2015 Coventry Commercial Prescription Drug List

Transcription

1 2015 Coventry Commercial Prescription Drug List This is not meant to be a complete list of the drugs covered under your plan. Not all dosage forms of the drugs listed below are covered. We periodically review our Prescription Drug List. This is the most current list at the time of printing and is subject to change. Some medications may require prior authorization or have quantity limits. Please call Customer Service at the number on your member ID card with any questions about your coverage or for more information. Specialty Medications Specialty medications are typically high-cost drugs, including but not limited to the oral, topical, inhaled, inserted or implanted, and injected routes of administration used to treat rare and complex diseases. Specialty medications require prior authorization unless otherwise indicated. Your doctor should contact Coventry s Pharmacy Call Center at to request prior authorization. Except in urgent situations, all specialty medications are distributed through a participating specialty pharmacy. Specialty drugs are limited to a 30 day supply at a time or the quantity prescribed in the prescription order, whichever is less. Please call Customer Service at the number on your member ID card for a referral to a participating specialty pharmacy or with questions regarding your pharmacy benefit. Please refer to your health plan documents regarding coverage of and any limitations or exclusions that may apply to your specialty drug benefit. Prior authorization Coventry Health Care has two broad goals for the prescription drug benefit we offer. One is to never compromise the quality or effectiveness of treatment. The second is to provide a comprehensive, affordable pharmacy benefit. One of the tools we use to help control prescription drug costs is to require prior approval, or authorization, before we will cover the cost of certain medications. These medications include those that (1) are not suggested for first-line therapy, (2) may require special tests before starting them or (3) have very limited approval for use. Step Therapy is an automated form of Prior Authorization based on past drug treatment. Drugs designated as stepped therapy will require prior authorization if the condition is not met when the pharmacist would attempt to transmit a prescription claim. Only your physician can provide the information necessary to complete the prior authorization process. If you have been prescribed a drug that requires prior authorization, make sure your doctor knows that this medicationrequires prior authorization. Your doctor should contact Coventry s Pharmacy Call Center at

2 2015 Coventry Prescription Drug List Table of Contents Alternative Therapy... 3 Analgesic, Anti-Inflammatory Or Antipyretic... 4 Anorectal Preparations... 9 Antidotes And Other Reversal Agents... 9 Anti-Infective Agents... 9 Antineoplastics Biologicals Cardiovascular Therapy Agents Central Nervous System Agents Chemical Dependency, Agents To Treat Chemicals-Pharmaceutical Adjuvants Cognitive Disorder Therapy Contraceptives Dermatological Diagnostic Agents Drugs To Treat Erectile Dysfunction Eating Disorder Therapy Electrolyte Balance-Nutritional Products Endocrine Gastrointestinal Therapy Agents Genitourinary Therapy Gout And Hyperuricemia Therapy Hematological Agents Immunosuppressive Agents Locomotor System Medical Supplies And Durable Medical Equipment (Dme) Medical Supply, Fdb Superset Metabolic Modifiers Mouth-Throat-Dental - Preparations Multiple Sclerosis Agents Ophthalmic Agents Otic Respiratory Therapy Agents Vaginal Products

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4 2015 Coventry Prescription Drug List lowercase italics = Generic drugs UPPERCASE = Brand name drugs Drug Status = = Copay Exception: Available to some members at no cost with a prescription from your provider when obtained at an in-network pharmacy = Limited Access - Coverage varies by benefit N/A = Not Applied = Not Covered NL = Not Listed = Preferred Generics Tier 2 = Preferred Brands = Non-Preferred Brands and Generics Tier 4 = Specialty Additional Information AL = Age Limit DS = Not available as a 90 day supply PA = Prior Authorization Applies = Quantity Limit ST = Step Therapy Applies Drug Name Drug Status Additional Information Alternative Therapy APPTRIM ENTERAGAM FOSTEUM FOSTEUM PLUS GABADONE HYPERTENSA L-METHYL-MC NAC LIMBREL LIMBREL250 LIMBREL500 METAFOLBIC PLUS PERCURA PROTEOLIN PROTEOLIN DS SENTRA AM SENTRA PM TEARS AGAIN HYDRATE THERAMINE 3

5 TREPADONE (WITH BROMEIN) VAYACOG VAYARIN VP-GSTN VP-PRECIP Analgesic, Anti-Inflammatory Or Antipyretic ABSTRAL PA; DS acetaminophen-codeine oral solution 120 mg-12 mg /5 ml (5 ml), mg/5 ml, 240 mg-24 mg /10 ml (10 ml), 300 mg-30 mg /12.5 ml acetaminophen-codeine oral tablet mg DS acetaminophen-codeine oral tablet mg, mg ACTEMRA SUBCUTANEOUS Tier 4 PA; ACTIQ PA; DS; ADULT LOW DOSE ASPIRIN ANAPROX ANAPROX DS ARAVA ARCALYST Tier 4 PA ARTHROTEC 50 ARTHROTEC 75 ASPIR-81 ASPIR-LOW ASPIR-TRIN aspirin oral tablet 325 mg aspirin oral tablet,chewable aspirin oral tablet,delayed release (dr/ec) 325 mg, 500 mg, 81 mg ASPIRIN CHILDRENS ASPIRIN LOW DOSE ASPIRIN LOW-STRENGTH AVINZA PA; DS; azathioprine AZULFIDINE ST; AZULFIDINE EN-TABS ST; BAYER ADVAED BAYER ASPIRIN BAYER CHEWABLE ASPIRIN BAYER CHILDRENS ASPIRIN butalbital-acetaminop-caf-cod DS butalbital-acetaminophen butalbital-acetaminophen-caff oral capsule mg DS butalbital-acetaminophen-caff oral tablet mg DS butalbital-aspirin-caffeine oral capsule DS 4

6 butorphanol tartrate nasal BUTRANS TRANSDERMAL PATCH WEEKLY 10 MCG/HOUR, 15 MCG/HOUR, 20 MCG/HOUR, 5 MCG/HOUR CAMBIA Tier 2 CATAFM DS; LEBREX ST; LLPT ORAL CAPSULE Tier 4 LLPT ORAL SUSPENSION FOR RECONSTITUTION Tier 4 LLPT ORAL TABLET Tier 4 CHILD ASPIRIN CHILDREN'S ASPIRIN choline,magnesium salicylate oral liquid CIMZIA Tier 4 PA; CIMZIA POWDER FOR RECONST Tier 4 PA; CIMZIA STARTER KIT Tier 4 PA; codeine sulfate oral solution 30 mg/5 ml codeine sulfate oral tablet DS COMFORT PAC-IBUPROFEN COMFORT PAC-MELOXICAM COMFORT PAC-NAPROXEN CONZIP ORAL CAPSULE,ER BIPHASE 24 HR DS; CONZIP ORAL CAPSULE,ER BIPHASE 24 HR MG, 200 MG CUPRIMINE Tier 2 cyclophosphamide oral capsule Tier 4 cyclophosphamide oral tablet Tier 4 cyclosporine oral capsule Tier 4 cyclosporine modified Tier 4 DAYPRO DEMEROL ORAL DS DEPEN TITRATABS Tier 2 diclofenac potassium diclofenac sodium oral tablet extended release 24 hr diclofenac sodium oral tablet,delayed release (dr/ec) diclofenac-misoprostol diflunisal DIUDID ORAL TABLET DS DOLOPHINE ORAL DS DUEXIS DS; DURAGESIC PA; DS; E.C. PRIN EC-NAPROSYN 5

7 ECOTRIN ECOTRIN LOW STRENGTH ENBREL SUBCUTANEOUS KIT Tier 4 PA; ENBREL SUBCUTANEOUS SYRINGE 25 MG/0.5ML (0.51), 50 MG/ML (0.98 ML) Tier 4 PA; ENBREL SURECLICK Tier 4 PA; ENTERIC COATED ASPIRIN etodolac EXALGO ER PA; DS; EXTRA STRENGTH BAYER FELDENE fenoprofen oral tablet fentanyl PA; DS; fentanyl citrate PA; DS; FENTORA PA; DS; FIORINAL DS FIORINAL-CODEINE #3 DS flurbiprofen GENGRAF Tier 4 HUMIRA SUBCUTANEOUS SYRINGE KIT 20 MG/0.4 ML, 40 MG/0.8 ML Tier 4 HUMIRA CROHN'S DIS START PCK Tier 4 PA; HUMIRA PEN Tier 4 PA; HUMIRA PSORIASIS STARTER PACK Tier 4 hydrocodone-acetaminophen oral tablet mg, mg, mg, mg hydrocodone-acetaminophen oral tablet mg, mg hydrocodone-ibuprofen oral tablet mg hydromorphone oral liquid DS hydromorphone oral tablet DS hydroxychloroquine oral ibuprofen oral tablet 400 mg, 600 mg, 800 mg IRIS (PF) Tier 4 PA; IMURAN DS INDOCIN ORAL Tier 2 INDOCIN RECTAL indomethacin oral KADIAN ORAL CAPSULE,EXTEND.RELEASE PELLETS 10 MG, 100 MG, 20 MG, 200 MG, 30 MG, 40 MG, 50 MG, 60 MG, 80 MG ketoprofen oral capsule ketoprofen oral capsule,ext rel. pellets 24 hr 200 mg ketorolac oral DS DS DS PA; DS; KINERET Tier 4 PA; 6

