Four-Tier Blue Selections Rx Member Guide

Transcription

1 Four-Tier Blue Selections Rx Member Guide HR1216 R08/17 Blue Cross and Blue Shield of Louisiana is incorporated as Louisiana Health Service & Indemnity Company. HMO Louisiana, Inc. is a subsidiary of Blue Cross and Blue Shield of Louisiana. Both companies are independent licensees of the Blue Cross and Blue Shield Association.

2 Your Guide to Your Prescription Drug Program Blue Cross and Blue Shield of Louisiana and our subsidiary, HMO Louisiana, Inc., along with Express Scripts, an independent company that serves as our pharmacy benefit manager, created this Blue Selections Rx Member Guide to help you understand your drug benefits. Because drug benefits can be complex, understanding your benefits is key to getting the most from your health plan. Throughout the year, our Blue Cross Pharmacy and Therapeutics Committee, a group of Louisiana doctors and pharmacists, reviews literature about the safety, efficacy and cost of prescription drugs. You and your doctor always make the final decision for your healthcare needs. The information in this Guide can help you and your doctor make informed decisions before you fill your next prescription. That way, together you may choose the best drug for you while keeping your costs down. Please talk to your doctor or pharmacist about any questions or concerns you may have about your drug therapy. Please Note: Just because a drug is on this list does not mean that your doctor or other authorized prescriber will prescribe it for a particular medical condition or mental illness. This Guide is intended as a general reference for plans with a 4 tier, open formulary. Because not all plans offer the same benefits, inclusion of a drug in this guide does not guarantee coverage under your plan. Check your member contract for coverage restrictions, exclusions or limitations that may apply to you. How can you find information about your drugs? Use the index at the end of this Guide to look up a drug you may take to quickly learn several important things: If you must first try one or more prescription drugs before your plan will cover a specific drug for your condition, If your doctor must get prior authorization before your plan will pay for a drug If your plan limits the quantity that will be covered each time you fill a prescription Important Notes: This Guide includes most drugs that your plan covers as of the date it was created. The Guide may change as changes occur in the marketplace. The Guide may not apply to all benefit plans. Some benefit plans may have different coverage for specific drugs. The Guide applies only to prescription drugs that participating pharmacies dispense on an outpatient basis. Read your member contract or certificate for pharmacy coverage for any exclusions or limitations that apply. 04HR1216 R08/17 1

3 How are prescription drugs classified? Your plan offers a 4 tier structure for drugs that are covered: Tier Description of prescription drugs 1 Value drugs Primarily generic drugs, although some brand name drugs may fall into this category. 2 Preferred brand drugs Brand name drugs. 3 Non preferred brand or generic drugs Primarily brand name drugs that may have a therapeutic alternative that is in Tier 1 or Tier 2, although some generic drugs may fall into this category. Covered compounded drugs are included in this tier. 4 Specialty drugs High cost brand name or generic drugs that are identified as specialty drugs. Generally, you will pay the least out of pocket when you buy value drugs, or drugs that are in Tier 1. You will pay the most out of pocket for non preferred brand or generic drugs (Tier 3) and specialty drugs (Tier 4). What does it mean when there is a + sign in the Tier section? You will pay more for some covered brand name drugs marked with a + that have lost patent protection because a generic equivalent has become available. If you or your doctor decides you should continue to take the brand name drug instead of the generic drug, you will be responsible for the generic (or value drug) copay amount, plus the difference in cost between that brand and the generic drug. This is called brand buy up. This will also apply to covered brand name drugs for which a generic equivalent becomes available after the publishing of this Guide. What does it mean when the Tier section shows $0? Certain drugs may be eligible for first dollar coverage. That means you do not pay out of pocket for them and you do not pay a deductible. Drugs in these programs are marked with a $0 under the tier column. Because some benefit plans do not have this type of coverage, you should read your plan materials to find out if you have it. Note that restrictions or limitations apply, including age, gender or frequency. Broad categories of drugs that may be eligible for this coverage include: $0 Selected contraceptives for women $0 Selected preventive drugs as recommended by the U.S. Preventive Services Task Force (USPSTF). For example, selected bowel prep products when used with a wellness screening colonoscopy, selected vitamin D products for people identified as having an increased risk for falls and selected generic cholesterol lowering drugs for those who qualify may be covered. Example of How Drugs Are Listed: Drug Tier Requirements/Limits generic drug name 1 QPD BRAND DRUG NAME 2 PA; ST Key: Key: generic drugs are in lowercase italics PA = Prior authorization BRAND NAME drugs are in ALL CAPS QPD = Quantity per dispensing limits ST = Step therapy restrictions 04HR1216 R08/17 2

4 What do the abbreviations in the Requirements/Limits column mean? PA: Medications requiring prior authorization We must authorize certain drugs before your plan will pay for them. After considering current medical literature, the Pharmacy and Therapeutics Committee sets up the criteria needed for the drugs to be authorized. Then, Express Scripts processes the prior authorization requests. If you need prior authorization, have your doctor contact Express Scripts: Call: Fax: For the physician fax form, go to: > Provider > Pharmacy. QPD: Medications that have quantity per dispensing limitations Covered prescriptions have a day supply limitation (typically up to a 30 day supply at a retail pharmacy and up to a 90 day supply for mail order). Your plan also limits the amount of certain drugs that can be dispensed at one time. We call those restrictions quantity per dispensing (QPD) limitations. QPD limits are additional to the day supply limitation and are based on the manufacturer s recommended dosage and duration of therapy, common usage for episodic or intermittent treatment, FDA approved recommendations or clinical studies, and as determined by Blue Cross. QPD limits or allowances are subject to quantity limits per day supply, per dispensing event, or any combination of the two. Read your member contract or certificate for the limits for your plan. For a complete list of drugs and their QPD limitations, go to ST: Medications requiring participation in the step therapy program For drugs in our step therapy program, you must first try certain prescription drugs (Step 1) before your plan will cover other drugs (Step 2) for your condition. If one of the Step 1 drugs is not right for you, your doctor may call us for a prior authorization for a Step 2 drug. You can find more information about drugs that you must try first at under Save on Rx Drugs. What additional Requirements apply to my plan? Specialty Pharmacy Program Restrictions on Tier 4 Drugs Certain drugs are commonly called specialty drugs. Covered specialty drugs are in Tier 4 on this plan. Specialty drugs include biotechnology drugs or other drug products that may require special ordering, handling or customer service. Your policy may limit specialty drugs to the retail day supply listed in your plan (typically a 30 day supply). Read your Schedule of Benefits for any restrictions that apply to you. For a complete list of specialty drugs, go to Questions? If your doctor prescribes a drug that is not in this Guide, or if you have any questions, call Express Scripts at For more information and updates, go to or scripts.com. 04HR1216 R08/17 3

5 Table of Contents *Adhd/Anti-Narcolepsy/Anti-Obesity/Anorexiants*...5 *Amino Acids***...7 *Aminoglycosides*...7 *Analgesics - Anti-Inflammatory*... 7 *Analgesics - Nonnarcotic* *Analgesics - Opioid* *Androgens-Anabolic* *Anorectal Agents* *Anthelmintics*...18 *Antianginal Agents*...18 *Antianxiety Agents*...18 *Antiarrhythmics* *Antiasthmatic And Bronchodilator Agents*...20 *Anticoagulants*...22 *Anticonvulsants* *Antidementia Agent Combinations*** *Antidepressants*...26 *Antidiabetics*...28 *Antidiarrheals* *Antidotes And Specific Antagonists*...33 *Antidotes* *Antiemetics*...33 *Antifungals*...34 *Antihistamines*...35 *Antihyperlipidemics*...36 *Antihypertensives*...38 *Anti-Infective Agents - Misc.*...41 *Antimalarials*...42 *Antimyasthenic Agents*...43 *Antimyasthenic/Cholinergic Agents* *Antimycobacterial Agents* *Antineoplastic - Bcl-2 Inhibitors*** *Antineoplastics And Adjunctive Therapies* *Antiparkinson Agents* *Antipsychotics/Antimanic Agents*...49 *Antiretrovirals Adjuvants***...51 *Antivirals*...51 *Assorted Classes* *Atopic Dermatitis - Monoclonal Antibodies*** *Beta Blocker & Angiotensin Ii Receptor Antagonist Comb***...56 *Beta Blockers* *Bile Acid Synthesis Disorder Agents*** *Biologicals Misc* *Calcium Channel Blockers*...57 *Cardiotonics*...59 *Cardiovascular Agents - Misc.*...59 *Cephalosporins* *Chemicals*...60 *Cic Agents - Guanylate Cyclase-C (Gc-C) Agonists*** *Contraceptives*...61 *Corticosteroids*

