Your Guide to Prescription Drug Benefits

Transcription

1 Your Guide to Prescription Drug Benefits 2017 ESSENTIAL FORMULARY GUIDE FOR INDIVIDUAL AND SMALL GROUP* PLANS * Does not apply to the following Small Group plans. For these plans, please refer to the 2017 Essential Formulary with Preventive Drug Copays: BlueCross SG Bronze 17 BlueCross SG Silver 23 BlueCross SG Silver 25 BlueCross SG Silver 41 BlueCross SG Gold 24 BlueCross SG Gold 25 BlueCross SG Gold 26

2 2017 Essential Formulary for Individual and Small Groups Table of Contents Abbreviations and Key to Drug Tiers...2 Drug Classes: Anti - Infectives... 5 Antineoplastic & Immunosuppressant Drugs Autonomic & Cns Drugs, Neurology & Psych Cardiovascular, Hypertension & Lipids Dermatologicals/Topical Therapy Diagnostics & Miscellaneous Agents Ear, Nose & Throat Medications Endocrine/Diabetes Gastroenterology Immunology, Vaccines & Biotechnology Musculoskeletal & Rheumatology Obstetrics & Gynecology Ophthalmology Respiratory, Allergy, Cough & Cold Urologicals Vitamins, Hematinics & Electrolytes Index of Drugs

3 Requirements/Limits AGE-A = Age edit is applicable. Prior authorization is required for members 17 years of age and younger. Your network provider must call Express Scripts at to request a coverage review. = Affordable Care Act LD = Limited Distribution. This medication may be available only at certain pharmacies. For more information, please call BlueCross BlueShield Member Services at the phone number listed on your BlueCross BlueShield of Tennessee member ID card. PA = Prior Authorization. The plan requires your physician to obtain prior authorization for certain drugs. This means that you will need to get approval before you may fill your prescription. Your network provider must call Express Scripts at to request a coverage review for a drug that requires prior authorization. QL = Quantity Limit. For certain drugs, the plan limits the amount of the drug that will be covered. SPRx = Specialty Medication. Includes high-cost medications for chronic, serious diseases such as hepatitis C, multiple sclerosis, arthritis, hemophilia and other conditions. Some plans may cover specialty medications at different benefit levels or may require the use of a preferred specialty pharmacy. ST = Step Therapy. In some cases, your plan requires you to first try certain drugs to treat your medical condition before we will cover another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, we may not cover Drug B unless you try Drug A first. If Drug A does not work for you, we will then cover Drug B. Your network provider must call Express Scripts at to request a coverage review. Please refer to the Step Therapy list included within this guidebook on page 3 for medications that require step therapy and the agents that are required to be taken first. lowercase italics= Generic drugs UPPERCASE BOLD= Brand name drugs 2

4 Step Therapy Medication(s) Requiring Step Therapy Step Therapy Requirements Edarbi Edarbyclor Trial and failure of generic ARB Betaseron Trial and failure of Avonex, Copaxone, Extavia, or Rebif Non-preferred diabetic test strips (e.g., Accu- Chek, Freestyle) QL Rescula Xalatan Zioptan Apidra Apidra Solostar Humalog Trial and failure of preferred products made by Lifescan (OneTouch) or Bayer (Contour or Breeze2) QL Trial and failure of latanoprost, Lumigan, or Travatan Z Trial and failure of Novolog Humulin Trial and failure of Novolin Proventil HFA QL Ventolin HFA QL Xopenex HFA QL Trial and failure of ProAir HFA QL or ProAir Respiclick QL Acuvail Ilevro Nevanac Alocril Alomide Alrex Bepreve Elestat Emadine Lastacaft Azopt Betimol Betopic S Cosopt PF Istalol Simbrinza Osphena Premarin Cream Vagifem Trial and failure of Prolensa Trial and failure of Pataday or Pazeo Trial and failure of Alphagan P or Combigan Trial and failure of Estrace 0.01% cream 3

5 Drug Tiers = Generic Drugs = Preferred Brand Drugs = Non-Preferred Brand Drugs Tier 4= Specialty Drugs = Drugs with $0 Cost Share- per Affordable Care Act () $0 Copay Preventive List Pharmacy Appeals To appeal a denial based on the prior authorization criteria or to request a medical exception to the quantity limit, please FAX a written request to: Pharmacy Management Appeals BlueCross BlueShield of Tennessee 1 Cameron Hill Circle Chattanooga, TN Fax: Please provide the following information with your written request: 1. Patient name and cardholder ID number 2. Physician name and phone number 3. Drug and diagnosis information 4

6 Anti - Infectives Antifungal Agents clotrimazole mucous membrane troche CRESEMBA ORAL CAPSULE fluconazole oral suspension for reconstitution fluconazole oral tablet flucytosine oral capsule griseofulvin microsize oral suspension griseofulvin microsize oral tablet griseofulvin ultramicrosize oral tablet itraconazole oral capsule ketoconazole oral tablet NOXAFIL ORAL SUSPENSION NOXAFIL ORAL TABLET,DELAYED RELEASE (DR/EC) 5 nystatin oral powder nystatin oral suspension nystatin oral tablet ONMEL ORAL TABLET ORAVIG BUCCAL MUCO-ADHESIVE BUCCAL TABLET SPORANOX ORAL SOLUTION terbinafine hcl oral tablet voriconazole oral suspension for reconstitution voriconazole oral tablet Antivirals abacavir oral tablet abacavir-lamivudine-zidovudine oral tablet acyclovir oral capsule acyclovir oral suspension 200 mg/5 ml acyclovir oral tablet adefovir oral tablet amantadine hcl oral capsule

7 amantadine hcl oral solution amantadine hcl oral tablet APTIVUS ORAL CAPSULE APTIVUS ORAL SOLUTION ATRIPLA ORAL TABLET Tier 4 SPRx BARACLUDE ORAL SOLUTION COMPLERA ORAL TABLET Tier 4 SPRx CRIXIVAN ORAL CAPSULE 200 MG, 400 MG DAKLINZA ORAL TABLET Tier 4 PA; SPRx DESCOVY ORAL TABLET Tier 4 SPRx didanosine oral capsule,delayed release(dr/ec) EDURANT ORAL TABLET EMTRIVA ORAL CAPSULE EMTRIVA ORAL SOLUTION entecavir oral tablet EPCLUSA ORAL TABLET Tier 4 PA; SPRx EPIVIR HBV ORAL SOLUTION EPZICOM ORAL TABLET EVOTAZ ORAL TABLET Tier 4 SPRx famciclovir oral tablet FUZEON SUBCUTANEOUS RECON SOLN Tier 4 SPRx GENVOYA ORAL TABLET Tier 4 SPRx HARVONI ORAL TABLET Tier 4 PA; SPRx INTELENCE ORAL TABLET INVIRASE ORAL CAPSULE INVIRASE ORAL TABLET ISENTRESS ORAL POWDER IN PACKET ISENTRESS ORAL TABLET ISENTRESS ORAL TABLET,CHEWABLE KALETRA ORAL SOLUTION KALETRA ORAL TABLET lamivudine oral solution 6

8 lamivudine oral tablet lamivudine-zidovudine oral tablet LEXIVA ORAL SUSPENSION LEXIVA ORAL TABLET nevirapine oral suspension nevirapine oral tablet nevirapine oral tablet extended release 24 hr NORVIR ORAL CAPSULE NORVIR ORAL SOLUTION NORVIR ORAL TABLET ODEFSEY ORAL TABLET Tier 4 SPRx oseltamivir oral capsule 30 mg QL (20 EA per 180 days) oseltamivir oral capsule 45 mg, 75 mg QL (10 EA per 180 days) PREZCOBIX ORAL TABLET Tier 4 SPRx PREZISTA ORAL SUSPENSION PREZISTA ORAL TABLET 150 MG, 600 MG, 75 MG, 800 MG RELENZA DISKHALER INHALATION BLISTER WITH DEVICE 7 RESCRIPTOR ORAL TABLET RESCRIPTOR ORAL TABLET, DISPERSIBLE REYATAZ ORAL CAPSULE 150 MG, 200 MG, 300 MG REYATAZ ORAL POWDER IN PACKET rimantadine oral tablet SELZENTRY ORAL TABLET SOVALDI ORAL TABLET Tier 4 PA; SPRx stavudine oral capsule stavudine oral recon soln STRIBILD ORAL TABLET Tier 4 SPRx SUSTIVA ORAL CAPSULE SUSTIVA ORAL TABLET QL (20 EA per 180 days) TAMIFLU ORAL CAPSULE 30 MG QL (20 EA per 180 days)