8 ZANDA PA; DS; leflunomide DS; LITE COAT ASPIRIN LO-DOSE ASPIRIN meclofenamate oral meloxicam meperidine oral tablet DS methadone oral tablet DS methadone oral tablet,soluble DS methotrexate sodium oral DS MINOCIN ORAL CAPSULE 100 MG, 50 MG minocycline oral capsule DS minocycline oral tablet MOBIC morphine oral capsule, er multiphase 24 hr PA; morphine oral capsule,extend.release pellets PA; DS; morphine oral solution 10 mg/5 ml DS morphine oral tablet 15 mg DS morphine oral tablet extended release DS MS CONTIN DS mycophenolate mofetil Tier 4 nabumetone NALFON ORAL CAPSULE 400 MG Tier 2 NAPREN CR NAPROSYN naproxen oral suspension naproxen oral tablet naproxen oral tablet,delayed release (dr/ec) 375 mg naproxen sodium oral tablet 275 mg, 550 mg NEORAL Tier 4 NUCYNTA ST; DS; NUCYNTA ER PA; DS; OPANA ORAL ST; DS OPANA ER ORAL TABLET,ORAL ONLY,EXT.REL.12 HR Tier 2 OREIA Tier 4 PA; OTEZ Tier 4 PA; OTEZ STARTER Tier 4 PA; OTREXUP (PF) oxaprozin OXECTA DS oxycodone oral capsule DS oxycodone oral tablet DS 7

9 OXYCONTIN PA; DS; oxymorphone oral tablet ST oxymorphone oral tablet extended release 12 hr PERCOT ORAL TABLET MG, MG, MG, MG PERCODAN piroxicam PQUENIL PONSTEL PRIMLEV RIDAURA Tier 2 salsalate SANDIMMUNE ORAL Tier 4 SIMPONI SUBCUTANEOUS PEN INJECTOR Tier 4 PA SIMPONI SUBCUTANEOUS SYRINGE 100 MG/ML Tier 4 PA SIMPONI SUBCUTANEOUS SYRINGE 50 MG/0.5 ML Tier 4 PA; SPRIX DS; ST. JOSEPH ASPIRIN SUBSYS PA; DS; sulfasalazine SULFAZINE SULFAZINE EC sulindac oral SYNALGOS-DC tolmetin tramadol oral capsule,er biphase 24 hr DS tramadol oral tablet DS tramadol oral tablet extended release 24 hr DS tramadol oral tablet, er multiphase 24 hr tramadol-acetaminophen TYLENOL TYLENOL-CODEINE #3 DS TYLENOL-CODEINE #4 DS ULTRAT ULTRAM DS ULTRAM ER DS; VICOPROFEN VIMOVO VOLTAREN-XR XARTEMIS XR ST; XELJANZ Tier 4 PA; XODOL 10/300 XODOL 5/300 8

10 XODOL 7.5/300 ZAMIT ZIPSOR ZOHYDRO ER PA; DS; ZORVOLEX ST Anorectal Preparations ANALPRAM-HC ANUSOL-HC RECTAL CREAM hydrocortisone rectal cream lidocaine hcl-hydrocortison ac rectal cream % lidocaine hcl-hydrocortison ac rectal kit PROCTOCORT RECTAL CREAM PROCTOCREAM-HC PROCTOFOAM HC PROCTOZONE-HC RECTIV ZYPRAM Antidotes And Other Reversal Agents acetylcysteine solution CUPRIMINE Tier 2 DEPEN TITRATABS Tier 2 EVZIO PA EXJADE Tier 4 PA; DS FERRIPROX Tier 4 PA naltrexone oral DS RELISTOR REVIA SYPRINE Anti-Infective Agents abacavir Tier 4 abacavir-lamivudine-zidovudine Tier 4 DS ACTICTE ACTIMMUNE Tier 4 PA acyclovir oral capsule acyclovir oral suspension 200 mg/5 ml acyclovir oral tablet adefovir Tier 4 ADOXA ORAL CAPSULE ALBENZA ALINIA ORAL SUSPENSION FOR RECONSTITUTION ALINIA ORAL TABLET amoxicillin oral capsule DS amoxicillin oral suspension for reconstitution DS 9

11 amoxicillin oral tablet DS amoxicillin oral tablet,chewable 125 mg, 250 mg, 400 mg DS amoxicillin-pot clavulanate oral suspension for reconstitution amoxicillin-pot clavulanate oral tablet DS amoxicillin-pot clavulanate oral tablet,chewable DS ampicillin oral capsule 250 mg, 500 mg DS ampicillin oral suspension for reconstitution DS AOBON aptivus oral capsule Tier 4 DS; APTIVUS ORAL SOLUTION Tier 4 DS atovaquone atovaquone-proguanil PA; DS; ATRIP Tier 4 AUGMENTIN ORAL SUSPENSION FOR RECONSTITUTION MG/5 ML AUGMENTIN ORAL SUSPENSION FOR RECONSTITUTION MG/5 ML AUGMENTIN ORAL TABLET MG, MG Tier 2 AUGMENTIN XR AVELOX DS; AVIDOXY AVIDOXY DK azithromycin oral suspension for reconstitution DS azithromycin oral tablet 250 mg, 500 mg DS; BACTRIM DS BACTRIM DS DS BARACLUDE ORAL SOLUTION Tier 4 BARACLUDE ORAL TABLET Tier 4 BETHKIS Tier 4 BIAXIN ORAL SUSPENSION FOR RECONSTITUTION 250 MG/5 ML DS DS; BIAXIN ORAL TABLET DS; BIAXIN XL DS; BILTRICIDE Tier 2 DS CAYSTON Tier 4 DAX cefaclor oral capsule DS cefaclor oral suspension for reconstitution 125 mg/5 ml, 250 mg/5 ml, 375 mg/5 ml cefaclor oral tablet extended release 12 hr DS; cefadroxil oral capsule DS cefadroxil oral suspension for reconstitution 250 mg/5 ml, 500 mg/5 ml 10 DS DS

12 cefadroxil oral tablet DS cefdinir DS cefprozil DS FTIN ORAL SUSPENSION FOR RECONSTITUTION FTIN ORAL TABLET 250 MG, 500 MG cefuroxime axetil oral tablet DS cephalexin oral capsule DS cephalexin oral tablet DS chloroquine phosphate oral DS CIPRO ORAL SUSPENSION,MICROCAPSULE RECON DS CIPRO ORAL TABLET 250 MG, 500 MG DS ciprofloxacin oral suspension,microcapsule recon 250 mg/5 ml ciprofloxacin oral tablet DS clarithromycin oral suspension for reconstitution 125 mg/5 ml clarithromycin oral suspension for reconstitution 250 mg/5 ml clarithromycin oral tablet DS clarithromycin oral tablet extended release 24 hr DS CLEOCIN ORAL clindamycin hcl DS DS DS DS; COARTEM Tier 2 PA; DS; COMBIVIR Tier 4 COMPLERA Tier 4 COPEGUS Tier 4 PA CRIXIVAN ORAL CAPSULE 200 MG, 400 MG Tier 4 dapsone Tier 2 DARAPRIM Tier 2 DS dicloxacillin DS didanosine Tier 4 DIFICID DS; DIFLUCAN ORAL SUSPENSION FOR RECONSTITUTION DIFLUCAN ORAL TABLET 100 MG, 200 MG, 50 MG DIFLUCAN ORAL TABLET 150 MG DORYX ORAL TABLET,DEYED RELEASE (DR/EC) 150 MG, 200 MG doxycycline hyclate oral capsule doxycycline hyclate oral tablet 100 mg doxycycline hyclate oral tablet,delayed release (dr/ec) doxycycline monohydrate oral capsule 100 mg, 50 mg doxycycline monohydrate oral capsule 150 mg, 75 mg doxycycline monohydrate oral suspension for reconstitution doxycycline monohydrate oral tablet 11

13 E.E.S. 200 Tier 2 E.E.S. 400 ORAL TABLET DS E.E.S. GRANULES Tier 2 DS EDURANT Tier 4 EMTRIVA Tier 4 EPIVIR Tier 4 EPIVIR HBV Tier 4 DS EPZICOM Tier 4 ERY-TAB DS ERYTHROCIN (AS STEARATE) ORAL TABLET 250 MG erythromycin oral tablet DS erythromycin ethylsuccinate oral suspension for reconstitution erythromycin ethylsuccinate oral tablet DS erythromycin stearate oral tablet 250 mg ethambutol DS FACTIVE DS; famciclovir DS; FAMVIR FGYL FGYL ER fluconazole oral suspension for reconstitution AL fluconazole oral tablet FLUMADINE ORAL TABLET FUZEON SUBCUTANEOUS RECON SOLN Tier 4 GRIFULVIN V ORAL TABLET Tier 2 DS GRIS-PEG (ULTRAMICROSIZE) Tier 2 DS griseofulvin microsize oral suspension DS griseofulvin microsize oral tablet DS griseofulvin ultramicrosize DS HEPSERA Tier 4 hydroxychloroquine oral IIVEK Tier 4 PA; INTELEE ORAL TABLET 100 MG, 200 MG, 25 MG Tier 4 INVIRASE Tier 4 ISENTRESS ORAL POWDER IN PACKET Tier 4 ISENTRESS ORAL TABLET Tier 4 ISENTRESS ORAL TABLET,CHEWABLE Tier 4 isoniazid oral DS itraconazole KALETRA Tier 4 PA KEFLEX ORAL CAPSULE DS KETEK 12 DS