6 *Cough/Cold/Allergy* *Cyclin-Dependent Kinases (Cdk) Inhibitors***...69 *Cystic Fibrosis Agent - Combinations***...69 *Dermatologicals*...69 *Diagnostic Products*...80 *Dietary Products/Dietary Management Products* *Digestive Aids* *Direct-Acting P2y12 Inhibitors***...86 *Diuretics*...86 *Endocrine And Metabolic Agents - Misc.*...87 *Estrogens* *Estrogen-Selective Estrogen Receptor Modulator Comb***...91 *Farnesoid X Receptor (Fxr) Agonists***...91 *Fluoroquinolones*...91 *Gastrointestinal Agents - Misc.*...92 *Genitourinary Agents - Miscellaneous* *Gout Agents*...95 *Hematological Agents - Misc.* *Hematopoietic Agents*...96 *Hemostatics*...98 *Hepatitis C Agent - Combinations***...98 *Hereditary Orotic Aciduria Treatment - Agents**...99 *Hypnotics*...99 *Hypophosphatasia (Hpp) Agents*** *Ibs Agent - Mu-Opioid Receptor Agonists*** *Insulin-Incretin Mimetic Combinations*** *Isocitrate Dehydrogenase-2 (Idh2) Inhibitors*** *Laxatives* *Leptin Analogues*** *Lymphocyte Function-Associated Antigen-1 (Lfa-1) Antag*** *Macrolides* *Medical Devices* *Migraine Products* *Minerals & Electrolytes* *Mixed Allergenic Extracts*** *Mouth/Throat/Dental Agents* *Multivitamins* *Musculoskeletal Therapy Agents* *Nasal Agents - Systemic And Topical* *Neprilysin Inhib (Arni)-Angiotensin Ii Recept Antag Comb*** *Neurogenic Orthostatic Hypotension (Noh) - Agents*** *Neuromuscular Agents* *Nutrients* *Ophthalmic Agents* *Orexin Receptor Antagonists*** *Otic Agents* *Oxaborole-Related Antifungals - Topical*** *Oxytocics* *Passive Immunizing Agents* *Pcsk9 Inhibitors*** *Pediatric Multiple Vitamins & Minerals W/ Fluoride*** *Pediatric Multiple Vitamins W/Fluoride-Iron-Zinc*** *Penicillins* *Pharmaceutical Adjuvants*

7 *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*** *Prenatal Mv & Minerals W/Fa Without Iron*** *Progestins* *Protease-Activated Receptor-1 (Par-1) Antagonists*** *Psychotherapeutic And Neurological Agents - Misc.* *Pulmonary Fibrosis Agents - Kinase Inhibitors*** *Pulmonary Fibrosis Agents*** *Pulmonary Hypertension - Prostacyclin Receptor 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* *Toxoids* *Tryptophan Hydroxylase Inhibitors*** *Ulcer Drugs* *Urinary Anti-Infectives* *Urinary Antispasmodics* *Vaccines* *Vaginal Products* *Vasopressors* *Vitamins*

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9 *Adhd/Anti-Narcolepsy/Anti- Obesity/Anorexiants* *Adhd Agent - Selective Alpha Adrenergic Agonists*** clonidine hcl er 1 QPD guanfacine hcl er 1 QPD INTUNIV 3+ QPD KAPVAY ORAL TABLET EXTENDED RELEASE 12 HOUR 3+ QPD *Adhd Agent - Selective Norepinephrine Reuptake Inhibitor*** atomoxetine hcl oral capsule 10 mg, 100 mg, 18 mg, 25 mg, 40 mg, 60 mg, 80 mg STRATTERA ORAL CAPSULE 10 MG, 100 MG, 18 MG, 25 MG, 40 MG, 60 MG, 80 MG *Amphetamine Mixtures*** ADDERALL ORAL TABLET 10 MG, 12.5 MG, 15 MG, 20 MG, 30 MG, 5 MG, 7.5 MG ADDERALL XR ORAL CAPSULE EXTENDED RELEASE 24 HOUR 10 MG, 15 MG, 20 MG, 25 MG, 30 MG, 5 MG amphetamine-dextroamphet er oral capsule extended release 24 hour 10 mg, 15 mg, 20 mg, 25 mg, 30 mg, 5 mg amphetamine-dextroamphetamine oral tablet 10 mg, 12.5 mg, 15 mg, 20 mg, 30 mg, 5 mg, 7.5 mg 1 QPD 3+ QPD 3+ QPD 3+ QPD 1 QPD 1 QPD MYDAYIS 2 QPD *Amphetamines*** ADZENYS XR-ODT 3 QPD DESOXYN 3+ QPD DEXEDRINE ORAL CAPSULE EXTENDED RELEASE 24 HOUR 10 MG, 15 MG, 5 MG dextroamphetamine sulfate er oral capsule extended release 24 hour 10 mg, 15 mg, 5 mg dextroamphetamine sulfate oral solution 1 3+ QPD 1 QPD dextroamphetamine sulfate oral tablet 1 QPD DYANAVEL XR 3 QPD EVEKEO 3 QPD methamphetamine hcl 1 QPD procentra 1 VYVANSE ORAL CAPSULE 10 MG, 20 MG, 30 MG, 40 MG, 50 MG, 60 MG, 70 MG 2 QPD VYVANSE ORAL TABLET CHEWABLE 2 QPD 5

10 zenzedi oral tablet 10 mg, 5 mg 1 QPD ZENZEDI ORAL TABLET 15 MG, 2.5 MG, 20 MG, 30 MG, 7.5 MG *Analeptics*** caffeine citrate oral 1 *Stimulants - Misc.*** 3 QPD APTENSIO XR 3 QPD armodafinil oral tablet 150 mg, 200 mg, 250 mg, 50 mg CONCERTA ORAL TABLET EXTENDED RELEASE 18 MG, 27 MG, 36 MG, 54 MG COTEMPLA XR-ODT ORAL TABLET EXTENDED RELEASE DISPERSIBLE 17.3 MG, 25.9 MG, 8.6 MG 1 PA; QPD 3+ QPD 3 PA; QPD DAYTRANA 3 QPD dexmethylphenidate hcl 1 QPD dexmethylphenidate hcl er 1 QPD FOCALIN 3+ QPD FOCALIN XR 3+ QPD metadate er oral tablet extended release 20 mg 1 QPD METHYLIN ORAL SOLUTION 3+ QPD methylphenidate hcl er (cd) oral capsule extended release 10 mg, 20 mg, 30 mg, 40 mg, 50 mg, 60 mg methylphenidate hcl er (la) oral capsule extended release 24 hour 20 mg, 30 mg, 40 mg, 60 mg 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 1 QPD 1 QPD 1 QPD 1 QPD methylphenidate hcl oral solution 1 QPD methylphenidate hcl oral tablet 1 QPD methylphenidate hcl oral tablet chewable 1 QPD modafinil 1 PA; QPD NUVIGIL ORAL TABLET 150 MG, 200 MG, 250 MG, 50 MG 3+ PA; QPD PROVIGIL 3+ PA; QPD QUILLICHEW ER ORAL TABLET CHEWABLE EXTENDED RELEASE 20 MG, 30 MG, 40 MG 3 QPD QUILLIVANT XR 3 QPD RITALIN 3+ QPD 6

11 RITALIN LA ORAL CAPSULE EXTENDED RELEASE 24 HOUR 10 MG RITALIN LA ORAL CAPSULE EXTENDED RELEASE 24 HOUR 20 MG, 30 MG, 40 MG *Amino Acids*** *Amino Acids*** 3 QPD 3+ QPD ENDARI 4 PA; QPD *Aminoglycosides* *Aminoglycosides*** BETHKIS 4 PA; QPD neomycin sulfate oral 1 paromomycin sulfate oral 1 TOBI 4 PA; QPD TOBI PODHALER 4 PA; QPD tobramycin inhalation 4 PA; QPD *Analgesics - Anti-Inflammatory* *Antirheumatic - Janus Kinase (Jak) Inhibitors*** XELJANZ 4 PA; QPD XELJANZ XR 4 PA; QPD *Antirheumatic Antimetabolites*** OTREXUP SUBCUTANEOUS SOLUTION AUTO- INJECTOR 10 MG/0.4ML, 12.5 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 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 *Anti-Tnf-Alpha - Monoclonal Antibodies*** 4 PA; QPD 4 QPD HUMIRA PEDIATRIC CROHNS START SUBCUTANEOUS PREFILLED SYRINGE KIT 40 MG/0.8ML 4 PA; QPD HUMIRA PEN SUBCUTANEOUS PEN-INJECTOR KIT 4 PA; QPD HUMIRA PEN-CROHNS STARTER SUBCUTANEOUS PEN-INJECTOR KIT HUMIRA PEN-PSORIASIS STARTER SUBCUTANEOUS PEN-INJECTOR KIT 4 PA; QPD 4 PA; QPD HUMIRA SUBCUTANEOUS PREFILLED SYRINGE KIT 4 PA; QPD SIMPONI SUBCUTANEOUS SOLUTION AUTO-INJECTOR 4 PA; QPD SIMPONI SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 4 PA; QPD 7

