AETNA BETTER HEALTH Formulary Guide. Aetna Better Health of Michigan Formulary Guide April 2017

Transcription

1 AETNA BETTER HEALTH Formulary Guide Aetna Better Health of Michigan Formulary Guide April 2017

2 AETNA BETTER HEALTH Formulary Guide What is the Aetna Better Health of Michigan 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 coverage rules for the drug Drugs are also grouped by the type of condition they treat. Drugs used to treat an earache are listed under the section, Ear-Nose-Throat Medications. If you know what your drug is used for, please look for that section name on the drug list. Then look under that section 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 () drugs covered? The plan will cover drugs on the formulary. Some drugs may have coverage rules. If the rules for that drug are met, the plan will cover the drug. Like other drugs, drugs need a prescription from a doctor if they are to be covered by the plan. Updated: 04/01/2017 Page 2

3 AETNA BETTER HEALTH Formulary Guide Are there Medication Copays? Copays for brand drugs are $0 and copays for generic drugs are $0. What are some types of coverage rules? Prior Approval (): 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: 04/01/2017 Page 3

4 Aetna Better Health Michigan Table of Contents *Adhd/Anti-Narcolepsy/Anti-Obesity/Anorexiants*... 3 *Alternative Medicines*...3 *Aminoglycosides*... 3 *Analgesics - Anti-Inflammatory*... 4 *Analgesics - Nonnarcotic*...5 *Analgesics - Opioid*... 7 *Androgens-Anabolic* *Anorectal Agents*...10 *Antacids* *Anthelmintics* *Antianginal Agents*...11 *Antianxiety Agents*...12 *Antiarrhythmics* *Antiasthmatic And Bronchodilator Agents* *Anticoagulants* *Antidiabetics* *Antidiarrheals*...19 *Antidotes*...19 *Antiemetics*...19 *Antifungals*...20 *Antihistamines*...20 *Antihyperlipidemics* *Antihypertensives* *Anti-Infective Agents - Misc.*...25 *Antimalarials*...26 *Antimycobacterial Agents* *Antineoplastics And Adjunctive Therapies*...26 *Antiparkinson Agents* *Antipsychotics/Antimanic Agents* *Antivirals*...30 *Assorted Classes* *Beta Blockers*...32 *Calcium Channel Blockers* *Cardiotonics* *Cardiovascular Agents - Misc.*...35 *Cephalosporins*...35 *Chemicals* *Contraceptives*...37 *Corticosteroids* *Cough/Cold/Allergy* *Dermatologicals* *Diagnostic Products*

5 *Dietary Products/Dietary Management Products*...50 *Digestive Aids* *Diuretics*...51 *Endocrine And Metabolic Agents - Misc.*...52 *Estrogens*...53 *Fluoroquinolones* *Gastrointestinal Agents - Misc.* *Genitourinary Agents - Miscellaneous* *Gout Agents* *Hematological Agents - Misc.*...57 *Hematopoietic Agents* *Laxatives* *Macrolides*...63 *Medical Devices* *Migraine Products*...72 *Minerals & Electrolytes* *Mouth/Throat/Dental Agents*...78 *Multivitamins* *Musculoskeletal Therapy Agents*...84 *Nasal Agents - Systemic And Topical*...84 *Neprilysin Inhib (Arni)-Angiotensin Ii Recept Antag Comb*** *Nutrients* *Ophthalmic Agents*...85 *Otic Agents*...90 *Passive Immunizing Agents* *Penicillins* *Pharmaceutical Adjuvants*...91 *Potassium Removing Agents*** *Progestins* *Psychotherapeutic And Neurological Agents - Misc.*...92 *Respiratory Agents - Misc.*...94 *Sodium-Glucose Co-Transporter 2 Inhibitor-Biguanide Comb*** *Tetracyclines*...94 *Thyroid Agents*...95 *Ulcer Drugs*...96 *Urinary Anti-Infectives* *Urinary Antispasmodics*...97 *Vaginal Products* *Vasopressors*...99 *Vitamins*

6 Aetna Better Health Michigan lowercase italics = Generic drugs UPPERCASE BOLD = Brand name drugs Notes = QLL: cumulative acetaminophen limit of 4 grams per day AL = Age Limits Apply = Over the Counter = Prior Authorization Applies QLL = Quantity Level Limits Apply ST = Step Therapy Applies Drug Reference Notes *Adhd/Anti-Narcolepsy/Anti- Obesity/Anorexiants* *Analeptics*** caffeine anhydrous powder caffeine citrate oral solution 20 /ml, 60 /3ml caffeine citrated powder *Alternative Medicines* *Alternative Medicine - Ca's*** PRELIEF ORAL TABLET 340 (65-50) MG (CA-P) *Aminoglycosides* *Aminoglycosides*** neomycin sulfate oral tablet 500 paromomycin sulfate oral capsule 250 TOBI PODHALER INHALATION CAPSULE 28 MG tobramycin inhalation nebulization solution 300 /5ml Tobi AL (Max 1 Years) 3

7 *Analgesics - Anti-Inflammatory* *Anti-Tnf-Alpha - Monoclonal Antibodies*** HUMIRA SUBCUTANEOUS PREFILLED SYRINGE KIT 10 MG/0.2ML *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 10 MG/0.2ML, 20 MG/0.4ML, 40 MG/0.8ML *Cyclooxygenase 2 (Cox-2) Inhibitors*** celecoxib oral capsule 100, 200, 400, 50 *Nonsteroidal Anti-Inflammatory Agents (Nsaids)*** CeleBREX ; QLL (30 EA per 30 diclofenac potassium oral tablet 50 diclofenac sodium er oral tablet extended release 24 hour 100 diclofenac sodium oral tablet delayed release 25, 50, 75 etodolac oral capsule 200, 300 QLL (60 EA per 30 etodolac oral tablet 400 Lodine QLL (60 EA per 30 etodolac oral tablet 500 QLL (60 EA per 30 fenoprofen calcium oral tablet 600 flurbiprofen oral tablet 100, 50 ibuprofen oral tablet 400, 600, 800 4

8 indomethacin er oral capsule extended release 75 AL (Max 64 Years) indomethacin oral capsule 25, 50 AL (Max 64 Years) ketoprofen oral capsule 50, 75 ketorolac tromethamine oral tablet 10 AL (Max 64 Years) meloxicam oral tablet 15, 7.5 Mobic QLL (30 EA per 30 nabumetone oral tablet 500, 750 QLL (60 EA per 30 naproxen dr oral tablet delayed release 375, 500 EC-Naprosyn naproxen oral tablet 250, 500 Naprosyn naproxen oral tablet 375 naproxen sodium er oral tablet extended release 24 hour 500 Naprelan piroxicam oral capsule 10, 20 Feldene QLL (30 EA per 30 sulindac oral tablet 150, 200 *Pyrimidine Synthesis Inhibitors*** leflunomide oral tablet 10, 20 Arava QLL (30 EA per 30 *Soluble Tumor Necrosis Factor Receptor Agents*** ENBREL SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 25 MG/0.5ML, 50 MG/ML ENBREL SURECLICK SUBCUTANEOUS SOLUTION AUTO- INJECTOR 50 MG/ML *Analgesics - Nonnarcotic* *Analgesics Other*** acetaminophen oral elixir 160 /5ml acetaminophen rapid tabs child oral tablet dispersible 80 *Analgesics-Sedatives*** butalbital-acetaminophen oral tablet butalbital-apap-caffeine oral capsule Medi-Tabs Childrens Mapap Childrens Tencon Esgic QLL: cumulative acetaminophen limit of 4 grams per day; QLL: cumulative acetaminophen limit of 4 grams per day; QLL (120 EA per 30 ; AL (Min 10 Years and Max 64 Years) QLL (120 EA per 30 ; AL (Min 10 Years and Max 64 Years) 5