14 ketoconazole oral DS; MISIL ORAL GRANULES IN PACKET 125 MG, MG MISIL ORAL TABLET DS lamivudine oral tablet 100 mg, 150 mg, 300 mg Tier 4 DS lamivudine-zidovudine Tier 4 DS; LEVAQUIN ORAL SOLUTION DS; LEVAQUIN ORAL TABLET DS; levofloxacin oral DS LEXIVA Tier 4 MARONE PA; MARONE PEDIATRIC PA; MEPRON DS; metronidazole oral DS MINOCIN ORAL CAPSULE 100 MG, 50 MG minocycline oral capsule DS minocycline oral tablet minocycline oral tablet extended release 24 hr MODERIBA DOSE PACK MONODOX ORAL CAPSULE 100 MG, 50 MG MONODOX ORAL CAPSULE 75 MG MORGIDOX MORGIDOX 1X100 MORGIDOX 2X100 MOXATAG moxifloxacin DS; MYAMBUTOL ORAL TABLET 400 MG DS MYCOBUTIN DS NEBUPENT Tier 2 DS neomycin DS nevirapine oral suspension Tier 4 DS nevirapine oral tablet Tier 4 DS nevirapine oral tablet extended release 24 hr Tier 4 DS; NOROXIN DS; NORVIR Tier 4 NOXAFIL ORAL SUSPENSION DS; NOXAFIL ORAL TABLET,DEYED RELEASE (DR/EC) nystatin oral tablet DS ofloxacin oral tablet 400 mg DS DS; OLYSIO Tier 4 PA; ONMEL ORAA ORAVIG DS; 13

15 paromomycin DS PASER P PEGASYS Tier 4 PA PEGASYS PROCLICK Tier 4 PA PEGINTRON Tier 4 PA PEGINTRON REDIPEN Tier 4 PA penicillin v potassium DS PQUENIL PREZISTA ORAL SUSPENSION Tier 4 DS; PREZISTA ORAL TABLET 150 MG, 400 MG, 600 MG, 75 MG, 800 MG Tier 4 PRIFTIN primaquine pyrazinamide DS DS; QUAQUIN PA; DS; REBETOL ORAL CAPSULE Tier 4 PA REBETOL ORAL SOLUTION Tier 4 PA; RELENZA DISKHALER RESCRIPTOR Tier 4 RETROVIR ORAL CAPSULE Tier 4 RETROVIR ORAL SYRUP Tier 4 REYATAZ ORAL CAPSULE 150 MG, 200 MG, 300 MG Tier 4 RIBAPAK DOSE PACK RIBASPHERE Tier 4 PA ribavirin oral capsule Tier 4 PA ribavirin oral tablet 200 mg Tier 4 PA rifabutin RIFADIN RIFAMATE rifampin oral DS RIFATER rimantadine DS SELZENTRY Tier 4 PA; SIRTURO Tier 4 PA; SIVEXTRO ORAL PA; SOLODYN ORAL TABLET EXTENDED RELEASE 24 HR 105 MG, 115 MG, 55 MG, 65 MG, 80 MG SOVALDI Tier 4 PA; SPORANOX ORAL CAPSULE SPORANOX ORAL SOLUTION Tier 2 DS SPORANOX PULSEPAK stavudine Tier 4 STRIBILD Tier 4 PA; 14

16 STROMECTOL sulfadiazine oral sulfamethoxazole-trimethoprim oral suspension DS sulfamethoxazole-trimethoprim oral tablet mg, mg SUPRAX ORAL SUSPENSION FOR RECONSTITUTION 100 MG/5 ML, 200 MG/5 ML SUPRAX ORAL TABLET,CHEWABLE SUSTIVA Tier 4 TAMIFLU ORAL CAPSULE DS; TAMIFLU ORAL SUSPENSION FOR RECONSTITUTION 6 MG/ML terbinafine hcl oral DS TERBINEX tetracycline THALOMID Tier 4 PA TINDAMAX ORAL TABLET 250 MG, 500 MG TIVICAY Tier 4 TOBI Tier 4 DS DS; TOBI PODHALER INHATION CAPSULE Tier 4 PA; TOBI PODHALER INHATION CAPSULE, W/INHATION DEVI Tier 4 tobramycin in % nacl Tier 4 TRECATOR trimethoprim TRIZIVIR Tier 4 DS TRUVADA Tier 4 PA TYZEKA Tier 4 valacyclovir oral tablet 1 gram, 500 mg DS; VALCYTE Tier 2 PA; DS VALTREX ORAL TABLET 1 GRAM, 500 MG DS; VAOCIN ORAL CAPSULE 125 MG, 250 MG vancomycin intravenous VFEND ORAL SUSPENSION FOR RECONSTITUTION DS VFEND ORAL TABLET DS VIBRAMYCIN ORAL CAPSULE 100 MG VIBRAMYCIN ORAL SUSPENSION FOR RECONSTITUTION VIBRAMYCIN ORAL SYRUP VICTRELIS Tier 4 PA; VIDEX 2 GRAM PEDIATRIC Tier 4 VIDEX 4 GRAM PEDIATRIC Tier 4 VIDEX EC Tier 4 VIRAPT ORAL TABLET Tier 4 VIRAMUNE Tier 4 PA 15

17 VIRAMUNE XR ORAL TABLET EXTENDED RELEASE 24 HR 100 MG VIRAMUNE XR ORAL TABLET EXTENDED RELEASE 24 HR 400 MG Tier 4 Tier 4 VIREAD ORAL POWDER Tier 4 VIREAD ORAL TABLET Tier 4 voriconazole oral tablet DS XIFAXAN ORAL TABLET 200 MG DS; XIFAXAN ORAL TABLET 550 MG PA; DS; ZERIT Tier 4 ZIAGEN Tier 4 zidovudine Tier 4 ZITHROMAX ORAL SUSPENSION FOR RECONSTITUTION DS; ZITHROMAX ORAL TABLET 500 MG, 600 MG DS; ZITHROMAX TRI-PAK DS; ZMAX ZOVIRAX ORAL CAPSULE ZOVIRAX ORAL SUSPENSION ZOVIRAX ORAL TABLET ZYVOX ORAL SUSPENSION FOR RECONSTITUTION Tier 2 DS; ZYVOX ORAL TABLET Tier 2 DS; Antineoplastics AFINITOR Tier 4 PA; AFINITOR DISPERZ Tier 4 PA; ALKERAN ORAL Tier 4 anastrozole PA; DS ARIMIDEX PA; DS AROMASIN PA; DS; bicalutamide BOSULIF ORAL TABLET 100 MG Tier 4 PA; BOSULIF ORAL TABLET 500 MG Tier 4 PA capecitabine Tier 4 PA CAPRELSA ORAL TABLET 100 MG, 300 MG Tier 4 PA; CASODEX COMETRIQ Tier 4 PA; cyclophosphamide oral capsule Tier 4 cyclophosphamide oral tablet Tier 4 EMCYT Tier 2 DS ERIVEDGE Tier 4 PA; etoposide oral Tier 4 exemestane PA; DS; FARESTON Tier 2 FEMARA PA 16

18 flutamide GILOTRIF Tier 4 PA GLEEVEC Tier 4 PA HEXALEN Tier 4 HYCAMTIN ORAL Tier 4 PA; DS HYDREA DS hydroxyurea DS ICLUSIG ORAL TABLET 15 MG, 45 MG Tier 4 PA; IMBRUVICA Tier 4 PA INLYTA Tier 4 PA; INTRON A INJECTION Tier 4 PA JAKAFI Tier 4 PA; letrozole PA leucovorin calcium oral LEUKERAN Tier 2 leuprolide Tier 4 PA lomustine oral capsule 10 mg, 100 mg, 40 mg Tier 4 LYSODREN Tier 2 MATUNE Tier 4 megestrol oral tablet MEKINIST ORAL TABLET 0.5 MG, 2 MG Tier 4 PA; mercaptopurine DS methotrexate sodium DS methotrexate sodium (pf) injection solution MYLERAN Tier 4 NEXAVAR Tier 4 PA; NINDRON Tier 2 POMALYST Tier 4 PA; PURINETHOL PURIXAN Tier 4 PA; REVLIMID Tier 4 PA; SOLTAMOX SPRYL ORAL TABLET 100 MG, 140 MG, 20 MG, 50 MG, 70 MG, 80 MG Tier 4 PA; STIVARGA Tier 4 PA; SUTENT ORAL CAPSULE 12.5 MG, 25 MG, 37.5 MG, 50 MG Tier 4 SYTRON Tier 4 PA SYTRON 4-PACK SUBCUTANEOUS KIT 296 MCG, 444 MCG Tier 4 TABLOID Tier 2 PA; TAFINR Tier 4 PA; tamoxifen TARVA Tier 4 PA; PA 17