9 TAMIFLU ORAL CAPSULE 45 MG, 75 MG QL (10 EA per 180 days) TAMIFLU ORAL SUSPENSION FOR RECONSTITUTION 8 TIVICAY ORAL TABLET Tier 4 SPRx TRIUMEQ ORAL TABLET Tier 4 SPRx TRUVADA ORAL TABLET TYBOST ORAL TABLET TYZEKA ORAL TABLET valacyclovir oral tablet VALCYTE ORAL RECON SOLN valganciclovir oral recon soln valganciclovir oral tablet VIDEX 2 GRAM PEDIATRIC ORAL RECON SOLN VIRACEPT ORAL TABLET VIRAZOLE INHALATION RECON SOLN VIREAD ORAL POWDER VIREAD ORAL TABLET VITEKTA ORAL TABLET Tier 4 SPRx ZIAGEN ORAL SOLUTION zidovudine oral capsule zidovudine oral syrup zidovudine oral tablet Cephalosporins cefaclor oral capsule cefaclor oral suspension for reconstitution 125 mg/5 ml, 250 mg/5 ml, 375 mg/5 ml cefaclor oral tablet extended release 12 hr cefadroxil oral capsule cefadroxil oral suspension for reconstitution 250 mg/5 ml, 500 mg/5 ml cefadroxil oral tablet cefdinir oral capsule cefdinir oral suspension for reconstitution QL (180 ML per 180 days)

10 cefditoren pivoxil oral tablet cefixime oral suspension for reconstitution cefpodoxime oral suspension for reconstitution cefpodoxime oral tablet cefprozil oral suspension for reconstitution cefprozil oral tablet ceftibuten oral capsule ceftibuten oral suspension for reconstitution CEFTIN ORAL SUSPENSION FOR RECONSTITUTION 9 cefuroxime axetil oral tablet cephalexin oral capsule cephalexin oral suspension for reconstitution cephalexin oral tablet SUPRAX ORAL CAPSULE SUPRAX ORAL TABLET,CHEWABLE Erythromycins & Other Macrolides azithromycin oral packet azithromycin oral suspension for reconstitution azithromycin oral tablet clarithromycin oral suspension for reconstitution clarithromycin oral tablet clarithromycin oral tablet extended release 24 hr DIFICID ORAL TABLET e.e.s. 400 oral tablet E.E.S. GRANULES ORAL SUSPENSION FOR RECONSTITUTION ERYPED 200 ORAL SUSPENSION FOR RECONSTITUTION ERYPED 400 ORAL SUSPENSION FOR RECONSTITUTION ery-tab oral tablet,delayed release (dr/ec) 250 mg, 333 mg ERY-TAB ORAL TABLET,DELAYED RELEASE (DR/EC) 500 MG

11 erythrocin (as stearate) oral tablet 250 mg erythromycin ethylsuccinate oral tablet erythromycin oral capsule,delayed release(dr/ec) erythromycin oral tablet PCE ORAL TABLET, PARTICLES/CRYSTALS ZMAX ORAL SUSPENSION,EXTENDED REL RECON Miscellaneous Antiinfectives 10 ALBENZA ORAL TABLET ALINIA ORAL SUSPENSION FOR RECONSTITUTION ALINIA ORAL TABLET atovaquone oral suspension atovaquone-proguanil oral tablet BILTRICIDE ORAL TABLET CAYSTON INHALATION SOLUTION FOR NEBULIZATION Tier 4 chloroquine phosphate oral tablet CLEOCIN ORAL CAPSULE 75 MG clindamycin hcl oral capsule clindamycin palmitate hcl oral recon soln clindamycin pediatric oral recon soln COARTEM ORAL TABLET CYCLOSERINE ORAL CAPSULE dapsone oral tablet PA; LD; SPRx DARAPRIM ORAL TABLET Tier 4 PA; LD; SPRx EMVERM ORAL TABLET,CHEWABLE ethambutol oral tablet FLAGYL ER ORAL TABLET EXTENDED RELEASE hydroxychloroquine oral tablet isoniazid oral solution isoniazid oral tablet ivermectin oral tablet

12 KETEK ORAL TABLET KITABIS PAK INHALATION SOLUTION FOR NEBULIZATION 11 Tier 4 LD; SPRx; QL (56 ML per 30 days) linezolid oral suspension for reconstitution QL (14 day supply per 30 days) linezolid oral tablet QL (14 day supply per 30 days) mefloquine oral tablet MEPRON ORAL SUSPENSION metronidazole oral capsule metronidazole oral tablet NEBUPENT INHALATION RECON SOLN neomycin oral tablet paromomycin oral capsule PASER ORAL GRANULES DR FOR SUSP IN PACKET PRIFTIN ORAL TABLET PRIMAQUINE ORAL TABLET pyrazinamide oral tablet quinine sulfate oral capsule rifabutin oral capsule RIFAMATE ORAL CAPSULE rifampin oral capsule RIFATER ORAL TABLET SIRTURO ORAL TABLET Tier 4 PA; SPRx tinidazole oral tablet tobramycin in % nacl inhalation solution for nebulization Tier 4 TRECATOR ORAL TABLET XIFAXAN ORAL TABLET 200 MG XIFAXAN ORAL TABLET 550 MG Penicillins amoxicillin oral capsule amoxicillin oral suspension for reconstitution amoxicillin oral tablet amoxicillin oral tablet,chewable 125 mg, 250 mg SPRx; QL (56 ML per 30 days)

13 amoxicillin-pot clavulanate oral suspension for reconstitution 12 amoxicillin-pot clavulanate oral tablet amoxicillin-pot clavulanate oral tablet extended release 12 hr amoxicillin-pot clavulanate oral tablet,chewable ampicillin oral capsule ampicillin oral suspension for reconstitution dicloxacillin oral capsule penicillin v potassium oral recon soln penicillin v potassium oral tablet Quinolones AVELOX ABC PACK ORAL TABLET ciprofloxacin (mixture) oral tablet, er multiphase 24 hr ciprofloxacin hcl oral tablet ciprofloxacin oral suspension,microcapsule recon FACTIVE ORAL TABLET levofloxacin oral solution levofloxacin oral tablet moxifloxacin oral tablet ofloxacin oral tablet 400 mg Sulfa's & Related Agents sulfadiazine oral tablet sulfamethoxazole-trimethoprim oral suspension sulfamethoxazole-trimethoprim oral tablet mg sulfatrim oral suspension Tetracyclines AVIDOXY DK KIT avidoxy oral tablet demeclocycline oral tablet doxycycline hyclate oral capsule doxycycline hyclate oral tablet 100 mg, 20 mg

14 doxycycline hyclate oral tablet,delayed release (dr/ec) 100 mg, 150 mg, 75 mg 13 doxycycline monohydrate oral capsule doxycycline monohydrate oral suspension for reconstitution doxycycline monohydrate oral tablet minocycline oral capsule minocycline oral tablet tetracycline oral capsule VIBRAMYCIN ORAL SYRUP Urinary Tract Agents methenamine hippurate oral tablet methenamine mandelate oral tablet MONUROL ORAL PACKET nitrofurantoin macrocrystal oral capsule nitrofurantoin monohyd/m-cryst oral capsule nitrofurantoin oral suspension PRIMSOL ORAL SOLUTION trimethoprim oral tablet Vancomycin vancomycin oral capsule Antineoplastic & Immunosuppressant Drugs Adjunctive Agents leucovorin calcium oral tablet MESNEX ORAL TABLET Antineoplastic & Immunosuppressant Drugs AFINITOR DISPERZ ORAL TABLET FOR SUSPENSION Tier 4 PA; SPRx AFINITOR ORAL TABLET Tier 4 PA; SPRx ALECENSA ORAL CAPSULE Tier 4 PA; LD; SPRx ALKERAN ORAL TABLET anastrozole oral tablet ASTAGRAF XL ORAL CAPSULE,EXTENDED RELEASE 24HR Tier 4 SPRx

