Plan for your best health

Transcription

1 Plan for your best health 2018 Aetna Pharmacy Drug Guide Aetna Value Plan A (1/18) aetna.com

2 How to use this guide Your guide includes a list of commonly used drugs covered on your pharmacy plan. The amount you pay depends on the drug your doctor prescribes. It s either a flat fee or a percentage of the prescription s price after you meet your deductible, if applicable. Preferred generic drugs cost less. Preferred brand drugs will have a higher cost. Your plan includes Brand and generic drugs that are hand-picked for their quality and effectiveness Aetna Specialty Pharmacy fills specialty drug prescriptions (ones that are injected, infused or taken by mouth) and provides services that include personal support, helpful resources and training, and free secure home delivery Aetna Rx Home Delivery pharmacy that delivers maintenance drugs to your home or wherever you choose (for drugs that are taken regularly to treat conditions like arthritis, diabetes or asthma) What you can expect to pay With your pharmacy plan, the amount you pay depends on the drug your doctor prescribes. It s either a flat fee or a percentage of the drug s/medicine s price. Each drug is grouped as a generic, a brand or a specialty drug. The preferred drugs within these groups will generally save you money compared to a non-preferred drug. Generic drugs are less expensive than brands. Specialty prescription drugs typically include higher-cost drugs that require special handling, special storage or monitoring. These types of drugs may include, but are not limited to, drugs that are injected, infused, inhaled or taken by mouth. You re covered for all types of medicine some more expensive, and some less. Preferred generic: the lowest cost Preferred brand: a slightly higher cost Non-preferred brand and generic: a higher cost Preferred Specialty: lower cost for specialty drugs Non-preferred specialty: higher cost for non-preferred specialty drugs Your pharmacy plan may not have all the coverage levels listed above so check your plan documents to see how much you will pay. For your exact coverage and cost, and to learn more about your plan Visit the website that s on your member ID card. Then log in to your account, where you can: Find out the coverage and estimate of cost for specific drugs View your deductibles and plan limits Order medications Check your pharmacy order status Get a member ID card View your claims, Explanation of Benefits and more Aetna is the brand name used for products and services provided by one or more of the Aetna group of subsidiary companies, including Aetna Life Insurance Company and its affiliates (Aetna). Aetna Pharmacy Management refers to an internal business unit of Aetna Health Management, LLC. Aetna Pharmacy Management administers, but does not offer, insure or otherwise underwrite the prescription drug benefits portion of your health plan and has no financial responsibility therefor. Aetna Specialty Pharmacy refers to Aetna Specialty Pharmacy, LLC, a subsidiary of Aetna Inc., which is a licensed pharmacy that operates through specialty pharmacy prescription fulfillment. 2

3 Have more questions about your pharmacy benefits? We re here to help. There are several ways you can learn more about your benefits: Check your Plan Design and Benefits Summary in your enrollment kit. Call the toll-free number on your member ID card. Review our pharmacy frequently asked questions (FAQs) and answers. Just visit the website that s on your member ID card to search for the Pharmacy FAQ. Aetna Specialty Pharmacy Aetna Specialty Pharmacy medicine and support services is our in-house specialty pharmacy that can fill your prescriptions for specialty drugs. These are the types of drugs that may be injected, infused or taken by mouth. They often need special storage and handling. And they need to be delivered quickly. A nurse or pharmacist may monitor you during your treatment, if needed. With Aetna Specialty Pharmacy, you can get this medicine sent right to your mailbox. How to get started with Aetna Specialty Pharmacy Ordering your prescription through Aetna Specialty Pharmacy is easy. And we typically offer a 30-day medicine supply. To transfer your prescription, just call us toll-free at For a new prescription, your doctor can send it to us in one of four ways: 1. Electronically: Through e-prescribe Aetna Rx Home Delivery You can have maintenance drugs sent right to your home or anywhere else you choose with Aetna Rx Home Delivery pharmacy. These are drugs that are taken regularly for chronic conditions like arthritis, diabetes or asthma. Depending on your plan, you can get up to a 90-day supply of medicine for less cost. It s fast and convenient, and standard shipping is always free. Get started right away You can submit your order using one of these options: 1. Online Visit your secure member website and sign in to your account. There you can add or remove your prescriptions. 2. Phone Call us toll-free, 24/7 at If you need the help of a telephone device for the deaf, call Mail Get a new prescription from your doctor. Then mail it to us with a completed order form. You can find the form on your secure member website. The mailing address is on the form. Your doctor can submit your order using one of these options: 1. Online They can submit your prescriptions using the e-prescribe services on our provider website. 2. Fax They can fax your prescription to Make sure they include your member ID number, date of birth and mailing address on the fax cover sheet. Only a doctor may fax a prescription. 2. Fax: FAX-ASRX ( ) 3. Mail: Aetna Specialty Pharmacy 503 Sunport Lane Orlando, FL Phone: ASRX ( ), option 2 If you mail in your own prescription, please send it with a completed Patient Profile Form. To find this form, just visit the website that s on your member ID card, to search for the Patient Profile Form. 3

4 Frequently asked questions How can I save on prescriptions? Here are some tips to pay less out of pocket for your prescription drugs: Ask your doctor to consider prescribing drugs that are on the Pharmacy Drug Guide (formulary). Ask your doctor to consider prescribing generic drugs instead of brand-name drugs. Check to see if your plan includes our home delivery pharmacy service. Depending upon your plan, our home delivery service may save you money. For more information, visit the website on your member ID card and log in to your account. Remind your doctor to check your plan to make sure you get maximum coverage. What are generic drugs? Generic drugs are proven to be just as safe and effective as brand-name drugs. They contain the same active ingredients in the same amounts as the brand-name drugs and work the same way. So they have the same risks and benefits as brand-name drugs. However, they typically cost less. When appropriate, your doctor may decide to prescribe a generic drug or allow the pharmacist to substitute a generic drug. What is precertification? Precertification is one way that we can help you and your doctor find safe, appropriate drugs and keep costs down. Precertification means that you or your doctor need to get approval from the plan before certain drugs will be covered. Generally, precertification applies to drugs that: Are often taken in the wrong way Should only be used for certain conditions Often cost more than other drugs that are proven to be just as effective Keep in mind that your doctor must contact us to request approval of coverage for these drugs. What is step therapy? Some drugs require step therapy. This means that you must try one or more prerequisite drug(s) before a step therapy drug is covered. The prerequisite drugs are equally effective, have U.S. Food and Drug Administration (FDA) approval and may cost less. They treat the same condition as the step therapy drug. If you don t try the appropriate alternative drug first, you may need to pay full cost for the brand-name version. What are quantity limits? Quantity limits help your doctor and pharmacist make sure that you use your drug correctly and safely. We use medical guidelines and FDA-approved recommendations from drug makers to set these coverage limits. The quantity limit program includes: Dose efficiency edits Limits prescription coverage to one dose per day for drugs that have approval for once-daily dosing Maximum daily dose If a prescription is lower than the minimum or higher than the maximum allowed dose, a message is sent to the pharmacy Quantity limits over time Limits prescription coverage to a specific number of units over a specific amount of time What if I need a drug that requires an exception to the precertification, step therapy or quantity limits requirements? Or what if I need a drug that s not covered under my plan? In certain cases, you or your prescriber can request a medical exception to the precertification, step therapy or quantity limits requirements. And also for a drug that s not covered in your plan. If you ask for your request to be expedited, a coverage determination will be made within 24 hours of receiving it. We ll then contact you or your prescriber with our decision. All medically necessary outpatient prescription drugs will be covered. If a medical exception is approved, you only need to pay the copay after the deductible. This amount is based on your pharmacy plan design. 4