9 butalbital-apap-caffeine oral tablet butalbital-aspirin-caffeine oral capsule CACET ORAL CAPSULE MG ESGIC ORAL CAPSULE MG marten-tab oral tablet TENCON ORAL TABLET MG ZEBUTAL ORAL CAPSULE MG *Salicylate Combinations*** choline-mag trisalicylate oral liquid 500 /5ml *Salicylates*** aspir-81 oral tablet delayed release 81 aspirin adult low strength oral tablet chewable 81 aspirin adult low strength oral tablet delayed release 81 aspirin childrens oral tablet chewable 81 aspirin low strength oral tablet chewable 81 aspirin oral tablet chewable 81 ASPIR-LOW ORAL TABLET DELAYED RELEASE 81 MG BAYER LOW DOSE ORAL TABLET CHEWABLE 81 MG childrens aspirin low strength oral tablet chewable 81 Esgic Fiorinal Butalbital-AP-Caffeine Butalbital-AP-Caffeine Tencon Butalbital-Acetaminophen Butalbital-AP-Caffeine Aspir-Low Bayer Low Dose Aspir-Low Bayer Low Dose Bayer Low Dose Bayer Low Dose EQ Adult Aspirin Low Strength Aspirin Low Strength Bayer Low Dose QLL (120 EA per 30 ; AL (Min 10 Years and Max 64 Years) QLL (120 EA per 30 ; AL (Max 64 Years) QLL (120 EA per 30 ; AL (Min 10 Years and Max 64 Years) QLL (120 EA per 30 ; AL (Min 10 Years and Max 64 Years) QLL (120 EA per 30 ; AL (Min 10 Years and Max 64 Years) QLL (120 EA per 30 ; AL (Min 10 Years and Max 64 Years) QLL (120 EA per 30 ; AL (Min 10 Years and Max 64 Years) ; QLL (30 EA per 30 ; QLL (30 EA per 30 ; QLL (30 EA per 30 ; QLL (30 EA per 30 ; QLL (30 EA per 30 ; QLL (30 EA per 30 ; QLL (30 EA per 30 ; QLL (30 EA per 30 ; QLL (30 EA per 30 6

10 cvs aspirin low dose oral tablet delayed release 81 cvs childrens aspirin oral tablet chewable 81 ECOTRIN LOW STRENGTH ORAL TABLET DELAYED RELEASE 81 MG eq aspirin adult low dose oral tablet delayed release 81 eq aspirin low dose oral tablet chewable 81 eql aspirin low dose oral tablet delayed release 81 hm aspirin ec low dose oral tablet delayed release 81 px aspirin oral tablet chewable 81 qc aspirin low dose oral tablet delayed release 81 ra aspirin adult low dose oral tablet chewable 81 ra aspirin ec oral tablet delayed release 81 ra childrens aspirin oral tablet chewable 81 sb aspirin adult low strength oral tablet delayed release 81 sb childrens aspirin oral tablet chewable 81 sm aspirin ec low strength oral tablet delayed release 81 sm childrens aspirin oral tablet chewable 81 *Analgesics - Opioid* *Codeine Combinations*** acetaminophen-codeine #2 oral tablet acetaminophen-codeine #3 oral tablet acetaminophen-codeine #4 oral tablet Aspir-Low Bayer Low Dose EQ Adult Aspirin Low Strength Aspir-Low Bayer Low Dose Aspir-Low Aspir-Low Bayer Low Dose Aspir-Low Bayer Low Dose Aspir-Low Bayer Low Dose Aspir-Low Bayer Low Dose Aspir-Low Bayer Low Dose Tylenol with Codeine #3 Tylenol with Codeine #4 ; QLL (30 EA per 30 ; QLL (30 EA per 30 ; QLL (30 EA per 30 ; QLL (30 EA per 30 ; QLL (30 EA per 30 ; QLL (30 EA per 30 ; QLL (30 EA per 30 ; QLL (30 EA per 30 ; QLL (30 EA per 30 ; QLL (30 EA per 30 ; QLL (30 EA per 30 ; QLL (30 EA per 30 ; QLL (30 EA per 30 ; QLL (30 EA per 30 ; QLL (30 EA per 30 QLL (180 EA per 30 QLL (180 EA per 30 QLL (180 EA per 30 7

11 acetaminophen-codeine oral solution /5ml QLL (240 ML per 30 acetaminophen-codeine oral tablet QLL (180 EA per 30 acetaminophen-codeine oral tablet Tylenol with Codeine #4 QLL (180 EA per 30 ASCOMP-CODEINE ORAL CAPSULE MG butalbital-apap-caff-cod oral capsule butalbital-asa-caff-codeine oral capsule *Hydrocodone Combinations*** hydrocodone-acetaminophen oral solution /5ml, /10ml, /15ml hydrocodone-acetaminophen oral tablet , hydrocodone-acetaminophen oral tablet hydrocodone-ibuprofen oral tablet Butalbital-ASA-Caff- Codeine Fiorinal/Codeine #3 Hycet Lortab Lorcet LORCET HD ORAL TABLET MG Hydrocodone- Acetaminophen Hydrocodone- LORCET ORAL TABLET MG Acetaminophen LORCET PLUS ORAL TABLET MG LORTAB ORAL TABLET MG, MG, MG *Opioid Agonists*** codeine sulfate oral tablet 15, 30, 60 DEMEROL ORAL TABLET 100 MG, 50 MG fentanyl transdermal patch 72 hour 100 mcg/hr fentanyl transdermal patch 72 hour 12 mcg/hr fentanyl transdermal patch 72 hour 25 mcg/hr fentanyl transdermal patch 72 hour 50 mcg/hr Hydrocodone- Acetaminophen Hydrocodone- Acetaminophen Meperidine HCl Duragesic-100 Duragesic-12 Duragesic-25 Duragesic-50 QLL (120 EA per 30 QLL (120 EA per 30 QLL (120 EA per 30 QLL (1800 ML per 30 QLL (120 EA per 30 QLL (120 EA per 30 QLL (240 EA per 30 QLL (120 EA per 30 QLL (120 EA per 30 QLL (120 EA per 30 QLL (120 EA per 30 QLL (90 EA per 30 QLL (30 EA per 30 ; AL (Max 64 Years) 8

12 fentanyl transdermal patch 72 hour 75 mcg/hr Duragesic-75 hydromorphone hcl oral tablet 2, 4 Dilaudid QLL (120 EA per 30 hydromorphone hcl rectal suppository 3 QLL (120 EA per 30 meperidine hcl oral solution 50 /5ml QLL (300 ML per 30 ; AL (Max 64 Years) METHADONE HCL INTENSOL ORAL CONCENTRATE 10 MG/ML Methadone HCl QLL (240 ML per 30 methadone hcl oral concentrate 10 /ml Methadose QLL (240 ML per 30 methadone hcl oral solution 10 /5ml QLL (600 ML per 30 methadone hcl oral solution 5 /5ml QLL (900 ML per 30 methadone hcl oral tablet 10, 5 Dolophine QLL (120 EA per 30 methadone hcl oral tablet soluble 40 Methadose QLL (90 EA per 30 METHADOSE ORAL TABLET SOLUBLE 40 MG Methadone HCl QLL (90 EA per 30 morphine sulfate (concentrate) oral solution 100 /5ml QLL (240 ML per 30 morphine sulfate (concentrate) oral solution 20 /ml morphine sulfate er oral tablet extended MS Contin release 100, 15, 200, 30, 60 morphine sulfate oral solution 10 /5ml, 20 /5ml morphine sulfate oral tablet 15, 30 oxycodone hcl oral solution 5 /5ml QLL (60 EA per 30 QLL (240 ML per 30 QLL (120 EA per 30 oxycodone hcl oral tablet 5 Roxicodone QLL (120 EA per 30 tramadol hcl oral tablet 50 Ultram QLL (120 EA per 30 *Opioid Combinations*** ENDOCET ORAL TABLET MG, MG, MG oxycodone-acetaminophen oral tablet , oxycodone-acetaminophen oral tablet *Opioid Partial Agonists*** pentazocine-naloxone hcl oral tablet *Tramadol Combinations*** tramadol-acetaminophen oral tablet Oxycodone-Acetaminophen Endocet Percocet Ultracet QLL (120 EA per 30 QLL (120 EA per 30 QLL (120 EA per 30 QLL (12 Tablets Max Qty Per Fill Retail) QLL (240 EA per 30 9