12 *Anti-Tnf-Alpha - Monoclonoal Antibodies*** HUMIRA PEDIATRIC CROHNS START SUBCUTANEOUS PREFILLED SYRINGE KIT 40 MG/0.8ML 4 PA; QPD HUMIRA PEN SUBCUTANEOUS PEN-INJECTOR KIT 4 PA; QPD HUMIRA PEN-CROHNS STARTER SUBCUTANEOUS PEN-INJECTOR KIT HUMIRA PEN-PSORIASIS STARTER SUBCUTANEOUS PEN-INJECTOR KIT 4 PA; QPD 4 PA; QPD HUMIRA SUBCUTANEOUS PREFILLED SYRINGE KIT 4 PA; QPD SIMPONI SUBCUTANEOUS SOLUTION AUTO-INJECTOR 4 PA; QPD SIMPONI SUBCUTANEOUS SOLUTION PREFILLED SYRINGE *Cyclooxygenase 2 (Cox-2) Inhibitors*** 4 PA; QPD CELEBREX 3+ PA; ST; QPD celecoxib oral 1 QPD *Gold Compounds*** RIDAURA 3 *Interleukin-1 Blockers*** ARCALYST 4 QPD *Interleukin-1 Receptor Antagonist (Il-1Ra)*** KINERET SUBCUTANEOUS SOLUTION PREFILLED SYRINGE *Interleukin-6 Receptor Inhibitors*** 4 PA; QPD ACTEMRA SUBCUTANEOUS 4 PA; QPD KEVZARA 4 PA; QPD *Nonsteroidal Anti-Inflammatory Agent Combinations*** ARTHROTEC ORAL TABLET DELAYED RELEASE 3+ PA; ST diclofenac-misoprostol oral tablet delayed release 1 *Nonsteroidal Anti-Inflammatory Agents (Nsaids)*** ANAPROX DS 3+ PA; ST DAYPRO 3+ PA; ST diclofenac potassium 1 diclofenac sodium er 1 diclofenac sodium oral 1 EC-NAPROSYN 3+ PA; ST etodolac er 1 etodolac oral 1 8

13 FELDENE 3+ PA; ST FENOPROFEN CALCIUM ORAL CAPSULE 3 PA; ST fenoprofen calcium oral tablet 1 PA FENORTHO 3 PA; ST; QPD flurbiprofen oral 1 ibuprofen oral suspension 1 ibuprofen oral tablet 400 mg, 600 mg, 800 mg 1 INDOCIN ORAL 3 PA; ST INDOCIN RECTAL 3 PA; ST indomethacin er 1 indomethacin oral 1 ketoprofen er 1 PA ketoprofen oral capsule 75 mg 1 ketorolac tromethamine oral 1 QPD LODINE 3+ PA; ST meclofenamate sodium oral 1 mefenamic acid oral 1 PA meloxicam oral tablet 1 QPD MOBIC ORAL TABLET 3+ PA; ST; QPD nabumetone oral 1 NALFON ORAL CAPSULE 400 MG 3 PA; ST NAPROSYN ORAL SUSPENSION 3+ PA; ST NAPROSYN ORAL TABLET 250 MG, 500 MG 3+ PA; ST naproxen dr 1 naproxen oral 1 naproxen sodium oral tablet 275 mg, 550 mg 1 oxaprozin 1 piroxicam oral 1 PONSTEL 3+ PA; ST profeno 1 PA SPRIX 3 PA; ST; QPD sulindac oral 1 TIVORBEX 3 PA; ST; QPD tolmetin sodium 1 PA VIVLODEX 3 PA; ST; QPD ZIPSOR 3 PA; ST ZORVOLEX 3 PA; ST; QPD 9

14 *Pyrimidine Synthesis Inhibitors*** ARAVA 3+ QPD leflunomide oral 1 QPD *Selective Costimulation Modulators*** ORENCIA CLICKJECT 4 PA; QPD ORENCIA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE *Soluble Tumor Necrosis Factor Receptor Agents*** 4 PA; QPD ENBREL MINI 4 PA; QPD ENBREL SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 25 MG/0.5ML, 50 MG/ML 4 PA; QPD ENBREL SUBCUTANEOUS SOLUTION RECONSTITUTED 4 PA; QPD ENBREL SURECLICK SUBCUTANEOUS SOLUTION AUTO-INJECTOR *Analgesics - Nonnarcotic* *Analgesic Combinations*** 4 PA; QPD LEVACET 3 QPD *Analgesics-Sedatives*** butalbital-acetaminophen oral tablet mg 1 QPD butalbital-apap 1 QPD butalbital-apap-caffeine oral capsule 1 QPD butalbital-apap-caffeine oral tablet mg 1 QPD butalbital-asa-caffeine 1 butalbital-aspirin-caffeine 1 ESGIC 3+ QPD FIORICET ORAL CAPSULE 3+ QPD FIORINAL 3+ tencon oral tablet mg 1 QPD zebutal oral capsule mg 1 QPD *Salicylates*** adult aspirin ec low strength $0 aspir-81 $0 aspirin 81 $0 aspirin adult low dose $0 aspirin adult low strength $0 aspirin childrens $0 aspirin ec low dose $0 aspirin ec low strength $0 10

15 aspirin ec oral tablet delayed release 81 mg $0 aspirin low dose adult $0 aspirin low dose oral tablet chewable $0 aspirin low dose oral tablet delayed release $0 aspirin low strength $0 aspirin oral tablet chewable $0 aspirin oral tablet delayed release 81 mg $0 aspir-low $0 bayer aspirin ec low dose $0 bayer low dose $0 childrens aspirin $0 childrens aspirin low strength $0 cvs aspirin adult low dose $0 cvs aspirin adult low strength $0 cvs aspirin ec oral tablet delayed release 81 mg $0 cvs aspirin low dose $0 diflunisal oral 1 ec-81 aspirin $0 ecotrin low strength $0 eq aspirin adult low dose $0 eq aspirin low dose oral tablet chewable $0 eq childrens aspirin $0 eql aspirin low dose $0 gnp adult aspirin low strength oral tablet chewable $0 gnp aspirin low dose $0 gnp aspirin oral tablet delayed release 81 mg $0 goodsense aspirin adult low st $0 goodsense aspirin low dose $0 goodsense aspirin oral tablet chewable $0 hm aspirin ec low dose $0 hm aspirin oral tablet chewable $0 kls aspirin low dose $0 kp aspirin $0 miniprin low dose $0 px aspirin oral tablet chewable $0 px enteric aspirin oral tablet delayed release 81 mg $0 qc aspirin low dose $0 qc childrens aspirin $0 11

16 ra aspirin adult low dose $0 ra aspirin adult low strength $0 ra aspirin childrens $0 ra aspirin ec adult low st $0 ra aspirin ec oral tablet delayed release 81 mg $0 ra childrens aspirin $0 salsalate oral 1 sb aspirin adult low strength $0 sb aspirin oral tablet delayed release $0 sb childrens aspirin $0 sb low dose asa ec $0 sm aspirin adult low strength $0 sm aspirin ec low strength $0 sm childrens aspirin $0 st joseph low dose $0 tgt aspirin low dose oral tablet delayed release $0 tgt aspirin oral tablet chewable $0 tgt aspirin oral tablet delayed release $0 tgt childrens aspirin $0 *Analgesics - Opioid* *Codeine Combinations*** acetaminophen-codeine 1 PA; QPD acetaminophen-codeine #2 1 PA; QPD acetaminophen-codeine #3 1 PA; QPD acetaminophen-codeine #4 1 PA; QPD ascomp-codeine 1 PA; QPD butalbital-apap-caff-cod 1 PA; QPD butalbital-asa-caff-codeine 1 PA; QPD FIORICET/CODEINE ORAL CAPSULE MG 3+ PA; QPD FIORINAL/CODEINE #3 3+ PA; QPD TYLENOL WITH CODEINE #3 3+ PA; QPD TYLENOL WITH CODEINE #4 3+ PA; QPD *Hydrocodone Combinations*** HYCET 3+ PA; QPD hydrocodone-acetaminophen oral solution mg/15ml 1 PA; QPD 12