5 How can your provider request a medical exception? Submit their request through our secure provider website on NaviNet. Call the Aetna Pharmacy Precertification Unit at Fax the completed request form to Mail the completed request form to: Aetna Pharmacy Management 1300 East Campbell Road Richardson, TX How is the formulary (drug list) developed? Our Pharmacy and Therapeutics Committee meets regularly to review new drugs and new information about current drugs. We review them for their safety, effectiveness and current use in therapy. Can the formulary change during the year? The formulary can change throughout the year. Some reasons why they can change include: New drugs are approved. Existing drugs are removed from the market. Prescription drugs may become available over the counter (without a prescription). Over-the-counter drugs are not generally covered in a formulary. Brand-name drugs lose patent protection and generic versions become available. When this happens, the brand-name drug is likely to be covered at a higher cost. And the generic versions cost less. See the What are generic drugs? section above for more information. This committee includes licensed pharmacists and doctors. They are currently in practice or are Aetna employees. Once we complete our clinical review, we also consider overall value before adding or removing a drug from the formulary. We may recommend moving a drug to a different coverage level. Or that it be placed on our Formulary Exclusions List and no longer be covered. 5

6 Commercial 1557 Nondiscrimination Notice Aetna complies with applicable Federal civil rights laws and does not discriminate, exclude or treat people differently based on their race, color, national origin, sex, age, or disability. Aetna provides free aids/services to people with disabilities and to people who need language assistance. If you need a qualified interpreter, written information in other formats, translation or other services, call the number on your ID card. If you believe we have failed to provide these services or otherwise discriminated based on a protected class noted above, you can also file a grievance with the Civil Rights Coordinator by contacting: Civil Rights Coordinator, P.O. Box 14462, Lexington, KY (CA HMO customers: PO Box Fresno, CA 93779), , TTY: 711, Fax: (CA HMO customers: ), CRCoordinator@aetna.com. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights Complaint Portal, available at or at: U.S. Department of Health and Human Services, 200 Independence Avenue SW., Room 509F, HHH Building, Washington, DC 20201, or at , (TDD). Aetna is the brand name used for products and services provided by one or more of the Aetna group of subsidiary companies, including Aetna Life Insurance Company, Coventry Health Care plans and their affiliates (Aetna). 6

7 TTY: 711 To access language services at no cost to you, call the number on your ID card. Para acceder a los servicios de idiomas sin costo, llame al número que figura en su tarjeta de identificación. (Spanish) 如欲使用免費語言服務, 請致電您 ID 卡上的電話號碼 (Chinese) Afin d'accéder aux services langagiers sans frais, veuillez composer le numéro inscrit sur votre carte d'identité. (French) Para ma-access ang mga serbisyo sa wika nang wala kayong babayaran, tawagan ang numero sa inyong ID card. (Tagalog) (Navajo) Um auf für Sie kostenlose Sprachdienstleistungen zuzugreifen, rufen Sie die Nummer auf Ihrer ID-Karte an. (German) Për shërbime përkthimi falas për ju, telefononi në numrin që gjendet në kartën tuaj të identitetit. (Albanian) የቋንቋ አገልግሎቶችን ያለክፍያ ለማግኘት በመታወቂያዎት ላይ ያለውን ቁጥር ይደውሉ (Amharic) للحصول على الخدمات اللغوية دون أي تكلفة الرجاء االتصال على الرقم الموجود على بطاقتك الشخصية. Arabic( ) Անվճար լեզվական ծառայություններից օգտվելու համար զանգահարեք ձեր ինքնության (ID) քարտի վրա նշված հեռախոսահամարով: (Armenian) Kugira uronke serivisi z indimi atakiguzi, Hamagara inumero iri kuri karangamuntu kawe. (Bantu) আপন ক ব ন ম কয ভ ষ পব কষ পপক হকয আপন পব চয পক প ওয নম ক প বযক ন র ন (Bengali) Ngadto maakses ang mga serbisyo sa pinulongan alang libre, tawagan sa numero sa nimong ID card. (Bisayan-Visayan) သင အ န ဖင အခ ၾက င မ ပ ရပ ဘ သ စက ၀န ဆ င မ မ ရရ ငရန သင ID ကတ ပၚတ င ရ သ ဖ န န ပတအ ခၚဆ ပ (Burmese) Per accedir a serveis lingüístics sense cap cost per vostè, telefoni al número indicat a la seva targeta d identificació. (Catalan) Para un hago' i setbision lengguåhi ni dibåtde para hågu, ågang i numiru gi iyo-mu kard aidentifikasion. (Chamorro) 7

8 ᏩᎩᏍᏗ ᎦᏬᏂᎯᏍᏗ ᎢᏅᎾᏓᏛᏁᏗ Ꮭ ᎪᎱᏍᏗ ᏗᏣᎬᏩᎳᏁᏗ ᏱᎩ, ᏫᎨᎯᏏᎳᏛᏏ ᎾᏍᎩ ᏗᏎᏍᏗ ᏥᏕᎪᏪᎵ ᎤᎾᎢ ID ᏆᏂᏲᏍᏗ ᏣᏤᎵᎢ. (Cherokee) Anumpa tohsholi I toksvli ya peh pilla ho ish I paya hinla kvt chi holisso iskitini holhtena takanli ma I paya. (Choctaw) Tajaajiiloota afaanii gatii bilisaa ati argaachuuf,lakkoofsa duugda waraaqaa eenyummaa (ID) kee irraa jiruun bilbili. (Cushite-Oromo) Voor gratis toegang tot taaldiensten, bel het nummer op uw ID-kaart. (Dutch) Pou jwenn sèvis lang gratis, rele nimewo telefòn ki sou kat idantite ou a. (French Creole-Haitian) Για να επικοινωνήσετε χωρίς χρέωση με το κέντρο υποστήριξης πελατών στη γλώσσα σας, τηλεφωνήστε στον αριθμό που αναγράφεται στην κάρτα σας προνομίων μέλους. (Greek) તમ ર ક ઇ જ તન ખર ચ વ ન ભ ષ ન સ ઓન પહ ર મ ટ, તમ ર આઇડ ક ડચ ઉપરન ન બરન ક લ કર. (Gujarati) No ka walaʻau ʻana me ka lawelawe ʻōlelo e kahea aku i ka helu kelepona ma kāu kāleka ID. Kāki ʻole ʻia kēia kōkua nei. (Hawaiian) आपक ल ए ब न ककस क मत क भ ष सव ओ क उपय ग करन क ल ए, अपन आईड क ड ड पर द य नम र पर क कर (Hindi) Xav tau kev pab txhais lus tsis muaj nqi them rau koj, hu tus naj npawb ntawm koj daim npav ID. (Hmong) Iji nwetaòhèrè na ọrụ gasị asụsụ n'efu, kpọọ nọmba no na kaadị ID gị. (Ibo) Tapno maaksesyo dagiti serbisio maipapan iti pagsasao nga awan ti bayadanyo, tawagan ti numero idiay ID cardyo. (Ilocano) Untuk mengakses layanan bahasa tanpa dikenakan biaya, hubungi nomor telepon di kartu identitas Anda. (Indonesian) Per accedere ai servizi linguistici, senza alcun costo per lei, chiami il numero sulla tessera identificativa. (Italian) 言語サービスを無料でご利用いただくには ID カードに記載の番号にお電話ください (Japanese) v>w>furreh>fusd.ftw>frrp>rtw>fzh;w>frrwz.fv>wtd.f'd;tyshrv>eub.f[h.ftdrb.feh.f ud;b.fvdwjpded>f*h>fv>td.fv>ew>f*drcd.f (ID) tc;vdreh.fwuh>ff (Karen) 무료언어서비스를이용하려면보험 ID 카드에수록된번호로전화해주십시오. (Korean) 8