19 TARGRETIN ORAL Tier 4 TASIGNA Tier 4 PA; TEMODAR ORAL Tier 4 PA temozolomide Tier 4 PA THALOMID Tier 4 PA tretinoin (chemotherapy) Tier 4 TYKERB Tier 4 PA VOTRIENT Tier 4 PA; XALKORI ORAL CAPSULE 200 MG Tier 4 PA XALKORI ORAL CAPSULE 250 MG Tier 4 PA; XELODA Tier 4 PA XTANDI Tier 4 PA; ZELBORAF Tier 4 PA; ZOLINZA Tier 4 PA; ZYDELIG Tier 4 PA; DS; ZYKADIA Tier 4 PA ZYTIGA Tier 4 PA; Biologicals AFLURIA AFLURIA (PF) FLUVAL FLUVAL QUAD FLUVIRIN FLUVIRIN (PF) FLUZONE FLUZONE (PF) FLUZONE HIGH-DOSE (PF) FLUZONE INTRADERM (PF) FLUZONE QUAD FLUZONE QUAD (PF) FLUZONE QUAD PEDI (PF) GAMMAGARD LIQUID Tier 4 PA GAMMAKED Tier 4 PA GAMUNEX-C INJECTION SOLUTION 1 GRAM/10 ML (10 %), 10 GRAM/100 ML (10 %), 2.5 GRAM/25 ML (10 %), 20 GRAM/200 ML (10 %), 5 GRAM/50 ML (10 %) HIZENTRA SUBCUTANEOUS SOLUTION 1 GRAM/5 ML (20 %), 10 GRAM/50 ML (20 %), 2 GRAM/10 ML (20 %), 4 GRAM/20 ML (20 %) Tier 4 Tier 4 HYPERRHO S/D DS; PNEUMOVAX 23 INJECTION SYRINGE RHOGAM ULTRA-FILTERED PLUS SYNAGIS PA WINRHO SDF DS; 18 PA PA

20 Cardiovascular Therapy Agents ACCUPRIL ACCURETIC acebutolol oral AON ORAL TABLET 4 MG, 8 MG acetazolamide oral capsule, extended release acetazolamide oral tablet ADAT CC ORAL TABLET EXTENDED RELEASE 30 MG, 60 MG, 90 MG ADCIRCA Tier 4 PA; ADEMPAS Tier 4 PA ADRENACLICK PA; ADRENALIN INJECTION SOLUTION 1 MG/ML (1:1,000) (1ML) ADVICOR ORAL TABLET, ER MULTIPHASE 24 HR 1, MG, 1, MG, MG, MG AFEDITAB CR ORAL TABLET EXTENDED RELEASE 30 MG, 60 MG ALDACTAZIDE ALDACTONE ALTA ORAL CAPSULE 1.25 MG, 10 MG, 2.5 MG, 5 MG ALTOPREV ORAL TABLET EXTENDED RELEASE 24 HR 20 MG, 40 MG, 60 MG amiloride oral amiloride-hydrochlorothiazide amiodarone oral amlodipine amlodipine-benazepril ST; AMTURNIDE PA; ANTARA ORAL CAPSULE 30 MG, 90 MG ATACAND ATACAND HCT atenolol atenolol-chlorthalidone atorvastatin AUVI-Q Tier 2 AVALIDE AVAPRO AZOR ST; benazepril benazepril-hydrochlorothiazide BENICAR ST; BENICAR HCT ST; BETAPA 19

21 BETAPA AF BIDIL bisoprolol fumarate bisoprolol-hydrochlorothiazide bumetanide oral BYSTOLIC ORAL TABLET 10 MG, 2.5 MG, 20 MG, 5 MG CADUET CAN CAN SR candesartan candesartan-hydrochlorothiazid captopril captopril-hydrochlorothiazide CARDENE SR ORAL CAPSULE, EXTENDED RELEASE 30 MG, 45 MG CARDIZEM ORAL TABLET 120 MG, 30 MG, 60 MG CARDIZEM CD ORAL CAPSULE,EXTENDED RELEASE 24HR 120 MG, 180 MG, 240 MG, 300 MG, 360 MG CARDIZEM ORAL TABLET EXTENDED RELEASE 24 HR 120 MG, 180 MG, 240 MG, 300 MG, 360 MG, 420 MG CARDURA CARDURA XL CARTIA XT ORAL CAPSULE,EXTENDED RELEASE 24HR 120 MG, 180 MG, 240 MG, 300 MG carvedilol CATAPRES CATAPRES-TTS-1 CATAPRES-TTS-2 CATAPRES-TTS-3 chlorothiazide DS chlorthalidone oral tablet 25 mg, 50 mg cholestyramine (with sugar) oral powder in packet clonidine clonidine hcl oral tablet CLORPRES COLESTID colestipol oral granules colestipol oral tablet CORDARONE COREG COREG CR CORGARD 20

22 CORZIDE COZAAR CRESTOR Tier 2 DEMADEX DEMSER DIAMOX SEQUELS DIBENZYLINE Tier 2 DIGOX digoxin oral solution 50 mcg/ml digoxin oral tablet DITRATE-SR Tier 2 diltiazem hcl oral capsule, extended release 120 mg, 180 mg, 240 mg, 300 mg, 360 mg diltiazem hcl oral capsule,extended release 12 hr diltiazem hcl oral capsule,extended release 24hr 120 mg, 180 mg, 240 mg, 300 mg, 360 mg diltiazem hcl oral tablet diltiazem hcl oral tablet extended release 24 hr 180 mg, 240 mg, 300 mg, 360 mg, 420 mg DIOVAN DIOVAN HCT disopyramide phosphate oral capsule DIURIL doxazosin DUTOPROL DYAZIDE DYRENIUM EDARBI ST; EDARBYCLOR ST; EDECRIN enalapril maleate enalapril-hydrochlorothiazide EPANED PA; ; AL epinephrine injection auto-injector 0.15 mg/0.15 ml (1:1,000), 0.3 mg/0.3 ml (1:1,000) epinephrine injection solution 1 mg/ml (1:1,000) epinephrine (pf) EPIPEN Tier 2 DS; EPIPEN 2-PAK Tier 2 EPIPEN JR Tier 2 DS; EPIPEN JR 2-PAK Tier 2 eprosartan EXFORGE ST EXFORGE HCT ST; 21

23 felodipine fenofibrate oral tablet fenofibrate micronized oral capsule 130 mg, 43 mg fenofibrate micronized oral capsule 134 mg, 200 mg, 67 mg fenofibrate nanocrystallized fenofibric acid fenofibric acid (choline) FENOGLIDE FIBRICOR FIRAZYR Tier 4 PA; flecainide fluvastatin fosinopril fosinopril-hydrochlorothiazide furosemide oral tablet gemfibrozil oral guanfacine HEMANGEOL PA hydralazine oral hydrochlorothiazide HYZAAR IMDUR indapamide INDERAL INNOPRAN XL ORAL CAPSULE,EXTENDED RELEASE 24HR 120 MG, 80 MG INSPRA ORAL TABLET 25 MG, 50 MG irbesartan irbesartan-hydrochlorothiazide ISOCHRON ISORDIL Tier 2 ISORDIL TITRADOSE ORAL TABLET 5 MG isosorbide dinitrate oral tablet 10 mg, 20 mg, 30 mg, 5 mg isosorbide dinitrate oral tablet extended release isosorbide mononitrate oral tablet 10 mg, 20 mg isosorbide mononitrate oral tablet extended release 24 hr isoxsuprine oral tablet 10 mg isoxsuprine oral tablet 20 mg JUXTAPID ORAL CAPSULE 10 MG, 20 MG, 5 MG Tier 4 PA; KYNAMRO Tier 4 PA; labetalol oral NOXIN ORAL TABLET 125 MCG, 250 MCG Tier 2 NOXIN ORAL TABLET MCG, 62.5 MCG 22

24 NOXIN PEDIATRIC SIX LESCOL LESCOL XL LETAIRIS Tier 4 PA LIPITOR LIPOFEN LIPTRUZET ORAL TABLET MG, MG, MG, MG lisinopril lisinopril-hydrochlorothiazide ST; LIVALO ST; LOFIBRA LOPID LOPRESSOR ORAL TABLET 50 MG LOPRESSOR HCT ORAL TABLET MG losartan losartan-hydrochlorothiazide LOTENSIN ORAL TABLET 20 MG, 40 MG LOTENSIN HCT LOTREL lovastatin LOVAZA ST; MAVIK MAXZIDE MAXZIDE-25MG methazolamide oral methyldopa methyldopa-hydrochlorothiazide oral tablet mg, mg metolazone metoprolol succinate oral tablet extended release 24 hr 100 mg, 200 mg, 25 mg, 50 mg metoprolol ta-hydrochlorothiaz metoprolol tartrate oral mexiletine MICARDIS MICARDIS HCT MICROZIDE midodrine MINIPRESS MINITRAN TRANSDERMAL PATCH 24 HOUR 0.1 MG/HR, 0.2 MG/HR, 0.4 MG/HR, 0.6 MG/HR Tier 2 minoxidil oral 23

25 moexipril moexipril-hydrochlorothiazide MULTAQ nadolol NEPTAZANE niacin oral tablet extended release 24 hr DS NIASPAN EXTENDED-RELEASE nicardipine oral NIFEDICAL XL ORAL TABLET EXTENDED RELEASE 24HR 30 MG, 60 MG nifedipine oral capsule nifedipine oral tablet extended release 30 mg, 60 mg, 90 mg nifedipine oral tablet extended release 24hr 30 mg, 60 mg, 90 mg nimodipine nisoldipine oral tablet extended release 24 hr 17 mg, 25.5 mg, 34 mg, 8.5 mg nisoldipine oral tablet extended release 24 hr 20 mg, 30 mg, 40 mg NITRO-BID NITRO-DUR TRANSDERMAL PATCH 24 HOUR 0.1 MG/HR, 0.2 MG/HR, 0.3 MG/HR, 0.4 MG/HR, 0.6 MG/HR, 0.8 MG/HR Tier 2 NITRO-TIME nitroglycerin oral nitroglycerin transdermal patch 24 hour NITROLINGUAL NITROMIST NITROSTAT Tier 2 NORPA NORPA CR Tier 2 NORTHERA ORAL CAPSULE 100 MG, 200 MG, 300 MG Tier 4 NORVASC NYMALIZE PA PA; omega-3 acid ethyl esters ST; OPSUMIT Tier 4 PA ORENITRAM Tier 4 PA; DS papaverine oral perindopril erbumine oral tablet 2 mg, 4 mg, 8 mg pindolol PRAVACHOL ORAL TABLET 20 MG, 40 MG, 80 MG pravastatin prazosin oral PREVALITE 24

