AETNA BETTER HEALTH Formulary Guide. Aetna Better Health of Florida Florida Healthy Kids Formulary Guide October 2017

Transcription

1 AETNA BETTER HEALTH Formulary Guide Aetna Better Health of Florida Florida Healthy Kids Formulary Guide October 2017

2 AETNA BETTER HEALTH Formulary Guide What is a Formulary? A formulary is a list of drugs that are covered by the health plan. A formulary also tells you if there are any rules or restrictions on drugs, such as a limit on the amount you can get. If the rules for that drug are met, the plan will cover the drug. Drugs must also be filled at a plan network pharmacy. Can the Plan s Drug List change? The plan may add or remove drugs on the list. Utilizing members and their providers will be notified at least 30 days before a drug is removed from the formulary. All changes to the formulary will be posted on the plan s website. How do I use the Plan s Formulary? Column #1: lists the covered drug. Brand drugs are in upper case letters (e.g., DRUG). Generics are in lower case letters (e.g., drug). Column #2: shows coverage rules for the drug Drugs are also grouped by the type of condition they treat. Drugs used to treat an earache are listed under the section, Ear-Nose-Throat Medications. If you know what your drug is used for, please look for that section name on the drug list. Then look under that section for your drug. What are generic drugs? The plan covers both brand and generic drugs. Generic drugs cost less and are approved by the Food and Drug Administration (FDA). Are Over-The-Counter () drugs covered? The plan will cover drugs on the formulary. Some drugs may have coverage rules. If the rules for that drug are met, the plan will cover the drug. Like other drugs, drugs need a prescription from a doctor if they are to be covered by the plan. Updated: 10/01/2017 Pag e 2

3 AETNA BETTER HEALTH Formulary Guide Are there Medication Copays? Refer to member handbook for copay information. What are some types of coverage rules? Prior Approval (): This means your doctor will need to get approval from the plan first before the drug can be filled at the pharmacy. If it is not approved, the plan will not cover the drug. Call Member Services team at for more information. Quantity Level Limits (QLL): This means there is a limit on the amount of drug the plan will cover. For example, the plan provides 60 pills in 30 days for some drugs. Step Therapy (ST): This means you may need to try certain drugs first to treat your condition. After the first drug is tried, the plan will then cover the other drug for that same condition. For example, Drug A and Drug B may treat your condition. The plan may not cover Drug B unless you try Drug A first. If Drug A does not work for you, then Drug B will be covered. What if my drug is not on the plan s Formulary? First, please call your doctor and ask if your drug is covered. If the plan does not cover the drug, then: Ask your doctor for a similar drug that is covered. Your doctor can ask the plan to cover your drug through the prior approval process. Updated: 10/01/2017 Pag e 3

4 Aetna Better Health Florida CHIP Table of Contents *ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS*...5 *AMINOGLYCOSIDES*... 7 *ANALGESICS - ANTI-INFLAMMATORY*... 7 *ANALGESICS - NONNARCOTIC*...9 *ANALGESICS - OPIOID* *ANDROGENS-ANABOLIC* *ANORECTAL AGENTS*...14 *ANTACIDS*...14 *ANTHELMINTICS* *ANTIANGINAL AGENTS* *ANTIANXIETY AGENTS*...16 *ANTIARRHYTHMICS* *ANTIASTHMATIC AND BRONCHODILATOR AGENTS* *ANTICOAGULANTS* *ANTICONVULSANTS*...20 *ANTIDEPRESSANTS*...23 *ANTIDIABETICS* *ANTIDIARRHEALS*...31 *ANTIDOTES AND SPECIFIC ANTAGONISTS*...31 *ANTIDOTES* *ANTIEMETICS* *ANTIFUNGALS*...32 *ANTIHISTAMINES* *ANTIHYPERLIPIDEMICS*...34 *ANTIHYPERTENSIVES* *ANTI-INFECTIVE AGENTS - MISC.* *ANTIMALARIALS*...38 *ANTIMYASTHENIC AGENTS* *ANTIMYASTHENIC/CHOLINERGIC AGENTS* *ANTIMYCOBACTERIAL AGENTS* *ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES*...39 *ANTIRKINSON AGENTS*...45 *ANTIPSYCHOTICS/ANTIMANIC AGENTS* *ANTIRETROVIRALS ADJUVANTS*** *ANTIVIRALS*...50 *ASSORTED CLASSES* *BETA BLOCKERS* *BIOLOGICALS MISC* *CALCIUM CHANNEL BLOCKERS* *CARDIOTONICS* *CARDIOVASCULAR AGENTS - MISC.* *CEPHALOSPORINS*...58 *CONTRACEPTIVES*...60 *CORTICOSTEROIDS* *COUGH/COLD/ALLERGY*...68 *DERMATOLOGICALS* *DIAGNOSTIC PRODUCTS*...75 *DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS*

5 *DIGESTIVE AIDS*...76 *DIRECT-ACTING P2Y12 INHIBITORS*** *DIURETICS*...76 *ENDOCRINE AND METABOLIC AGENTS - MISC.*...77 *ESTROGENS*...79 *FLUOROQUINOLONES* *GASTROINTESTINAL AGENTS - MISC.*...80 *GENITOURINARY AGENTS - MISCELLANEOUS* *GOUT AGENTS*...82 *HEMATOLOGICAL AGENTS - MISC.* *HEMATOPOIETIC AGENTS*...85 *HEMOSTATICS*...88 *HETITIS C AGENT - COMBINATIONS*** *HYPNOTICS* *LAXATIVES* *LHRH/GNRH AGONIST ANALOG COMBINATIONS*** *LOCAL ANESTHETICS-RENTERAL* *MACROLIDES*...90 *MEDICAL DEVICES*...91 *MIGRAINE PRODUCTS* *MINERALS & ELECTROLYTES* *MOUTH/THROAT/DENTAL AGENTS* *MULTIVITAMINS* *MUSCULOSKELETAL THERAPY AGENTS* *NASAL AGENTS - SYSTEMIC AND TOPICAL* *NEPRILYSIN INHIB (ARNI)-ANGIOTENSIN II RECEPT ANTAG COMB*** *NEUROMUSCULAR AGENTS* *NUTRIENTS* *OPHTHALMIC AGENTS* *OTIC AGENTS* *SSIVE IMMUNIZING AGENTS - COMBINATIONS*** *SSIVE IMMUNIZING AGENTS* *PENICILLINS* *PERITONEAL DIALYSIS SOLUTIONS*** *PHARMACEUTICAL ADJUVANTS* *POTASSIUM REMOVING AGENTS*** *PROGESTINS* *PROTEIN-CARBOHYDRATE-LIPID WITH ELECTROLYTE COMBINATIONS*** *PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.* *PULMONARY HYPERTENSION - PROSTACYCLIN RECEPTOR AGONIST*** *RESPIRATORY AGENTS - MISC.* *SEROTONIN MODULATORS*** *SGLT2 INHIBITOR - DPP-4 INHIBITOR COMBINATIONS*** *SODIUM-GLUCOSE CO-TRANSPORTER 2 INHIBITOR-BIGUANIDE COMB*** *SULFONAMIDES* *TETRACYCLINES* *THYROID AGENTS* *ULCER DRUGS* *URINARY ANTI-INFECTIVES* *URINARY ANTISSMODICS* *VAGINAL PRODUCTS* *VASOPRESSORS*

6 *VITAMINS*

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8 Aetna Better Health Florida CHIP CURRENT AS OF 9/25/2017 *ADHD/ANTI- NARCOLEPSY/ANTI- OBESITY/ANOREXIANTS* *Adhd Agent - Selective Alpha Adrenergic Agonists*** guanfacine hcl er oral tablet extended release 24 hour Intuniv *Adhd Agent - Selective Norepinephrine Reuptake Inhibitor*** atomoxetine hcl oral capsule Strattera STRATTERA ORAL CAPSULE Atomoxetine HCl AL (Min 6 Years) *Amphetamine Mixtures*** amphetamine-dextroamphet er oral capsule extended release 24 hour Adderall XR AL (Min 6 Years) amphetamine-dextroamphetamine oral tablet Adderall AL (Min 3 Years) *Amphetamines*** dextroamphetamine sulfate oral tablet Zenzedi DYANAVEL XR ORAL SUSPENSION EXTENDED RELEASE VYVANSE ORAL CAPSULE QLL (30 EA per 30 days); AL (Min 6 Years) *Analeptics*** caffeine citrate intravenous solution Cafcit AL (Max 11 Months) caffeine citrate oral solution *Stimulants - Misc.*** dexmethylphenidate hcl er capsule extended release 24 hour 10 mg oral Focalin XR dexmethylphenidate hcl er capsule extended release 24 hour 10 mg oral Focalin XR AL (Min 6 Years) dexmethylphenidate hcl er capsule extended release 24 hour 15 mg oral Focalin XR AL (Min 6 Years) dexmethylphenidate hcl er capsule extended release 24 hour 20 mg oral Focalin XR dexmethylphenidate hcl er capsule extended release 24 hour 20 mg oral Focalin XR AL (Min 6 Years) 5