9 ड ន M dyi wuɖu-dù kà kò ɖò ɓě dyi mɔúń nì pídyi ní, nìí, ɖá nɔ ɓà nìà nì ID káàɔ kɔ ɛ. (Kru-Bassa) بۆ دەسپێڕاگەيشتن بە خزمەتگوزاری زمان بەبێ تێچوون بۆ تۆ پەيوەندی بکە بە ژمارەی سەر ئای دی) ID ( کارتی خۆت. )Kurdish( ເພອເຂາໃຊການບລການພາສາໂດຍບເສຍຄາຕກບທານ, ໃຫໂທຫາເບໂທທບອກໄວໃນບດປະຈາຕວຂອງທານ. (Laotian) क णत य ह शल क लशव य भ ष स व प प त करण य स ठ, तमच य ID क ड डवर क म क वर फ न कर. (Marathi) Nan etal nan jikin jiban ko ikijen kajin ilo an ejelok onen nan kwe, kirlok nomba eo ilo ID kaat eo am. (Marshallese) Pwehn alehdi sawas en lokaia kan ni sohte pweipwei, koahlih nempe nan amhw doaropwe en ID. (Micronesian-Pohnpeian) ដ ម ប ទទលប នដ វ កម ភ ស ដ ម លឥតគ តថ ល ម រ ប ដ កអ ក ន ម ដ ទរ ព ដ ក ន ទ ដលខដ ល នដ ដលប ណ ណ ល ខល ន រប ដ កអ ក (Mon-Khmer, Cambodian) नन शल क भ ष स व प प त गन आफ न पररचयपत म भएक नम रम टल फ न गनह स ड (Nepali) Të kɔɔr yïn wɛ ɛ r de thokic ke cïn wëu kɔr keek tënɔŋ yïn. Ke cɔl kɔc ye kɔc kuɔny në nɔmba de abac tɔ në ID kard du kɔü. (Nilotic-Dinka) For tilgang til kostnadsfri språktjenester, ring nummeret på ID-kortet ditt. (Norwegian) Um Schprooch Services zu griege mitaus Koscht, ruff die Nummer uff dei ID Kaart. (Pennsylvania Dutch) برای دسترسی بە خدمات زبان بە طور رايگان با شماره قيد شده روی کارت شناسايی خود تماس بگيريد. ( Persian-Farsi ) Aby uzyskać dostęp do bezpłatnych usług językowych proszę zadzwonić numer telefonu na Twojej Karcie Identykującej (Polish) Para acessar os serviços de idiomas sem custo para você, ligue para o número que consta na sua identidade. (Portuguese) ਤ ਹ ਡ ਲਈ ਬ ਨ ਬ ਸ ਮਤ ਵ ਲ ਆ ਭ ਸ਼ ਸ ਵ ਵ ਦ ਵਰਤ ਰਨ ਲਈ, ਆਪਣ ਆਈਡ ਰਡ ਤ ਬਦ ਤ ਨ ਰ ਤ ਫ਼ ਨ ਰ (Punjabi) Pentru a accesa gratuit serviciile de limbă, apelați numărul de pe cardul dvs. de identificare. (Romanian) Для того чтобы бесплатно получить помощь переводчика, позвоните по телефону, приведенному на вашей карточке участника плана. (Russian) 9

10 Mo le mauaina o auaunaga tau gagana e aunoa ma se totogi, vala au le numera I luga o lau pepa ID. (Samoan) Za besplatne prevodilačke usluge pozovite broj naveden na Vašoj identifikacionoj kartici. (Serbo- Croatian) Heeba a nasta jangirde djey wolde, apelou lamba djey do windi ha dereji Maada. (Sudanic-Fulfulde) Kupata huduma za lugha bila malipo kwako, piga nambari iliyo kwenye kadi yako ya kitambulisho. (Swahili) ܐܢ ܣܢܝܩܐ ܝܬܘܢ ܥܠ ܚܠܡܬܐ ܕܗܝܪܬܐ ܒܠܫܢܐ ܡܓܢܐܝܬ ܩܪܝܡܘܢ ܡܢܝܢܐ ܥܠ ܦܬܩܐ ܗܕܡܝܘܬܐ ܕܝܘܟܘܢ. Syriac-( )Assyrian మ ర భ ష స వలన ఉచ త గ అ ద క న ద క, మ ID క ర ప ఉనన న బర క క ల చ య డ (Telugu) หากท านตองการเขาถงการบรการทางดานภาษาโดยไม ม ค าใชจ าย โปรดโทรหมายเลขท แสดงอย บนบตรประจาตวของท าน (Thai) Kapau oku ke fiema u ta etōtōngi a e ngaahi sēvesi kotoa pē he ngaahi lea kotoa, telefoni ki he fika oku hā atu i ho o ID kaati. (Tongan) Ren omw kopwe angei aninisin eman chon awewei (ese kamo), kopwe kori ewe nampa mei mak won noum ena katen ID (Trukese) Sizin için ücretsiz dil hizmetlerine erişebilmek için, kartınızdaki numarayı arayın. (Turkish) Щоб отримати безкоштовний доступ до мовних послуг, задзвоніть за номером, вказаним на Вашій ідентифікайній картці. (Ukrainian) بالقیمت زبان سے متعلقہ خدمات حاصل کرنے کے لیے اپنے شناختی کارڈ پر درج نمبرپر بات کریں )Urdu( Nếu quý vị muốn sử dụng miễn phí các dịch vụ ngôn ngữ, hãy gọi tới số điện thoại ghi trên thẻ ID (Nhận dạng) của quý vị. (Vietnamese) צוטריט ש פר אך ב אדינונגען אין קיין פרייז צו איר, רופן די נומער אויף דיין שיין ק ארט. )Yiddish( Lati wọnú awọn isẹ èdè l ọfẹ fun ọ, pe nọmba ori káádi idánimọ rẹ. (Yoruba) 10

11 Remember to visit the website on your member ID card. Then sign in to your account for the most up-to-date information. Please note that if your prescription drug benefits plan changes, the information here may no longer apply. A copayment is a flat fee. Coinsurance is a percentage of the rate that Aetna negotiates with the plan sponsor for covered prescriptions except as required by law to be otherwise. Some drugs on the Preferred Drug List are subject to manufacturer rebates. Coinsurance is calculated before any rebates are subtracted. That means it may be possible for your cost of a preferred drug to be higher than your cost of a non-preferred drug. Not all health services are covered. See plan documents for a complete description of benefits, exclusions, limitations and conditions of coverage. Plan features and availability may vary by location and are subject to change. Aetna receives rebates from drug manufacturers that may be taken into account in determining Aetna s Pharmacy Drug (formulary) Guide. Rebates do not reduce the amount a member pays the pharmacy for covered prescriptions. Information is subject to change. The drugs on the Pharmacy Drug (formulary) Guide, Formulary Exclusions, Precertification, and Quantity Limit Lists are subject to change. The quantity limits and drug coverage review programs are not available in all service areas. In accordance with state law, commercial fully insured members in Louisiana and Texas (except Federal Employee Health Benefit Plan members) who are receiving coverage for medications that are added or removed from the Pharmacy Drug (formulary) Guide, Precertification, Quantity Limits or Step-Therapy Lists during the plan year will continue to have those medications covered at the same benefit level until their plan s renewal date. In Texas, precertification approval is known as pre-service utilization review. It is not verification as defined by Texas law. In accordance with state law, fully insured Commercial California health maintenance organization (HMO) members (except Federal Employee Health Benefit Plan members) who are receiving coverage for medications that are added to the Precertification or Step-Therapy Lists will continue to have those medications covered, for as long as the treating physician continues prescribing them, provided that the drug is appropriately prescribed and is considered safe and effective for treating the enrollee s medical condition. In accordance with state law, fully insured Commercial Connecticut preferred provider organization (PPO) members (except Federal Employee Health Benefit Plan members) who are receiving coverage for medications that are added to the Precertification or Step-Therapy Lists will continue to have those medications covered for as long as the treating physician prescribes them, provided the drug is medically necessary and more medically beneficial than other covered drugs. Nothing in this section shall preclude the prescribing provider from prescribing another drug covered by the plan that is medically appropriate for the enrollee, nor shall anything in this section be construed to prohibit generic drug substitutions. This material is for information only. It contains only a partial, general description of plan benefits or programs and does not constitute a contract. See plan documents for a complete description of benefits, exclusions, limitations and conditions of coverage. Plan features and availability may vary by location and are subject to change. Providers are independent contractors and are not agents of Aetna. Provider participation may change without notice. Aetna does not provide care or guarantee access to health services. Information is subject to change Aetna Inc A (1/18) aetna.com