13 *Androgens-Anabolic* *Androgens*** danazol oral capsule 100, 200, 50 testosterone cypionate intramuscular solution Depo-Testosterone 100 /ml, 200 /ml *Anorectal Agents* *Rectal Anesthetic/Steroids*** LIDAZONE HC RECTAL CREAM % lidocaine-hydrocortisone ace rectal cream % *Rectal Steroids*** PROCTO-K RECTAL CREAM 1 % *Antacids* *Antacid & Simethicone*** E-Z-GAS II ORAL CKET GM *Antacid Combinations*** ALKA-SELTZER HEARTBURN ORAL TABLET EFFERVESCENT MG antacid ultra strength oral tablet chewable DEWEES CARMINATIVE ORAL LIQUID GAVISCON EXTRA RELIEF FORMULA ORAL SUSPENSION MG/10ML GAVISCON ORAL TABLET CHEWABLE MG mag-al oral liquid /5ml *Antacids - Aluminum Salts*** aluminum hydroxide gel oral suspension 320 /5ml *Antacids - Bicarbonate Combinations*** ALKA-SELTZER GOLD ORAL TABLET EFFERVESCENT MG Lidocaine-Hydrocortisone Ace LidaZone HC Hydrocortisone 10

14 *Antacids - Magnesium Salts*** magnesium oxide oral capsule 400 URO-MAG ORAL CAPSULE 140 MG *Anthelmintics* *Anthelmintics*** ivermectin oral tablet 3 reeses pinworm medicine oral suspension 144 /ml *Antianginal Agents* *Antianginals-Other*** RANEXA ORAL TABLET EXTENDED RELEASE 12 HOUR 1000 MG, 500 MG *Nitrates*** isosorbide dinitrate er oral tablet extended release 40 isosorbide dinitrate oral tablet 10, 20, 30 isosorbide dinitrate oral tablet 5 isosorbide mononitrate er oral tablet extended release 24 hour 120 isosorbide mononitrate er oral tablet extended release 24 hour 30, 60 isosorbide mononitrate oral tablet 10, 20 MINITRAN TRANSDERMAL TCH 24 HOUR 0.1 MG/HR, 0.2 MG/HR, 0.4 MG/HR, 0.6 MG/HR NITRO-BID TRANSDERMAL OINTMENT 2 % nitroglycerin er oral capsule extended release 2.5, 6.5, 9 nitroglycerin transdermal patch 24 hour 0.1 /hr, 0.4 /hr nitroglycerin transdermal patch 24 hour 0.2 /hr, 0.6 /hr nitroglycerin translingual solution 0.4 /spray NITROSTAT SUBLINGUAL TABLET SUBLINGUAL 0.3 MG, 0.4 MG, 0.6 MG Stromectol Isordil Titradose Nitroglycerin Nitro-Time Nitro-Dur Minitran Nitrolingual Nitroglycerin QLL (60 EA per 30 QLL (30 EA per 30 QLL (30 EA per 30 QLL (30 EA per 30 QLL (30 EA per 30 11

15 NITRO-TIME ORAL CAPSULE EXTENDED RELEASE 2.5 MG, 6.5 MG, 9 MG *Antianxiety Agents* *Antianxiety Agents - Misc.*** hydroxyzine hcl oral syrup 10 /5ml hydroxyzine hcl oral tablet 10, 25, 50 hydroxyzine pamoate oral capsule 100 hydroxyzine pamoate oral capsule 25, 50 *Antiarrhythmics* *Antiarrhythmics Type I-A*** disopyramide phosphate oral capsule 100, 150 quinidine sulfate oral tablet 200 quinidine sulfate oral tablet 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, 400 CERONE ORAL TABLET 100 MG, 200 MG, 400 MG *Antiasthmatic And Bronchodilator Agents* *Adrenergic Combinations*** ADVAIR DISKUS INHALATION AEROSOL POWDER BREATH ACTIVATED MCG/DOSE, MCG/DOSE, MCG/DOSE Nitroglycerin ER Vistaril Norpace Pacerone Amiodarone HCl AL (Max 12 Years) AL (Max 64 Years) AL (Max 64 Years) AL (Max 64 Years) AL (Max 64 Years) QLL (49 EA per

16 ADVAIR HFA INHALATION AEROSOL MCG/ACT, MCG/ACT, MCG/ACT COMBIVENT RESPIMAT INHALATION AEROSOL SOLUTION MCG/ACT DULERA INHALATION AEROSOL MCG/ACT, MCG/ACT ipratropium-albuterol inhalation solution (3) /3ml SYMBICORT INHALATION AEROSOL MCG/ACT, MCG/ACT *Anti-Inflammatory Agents*** cromolyn sodium inhalation nebulization solution 20 /2ml *Beta Adrenergics*** albuterol sulfate inhalation nebulization solution (2.5 /3ml) 0.083%, (5 /ml) 0.5% albuterol sulfate inhalation nebulization solution 0.63 /3ml, 1.25 /3ml albuterol sulfate oral syrup 2 /5ml metaproterenol sulfate oral tablet 10, 20 SEREVENT DISKUS INHALATION AEROSOL POWDER BREATH ACTIVATED 50 MCG/DOSE terbutaline sulfate oral tablet 2.5, 5 VENTOLIN HFA INHALATION AEROSOL SOLUTION 108 (90 BASE) MCG/ACT *Bronchodilators - Anticholinergics*** ATROVENT HFA INHALATION AEROSOL SOLUTION 17 MCG/ACT INCRUSE ELLIPTA INHALATION AEROSOL POWDER BREATH ACTIVATED 62.5 MCG/INH ipratropium bromide inhalation solution 0.02 % SPIRIVA HANDIHALER INHALATION CAPSULE 18 MCG QLL (13 GM per 30 QLL (90 ML per 30 QLL (225 ML per 30 QLL (60 EA per 30 QLL (18 GM per 30 QLL (30 EA per 30 13

17 SPIRIVA RESPIMAT INHALATION AEROSOL SOLUTION 1.25 MCG/ACT SPIRIVA RESPIMAT INHALATION AEROSOL SOLUTION 2.5 MCG/ACT TUDORZA PRESSAIR INHALATION AEROSOL POWDER BREATH ACTIVATED 400 MCG/ACT *Leukotriene Receptor Antagonists*** montelukast sodium oral packet 4 montelukast sodium oral tablet 10 montelukast sodium oral tablet chewable 4 montelukast sodium oral tablet chewable 5 *Steroid Inhalants*** AEROSN INHALATION AEROSOL SOLUTION 80 MCG/ACT budesonide inhalation suspension 0.25 /2ml, 0.5 /2ml, 1 /2ml 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 MCG/ACT PULMICORT INHALATION SUSPENSION 1 MG/2ML QVAR INHALATION AEROSOL SOLUTION 40 MCG/ACT, 80 MCG/ACT *Xanthines*** ELIXOPHYLLIN ORAL ELIXIR 80 MG/15ML THEOCHRON ORAL TABLET EXTENDED RELEASE 12 HOUR 100 MG, 200 MG, 300 MG Singulair Singulair Singulair Singulair Pulmicort Budesonide Theophylline Theophylline ER QLL (4 GM per 30 QLL (1 EA per 30 QLL (30 EA per 30 ; AL (Max 5 Years) QLL (30 EA per 30 ; AL (Min 15 Years) QLL (30 EA per 30 ; AL (Max 5 Years) QLL (30 EA per 30 ; AL (Min 6 Years and Max 14 Years) QLL (18 GM per 30 QLL (60 ML per 30 ; AL (Max 6 Years) QLL (30 EA per 60 QLL (1 EA per 30 QLL (60 ML per 30 ; AL (Max 6 Years) 14

