combinations*** abacavir sulfate-lamivudine oral tablet 600 Epzicom 300 abacavir-lamivudine-zidovudine oral tablet Trizivir lamivudine-zidovudine oral tablet Combivir lopinavir-ritonavir oral solution Kaletra /5ml ATRIPLA ORAL TABLET MG COMPLERA ORAL TABLET MG DESCOVY ORAL TABLET MG EVOTAZ ORAL TABLET MG GENVOYA ORAL TABLET MG KALETRA ORAL TABLET MG, MG STRIBILD ORAL TABLET MG TRIUMEQ ORAL TABLET MG TRUVADA ORAL TABLET MG, MG, MG, MG *Antiretrovirals - Ccr5 Antagonists (Entry Inhibitor)*** SELZENTRY ORAL TABLET 150 MG, 25 MG, 300 MG, 75 MG *Antiretrovirals - Fusion Inhibitors*** FUZEON SUBCUTANEOUS SOLUTION RECONSTITUTED 90 MG *Antiretrovirals - Integrase Inhibitors*** ISENTRESS ORAL PACKET 100 MG ISENTRESS ORAL TABLET 400 MG ISENTRESS ORAL TABLET CHEWABLE 100 MG, 25 MG TIVICAY ORAL TABLET 10 MG, 25 MG, 50 MG QLL (30 EA per 30 Days) QLL (30 EA per 30 Days) QLL (30 EA per 30 days) QLL (30 EA per 30 days) QLL (120 EA per 30 days) QLL (180 EA per 30 days) QLL (60 EA per 30 days) 36