12 2018 Aetna Pharmacy Drug Guide - Value Plan Table of Contents *ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS*...16 *AMINOGLYCOSIDES*...18 *ANALGESICS - ANTI-INFLAMMATORY* *ANALGESICS - NONNARCOTIC*...22 *ANALGESICS - OPIOID*...22 *ANDROGENS-ANABOLIC* *ANORECTAL AGENTS* *ANTHELMINTICS* *ANTIANGINAL AGENTS* *ANTIANXIETY AGENTS*...28 *ANTIARRHYTHMICS*...29 *ANTIASTHMATIC AND BROHODILATOR AGENTS*...30 *ANTICOAGULANTS* *ANTICONVULSANTS* *ANTIDEMENTIA AGENT COMBINATIONS*** *ANTIDEPRESSANTS* *ANTIDIABETICS*...38 *ANTIDIARRHEALS*...42 *ANTIDOTES AND SPECIFIC ANTAGONISTS*...42 *ANTIDOTES*...42 *ANTIEMETICS* *ANTIFUNGALS*...44 *ANTIHISTAMINES* *ANTIHYPERLIPIDEMICS* *ANTIHYPERTENSIVES*...47 *ANTI-INFECTIVE AGENTS - MISC.*...51 *ANTIMALARIALS* *ANTIMYASTHENIC AGENTS* *ANTIMYASTHENIC/CHOLINERGIC AGENTS* *ANTIMYCOBACTERIAL AGENTS* *ANTINEOPLASTIC - BCL-2 INHIBITORS***...53 *ANTINEOPLASTICS AND ADJUTIVE THERAPIES* *ANTIPARKINSON AGENTS* *ANTIPSYCHOTICS/ANTIMANIC AGENTS* *ANTIRETROVIRALS ADJUVANTS***...60 *ANTIVIRALS* *ASSORTED CLASSES* *ATOPIC DERMATITIS - MONOCLONAL ANTIBODIES***...65 *BETA BLOCKER & ANGIOTENSIN II REPTOR ANTAGONIST COMB*** *BETA BLOCKERS* *BILE ACID SYNTHESIS DISORDER AGENTS*** *BIOLOGICALS MISC* *CALCIUM CHANNEL BLOCKERS* *CARDIOTONICS* *CARDIOVASCULAR AGENTS - MISC.*...69 *PHALOSPORINS* *CIC AGENTS - GUANYLATE CYCLASE-C (GC-C) AGONISTS***

13 *CONTRAPTIVES* *CORTICOSTEROIDS* *COUGH/COLD/ALLERGY*...77 *CYCLIN-DEPENDENT KINASES (CDK) INHIBITORS*** *CYSTIC FIBROSIS AGENT - COMBINATIONS***...78 *DERMATOLOGICALS* *DIAGNOSTIC PRODUCTS* *DIGESTIVE AIDS* *DIRECT-ACTING P2Y12 INHIBITORS***...95 *DIURETICS*...95 *ENDOCRINE AND METABOLIC AGENTS - MISC.*...96 *ESTROGENS* *ESTROGEN-SELECTIVE ESTROGEN REPTOR MODULATOR COMB*** *FARNESOID X REPTOR (FXR) AGONISTS*** *FLUOROQUINOLONES* *GASTROINTESTINAL AGENTS - MISC.* *GENITOURINARY AGENTS - MISLLANEOUS* *GOUT AGENTS* *HEMATOLOGICAL AGENTS - MISC.* *HEMATOPOIETIC AGENTS* *HEMOSTATICS* *HEPATITIS C AGENT - COMBINATIONS*** *HEREDITARY OROTIC ACIDURIA TREATMENT - AGENTS** *HYPNOTICS* *HYPOPHOSPHATASIA (HPP) AGENTS*** *IBS AGENT - MU-OPIOID REPTOR AGONISTS*** *INSULIN-IRETIN MIMETIC COMBINATIONS*** *INTEGRIN REPTOR ANTAGONISTS*** *INTERLEUKIN ANTAGONISTS*** *INTERLEUKIN-5 ANTAGONISTS (IGG1 KAPPA)*** *INTERLEUKIN-5 ANTAGONISTS (IGG4 KAPPA)*** *ISOCITRATE DEHYDROGENASE-2 (IDH2) INHIBITORS*** *LAXATIVES* *LEPTIN ANALOGUES*** *LHRH/GNRH AGONIST ANALOG COMBINATIONS*** *LYMPHOCYTE FUTION-ASSOCIATED ANTIGEN-1 (LFA-1) ANTAG*** *LYSOSOMAL ACID LIPASE (LAL) DEFICIEY - AGENTS*** *MACROLIDES* *MEDICAL DEVIS* *MIGRAINE PRODUCTS* *MINERALS & ELECTROLYTES* *MOUTH/THROAT/DENTAL AGENTS* *MUCOPOLYSACCHARIDOSIS IV (MPS IV) - AGENTS*** *MULTIPLE VITAMINS W/ MINERALS & FLUORIDE-IRON-FOLIC ACID*** *MULTIVITAMINS* *MUSCULOSKELETAL THERAPY AGENTS* *NASAL AGENTS - SYSTEMIC AND TOPICAL* *NEPRILYSIN INHIB (ARNI)-ANGIOTENSIN II REPT ANTAG COMB*** *NEUROGENIC ORTHOSTATIC HYPOTENSION (NOH) - AGENTS*** *NEUROMUSCULAR AGENTS*

14 *OPHTHALMIC AGENTS* *OREXIN REPTOR ANTAGONISTS*** *OTIC AGENTS* *OXABOROLE-RELATED ANTIFUNGALS - TOPICAL*** *OXYTOCICS* *PASSIVE IMMUNIZING AGENTS - COMBINATIONS*** *PASSIVE IMMUNIZING AGENTS* *PCSK9 INHIBITORS*** *PEDIATRIC MULTIPLE VITAMINS W/FLUORIDE-IRON-ZI*** *PENICILLINS* *PHOSPHATIDYLINOSITOL 3-KINASE (PI3K) INHIBITORS*** *PHOSPHODIESTERASE 4 (PDE4) INHIBITORS - TOPICAL*** *PHOSPHODIESTERASE 4 (PDE4) INHIBITORS*** *POLY (ADP-RIBOSE) POLYMERASE (PARP) INHIBITORS** *POLY (ADP-RIBOSE) POLYMERASE (PARP) INHIBITORS*** *POTASSIUM REMOVING AGENTS*** *PROGESTINS* *PROTEASE-ACTIVATED REPTOR-1 (PAR-1) ANTAGONISTS*** *PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.* *PULMONARY FIBROSIS AGENTS - KINASE INHIBITORS*** *PULMONARY FIBROSIS AGENTS*** *PULMONARY HYPERTENSION - PROSTACYCLIN REPTOR AGONIST*** *RESPIRATORY AGENTS - MISC.* *SEROTONIN MODULATORS*** *SGLT2 INHIBITOR - DPP-4 INHIBITOR COMBINATIONS*** *SINUS NODE INHIBITORS** *SODIUM-GLUCOSE CO-TRANSPORTER 2 INHIBITOR-BIGUANIDE COMB*** *SULFONAMIDES* *TETRACYCLINES* *THYROID AGENTS* *TRYPTOPHAN HYDROXYLASE INHIBITORS*** *ULR DRUGS* *URINARY ANTI-INFECTIVES* *URINARY ANTISPASMODICS* *VAGINAL PRODUCTS* *VASOPRESSORS* *VITAMINS*

15 15

16 lowercase italics = Generic drugs UPPERCASE = Brand name drugs 2018 Aetna Pharmacy Drug Guide - Value Plan Drug Details # = Brand-name drug expected to become available generically in the near future. After the generic drug becomes available, the brandname drug may be covered at a higher non-preferred copay and/or added to the Formulary Exclusion List. The brand-name drug may also be subject to precertification and/or step-therapy. AL = Age Limit LGC = Lowest Generic Copay MA = Step Therapy does not apply to members residing in Massachusetts. N1 = Refer to member plan documents for erectile dysfuncition use/coverage PA = Prior Authorization = Quantity Limit Select OTC = Select OTC Program if your pharmacy plan Drug Status includes this program you may = Copay Exception: Available have coverage for products noted to some members at no cost with a with a doctors prescription. prescription from your provider Please see your plan benefit when obtained at an in-network information for specific coverage pharmacy. Certain limitations may details. apply. SP = You may pay higher out of = Not Covered pocket costs and may be required = Non-Preferred Brand and to get these products at an Aetna Generic Specialty Pharmacy network S = Non-Preferred Specialty provider, like Aetna Specialty = Preferred Brand Pharmacy. Specialty products are = Preferred Generic limited to a 30 day supply. PSP = Preferred Specialty ST = Step Therapy Drug Name Drug Status Drug Details *ADHD/ANTI-NARCOLEPSY/ANTI- OBESITY/ANOREXIANTS* ADDERALL ST; ADDERALL XR ST; ADZENYS XR-ODT PA; ST; 16