18 theophylline er oral tablet extended release 12 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 *Anticoagulants* *Coumarin Anticoagulants*** JANTOVEN ORAL TABLET 1 MG, 10 MG, 2 MG, 2.5 MG, 3 MG, 4 MG, 5 MG, 6 MG, 7.5 MG warfarin sodium oral tablet 1, 10, 2, 4, 6, 7.5 warfarin sodium oral tablet 2.5, 3, 5 *Direct Factor Xa Inhibitors*** XARELTO ORAL TABLET 10 MG, 15 MG, 20 MG *Heparins And Heparinoid-Like Agents*** heparin sodium (porcine) injection solution 1000 unit/ml, unit/ml, 5000 unit/ml *Low Molecular Weight Heparins*** enoxaparin sodium subcutaneous solution 100 /ml, 120 /0.8ml, 150 /ml, 30 /0.3ml, 40 /0.4ml, 60 /0.6ml, 80 /0.8ml *Synthetic Heparinoid-Like Agents*** fondaparinux sodium subcutaneous solution 10 /0.8ml, 2.5 /0.5ml, 5 /0.4ml, 7.5 /0.6ml *Antidiabetics* *Alpha-Glucosidase Inhibitors*** Theochron Warfarin Sodium Jantoven Coumadin Lovenox Arixtra ; QLL (30 EA per 30 acarbose oral tablet 100 Precose QLL (120 EA per 30 acarbose oral tablet 25, 50 Precose QLL (90 EA per 30 *Biguanides*** metformin hcl er oral tablet extended release 24 hour 500, 750 Glucophage XR 15

19 metformin hcl oral tablet 1000, 500, 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, 6.25 JANUVIA ORAL TABLET 100 MG, 25 MG, 50 MG TRADJENTA ORAL TABLET 5 MG *Dipeptidyl Peptidase-4 Inhibitor- Biguanide Combinations*** alogliptin-metformin hcl oral tablet , JANUMET ORAL TABLET MG, MG JANUMET XR ORAL TABLET EXTENDED RELEASE 24 HOUR MG, MG, MG JENTADUETO ORAL TABLET MG, MG, MG JENTADUETO XR ORAL TABLET EXTENDED RELEASE 24 HOUR MG JENTADUETO XR ORAL TABLET EXTENDED RELEASE 24 HOUR MG *Dpp-4 Inhibitor-Thiazolidinedione Combinations*** Glucophage Nesina Kazano alogliptin-pioglitazone oral tablet , , , 25-15, Oseni, *Human Insulin*** APIDRA INJECTION SOLUTION 100 UNIT/ML QLL (60 EA per 30 QLL (1 EA per 30 QLL (1 EA per 28 ST; QLL (30 EA per 30 ST; QLL (30 EA per 30 ST; QLL (60 EA per 30 ST; QLL (30 EA per 30 ST; QLL (60 EA per 30 ST; QLL (60 EA per 30 ST; QLL (30 EA per 30 ; QLL (30 EA per 30 QLL (60 ML per 30 16

20 APIDRA SOLOSTAR SUBCUTANEOUS SOLUTION PEN-INJECTOR 100 UNIT/ML HUMALOG KWIKPEN SUBCUTANEOUS SOLUTION PEN- INJECTOR 100 UNIT/ML HUMALOG MIX 50/50 KWIKPEN SUBCUTANEOUS SUSPENSION PEN- INJECTOR (50-50) 100 UNIT/ML HUMALOG MIX 50/50 SUBCUTANEOUS SUSPENSION (50-50) 100 UNIT/ML HUMALOG MIX 75/25 KWIKPEN SUBCUTANEOUS SUSPENSION PEN- INJECTOR (75-25) 100 UNIT/ML HUMALOG MIX 75/25 SUBCUTANEOUS SUSPENSION (75-25) 100 UNIT/ML HUMALOG SUBCUTANEOUS SOLUTION 100 UNIT/ML HUMALOG SUBCUTANEOUS SOLUTION CARTRIDGE 100 UNIT/ML HUMULIN 70/30 KWIKPEN SUBCUTANEOUS SUSPENSION PEN- INJECTOR (70-30) 100 UNIT/ML HUMULIN N KWIKPEN SUBCUTANEOUS SUSPENSION PEN- INJECTOR 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 NOVOLOG FLEXPEN SUBCUTANEOUS SOLUTION PEN- INJECTOR 100 UNIT/ML NOVOLOG MIX 70/30 FLEXPEN SUBCUTANEOUS SUSPENSION PEN- INJECTOR (70-30) 100 UNIT/ML QLL (30 ML per 30 ; AL (Max 21 Years) QLL (30 ML per 30 ; AL (Max 21 Years) QLL (30 ML per 30 ; AL (Max 21 Years) QLL (60 ML per 30 QLL (30 ML per 30 ; AL (Max 21 Years) QLL (60 ML per 30 QLL (60 ML per 30 QLL (30 ML per 30 ; AL (Max 21 Years) ; QLL (30 ML per 30 ; AL (Max 21 Years) ; QLL (30 ML per 30 ; AL (Max 21 Years) ; QLL (60 ML per 30 QLL (30 ML per 30 ; AL (Max 21 Years) QLL (60 ML per 30 QLL (30 ML per 30 ; AL (Max 21 Years) QLL (30 ML per 30 ; AL (Max 21 Years) 17

21 NOVOLOG MIX 70/30 SUBCUTANEOUS SUSPENSION (70-30) 100 UNIT/ML QLL (60 ML per 30 NOVOLOG PENFILL SUBCUTANEOUS SOLUTION CARTRIDGE 100 UNIT/ML NOVOLOG SUBCUTANEOUS SOLUTION 100 UNIT/ML *Incretin Mimetic Agents (Glp-1 Receptor Agonists)*** TANZEUM SUBCUTANEOUS PEN- INJECTOR 30 MG, 50 MG TRULICITY SUBCUTANEOUS SOLUTION PEN-INJECTOR 0.75 MG/0.5ML, 1.5 MG/0.5ML VICTOZA SUBCUTANEOUS SOLUTION PEN-INJECTOR 18 MG/3ML *Meglitinide Analogues*** QLL (30 ML per 30 ; AL (Max 21 Years) QLL (60 ML per 30 ST; QLL (4 EA per 28 nateglinide oral tablet 120, 60 Starlix QLL (90 EA per 30 repaglinide oral tablet 0.5 QLL (120 EA per 30 repaglinide oral tablet 1, 2 Prandin QLL (120 EA per 30 *Sodium-Glucose Co-Transporter 2 (Sglt2) Inhibitors*** FARXIGA ORAL TABLET 10 MG, 5 MG INVOKANA ORAL TABLET 100 MG, 300 MG *Sulfonylurea-Biguanide Combinations*** glipizide-metformin hcl oral tablet , , glyburide-metformin oral tablet glyburide-metformin oral tablet , *Sulfonylureas*** chlorpropamide oral tablet 100 chlorpropamide oral tablet 250 glimepiride oral tablet 1, 2, 4 Glucovance Amaryl ST ST ST; QLL (30 EA per 30 ST; QLL (30 EA per 30 QLL (120 EA per 30 ; AL (Max 64 Years) QLL (90 EA per 30 ; AL (Max 64 Years) 18

22 glipizide er oral tablet extended release 24 hour 10, 2.5, 5 glipizide oral tablet 10, 5 glipizide xl oral tablet extended release 24 hour 10, 2.5, 5 glyburide micronized oral tablet 1.5, 3, 6 glyburide oral tablet 1.25, 2.5, 5 tolazamide oral tablet 250, 500 tolbutamide oral tablet 500 *Thiazolidinediones*** pioglitazone hcl oral tablet 15, 30, 45 *Antidiarrheals* *Antiperistaltic Agents*** diphenoxylate-atropine oral liquid /5ml diphenoxylate-atropine oral tablet lofene oral tablet loperamide hcl oral capsule 2 *Antidotes* *Antidotes - Chelating Agents*** CHEMET ORAL CAPSULE 100 MG *Opioid Antagonists*** NARCAN NASAL LIQUID 4 MG/0.1ML *Antiemetics* *5-Ht3 Receptor Antagonists*** Glucotrol XL Glucotrol Glucotrol XL Glynase Actos Lomotil Lomotil Imodium A-D QLL (30 EA per 30 QLL (2 EA per 90 granisetron hcl oral tablet 1 ST; QLL (4 EA per 30 ondansetron hcl oral solution 4 /5ml Zofran QLL (300 ML per 30 ; AL (Max 12 Years) ondansetron hcl oral tablet 24 QLL (30 EA per 30 ondansetron hcl oral tablet 4, 8 Zofran QLL (90 EA per 30 ondansetron oral tablet dispersible 4, 8 Zofran ODT QLL (90 EA per 30 *Antiemetics - Miscellaneous*** MARINOL ORAL CAPSULE 10 MG, 2.5 MG, 5 MG Dronabinol 19