17 hydrocodone-acetaminophen oral tablet mg, mg, mg, mg, mg, mg, mg hydrocodone-ibuprofen oral tablet mg, mg, mg 1 PA; QPD 1 PA; QPD IBUDONE ORAL TABLET MG 3+ PA; QPD IBUDONE ORAL TABLET MG 3 PA; QPD lorcet 1 PA; QPD lorcet hd 1 PA; QPD lorcet plus oral tablet mg 1 PA; QPD LORTAB ORAL ELIXIR MG/15ML 3 PA; QPD NORCO 3+ PA; QPD verdrocet 1 PA; QPD vicodin es oral tablet mg 1 PA; QPD vicodin hp oral tablet mg 1 PA; QPD vicodin oral tablet mg 1 PA; QPD XODOL ORAL TABLET MG, MG 3+ PA; QPD *Opioid Agonists*** ABSTRAL 3 PA; QPD ACTIQ 3+ PA; QPD ARYMO ER 3 PA; ST codeine sulfate oral tablet 1 PA CONZIP 3 QPD DEMEROL ORAL 3+ PA DILAUDID ORAL 3+ PA DOLOPHINE 3+ PA DURAGESIC PA; QPD DURAGESIC PA; QPD DURAGESIC PA; QPD DURAGESIC PA; QPD DURAGESIC PA; QPD EMBEDA 3 PA; ST; QPD EXALGO ORAL TABLET ER 24 HOUR ABUSE- DETERRENT 3+ PA; ST; QPD fentanyl citrate buccal 1 PA; QPD fentanyl transdermal patch 72 hour 100 mcg/hr, 12 mcg/hr, 25 mcg/hr, 50 mcg/hr, 75 mcg/hr FENTANYL TRANSDERMAL PATCH 72 HOUR 37.5 MCG/HR, 62.5 MCG/HR, 87.5 MCG/HR 1 PA; QPD 3 PA; QPD 13

18 FENTORA BUCCAL TABLET 100 MCG, 200 MCG, 400 MCG, 600 MCG, 800 MCG 3 PA; QPD hydromorphone hcl er 1 PA; QPD hydromorphone hcl oral 1 PA hydromorphone hcl rectal 1 PA HYSINGLA ER 2 PA; QPD KADIAN ORAL CAPSULE EXTENDED RELEASE 24 HOUR 10 MG, 100 MG, 20 MG, 30 MG, 50 MG, 60 MG, 80 MG KADIAN ORAL CAPSULE EXTENDED RELEASE 24 HOUR 200 MG, 40 MG 3+ PA; ST; QPD 3 PA; ST; QPD LAZANDA 3 PA; QPD levorphanol tartrate oral 1 PA meperidine hcl oral 1 PA methadone hcl intensol 1 PA methadone hcl oral 1 PA methadose oral concentrate 10 mg/ml 1 PA methadose oral tablet soluble 1 PA methadose sugar-free 1 PA MORPHABOND ER 3 PA; ST morphine sulfate (concentrate) oral solution 100 mg/5ml, 20 mg/ml 1 PA morphine sulfate er beads 1 PA; QPD morphine sulfate er oral capsule extended release 24 hour 1 PA; QPD morphine sulfate er oral tablet extended release 1 PA; QPD morphine sulfate oral 1 PA morphine sulfate rectal 1 PA MS CONTIN ORAL TABLET EXTENDED RELEASE 3+ PA; ST; QPD NUCYNTA 2 PA NUCYNTA ER 3 PA; ST; QPD OPANA ER ORAL TABLET ER 12 HOUR ABUSE- DETERRENT 3 PA; ST; QPD OPANA ORAL 3+ PA OXAYDO 3 PA OXYCODONE HCL ER ORAL TABLET ER 12 HOUR ABUSE-DETERRENT 3 PA; ST; QPD oxycodone hcl oral capsule 1 PA oxycodone hcl oral concentrate 100 mg/5ml 1 PA oxycodone hcl oral solution 1 PA 14

19 oxycodone hcl oral tablet 1 PA OXYCONTIN ORAL TABLET ER 12 HOUR ABUSE- DETERRENT 2 PA; QPD oxymorphone hcl 1 PA oxymorphone hcl er 1 PA; QPD ROXICODONE ORAL TABLET 3+ PA SUBSYS 3 PA; QPD tramadol hcl er (biphasic) oral tablet extended release 24 hour 100 mg, 200 mg, 300 mg TRAMADOL HCL ER ORAL CAPSULE EXTENDED RELEASE 24 HOUR 1 QPD 3 QPD tramadol hcl er oral tablet extended release 24 hour 1 QPD tramadol hcl oral 1 ULTRAM 3+ XTAMPZA ER 3 PA; ST; QPD ZOHYDRO ER ORAL CAPSULE ER 12 HOUR ABUSE- DETERRENT *Opioid Combinations*** endocet oral tablet mg, mg, mg, mg 3 PA; ST; QPD 1 PA; QPD oxycodone-acetaminophen oral solution 1 PA; QPD oxycodone-acetaminophen oral tablet mg, mg, mg, mg 1 PA; QPD oxycodone-aspirin oral tablet mg 1 PA; QPD oxycodone-ibuprofen 1 PA; QPD PERCOCET ORAL TABLET MG, MG, MG, MG *Opioid Partial Agonists*** 3+ PA; QPD BELBUCA 3 PA; QPD BUNAVAIL 3 PA BUPRENORPHINE 3 PA; QPD buprenorphine hcl sublingual 1 PA buprenorphine hcl-naloxone hcl 1 PA butorphanol tartrate nasal 1 QPD BUTRANS 2 PA; QPD pentazocine-naloxone hcl 1 SUBOXONE SUBLINGUAL FILM 2 PA ZUBSOLV 2 PA 15

20 *Tramadol Combinations*** tramadol-acetaminophen 1 QPD ULTRACET 3+ QPD *Androgens-Anabolic* *Anabolic Steroids*** ANADROL-50 3 OXANDRIN 3+ oxandrolone oral 1 *Androgens*** ANDRODERM TRANSDERMAL PATCH 24 HOUR 3 PA; QPD 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 3+ danazol oral 1 DEPO-TESTOSTERONE INTRAMUSCULAR SOLUTION 100 MG/ML DEPO-TESTOSTERONE INTRAMUSCULAR SOLUTION 200 MG/ML 2 PA; QPD 2 PA; QPD 3+ PA; QPD FORTESTA 3 PA; QPD METHITEST 3 methyltestosterone oral 1 NATESTO 3 PA; QPD STRIANT 3 PA; QPD TESTIM 3+ PA; QPD testosterone cypionate intramuscular solution 100 mg/ml, 200 mg/ml testosterone enanthate intramuscular solution 1 testosterone gel 12.5 mg/act (1%) transdermal 1 PA; QPD TESTOSTERONE GEL 12.5 MG/ACT (1%) TRANSDERMAL PA; QPD testosterone gel 50 mg/5gm (1%) transdermal 1 PA; QPD TESTOSTERONE GEL 50 MG/5GM (1%) TRANSDERMAL 3 PA; QPD TESTOSTERONE TRANSDERMAL GEL 10 MG/ACT (2%) 3 PA; QPD testosterone transdermal gel 12.5 mg/act (1%), 25 mg/2.5gm (1%), 50 mg/5gm (1%) 1 PA; QPD 16

21 testosterone transdermal solution 1 PA; QPD TESTRED 3+ VOGELXO PUMP 3 PA; QPD VOGELXO TRANSDERMAL GEL 50 MG/5GM (1%) 3+ PA; QPD *Anorectal Agents* *Intrarectal Steroids*** colocort 1 CORTENEMA 3+ CORTIFOAM 3 hydrocortisone rectal enema 1 UCERIS RECTAL 3 *Nitrate Vasodilating Agents*** RECTIV 3 *Rectal Anesthetic/Steroids*** ANALPRAM HC 3+ ANALPRAM HC SINGLES 3+ ANALPRAM-HC RECTAL CREAM 3 ANALPRAM-HC RECTAL LOTION % 3+ ST hydrocortisone ace-pramoxine rectal cream 1-1 % 1 hydrocortisone ace-pramoxine rectal cream % 1 QPD LIDOCAINE-HYDROCORTISONE ACE KIT 3-1 % RECTAL 3 LIDOCAINE-HYDROCORTISONE ACE KIT % RECTAL lidocaine-hydrocortisone ace rectal cream 1 pramcort rectal 1 PROCORT 3 PROCTOFOAM HC 3 *Rectal Steroids*** anucort-hc 1 ANUSOL-HC RECTAL CREAM 3+ ST hydrocortisone acetate rectal 1 hydrocortisone rectal cream 1 PROCTOCORT RECTAL CREAM 3+ ST PROCTOCORT RECTAL SUPPOSITORY 3+ procto-med hc 1 procto-pak 1 proctosol hc 1 proctozone-hc rectal