9 dexmethylphenidate hcl er capsule extended release 24 hour 25 mg oral dexmethylphenidate hcl er capsule extended release 24 hour 25 mg oral dexmethylphenidate hcl er capsule extended release 24 hour 30 mg oral dexmethylphenidate hcl er capsule extended release 24 hour 35 mg oral dexmethylphenidate hcl er capsule extended release 24 hour 35 mg oral dexmethylphenidate hcl er capsule extended release 24 hour 40 mg oral dexmethylphenidate hcl er capsule extended release 24 hour 5 mg oral dexmethylphenidate hcl oral tablet methylphenidate hcl er (cd) oral capsule extended release methylphenidate hcl er oral tablet extended release 24 hour methylphenidate hcl er tablet extended release 10 mg oral methylphenidate hcl er tablet extended release 18 mg oral methylphenidate hcl er tablet extended release 18 mg oral methylphenidate hcl er tablet extended release 20 mg oral methylphenidate hcl er tablet extended release 27 mg oral methylphenidate hcl er tablet extended release 27 mg oral methylphenidate hcl er tablet extended release 36 mg oral methylphenidate hcl er tablet extended release 36 mg oral methylphenidate hcl er tablet extended release 54 mg oral methylphenidate hcl er tablet extended release 54 mg oral methylphenidate hcl oral tablet methylphenidate hcl oral tablet chewable modafinil oral tablet DAYTRANA TRANSDERMAL TCH 6 Focalin XR Focalin XR Focalin XR Focalin XR Focalin XR Focalin XR Focalin XR Focalin Concerta Concerta Metadate ER Concerta Concerta Concerta Concerta Concerta Concerta Ritalin Provigil AL (Min 6 Years) AL (Min 6 Years) AL (Min 6 Years) AL (Min 6 Years) AL (Min 6 Years) AL (Min 6 Years) AL (Min 6 Years) AL (Min 6 Years) AL (Min 6 Years) AL (Min 6 Years) AL (Min 6 Years)

10 QUILLICHEW ER ORAL TABLET CHEWABLE EXTENDED RELEASE QUILLIVANT XR ORAL SUSPENSION RECONSTITUTED *AMINOGLYCOSIDES* *Aminoglycosides*** gentamicin in saline intravenous solution gentamicin sulfate injection solution neomycin sulfate oral tablet tobramycin inhalation nebulization solution Tobi ; QLL (280 ML per 56 days) tobramycin sulfate injection solution *ANALGESICS - ANTI- INFLAMMATORY* *Antirheumatic - Janus Kinase (Jak) Inhibitors*** XELJANZ ORAL TABLET ; QLL (60 EA per 30 days); AL (Min 18 Years) XELJANZ XR ORAL TABLET EXTENDED RELEASE 24 HOUR *Anti-Tnf-Alpha - Monoclonal Antibodies*** HUMIRA PEDIATRIC CROHNS START SUBCUTANEOUS PREFILLED SYRINGE KIT HUMIRA PEN SUBCUTANEOUS PEN- INJECTOR KIT HUMIRA PEN-CROHNS STARTER SUBCUTANEOUS PEN-INJECTOR KIT HUMIRA PEN-PSORIASIS STARTER SUBCUTANEOUS PEN-INJECTOR KIT HUMIRA PREFILLED SYRINGE KIT 10 MG/0.2ML SUBCUTANEOUS HUMIRA PREFILLED SYRINGE KIT 20 MG/0.4ML SUBCUTANEOUS HUMIRA PREFILLED SYRINGE KIT 40 MG/0.8ML SUBCUTANEOUS *Anti-Tnf-Alpha - Monoclonoal Antibodies*** HUMIRA PEDIATRIC CROHNS START SUBCUTANEOUS PREFILLED SYRINGE KIT ; QLL (30 EA per 30 days); AL (Min 18 Years) 7

11 HUMIRA PEN SUBCUTANEOUS PEN- INJECTOR KIT HUMIRA PEN-CROHNS STARTER SUBCUTANEOUS PEN-INJECTOR KIT HUMIRA PEN-PSORIASIS STARTER SUBCUTANEOUS PEN-INJECTOR KIT HUMIRA PREFILLED SYRINGE KIT 10 MG/0.2ML SUBCUTANEOUS HUMIRA PREFILLED SYRINGE KIT 20 MG/0.4ML SUBCUTANEOUS HUMIRA PREFILLED SYRINGE KIT 40 MG/0.8ML SUBCUTANEOUS *Cyclooxygenase 2 (Cox-2) Inhibitors*** celecoxib capsule 100 mg oral CeleBREX celecoxib capsule 100 mg oral CeleBREX QLL (60 EA per 30 days) celecoxib capsule 200 mg oral CeleBREX celecoxib capsule 200 mg oral CeleBREX QLL (60 EA per 30 days) celecoxib capsule 400 mg oral CeleBREX celecoxib capsule 400 mg oral CeleBREX QLL (30 EA per 30 days) celecoxib capsule 50 mg oral CeleBREX celecoxib capsule 50 mg oral CeleBREX QLL (60 EA per 30 days) *Nonsteroidal Anti-Inflammatory Agent Combinations*** diclofenac-misoprostol oral tablet delayed release Arthrotec *Nonsteroidal Anti-Inflammatory Agents (Nsaids)*** diclofenac potassium oral tablet diclofenac sodium er oral tablet extended release 24 hour diclofenac sodium oral tablet delayed release ibuprofen oral suspension Childrens Motrin ibuprofen oral tablet indomethacin oral capsule ketorolac tromethamine oral tablet QLL (120 EA per 30 days); AL (Min 17 Years) ketorolac tromethamine solution 15 mg/ml injection ketorolac tromethamine solution 15 mg/ml injection 8 QLL (120 ML per 30 days); AL (Min 17 Years)

12 ketorolac tromethamine solution 30 mg/ml injection ketorolac tromethamine solution 30 mg/ml injection ketorolac tromethamine solution 60 mg/2ml injection ketorolac tromethamine solution 60 mg/2ml intramuscular ketorolac tromethamine solution 60 mg/2ml intramuscular meloxicam oral tablet nabumetone oral tablet naproxen dr oral tablet delayed release naproxen oral tablet NAPROSYN ORAL TABLET *Pyrimidine Synthesis Inhibitors*** leflunomide oral tablet *ANALGESICS - NONNARCOTIC* *Analgesics Other*** 8 hour arthritis pain reliever oral tablet extended release Mobic EC-Naprosyn Naprosyn Naproxen Arava Tylenol 8 Hour QLL (120 ML per 30 days); AL (Min 17 Years) QLL (60 ML per 30 days); AL (Min 17 Years) QLL (60 ML per 30 days); AL (Min 17 Years) 8 hour pain relief oral tablet extended release Tylenol 8 Hour acetaminophen er oral tablet extended release Tylenol 8 Hour acetaminophen oral liquid Little Remedies for Fever ; AL (Max 6 Years) arthritis pain relief oral tablet extended release Tylenol 8 Hour childrens acetaminophen oral suspension Mapap Childrens ; AL (Max 6 Years) childrens silapap oral liquid Little Remedies for Fever ; AL (Max 6 Years) ed-apap oral liquid Little Remedies for Fever ; AL (Max 6 Years) gnp 8 hour pain reliever oral tablet extended release Tylenol 8 Hour gnp arthritis pain relief oral tablet extended release Tylenol 8 Hour gnp childrens pain relief oral suspension Mapap Childrens ; AL (Max 6 Years) gnp infants pain relief oral suspension Mapap Childrens ; AL (Max 6 Years) gnp infants pain/fever oral suspension Mapap Childrens ; AL (Max 6 Years) gnp pain & fever childrens oral suspension Mapap Childrens ; AL (Max 6 Years) goodsense arthritis pain oral tablet extended release Tylenol 8 Hour goodsense pain & fever child oral suspension Mapap Childrens ; AL (Max 6 Years) 9