23 *Antifungals* *Antifungals*** griseofulvin microsize oral suspension 125 /5ml griseofulvin microsize oral tablet 500 griseofulvin ultramicrosize oral tablet 125, 250 Gris-PEG nystatin oral tablet unit terbinafine hcl oral tablet 250 LamISIL QLL (30 EA per 30 *Imidazoles*** ketoconazole oral tablet 200 *Triazoles*** fluconazole oral suspension reconstituted 10 /ml, 40 /ml fluconazole oral tablet 100, 150, 200, 50 itraconazole oral capsule 100 *Antihistamines* *Antihistamines - Ethanolamines*** Diflucan Diflucan Sporanox QLL (60 EA per 30 AL (Max 12 Years) ARBINOXA ORAL TABLET 4 MG Carbinoxamine Maleate carbinoxamine maleate oral solution 4 /5ml carbinoxamine maleate oral tablet 4 Arbinoxa clemastine fumarate oral tablet 2.68 diphenhydramine hcl oral capsule 50 Banophen AL (Max 64 Years) diphenhydramine hcl oral elixir 12.5 /5ml *Antihistamines - Non-Sedating*** cetirizine hcl oral solution 1 /ml *Antihistamines - Phenothiazines*** PHENADOZ RECTAL SUPPOSITORY 12.5 MG, 25 MG PHENERGAN RECTAL SUPPOSITORY 12.5 MG, 25 MG, 50 MG promethazine hcl oral solution 6.25 /5ml promethazine hcl oral syrup 6.25 /5ml ZyrTEC Childrens Allergy Promethazine HCl Promethazine HCl QLL (300 ML per 30 ; AL (Max 12 Years) AL (Min 2 Years and Max 64 Years) AL (Min 2 Years and Max 64 Years) AL (Min 2 Years and Max 64 Years) AL (Min 2 Years and Max 64 Years) 20

24 promethazine hcl oral tablet 12.5, 25, 50 promethazine hcl rectal suppository 12.5, 50 promethazine hcl rectal suppository 25 Phenergan Promethegan AL (Min 2 Years and Max 64 Years) AL (Min 2 Years and Max 64 Years) AL (Min 2 Years and Max 64 Years) PROMETHEGAN RECTAL SUPPOSITORY 12.5 MG, 25 MG, 50 MG Promethazine HCl AL (Min 2 Years and Max 64 Years) *Antihistamines - Piperidines*** cyproheptadine hcl oral syrup 2 /5ml cyproheptadine hcl oral tablet 4 *Antihyperlipidemics* *Antihyperlipidemics - Misc.*** omega-3-acid ethyl esters oral capsule 1 gm Lovaza *Bile Acid Sequestrants*** AL (Max 64 Years) AL (Max 64 Years) cholestyramine light oral packet 4 gm Prevalite cholestyramine light oral powder 4 gm/dose Prevalite QLL (240 GM per 30 cholestyramine oral packet 4 gm Questran cholestyramine oral powder 4 gm/dose Questran QLL (378 GM per 30 colestipol hcl oral granules 5 gm Colestid Flavored colestipol hcl oral packet 5 gm Colestid colestipol hcl oral tablet 1 gm Colestid PREVALITE ORAL CKET 4 GM Cholestyramine Light PREVALITE ORAL POWDER 4 GM/DOSE Cholestyramine Light QLL (240 GM per 30 *Fibric Acid Derivatives*** fenofibrate micronized oral capsule 134, 200, 67 Lofibra QLL (30 EA per 30 fenofibrate oral capsule 150, 50 Lipofen fenofibrate oral tablet 145, 48 Tricor QLL (30 EA per 30 fenofibrate oral tablet 160, 54 Lofibra QLL (30 EA per 30 fenofibric acid oral capsule delayed release 135, 45 Trilipix QLL (30 EA per 30 fenofibric acid oral tablet 105, 35 Fibricor gemfibrozil oral tablet 600 Lopid QLL (60 EA per 30 *H Coa Reductase Inhibitors*** atorvastatin calcium oral tablet 10, 20, 40, 80 Lipitor QLL (30 EA per 30 21

25 fluvastatin sodium oral capsule 20 Lescol QLL (30 EA per 30 fluvastatin sodium oral capsule 40 QLL (60 EA per 30 lovastatin oral tablet 10, 20 QLL (30 EA per 30 lovastatin oral tablet 40 Mevacor QLL (30 EA per 30 pravastatin sodium oral tablet 10 QLL (30 EA per 30 pravastatin sodium oral tablet 20, 40, Pravachol 80 QLL (30 EA per 30 simvastatin oral tablet 10, 20, 40, 5, 80 Zocor QLL (30 EA per 30 *Intestinal Cholesterol Absorption Inhibitors*** ZETIA ORAL TABLET 10 MG Ezetimibe QLL (30 EA per 30 *Nicotinic Acid Derivatives*** niacin er (antihyperlipidemic) oral tablet extended release 1000 niacin er (antihyperlipidemic) oral tablet extended release 500 niacin er (antihyperlipidemic) oral tablet extended release 750 *Antihypertensives* *Ace Inhibitor & Calcium Channel Blocker Combinations*** amlodipine besy-benazepril hcl oral capsule 10-20, 10-40, 5-10, 5-20 amlodipine besy-benazepril hcl oral capsule , 5-40 *Ace Inhibitors & Thiazide/Thiazide- Like*** enalapril-hydrochlorothiazide oral tablet enalapril-hydrochlorothiazide oral tablet lisinopril-hydrochlorothiazide oral tablet , , quinapril-hydrochlorothiazide oral tablet , , *Ace Inhibitors*** Niaspan Niaspan Niaspan Lotrel Vaseretic Zestoretic Accuretic QLL (60 EA per 30 QLL (120 EA per 30 QLL (90 EA per 30 QLL (30 EA per 30 QLL (30 EA per 30 QLL (60 EA per 30 QLL (60 EA per 30 QLL (60 EA per 30 benazepril hcl oral tablet 10, 20 Lotensin QLL (45 EA per 30 benazepril hcl oral tablet 40 Lotensin QLL (60 EA per 30 22

26 benazepril hcl oral tablet 5 QLL (45 EA per 30 captopril oral tablet 100, 12.5, 25, 50 enalapril maleate oral tablet 10, 2.5, 5 Vasotec QLL (45 EA per 30 enalapril maleate oral tablet 20 Vasotec QLL (60 EA per 30 ENED ORAL SOLUTION RECONSTITUTED 1 MG/ML AL (Max 12 Years) fosinopril sodium oral tablet 10, 20 QLL (45 EA per 30 fosinopril sodium oral tablet 40 QLL (60 EA per 30 lisinopril oral tablet 10, 2.5, 20, 30 Zestril QLL (45 EA per 30 lisinopril oral tablet 40 Zestril QLL (60 EA per 30 lisinopril oral tablet 5 Prinivil QLL (45 EA per 30 perindopril erbumine oral tablet 2 QLL (45 EA per 30 perindopril erbumine oral tablet 4 Aceon QLL (45 EA per 30 quinapril hcl oral tablet 10, 20, 40, Accupril 5 QLL (30 EA per 30 ramipril oral capsule 1.25, 10, 2.5, Altace 5 QLL (30 EA per 30 trandolapril oral tablet 1, 2, 4 Mavik QLL (30 EA per 30 *Adrenolytics-Central & Thiazide/Thiazide-Like Comb*** methyldopa-hydrochlorothiazide oral tablet , *Angiotensin Ii Receptor Antag & Thiazide/Thiazide-Like*** candesartan cilexetil-hctz oral tablet , , irbesartan-hydrochlorothiazide oral tablet , losartan potassium-hctz oral tablet , , valsartan-hydrochlorothiazide oral tablet , , valsartan-hydrochlorothiazide oral tablet , Atacand HCT Avalide Hyzaar Diovan HCT Diovan HCT QLL (30 EA per 30 QLL (30 EA per 30 QLL (30 EA per 30 23