15 AZASAN ORAL TABLET azathioprine oral tablet bexarotene oral capsule Tier 4 SPRx bicalutamide oral tablet BOSULIF ORAL TABLET Tier 4 PA; LD; SPRx CABOMETYX ORAL TABLET Tier 4 PA; LD; SPRx capecitabine oral tablet Tier 4 SPRx CAPRELSA ORAL TABLET Tier 4 PA; LD; SPRx COMETRIQ ORAL CAPSULE Tier 4 LD; SPRx COTELLIC ORAL TABLET Tier 4 PA; LD; SPRx cyclosporine modified oral capsule cyclosporine modified oral solution cyclosporine oral capsule DROXIA ORAL CAPSULE EMCYT ORAL CAPSULE ERIVEDGE ORAL CAPSULE Tier 4 PA; LD; SPRx etoposide oral capsule exemestane oral tablet FARESTON ORAL TABLET FARYDAK ORAL CAPSULE Tier 4 PA; LD; SPRx flutamide oral capsule gengraf oral capsule 100 mg, 25 mg gengraf oral solution GILOTRIF ORAL TABLET Tier 4 PA; LD; SPRx GLEOSTINE ORAL CAPSULE HEXALEN ORAL CAPSULE HYCAMTIN ORAL CAPSULE Tier 4 SPRx hydroxyurea oral capsule IBRANCE ORAL CAPSULE Tier 4 PA; LD; SPRx ICLUSIG ORAL TABLET Tier 4 PA; LD; SPRx imatinib oral tablet Tier 4 SPRx IMBRUVICA ORAL CAPSULE Tier 4 PA; LD; SPRx INLYTA ORAL TABLET Tier 4 PA; LD; SPRx 14

16 IRESSA ORAL TABLET Tier 4 PA; LD; SPRx JAKAFI ORAL TABLET Tier 4 PA; LD; SPRx LENVIMA ORAL CAPSULE Tier 4 PA; LD; SPRx letrozole oral tablet LEUKERAN ORAL TABLET leuprolide subcutaneous kit Tier 4 PA; SPRx LONSURF ORAL TABLET Tier 4 PA; LD; SPRx LYNPARZA ORAL CAPSULE Tier 4 PA; LD; SPRx LYSODREN ORAL TABLET MATULANE ORAL CAPSULE megestrol oral suspension 400 mg/10 ml (40 mg/ml), 625 mg/5 ml 15 megestrol oral tablet MEKINIST ORAL TABLET Tier 4 PA; SPRx mercaptopurine oral tablet methotrexate sodium (pf) injection recon soln methotrexate sodium (pf) injection solution methotrexate sodium injection solution methotrexate sodium oral tablet mycophenolate mofetil oral capsule mycophenolate mofetil oral suspension for reconstitution mycophenolate mofetil oral tablet mycophenolate sodium oral tablet,delayed release (dr/ec) MYLERAN ORAL TABLET NEXAVAR ORAL TABLET Tier 4 PA; LD; SPRx NILANDRON ORAL TABLET nilutamide oral tablet NINLARO ORAL CAPSULE Tier 4 PA; LD; SPRx octreotide acetate injection solution Tier 4 SPRx octreotide acetate injection syringe Tier 4 SPRx ODOMZO ORAL CAPSULE Tier 4 PA; SPRx PURIXAN ORAL SUSPENSION LD

17 RAPAMUNE ORAL SOLUTION SANDIMMUNE ORAL SOLUTION SANDOSTATIN INJECTION SOLUTION Tier 4 SPRx SIGNIFOR SUBCUTANEOUS SOLUTION Tier 4 PA; LD; SPRx sirolimus oral tablet SOLTAMOX ORAL SOLUTION SPRYCEL ORAL TABLET Tier 4 SPRx STIVARGA ORAL TABLET Tier 4 PA; LD; SPRx SUTENT ORAL CAPSULE Tier 4 PA; LD; SPRx TABLOID ORAL TABLET tacrolimus oral capsule TAFINLAR ORAL CAPSULE Tier 4 PA; LD; SPRx TAGRISSO ORAL TABLET Tier 4 PA; LD; SPRx tamoxifen oral tablet TARCEVA ORAL TABLET Tier 4 PA; LD; SPRx TARGRETIN TOPICAL GEL Tier 4 PA; SPRx TASIGNA ORAL CAPSULE Tier 4 SPRx temozolomide oral capsule Tier 4 PA; SPRx THALOMID ORAL CAPSULE Tier 4 PA; LD; SPRx tretinoin (chemotherapy) oral capsule TREXALL ORAL TABLET TYKERB ORAL TABLET Tier 4 PA; LD; SPRx VENCLEXTA ORAL TABLET Tier 4 PA; LD; SPRx VENCLEXTA STARTING PACK ORAL TABLETS,DOSE PACK Tier 4 PA; SPRx VOTRIENT ORAL TABLET Tier 4 PA; LD; SPRx XALKORI ORAL CAPSULE Tier 4 PA; LD; SPRx XTANDI ORAL CAPSULE Tier 4 PA; LD; SPRx ZELBORAF ORAL TABLET Tier 4 PA; LD; SPRx ZOLINZA ORAL CAPSULE Tier 4 SPRx ZORTRESS ORAL TABLET ZYDELIG ORAL TABLET Tier 4 PA; SPRx ZYKADIA ORAL CAPSULE Tier 4 PA; SPRx 16

18 ZYTIGA ORAL TABLET Tier 4 SPRx Autonomic & CNS Drugs, Neurology & Psych Agents For Narcotic Withdrawal BUNAVAIL BUCCAL FILM QL (90 EA per 30 days) buprenorphine-naloxone sublingual tablet QL (90 EA per 30 days) SUBOXONE SUBLINGUAL FILM QL (90 EA per 30 days) ZUBSOLV SUBLINGUAL TABLET MG, MG Anticonvulsants 17 APTIOM ORAL TABLET BANZEL ORAL SUSPENSION BANZEL ORAL TABLET carbamazepine oral capsule, er multiphase 12 hr carbamazepine oral suspension 100 mg/5 ml carbamazepine oral tablet carbamazepine oral tablet extended release 12 hr carbamazepine oral tablet,chewable CARBATROL ORAL CAPSULE, ER MULTIPHASE 12 HR CELONTIN ORAL CAPSULE 300 MG clonazepam oral tablet clonazepam oral tablet,disintegrating DEPAKENE ORAL CAPSULE DEPAKENE ORAL SOLUTION DEPAKOTE ER ORAL TABLET EXTENDED RELEASE 24 HR DEPAKOTE ORAL TABLET,DELAYED RELEASE (DR/EC) DEPAKOTE SPRINKLES ORAL CAPSULE, SPRINKLE DIASTAT ACUDIAL RECTAL KIT DIASTAT RECTAL KIT diazepam rectal kit DILANTIN EXTENDED ORAL CAPSULE QL (90 EA per 30 days)

19 DILANTIN INFATABS ORAL TABLET,CHEWABLE DILANTIN ORAL CAPSULE DILANTIN-125 ORAL SUSPENSION divalproex oral capsule, sprinkle divalproex oral tablet extended release 24 hr divalproex oral tablet,delayed release (dr/ec) epitol oral tablet EQUETRO ORAL CAPSULE, ER MULTIPHASE 12 HR ethosuximide oral solution felbamate oral suspension felbamate oral tablet FELBATOL ORAL SUSPENSION FELBATOL ORAL TABLET FYCOMPA ORAL SUSPENSION FYCOMPA ORAL TABLET FYCOMPA ORAL TABLETS,DOSE PACK gabapentin oral capsule 100 mg, 300 mg gabapentin oral capsule 400 mg QL (350 EA per 30 days) gabapentin oral solution 250 mg/5 ml gabapentin oral tablet 600 mg gabapentin oral tablet 800 mg QL (350 EA per 30 days) GABITRIL ORAL TABLET KEPPRA ORAL SOLUTION KEPPRA ORAL TABLET KEPPRA XR ORAL TABLET EXTENDED RELEASE 24 HR KLONOPIN ORAL TABLET LAMICTAL ODT ORAL TABLET,DISINTEGRATING 100 MG, 25 MG, 50 MG LAMICTAL ODT ORAL TABLET,DISINTEGRATING 200 MG QL (350 EA per 30 days) 18