13 goodsense pain relief oral tablet extended release Tylenol 8 Hour hm arthritis pain relief oral tablet extended release Tylenol 8 Hour hm pain & fever childrens oral suspension Mapap Childrens ; AL (Max 6 Years) hm pain & fever infants oral suspension Mapap Childrens ; AL (Max 6 Years) mapap arthritis pain oral tablet extended release Tylenol 8 Hour mapap oral liquid Little Remedies for Fever ; AL (Max 6 Years) non-aspirin childrens oral suspension Mapap Childrens ; AL (Max 6 Years) pain & fever childrens oral solution ; AL (Max 6 Years) pain & fever childrens oral suspension Mapap Childrens ; AL (Max 6 Years) pain & fever infants oral suspension Mapap Childrens ; AL (Max 6 Years) pain relief childrens oral suspension Mapap Childrens ; AL (Max 6 Years) qc arthritis pain relief oral tablet extended release Tylenol 8 Hour qc non-aspirin childrens oral suspension Mapap Childrens ; AL (Max 6 Years) qc non-aspirin jr strength oral tablet dispersible Junior Mapap ; AL (Max 6 Years) qc pain relief childrens oral suspension Mapap Childrens qc pain relief infants oral suspension Mapap Childrens sm 8 hour pain relief oral tablet extended release Tylenol 8 Hour sm arthritis pain relief oral tablet extended release Tylenol 8 Hour sm pain & fever childrens oral suspension Mapap Childrens ; AL (Max 6 Years) sm pain & fever infants oral suspension Mapap Childrens ; AL (Max 6 Years) JUNIOR MAP ORAL TABLET DISPERSIBLE MAP CHILDRENS ORAL TABLET CHEWABLE *Analgesics-Sedatives*** butalbital-acetaminophen oral tablet butalbital-apap-caffeine oral capsule butalbital-apap-caffeine oral tablet butalbital-aspirin-caffeine oral capsule *Salicylates*** Acetaminophen Junior Strength CVS Non-Aspirin Jr Tencon Fioricet Esgic Fiorinal ; AL (Max 6 Years) aspir-81 oral tablet delayed release Aspir-Low aspirin adult low strength oral tablet chewable Bayer Low Dose 10

14 aspirin ec low dose oral tablet delayed release Aspir-Low aspirin ec low strength oral tablet delayed release Aspir-Low aspirin ec oral tablet delayed release Aspir-Low aspirin low dose oral tablet chewable Bayer Low Dose aspirin low dose oral tablet delayed release Aspir-Low aspirin oral tablet Bayer Advanced Aspirin Reg St aspirin oral tablet chewable Bayer Low Dose aspirin oral tablet delayed release Aspir-Low aspirin rectal suppository childrens aspirin low strength oral tablet chewable Bayer Low Dose childrens aspirin oral tablet chewable Bayer Low Dose gnp adult aspirin low strength oral tablet chewable Bayer Low Dose gnp aspirin low dose oral tablet delayed release Aspir-Low gnp aspirin oral tablet Bayer Advanced Aspirin Reg St gnp aspirin oral tablet delayed release Bayer Aspirin Regimen goodsense aspirin oral tablet Bayer Advanced Aspirin Reg St goodsense aspirin oral tablet chewable Bayer Low Dose hm aspirin ec low dose oral tablet delayed release Aspir-Low hm aspirin ec oral tablet delayed release Bayer Aspirin Regimen hm aspirin oral tablet Bayer Advanced Aspirin Reg St hm aspirin oral tablet chewable Bayer Low Dose qc aspirin low dose oral tablet chewable Bayer Low Dose qc aspirin oral tablet Bayer Advanced Aspirin Reg St qc enteric aspirin oral tablet delayed release Bayer Aspirin Regimen salsalate oral tablet sb aspirin adult low strength oral tablet delayed release Aspir-Low sb aspirin oral tablet Bayer Advanced Aspirin Reg St sb aspirin oral tablet delayed release Aspir-Low sb childrens aspirin oral tablet chewable Bayer Low Dose 11

15 sb low dose asa ec oral tablet delayed release Aspir-Low sm aspirin adult low strength oral tablet chewable Bayer Low Dose sm aspirin adult low strength oral tablet delayed release Aspir-Low sm aspirin ec oral tablet delayed release Bayer Aspirin Regimen sm aspirin oral tablet Bayer Advanced Aspirin Reg St sm childrens aspirin oral tablet chewable Bayer Low Dose ASPIR-LOW ORAL TABLET DELAYED RELEASE HM Aspirin EC Low Dose ECPIRIN ORAL TABLET DELAYED RELEASE Meijer Aspirin EC *ANALGESICS - OPIOID* *Codeine Combinations*** acetaminophen-codeine #2 oral tablet acetaminophen-codeine #3 oral tablet Tylenol with Codeine #3 QLL (360 EA per 30 days); AL (Min 6 Years) acetaminophen-codeine #4 oral tablet Tylenol with Codeine #4 QLL (360 EA per 30 days); AL (Min 6 Years) acetaminophen-codeine oral solution acetaminophen-codeine tablet mg oral acetaminophen-codeine tablet mg oral Tylenol with Codeine #4 QLL (360 EA per 30 days); AL (Min 6 Years) butalbital-apap-caff-cod oral capsule *Hydrocodone Combinations*** hydrocodone-acetaminophen oral solution Hycet hydrocodone-acetaminophen tablet mg Vicodin HP oral hydrocodone-acetaminophen tablet mg Vicodin HP oral QLL (180 EA per 30 days) hydrocodone-acetaminophen tablet mg Norco oral hydrocodone-acetaminophen tablet mg oral Verdrocet hydrocodone-acetaminophen tablet mg oral Vicodin hydrocodone-acetaminophen tablet mg oral Lorcet hydrocodone-acetaminophen tablet mg oral Vicodin ES 12

16 hydrocodone-acetaminophen tablet mg oral Vicodin ES QLL (180 EA per 30 days) hydrocodone-acetaminophen tablet mg oral Lorcet Plus hydrocodone-ibuprofen oral tablet Ibudone VICODIN ES ORAL TABLET Hydrocodone-Acetaminophen QLL (180 EA per 30 days) VICODIN HP ORAL TABLET Hydrocodone-Acetaminophen QLL (180 EA per 30 days) VICODIN ORAL TABLET Hydrocodone-Acetaminophen *Opioid Agonists*** codeine sulfate oral tablet fentanyl transdermal patch 72 hour Duragesic-12 QLL (10 EA per 30 days) hydromorphone hcl injection solution Dilaudid hydromorphone hcl oral tablet Dilaudid morphine sulfate (concentrate) oral solution morphine sulfate oral solution morphine sulfate oral tablet oxycodone hcl oral solution oxycodone hcl oral tablet Roxicodone tramadol hcl oral tablet Ultram QLL (240 EA per 30 days) ARYMO ER ORAL TABLET EXTENDED RELEASE ABUSE-DETERRENT AL (Min 18 Years) EMBEDA ORAL CAPSULE EXTENDED RELEASE HYSINGLA ER ORAL TABLET ER 24 HOUR ABUSE-DETERRENT MORPHABOND ER ORAL TABLET ER 12 HOUR ABUSE-DETERRENT XTAMPZA ER ORAL CAPSULE ER 12 HOUR ABUSE-DETERRENT *Opioid Combinations*** oxycodone-acetaminophen oral solution oxycodone-acetaminophen oral tablet *Opioid Partial Agonists*** buprenorphine hcl sublingual tablet sublingual buprenorphine transdermal patch weekly BUTRANS TRANSDERMAL TCH WEEKLY SUBOXONE SUBLINGUAL FILM Endocet Butrans Buprenorphine QLL (60 EA per 30 days); AL (Min 18 Years) Maximum of 1 fill every 28 days.; QLL (120 EA per 30 days); AL (Min 18 Years) 13