26 PRINIVIL ORAL TABLET 10 MG, 20 MG, 5 MG PROCARDIA PROCARDIA XL ORAL TABLET EXTENDED RELEASE 24HR 30 MG, 60 MG, 90 MG propafenone propranolol oral capsule,extended release 24 hr propranolol oral solution propranolol oral tablet 10 mg, 20 mg, 40 mg, 60 mg, 80 mg propranolol-hydrochlorothiazid QUESTRAN QUESTRAN LIGHT ORAL POWDER quinapril quinapril-hydrochlorothiazide quinidine gluconate oral quinidine sulfate ramipril RANEXA Tier 2 reserpine REVATIO ORAL TABLET Tier 4 PA; RYTHMOL ORAL TABLET 150 MG, 225 MG RYTHMOL SR SAMSCA ORAL TABLET 15 MG, 30 MG Tier 4 PA; SECTRAL sildenafil Tier 4 PA; SIMCOR simvastatin sotalol oral SOTALOL AF spironolacton-hydrochlorothiaz spironolactone SUR ORAL TABLET EXTENDED RELEASE 24 HR 17 MG, 34 MG, 8.5 MG TARKA TAZTIA XT ORAL CAPSULE, EXTENDED RELEASE 120 MG, 180 MG, 240 MG, 300 MG, 360 MG TEKAMLO PA; TEKTURNA PA; TEKTURNA HCT PA; telmisartan telmisartan-amlodipine ST; telmisartan-hydrochlorothiazid TENEX TENORETIC 100 TENORETIC 50 25

27 TENORMIN terazosin TEVETEN ORAL TABLET 600 MG TEVETEN HCT ST; TIAZAC ORAL CAPSULE, EXTENDED RELEASE 120 MG, 180 MG, 240 MG, 300 MG, 360 MG, 420 MG TIKOSYN Tier 2 timolol maleate oral TOPROL XL ORAL TABLET EXTENDED RELEASE 24 HR 100 MG, 200 MG, 25 MG, 50 MG torsemide oral TRACLEER Tier 4 PA TRANDATE ORAL trandolapril triamterene-hydrochlorothiazid TRIBENZOR ST; TRICOR TRIGLIDE ORAL TABLET 160 MG TRILIPIX TWYNSTA ST; TYVASO Tier 4 PA; TYVASO REFILL KIT Tier 4 PA; TYVASO STARTER KIT Tier 4 PA; UNIVASC valsartan valsartan-hydrochlorothiazide VASCAZEN VASPA Tier 2 ST; VASERETIC VASOTEC VAYAROL VECAMYL Tier 4 PA; VENTAVIS INHATION SOLUTION FOR NEBULIZATION 10 MCG/ML, 20 MCG/ML Tier 4 verapamil oral capsule, 24 hr er pellet ct verapamil oral capsule,ext rel. pellets 24 hr verapamil oral tablet verapamil oral tablet extended release VEREN VEREN PM ORAL CAPSULE, 24 HR ER PELLET CT 100 MG, 200 MG, 300 MG VYTORIN ST; VYTORIN ST; VYTORIN ST; 26 PA

28 VYTORIN ST; WELCHOL ORAL POWDER IN PACKET WELCHOL ORAL TABLET ZAROXOLYN ORAL TABLET 2.5 MG, 5 MG ZEBETA ZESTORETIC ZESTRIL ZETIA Tier 2 ZIAC ZOCOR ORAL TABLET 10 MG, 20 MG, 40 MG, 5 MG, 80 MG Central Nervous System Agents ABILIFY ORAL SOLUTION ST; ABILIFY ORAL TABLET PA; ABILIFY DISCMELT ST; ADDERALL ORAL TABLET 10 MG, 12.5 MG, 15 MG, 20 MG, 30 MG, 5 MG, 7.5 MG DS; ADDERALL XR PA; DS; ; AL alprazolam oral tablet DS; AL alprazolam oral tablet extended release 24 hr 0.5 mg, 1 mg, 2 mg DS; ; AL alprazolam oral tablet extended release 24 hr 3 mg DS; AL alprazolam oral tablet,disintegrating DS; AL ALSUMA amantadine hcl oral AMBIEN DS; ; AL AMBIEN CR ST; DS; ; AL AMERGE DS; amitriptyline amitriptyline-chlordiazepoxide amoxapine AMPHETAMINE SALT COMBO ORAL TABLET 10 MG, 12.5 MG, 15 MG, 20 MG, 30 MG, 5 MG, 7.5 MG ANAFRANIL APLENZIN ORAL TABLET EXTENDED RELEASE 24 HR 174 MG, 348 MG, 522 MG APOKYN Tier 4 APTIOM ORAL TABLET 200 MG, 400 MG, 600 MG, 800 MG ATIVAN ORAL DS DS; AXERT ST; DS; AZILECT BANZEL ORAL TABLET benztropine oral BRINTELLIX PA; 27

29 bromocriptine bupropion hcl oral tablet bupropion hcl oral tablet extended release 100 mg, 200 mg bupropion hcl oral tablet extended release 150 mg bupropion hcl oral tablet extended release 24 hr buspirone BUTISOL ORAL TABLET CAFERGOT Tier 2 DS CAMBIA carbamazepine oral capsule, er multiphase 12 hr 100 mg, 200 mg carbamazepine oral tablet carbamazepine oral tablet extended release 12 hr carbamazepine oral tablet,chewable CARBATROL Tier 2 carbidopa carbidopa-levodopa oral tablet LEXA ORAL TABLET 10 MG, 20 MG, 40 MG LONTIN ORAL CAPSULE 300 MG Tier 2 chlordiazepoxide hcl DS; AL chlorpromazine oral citalopram oral solution citalopram oral tablet 10 mg, 20 mg, 40 mg clomipramine clonazepam oral tablet DS clonazepam oral tablet,disintegrating DS clonidine hcl oral tablet extended release 12 hr PA; clorazepate dipotassium DS clozapine oral tablet 100 mg, 200 mg, 25 mg, 50 mg DS; clozapine oral tablet,disintegrating 100 mg, 12.5 mg, 25 mg CLOZARIL ORAL TABLET 100 MG, 25 MG COMTAN Tier 2 COERTA ORAL TABLET EXTENDED RELEASE 24HR 18 MG, 27 MG, 36 MG, 54 MG CYMBALTA ORAL CAPSULE,DEYED RELEASE(DR/EC) 20 MG, 60 MG CYMBALTA ORAL CAPSULE,DEYED RELEASE(DR/EC) 30 MG D.H.E.45 PA; DS; ; AL PA; DAYTRANA PA; DS; ; AL DEPAKENE DEPAKOTE DEPAKOTE ER DEPAKOTE SPRINKLES 28 PA

30 desipramine oral DESOXYN desvenlafaxine PA; desvenlafaxine fumarate PA; DEXEDRINE SPANSULE PA; dexmethylphenidate oral capsule,er biphasic DS; ; AL dexmethylphenidate oral tablet DS; dextroamphetamine oral capsule, extended release dextroamphetamine oral solution PA; dextroamphetamine oral tablet dextroamphetamine-amphetamine oral capsule,extended release 24hr DIASTAT Tier 2 diazepam oral tablet DS dihydroergotamine injection dihydroergotamine nasal DS DINTIN Tier 2 DINTIN EXTENDED Tier 2 DINTIN INFATABS Tier 2 DINTIN-125 Tier 2 divalproex DORAL doxepin oral duloxetine oral capsule,delayed release(dr/ec) 20 mg, 30 mg, 60 mg PA; DS; PA; EDLUAR SUBLINGUAL TABLET 10 MG, 5 MG ; AL EFFEXOR XR ORAL CAPSULE,EXTENDED RELEASE 24HR 150 MG, 37.5 MG, 75 MG ELDEPRYL EMSAM EQUETRO escitalopram oxalate oral solution escitalopram oxalate oral tablet 10 mg, 20 mg, 5 mg estazolam AL eszopiclone oral tablet 1 mg, 2 mg ST; ; AL eszopiclone oral tablet 3 mg ST; AL ethosuximide FANAPT ORAL TABLET ST; FANAPT ORAL TABLETS,DOSE PACK ST; FAZACLO ORAL TABLET,DISINTEGRATING 100 MG, 12.5 MG, 150 MG, 200 MG, 25 MG FELBATOL FETZIMA PA; fluoxetine oral capsule 10 mg, 20 mg, 40 mg 29