27 *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, Diovan 80 *Antiadrenergics - Centrally Acting*** clonidine hcl oral tablet 0.1, 0.2, 0.3 guanfacine hcl oral tablet 1, 2 methyldopa oral tablet 250, 500 *Antiadrenergics - Peripherally Acting*** Catapres QLL (30 EA per 30 QLL (30 EA per 30 QLL (60 EA per 30 AL (Max 64 Years) doxazosin mesylate oral tablet 1, 2, 4 Cardura QLL (30 EA per 30 doxazosin mesylate oral tablet 8 Cardura QLL (60 EA per 30 prazosin hcl oral capsule 1, 2, 5 Minipress QLL (60 EA per 30 terazosin hcl oral capsule 1, 5 QLL (30 EA per 30 terazosin hcl oral capsule 10, 2 QLL (60 EA per 30 *Beta Blocker & Diuretic Combinations*** atenolol-chlorthalidone oral tablet Tenoretic 100 atenolol-chlorthalidone oral tablet Tenoretic 50 bisoprolol-hydrochlorothiazide oral tablet 10- Ziac 6.25 bisoprolol-hydrochlorothiazide oral tablet Ziac , metoprolol-hydrochlorothiazide oral tablet metoprolol-hydrochlorothiazide oral tablet Lopressor HCT QLL (60 EA per 30 QLL (45 EA per 30 24

28 *Direct Renin Inhibitors & Thiazide/Thiazide-Like Comb*** TEKTURNA HCT ORAL TABLET MG, MG, MG, MG *Direct Renin Inhibitors*** TEKTURNA ORAL TABLET 150 MG, 300 MG *Vasodilators*** hydralazine hcl injection solution 20 /ml hydralazine hcl oral tablet 10, 100, 50 hydralazine hcl oral tablet 25 minoxidil oral tablet 10, 2.5 *Anti-Infective Agents - Misc.* *Anti-Infective Agents - Misc.*** CAYSTON INHALATION SOLUTION RECONSTITUTED 75 MG metronidazole oral tablet 250, 500 tinidazole oral tablet 250 tinidazole oral tablet 500 trimethoprim oral tablet 100 vancomycin hcl intravenous solution reconstituted 10 gm, 1000, 500, 5000, 750 *Anti-Infective Misc. - Combinations*** sulfamethoxazole-trimethoprim oral suspension /5ml sulfamethoxazole-trimethoprim oral tablet sulfamethoxazole-trimethoprim oral tablet SULFATRIM PEDIATRIC ORAL SUSPENSION MG/5ML *Antiprotozoal Agents*** MEPRON ORAL SUSPENSION 750 MG/5ML Flagyl Tindamax Sulfatrim Pediatric Bactrim Bactrim DS Sulfamethoxazole- Trimethoprim Atovaquone ; QLL (30 EA per 30 ; QLL (30 EA per 30 QLL (90 EA per 30 QLL (120 EA per 30 25

29 *Leprostatics*** dapsone oral tablet 100, 25 *Lincosamides*** clindamycin hcl oral capsule 150, 300, 75 clindamycin palmitate hcl oral solution reconstituted 75 /5ml *Oxazolidinones*** Cleocin Cleocin linezolid oral suspension reconstituted 100 /5ml Zyvox linezolid oral tablet 600 Zyvox *Antimalarials* *Antimalarials*** chloroquine phosphate oral tablet 250, 500 DARAPRIM ORAL TABLET 25 MG hydroxychloroquine sulfate oral tablet 200 mefloquine hcl oral tablet 250 primaquine phosphate oral tablet 26.3 *Antimycobacterial Agents* *Antimycobacterial Agents*** Plaquenil ethambutol hcl oral tablet 100, 400 Myambutol isoniazid oral syrup 50 /5ml isoniazid oral tablet 100, 300 pyrazinamide oral tablet 500 rifabutin oral capsule 150 Mycobutin rifampin oral capsule 150, 300 Rifadin SEROMYCIN ORAL CAPSULE 250 MG CycloSERINE TRECATOR ORAL TABLET 250 MG *Antineoplastics And Adjunctive Therapies* *Alkylating Agents*** HEXALEN ORAL CAPSULE 50 MG MYLERAN ORAL TABLET 2 MG AL (Max 12 Years) QLL (30 EA per 30 AL (Max 12 Years) 26

30 *Androgen Biosynthesis Inhibitors*** ZYTIGA ORAL TABLET 250 MG *Antiadrenals*** LYSODREN ORAL TABLET 500 MG *Antiandrogens*** ; QLL (120 EA per 30 bicalutamide oral tablet 50 Casodex flutamide oral capsule 125 NILANDRON ORAL TABLET 150 MG Nilutamide XTANDI ORAL CAPSULE 40 MG ; QLL (120 EA per 30 *Antiestrogens*** FARESTON ORAL TABLET 60 MG tamoxifen citrate oral tablet 10, 20 *Antimetabolites*** capecitabine oral tablet 150, 500 Xeloda mercaptopurine oral tablet 50 methotrexate oral tablet 2.5 TABLOID ORAL TABLET 40 MG *Antineoplastic - Hedgehog Pathway Inhibitors*** ERIVEDGE ORAL CAPSULE 150 MG *Antineoplastic - Histone Deacetylase Inhibitors*** FARYDAK ORAL CAPSULE 10 MG, 15 MG, 20 MG ZOLINZA ORAL CAPSULE 100 MG *Antineoplastic - Immunomodulators*** POMALYST ORAL CAPSULE 1 MG, 2 MG, 3 MG, 4 MG *Antineoplastic - Mtor Kinase Inhibitors*** AFINITOR DISPERZ ORAL TABLET SOLUBLE 2 MG, 3 MG, 5 MG AFINITOR ORAL TABLET 10 MG AFINITOR ORAL TABLET 2.5 MG, 5 MG QLL (60 EA per 30 ; QLL (30 EA per 30 ; QLL (60 EA per 30 ; QLL (60 EA per 30 ; QLL (30 EA per 30 27

31 AFINITOR ORAL TABLET 7.5 MG *Antineoplastics Misc.*** hydroxyurea oral capsule 500 INTRON A INJECTION SOLUTION UNIT/ML, UNIT/ML MATULANE ORAL CAPSULE 50 MG *Aromatase Inhibitors*** anastrozole oral tablet 1 exemestane oral tablet 25 letrozole oral tablet 2.5 *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 *Janus Associated Kinase (Jak) Inhibitors*** JAKAFI ORAL TABLET 10 MG, 15 MG, 20 MG, 25 MG, 5 MG *Mitotic Inhibitors*** etoposide oral capsule 50 *Nitrogen Mustards*** ALKERAN ORAL TABLET 2 MG cyclophosphamide oral capsule 25, 50 LEUKERAN ORAL TABLET 2 MG *Nitrosoureas*** GLEOSTINE ORAL CAPSULE 10 MG, 100 MG, 40 MG *Progestins-Antineoplastic*** megestrol acetate oral suspension 40 /ml, 400 /10ml megestrol acetate oral tablet 20, 40 Hydrea Arimidex Aromasin Femara Temodar Megace Oral QLL (30 EA per 30 ; AL (Min 18 Years) ; QLL (60 EA per 30 28