17 amphetamine-dextroamphet er amphetamine-dextroamphetamine APTENSIO XR PA; ST; armodafinil oral tablet 150 mg, 200 mg, 250 mg, 50 mg atomoxetine hcl oral capsule 10 mg, 100 mg, 18 mg, 25 mg, 40 mg, 60 mg, 80 mg PA; clonidine hcl er PA; COERTA ORAL TABLET EXTENDED RELEASE 18 MG, 27 MG, 36 MG, 54 MG ST; COTEMPLA XR-ODT PA; ST; DAYTRANA PA; ST; #; DESOXYN PA; ST; DEXEDRINE ORAL CAPSULE EXTENDED RELEASE 24 HOUR dexmethylphenidate hcl dexmethylphenidate hcl er dextroamphetamine sulfate er dextroamphetamine sulfate oral solution dextroamphetamine sulfate oral tablet DIDREX ST; DYANAVEL XR PA; ST; EVEKEO PA; ST; FOCALIN ST; FOCALIN XR ST; guanfacine hcl er PA; INTUNIV PA; ST; KAPVAY ORAL TABLET EXTENDED RELEASE 12 HOUR METADATE ER ORAL TABLET EXTENDED RELEASE 20 MG PA; ST; methamphetamine hcl PA; METHYLIN ORAL SOLUTION 10 MG/5ML, 5 MG/5ML methylphenidate hcl er (cd) methylphenidate hcl er (la) ST; 17

18 methylphenidate hcl er oral tablet extended release 10 mg, 18 mg, 20 mg, 27 mg, 36 mg, 54 mg methylphenidate hcl er oral tablet extended release 24 hour 18 mg, 27 mg, 36 mg, 54 mg methylphenidate hcl oral solution 10 mg/5ml methylphenidate hcl oral solution 5 mg/5ml methylphenidate hcl oral tablet methylphenidate hcl oral tablet chewable modafinil PA; MYDAYIS PA; ST; NUVIGIL ORAL TABLET 150 MG, 200 MG, 250 MG, 50 MG PA; #; PRONTRA ST; PROVIGIL PA; QUILLICHEW ER ORAL TABLET CHEWABLE EXTENDED RELEASE 20 MG, 30 MG, 40 MG PA; ST; QUILLIVANT XR PA; ST; RITALIN ST; RITALIN LA ORAL CAPSULE EXTENDED RELEASE 24 HOUR 10 MG, 20 MG, 30 MG, 40 MG STRATTERA ORAL CAPSULE 10 MG, 100 MG, 18 MG, 25 MG, 40 MG, 60 MG, 80 MG VYVANSE ZENZEDI ORAL TABLET 10 MG, 5 MG ZENZEDI ORAL TABLET 15 MG, 2.5 MG, 20 MG, 30 MG, 7.5 MG *AMINOGLYCOSIDES* ST; ST; #; BETHKIS S SP; gentamicin sulfate injection gentamicin sulfate intravenous neomycin sulfate oral paromomycin sulfate oral streptomycin sulfate intramuscular TOBI S SP; 18

19 TOBI PODHALER PSP SP; tobramycin inhalation PSP SP; tobramycin sulfate injection *ANALGESICS - ANTI-INFLAMMATORY* ACTEMRA INTRAVENOUS S PA; ST; SP ACTEMRA SUBCUTANEOUS S PA; ST; SP; ANAPROX DS ARAVA ARCALYST S PA; SP ARTHROTEC ORAL TABLET DELAYED RELEASE LEBREX ST; celecoxib oral DAYPRO diclofenac potassium diclofenac sodium er diclofenac sodium oral tablet delayed release 25 mg, 50 mg diclofenac sodium oral tablet delayed release 75 mg diclofenac-misoprostol oral tablet delayed release DUEXIS EC-NAPROSYN ENBREL SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 25 MG/0.5ML, 50 MG/ML ENBREL SURECLICK SUBCUTANEOUS SOLUTION AUTO-INJECTOR etodolac er etodolac oral FELDENE fenoprofen calcium oral flurbiprofen oral HUMIRA PEDIATRIC CROHNS START SUBCUTANEOUS PREFILLED SYRINGE KIT 40 MG/0.8ML PSP PSP S LGC PA; ST; SP; PA; ST; SP; PA; ST; SP; 19

20 HUMIRA PEN SUBCUTANEOUS PEN- INJECTOR KIT HUMIRA PEN-CROHNS STARTER SUBCUTANEOUS PEN-INJECTOR KIT HUMIRA PEN-PSORIASIS STARTER SUBCUTANEOUS PEN-INJECTOR KIT HUMIRA SUBCUTANEOUS PREFILLED SYRINGE KIT 10 MG/0.2ML, 20 MG/0.4ML, 40 MG/0.8ML IBUPROFEN COMFORT PAC S S S S ibuprofen oral tablet 400 mg, 600 mg, 800 mg LGC IC 400 IC 800 ILARIS S PA; SP ILARIS (150MG DELIVERED) S PA; SP INDOCIN ORAL INDOCIN RECTAL indomethacin er indomethacin oral ketoprofen er ketoprofen oral ketorolac tromethamine oral PA; ST; SP; PA; ST; SP; PA; ST; SP; PA; ST; SP; KEVZARA S PA; ST; SP; KINERET SUBCUTANEOUS SOLUTION PREFILLED SYRINGE S leflunomide oral meclofenamate sodium oral mefenamic acid oral MELOXICAM COMFORT PAC meloxicam oral tablet LGC MOBIC ORAL TABLET nabumetone oral NALFON ORAL CAPSULE 400 MG NAPRELAN ORAL TABLET EXTENDED RELEASE 24 HOUR 375 MG, 500 MG, 750 MG NAPROSYN ORAL SUSPENSION 20 PA; ST; SP;

21 NAPROSYN ORAL TABLET 250 MG, 500 MG NAPROXEN COMFORT PAC naproxen dr naproxen oral suspension naproxen oral tablet LGC naproxen sodium er naproxen sodium oral tablet 275 mg, 550 mg OREIA CLICKJECT S PA; ST; SP; OREIA INTRAVENOUS S PA; ST; SP OREIA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 125 MG/ML, 50 MG/0.4ML, 87.5 MG/0.7ML OTREXUP SUBCUTANEOUS SOLUTION AUTO-INJECTOR 10 MG/0.4ML, 15 MG/0.4ML, 17.5 MG/0.4ML, 20 MG/0.4ML, 22.5 MG/0.4ML, 25 MG/0.4ML OTREXUP SUBCUTANEOUS SOLUTION AUTO-INJECTOR 12.5 MG/0.4ML oxaprozin piroxicam oral PONSTEL RASUVO SUBCUTANEOUS SOLUTION AUTO-INJECTOR 10 MG/0.2ML, 12.5 MG/0.25ML, 15 MG/0.3ML, 17.5 MG/0.35ML, 20 MG/0.4ML, 22.5 MG/0.45ML, 25 MG/0.5ML, 30 MG/0.6ML, 7.5 MG/0.15ML RIDAURA S S S S PA; ST; SP; ST; SP ST ST; SP SIMPONI ARIA PSP PA; ST; SP; SIMPONI SUBCUTANEOUS SOLUTION AUTO-INJECTOR SIMPONI SUBCUTANEOUS SOLUTION PREFILLED SYRINGE PSP PSP SPRIX # sulindac oral TIVORBEX tolmetin sodium PA; ST; SP; PA; ST; SP; 21