31 fluoxetine oral capsule,delayed release(dr/ec) fluoxetine oral tablet 10 mg, 20 mg fluoxetine oral tablet 60 mg fluphenazine hcl oral concentrate fluphenazine hcl oral tablet flurazepam AL fluvoxamine oral capsule,extended release 24hr fluvoxamine oral tablet 100 mg, 25 mg, 50 mg FOCALIN DS; FOCALIN XR ORAL CAPSULE,ER BIPHASIC MG, 15 MG, 20 MG, 25 MG, 30 MG, 35 MG, 40 MG, 5 MG FORFIVO XL FROVA ST; FYCOMPA PA; gabapentin oral capsule gabapentin oral solution 250 mg/5 ml gabapentin oral tablet 600 mg, 800 mg GABITRIL ORAL TABLET 12 MG, 16 MG, 2 MG, 4 MG GEODON ORAL GRALISE ORAL TABLET EXTENDED RELEASE 24 HR 300 MG, 600 MG PA; DS; ; AL PA; GRALISE 30-DAY STARTER PACK PA; HALCION ORAL TABLET 0.25 MG DS; AL haloperidol haloperidol lactate oral HETLIOZ Tier 4 PA HORIZANT ORAL TABLET EXTENDED RELEASE 300 MG, 600 MG hydroxyzine hcl oral syrup 10 mg/5 ml hydroxyzine hcl oral tablet hydroxyzine pamoate oral capsule 25 mg, 50 mg imipramine hcl imipramine pamoate IMITREX NASAL SPRAY,NON-AEROSOL 20 MG/ACTUATION, 5 MG/ACTUATION PA; DS; IMITREX ORAL DS; IMITREX SUBCUTANEOUS DS; IMITREX STATDOSE KIT REFILL DS; INTERMEZZO ; AL INTUNIV ER PA; INVEGA ORAL TABLET EXTENDED RELEASE 24HR 1.5 MG, 3 MG, 6 MG, 9 MG isometh-dichloral-acetaminophn DS ST; KAPVAY PA; 30

32 KEPPRA ORAL KEPPRA XR ORAL TABLET EXTENDED RELEASE 24 HR 500 MG, 750 MG KHEDEZ PA; KLONOPIN DS MICTAL ORAL TABLET MICTAL ORAL TABLET, CHEWABLE DISPERSIBLE MICTAL ODT ORAL TABLET,DISINTEGRATING 100 MG, 200 MG, 25 MG, 50 MG MICTAL ODT STARTER (BLUE) ST MICTAL ODT STARTER (GREEN) ST MICTAL ODT STARTER (ORANGE) ST MICTAL XR ORAL TABLET EXTENDED RELEASE 24HR 100 MG, 200 MG, 25 MG, 250 MG, 50 MG MICTAL XR ORAL TABLET EXTENDED RELEASE 24HR 300 MG lamotrigine oral tablet lamotrigine oral tablet extended release 24hr ST lamotrigine oral tablet, chewable dispersible ST lamotrigine oral tablets,dose pack 25 mg (35) ST; ST; TUDA Tier 2 ST; levetiracetam oral tablet levetiracetam oral tablet extended release 24 hr 500 mg levetiracetam oral tablet extended release 24 hr 750 mg LEXAPRO ORAL SOLUTION LEXAPRO ORAL TABLET 10 MG, 20 MG, 5 MG lithium carbonate oral capsule lithium carbonate oral tablet lithium carbonate oral tablet extended release 450 mg lithium citrate oral solution 8 meq/5 ml LITHOBID LODOSYN lorazepam oral tablet DS loxapine succinate LUNESTA ORAL TABLET 1 MG, 2 MG, 3 MG ST; DS; ; AL LUVOX CR ORAL CAPSULE,EXTENDED RELEASE 24HR 100 MG LYRICA ORAL CAPSULE 100 MG, 150 MG, 200 MG, 225 MG, 25 MG, 300 MG, 50 MG, 75 MG ST PA; DS; LYRICA ORAL SOLUTION PA; DS; maprotiline MAXALT DS; MAXALT-MLT DS; METADATE CD PA; DS; 31

33 METADATE ER DS; methamphetamine METHYLIN ORAL SOLUTION 10 MG/5 ML, 5 MG/5 ML METHYLIN ORAL TABLET,CHEWABLE PA; methylphenidate oral capsule, er biphasic DS; ; AL methylphenidate oral capsule,er biphasic mg, 30 mg, 40 mg methylphenidate oral solution 10 mg/5 ml, 5 mg/5 ml PA; ; AL methylphenidate oral tablet DS; methylphenidate oral tablet extended release 20 mg methylphenidate oral tablet extended release 24hr 18 mg, 27 mg, 36 mg, 54 mg MIGRANAL MIRAPEX MIRAPEX ER mirtazapine oral tablet 15 mg, 30 mg, 45 mg, 7.5 mg mirtazapine oral tablet,disintegrating modafinil PA; MYSOLINE naratriptan DS; NARDIL Tier 2 nefazodone NEUPRO ST NEURONTIN ORAL CAPSULE NEURONTIN ORAL SOLUTION NEURONTIN ORAL TABLET NORPRAMIN ORAL TABLET 10 MG, 100 MG, 150 MG, 25 MG, 50 MG, 75 MG nortriptyline oral capsule NUEDEXTA NUVIGIL ORAL TABLET 150 MG, 200 MG, 250 MG, 50 MG olanzapine oral tablet olanzapine oral tablet,disintegrating 15 mg, 20 mg, 5 mg OLEPTRO ER ONFI ORAL TABLET 10 MG, 20 MG ORAP oxazepam DS; AL oxcarbazepine OXTELR XR ORAL TABLET EXTENDED RELEASE 24 HR 150 MG, 300 MG, 600 MG PAMELOR PARLODEL PARNATE 32 PA; DS; ; AL ST;

34 paroxetine hcl oral tablet 10 mg, 20 mg, 30 mg, 40 mg paroxetine hcl oral tablet extended release 24 hr 12.5 mg, 25 mg, 37.5 mg PAXIL ORAL SUSPENSION PAXIL ORAL TABLET 10 MG, 20 MG, 30 MG, 40 MG PAXIL CR PEGANONE perphenazine perphenazine-amitriptyline oral tablet 2-10 mg, 2-25 mg, 4-25 mg PEXEVA ORAL TABLET 10 MG, 20 MG, 30 MG, 40 MG phenobarbital DS PHENYTEK Tier 2 phenytoin oral tablet,chewable phenytoin sodium extended oral capsule 100 mg, 200 mg, 300 mg POTIGA ORAL TABLET 200 MG, 300 MG, 400 MG, 50 MG pramipexole primidone DS; PRISTIQ PA; PRONTRA PA; protriptyline PROVIGIL PROZAC ORAL CAPSULE 10 MG, 20 MG, 40 MG PROZAC WEEKLY QUDEXY XR ST; quetiapine oral tablet 100 mg, 200 mg, 25 mg, 300 mg, 400 mg, 50 mg QUILLIVANT XR PA; DS; RELPAX ST; DS; REMERON REMERON SOLTAB REQUIP REQUIP XL ORAL TABLET EXTENDED RELEASE 24 HR 12 MG, 2 MG, 4 MG, 6 MG, 8 MG RESTORIL ORAL CAPSULE 15 MG, 30 MG AL RESTORIL ORAL CAPSULE 22.5 MG, 7.5 MG ; AL RISPERDAL ORAL SOLUTION ST RISPERDAL ORAL TABLET 0.25 MG, 0.5 MG, 1 MG, 2 MG, 3 MG, 4 MG RISPERDAL M-TAB ORAL TABLET,DISINTEGRATING 0.5 MG, 1 MG, 2 MG, 3 MG, 4 MG risperidone oral solution ST ST; ST; 33

35 risperidone oral tablet 0.25 mg, 0.5 mg, 1 mg, 2 mg, 3 mg, 4 mg risperidone oral tablet,disintegrating 0.25 mg, 0.5 mg, 1 mg, 2 mg, 3 mg, 4 mg ST; ST; RITALIN DS; RITALIN ORAL CAPSULE,ER BIPHASIC MG, 20 MG, 30 MG, 40 MG rizatriptan DS; ropinirole oral tablet ropinirole oral tablet extended release 24 hr 12 mg, 2 mg, 4 mg, 6 mg, 8 mg PA; DS; ; AL ROZEREM ST; ; AL SABRIL Tier 4 PA; SAPHRIS ST; SARAFEM ORAL TABLET 10 MG, 20 MG SAVEL ORAL TABLET PA; SAVEL ORAL TABLETS,DOSE PACK PA; selegiline hcl SEROQUEL ORAL TABLET 100 MG, 200 MG, 25 MG, 300 MG, 400 MG, 50 MG SEROQUEL XR ORAL TABLET EXTENDED RELEASE 24 HR 150 MG, 200 MG, 300 MG, 400 MG, 50 MG sertraline oral concentrate sertraline oral tablet 100 mg, 25 mg, 50 mg PA; SILENOR ; AL SINEMET SINEMET CR SONATA STALEVO 100 STALEVO 125 STALEVO 150 STALEVO 200 STALEVO 50 STALEVO 75 STAVZOR STRATTERA Tier 2 sumatriptan nasal spray,non-aerosol 20 mg/actuation, 5 mg/actuation DS; sumatriptan succinate oral DS; sumatriptan succinate subcutaneous cartridge DS; sumatriptan succinate subcutaneous pen injector DS; sumatriptan succinate subcutaneous syringe 6 mg/0.5 ml DS; SUMAVEL DOSEPRO SUBCUTANEOUS NEEDLE-FREE INJECTOR 6 MG/0.5 ML SURMONTIL 34