17 *ANDROGENS-ANABOLIC* *Androgens*** danazol oral capsule testosterone cypionate intramuscular solution Depo-Testosterone testosterone enanthate intramuscular solution ANDROGEL PUMP TRANSDERMAL GEL ; M; AL (Min 18 Years) ANDROGEL TRANSDERMAL GEL Testosterone ; M; AL (Min 18 Years) *ANORECTAL AGENTS* *Intrarectal Steroids*** hydrocortisone rectal enema Colocort *Rectal Anesthetic/Steroids*** lidocaine-hydrocortisone ace rectal gel lidocaine-hydrocortisone ace rectal kit Ana-Lex PROCTOFOAM HC RECTAL FOAM *Rectal Steroids*** hydrocortisone rectal cream Proctocort ANUSOL-HC RECTAL CREAM Hydrocortisone PROCTO-K RECTAL CREAM Hydrocortisone PROCTOSOL HC RECTAL CREAM Hydrocortisone PROCTOZONE-HC RECTAL CREAM Hydrocortisone *ANTACIDS* *Antacids - Calcium Salts*** antacid calcium oral tablet chewable Tums antacid extra strength oral tablet chewable Tums Smoothies antacid oral tablet chewable Tums calcium antacid extra strength oral tablet chewable Tums Smoothies calcium antacid oral tablet chewable Tums calcium antacid ultra max st oral tablet chewable Tums Ultra 1000 calcium antacid ultra oral tablet chewable Tums Ultra 1000 calcium antacid ultra strength oral tablet chewable Tums Ultra 1000 calcium carbonate antacid oral tablet gnp antacid extra strength oral tablet chewable Tums Smoothies hm calcium antacid ex st oral tablet chewable Tums Smoothies 14

18 hm calcium antacid oral tablet chewable Tums hm calcium antacid ultra st oral tablet chewable Tums Ultra 1000 sb antacid extra strength oral tablet chewable Tums Smoothies sb antacid oral tablet chewable Tums sm calcium antacid ex st oral tablet chewable Tums Smoothies sm calcium antacid oral tablet chewable Tums sm calcium antacid ultra st oral tablet chewable Tums Ultra 1000 CAL-GEST ANTACID ORAL TABLET CHEWABLE RA Antacid TUMS CHEWY DELIGHTS ORAL TABLET CHEWABLE Antacid Soft Chews TUMS E-X 750 ORAL TABLET CHEWABLE CVS Smooth Antacid Extra St TUMS FRESHERS ORAL TABLET CHEWABLE RA Antacid TUMS KIDS ORAL TABLET CHEWABLE CVS Smooth Antacid Extra St TUMS ORAL TABLET CHEWABLE RA Antacid TUMS SMOOTHIES ORAL TABLET CHEWABLE CVS Smooth Antacid Extra St TUMS ULTRA 1000 ORAL TABLET CHEWABLE Antacid Ultra Strength *ANTHELMINTICS* *Anthelmintics*** ALBENZA ORAL TABLET BILTRICIDE ORAL TABLET STROMECTOL ORAL TABLET Ivermectin *ANTIANGINAL AGENTS* *Antianginals-Other*** RANEXA ORAL TABLET EXTENDED RELEASE 12 HOUR *Nitrates*** isosorbide dinitrate oral tablet Isordil Titradose isosorbide mononitrate er oral tablet extended release 24 hour isosorbide mononitrate oral tablet nitroglycerin er oral capsule extended release Nitro-Time nitroglycerin transdermal patch 24 hour Minitran 15

19 NITROSTAT SUBLINGUAL TABLET SUBLINGUAL Nitroglycerin *ANTIANXIETY AGENTS* *Antianxiety Agents - Misc.*** buspirone hcl oral tablet droperidol injection solution hydroxyzine hcl intramuscular solution hydroxyzine hcl oral syrup hydroxyzine hcl oral tablet hydroxyzine pamoate oral capsule Vistaril *Benzodiazepines*** alprazolam oral tablet Xanax QLL (150 EA per 30 days); AL (Min 7 Years) chlordiazepoxide hcl oral capsule clorazepate dipotassium oral tablet diazepam oral solution diazepam oral tablet Valium lorazepam injection solution Ativan lorazepam oral concentrate LORazepam Intensol lorazepam oral tablet Ativan QLL (150 EA per 30 days) oxazepam oral capsule LORAZEM INTENSOL ORAL CONCENTRATE LORazepam *ANTIARRHYTHMICS* *Antiarrhythmics Type I-A*** disopyramide phosphate oral capsule Norpace quinidine gluconate er oral tablet extended release quinidine sulfate oral tablet *Antiarrhythmics Type I-B*** mexiletine hcl oral capsule *Antiarrhythmics Type I-C*** flecainide acetate oral tablet propafenone hcl oral tablet *Antiarrhythmics Type Iii*** amiodarone hcl oral tablet Pacerone TIKOSYN ORAL CAPSULE Dofetilide 16

20 *ANTIASTHMATIC AND BRONCHODILATOR AGENTS* *Adrenergic Combinations*** ipratropium-albuterol inhalation solution ADVAIR DISKUS INHALATION AEROSOL POWDER BREATH ACTIVATED ADVAIR HFA INHALATION AEROSOL DULERA INHALATION AEROSOL STIOLTO RESPIMAT INHALATION AEROSOL SOLUTION SYMBICORT INHALATION AEROSOL *Anti-Inflammatory Agents*** cromolyn sodium inhalation nebulization solution *Beta Adrenergics*** albuterol sulfate inhalation nebulization solution albuterol sulfate oral syrup terbutaline sulfate injection solution PROAIR HFA INHALATION AEROSOL SOLUTION PROVENTIL HFA INHALATION AEROSOL SOLUTION SEREVENT DISKUS INHALATION AEROSOL POWDER BREATH ACTIVATED *Bronchodilators - Anticholinergics*** ipratropium bromide inhalation solution ATROVENT HFA INHALATION AEROSOL SOLUTION SPIRIVA HANDIHALER INHALATION CAPSULE *Leukotriene Receptor Antagonists*** QLL (28 EA per 28 days); AL (Min 4 Years) QLL (25.8 GM per 30 days) QLL (30 EA per 30 days); AL (Min 18 Years) montelukast sodium oral packet Singulair AL (Max 4 Years) montelukast sodium tablet 10 mg oral Singulair montelukast sodium tablet 10 mg oral Singulair QLL (30 EA per 30 days) montelukast sodium tablet chewable 4 mg oral Singulair 17

21 montelukast sodium tablet chewable 5 mg oral Singulair QLL (30 EA per 30 days) zafirlukast oral tablet Accolate QLL (90 EA per 30 days) *Selective Phosphodiesterase 4 (Pde4) Inhibitors*** DALIRESP ORAL TABLET *Steroid Inhalants*** budesonide inhalation suspension ASMANEX 120 METERED DOSES INHALATION AEROSOL POWDER BREATH ACTIVATED ASMANEX 14 METERED DOSES INHALATION AEROSOL POWDER BREATH ACTIVATED ASMANEX 30 METERED DOSES INHALATION AEROSOL POWDER BREATH ACTIVATED ASMANEX 60 METERED DOSES INHALATION AEROSOL POWDER BREATH ACTIVATED ASMANEX 7 METERED DOSES INHALATION AEROSOL POWDER BREATH ACTIVATED FLOVENT DISKUS INHALATION AEROSOL POWDER BREATH ACTIVATED FLOVENT HFA AEROSOL 110 MCG/ACT INHALATION FLOVENT HFA AEROSOL 220 MCG/ACT INHALATION FLOVENT HFA AEROSOL 44 MCG/ACT INHALATION QVAR INHALATION AEROSOL SOLUTION *Xanthines*** theophylline er oral tablet extended release 12 hour theophylline er oral tablet extended release 24 hour theophylline oral solution ELIXOPHYLLIN ORAL ELIXIR Pulmicort Theochron ; QLL (30 EA per 30 days); AL (Min 18 Years) QLL (120 ML per 30 days); AL (Min 1 Years and Max 8 Years) AL (Min 4 Years) AL (Min 4 Years) AL (Min 4 Years) AL (Min 4 Years) AL (Min 4 Years) AL (Min 4 Years) QLL (24 GM per 30 days) QLL (24 GM per 30 days) QLL (21.2 GM per 30 days) AL (Min 5 Years) 18