20 LAMICTAL ODT STARTER (BLUE) ORAL TABLET DISINTEGRATING, DOSE PK LAMICTAL ODT STARTER (GREEN) ORAL TABLET DISINTEGRATING, DOSE PK LAMICTAL ODT STARTER (ORANGE) ORAL TABLET DISINTEGRATING, DOSE PK LAMICTAL ORAL TABLET 100 MG, 150 MG, 25 MG 19 LAMICTAL ORAL TABLET 200 MG QL (350 EA per 30 days) LAMICTAL ORAL TABLET, CHEWABLE DISPERSIBLE 25 MG, 5 MG LAMICTAL STARTER (BLUE) KIT ORAL TABLETS,DOSE PACK LAMICTAL STARTER (GREEN) KIT ORAL TABLETS,DOSE PACK LAMICTAL STARTER (ORANGE) KIT ORAL TABLETS,DOSE PACK LAMICTAL XR ORAL TABLET EXTENDED RELEASE 24HR 100 MG, 25 MG, 250 MG, 300 MG, 50 MG LAMICTAL XR ORAL TABLET EXTENDED RELEASE 24HR 200 MG LAMICTAL XR STARTER (BLUE) ORAL TABLET EXTENDED REL,DOSE PACK LAMICTAL XR STARTER (GREEN) ORAL TABLET EXTENDED REL,DOSE PACK LAMICTAL XR STARTER (ORANGE) ORAL TABLET EXTENDED REL,DOSE PACK lamotrigine oral tablet 100 mg, 150 mg, 25 mg QL (350 EA per 30 days) lamotrigine oral tablet 200 mg QL (350 EA per 30 days) lamotrigine oral tablet disintegrating, dose pk lamotrigine oral tablet extended release 24hr 100 mg, 25 mg, 250 mg, 300 mg, 50 mg lamotrigine oral tablet extended release 24hr 200 mg lamotrigine oral tablet, chewable dispersible QL (350 EA per 30 days)

21 lamotrigine oral tablet,disintegrating 100 mg, 25 mg, 50 mg lamotrigine oral tablet,disintegrating 200 mg QL (350 EA per 30 days) levetiracetam oral solution levetiracetam oral tablet levetiracetam oral tablet extended release 24 hr LYRICA ORAL CAPSULE LYRICA ORAL SOLUTION MYSOLINE ORAL TABLET NEURONTIN ORAL CAPSULE 100 MG, 300 MG NEURONTIN ORAL CAPSULE 400 MG QL (350 EA per 30 days) NEURONTIN ORAL SOLUTION NEURONTIN ORAL TABLET 600 MG NEURONTIN ORAL TABLET 800 MG QL (350 EA per 30 days) ONFI ORAL SUSPENSION ONFI ORAL TABLET 10 MG, 20 MG oxcarbazepine oral suspension oxcarbazepine oral tablet OXTELLAR XR ORAL TABLET EXTENDED RELEASE 24 HR PEGANONE ORAL TABLET phenobarbital oral elixir phenobarbital oral tablet PHENYTEK ORAL CAPSULE phenytoin oral suspension 125 mg/5 ml phenytoin oral tablet,chewable phenytoin sodium extended oral capsule POTIGA ORAL TABLET primidone oral tablet QUDEXY XR ORAL CAPSULE,SPRINKLE,ER 24HR 100 MG, 150 MG, 50 MG 20

22 QUDEXY XR ORAL CAPSULE,SPRINKLE,ER 24HR 200 MG, 25 MG roweepra oral tablet SABRIL ORAL POWDER IN PACKET LD; SPRx SABRIL ORAL TABLET LD; SPRx SPRITAM ORAL TABLET FOR SUSPENSION TEGRETOL ORAL SUSPENSION TEGRETOL ORAL TABLET TEGRETOL XR ORAL TABLET EXTENDED RELEASE 12 HR tiagabine oral tablet TOPAMAX ORAL CAPSULE, SPRINKLE 15 MG TOPAMAX ORAL CAPSULE, SPRINKLE 25 MG TOPAMAX ORAL TABLET 100 MG, 50 MG QL (350 EA per 30 days) QL (350 EA per 30 days) TOPAMAX ORAL TABLET 200 MG, 25 MG QL (350 EA per 30 days) topiramate oral capsule, sprinkle 15 mg topiramate oral capsule, sprinkle 25 mg QL (350 EA per 30 days) TOPIRAMATE ORAL CAPSULE,SPRINKLE,ER 24HR 100 MG, 150 MG, 50 MG TOPIRAMATE ORAL CAPSULE,SPRINKLE,ER 24HR 200 MG, 25 MG topiramate oral tablet 100 mg, 50 mg QL (350 EA per 30 days) topiramate oral tablet 25 mg QL (350 EA per 30 days) TRILEPTAL ORAL SUSPENSION TRILEPTAL ORAL TABLET TROKENDI XR ORAL CAPSULE,EXTENDED RELEASE 24HR 100 MG, 50 MG TROKENDI XR ORAL CAPSULE,EXTENDED RELEASE 24HR 200 MG, 25 MG QL (350 EA per 30 days) 21

23 valproic acid (as sodium salt) oral solution 250 mg/5 ml 22 valproic acid oral capsule VIMPAT ORAL SOLUTION VIMPAT ORAL TABLET ZARONTIN ORAL CAPSULE ZARONTIN ORAL SOLUTION ZONEGRAN ORAL CAPSULE 100 MG, 25 MG zonisamide oral capsule Antiparkinsonism Agents APOKYN SUBCUTANEOUS CARTRIDGE Tier 4 SPRx AZILECT ORAL TABLET benztropine oral tablet bromocriptine oral capsule bromocriptine oral tablet carbidopa oral tablet carbidopa-levodopa oral tablet carbidopa-levodopa oral tablet extended release carbidopa-levodopa oral tablet,disintegrating carbidopa-levodopa-entacapone oral tablet DUOPA J-TUBE INTESTINAL PUMP SUSPENSION Tier 4 entacapone oral tablet MIRAPEX ER ORAL TABLET EXTENDED RELEASE 24 HR 3.75 MG NEUPRO TRANSDERMAL PATCH 24 HOUR pramipexole oral tablet pramipexole oral tablet extended release 24 hr mg, 0.75 mg, 1.5 mg, 2.25 mg, 3 mg, 4.5 mg ropinirole oral tablet ropinirole oral tablet extended release 24 hr selegiline hcl oral capsule selegiline hcl oral tablet PA; LD; SPRx

24 tolcapone oral tablet trihexyphenidyl oral elixir trihexyphenidyl oral tablet ZELAPAR ORAL TABLET,DISINTEGRATING Migraine & Cluster Headache Therapy almotriptan malate oral tablet QL (18 EA per 30 days) CAFERGOT ORAL TABLET D.H.E.45 INJECTION SOLUTION dihydroergotamine injection solution dihydroergotamine nasal spray,non-aerosol QL (8 ML per 30 days) isometh-dichloral-acetaminophn oral capsule isomethepten-caf-acetaminophen oral tablet mg migergot rectal suppository naratriptan oral tablet QL (18 EA per 30 days) nodolor oral capsule RELPAX ORAL TABLET QL (18 EA per 30 days) rizatriptan oral tablet QL (18 EA per 30 days) rizatriptan oral tablet,disintegrating QL (18 EA per 30 days) sumatriptan nasal spray,non-aerosol QL (12 EA per 30 days) sumatriptan succinate oral tablet QL (18 EA per 30 days) sumatriptan succinate subcutaneous cartridge 4 mg/0.5 ml sumatriptan succinate subcutaneous cartridge 6 mg/0.5 ml sumatriptan succinate subcutaneous pen injector 4 mg/0.5 ml sumatriptan succinate subcutaneous pen injector 6 mg/0.5 ml QL (12 ML per 30 days) QL (8 ML per 30 days) QL (12 ML per 30 days) QL (8 ML per 30 days) sumatriptan succinate subcutaneous solution QL (8 ML per 30 days) sumatriptan succinate subcutaneous syringe 6 mg/0.5 ml SUMAVEL DOSEPRO SUBCUTANEOUS NEEDLE-FREE INJECTOR 4 MG/0.5 ML QL (8 ML per 30 days) QL (12 ML per 30 days) 23

25 SUMAVEL DOSEPRO SUBCUTANEOUS NEEDLE-FREE INJECTOR 6 MG/0.5 ML 24 QL (8 ML per 30 days) zolmitriptan oral tablet QL (18 EA per 30 days) zolmitriptan oral tablet,disintegrating QL (18 EA per 30 days) Miscellaneous Neurological Therapy AMPYRA ORAL TABLET EXTENDED RELEASE 12 HR donepezil oral tablet donepezil oral tablet,disintegrating galantamine oral capsule,ext rel. pellets 24 hr galantamine oral solution galantamine oral tablet HORIZANT ORAL TABLET EXTENDED RELEASE PA; SPRx KEVEYIS ORAL TABLET Tier 4 PA; LD; SPRx memantine oral solution memantine oral tablet memantine oral tablets,dose pack NAMENDA TITRATION PAK ORAL TABLETS,DOSE PACK NAMENDA XR ORAL CAP,SPRINKLE,ER 24HR DOSE PACK NAMENDA XR ORAL CAPSULE,SPRINKLE,ER 24HR NAMZARIC ORAL CAP,SPRINKLE,ER 24HR DOSE PACK NAMZARIC ORAL CAPSULE,SPRINKLE,ER 24HR NUEDEXTA ORAL CAPSULE rivastigmine tartrate oral capsule rivastigmine transdermal patch 24 hour tetrabenazine oral tablet Tier 4 PA; SPRx Muscle Relaxants & Antispasmodic Therapy AMRIX ORAL CAPSULE,EXTENDED RELEASE 24HR baclofen oral tablet QL (350 EA per 30 days)