22 *Anthelmintics* *Anthelmintics*** ALBENZA 3 BENZNIDAZOLE 3 BILTRICIDE 3 EMVERM 3 QPD ivermectin oral 1 STROMECTOL 3+ *Antianginal Agents* *Antianginals-Other*** RANEXA 3 *Nitrates*** DILATRATE-SR 3 GONITRO 3 ISORDIL TITRADOSE ORAL TABLET 40 MG 3 ISORDIL TITRADOSE ORAL TABLET 5 MG 3+ isosorbide dinitrate er 1 isosorbide dinitrate oral 1 isosorbide mononitrate 1 isosorbide mononitrate er 1 MINITRAN 3 nitro-bid 1 NITRO-DUR 3 nitroglycerin er 1 nitroglycerin sublingual 1 nitroglycerin transdermal patch 24 hour 1 nitroglycerin translingual solution 1 NITROLINGUAL 3+ NITROMIST 3+ NITROSTAT 3+ nitro-time 1 *Antianxiety Agents* *Antianxiety Agents - Misc.*** buspirone hcl oral 1 hydroxyzine hcl oral syrup 1 hydroxyzine hcl oral tablet 1 hydroxyzine pamoate oral 1 18

23 meprobamate 1 VISTARIL 3+ *Benzodiazepines*** alprazolam er 1 alprazolam intensol 1 alprazolam oral 1 alprazolam xr 1 ATIVAN ORAL 3+ chlordiazepoxide hcl 1 clorazepate dipotassium 1 diazepam intensol 1 diazepam oral solution 1 mg/ml 1 diazepam oral tablet 1 lorazepam intensol 1 lorazepam oral 1 oxazepam 1 TRANXENE-T ORAL TABLET 7.5 MG 3+ VALIUM 3+ XANAX 3+ XANAX XR 3+ *Antiarrhythmics* *Antiarrhythmics Type I-A*** disopyramide phosphate oral 1 NORPACE 3+ NORPACE CR 3 quinidine gluconate er 1 quinidine sulfate oral 1 *Antiarrhythmics Type I-B*** mexiletine hcl oral 1 *Antiarrhythmics Type I-C*** flecainide acetate 1 propafenone hcl 1 propafenone hcl er 1 RYTHMOL SR 3+ *Antiarrhythmics Type Iii*** amiodarone hcl oral 1 dofetilide 1 19

24 MULTAQ 3 pacerone oral tablet 100 mg, 200 mg, 400 mg 1 TIKOSYN 3+ *Antiasthmatic And Bronchodilator Agents* *5-Lipoxygenase Inhibitors*** zileuton er 1 PA; QPD ZYFLO 3 PA; QPD ZYFLO CR 3+ PA; QPD *Adrenergic Combinations*** ADVAIR DISKUS 2 QPD ADVAIR HFA 2 QPD AIRDUO RESPICLICK 113/14 3 PA; QPD AIRDUO RESPICLICK 232/14 3 PA; QPD AIRDUO RESPICLICK 55/14 3 PA; QPD ANORO ELLIPTA 2 QPD BEVESPI AEROSPHERE 3 PA; QPD BREO ELLIPTA 2 QPD COMBIVENT RESPIMAT 3 QPD DULERA 3 PA; QPD FLUTICASONE-SALMETEROL 2 QPD ipratropium-albuterol 1 QPD STIOLTO RESPIMAT 2 QPD SYMBICORT 2 QPD TRELEGY ELLIPTA 2 QPD UTIBRON NEOHALER 3 PA; QPD *Anti-Inflammatory Agents*** cromolyn sodium inhalation 1 *Beta Adrenergics*** albuterol sulfate er 1 albuterol sulfate inhalation 1 albuterol sulfate oral 1 ARCAPTA NEOHALER 3 PA; QPD BROVANA 3 PA; QPD levalbuterol hcl inhalation nebulization solution 0.31 mg/3ml, 0.63 mg/3ml, 1.25 mg/0.5ml, 1.25 mg/3ml LEVALBUTEROL TARTRATE 3 PA; QPD metaproterenol sulfate oral 1 PERFOROMIST 3 PA; QPD 1 20

25 PROAIR HFA 2 QPD PROAIR RESPICLICK 2 QPD PROVENTIL HFA 3 PA; QPD SEREVENT DISKUS 2 QPD STRIVERDI RESPIMAT 2 QPD terbutaline sulfate oral 1 VENTOLIN HFA 2 QPD XOPENEX 3+ XOPENEX CONCENTRATE 3+ XOPENEX HFA 3 PA; QPD *Bronchodilators - Anticholinergics*** ATROVENT HFA 2 QPD INCRUSE ELLIPTA 2 QPD ipratropium bromide inhalation 1 SEEBRI NEOHALER 3 PA; QPD SPIRIVA HANDIHALER 2 QPD SPIRIVA RESPIMAT 2 QPD TUDORZA PRESSAIR INHALATION AEROSOL POWDER BREATH ACTIVATED *Leukotriene Receptor Antagonists*** 3 PA; QPD ACCOLATE 3+ QPD montelukast sodium oral 1 QPD SINGULAIR 3+ ST; QPD zafirlukast 1 QPD *Selective Phosphodiesterase 4 (Pde4) Inhibitors*** DALIRESP 3 QPD *Steroid Inhalants*** ALVESCO 3 PA; QPD ARMONAIR RESPICLICK PA; QPD ARMONAIR RESPICLICK PA; QPD ARMONAIR RESPICLICK 55 3 PA; QPD ARNUITY ELLIPTA 2 QPD ASMANEX 120 METERED DOSES 3 PA; QPD ASMANEX 14 METERED DOSES 3 PA; QPD ASMANEX 30 METERED DOSES 3 PA; QPD ASMANEX 60 METERED DOSES 3 PA; QPD ASMANEX 7 METERED DOSES 3 PA; QPD ASMANEX HFA 3 PA; QPD 21

26 budesonide inhalation suspension 0.25 mg/2ml, 0.5 mg/2ml, 1 mg/2ml FLOVENT DISKUS INHALATION AEROSOL POWDER BREATH ACTIVATED 100 MCG/BLIST, 250 MCG/BLIST, 50 MCG/BLIST FLOVENT HFA INHALATION AEROSOL 110 MCG/ACT, 220 MCG/ACT, 44 MCG/ACT PULMICORT FLEXHALER INHALATION AEROSOL POWDER BREATH ACTIVATED 180 MCG/ACT, 90 MCG/ACT PULMICORT INHALATION SUSPENSION 0.25 MG/2ML, 0.5 MG/2ML, 1 MG/2ML 1 QPD 2 QPD 2 QPD 3 PA; QPD 3+ QPD QVAR INHALATION AEROSOL SOLUTION 2 QPD QVAR REDIHALER 2 QPD *Xanthines*** ELIXOPHYLLIN 3 THEO-24 3 theochron oral tablet extended release 12 hour 100 mg, 200 mg, 300 mg theophylline 1 theophylline er 1 *Anticoagulants* *Coumarin Anticoagulants*** COUMADIN ORAL 2+ jantoven 1 warfarin sodium oral 1 *Direct Factor Xa Inhibitors*** BEVYXXA 3 QPD ELIQUIS 2 QPD SAVAYSA 3 PA; QPD XARELTO 2 QPD XARELTO STARTER PACK 2 QPD *Heparins And Heparinoid-Like Agents*** heparin lock flush intravenous solution 1 unit/ml, 10 unit/ml, 100 unit/ml heparin sodium (porcine) injection solution 1000 unit/ml, unit/ml, unit/ml, 5000 unit/ml heparin sodium (porcine) pf 1 heparin sodium lock flush intravenous solution 100 unit/ml

27 *Low Molecular Weight Heparins*** enoxaparin sodium 1 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 LOVENOX 3+ *Synthetic Heparinoid-Like Agents*** ARIXTRA 3+ fondaparinux sodium 1 *Thrombin Inhibitors - Selective Direct & Reversible*** PRADAXA 3 PA; QPD *Anticonvulsants* *Ampa Glutamate Receptor Antagonists*** FYCOMPA 3 *Anticonvulsants - Benzodiazepines*** clonazepam oral 1 DIASTAT ACUDIAL 3+ DIASTAT PEDIATRIC 3 diazepam rectal 1 KLONOPIN 3+ ONFI ORAL SUSPENSION 2 ONFI ORAL TABLET 10 MG, 20 MG 2 *Anticonvulsants - Misc.*** APTIOM ORAL TABLET 200 MG, 400 MG, 600 MG, 800 MG BANZEL QPD BRIVIACT ORAL SOLUTION 3 PA; QPD BRIVIACT ORAL TABLET 3 PA; QPD carbamazepine er 1 carbamazepine oral 1 CARBATROL 3+ epitol 1 gabapentin oral capsule 1 gabapentin oral solution 250 mg/5ml 1 gabapentin oral tablet 1 KEPPRA ORAL 3+ KEPPRA XR 3+ 23