32 *Retinoids*** tretinoin oral capsule 10 *Selective Retinoid X Receptor Agonists*** bexarotene oral capsule 75 Targretin *Topoisomerase I Inhibitors*** HYCAMTIN ORAL CAPSULE 0.25 MG, 1 MG *Urinary Tract Protective Agents*** MESNEX ORAL TABLET 400 MG *Antiparkinson Agents* *Antiparkinson Dopaminergics*** amantadine hcl oral capsule 100 QLL (120 EA per 30 amantadine hcl oral syrup 50 /5ml QLL (240 ML per 30 amantadine hcl oral tablet 100 bromocriptine mesylate oral capsule 5 Parlodel bromocriptine mesylate oral tablet 2.5 Parlodel QLL (180 EA per 30 *Antiparkinson Monoamine Oxidase Inhibitors*** selegiline hcl oral capsule 5 Eldepryl QLL (60 EA per 30 *Levodopa Combinations*** carbidopa-levodopa er oral tablet extended release , carbidopa-levodopa oral tablet , , carbidopa-levodopa oral tablet dispersible , carbidopa-levodopa oral tablet dispersible *Nonergoline Dopamine Receptor Agonists*** MIRAPEX ORAL TABLET 0.75 MG pramipexole dihydrochloride oral tablet 0.125, 0.25, 0.5, 0.75, 1, 1.5 ropinirole hcl oral tablet 0.25, 0.5, 1, 2, 3, 4, 5 Sinemet CR Sinemet Pramipexole Dihydrochloride Mirapex Requip QLL (30 EA per 30 QLL (30 EA per 30 QLL (30 EA per 30 QLL (30 EA per 30 29

33 *Antipsychotics/Antimanic Agents* *Phenothiazines*** COMPRO RECTAL SUPPOSITORY 25 MG Prochlorperazine QLL (60 EA per 30 prochlorperazine maleate oral tablet 10 QLL (150 EA per 30 prochlorperazine maleate oral tablet 5 QLL (120 EA per 30 prochlorperazine rectal suppository 25 Compro QLL (60 EA per 30 *Antivirals* *Cmv Agents*** valganciclovir hcl oral tablet 450 Valcyte ; QLL (60 EA per 30 *Hepatitis B Agents*** entecavir oral tablet 0.5, 1 HEPSERA ORAL TABLET 10 MG lamivudine oral tablet 100 *Herpes Agents - Purine Analogues*** Baraclude Adefovir Dipivoxil Epivir HBV acyclovir oral capsule 200 Zovirax QLL (60 EA per 30 acyclovir oral suspension 200 /5ml Zovirax AL (Max 12 Years) acyclovir oral tablet 400 Zovirax QLL (60 EA per 30 acyclovir oral tablet 800 Zovirax QLL (30 EA per 30 valacyclovir hcl oral tablet 1 gm Valtrex QLL (30 EA per 30 valacyclovir hcl oral tablet 500 Valtrex QLL (60 EA per 30 *Herpes Agents - Thymidine Analogues*** famciclovir oral tablet 125, 250 QLL (90 EA per 30 famciclovir oral tablet 500 Famvir QLL (90 EA per 30 *Influenza Agents*** rimantadine hcl oral tablet 100 *Neuraminidase Inhibitors*** RELENZA DISKHALER INHALATION AEROSOL POWDER BREATH ACTIVATED 5 MG/BLISTER TAMIFLU ORAL CAPSULE 30 MG, 45 MG, 75 MG TAMIFLU ORAL SUSPENSION RECONSTITUTED 6 MG/ML Flumadine Oseltamivir Phosphate QLL (20 EA per 180 ; AL (Min 5 Years) QLL (10 Capsules Max Qty Per Fill Retail) QLL (3 Bottles Max Qty Per Fill Retail); AL (Max 12 Years) 30

34 *Assorted Classes* *Antileprotics*** THALOMID ORAL CAPSULE 100 MG, 150 MG, 200 MG, 50 MG *Cyclosporine Analogs*** cyclosporine modified oral capsule 100, 25 Neoral QLL (30 EA per 30 cyclosporine modified oral capsule 50 Gengraf cyclosporine modified oral solution 100 /ml Neoral AL (Max 12 Years) cyclosporine oral capsule 100 SandIMMUNE QLL (150 EA per 30 cyclosporine oral capsule 25 SandIMMUNE GENGRAF ORAL CAPSULE 100 MG, 25 CycloSPORINE Modified MG QLL (30 EA per 30 GENGRAF ORAL SOLUTION 100 MG/ML CycloSPORINE Modified AL (Max 12 Years) *Immunomodulators For Myelodysplastic Syndromes*** REVLIMID ORAL CAPSULE 10 MG, 15 MG, 25 MG, 5 MG REVLIMID ORAL CAPSULE 2.5 MG, 20 MG *Inosine Monophosphate Dehydrogenase Inhibitors*** ; QLL (30 EA per 30 mycophenolate mofetil oral capsule 250 CellCept QLL (30 EA per 30 mycophenolate mofetil oral suspension reconstituted 200 /ml CellCept AL (Max 12 Years) mycophenolate mofetil oral tablet 500 CellCept *Irrigation Solutions*** ARGYLE STERILE WATER Sterile Water for Irrigation IRRIGATION SOLUTION sterile water for irrigation irrigation solution Argyle Sterile Water *Macrolide Immunosuppressants*** sirolimus oral tablet 0.5, 1, 2 tacrolimus oral capsule 0.5, 1, 5 *Potassium Removing Resins*** KIONEX ORAL POWDER Rapamune Prograf Sodium Polystyrene Sulfonate 31

35 KIONEX ORAL SUSPENSION 15 GM/60ML sodium polystyrene sulfonate oral powder sodium polystyrene sulfonate oral suspension 15 gm/60ml sodium polystyrene sulfonate rectal suspension 30 gm/120ml, 50 gm/200ml SPS ORAL SUSPENSION 15 GM/60ML *Purine Analogs*** Sodium Polystyrene Sulfonate Kionex Kionex Sodium Polystyrene Sulfonate azathioprine oral tablet 50 Imuran QLL (240 EA per 30 *Beta Blockers* *Alpha-Beta Blockers*** carvedilol oral tablet 12.5, 25, 3.125, 6.25 labetalol hcl oral tablet 100, 200, 300 *Beta Blockers Cardio-Selective*** Coreg acebutolol hcl oral capsule 200, 400 atenolol oral tablet 100, 25, 50 Tenormin betaxolol hcl oral tablet 10, 20 bisoprolol fumarate oral tablet 10 Zebeta QLL (60 EA per 30 bisoprolol fumarate oral tablet 5 QLL (45 EA per 30 metoprolol succinate er oral tablet extended release 24 hour 100, 25, 50 Toprol XL QLL (45 EA per 30 metoprolol succinate er oral tablet extended release 24 hour 200 Toprol XL QLL (60 EA per 30 metoprolol tartrate oral tablet 100, 50 Lopressor QLL (90 EA per 30 metoprolol tartrate oral tablet 25 QLL (90 EA per 30 *Beta Blockers Non-Selective*** HEMANGEOL ORAL SOLUTION 4.28 MG/ML nadolol oral tablet 20, 40, 80 pindolol oral tablet 10, 5 propranolol hcl er oral capsule extended release 24 hour 120, 160 propranolol hcl er oral capsule extended release 24 hour 60 Corgard Inderal LA Inderal LA AL (Max 4 Years) QLL (60 EA per 30 QLL (120 EA per 30 32

36 propranolol hcl er oral capsule extended release 24 hour 80 Inderal LA QLL (90 EA per 30 propranolol hcl oral solution 20 /5ml, 40 /5ml propranolol hcl oral tablet 10, 20, 40, 60, 80 SORINE ORAL TABLET 120 MG, 160 MG, 240 MG, 80 MG Sotalol HCl QLL (60 EA per 30 sotalol hcl (af) oral tablet 120, 160, 80 Betapace AF sotalol hcl oral tablet 120, 160, 240, 80 Sorine QLL (60 EA per 30 timolol maleate oral tablet 10, 20, 5 *Calcium Channel Blockers* *Calcium Channel Blockers*** AFEDITAB CR ORAL TABLET EXTENDED RELEASE 24 HOUR 30 MG, NIFEdipine ER 60 MG amlodipine besylate oral tablet 10, 2.5 Norvasc, 5 CARTIA XT ORAL CAPSULE EXTENDED RELEASE 24 HOUR 120 MG, 180 MG, 240 MG, 300 MG diltiazem cd oral capsule extended release 24 hour 120, 180 diltiazem cd oral capsule extended release 24 hour 240 diltiazem hcl er beads oral capsule extended release 24 hour 120, 240, 300 diltiazem hcl er beads oral capsule extended release 24 hour 180, 360, 420 diltiazem hcl er coated beads oral capsule extended release 24 hour 120, 300 diltiazem hcl er coated beads oral capsule extended release 24 hour 180 diltiazem hcl er coated beads oral capsule extended release 24 hour 240 diltiazem hcl er coated beads oral tablet extended release 24 hour 180 diltiazem hcl er coated beads oral tablet extended release 24 hour 300 Diltiazem HCl ER Coated Beads Cartia XT Cardizem CD Taztia XT Tiazac Cartia XT Cartia XT Cardizem CD Matzim LA Cardizem LA QLL (30 EA per 30 QLL (30 EA per 30 QLL (30 EA per 30 QLL (30 EA per 30 QLL (30 EA per 30 QLL (30 EA per 30 QLL (30 EA per 30 QLL (30 EA per 30 QLL (60 EA per 30 QLL (30 EA per 30 QLL (30 EA per 30 QLL (30 EA per 30 33