22 VIMOVO VIVLODEX XELJANZ PSP PA; ST; SP; XELJANZ XR PSP PA; ST; SP; ZIPSOR ZORVOLEX *ANALGESICS - NONNARCOTIC* ALLZITAL butalbital-acetaminophen oral tablet mg butalbital-apap-caffeine oral capsule mg butalbital-apap-caffeine oral tablet mg butalbital-asa-caffeine choline-mag trisalicylate diflunisal oral eq aspirin low dose oral tablet chewable eq aspirin low dose oral tablet delayed release FIORINAL PRIALT S SP salsalate oral VANATOL LQ *ANALGESICS - OPIOID* ABSTRAL PA; ST; #; acetaminophen-codeine PA; acetaminophen-codeine #2 PA; acetaminophen-codeine #3 PA; acetaminophen-codeine #4 PA; ACTIQ PA; ST; apap-caff-dihydrocodeine oral capsule PA; apap-caff-dihydrocodeine oral tablet mg PA; ARYMO ER PA; ST; ASCOMP-CODEINE PA; aspirin-caff-dihydrocodeine PA; BELBUCA PA; 22

23 BUNAVAIL BUCCAL FILM MG, MG, MG ST; MA; buprenorphine PA; buprenorphine hcl sublingual buprenorphine hcl-naloxone hcl butalbital-apap-caff-cod PA; butalbital-asa-caff-codeine PA; butorphanol tartrate nasal PA; BUTRANS PA; #; codeine sulfate oral tablet PA; CONZIP DEMEROL ORAL PA; DILAUDID ORAL PA; DOLOPHINE PA; DURAGESIC-100 PA; ST; DURAGESIC-12 PA; ST; DURAGESIC-25 PA; ST; DURAGESIC-50 PA; ST; DURAGESIC-75 PA; ST; EMBEDA PA; ENDOT ORAL TABLET MG, MG, MG, MG PA; EXALGO PA; ST; fentanyl PA; fentanyl citrate buccal PA; ST; FENTORA BUCCAL TABLET 100 MCG, 200 MCG, 400 MCG, 600 MCG, 800 MCG FIORIT/CODEINE ORAL CAPSULE MG PA; ST; #; PA; FIORINAL/CODEINE #3 PA; HYT PA; hydrocodone-acetaminophen oral solution mg/5ml, mg/10ml, mg/15ml hydrocodone-acetaminophen oral tablet mg, mg, mg, mg, mg, mg, mg PA; PA; 23

24 hydrocodone-ibuprofen oral tablet mg, mg, mg PA; hydromorphone hcl er PA; hydromorphone hcl oral PA; hydromorphone hcl rectal PA; HYSINGLA ER PA; #; IBUDONE ORAL TABLET MG PA; ibudone oral tablet mg PA; KADIAN PA; ST; LAZANDA NASAL SOLUTION 100 MCG/ACT, 300 MCG/ACT, 400 MCG/ACT PA; ST; levorphanol tartrate oral PA; LORT PA; LORT HD PA; LORT PLUS ORAL TABLET MG PA; LORTAB ORAL ELIXIR MG/15ML PA; meperidine hcl oral PA; meperidine-promethazine METHADONE HCL INTENSOL PA; methadone hcl oral concentrate PA; methadone hcl oral solution PA; methadone hcl oral tablet PA; methadone hcl oral tablet soluble PA; METHADOSE ORAL COENTRATE 10 MG/ML PA; METHADOSE SUGAR-FREE PA; MORPHABOND ER PA; ST; morphine sulfate (concentrate) oral solution 100 mg/5ml PA; morphine sulfate er beads PA; morphine sulfate er oral capsule extended release 24 hour PA; morphine sulfate er oral tablet extended release PA; morphine sulfate oral PA; morphine sulfate rectal PA; 24

25 MS CONTIN ORAL TABLET EXTENDED RELEASE nalbuphine hcl injection PA; ST; NORCO PA; NUCYNTA PA; ST; NUCYNTA ER PA; ST; OPANA ER ORAL TABLET ER 12 HOUR ABUSE-DETERRENT PA; ST; OPANA ORAL PA; OXAYDO PA; oxycodone hcl er oral tablet er 12 hour abusedeterrent PA; oxycodone hcl oral capsule PA; oxycodone hcl oral concentrate 100 mg/5ml PA; oxycodone hcl oral solution PA; oxycodone hcl oral tablet PA; oxycodone-acetaminophen oral solution PA; oxycodone-acetaminophen oral tablet mg, mg, mg, mg PA; oxycodone-aspirin oral tablet mg PA; oxycodone-ibuprofen PA; OXYCONTIN ORAL TABLET ER 12 HOUR ABUSE-DETERRENT PA; oxymorphone hcl PA; oxymorphone hcl er PA; pentazocine-naloxone hcl PA; PERCOT ORAL TABLET MG, MG, MG, MG PA; PRIMLEV PA; ROXICODONE ORAL TABLET PA; SUBOXONE SUBLINGUAL FILM #; SUBSYS PA; ST; SYNALGOS-DC PA; tramadol hcl er (biphasic) PA; tramadol hcl er oral capsule extended release 24 hour 25

26 tramadol hcl er oral tablet extended release 24 hour PA; tramadol hcl oral PA; tramadol-acetaminophen PA; TREZIX ORAL CAPSULE MG PA; TYLENOL WITH CODEINE #3 PA; TYLENOL WITH CODEINE #4 PA; ULTRAT PA; ULTRAM PA; ULTRAM ER ORAL TABLET EXTENDED RELEASE 24 HOUR 300 MG PA; VERDROT PA; vicodin es oral tablet mg PA; vicodin hp oral tablet mg PA; vicodin oral tablet mg PA; XODOL PA; XTAMPZA ER PA; ST; XYLON ZAMIT PA; ZOHYDRO ER ORAL CAPSULE ER 12 HOUR ABUSE-DETERRENT ZUBSOLV SUBLINGUAL TABLET SUBLINGUAL MG, MG, MG, MG, MG, MG *ANDROGENS-ANABOLIC* ANADROL-50 ANDRODERM TRANSDERMAL PATCH 24 HOUR ANDROGEL PUMP TRANSDERMAL GEL MG/ACT (1.62%) ANDROGEL TRANSDERMAL GEL MG/1.25GM (1.62%), 40.5 MG/2.5GM (1.62%) ANDROGEL TRANSDERMAL GEL 25 MG/2.5GM (1%), 50 MG/5GM (1%) ANDROID AXIRON # 26 PA; ST; ST; MA; PA; #; PA; #;

27 danazol oral DEPO-TESTOSTERONE INTRAMUSCULAR SOLUTION FIRST-TESTOSTERONE FIRST-TESTOSTERONE MC FORTESTA methyltestosterone oral NATESTO OXANDRIN STRIANT TESTIM testosterone cypionate intramuscular solution 200 mg/ml testosterone enanthate intramuscular solution testosterone transdermal gel 10 mg/act (2%) testosterone transdermal gel 12.5 mg/act (1%), 25 mg/2.5gm (1%), 50 mg/5gm (1%) PA; testosterone transdermal solution PA; VOGELXO PUMP VOGELXO TRANSDERMAL GEL 50 MG/5GM (1%) *ANORECTAL AGENTS* ANA-LEX ANALPRAM-HC RECTAL CREAM anucort-hc ANUSOL-HC RECTAL CREAM ANUSOL-HC RECTAL SUPPOSITORY CORTIFOAM hydrocortisone ace-pramoxine rectal cream % hydrocortisone acetate rectal hydrocortisone rectal cream 2.5 % lidocaine-hydrocortisone ace rectal PROCTOCORT PROCTOFOAM HC PROCTOZONE-HC RECTAL 27

28 RECTIV URIS RECTAL PA; #; *ANTHELMINTICS* ALBENZA BILTRICIDE EMVERM ivermectin oral STROMECTOL *ANTIANGINAL AGENTS* DILATRATE-SR GONITRO ISORDIL TITRADOSE isosorbide dinitrate er isosorbide dinitrate oral isosorbide mononitrate isosorbide mononitrate er MINITRAN NITRO-BID NITRO-DUR nitroglycerin er oral capsule extended release 9 mg nitroglycerin sublingual nitroglycerin transdermal patch 24 hour nitroglycerin translingual aerosol solution nitroglycerin translingual solution NITROLINGUAL NITROMIST NITROSTAT ST NITRO-TIME ORAL CAPSULE EXTENDED RELEASE 9 MG RANEXA *ANTIANXIETY AGENTS* alprazolam er ; AL ALPRAZOLAM INTENSOL alprazolam oral AL 28