28 LAMICTAL ODT 3+ LAMICTAL ORAL TABLET 3+ LAMICTAL ORAL TABLET CHEWABLE 25 MG, 5 MG 3+ LAMICTAL STARTER 3+ LAMICTAL XR ORAL KIT 3 LAMICTAL XR ORAL TABLET EXTENDED RELEASE 24 HOUR lamotrigine er 1 lamotrigine oral kit 25 & 50 & 100 mg, 25 (21)-50 (7) mg, 50 (42)-100(14) mg lamotrigine oral tablet 1 lamotrigine oral tablet chewable 1 lamotrigine oral tablet dispersible 1 lamotrigine starter kit-blue 1 lamotrigine starter kit-green 1 lamotrigine starter kit-orange 1 levetiracetam er 1 levetiracetam oral 1 LYRICA 3 MYSOLINE 3+ NEURONTIN 3+ PA oxcarbazepine 1 OXTELLAR XR 3 primidone oral 1 QUDEXY XR ORAL CAPSULE ER 24 HOUR SPRINKLE 100 MG, 150 MG, 200 MG, 25 MG, 50 MG roweepra 1 SPRITAM ORAL TABLET DISINTEGRATING SOLUBLE 1000 MG, 250 MG, 500 MG, 750 MG TEGRETOL ORAL SUSPENSION 2+ TEGRETOL ORAL TABLET 2+ TEGRETOL-XR 3+ TOPAMAX 3+ TOPAMAX SPRINKLE 3+ TOPIRAMATE ER ORAL CAPSULE ER 24 HOUR SPRINKLE 100 MG, 150 MG, 200 MG, 25 MG, 50 MG topiramate oral 1 TRILEPTAL PA; QPD 3 PA; QPD 3 PA; QPD 24

29 TROKENDI XR ORAL CAPSULE EXTENDED RELEASE 24 HOUR 100 MG, 200 MG, 25 MG, 50 MG VIMPAT ORAL 3 ZONEGRAN 3+ zonisamide oral 1 *Carbamates*** felbamate 1 FELBATOL 3+ *Gaba Modulators*** GABITRIL ORAL TABLET 12 MG, 16 MG 2 GABITRIL ORAL TABLET 2 MG, 4 MG 3+ 3 PA; QPD SABRIL ORAL PACKET 4 PA; QPD SABRIL ORAL TABLET 4 PA; QPD tiagabine hcl 1 vigabatrin 4 PA; QPD *Hydantoins*** DILANTIN INFATABS 2+ DILANTIN ORAL CAPSULE 100 MG 2+ DILANTIN ORAL CAPSULE 30 MG 2 DILANTIN ORAL SUSPENSION 2+ PEGANONE 3 PHENYTEK 3+ phenytoin infatabs 1 phenytoin oral suspension 125 mg/5ml 1 phenytoin oral tablet chewable 1 phenytoin sodium extended 1 *Succinimides*** CELONTIN 3 ethosuximide oral 1 ZARONTIN 3+ *Valproic Acid*** DEPAKENE ORAL CAPSULE 3+ DEPAKENE ORAL SOLUTION 3+ DEPAKOTE 3+ DEPAKOTE ER 3+ DEPAKOTE SPRINKLES ORAL CAPSULE DELAYED RELEASE SPRINKLE 3+ 25

30 divalproex sodium er oral tablet extended release 24 hour divalproex sodium oral capsule delayed release sprinkle divalproex sodium oral tablet delayed release 1 valproate sodium oral solution 1 valproic acid oral capsule 1 valproic acid oral solution 1 *Antidementia Agent Combinations*** *Antidementia Agent Combinations*** 1 1 NAMZARIC ORAL CAPSULE ER 24 HOUR THERAPY PACK NAMZARIC ORAL CAPSULE EXTENDED RELEASE 24 HOUR *Antidepressants* *Alpha-2 Receptor Antagonists (Tetracyclics)*** 3 QPD 3 mirtazapine oral tablet 15 mg, 30 mg, 45 mg, 7.5 mg 1 QPD mirtazapine oral tablet dispersible 15 mg, 30 mg, 45 mg 1 QPD REMERON ORAL TABLET 15 MG, 30 MG, 45 MG 3+ QPD REMERON SOLTAB ORAL TABLET DISPERSIBLE 15 MG, 30 MG, 45 MG *Antidepressants - Misc.*** 3+ QPD APLENZIN 3 PA; QPD bupropion hcl er (sr) 1 QPD bupropion hcl er (xl) oral tablet extended release 24 hour 150 mg, 300 mg bupropion hcl oral 1 1 QPD FORFIVO XL 3 PA; QPD maprotiline hcl 1 WELLBUTRIN SR 3+ PA; QPD WELLBUTRIN XL ORAL TABLET EXTENDED RELEASE 24 HOUR 150 MG, 300 MG *Modified Cyclics*** nefazodone hcl 1 trazodone hcl oral 1 3+ PA; QPD TRINTELLIX 3 ST VIIBRYD ORAL TABLET 3 ST; QPD VIIBRYD STARTER PACK 3 ST; QPD 26

31 *Monoamine Oxidase Inhibitors (Maois)*** EMSAM 3 QPD MARPLAN 3 NARDIL 3+ PARNATE 3+ phenelzine sulfate oral 1 tranylcypromine sulfate 1 *Selective Serotonin Reuptake Inhibitors (Ssris)*** CELEXA ORAL TABLET 3+ ST; QPD citalopram hydrobromide oral solution 1 QPD citalopram hydrobromide oral tablet 1 QPD escitalopram oxalate oral solution 1 QPD escitalopram oxalate oral tablet 1 QPD fluoxetine hcl oral capsule 10 mg, 20 mg, 40 mg 1 QPD fluoxetine hcl oral capsule delayed release 1 QPD fluoxetine hcl oral solution 1 QPD fluoxetine hcl oral tablet 10 mg, 20 mg, 60 mg 1 QPD fluvoxamine maleate 1 QPD fluvoxamine maleate er 1 QPD LEXAPRO ORAL TABLET 3+ ST; QPD paroxetine hcl er oral tablet extended release 24 hour 12.5 mg, 25 mg, 37.5 mg paroxetine hcl oral tablet 10 mg, 20 mg, 30 mg, 40 mg PAXIL CR ORAL TABLET EXTENDED RELEASE 24 HOUR 12.5 MG, 25 MG, 37.5 MG 1 QPD 1 QPD 3+ ST; QPD PAXIL ORAL SUSPENSION 2 ST; QPD PAXIL ORAL TABLET 10 MG, 20 MG, 30 MG, 40 MG 3+ ST; QPD PEXEVA ORAL TABLET 10 MG, 20 MG, 30 MG, 40 MG 3 ST; QPD PROZAC ORAL CAPSULE 10 MG, 20 MG, 40 MG 3+ ST; QPD sertraline hcl oral concentrate 1 QPD sertraline hcl oral tablet 100 mg, 25 mg, 50 mg 1 QPD ZOLOFT ORAL CONCENTRATE 3+ ST; QPD ZOLOFT ORAL TABLET 100 MG, 25 MG, 50 MG 3+ ST; QPD *Serotonin-Norepinephrine Reuptake Inhibitors (Snris)*** CYMBALTA ORAL CAPSULE DELAYED RELEASE PARTICLES 20 MG, 30 MG, 60 MG 3+ QPD DESVENLAFAXINE ER 3 ST; QPD 27

32 desvenlafaxine succinate er 1 QPD duloxetine hcl oral capsule delayed release particles 20 mg, 30 mg, 40 mg, 60 mg EFFEXOR XR ORAL CAPSULE EXTENDED RELEASE 24 HOUR 150 MG, 37.5 MG, 75 MG 1 QPD 3+ ST; QPD FETZIMA 3 ST FETZIMA TITRATION 3 ST KHEDEZLA 3 ST; QPD PRISTIQ 3+ ST; QPD venlafaxine hcl 1 QPD venlafaxine hcl er oral capsule extended release 24 hour 150 mg, 37.5 mg, 75 mg 1 QPD venlafaxine hcl er oral tablet extended release 24 hour 1 QPD *Tricyclic Agents*** amitriptyline hcl oral 1 amoxapine 1 ANAFRANIL 3+ clomipramine hcl oral 1 desipramine hcl oral 1 doxepin hcl oral 1 imipramine hcl oral 1 imipramine pamoate 1 NORPRAMIN ORAL TABLET 10 MG, 25 MG 3+ nortriptyline hcl oral 1 PAMELOR ORAL CAPSULE 3+ protriptyline hcl 1 SURMONTIL 3+ TOFRANIL 3+ trimipramine maleate oral 1 *Antidiabetics* *Alpha-Glucosidase Inhibitors*** acarbose 1 GLYSET 3+ miglitol 1 PRECOSE 3+ *Antidiabetic - Amylin Analogs*** SYMLINPEN 120 SUBCUTANEOUS SOLUTION PEN- INJECTOR 3 PA; QPD 28