26 carisoprodol oral tablet carisoprodol-asa-codeine oral tablet carisoprodol-aspirin oral tablet chlorzoxazone oral tablet cyclobenzaprine oral tablet 10 mg QL (350 EA per 30 days) cyclobenzaprine oral tablet 5 mg, 7.5 mg dantrolene oral capsule meprobamate oral tablet MESTINON ORAL SYRUP metaxalone oral tablet 800 mg methocarbamol oral tablet orphenadrine citrate oral tablet extended release pyridostigmine bromide oral tablet pyridostigmine bromide oral tablet extended release 25 tizanidine oral capsule 2 mg, 6 mg tizanidine oral capsule 4 mg QL (350 EA per 30 days) tizanidine oral tablet 2 mg tizanidine oral tablet 4 mg QL (350 EA per 30 days) Narcotic Analgesics ABSTRAL SUBLINGUAL TABLET QL (9 EA per 30 days) acetaminophen-caff-dihydrocod oral capsule QL (120 EA per 30 days) acetaminophen-codeine oral solution mg/5 ml QL (4500 ML per 30 days) acetaminophen-codeine oral tablet QL (180 EA per 30 days) ascomp with codeine oral capsule QL (120 EA per 30 days) aspirin-caffeine-dihydrocodein oral capsule QL (240 EA per 30 days) BUPAP ORAL TABLET MG QL (120 EA per 30 days) butalbital compound w/codeine oral capsule QL (120 EA per 30 days) butalbital-acetaminop-caf-cod oral capsule QL (120 EA per 30 days) butalbital-acetaminophen oral tablet QL (120 EA per 30 days) butalbital-acetaminophen-caff oral capsule QL (120 EA per 30 days) butalbital-acetaminophen-caff oral tablet mg QL (120 EA per 30 days)

27 butalbital-aspirin-caffeine oral capsule QL (120 EA per 30 days) butorphanol tartrate nasal spray,non-aerosol QL (5 ML per 28 days) BUTRANS TRANSDERMAL PATCH WEEKLY PA; QL (4 EA per 28 days) capacet oral capsule QL (120 EA per 30 days) CAPITAL WITH CODEINE ORAL SUSPENSION codeine sulfate oral tablet QL (180 EA per 30 days) codeine-butalbital-asa-caff oral capsule QL (120 EA per 30 days) diskets oral tablet,soluble PA; QL (50 EA per 30 days) endocet oral tablet mg, mg, mg, mg fentanyl citrate buccal lozenge on a handle 1,200 mcg fentanyl citrate buccal lozenge on a handle 1,600 mcg fentanyl citrate buccal lozenge on a handle 200 mcg fentanyl citrate buccal lozenge on a handle 400 mcg fentanyl citrate buccal lozenge on a handle 600 mcg fentanyl citrate buccal lozenge on a handle 800 mcg fentanyl transdermal patch 72 hour 100 mcg/hr, 12 mcg/hr, 25 mcg/hr, 50 mcg/hr, 75 mcg/hr FENTORA BUCCAL TABLET, EFFERVESCENT hydrocodone-acetaminophen oral solution mg/15 ml(15 ml) hydrocodone-acetaminophen oral solution mg/5 ml hydrocodone-acetaminophen oral solution mg/15 ml hydrocodone-acetaminophen oral tablet mg, mg, mg, mg, mg, mg, mg QL (120 EA per 30 days) QL (39 EA per 30 days) QL (29 EA per 30 days) QL (120 EA per 30 days) QL (116 EA per 30 days) QL (77 EA per 30 days) QL (58 EA per 30 days) PA; QL (10 EA per 30 days) PA; QL (9 EA per 30 days) QL (480 ML per 30 days) QL (240 ML per 30 days) QL (5550 ML per 30 days) QL (120 EA per 30 days) 26

28 hydrocodone-ibuprofen oral tablet mg, mg, mg QL (120 EA per 30 days) hydromorphone oral liquid QL (30 ML per 30 days) hydromorphone oral tablet QL (120 EA per 30 days) hydromorphone rectal suppository QL (60 EA per 30 days) ibuprofen-oxycodone oral tablet QL (28 EA per 30 days) KADIAN ORAL CAPSULE,EXTEND.RELEASE PELLETS 200 MG, 40 MG PA; QL (60 EA per 30 days) levorphanol tartrate oral tablet QL (120 EA per 30 days) lorcet (hydrocodone) oral tablet QL (120 EA per 30 days) lorcet hd oral tablet QL (120 EA per 30 days) lorcet plus oral tablet mg QL (120 EA per 30 days) lortab oral tablet QL (120 EA per 30 days) lortab oral tablet QL (120 EA per 30 days) lortab oral tablet QL (120 EA per 30 days) LORTAB ELIXIR ORAL SOLUTION MG/15 ML QL (480 ML per 30 days) margesic oral capsule QL (120 EA per 30 days) marten-tab oral tablet QL (120 EA per 30 days) meperidine oral solution QL (480 ML per 30 days) meperidine oral tablet QL (120 EA per 30 days) METHADONE INTENSOL ORAL CONCENTRATE PA; QL (120 ML per 30 days) methadone oral concentrate PA; QL (120 ML per 30 days) methadone oral solution 10 mg/5 ml PA; QL (480 ML per 30 days) methadone oral solution 5 mg/5 ml PA; QL (960 ML per 30 days) methadone oral tablet PA; QL (120 EA per 30 days) methadone oral tablet,soluble PA; QL (50 EA per 30 days) methadose oral concentrate PA; QL (120 ML per 30 days) methadose oral tablet,soluble PA; QL (50 EA per 30 days) morphine concentrate oral solution QL (300 ML per 30 days) morphine oral capsule, er multiphase 24 hr 120 mg PA; QL (50 EA per 30 days) 27

29 morphine oral capsule, er multiphase 24 hr 30 mg, 45 mg, 60 mg, 75 mg, 90 mg 28 PA; QL (60 EA per 30 days) morphine oral capsule,extend.release pellets PA; QL (60 EA per 30 days) morphine oral solution QL (900 ML per 30 days) morphine oral tablet QL (120 EA per 30 days) morphine oral tablet extended release 100 mg, 15 mg, 30 mg, 60 mg PA; QL (60 EA per 30 days) morphine oral tablet extended release 200 mg PA; QL (30 EA per 30 days) morphine rectal suppository QL (120 EA per 30 days) NUCYNTA ER ORAL TABLET EXTENDED RELEASE 12 HR PA; QL (60 EA per 30 days) NUCYNTA ORAL TABLET QL (120 EA per 30 days) oxycodone oral capsule QL (120 EA per 30 days) oxycodone oral concentrate QL (120 ML per 30 days) oxycodone oral solution QL (480 ML per 30 days) oxycodone oral tablet QL (120 EA per 30 days) oxycodone-acetaminophen oral solution oxycodone-acetaminophen oral tablet mg, mg, mg, mg QL (120 EA per 30 days) oxycodone-aspirin oral tablet QL (120 EA per 30 days) OXYCONTIN ORAL TABLET,ORAL ONLY,EXT.REL.12 HR 10 MG, 15 MG, 20 MG, 30 MG, 40 MG, 60 MG OXYCONTIN ORAL TABLET,ORAL ONLY,EXT.REL.12 HR 80 MG PA; QL (60 EA per 30 days) PA; QL (50 EA per 30 days) oxymorphone oral tablet QL (120 EA per 30 days) oxymorphone oral tablet extended release 12 hr PA; QL (60 EA per 30 days) pentazocine-naloxone oral tablet QL (120 EA per 30 days) PRIMLEV ORAL TABLET QL (120 EA per 30 days) reprexain oral tablet QL (120 EA per 30 days) SYNALGOS-DC ORAL CAPSULE QL (240 EA per 30 days) tencon oral tablet mg QL (120 EA per 30 days) tramadol oral tablet QL (240 EA per 30 days) tramadol oral tablet extended release 24 hr PA; QL (30 EA per 30 days) tramadol oral tablet, er multiphase 24 hr PA; QL (30 EA per 30 days)