29 alprazolam xr ; AL ATIVAN ORAL # buspirone hcl oral tablet 10 mg, 5 mg LGC buspirone hcl oral tablet 15 mg, 30 mg, 7.5 mg chlordiazepoxide hcl AL clorazepate dipotassium AL diazepam oral hydroxyzine hcl oral syrup hydroxyzine hcl oral tablet hydroxyzine pamoate oral capsule 25 mg, 50 mg lorazepam oral meprobamate oxazepam AL TRANXENE-T ORAL TABLET 7.5 MG AL VALIUM VISTARIL XANAX AL XANAX XR AL *ANTIARRHYTHMICS* amiodarone hcl oral disopyramide phosphate oral dofetilide flecainide acetate mexiletine hcl oral MULTAQ NORPA NORPA CR propafenone hcl propafenone hcl er SP; quinidine gluconate er quinidine sulfate oral RYTHMOL SR TIKOSYN # 29

30 *ANTIASTHMATIC AND BROHODILATOR AGENTS* ACCOLATE ADVAIR DISKUS #; ADVAIR HFA #; AEROSPAN PA; ST; AIRDUO RESPICLICK 113/14 PA; ST; AIRDUO RESPICLICK 232/14 PA; ST; AIRDUO RESPICLICK 55/14 PA; ST; albuterol sulfate er albuterol sulfate inhalation albuterol sulfate oral ALVESCO PA; ST; ANORO ELLIPTA ARCAPTA NEOHALER PA; ST; ARMONAIR RESPICLICK 113 PA; ST; ARMONAIR RESPICLICK 232 PA; ST; ARMONAIR RESPICLICK 55 PA; ST; ARNUITY ELLIPTA ASMANEX 120 METERED DOSES #; ASMANEX 14 METERED DOSES #; ASMANEX 30 METERED DOSES #; ASMANEX 60 METERED DOSES #; ASMANEX 7 METERED DOSES #; ASMANEX HFA ATROVENT HFA BEVESPI AEROSPHERE PA; ST; BREO ELLIPTA BROVANA PA; ST; budesonide inhalation PA; ; AL COMBIVENT RESPIMAT cromolyn sodium inhalation DALIRESP PA; ST; DULERA ELIXOPHYLLIN 30

31 FLOVENT DISKUS #; FLOVENT HFA fluticasone-salmeterol IRUSE ELLIPTA ipratropium bromide inhalation ipratropium-albuterol levalbuterol hcl inhalation nebulization solution 0.31 mg/3ml, 0.63 mg/3ml, 1.25 mg/0.5ml, 1.25 mg/3ml metaproterenol sulfate oral montelukast sodium oral PERFOROMIST PA; ST; PROAIR HFA # PROAIR RESPICLICK PROVENTIL HFA ST; # PULMICORT PA; ; AL PULMICORT FLEXHALER PA; ST; QVAR INHALATION AEROSOL SOLUTION SEEBRI NEOHALER PA; ST; SEREVENT DISKUS SINGULAIR SPIRIVA HANDIHALER SPIRIVA RESPIMAT STIOLTO RESPIMAT STRIVERDI RESPIMAT PA; ST; SYMBICORT THEO-24 THEOCHRON ORAL TABLET EXTENDED RELEASE 12 HOUR 100 MG, 200 MG, 300 MG theophylline theophylline er TUDORZA PRESSAIR INHALATION AEROSOL POWDER BREATH ACTIVATED ST; UTIBRON NEOHALER PA; ST; 31

32 VENTOLIN HFA VOSPIRE ER XOLAIR PSP PA; ST; SP XOPENEX XOPENEX COENTRATE XOPENEX HFA ST; zafirlukast zileuton er ZYFLO ZYFLO CR *ANTICOAGULANTS* ARIXTRA COUMADIN ORAL ELIQUIS enoxaparin sodium fondaparinux sodium FRAGMIN SUBCUTANEOUS SOLUTION UNIT/ML, UNIT/0.5ML, UNIT/0.6ML, UNT/0.72ML, 2500 UNIT/0.2ML, 5000 UNIT/0.2ML, 7500 UNIT/0.3ML, UNIT/3.8ML heparin sodium (porcine) injection solution 1000 unit/ml, unit/ml, unit/ml, 5000 unit/ml heparin sodium (porcine) pf IPRIVASK JANTOVEN LOVENOX PRADAXA ST SAVAYSA ST warfarin sodium oral LGC XARELTO XARELTO STARTER PACK *ANTICONVULSANTS* APTIOM ORAL TABLET 200 MG, 400 MG, 600 MG, 800 MG PA; BANZEL ORAL TABLET PA; 32

33 BRIVIACT ORAL SOLUTION PA; BRIVIACT ORAL TABLET PA; carbamazepine er oral capsule extended release 12 hour 100 mg, 200 mg carbamazepine er oral tablet extended release 12 hour carbamazepine oral CARBATROL LONTIN clonazepam oral DEPAKENE ORAL CAPSULE DEPAKOTE DEPAKOTE ER DIASTAT ACUDIAL DIASTAT PEDIATRIC diazepam rectal DILANTIN DILANTIN INFATABS divalproex sodium er oral tablet extended release 24 hour divalproex sodium oral tablet delayed release EPITOL ethosuximide oral felbamate FELBATOL FYCOMPA ORAL SUSPENSION FYCOMPA ORAL TABLET PA; gabapentin oral capsule gabapentin oral solution 250 mg/5ml gabapentin oral tablet GABITRIL ORAL TABLET 12 MG, 16 MG, 2 MG, 4 MG KEPPRA ORAL KEPPRA XR ORAL TABLET EXTENDED RELEASE 24 HOUR 500 MG, 750 MG KLONOPIN 33

34 LAMICTAL ODT ORAL KIT LAMICTAL ODT ORAL TABLET DISPERSIBLE 100 MG, 200 MG, 25 MG, 50 MG LAMICTAL ORAL TABLET LAMICTAL ORAL TABLET CHEWABLE 25 MG, 5 MG LAMICTAL STARTER LAMICTAL XR ORAL KIT ST LAMICTAL XR ORAL TABLET EXTENDED RELEASE 24 HOUR 100 MG, 200 MG, 25 MG, 250 MG, 300 MG, 50 MG lamotrigine er oral tablet extended release 24 hour 100 mg, 200 mg, 25 mg, 250 mg, 300 mg, 50 mg lamotrigine oral tablet lamotrigine oral tablet chewable lamotrigine oral tablet dispersible 100 mg, 200 mg, 25 mg, 50 mg levetiracetam er oral tablet extended release 24 hour 500 mg, 750 mg levetiracetam oral LYRICA MYSOLINE NEURONTIN ORAL CAPSULE NEURONTIN ORAL SOLUTION NEURONTIN ORAL TABLET PA; ST; PA; ST; PA; ST; PA; ST; ONFI ORAL SUSPENSION PA; # ONFI ORAL TABLET 10 MG, 20 MG PA; #; oxcarbazepine OXTELLAR XR ORAL TABLET EXTENDED RELEASE 24 HOUR 150 MG, 300 MG, 600 MG PEGANONE PHENYTEK PHENYTOIN INFATABS phenytoin oral suspension 125 mg/5ml phenytoin oral tablet chewable 34 ST;

35 phenytoin sodium extended primidone oral QUDEXY XR ORAL CAPSULE ER 24 HOUR SPRINKLE 100 MG, 150 MG, 200 MG, 25 MG, 50 MG ST; SABRIL S PA; #; SP; SPRITAM ST; TEGRETOL ORAL SUSPENSION TEGRETOL ORAL TABLET TEGRETOL-XR ORAL TABLET EXTENDED RELEASE 12 HOUR 100 MG TEGRETOL-XR ORAL TABLET EXTENDED RELEASE 12 HOUR 200 MG, 400 MG # tiagabine hcl oral tablet 2 mg, 4 mg TOPAMAX TOPAMAX SPRINKLE topiramate oral capsule sprinkle topiramate oral tablet TRILEPTAL TROKENDI XR ORAL CAPSULE EXTENDED RELEASE 24 HOUR 100 MG, 200 MG, 25 MG, 50 MG valproic acid oral capsule valproic acid oral solution ST; #; VIMPAT ORAL SOLUTION #; VIMPAT ORAL TABLET #; ZARONTIN ZONEGRAN zonisamide oral *ANTIDEMENTIA AGENT COMBINATIONS*** NAMZARIC ORAL CAPSULE ER 24 HOUR THERAPY PACK NAMZARIC ORAL CAPSULE EXTENDED RELEASE 24 HOUR MG, MG, MG, 7-10 MG PA; AL PA; AL 35