22 THEO-24 ORAL CAPSULE EXTENDED RELEASE 24 HOUR *ANTICOAGULANTS* *Coumarin Anticoagulants*** warfarin sodium oral tablet Jantoven QLL (120 EA per 30 days) COUMADIN ORAL TABLET Warfarin Sodium QLL (120 EA per 30 days) JANTOVEN ORAL TABLET Warfarin Sodium QLL (120 EA per 30 days) *Direct Factor Xa Inhibitors*** ELIQUIS TABLET 2.5 MG ORAL QLL (60 EA per 30 days); AL (Min 18 Years) ELIQUIS TABLET 5 MG ORAL ELIQUIS TABLET 5 MG ORAL QLL (74 EA per 30 days); AL (Min 18 Years) SAVAYSA ORAL TABLET QLL (30 EA per 30 days); AL (Min 18 Years) XARELTO ORAL TABLET *Heparins And Heparinoid-Like Agents*** heparin (porcine) in d5w intravenous solution heparin (porcine) in nacl injection solution heparin lock flush intravenous solution heparin sod (porcine) in d5w intravenous solution heparin sodium (porcine) injection solution heparin sodium (porcine) pf injection solution *Low Molecular Weight Heparins*** enoxaparin sodium injection solution Lovenox QLL (180 ML per 30 days) enoxaparin sodium solution 100 mg/ml subcutaneous Lovenox QLL (60 ML per 30 days) enoxaparin sodium solution 120 mg/0.8ml subcutaneous Lovenox QLL (48 ML per 30 days) enoxaparin sodium solution 150 mg/ml subcutaneous Lovenox QLL (60 ML per 30 days) enoxaparin sodium solution 30 mg/0.3ml subcutaneous Lovenox QLL (18 ML per 30 days) enoxaparin sodium solution 40 mg/0.4ml subcutaneous Lovenox QLL (24 ML per 30 days) enoxaparin sodium solution 60 mg/0.6ml subcutaneous Lovenox QLL (36 ML per 30 days) enoxaparin sodium solution 80 mg/0.8ml subcutaneous Lovenox QLL (48 ML per 30 days) 19

23 *Thrombin Inhibitors - Selective Direct & Reversible*** PRADAXA ORAL CAPSULE *ANTICONVULSANTS* *Anticonvulsants - Benzodiazepines*** clonazepam oral tablet dispersible clonazepam tablet 0.5 mg oral KlonoPIN QLL (90 EA per 30 days) clonazepam tablet 1 mg oral KlonoPIN clonazepam tablet 1 mg oral KlonoPIN QLL (90 EA per 30 days) clonazepam tablet 2 mg oral KlonoPIN QLL (90 EA per 30 days) diazepam rectal gel Diastat AcuDial *Anticonvulsants - Misc.*** carbamazepine er oral capsule extended release 12 hour Carbatrol carbamazepine er oral tablet extended release TEGretol-XR 12 hour carbamazepine oral suspension TEGretol carbamazepine oral tablet chewable carbamazepine tablet 200 mg oral Epitol carbamazepine tablet 200 mg oral Epitol gabapentin capsule 100 mg oral Neurontin gabapentin capsule 100 mg oral Neurontin gabapentin capsule 300 mg oral Neurontin gabapentin capsule 300 mg oral Neurontin gabapentin capsule 400 mg oral Neurontin gabapentin capsule 400 mg oral Neurontin gabapentin oral solution Neurontin gabapentin oral tablet Neurontin lamotrigine oral tablet chewable LaMICtal ; AL (Min 13 Years) lamotrigine oral tablet dispersible LaMICtal ODT lamotrigine tablet 100 mg oral LaMICtal lamotrigine tablet 100 mg oral LaMICtal lamotrigine tablet 150 mg oral LaMICtal lamotrigine tablet 150 mg oral LaMICtal lamotrigine tablet 200 mg oral LaMICtal lamotrigine tablet 200 mg oral LaMICtal lamotrigine tablet 25 mg oral LaMICtal 20

24 lamotrigine tablet 25 mg oral LaMICtal levetiracetam er oral tablet extended release 24 hour Keppra XR levetiracetam oral solution Keppra levetiracetam oral tablet Keppra levetiracetam solution 500 mg/5ml intravenous Keppra levetiracetam solution 500 mg/5ml intravenous Keppra oxcarbazepine oral suspension Trileptal oxcarbazepine oral tablet Trileptal primidone tablet 250 mg oral Mysoline primidone tablet 250 mg oral Mysoline primidone tablet 50 mg oral Mysoline primidone tablet 50 mg oral Mysoline topiramate oral capsule sprinkle Topamax Sprinkle topiramate oral tablet Topamax zonisamide capsule 100 mg oral Zonegran zonisamide capsule 100 mg oral Zonegran zonisamide capsule 25 mg oral Zonegran zonisamide capsule 50 mg oral APTIOM ORAL TABLET ; AL (Min 18 Years) CARBATROL ORAL CAPSULE EXTENDED RELEASE 12 HOUR CarBAMazepine ER EPITOL ORAL TABLET CarBAMazepine KEPPRA ORAL SOLUTION LevETIRAcetam KEPPRA ORAL TABLET LevETIRAcetam KEPPRA XR ORAL TABLET EXTENDED RELEASE 24 HOUR LevETIRAcetam ER LAMICTAL ORAL TABLET LamoTRIgine LAMICTAL ORAL TABLET CHEWABLE LamoTRIgine ; AL (Min 13 Years) LAMICTAL STARTER KIT 25 (35) MG ORAL LamoTRIgine Starter Kit-Blue LAMICTAL STARTER KIT 25 (42)-100 (7) MG ORAL LAMICTAL STARTER KIT 25 (84)- 100(14) MG ORAL LYRICA CAPSULE 100 MG ORAL LYRICA CAPSULE 150 MG ORAL LamoTRIgine Starter Kit- Orange LamoTRIgine Starter Kit- Green ; QLL (1 FILL per 28 days) QLL (180 EA per 30 days) QLL (120 EA per 30 days) 21

25 LYRICA CAPSULE 200 MG ORAL LYRICA CAPSULE 225 MG ORAL LYRICA CAPSULE 25 MG ORAL LYRICA CAPSULE 300 MG ORAL LYRICA CAPSULE 50 MG ORAL LYRICA CAPSULE 75 MG ORAL MYSOLINE ORAL TABLET Primidone NEURONTIN ORAL CAPSULE Gabapentin NEURONTIN ORAL SOLUTION Gabapentin NEURONTIN ORAL TABLET Gabapentin ROWEEPRA ORAL TABLET LevETIRAcetam TEGRETOL ORAL SUSPENSION CarBAMazepine TEGRETOL ORAL TABLET CarBAMazepine TEGRETOL-XR ORAL TABLET EXTENDED RELEASE 12 HOUR CarBAMazepine ER TOMAX ORAL TABLET Topiramate TOMAX SPRINKLE ORAL CAPSULE Topiramate SPRINKLE TRILEPTAL ORAL SUSPENSION OXcarbazepine TRILEPTAL ORAL TABLET OXcarbazepine VIMT ORAL SOLUTION VIMT ORAL TABLET ZONEGRAN ORAL CAPSULE Zonisamide *Carbamates*** felbamate oral tablet Felbatol felbamate suspension 600 mg/5ml oral Felbatol felbamate suspension 600 mg/5ml oral Felbatol FELBATOL ORAL SUSPENSION Felbamate FELBATOL ORAL TABLET Felbamate *Gaba Modulators*** tiagabine hcl oral tablet Gabitril GABITRIL ORAL TABLET TiaGABine HCl *Hydantoins*** phenytoin oral suspension Dilantin phenytoin oral tablet chewable Dilantin Infatabs phenytoin sodium extended oral capsule Dilantin DILANTIN INFATABS ORAL TABLET CHEWABLE Phenytoin DILANTIN ORAL CAPSULE 22 QLL (90 EA per 30 days) QLL (60 EA per 30 days) QLL (720 EA per 30 days) QLL (60 EA per 30 days) QLL (360 EA per 30 days) QLL (240 EA per 30 days)