30 tramadol-acetaminophen oral tablet QL (240 EA per 30 days) TREZIX ORAL CAPSULE MG QL (120 EA per 30 days) verdrocet oral tablet QL (120 EA per 30 days) vicodin es oral tablet QL (120 EA per 30 days) vicodin hp oral tablet QL (120 EA per 30 days) vicodin oral tablet QL (120 EA per 30 days) xylon 10 oral tablet QL (150 EA per 30 days) zamicet oral solution QL (480 ML per 30 days) zebutal oral capsule mg QL (120 EA per 30 days) Non-Narcotic Analgesics celecoxib oral capsule choline,magnesium salicylate oral liquid diclofenac potassium oral tablet QL (350 EA per 30 days) diclofenac sodium oral tablet extended release 24 hr diclofenac sodium oral tablet,delayed release (dr/ec) 25 mg, 50 mg diclofenac sodium oral tablet,delayed release (dr/ec) 75 mg 29 QL (350 EA per 30 days) QL (350 EA per 30 days) diclofenac sodium topical gel 1 % QL (100 GM per 30 days) diclofenac-misoprostol oral tablet,ir,delayed rel,biphasic diflunisal oral tablet etodolac oral capsule etodolac oral tablet etodolac oral tablet extended release 24 hr fenoprofen oral tablet flurbiprofen oral tablet 100 mg QL (350 EA per 30 days) flurbiprofen oral tablet 50 mg ibuprofen oral suspension ibuprofen oral tablet 400 mg, 600 mg, 800 mg INDOCIN ORAL SUSPENSION INDOCIN RECTAL SUPPOSITORY indomethacin oral capsule

31 indomethacin oral capsule, extended release ketoprofen oral capsule QL (350 EA per 30 days) ketoprofen oral capsule,ext rel. pellets 24 hr 200 mg 30 ketorolac oral tablet LODINE ORAL TABLET meclofenamate oral capsule mefenamic acid oral capsule meloxicam oral suspension meloxicam oral tablet 15 mg QL (350 EA per 30 days) meloxicam oral tablet 7.5 mg nabumetone oral tablet NAPRELAN CR ORAL TABLET, ER MULTIPHASE 24 HR 750 MG naproxen oral suspension naproxen oral tablet naproxen oral tablet,delayed release (dr/ec) naproxen sodium oral tablet 275 mg, 550 mg oxaprozin oral tablet piroxicam oral capsule salsalate oral tablet SPRIX NASAL SPRAY,NON-AEROSOL LD sulindac oral tablet tolmetin oral capsule tolmetin oral tablet VOLTAREN TOPICAL GEL QL (100 GM per 30 days) Opiate/Narcotic Reversal Agents - Opiate Antagonists naloxone injection solution QL (2 units per 1 claim) naloxone injection syringe QL (2 units per 1 claim) naltrexone oral tablet NARCAN NASAL SPRAY,NON-AEROSOL QL (2 units per 1 claim) Psychotherapeutic Drugs ABILIFY MAINTENA INTRAMUSCULAR SUSPENSION,EXTENDED REL RECON Tier 4 SPRx; AGE-A

32 ABILIFY MAINTENA INTRAMUSCULAR SUSPENSION,EXTENDED REL SYRING ADDERALL XR ORAL CAPSULE,EXTENDED RELEASE 24HR 31 Tier 4 alprazolam intensol oral concentrate alprazolam oral tablet alprazolam oral tablet extended release 24 hr alprazolam oral tablet,disintegrating amitriptyline oral tablet amitriptyline-chlordiazepoxide oral tablet amoxapine oral tablet SPRx; AGE-A aripiprazole oral solution AGE-A aripiprazole oral tablet AGE-A aripiprazole oral tablet,disintegrating AGE-A ARISTADA INTRAMUSCULAR SUSPENSION,EXTENDED REL SYRING Tier 4 armodafinil oral tablet PA bupropion hcl oral tablet bupropion hcl oral tablet extended release 100 mg, 200 mg bupropion hcl oral tablet extended release 24 hr buspirone oral tablet BUTISOL ORAL TABLET 30 MG chlordiazepoxide hcl oral capsule chlorpromazine oral tablet citalopram oral solution citalopram oral tablet 10 mg, 40 mg clomipramine oral capsule clonidine hcl oral tablet extended release 12 hr clorazepate dipotassium oral tablet SPRx; AGE-A clozapine oral tablet AGE-A clozapine oral tablet,disintegrating 100 mg, 12.5 mg, 25 mg clozapine oral tablet,disintegrating 150 mg, 200 mg AGE-A AGE-A

33 CONCERTA ORAL TABLET EXTENDED RELEASE 24HR DAYTRANA TRANSDERMAL PATCH 24 HOUR 32 desipramine oral tablet dexedrine oral tablet dexmethylphenidate oral capsule,er biphasic dexmethylphenidate oral tablet dextroamphetamine oral capsule, extended release dextroamphetamine oral solution dextroamphetamine oral tablet dextroamphetamine-amphetamine oral tablet diazepam intensol oral concentrate diazepam oral solution 5 mg/5 ml (1 mg/ml) diazepam oral tablet DORAL ORAL TABLET doxepin oral capsule doxepin oral concentrate duloxetine oral capsule,delayed release(dr/ec) EMSAM TRANSDERMAL PATCH 24 HOUR ergoloid oral tablet escitalopram oxalate oral solution escitalopram oxalate oral tablet estazolam oral tablet eszopiclone oral tablet FANAPT ORAL TABLET AGE-A FANAPT ORAL TABLETS,DOSE PACK AGE-A FAZACLO ORAL TABLET,DISINTEGRATING 150 MG, 200 MG fluoxetine oral capsule fluoxetine oral capsule,delayed release(dr/ec) fluoxetine oral solution fluoxetine oral tablet 10 mg, 20 mg AGE-A

34 fluoxetine oral tablet 60 mg fluphenazine hcl oral concentrate fluphenazine hcl oral elixir fluphenazine hcl oral tablet flurazepam oral capsule fluvoxamine oral capsule,extended release 24hr fluvoxamine oral tablet FOCALIN XR ORAL CAPSULE,ER BIPHASIC MG, 35 MG 33 guanfacine oral tablet extended release 24 hr guanidine oral tablet haloperidol lactate oral concentrate haloperidol oral tablet imipramine hcl oral tablet imipramine pamoate oral capsule INVEGA SUSTENNA INTRAMUSCULAR SYRINGE INVEGA TRINZA INTRAMUSCULAR SYRINGE Tier 4 Tier 4 SPRx SPRx LATUDA ORAL TABLET AGE-A lithium carbonate oral capsule lithium carbonate oral tablet lithium carbonate oral tablet extended release lithium citrate oral solution 8 meq/5 ml lorazepam intensol oral concentrate lorazepam oral concentrate lorazepam oral tablet loxapine succinate oral capsule maprotiline oral tablet MARPLAN ORAL TABLET metadate er oral tablet extended release methamphetamine oral tablet methylphenidate oral capsule, er biphasic methylphenidate oral capsule,er biphasic 50-50

35 methylphenidate oral solution methylphenidate oral tablet methylphenidate oral tablet extended release methylphenidate oral tablet,chewable midazolam oral syrup 2 mg/ml mirtazapine oral tablet mirtazapine oral tablet,disintegrating modafinil oral tablet PA molindone oral tablet nefazodone oral tablet nortriptyline oral capsule nortriptyline oral solution NUPLAZID ORAL TABLET Tier 4 PA; SPRx NUVIGIL ORAL TABLET PA olanzapine oral tablet AGE-A olanzapine oral tablet,disintegrating AGE-A olanzapine-fluoxetine oral capsule AGE-A oxazepam oral capsule paliperidone oral tablet extended release 24hr AGE-A paroxetine hcl oral tablet paroxetine hcl oral tablet extended release 24 hr PAXIL ORAL SUSPENSION perphenazine oral tablet perphenazine-amitriptyline oral tablet PEXEVA ORAL TABLET phenelzine oral tablet pimozide oral tablet PRISTIQ ORAL TABLET EXTENDED RELEASE 24 HR procentra oral solution protriptyline oral tablet quazepam oral tablet quetiapine oral tablet AGE-A 34