37 diltiazem hcl er oral capsule extended release 24 hour 120, 180, 240 QLL (30 EA per 30 diltiazem hcl oral tablet 120, 30, 60 Cardizem QLL (30 EA per 30 diltiazem hcl oral tablet 90 QLL (120 EA per 30 dilt-xr oral capsule extended release 24 hour 120, 180, 240 QLL (30 EA per 30 felodipine er oral tablet extended release 24 hour 10 QLL (60 EA per 30 felodipine er oral tablet extended release 24 hour 2.5, 5 QLL (30 EA per 30 isradipine oral capsule 2.5, 5 QLL (60 EA per 30 MATZIM LA ORAL TABLET EXTENDED RELEASE 24 HOUR 180 MG, 300 MG nicardipine hcl oral capsule 20, 30 NIFEDIAC CC ORAL TABLET EXTENDED RELEASE 24 HOUR 30 MG NIFEDICAL XL ORAL TABLET EXTENDED RELEASE 24 HOUR 60 MG nifedipine er oral tablet extended release 24 hour 30, 90 nifedipine er oral tablet extended release 24 hour 60 nifedipine er osmotic release oral tablet extended release 24 hour 30, 90 nifedipine er osmotic release oral tablet extended release 24 hour 60 nifedipine oral capsule 10 nifedipine oral capsule 20 Diltiazem HCl ER Coated Beads NIFEdipine ER NIFEdipine ER Osmotic Release Adalat CC Afeditab CR Procardia XL Nifedical XL Procardia nimodipine oral capsule 30 TAZTIA XT ORAL CAPSULE EXTENDED RELEASE 24 HOUR 120 Diltiazem HCl ER Beads MG, 180 MG, 240 MG, 300 MG, 360 MG verapamil hcl er oral capsule extended Verelan PM release 24 hour 100, 200, 300 verapamil hcl er oral capsule extended release 24 hour 120, 180, 240, 360 Verelan QLL (30 EA per 30 QLL (30 EA per 30 QLL (30 EA per 30 QLL (30 EA per 30 QLL (30 EA per 30 QLL (30 EA per 30 QLL (30 EA per 30 QLL (120 EA per 30 ; AL (Max 64 Years) QLL (120 EA per 30 ; AL (Max 64 Years) QLL (30 EA per 30 QLL (30 EA per 30 QLL (30 EA per 30 QLL (30 EA per 30 34

38 verapamil hcl er oral tablet extended release 120, 180 verapamil hcl er oral tablet extended release 240 verapamil hcl oral tablet 120, 80 verapamil hcl oral tablet 40 VERELAN PM ORAL CAPSULE EXTENDED RELEASE 24 HOUR 100 MG, 200 MG *Cardiotonics* *Cardiac Glycosides*** DIGITEK ORAL TABLET 125 MCG, 250 MCG DIGOX ORAL TABLET 125 MCG, 250 MCG digoxin oral solution 0.05 /ml digoxin oral tablet 125 mcg digoxin oral tablet 250 mcg *Cardiovascular Agents - Misc.* *Pulm Hyperten-Soluble Guanylate Cyclase Stimulator (Sgc)*** ADEMS ORAL TABLET 0.5 MG, 1 MG, 1.5 MG, 2 MG, 2.5 MG *Pulmonary Hypertension - Endothelin Receptor Antagonists*** LETAIRIS ORAL TABLET 10 MG, 5 MG TRACLEER ORAL TABLET 125 MG, 62.5 MG *Pulmonary Hypertension - Phosphodiesterase Inhibitors*** Calan SR Isoptin SR Calan Verapamil HCl ER Digoxin Digoxin Digitek Digox QLL (30 EA per 30 QLL (30 EA per 30 QLL (30 EA per 30 ; QLL (90 EA per 30 ; QLL (30 EA per 30 ; QLL (60 EA per 30 ADCIRCA ORAL TABLET 20 MG ; QLL (60 EA per 30 sildenafil citrate oral tablet 20 Revatio *Cephalosporins* *Cephalosporins - 1St Generation*** cefadroxil oral capsule 500 cefadroxil oral suspension reconstituted 250 /5ml, 500 /5ml cefadroxil oral tablet 1 gm AL (Max 12 Years) 35

39 cephalexin oral capsule 250, 500 cephalexin oral suspension reconstituted 125 /5ml, 250 /5ml *Cephalosporins - 2Nd Generation*** Keflex cefaclor oral capsule 250, 500 cefaclor oral suspension reconstituted 125 /5ml, 250 /5ml, 375 /5ml cefprozil oral suspension reconstituted 125 /5ml, 250 /5ml cefprozil oral tablet 250, 500 cefuroxime axetil oral tablet 250, 500 Ceftin *Cephalosporins - 3Rd Generation*** cefdinir oral capsule 300 cefdinir oral suspension reconstituted 125 /5ml, 250 /5ml cefpodoxime proxetil oral suspension reconstituted 100 /5ml, 50 /5ml cefpodoxime proxetil oral tablet 100, 200 ceftriaxone sodium injection solution reconstituted 250, 500 *Chemicals* *Bulk Chemicals - Hy's*** hydroxyprogesterone caproate powder *Bulk Chemicals - La's*** acidophilus lactobacillus powder *Bulk Chemicals - Le's*** leucovorin calcium powder *Bulk Chemicals - Py's*** pyrimethamine powder *Bulk Chemicals - St's*** stevia extract powder steviol glycosides powder 95 % stevioside fluid extract 15 % *Liquids*** glycerine liquid AL (Max 12 Years) AL (Max 12 Years) AL (Max 12 Years) AL (Max 12 Years) QLL (2 Grams Max Qty Per Fill Retail) 36

40 *Solids*** sorbitol powder *Contraceptives* *Biphasic Contraceptives - Oral*** AZURETTE ORAL TABLET /0.01 MG (21/5) desogestrel-ethinyl estradiol oral tablet /0.01 (21/5) KARIVA ORAL TABLET /0.01 MG (21/5) KIMIDESS ORAL TABLET /0.01 MG (21/5) LO LOESTRIN FE ORAL TABLET 1 MG-10 MCG / 10 MCG NECON 10/11 (28) ORAL TABLET 35 MCG PIMTREA ORAL TABLET /0.01 MG (21/5) viorele oral tablet /0.01 (21/5) *Combination Contraceptives - Oral*** ALTAVERA ORAL TABLET MG- MCG Viorele Pimtrea Viorele Viorele Viorele Pimtrea Levonorgestrel-Ethinyl Estrad alyacen 1/35 oral tablet mcg Pirmella 1/35 APRI ORAL TABLET MG-MCG AUBRA ORAL TABLET MG-MCG Levonorgestrel-Ethinyl Estrad AVIANE ORAL TABLET MG- MCG BALZIVA ORAL TABLET MG- MCG briellyn oral tablet mcg CHATEAL ORAL TABLET MG- MCG CRYSELLE-28 ORAL TABLET MG-MCG CYCLAFEM 1/35 ORAL TABLET 1-35 MG-MCG CYRED ORAL TABLET MG- MCG Levonorgestrel-Ethinyl Estrad Briellyn Gildagia Levonorgestrel-Ethinyl Estrad Alyacen 1/35 37