26 DILANTIN ORAL SUSPENSION Phenytoin PEGANONE ORAL TABLET PHENYTEK ORAL CAPSULE Phenytoin Sodium Extended PHENYTOIN INFATABS ORAL TABLET Phenytoin CHEWABLE *Succinimides*** ethosuximide capsule 250 mg oral Zarontin ethosuximide capsule 250 mg oral Zarontin ethosuximide oral solution Zarontin CELONTIN ORAL CAPSULE ZARONTIN ORAL CAPSULE Ethosuximide ZARONTIN ORAL SOLUTION Ethosuximide *Valproic Acid*** divalproex sodium er tablet extended release 24 hour 250 mg oral Depakote ER divalproex sodium er tablet extended release 24 hour 250 mg oral Depakote ER divalproex sodium er tablet extended release 24 hour 500 mg oral Depakote ER divalproex sodium oral capsule delayed release sprinkle Depakote Sprinkles divalproex sodium oral tablet delayed release Depakote valproate sodium solution 250 mg/5ml oral Depakene valproate sodium solution 250 mg/5ml oral Depakene valproic acid oral capsule Depakene valproic acid oral solution Depakene DEKENE ORAL CAPSULE Valproic Acid DEKENE ORAL SOLUTION Valproate Sodium DEKOTE ER ORAL TABLET EXTENDED RELEASE 24 HOUR Divalproex Sodium ER DEKOTE ORAL TABLET DELAYED RELEASE Divalproex Sodium DEKOTE SPRINKLES ORAL CAPSULE DELAYED RELEASE Divalproex Sodium SPRINKLE *ANTIDEPRESSANTS* *Alpha-2 Receptor Antagonists (Tetracyclics)*** mirtazapine tablet 15 mg oral Remeron mirtazapine tablet 15 mg oral Remeron AL (Min 6 Years) 23

27 mirtazapine tablet 30 mg oral Remeron mirtazapine tablet 30 mg oral Remeron AL (Min 6 Years) mirtazapine tablet 45 mg oral Remeron mirtazapine tablet 45 mg oral Remeron AL (Min 6 Years) mirtazapine tablet 7.5 mg oral mirtazapine tablet 7.5 mg oral AL (Min 6 Years) mirtazapine tablet dispersible 15 mg oral Remeron SolTab AL (Min 6 Years) mirtazapine tablet dispersible 30 mg oral Remeron SolTab AL (Min 6 Years) mirtazapine tablet dispersible 45 mg oral Remeron SolTab mirtazapine tablet dispersible 45 mg oral Remeron SolTab AL (Min 6 Years) *Antidepressants - Misc.*** bupropion hcl er (sr) tablet extended release 12 hour 100 mg oral Wellbutrin SR QLL (60 EA per 30 days) bupropion hcl er (sr) tablet extended release 12 hour 150 mg oral Wellbutrin SR bupropion hcl er (sr) tablet extended release 12 hour 150 mg oral Wellbutrin SR QLL (60 EA per 30 days) bupropion hcl er (sr) tablet extended release 12 hour 200 mg oral Wellbutrin SR QLL (60 EA per 30 days) bupropion hcl er (xl) tablet extended release 24 hour 150 mg oral Wellbutrin XL bupropion hcl er (xl) tablet extended release 24 hour 150 mg oral Wellbutrin XL QLL (30 EA per 30 days) bupropion hcl er (xl) tablet extended release 24 hour 300 mg oral Wellbutrin XL bupropion hcl er (xl) tablet extended release 24 hour 300 mg oral Wellbutrin XL QLL (30 EA per 30 days) bupropion hcl oral tablet *Modified Cyclics*** trazodone hcl oral tablet TRINTELLIX ORAL TABLET ; QLL (30 EA per 30 days); AL (Min 18 Years) VIIBRYD ORAL TABLET VIIBRYD STARTER CK ORAL KIT AL (Min 18 Years) *Selective Serotonin Reuptake Inhibitors (Ssris)*** citalopram hydrobromide oral solution QLL (900 ML per 30 days); AL (Min 6 Years and Max 11 Years) citalopram hydrobromide tablet 10 mg oral CeleXA citalopram hydrobromide tablet 20 mg oral CeleXA 24

28 citalopram hydrobromide tablet 20 mg oral CeleXA QLL (30 EA per 30 days); AL (Min 6 Years) citalopram hydrobromide tablet 40 mg oral CeleXA citalopram hydrobromide tablet 40 mg oral CeleXA QLL (30 EA per 30 days); AL (Min 6 Years) escitalopram oxalate tablet 10 mg oral Lexapro escitalopram oxalate tablet 10 mg oral Lexapro QLL (30 EA per 30 days); AL (Min 6 Years) escitalopram oxalate tablet 20 mg oral Lexapro escitalopram oxalate tablet 20 mg oral Lexapro QLL (30 EA per 30 days); AL (Min 6 Years) escitalopram oxalate tablet 5 mg oral Lexapro QLL (30 EA per 30 days); AL (Min 6 Years) fluoxetine hcl capsule 10 mg oral PROzac fluoxetine hcl capsule 10 mg oral PROzac AL (Min 6 Years) fluoxetine hcl capsule 20 mg oral PROzac AL (Min 6 Years) fluoxetine hcl capsule 40 mg oral PROzac AL (Min 6 Years) fluoxetine hcl oral capsule 10 mg PROzac fluoxetine hcl oral solution fluvoxamine maleate oral tablet paroxetine hcl tablet 10 mg oral Paxil paroxetine hcl tablet 10 mg oral Paxil QLL (60 EA per 30 days); AL (Min 6 Years) paroxetine hcl tablet 20 mg oral Paxil paroxetine hcl tablet 20 mg oral Paxil QLL (60 EA per 30 days); AL (Min 6 Years) paroxetine hcl tablet 30 mg oral Paxil paroxetine hcl tablet 30 mg oral Paxil QLL (60 EA per 30 days); AL (Min 6 Years) paroxetine hcl tablet 40 mg oral Paxil paroxetine hcl tablet 40 mg oral Paxil QLL (60 EA per 30 days); AL (Min 6 Years) sertraline hcl oral concentrate Zoloft QLL (300 ML per 30 days); AL (Min 6 Years and Max 11 Years) sertraline hcl oral tablet Zoloft *Serotonin-Norepinephrine Reuptake Inhibitors (Snris)*** duloxetine hcl capsule delayed release particles 20 mg oral Cymbalta 25

29 duloxetine hcl capsule delayed release particles 20 mg oral duloxetine hcl capsule delayed release particles 30 mg oral duloxetine hcl capsule delayed release particles 30 mg oral duloxetine hcl capsule delayed release particles 40 mg oral duloxetine hcl capsule delayed release particles 60 mg oral duloxetine hcl capsule delayed release particles 60 mg oral venlafaxine hcl er capsule extended release 24 hour 150 mg oral venlafaxine hcl er capsule extended release 24 hour 150 mg oral venlafaxine hcl er capsule extended release 24 hour 37.5 mg oral venlafaxine hcl er capsule extended release 24 hour 37.5 mg oral venlafaxine hcl er capsule extended release 24 hour 75 mg oral venlafaxine hcl er capsule extended release 24 hour 75 mg oral venlafaxine hcl oral tablet PRISTIQ ORAL TABLET EXTENDED RELEASE 24 HOUR *Tricyclic Agents*** amitriptyline hcl oral tablet amoxapine oral tablet clomipramine hcl capsule 25 mg oral Cymbalta Cymbalta Cymbalta Cymbalta Cymbalta Effexor XR Effexor XR Effexor XR Effexor XR Effexor XR Effexor XR Desvenlafaxine Succinate ER QLL (60 EA per 30 days); AL (Min 6 Years) QLL (60 EA per 30 days); AL (Min 6 Years) AL (Min 6 Years) QLL (60 EA per 30 days); AL (Min 6 Years) QLL (30 EA per 30 days); AL (Min 6 Years) QLL (30 EA per 30 days); AL (Min 6 Years) QLL (90 EA per 30 days); AL (Min 6 Years) ; QLL (30 EA per 30 days); AL (Min 18 Years) Anafranil clomipramine hcl capsule 25 mg oral Anafranil AL (Min 6 Years) clomipramine hcl capsule 50 mg oral Anafranil clomipramine hcl capsule 50 mg oral Anafranil AL (Min 6 Years) clomipramine hcl capsule 75 mg oral Anafranil clomipramine hcl capsule 75 mg oral Anafranil AL (Min 6 Years) desipramine hcl oral tablet Norpramin doxepin hcl oral capsule doxepin hcl oral concentrate imipramine hcl oral tablet Tofranil nortriptyline hcl capsule 10 mg oral Pamelor AL (Min 6 Years) 26