36 quetiapine oral tablet extended release 24 hr Age-A QUILLIVANT XR ORAL SUSPENSION,EXT REL 24HR,RECON RISPERDAL CONSTA INTRAMUSCULAR SYRINGE 35 Tier 4 SPRx; AGE-A risperidone oral solution AGE-A risperidone oral tablet AGE-A risperidone oral tablet,disintegrating AGE-A RITALIN LA ORAL CAPSULE,ER BIPHASIC MG ROZEREM ORAL TABLET SAPHRIS (BLACK CHERRY) SUBLINGUAL TABLET 2.5 MG, 5 MG SARAFEM ORAL TABLET 10 MG, 20 MG seconal sodium oral capsule SEROQUEL XR ORAL TABLET EXTENDED RELEASE 24 HR sertraline oral concentrate sertraline oral tablet STRATTERA ORAL CAPSULE temazepam oral capsule thioridazine oral tablet thiothixene oral capsule tranylcypromine oral tablet trazodone oral tablet triazolam oral tablet trifluoperazine oral tablet trimipramine oral capsule TRINTELLIX ORAL TABLET venlafaxine oral capsule,extended release 24hr venlafaxine oral tablet VIIBRYD ORAL TABLET VIIBRYD ORAL TABLETS,DOSE PACK 10 MG (7)- 20 MG (23) VYVANSE ORAL CAPSULE AGE-A AGE-A

37 XYREM ORAL SOLUTION PA zaleplon oral capsule zenzedi oral tablet 10 mg, 5 mg ZENZEDI ORAL TABLET 15 MG, 2.5 MG, 20 MG, 30 MG, 7.5 MG 36 ziprasidone hcl oral capsule AGE-A zolpidem oral tablet zolpidem oral tablet,ext release multiphase ZYPREXA RELPREVV INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION Cardiovascular, Hypertension & Lipids Antiarrhythmic Agents Tier 4 amiodarone oral tablet disopyramide phosphate oral capsule flecainide oral tablet mexiletine oral capsule MULTAQ ORAL TABLET NORPACE CR ORAL CAPSULE, EXTENDED RELEASE NORPACE ORAL CAPSULE pacerone oral tablet 100 mg, 200 mg, 400 mg propafenone oral capsule,extended release 12 hr propafenone oral tablet quinidine gluconate oral tablet extended release quinidine sulfate oral tablet sorine oral tablet sotalol af oral tablet sotalol oral tablet SOTYLIZE ORAL SOLUTION TIKOSYN ORAL CAPSULE Antihypertensive Therapy acebutolol oral capsule afeditab cr oral tablet extended release ALDACTAZIDE ORAL TABLET MG SPRx

38 amiloride oral tablet amiloride-hydrochlorothiazide oral tablet amlodipine oral tablet amlodipine-benazepril oral capsule amlodipine-olmesartan oral tablet amlodipine-valsartan oral tablet amlodipine-valsartan-hcthiazid oral tablet atenolol oral tablet atenolol-chlorthalidone oral tablet AZOR ORAL TABLET benazepril oral tablet benazepril-hydrochlorothiazide oral tablet BENICAR HCT ORAL TABLET BENICAR ORAL TABLET betaxolol oral tablet BIDIL ORAL TABLET bisoprolol fumarate oral tablet bisoprolol-hydrochlorothiazide oral tablet bumetanide oral tablet BYSTOLIC ORAL TABLET candesartan oral tablet candesartan-hydrochlorothiazid oral tablet captopril oral tablet captopril-hydrochlorothiazide oral tablet CARDIZEM LA ORAL TABLET EXTENDED RELEASE 24 HR 120 MG CARDURA XL ORAL TABLET EXTENDED RELEASE 24HR 37 carvedilol oral tablet chlorothiazide oral tablet chlorthalidone oral tablet 25 mg, 50 mg clonidine hcl oral tablet clonidine transdermal patch weekly clorpres oral tablet mg, mg

39 CLORPRES ORAL TABLET MG COREG CR ORAL CAPSULE, ER MULTIPHASE 24 HR DEMSER ORAL CAPSULE diltiazem hcl oral capsule,extended release 24hr 120 mg DIURIL ORAL SUSPENSION doxazosin oral tablet DUTOPROL ORAL TABLET EXTENDED RELEASE 24 HR DYRENIUM ORAL CAPSULE EDARBI ORAL TABLET EDARBYCLOR ORAL TABLET EDECRIN ORAL TABLET enalapril maleate oral tablet enalapril-hydrochlorothiazide oral tablet EPANED ORAL RECON SOLN eplerenone oral tablet epoprostenol (glycine) intravenous recon soln Tier 4 PA; SPRx eprosartan oral tablet felodipine oral tablet extended release 24 hr FLOLAN INTRAVENOUS RECON SOLN Tier 4 PA; LD; SPRx fosinopril oral tablet fosinopril-hydrochlorothiazide oral tablet furosemide oral solution 10 mg/ml, 40 mg/5 ml (8 mg/ml) furosemide oral tablet guanfacine oral tablet hydralazine oral tablet hydrochlorothiazide oral capsule hydrochlorothiazide oral tablet indapamide oral tablet INDERAL LA ORAL CAPSULE,EXTENDED RELEASE 24 HR 120 MG, 80 MG 38

40 INDERAL XL ORAL CAPSULE,EXTENDED RELEASE 24HR INNOPRAN XL ORAL CAPSULE,EXTENDED RELEASE 24HR 39 irbesartan oral tablet irbesartan-hydrochlorothiazide oral tablet isradipine oral capsule labetalol oral tablet LEVATOL ORAL TABLET lisinopril oral tablet lisinopril-hydrochlorothiazide oral tablet losartan oral tablet losartan-hydrochlorothiazide oral tablet methyclothiazide oral tablet methyldopa oral tablet methyldopa-hydrochlorothiazide oral tablet metolazone oral tablet metoprolol succinate oral tablet extended release 24 hr metoprolol ta-hydrochlorothiaz oral tablet metoprolol tartrate oral tablet minoxidil oral tablet moexipril oral tablet moexipril-hydrochlorothiazide oral tablet nadolol oral tablet nadolol-bendroflumethiazide oral tablet nicardipine oral capsule nifedical xl oral tablet extended release 24hr nifedipine oral capsule nifedipine oral tablet extended release nifedipine oral tablet extended release 24hr nimodipine oral capsule nisoldipine oral tablet extended release 24 hr olmesartan oral tablet

41 olmesartan-amlodipin-hcthiazid oral tablet olmesartan-hydrochlorothiazide oral tablet ORENITRAM ORAL TABLET EXTENDED RELEASE 40 Tier 4 perindopril erbumine oral tablet phenoxybenzamine oral capsule pindolol oral tablet prazosin oral capsule propranolol oral capsule,extended release 24 hr propranolol oral solution propranolol oral tablet propranolol-hydrochlorothiazid oral tablet quinapril oral tablet quinapril-hydrochlorothiazide oral tablet ramipril oral capsule PA; LD; SPRx REMODULIN INJECTION SOLUTION Tier 4 PA; LD; SPRx reserpine oral tablet spironolactone oral tablet spironolacton-hydrochlorothiaz oral tablet TEKTURNA HCT ORAL TABLET TEKTURNA ORAL TABLET telmisartan oral tablet telmisartan-amlodipine oral tablet telmisartan-hydrochlorothiazid oral tablet terazosin oral capsule timolol maleate oral tablet torsemide oral tablet 100 mg, 20 mg trandolapril oral tablet 2 mg, 4 mg trandolapril-verapamil oral tablet, ir - er, biphasic 24hr triamterene-hydrochlorothiazid oral capsule triamterene-hydrochlorothiazid oral tablet TRIBENZOR ORAL TABLET valsartan oral tablet

42 valsartan-hydrochlorothiazide oral tablet VELETRI INTRAVENOUS RECON SOLN Tier 4 PA; LD; SPRx verapamil oral capsule, 24 hr er pellet ct verapamil oral capsule,ext rel. pellets 24 hr verapamil oral tablet verapamil oral tablet extended release Cardiac Glycosides digitek oral tablet digox oral tablet digoxin oral solution 50 mcg/ml digoxin oral tablet LANOXIN ORAL TABLET Coagulation Therapy ADVATE INTRAVENOUS RECON SOLN Tier 4 SPRx ALPHANATE INTRAVENOUS RECON SOLN ALPHANINE SD INTRAVENOUS RECON SOLN 41 Tier 4 Tier 4 SPRx SPRx ALPROLIX INTRAVENOUS RECON SOLN Tier 4 SPRx AMICAR ORAL SOLUTION AMICAR ORAL TABLET aspirin-dipyridamole oral capsule, er multiphase 12 hr BEBULIN INTRAVENOUS RECON SOLN Tier 4 LD; SPRx BENEFIX INTRAVENOUS KIT Tier 4 LD; SPRx BRILINTA ORAL TABLET cilostazol oral tablet clopidogrel oral tablet COAGADEX INTRAVENOUS RECON SOLN Tier 4 LD; SPRx CORIFACT INTRAVENOUS KIT Tier 4 SPRx COUMADIN ORAL TABLET dipyridamole oral tablet EFFIENT ORAL TABLET ELIQUIS ORAL TABLET