36 SYMBYAX TASMAR ORAL TABLET 100 MG TEGRETOL ORAL SUSPENSION Tier 2 TEGRETOL ORAL TABLET Tier 2 TEGRETOL XR Tier 2 temazepam oral capsule 15 mg, 30 mg AL temazepam oral capsule 22.5 mg, 7.5 mg ; AL thioridazine thiothixene tiagabine oral tablet 2 mg, 4 mg TOFRANIL TOFRANIL-PM TOPAMAX ORAL CAPSULE, SPRINKLE TOPAMAX ORAL TABLET 100 MG, 25 MG, 50 MG topiramate oral capsule, sprinkle topiramate oral tablet TRANXENE T-TAB ORAL TABLET 3.75 MG, 7.5 MG DS tranylcypromine trazodone TREXIMET triazolam DS; AL trifluoperazine trihexyphenidyl TRILEPTAL TROKENDI XR ORAL CAPSULE,EXTENDED RELEASE 24HR 100 MG, 200 MG, 25 MG, 50 MG VALIUM DS valproic acid valproic acid (as sodium salt) oral solution 250 mg/5 ml venlafaxine oral capsule,extended release 24hr venlafaxine oral tablet 100 mg, 25 mg, 37.5 mg, 50 mg, 75 mg venlafaxine oral tablet extended release 24hr VERSACLOZ ST ST; VIIBRYD ORAL TABLET PA; VIIBRYD ORAL TABLETS,DOSE PACK PA; VIMPAT ORAL TABLET VISTARIL VIVACTIL VYVANSE Tier 2 DS; ; AL WELLBUTRIN WELLBUTRIN SR WELLBUTRIN XL XANAX DS; AL 35

37 XANAX XR DS; ; AL XENAZINE ORAL TABLET 12.5 MG, 25 MG Tier 4 PA; XYREM Tier 4 PA ZARONTIN ZEPAR ZENZEDI ORAL TABLET 10 MG, 5 MG ZENZEDI ORAL TABLET 15 MG, 2.5 MG, 20 MG, 30 MG, 7.5 MG ziprasidone hcl zolmitriptan oral tablet 2.5 mg, 5 mg zolmitriptan oral tablet,disintegrating 2.5 mg, 5 mg ZOLOFT ORAL COENTRATE ZOLOFT ORAL TABLET 100 MG, 25 MG, 50 MG zolpidem oral tablet DS; ; AL zolpidem oral tablet,ext release multiphase ST; DS; ; AL ZOLPIMIST ZOMIG NASAL ST; ZOMIG ORAL TABLET 2.5 MG, 5 MG ZOMIG ZMT ORAL TABLET,DISINTEGRATING 2.5 MG, 5 MG ZONEGRAN ORAL CAPSULE 100 MG, 25 MG zonisamide ZYPREXA ORAL TABLET 10 MG, 15 MG, 2.5 MG, 20 MG, 5 MG, 7.5 MG ZYPREXA ZYDIS Chemical Dependency, Agents To Treat acamprosate ANTABUSE ST; buprenorphine hcl sublingual PA; buprenorphine-naloxone PA; BUPROBAN bupropion hcl oral tablet extended release 150 mg CAMPRAL CHANTIX ORAL TABLET 0.5 MG CHANTIX ORAL TABLET 1 MG CHANTIX CONTINUING MONTH BOX CHANTIX CONTINUING MONTH PAK CHANTIX STARTING MONTH BOX CHANTIX STARTING MONTH PAK disulfiram NICODERM CQ NICORELIEF BUCCAL GUM NICORETTE BUCCAL GUM NICORETTE BUCCAL LOZENGE 36

38 nicotine transdermal patch 24 hour 14 mg/24 hr, 21 mg/24 hr, 7 mg/24 hr NICOTROL NICOTROL NS NTS STEP 1 SUBOXONE SUBLINGUAL FILM 12-3 MG, MG, 4-1 MG, 8-2 MG ZUBSOLV PA ZYBAN Chemicals-Pharmaceutical Adjuvants anthralin chloral hydrate cyclopentolate (bulk) NAPRODERM polyethylene glycol 3350 sodium chloride inhalation solution for nebulization 0.9 %, 10 %, 3 % sulfisoxazole Cognitive Disorder Therapy ARIPT ORAL TABLET 10 MG, 5 MG AL PA; ARIPT ORAL TABLET 23 MG ; AL ARIPT ODT ORAL TABLET,DISINTEGRATING 10 MG donepezil oral tablet 10 mg, 5 mg AL donepezil oral tablet 23 mg ; AL donepezil oral tablet,disintegrating AL ergoloid EXELON ORAL CAPSULE EXELON TRANSDERMAL PATCH 24 HOUR 13.3 MG/24 HOUR, 4.6 MG/24 HR, 9.5 MG/24 HR galantamine NAMENDA ORAL SOLUTION Tier 2 AL NAMENDA ORAL TABLET Tier 2 ; AL NAMENDA TITRATION PAK Tier 2 ; AL NAMENDA XR Tier 2 ; AL RAZADYNE ORAL TABLET AL RAZADYNE ER ; AL Contraceptives ALTAVERA (28) ALYAN 1/35 (28) ALYAN 7/7/7 (28) AMETHIA AMETHIA LO AMETHYST APRI AL 37

39 ARANELLE (28) AVIANE AZURETTE (28) BALZIVA (28) BEYAZ BREVICON (28) BRIELLYN CAMRESE CAMRESE LO CAZIANT (28) CHATEAL CRYSELLE (28) CYCFEM 1/35 (28) CYCLESSA (28) DASETTA 1/35 (28) DASETTA 7/7/7 (28) daysee DEPO-PROVERA INTRAMUSCUR SUSPENSION DEPO-PROVERA INTRAMUSCUR SYRINGE DEPO-SUBQ PROVERA 104 DESOGEN desogestrel-ethinyl estradiol drospirenone-ethinyl estradiol ELINEST EL EMOQUETTE ENPRESSE ENSKY ERRIN ESTARYL ESTROSTEP FE-28 FALMINA (28) FEMCON FE GENERESS FE GIANVI (28) GILDAGIA GILDESS GILDESS FE INTROVALE JEYC jolessa JOLIVETTE JUNEL 1.5/30 (21) 38

40 JUNEL 1/20 (21) JUNEL FE 1.5/30 (28) JUNEL FE 1/20 (28) KARIVA (28) KELNOR 1/35 (28) KURVELO l norgest&e estradiol-e estrad LEENA 28 LESSINA LEVONEST (28) levonorgestrel oral tablet 0.75 mg levonorgestrel-ethinyl estrad oral tablet mg-mcg levonorgestrel-ethinyl estrad oral tablet mg-mcg levonorgestrel-ethinyl estrad oral tablets,dose pack,3 month LEVORA 0.15/30 (28) LEVORA-28 LO LOESTRIN FE LOESTRIN 1.5/30 (21) LOESTRIN 1/20 (21) LOESTRIN FE 1.5/30 (28) LOESTRIN FE 1/20 (28) LORYNA (28) LOSEASONIQUE LOW-OGESTREL (28) LUTERA (28) LYZA MARLISSA medroxyprogesterone intramuscular MICROGESTIN 1.5/30 (21) MICROGESTIN 1/20 (21) MICROGESTIN FE 1.5/30 (28) MICROGESTIN FE 1/20 (28) MINASTRIN 24 FE MIRTTE (28) MIRENA MODICON (28) MONO-LINYAH MONONESSA (28) MYZILRA NATAZIA NECON 0.5/35 (28) NECON 1/35 (28) NECON 1/50 (28) 39

41 NECON 10/11 (28) NEXPNON NEXT CHOI ONE DOSE NOR-QD NORA-BE norethindrone (contraceptive) norgestimate-ethinyl estradiol NORINYL 1+35 (28) NORINYL 1+50 (28) NORTREL 0.5/35 (28) NORTREL 1/35 (21) NORTREL 1/35 (28) NORTREL 7/7/7 (28) NUVARING Tier 2 OL OGESTREL (28) ORSYTHIA ORTHO EVRA ORTHO MICRONOR ORTHO TRI-CYCLEN (28) ORTHO TRI-CYCLEN LO (28) ORTHO-PT (28) ORTHO-CYCLEN (28) ORTHO-NOVUM 1/35 (28) ORTHO-NOVUM 7/7/7 (28) OVCON-35 (28) PARAGARD T 380A PHILITH PIRMEL ORAL TABLET 1-35 MG-MCG PN B ONE-STEP PORTIA PREVIFEM QUARTETTE QUASENSE RECLIPSEN (28) SEASONIQUE SPRINTEC (28) SRONYX SYEDA TILIA FE TODAY CONTRAPTIVE SPONGE TRI-ESTARYL TRI-LEGEST FE 40

42 TRI-LINYAH TRI-NORINYL (28) TRI-PREVIFEM (28) TRI-SPRINTEC (28) TRINESSA (28) TRIVORA (28) VAGINAL CONTRAPTIVE FILM VAGINAL CONTRAPTIVE FOAM VCF CONTRAPTIVE FILM VELIVET TRIPHASIC REGIMEN (28) VESTURA (28) VIORELE (28) WERA (28) WYMZYA FE XUNE YASMIN (28) YAZ (28) ZARAH ZEHENT (28) ZEHENT FE ZEOSA ZOVIA 1/35E (28) ZOVIA 1/50E (28) Dermatological ABREVA ABSORICA ORAL CAPSULE 10 MG, 20 MG, 25 MG, 30 MG, 35 MG, 40 MG ACANYA acitretin oral capsule 10 mg, 25 mg acitretin oral capsule 17.5 mg acyclovir topical ACZONE adapalene topical cream adapalene topical gel 0.1 % alclometasone ALDARA ALTABAX aluminum acetate topical aluminum chloride topical AMNESTEEM PA; DS; ATRALIN ST; AVAR TOPICAL CLEANSER AVAR-E 41