30 nortriptyline hcl capsule 25 mg oral Pamelor AL (Min 6 Years) nortriptyline hcl capsule 50 mg oral Pamelor nortriptyline hcl capsule 50 mg oral Pamelor AL (Min 6 Years) nortriptyline hcl capsule 75 mg oral Pamelor AL (Min 6 Years) nortriptyline hcl oral solution *ANTIDIABETICS* *Alpha-Glucosidase Inhibitors*** acarbose oral tablet miglitol oral tablet *Antidiabetic - Amylin Analogs*** SYMLINPEN 120 SUBCUTANEOUS SOLUTION PEN-INJECTOR SYMLINPEN 60 SUBCUTANEOUS SOLUTION PEN-INJECTOR *Biguanides*** metformin hcl er oral tablet extended release 24 hour metformin hcl tablet 1000 mg oral metformin hcl tablet 500 mg oral metformin hcl tablet 850 mg oral metformin hcl tablet 850 mg oral *Diabetic Other*** GLUCAGEN HYPOKIT INJECTION SOLUTION RECONSTITUTED GLUCAGON EMERGENCY INJECTION KIT PROGLYCEM ORAL SUSPENSION *Dipeptidyl Peptidase-4 (Dpp-4) Inhibitors*** alogliptin benzoate oral tablet JANUVIA TABLET 100 MG ORAL JANUVIA TABLET 25 MG ORAL JANUVIA TABLET 50 MG ORAL Precose Glyset Glucophage XR Glucophage Glucophage Glucophage Glucophage Nesina Maintenance drugs with max 100 days supply; QLL (90 EA per 30 days) QLL (30 EA per 30 days); AL (Min 18 Years) QLL (60 EA per 30 days); AL (Min 18 Years) QLL (30 EA per 30 days); AL (Min 18 Years) QLL (30 EA per 30 days); AL (Min 18 Years) 27

31 ONGLYZA ORAL TABLET TRADJENTA ORAL TABLET *Dipeptidyl Peptidase-4 Inhibitor- Biguanide Combinations*** alogliptin-metformin hcl oral tablet JANUMET TABLET MG ORAL JANUMET TABLET MG ORAL JANUMET XR TABLET EXTENDED RELEASE 24 HOUR MG ORAL JANUMET XR TABLET EXTENDED RELEASE 24 HOUR MG ORAL JANUMET XR TABLET EXTENDED RELEASE 24 HOUR MG ORAL JENTADUETO ORAL TABLET JENTADUETO XR TABLET EXTENDED RELEASE 24 HOUR MG ORAL JENTADUETO XR TABLET EXTENDED RELEASE 24 HOUR MG ORAL KOMBIGLYZE XR TABLET EXTENDED RELEASE 24 HOUR MG ORAL KOMBIGLYZE XR TABLET EXTENDED RELEASE 24 HOUR MG ORAL KOMBIGLYZE XR TABLET EXTENDED RELEASE 24 HOUR MG ORAL *Dpp-4 Inhibitor-Thiazolidinedione Combinations*** alogliptin-pioglitazone oral tablet *Human Insulin*** HUMALOG KWIKPEN SUBCUTANEOUS SOLUTION PEN- INJECTOR HUMALOG MIX 50/50 KWIKPEN SUBCUTANEOUS SUSPENSION PEN- INJECTOR Kazano Oseni QLL (30 EA per 30 days); AL (Min 18 Years) QLL (30 EA per 30 days); AL (Min 18 Years) QLL (60 EA per 30 days); AL (Min 18 Years) AL (Min 18 Years) QLL (60 EA per 30 days); AL (Min 18 Years) QLL (30 EA per 30 days); AL (Min 18 Years) QLL (60 EA per 30 days); AL (Min 18 Years) AL (Min 18 Years) QLL (60 EA per 30 days); AL (Min 18 Years) QLL (60 EA per 30 days); AL (Min 18 Years) QLL (30 EA per 30 days); AL (Min 18 Years) QLL (60 EA per 30 days); AL (Min 18 Years) QLL (30 EA per 30 days); AL (Min 18 Years) QLL (30 EA per 30 days); AL (Min 18 Years) QLL (30 EA per 30 days); AL (Min 18 Years) 28

32 HUMALOG MIX 50/50 SUBCUTANEOUS SUSPENSION HUMALOG MIX 75/25 KWIKPEN SUBCUTANEOUS SUSPENSION PEN- INJECTOR HUMALOG MIX 75/25 SUBCUTANEOUS SUSPENSION HUMALOG SUBCUTANEOUS SOLUTION HUMALOG SUBCUTANEOUS SOLUTION CARTRIDGE HUMULIN 70/30 KWIKPEN SUBCUTANEOUS SUSPENSION PEN- INJECTOR HUMULIN 70/30 SUBCUTANEOUS SUSPENSION HUMULIN N KWIKPEN SUBCUTANEOUS SUSPENSION PEN- INJECTOR HUMULIN N SUBCUTANEOUS SUSPENSION HUMULIN R INJECTION SOLUTION LANTUS SOLOSTAR SUBCUTANEOUS SOLUTION PEN-INJECTOR LANTUS SUBCUTANEOUS SOLUTION LEVEMIR FLEXTOUCH SUBCUTANEOUS SOLUTION PEN- INJECTOR LEVEMIR SUBCUTANEOUS SOLUTION NOVOLIN 70/30 RELION SUBCUTANEOUS SUSPENSION NOVOLIN 70/30 SUBCUTANEOUS SUSPENSION NOVOLIN N RELION SUBCUTANEOUS SUSPENSION NOVOLIN N SUBCUTANEOUS SUSPENSION NOVOLIN R INJECTION SOLUTION NOVOLIN R RELION INJECTION SOLUTION NOVOLOG FLEXPEN SUBCUTANEOUS SOLUTION PEN-INJECTOR 29

33 NOVOLOG MIX 70/30 FLEXPEN SUBCUTANEOUS SUSPENSION PEN- INJECTOR NOVOLOG MIX 70/30 SUBCUTANEOUS SUSPENSION NOVOLOG PENFILL SUBCUTANEOUS SOLUTION CARTRIDGE NOVOLOG SUBCUTANEOUS SOLUTION *Incretin Mimetic Agents (Glp-1 Receptor Agonists)*** BYDUREON SUBCUTANEOUS SUSPENSION RECONSTITUTED ER BYETTA 10 MCG PEN SUBCUTANEOUS SOLUTION PEN-INJECTOR BYETTA 5 MCG PEN SUBCUTANEOUS SOLUTION PEN-INJECTOR *Meglitinide Analogues*** nateglinide oral tablet Starlix repaglinide oral tablet *Sodium-Glucose Co-Transporter 2 (Sglt2) Inhibitors*** FARXIGA ORAL TABLET INVOKANA ORAL TABLET *Sulfonylurea-Biguanide Combinations*** glipizide-metformin hcl oral tablet glyburide-metformin oral tablet *Sulfonylureas*** chlorpropamide oral tablet glimepiride tablet 1 mg oral Amaryl glimepiride tablet 2 mg oral Amaryl glimepiride tablet 4 mg oral Amaryl glimepiride tablet 4 mg oral Amaryl QLL (60 EA per 30 days) glipizide er oral tablet extended release 24 Glucotrol XL hour glipizide oral tablet Glucotrol glipizide xl oral tablet extended release 24 Glucotrol XL hour glyburide micronized oral tablet Glynase 30