33 SYMLINPEN 60 SUBCUTANEOUS SOLUTION PEN- INJECTOR *Biguanides*** FORTAMET ORAL TABLET EXTENDED RELEASE 24 HOUR 1000 MG, 500 MG GLUCOPHAGE ORAL TABLET 1000 MG, 500 MG, 850 MG GLUCOPHAGE XR ORAL TABLET EXTENDED RELEASE 24 HOUR 500 MG, 750 MG GLUMETZA ORAL TABLET EXTENDED RELEASE 24 HOUR 1000 MG, 500 MG metformin hcl er (mod) oral tablet extended release 24 hour 1000 mg, 500 mg 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, 750 mg 3 PA; QPD 3+ PA; ST; QPD 3+ ST; QPD 3+ PA; ST; QPD 3+ PA; ST; QPD 1 PA; QPD 1 PA; QPD 1 QPD metformin hcl oral tablet 1000 mg, 500 mg, 850 mg 1 QPD RIOMET 3 ST; QPD *Diabetic Other*** GLUCAGEN HYPOKIT 3 GLUCAGON EMERGENCY 2 PROGLYCEM 4 *Dipeptidyl Peptidase-4 (Dpp-4) Inhibitors*** ALOGLIPTIN BENZOATE 3 PA; ST; QPD JANUVIA 2 ST; QPD NESINA 3 PA; ST; QPD ONGLYZA 3 PA; ST; QPD TRADJENTA 2 ST; QPD *Dipeptidyl Peptidase-4 Inhibitor-Biguanide Combinations*** ALOGLIPTIN-METFORMIN HCL 3 PA; ST; QPD JANUMET 2 ST; QPD JANUMET XR ORAL TABLET EXTENDED RELEASE 24 HOUR MG, MG, MG 2 ST; QPD JENTADUETO 2 ST; QPD JENTADUETO XR ORAL TABLET EXTENDED RELEASE 24 HOUR MG, MG 2 ST; QPD KAZANO 3 PA; ST; QPD KOMBIGLYZE XR ORAL TABLET EXTENDED RELEASE 24 HOUR MG, MG, MG 3 PA; ST; QPD 29

34 *Dopamine Receptor Agonists - Ergot Derivatives*** CYCLOSET 3 ST *Dpp-4 Inhibitor-Thiazolidinedione Combinations*** ALOGLIPTIN-PIOGLITAZONE 3 ST; QPD OSENI 3 ST; QPD *Human Insulin*** 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 3 PA APIDRA 3 PA APIDRA SOLOSTAR SUBCUTANEOUS SOLUTION PEN- INJECTOR 3 PA BASAGLAR KWIKPEN 3 PA FIASP 2 FIASP FLEXTOUCH 2 HUMALOG 3 PA HUMALOG JUNIOR KWIKPEN 3 PA HUMALOG KWIKPEN SUBCUTANEOUS SOLUTION PEN-INJECTOR 100 UNIT/ML, 200 UNIT/ML 3 PA HUMALOG MIX 50/50 3 PA HUMALOG MIX 50/50 KWIKPEN SUBCUTANEOUS SUSPENSION PEN-INJECTOR 3 PA HUMALOG MIX 75/25 3 PA HUMALOG MIX 75/25 KWIKPEN SUBCUTANEOUS SUSPENSION PEN-INJECTOR 3 PA HUMULIN 70/30 3 PA HUMULIN 70/30 KWIKPEN SUBCUTANEOUS SUSPENSION PEN-INJECTOR 3 PA HUMULIN N 3 PA HUMULIN N KWIKPEN SUBCUTANEOUS SUSPENSION PEN-INJECTOR 3 PA HUMULIN R 3 PA HUMULIN R U-500 (CONCENTRATED) 2 HUMULIN R U-500 KWIKPEN SUBCUTANEOUS SOLUTION PEN-INJECTOR LANTUS 2 LANTUS SOLOSTAR SUBCUTANEOUS SOLUTION PEN- INJECTOR LEVEMIR

35 LEVEMIR FLEXTOUCH 2 NOVOLIN 70/30 2 NOVOLIN 70/30 RELION 2 NOVOLIN N 2 NOVOLIN N RELION 2 NOVOLIN R 2 NOVOLIN R RELION 2 NOVOLOG 2 NOVOLOG FLEXPEN SUBCUTANEOUS SOLUTION PEN- INJECTOR NOVOLOG MIX 70/30 2 NOVOLOG MIX 70/30 FLEXPEN SUBCUTANEOUS SUSPENSION PEN-INJECTOR NOVOLOG PENFILL SUBCUTANEOUS SOLUTION CARTRIDGE TOUJEO SOLOSTAR 2 TRESIBA FLEXTOUCH 2 *Incretin Mimetic Agents (Glp-1 Receptor Agonists)*** ADLYXIN 3 PA; QPD ADLYXIN STARTER PACK 3 PA; QPD BYDUREON BCISE 2 PA; QPD BYDUREON SUBCUTANEOUS PEN-INJECTOR 2 PA; QPD BYDUREON SUBCUTANEOUS SUSPENSION RECONSTITUTED ER BYETTA 10 MCG PEN SUBCUTANEOUS SOLUTION PEN-INJECTOR BYETTA 5 MCG PEN SUBCUTANEOUS SOLUTION PEN- INJECTOR PA; QPD 2 PA; QPD 2 PA; QPD TANZEUM 3 PA; QPD TRULICITY 3 PA; QPD VICTOZA SUBCUTANEOUS SOLUTION PEN-INJECTOR 2 PA; QPD *Meglitinide Analogues*** nateglinide 1 PRANDIN ORAL TABLET 1 MG, 2 MG 3+ repaglinide 1 STARLIX 3+ *Meglitinide-Biguanide Combinations*** repaglinide-metformin hcl 1 QPD 31

36 *Progesterone Receptor Antagonists*** KORLYM 4 PA; QPD *Sodium-Glucose Co-Transporter 2 (Sglt2) Inhibitors*** FARXIGA 2 ST; QPD INVOKANA 2 ST; QPD JARDIANCE 2 ST; QPD *Sulfonylurea-Biguanide Combinations*** glipizide-metformin hcl oral tablet mg, mg, mg 1 QPD GLUCOVANCE ORAL TABLET MG, MG 3+ QPD glyburide-metformin oral tablet mg, mg, mg *Sulfonylureas*** 1 QPD AMARYL 3+ QPD chlorpropamide 1 QPD glimepiride 1 QPD glipizide er 1 QPD glipizide oral tablet 10 mg, 5 mg 1 QPD glipizide xl 1 QPD GLUCOTROL ORAL TABLET 10 MG, 5 MG 3+ QPD GLUCOTROL XL 3+ QPD glyburide micronized 1 QPD glyburide oral tablet 1.25 mg, 2.5 mg, 5 mg 1 QPD GLYNASE 3+ QPD tolazamide 1 QPD tolbutamide 1 QPD *Sulfonylurea-Thiazolidinedione Combinations*** DUETACT 3+ ST; QPD pioglitazone hcl-glimepiride 1 QPD *Thiazolidinedione-Biguanide Combinations*** ACTOPLUS MET 3+ ST; QPD ACTOPLUS MET XR ORAL TABLET EXTENDED RELEASE 24 HOUR MG, MG 2 ST; QPD pioglitazone hcl-metformin hcl 1 QPD *Thiazolidinediones*** ACTOS 3+ ST; QPD AVANDIA ORAL TABLET 2 MG, 4 MG 3 ST; QPD pioglitazone hcl 1 QPD 32

37 *Antidiarrheals* *Antidiarrheal - Chloride Channel Antagonists*** MYTESI 4 QPD *Antiperistaltic Agents*** diphenoxylate-atropine 1 LOMOTIL ORAL TABLET 3+ loperamide hcl oral capsule 1 opium 1 paregoric 1 *Antidotes And Specific Antagonists* *Antidotes And Specific Antagonists*** CETYLEV 3 VISTOGARD 4 QPD *Antidotes* *Antidotes - Chelating Agents*** CHEMET 4 EXJADE 4 FERRIPROX 4 JADENU 4 JADENU SPRINKLE 4 *Antidotes*** CETYLEV 3 VISTOGARD 4 QPD *Opioid Antagonists*** EVZIO 3 PA; QPD naloxone hcl injection solution 0.4 mg/ml, 4 mg/10ml 1 QPD naloxone hcl injection solution cartridge 1 QPD naloxone hcl injection solution prefilled syringe 1 QPD naltrexone hcl oral 1 NARCAN 3 QPD *Antiemetics* *5-Ht3 Receptor Antagonists*** ANZEMET ORAL 3 QPD granisetron hcl oral 1 QPD ondansetron 1 QPD ondansetron hcl oral solution 1 QPD ondansetron hcl oral tablet 24 mg, 4 mg, 8 mg 1 QPD 33