36 *ANTIDEPRESSANTS* amitriptyline hcl oral tablet 10 mg, 100 mg, 25 mg, 50 mg, 75 mg amitriptyline hcl oral tablet 150 mg amoxapine ANAFRANIL APLENZIN bupropion hcl er (sr) bupropion hcl er (xl) bupropion hcl oral LEXA ORAL TABLET citalopram hydrobromide oral solution LGC citalopram hydrobromide oral tablet LGC; clomipramine hcl oral CYMBALTA ORAL CAPSULE DELAYED RELEASE PARTICLES 20 MG, 30 MG, 60 MG desipramine hcl oral desvenlafaxine er PA; desvenlafaxine succinate er PA; ST; doxepin hcl oral duloxetine hcl oral capsule delayed release particles 20 mg, 30 mg, 40 mg, 60 mg EFFEXOR XR EMSAM #; escitalopram oxalate oral solution escitalopram oxalate oral tablet 10 mg, 20 mg, 5 mg FETZIMA PA; ST; FETZIMA TITRATION PA; ST; fluoxetine hcl oral capsule 10 mg, 20 mg, 40 mg LGC; fluoxetine hcl oral capsule delayed release fluoxetine hcl oral tablet 10 mg, 20 mg fluoxetine hcl oral tablet 60 mg fluvoxamine maleate er 36

37 fluvoxamine maleate oral tablet 100 mg, 25 mg, 50 mg FORFIVO XL # imipramine hcl oral imipramine pamoate KHEDEZLA PA; ST; LEXAPRO ORAL TABLET 10 MG, 20 MG, 5 MG maprotiline hcl oral tablet 25 mg, 50 mg, 75 mg mirtazapine oral NARDIL nefazodone hcl NORPRAMIN ORAL TABLET 10 MG, 25 MG nortriptyline hcl oral capsule 10 mg, 25 mg LGC nortriptyline hcl oral capsule 50 mg, 75 mg PAMELOR ORAL CAPSULE PARNATE paroxetine hcl er paroxetine hcl oral tablet 10 mg, 20 mg, 30 mg, 40 mg PAXIL CR PAXIL ORAL SUSPENSION PAXIL ORAL TABLET 10 MG, 20 MG, 30 MG, 40 MG PEXEVA LGC; PRISTIQ PA; ST; #; protriptyline hcl PROZAC ORAL CAPSULE 10 MG, 20 MG, 40 MG REMERON REMERON SOLTAB sertraline hcl oral concentrate sertraline hcl oral tablet 100 mg, 25 mg, 50 mg LGC; SURMONTIL TOFRANIL 37

38 tranylcypromine sulfate trazodone hcl oral tablet 100 mg, 150 mg, 50 mg LGC trazodone hcl oral tablet 300 mg TRINTELLIX PA; ST; venlafaxine hcl er oral capsule extended release 24 hour 150 mg, 37.5 mg, 75 mg venlafaxine hcl er oral tablet extended release 24 hour 150 mg, 225 mg, 37.5 mg, 75 mg venlafaxine hcl oral tablet 100 mg, 25 mg, 37.5 mg, 50 mg, 75 mg VIIBRYD ORAL TABLET PA; ST; VIIBRYD STARTER PACK PA; ST WELLBUTRIN SR WELLBUTRIN XL # ZOLOFT ORAL COENTRATE ZOLOFT ORAL TABLET 100 MG, 25 MG, 50 MG *ANTIDIABETICS* acarbose ACTOPLUS MET ACTOPLUS MET XR ORAL TABLET EXTENDED RELEASE 24 HOUR MG, MG ACTOS ADLYXIN ADLYXIN STARTER PACK AFREZZA INHALATION POWDER 12 UNIT, 4 & 8 & 12 UNIT, 4 (30) & 8 (60) UNIT, 4 (60) & 8 (30) UNIT, 4 (90) & 8 (90) UNIT, 4 UNIT, 8 (60)& 12 (30) UNIT, 8 UNIT alogliptin benzoate alogliptin-metformin hcl alogliptin-pioglitazone AMARYL APIDRA APIDRA SOLOSTAR SUBCUTANEOUS SOLUTION PEN-INJECTOR 38 PA

39 AVANDIA ORAL TABLET 2 MG, 4 MG BASAGLAR KWIKPEN BYDUREON SUBCUTANEOUS PEN- INJECTOR BYDUREON SUBCUTANEOUS SUSPENSION RECONSTITUTED ER BYETTA 10 MCG PEN SUBCUTANEOUS SOLUTION PEN-INJECTOR BYETTA 5 MCG PEN SUBCUTANEOUS SOLUTION PEN-INJECTOR chlorpropamide # # CYCLOSET DUETACT FARXIGA FORTAMET # glimepiride LGC glipizide er oral tablet extended release 24 hour 10 mg, 5 mg glipizide er oral tablet extended release 24 hour 2.5 mg LGC glipizide oral LGC glipizide xl glipizide-metformin hcl GLUCAGEN HYPOKIT GLUCAGON EMERGEY GLUCOPHAGE GLUCOPHAGE XR GLUCOTROL GLUCOTROL XL GLUCOVAE ORAL TABLET MG, MG GLUMETZA glyburide micronized oral tablet 1.5 mg glyburide micronized oral tablet 3 mg, 6 mg LGC glyburide oral tablet 1.25 mg glyburide oral tablet 2.5 mg, 5 mg LGC glyburide-metformin 39

40 GLYNASE GLYSET HUMALOG HUMALOG KWIKPEN SUBCUTANEOUS SOLUTION PEN-INJECTOR 100 UNIT/ML, 200 UNIT/ML HUMALOG MIX 50/50 HUMALOG MIX 50/50 KWIKPEN SUBCUTANEOUS SUSPENSION PEN- INJECTOR HUMALOG MIX 75/25 HUMALOG MIX 75/25 KWIKPEN SUBCUTANEOUS SUSPENSION PEN- INJECTOR HUMULIN 70/30 HUMULIN 70/30 KWIKPEN SUBCUTANEOUS SUSPENSION PEN- INJECTOR HUMULIN N HUMULIN N KWIKPEN SUBCUTANEOUS SUSPENSION PEN- INJECTOR HUMULIN R HUMULIN R U-500 (COENTRATED) HUMULIN R U-500 KWIKPEN SUBCUTANEOUS SOLUTION PEN- INJECTOR INVOKANA JANUMET JANUMET XR ORAL TABLET EXTENDED RELEASE 24 HOUR MG, MG, MG JANUVIA JARDIAE JENTADUETO JENTADUETO XR ORAL TABLET EXTENDED RELEASE 24 HOUR MG, MG KAZANO 40

41 KOMBIGLYZE XR KORLYM S PA; SP; LANTUS LANTUS SOLOSTAR SUBCUTANEOUS SOLUTION PEN-INJECTOR LEVEMIR LEVEMIR FLEXTOUCH metformin hcl er (mod) # metformin hcl er (osm) oral tablet extended release 24 hour 1000 mg, 500 mg metformin hcl er oral tablet extended release 24 hour 500 mg metformin hcl er oral tablet extended release 24 hour 750 mg # LGC metformin hcl oral LGC miglitol nateglinide NESINA NOVOLIN 70/30 NOVOLIN 70/30 RELION NOVOLIN N NOVOLIN N RELION NOVOLIN R NOVOLIN R RELION NOVOLOG NOVOLOG FLEXPEN SUBCUTANEOUS SOLUTION PEN-INJECTOR NOVOLOG MIX 70/30 NOVOLOG MIX 70/30 FLEXPEN SUBCUTANEOUS SUSPENSION PEN- INJECTOR NOVOLOG PENFILL SUBCUTANEOUS SOLUTION CARTRIDGE ONGLYZA OSENI pioglitazone hcl pioglitazone hcl-glimepiride 41