34 glyburide oral tablet tolazamide oral tablet tolbutamide oral tablet *Thiazolidinedione-Biguanide Combinations*** pioglitazone hcl-metformin hcl oral tablet Actoplus Met *Thiazolidinediones*** pioglitazone hcl oral tablet Actos *ANTIDIARRHEALS* *Antiperistaltic Agents*** diphenoxylate-atropine oral tablet Lomotil loperamide hcl oral capsule Imodium A-D *ANTIDOTES AND SPECIFIC ANTAGONISTS* *Antidotes And Specific Antagonists*** acetylcysteine intravenous solution Acetadote QLL (1 ML per 365 days) deferoxamine mesylate injection solution reconstituted Desferal QLL (1 EA per 365 days) *ANTIDOTES* *Antidotes*** acetylcysteine intravenous solution Acetadote QLL (1 ML per 365 days) deferoxamine mesylate injection solution reconstituted Desferal QLL (1 EA per 365 days) *Opioid Antagonists*** naloxone hcl injection solution cartridge QLL (1 ML per 365 days) naloxone hcl injection solution prefilled syringe QLL (1 ML per 365 days) naloxone hcl solution 0.4 mg/ml injection naloxone hcl solution 0.4 mg/ml injection QLL (1 ML per 365 days) naloxone hcl solution 4 mg/10ml injection naloxone hcl solution 4 mg/10ml injection QLL (1 ML per 365 days) naltrexone hcl oral tablet QLL (1 EA per 365 days) NARCAN NASAL LIQUID QLL (2 EA per 365 days) *ANTIEMETICS* *5-Ht3 Receptor Antagonists*** ondansetron hcl injection solution ondansetron hcl oral solution Zofran QLL (600 ML per 28 days) 31

35 ondansetron hcl oral tablet Zofran ondansetron oral tablet dispersible Zofran ODT QLL (60 EA per 30 days) *Antiemetic Combinations*** DICLEGIS ORAL TABLET DELAYED RELEASE *Antiemetics - Anticholinergic*** meclizine hcl oral tablet *Substance P/Neurokinin 1 (Nk1) Receptor Antagonists*** aprepitant capsule 125 mg oral Emend QLL (2 EA per 28 days) aprepitant capsule 40 mg oral Emend QLL (4 EA per 28 days) aprepitant capsule 80 & 125 mg oral Emend Tri-Pack aprepitant capsule 80 mg oral Emend QLL (4 EA per 28 days) *ANTIFUNGALS* *Antifungal - Glucan Synthesis Inhibitors (Echinocandins)*** ERAXIS INTRAVENOUS SOLUTION RECONSTITUTED *Antifungals*** amphotericin b injection solution reconstituted griseofulvin microsize oral suspension nystatin oral tablet terbinafine hcl oral tablet LamISIL QLL (84 EA per 365 days) ABELCET INTRAVENOUS SUSPENSION *Triazoles*** fluconazole in dextrose intravenous solution fluconazole in sodium chloride intravenous solution fluconazole oral suspension reconstituted Diflucan fluconazole oral tablet Diflucan *ANTIHISTAMINES* *Antihistamines - Ethanolamines*** carbinoxamine maleate oral solution carbinoxamine maleate oral tablet clemastine fumarate oral tablet diphenhydramine hcl injection solution diphenhydramine hcl oral elixir 32

36 *Antihistamines - Non-Sedating*** all day allergy childrens oral solution ZyrTEC Childrens Allergy all day allergy childrens oral tablet chewable Wal-Zyr Childrens all day allergy oral tablet ZyrTEC Allergy allergy oral tablet Claritin allergy relief child oral syrup Wal-itin Childrens allergy relief childrens oral solution ZyrTEC Childrens Allergy allergy relief oral tablet Claritin allergy relief oral tablet dispersible Wal-vert cetirizine hcl allergy child oral solution ZyrTEC Childrens Allergy cetirizine hcl childrens alrgy oral syrup ZyrTEC Childrens Allergy cetirizine hcl childrens oral tablet chewable Wal-Zyr Childrens cetirizine hcl hives relief oral solution ZyrTEC Childrens Allergy cetirizine hcl oral solution ZyrTEC Childrens Allergy cetirizine hcl oral syrup ZyrTEC Childrens Allergy cetirizine hcl oral tablet cetirizine hcl oral tablet chewable Wal-Zyr Childrens childrens loratadine oral solution Wal-itin Childrens childrens loratadine oral syrup Wal-itin Childrens eq allergy relief oral tablet Claritin gnp all day allergy childrens oral solution ZyrTEC Childrens Allergy gnp all day allergy childrens oral syrup ZyrTEC Childrens Allergy gnp all day allergy oral tablet ZyrTEC Allergy gnp allergy relief oral tablet dispersible Wal-vert gnp loratadine childrens oral syrup Wal-itin Childrens gnp loratadine oral syrup Wal-itin Childrens gnp loratadine oral tablet Claritin goodsense all day allergy oral tablet ZyrTEC Allergy hm all day allergy oral tablet ZyrTEC Allergy hm allergy complete childrens oral solution ZyrTEC Childrens Allergy hm cetirizine hcl childrens oral solution ZyrTEC Childrens Allergy hm loratadine childrens oral syrup Wal-itin Childrens hm loratadine oral tablet Claritin loratadine childrens oral solution Wal-itin Childrens loratadine childrens oral syrup Wal-itin Childrens loratadine hives relief oral solution Wal-itin Childrens loratadine oral tablet Claritin qc all day allergy oral tablet ZyrTEC Allergy 33

37 qc loratadine allergy relief oral tablet Claritin sb allergy oral tablet ZyrTEC Allergy sb loratadine oral tablet Claritin sm all day allergy childrens oral solution ZyrTEC Childrens Allergy sm all day allergy oral tablet ZyrTEC Allergy sm allergy relief loratadine oral tablet Claritin sm childrens loratadine oral syrup Wal-itin Childrens sm loratadine oral syrup Wal-itin Childrens *Antihistamines - Phenothiazines*** promethazine hcl injection solution Phenergan promethazine hcl oral solution promethazine hcl oral syrup promethazine hcl oral tablet promethazine hcl rectal suppository Phenadoz *Antihistamines - Piperidines*** cyproheptadine hcl oral syrup cyproheptadine hcl oral tablet *ANTIHYPERLIPIDEMICS* *Bile Acid Sequestrants*** cholestyramine light oral packet Prevalite cholestyramine light oral powder Prevalite cholestyramine oral packet Questran cholestyramine oral powder Questran colestipol hcl oral tablet Colestid *Fibric Acid Derivatives*** fenofibrate oral tablet Tricor gemfibrozil oral tablet Lopid *Hmg Coa Reductase Inhibitors*** atorvastatin calcium tablet 10 mg oral Lipitor atorvastatin calcium tablet 10 mg oral Lipitor QLL (30 EA per 30 days) atorvastatin calcium tablet 20 mg oral Lipitor atorvastatin calcium tablet 20 mg oral Lipitor QLL (30 EA per 30 days) atorvastatin calcium tablet 40 mg oral Lipitor atorvastatin calcium tablet 40 mg oral Lipitor QLL (30 EA per 30 days) atorvastatin calcium tablet 80 mg oral Lipitor atorvastatin calcium tablet 80 mg oral Lipitor QLL (30 EA per 30 days) lovastatin oral tablet 34

38 pravastatin sodium oral tablet simvastatin oral tablet *Intestinal Cholesterol Absorption Inhibitors*** ezetimibe tablet 10 mg oral ezetimibe tablet 10 mg oral Zocor Zetia Zetia *Nicotinic Acid Derivatives*** niacin er (antihyperlipidemic) oral tablet Niaspan extended release NIACOR ORAL TABLET *ANTIHYPERTENSIVES* *Ace Inhibitor & Calcium Channel Blocker Combinations*** amlodipine besy-benazepril hcl oral capsule *Ace Inhibitors & Thiazide/Thiazide- Like*** enalapril-hydrochlorothiazide oral tablet fosinopril sodium-hctz oral tablet lisinopril-hydrochlorothiazide tablet Zestoretic mg oral lisinopril-hydrochlorothiazide tablet Zestoretic mg oral lisinopril-hydrochlorothiazide tablet Zestoretic mg oral lisinopril-hydrochlorothiazide tablet Zestoretic mg oral lisinopril-hydrochlorothiazide tablet mg Zestoretic oral lisinopril-hydrochlorothiazide tablet mg Zestoretic oral quinapril-hydrochlorothiazide oral tablet Accuretic *Ace Inhibitors*** benazepril hcl oral tablet captopril oral tablet enalapril maleate oral tablet Vasotec fosinopril sodium oral tablet lisinopril oral tablet Zestril quinapril hcl oral tablet Accupril ramipril capsule 1.25 mg oral Altace QLL (30 EA per 30 days); AL (Min 10 Years) Maintenance drugs with max 100 days supply Maintenance drugs with max 100 days supply Maintenance drugs with max 100 days supply 35