38 SANCUSO 3 QPD ZOFRAN ODT 3+ QPD ZOFRAN ORAL SOLUTION 3+ QPD ZOFRAN ORAL TABLET 3+ QPD ZUPLENZ 3 QPD *Antiemetic Combinations*** AKYNZEO 3 QPD DICLEGIS 3 QPD *Antiemetics - Anticholinergic*** meclizine hcl oral tablet 1 scopolamine 1 TIGAN ORAL 3+ TRANSDERM-SCOP (1.5 MG) 3+ trimethobenzamide hcl oral 1 *Antiemetics - Miscellaneous*** CESAMET 3 QPD dronabinol 1 MARINOL 3+ SYNDROS 3 PA *Substance P/Neurokinin 1 (Nk1) Receptor Antagonists*** aprepitant oral capsule 125 mg, 40 mg, 80 & 125 mg, 80 mg 1 QPD EMEND ORAL CAPSULE 125 MG, 40 MG, 80 MG 2 QPD EMEND ORAL SUSPENSION RECONSTITUTED 3 QPD EMEND TRI-PACK 2 QPD VARUBI ORAL 3 QPD *Antifungals* *Antifungals*** ANCOBON 3+ flucytosine oral 1 griseofulvin microsize oral 1 griseofulvin ultramicrosize 1 GRIS-PEG 3+ LAMISIL ORAL TABLET 3+ QPD nystatin oral tablet 1 terbinafine hcl oral 1 QPD 34

39 *Imidazoles*** ketoconazole oral 1 *Triazoles*** CRESEMBA ORAL 3 QPD DIFLUCAN ORAL SUSPENSION RECONSTITUTED 3+ DIFLUCAN ORAL TABLET 100 MG, 200 MG, 50 MG 3+ DIFLUCAN ORAL TABLET 150 MG 3+ QPD fluconazole oral suspension reconstituted 1 fluconazole oral tablet 100 mg, 200 mg, 50 mg 1 fluconazole oral tablet 150 mg 1 QPD itraconazole oral 1 QPD NOXAFIL ORAL SUSPENSION 3 QPD NOXAFIL ORAL TABLET DELAYED RELEASE 3 QPD ONMEL 3 PA; QPD SPORANOX ORAL CAPSULE 3+ QPD SPORANOX ORAL SOLUTION 3 QPD SPORANOX PULSEPAK 3+ QPD VFEND ORAL SUSPENSION RECONSTITUTED 3+ QPD VFEND ORAL TABLET 200 MG, 50 MG 3+ QPD voriconazole oral suspension reconstituted 1 QPD voriconazole oral tablet 200 mg, 50 mg 1 QPD *Antihistamines* *Antihistamines - Ethanolamines*** carbinoxamine maleate oral solution 1 carbinoxamine maleate oral tablet 4 mg 1 carbinoxamine maleate oral tablet 6 mg 1 PA clemastine fumarate oral tablet 2.68 mg 1 diphenhydramine hcl oral capsule 50 mg 1 KARBINAL ER ORAL SUSPENSION EXTENDED RELEASE 3 RYVENT 3 PA *Antihistamines - Non-Sedating*** CLARINEX ORAL SYRUP 3 ST CLARINEX ORAL TABLET 3+ ST; QPD desloratadine 1 QPD *Antihistamines - Phenothiazines*** phenadoz 1 phenergan rectal 1 35

40 promethazine hcl oral 1 promethazine hcl rectal 1 promethegan 1 *Antihistamines - Piperidines*** cyproheptadine hcl oral 1 *Antihyperlipidemics* *Antihyperlipidemics - Misc.*** KYNAMRO SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 4 PA; QPD LOVAZA 3+ PA omega-3-acid ethyl esters 1 PA triklo 1 PA VASCEPA ORAL CAPSULE 0.5 GM, 1 GM 3 PA; QPD *Bile Acid Sequestrants*** cholestyramine light 1 cholestyramine oral 1 COLESTID 3+ COLESTID FLAVORED ORAL GRANULES 3 COLESTID FLAVORED ORAL PACKET 2 colestipol hcl 1 prevalite 1 QUESTRAN 3+ QUESTRAN LIGHT ORAL POWDER 3+ WELCHOL 2 *Fibric Acid Derivatives*** ANTARA ORAL CAPSULE 30 MG, 90 MG 3 choline fenofibrate 1 fenofibrate micronized 1 FENOFIBRATE ORAL CAPSULE 3 fenofibrate oral tablet 1 fenofibric acid 1 FENOGLIDE 3+ FIBRICOR 3+ gemfibrozil oral 1 LIPOFEN 3 LOFIBRA ORAL CAPSULE 134 MG, 67 MG 3+ LOFIBRA ORAL TABLET 54 MG 3+ LOPID 3+ 36

41 TRICOR 3+ TRIGLIDE ORAL TABLET 160 MG 3 TRILIPIX 3+ *Hmg Coa Reductase Inhibitors*** ALTOPREV 3 PA; ST; QPD atorvastatin calcium oral tablet 10 mg, 20 mg $0 QPD atorvastatin calcium oral tablet 40 mg, 80 mg 1 QPD CRESTOR 3+ PA; QPD FLOLIPID 3 PA; ST; QPD fluvastatin sodium er $0 QPD fluvastatin sodium oral capsule 20 mg, 40 mg $0 QPD LESCOL ORAL CAPSULE 20 MG 3+ ST; QPD LESCOL XL 3+ ST; QPD LIPITOR 3+ ST; QPD LIVALO 3 PA; ST; QPD lovastatin oral tablet 10 mg, 20 mg, 40 mg $0 QPD MEVACOR ORAL TABLET 40 MG 3+ ST; QPD PRAVACHOL ORAL TABLET 20 MG, 40 MG, 80 MG 3+ ST; QPD pravastatin sodium $0 QPD rosuvastatin calcium oral tablet 10 mg, 5 mg $0 QPD rosuvastatin calcium oral tablet 20 mg, 40 mg 1 QPD simvastatin oral tablet 10 mg, 20 mg, 40 mg, 5 mg $0 QPD simvastatin oral tablet 80 mg 1 QPD ZOCOR 3+ ST; QPD *Intest Cholest Absorp Inhib-Hmg Coa Reductase Inhib Comb*** ezetimibe-simvastatin 1 QPD VYTORIN 3+ ST; QPD *Intestinal Cholesterol Absorption Inhibitors*** ezetimibe 1 QPD ZETIA 3+ QPD *Microsomal Triglyceride Transfer Protein Inhibitors*** JUXTAPID 4 PA; QPD *Nicotinic Acid Derivatives*** niacin er (antihyperlipidemic) 1 NIACOR 3 NIASPAN 3+ 37

42 *Antihypertensives* *Ace Inhibitor & Calcium Channel Blocker Combinations*** amlodipine besy-benazepril hcl 1 LOTREL ORAL CAPSULE MG, MG, 5-10 MG, 5-20 MG 3+ ST PRESTALIA 3 ST TARKA 3+ ST trandolapril-verapamil hcl er 1 *Ace Inhibitors & Thiazide/Thiazide-Like*** ACCURETIC 3+ ST benazepril-hydrochlorothiazide 1 captopril-hydrochlorothiazide 1 enalapril-hydrochlorothiazide 1 fosinopril sodium-hctz 1 lisinopril-hydrochlorothiazide oral tablet mg, mg, mg LOTENSIN HCT ORAL TABLET MG, MG, MG moexipril-hydrochlorothiazide 1 quinapril-hydrochlorothiazide 1 1 QPD 3+ ST VASERETIC 3+ ST ZESTORETIC ORAL TABLET MG, MG, MG *Ace Inhibitors*** 3+ ST; QPD ACCUPRIL 3+ ST; QPD ALTACE ORAL CAPSULE 3+ ST; QPD benazepril hcl oral 1 QPD captopril oral 1 QPD enalapril maleate oral 1 QPD EPANED ORAL SOLUTION 3 ST; QPD fosinopril sodium 1 QPD lisinopril oral 1 QPD LOTENSIN ORAL TABLET 10 MG, 20 MG, 40 MG 3+ ST; QPD MAVIK ORAL TABLET 4 MG 3+ ST; QPD moexipril hcl 1 QPD perindopril erbumine 1 QPD PRINIVIL 3+ ST; QPD QBRELIS 3 ST; QPD 38