43 enoxaparin subcutaneous solution QL (42 ML per 365 days) enoxaparin subcutaneous syringe QL (42 ML per 365 days) FEIBA NF INTRAVENOUS RECON SOLN Tier 4 LD; SPRx fondaparinux subcutaneous syringe QL (42 ML per 365 days) FRAGMIN SUBCUTANEOUS SOLUTION QL (42 ML per 365 days) FRAGMIN SUBCUTANEOUS SYRINGE QL (42 ML per 365 days) HELIXATE FS INTRAVENOUS RECON SOLN HEMOFIL M HIGH INTRAVENOUS RECON SOLN HEMOFIL M LOW INTRAVENOUS RECON SOLN HEMOFIL M MID INTRAVENOUS RECON SOLN HEMOFIL M SUPER HIGH INTRAVENOUS RECON SOLN 42 Tier 4 Tier 4 Tier 4 Tier 4 Tier 4 hep flush-10 (pf) intravenous solution heparin (porcine) injection solution heparin lock flush (porcine) intravenous solution 100 unit/ml heparin lock flush (porcine) intravenous syringe heparin lock flush intravenous solution heparin lockflush(porcine)(pf) intravenous syringe heparin, porcine (pf) injection solution heparin, porcine (pf) injection syringe heparin, porcine (pf) intravenous solution 100 unit/ml (1 ml) heparin, porcine (pf) intravenous syringe 1 unit/ml, 100 unit/ml LD; SPRx LD; SPRx LD; SPRx LD; SPRx LD; SPRx HUMATE-P INTRAVENOUS RECON SOLN Tier 4 LD; SPRx jantoven oral tablet KOATE-DVI INTRAVENOUS RECON SOLN 1,000 (+/-) UNIT, 250 (+/-) UNIT KOGENATE FS INTRAVENOUS RECON SOLN Tier 4 Tier 4 MEPHYTON ORAL TABLET LD; SPRx LD; SPRx

44 MONOCLATE-P INTRAVENOUS RECON SOLN 43 Tier 4 monoject prefill (pf) intravenous syringe LD; SPRx MONONINE INTRAVENOUS KIT Tier 4 LD; SPRx NOVOSEVEN RT INTRAVENOUS RECON SOLN Tier 4 pentoxifylline oral tablet extended release PRADAXA ORAL CAPSULE 150 MG, 75 MG PROFILNINE INTRAVENOUS RECON SOLN Tier 4 LD; SPRx SPRx PROMACTA ORAL TABLET Tier 4 LD; SPRx RECOMBINATE INTRAVENOUS RECON SOLN Tier 4 LD; SPRx RIXUBIS INTRAVENOUS RECON SOLN Tier 4 LD; SPRx ticlopidine oral tablet warfarin oral tablet XARELTO ORAL TABLET XARELTO ORAL TABLETS,DOSE PACK XYNTHA INTRAVENOUS SOLUTION Tier 4 LD; SPRx XYNTHA SOLOFUSE INTRAVENOUS SYRINGE Tier 4 ZONTIVITY ORAL TABLET Lipid/Cholesterol Lowering Agents ALTOPREV ORAL TABLET EXTENDED RELEASE 24 HR amlodipine-atorvastatin oral tablet ANTARA ORAL CAPSULE 30 MG, 90 MG atorvastatin oral tablet cholestyramine (with sugar) oral powder cholestyramine (with sugar) oral powder in packet cholestyramine light oral powder cholestyramine light oral powder in packet COLESTID FLAVORED ORAL PACKET colestipol oral granules colestipol oral packet LD; SPRx

45 colestipol oral tablet CRESTOR ORAL TABLET ezetimibe oral tablet fenofibrate micronized oral capsule fenofibrate nanocrystallized oral tablet fenofibrate oral tablet 160 mg, 54 mg fenofibric acid (choline) oral capsule,delayed release(dr/ec) 44 fenofibric acid oral tablet FENOGLIDE ORAL TABLET fluvastatin oral capsule fluvastatin oral tablet extended release 24 hr gemfibrozil oral tablet JUXTAPID ORAL CAPSULE Tier 4 PA; LD; SPRx KYNAMRO SUBCUTANEOUS SYRINGE Tier 4 PA; LD; SPRx LIPOFEN ORAL CAPSULE LIVALO ORAL TABLET lovastatin oral tablet niacin oral tablet extended release 24 hr NIACOR ORAL TABLET PRALUENT PEN SUBCUTANEOUS PEN INJECTOR PRALUENT SYRINGE SUBCUTANEOUS SYRINGE Tier 4 Tier 4 pravastatin oral tablet prevalite oral powder prevalite oral powder in packet REPATHA PUSHTRONEX SUBCUTANEOUS WEARABLE INJECTOR REPATHA SURECLICK SUBCUTANEOUS PEN INJECTOR REPATHA SYRINGE SUBCUTANEOUS SYRINGE Tier 4 Tier 4 Tier 4 rosuvastatin oral tablet simvastatin oral tablet PA; LD; SPRx PA; LD; SPRx PA; SPRx PA; SPRx PA; SPRx

46 TRIGLIDE ORAL TABLET 160 MG VYTORIN ORAL TABLET VYTORIN ORAL TABLET VYTORIN ORAL TABLET VYTORIN ORAL TABLET WELCHOL ORAL POWDER IN PACKET WELCHOL ORAL TABLET ZETIA ORAL TABLET Miscellaneous Cardiovascular Agents CORLANOR ORAL TABLET ENTRESTO ORAL TABLET RANEXA ORAL TABLET EXTENDED RELEASE 12 HR Nitrates DILATRATE-SR ORAL CAPSULE, EXTENDED RELEASE 45 ISORDIL ORAL TABLET isosorbide dinitrate oral tablet isosorbide dinitrate oral tablet extended release isosorbide mononitrate oral tablet isosorbide mononitrate oral tablet extended release 24 hr MINITRAN TRANSDERMAL PATCH 24 HOUR nitro-bid transdermal ointment NITRO-DUR TRANSDERMAL PATCH 24 HOUR nitroglycerin oral capsule, extended release nitroglycerin transdermal patch 24 hour nitroglycerin translingual aerosol,spray nitroglycerin translingual spray,non-aerosol NITROSTAT SUBLINGUAL TABLET nitro-time oral capsule, extended release Dermatologicals/Topical Therapy

47 Antipsoriatic / Antiseborrheic acitretin oral capsule calcipotriene scalp solution calcipotriene topical cream calcipotriene topical ointment calcipotriene-betamethasone topical ointment calcitrene topical ointment calcitriol topical ointment COAL TAR TOPICAL SOLUTION COSENTYX (2 SYRINGES) SUBCUTANEOUS SYRINGE COSENTYX PEN (2 PENS) SUBCUTANEOUS PEN INJECTOR COSENTYX PEN SUBCUTANEOUS PEN INJECTOR 46 Tier 4 Tier 4 Tier 4 PA; LD; SPRx PA; LD; SPRx PA; LD; SPRx COSENTYX SUBCUTANEOUS SYRINGE Tier 4 PA; LD; SPRx drithocreme hp topical cream ENSTILAR TOPICAL FOAM EPIFOAM TOPICAL FOAM hydrocortisone-pramoxine topical cream OVACE PLUS SHAMPOO TOPICAL SHAMPOO OVACE PLUS TOPICAL CLEANSER,EXTENDED RELEASE OVACE PLUS TOPICAL CREAM OVACE PLUS TOPICAL LOTION OVACE PLUS WASH TOPICAL CLEANSER,GEL EXTENDED RELEASE seb-prev topical cleanser selenium sulfide topical lotion selenium sulfide topical shampoo 2.25 % SELRX TOPICAL SHAMPOO sulfacetamide sodium topical cleanser sulfacetamide sodium topical shampoo TACLONEX TOPICAL SUSPENSION