43 AVAR-E GREEN AVITA TOPICAL CREAM AVITA TOPICAL GEL ST; AZELEX Tier 2 BACTROBAN TOPICAL CREAM BACTROBAN TOPICAL OINTMENT BENZACLIN BENZACLIN PUMP BENZAMYCIN BENZAMYCINPAK betamethasone valerate topical cream betamethasone valerate topical lotion betamethasone valerate topical ointment betamethasone, augmented topical cream betamethasone, augmented topical lotion betamethasone, augmented topical ointment BP 10-1 calcipotriene topical cream ST calcipotriene topical ointment ST calcipotriene topical solution ST calcipotriene-betamethasone ST CALCITRENE ST CAPEX Tier 2 TACAINE TACAINE ANESTHETIC CICLODAN KIT ciclopirox topical cream DS ciclopirox topical gel DS ciclopirox topical shampoo CRAVIS PA; CRIFOAM EF Tier 2 CLEOCIN T CLINDACIN PAC CLINDAGEL clindamycin phosphate topical lotion DS clindamycin phosphate topical solution DS clindamycin phosphate topical swab DS clindamycin-benzoyl peroxide topical gel 1-5 % clobetasol topical cream clobetasol topical ointment clobetasol-emollient topical cream CLOBEX CLODERM 42

44 clotrimazole topical cream CNL 8 NAIL CONDYLOX CUTIVATE TOPICAL CREAM CUTIVATE TOPICAL LOTION DENAVIR DERMA-SMOOTHE/FS BODY OIL Tier 2 DERMA-SMOOTHE/FS SCALP OIL Tier 2 DERMATOP DERMAZENE DESONATE desonide topical cream desonide topical ointment DESOWEN TOPICAL CREAM diclofenac sodium topical gel DIFFERIN TOPICAL CREAM DIFFERIN TOPICAL GEL ST DIFFERIN TOPICAL LOTION ST DIPROLENE DIPROLENE AF DOVONEX TOPICAL CREAM ST DRYSOL DAB-O-MATIC DUAC econazole topical ECOZA EFUDEX TOPICAL CREAM ELIDEL PA; DS; ELIMITE ELOCON EM DS EPIDUO ST; ERTACZO erythromycin with ethanol topical solution erythromycin-benzoyl peroxide EURAX Tier 2 EVOCLIN EXELDERM Tier 2 EXTINA FABIOR ST FINAA FLECTOR fluocinolone topical oil fluocinolone-shower cap 43

45 fluocinonide topical cream 0.05 % fluocinonide topical gel fluocinonide topical ointment FLUOCINONIDE-E FLUOROPLEX fluorouracil topical cream 5 % fluorouracil topical solution fluticasone topical cream fluticasone topical lotion fluticasone topical ointment gentamicin topical GRANULEX halobetasol propionate HALOG HALONATE HALONATE PAC hydrocortisone topical cream 2.5 % hydrocortisone topical lotion 2.5 % hydrocortisone topical ointment 2.5 % hydrocortisone butyr-emollient hydrocortisone butyrate hydrocortisone valerate hydrocortisone-pramoxine topical HYTOPIC imiquimod iodoquinol-hc JUBLIA PA KENALOG TOPICAL KETODAN KIT KRON C-HYDRIN TISSE LEVUN lidocaine topical adhesive patch,medicated PA lidocaine-prilocaine topical cream DS LIDODERM PA LIDORX lindane topical lotion DS; lindane topical shampoo Tier 2 DS; LOCOID TOPICAL CREAM LOCOID TOPICAL LOTION LOCOID TOPICAL OINTMENT LOCOID LIPOCREAM 44

46 LOPROX TOPICAL SHAMPOO LOTRISONE TOPICAL CREAM LUXIQ LUZU MENTAX methoxsalen rapid METROCREAM METROGEL TOPICAL GEL 1 % ST METROGEL TOPICAL GEL WITH PUMP ST METROLOTION metronidazole topical cream DS metronidazole topical gel 0.75 % DS metronidazole topical gel 1 % DS metronidazole topical lotion DS MINOCIN KIT WITH WIPES minocycline oral tablet extended release 24 hr MIRVASO ST mometasone MOMEXIN mupirocin mupirocin calcium MYORISAN PA; NAFTIN TOPICAL CREAM 1 %, 2 % NAFTIN TOPICAL GEL 1 %, 2 % NAPRODERM NATROBA NEO-SYNAR NEO-SYNAR KIT NEUAC NEUAC KIT NORITATE nystatin topical cream DS nystatin topical ointment DS nystatin-triamcinolone DS OLUX OLUX-E ORAA OTEZ Tier 4 PA; OTEZ STARTER Tier 4 PA; OVA OVA PLUS TOPICAL LOTION OVIDE OXISTAT 45

47 OXSORALEN Tier 2 OXSORALEN ULTRA PANDEL PANRETIN PEDIADERM HC PENC PENNSAID TOPICAL DROPS permethrin topical cream DS permethrin topical liquid DS PICATO Tier 2 DS; PLEXION TOPICAL CLEANSER % ST PLEXION TOPICAL CREAM ST PLEXION TOPICAL LOTION ST PLEXION CLEANSING CLOTHS TOPICAL PADS, MEDICATED % PODOCON podofilox PRAMOSONE PROTOPIC PA; DS; REGRANEX RETIN-A RETIN-A MICRO ST; RETIN-A MICRO PUMP ST; ROSADAN TOPICAL CREAM ROSADAN TOPICAL GEL ROSADAN TOPICAL KIT, CLEANSER & GEL ROSADAN TOPICAL KIT,CLEANSER AND CREAM ROSANIL TOPICAL CLEANSER SALEX TOPICAL SHAMPOO SANTYL selenium sulfide topical shampoo selenium sulfide topical suspension 2.5 % SELRX SILVADENE silver sulfadiazine DS SORAZE SOLODYN ORAL TABLET EXTENDED RELEASE 24 HR 105 MG, 115 MG, 55 MG, 65 MG, 80 MG SORIATANE ORAL CAPSULE 10 MG, 17.5 MG, 25 MG Tier 2 STERA SUBCUTANEOUS SYRINGE 45 MG/0.5 ML, 90 MG/ML Tier 4 sulfacetamide sod-sulfur-urea sulfacetamide sodium-sulfur topical cleanser 10-5 % (w/w), % 46 ST PA;

48 sulfacetamide sodium-sulfur topical lotion 10-5 % (w/v) sulfacetamide sodium-sulfur topical suspension 10-5 % sulfacetamide-sulfur-cleansr23 SULFAMYLON SUMADAN SUMADAN XLT SUMAXIN CP SYNAR SYNAR CREAM KIT SYNAR OINTMENT KIT SYNAR TS SYNERA TACLONEX TOPICAL OINTMENT ST TARGRETIN TOPICAL Tier 4 TAZORAC ST TEMOVATE TOPICAL CREAM TEMOVATE TOPICAL OINTMENT TOPICORT TOPICAL CREAM TOPICORT TOPICAL GEL TOPICORT TOPICAL OINTMENT TOPICORT TOPICAL SPRAY,NON-AEROSOL TRETIN-X TOPICAL COMBO PACK TRETIN-X TOPICAL CREAM % ST; tretinoin topical cream % tretinoin topical cream 0.05 %, 0.1 % tretinoin topical gel 0.01 % tretinoin topical gel % tretinoin microspheres topical gel 0.04 % ST; tretinoin microspheres topical gel 0.1 % ST triamcinolone acetonide topical cream %, 0.1 %, 0.5 % triamcinolone acetonide topical ointment %, 0.1 %, 0.5 % ULESFIA ULTRAVATE ULTRAVATE X VALCHLOR Tier 4 PA VANOS ST VANOXIDE-HC TOPICAL SUSPENSION VECTICAL ST VELTIN ST VERDESO VEREGEN VOLTAREN TOPICAL 47

49 XERAC AC Tier 2 XOLEGEL ZENATANE ORAL CAPSULE 10 MG, 20 MG, 40 MG PA; ZIANA ST ZITHRANOL ZOVIRAX TOPICAL CREAM ZOVIRAX TOPICAL OINTMENT DS ZYCRA TOPICAL CREAM IN METERED-DOSE PUMP ZYCRA TOPICAL CREAM IN PACKET Diagnostic Agents ACCU-CHEK AVIVA ACCU-CHEK COMFORT CURVE TEST ACCU-CHEK SMARTVIEW TEST STRIP CONTOUR TEST STRIPS PA FREESTYLE INSULINX TEST STRIPS PA FREESTYLE LITE STRIPS PA FREESTYLE TEST PA KETONE URINE TEST NOVA MAX GLUCOSE TEST PA ONE TOUCH ULTRA TEST Tier 2 ONE TOUCH VERIO Tier 2 PRECISION XTRA TEST PA TRUETEST TEST STRIPS PA TRUETRACK TEST PA Drugs To Treat Erectile Dysfunction CAVERJECT DS; CAVERJECT IMPULSE CIALIS ORAL TABLET 10 MG, 20 MG, 5 MG Tier 2 cialis oral tablet 2.5 mg EDEX INTRACAVERNOSAL KIT 10 MCG, 20 MCG, 40 MCG DS; LEVITRA ST; DS; MUSE URETHRAL SUPPOSITORY 1,000 MCG, 125 MCG, 250 MCG, 500 MCG STAXYN ST; STENDRA ST; VIAGRA ST; DS; Eating Disorder Therapy ADIPEX-P ORAL TABLET ALLI BELVIQ benzphetamine DIDREX 48