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

Transcription

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

2 AETNA BETTER HEALTH Formulary Guide What is the Aetna Better Health of Michigan Formulary? This is a drug list created by Aetna Better Health ( plan ). The plan will cover drugs on this list. Some drugs may have coverage rules. If the rules for that drug are met, the plan will cover the drug. Drugs must also be filled at a plan network pharmacy. Can the Plan s Drug List change? The plan may add or remove drugs on the list. All drug removals from the formulary will be sent to the state for review before the change is made. Utilizing members and their providers will be notified at least 30 days before a drug is removed from the formulary. All changes to the formulary will be posted on the plan s website. How do I use the Plan s Formulary? Column #1: lists the covered drug. Brand drugs are in upper case letters (e.g., DRUG). Generics are in lower case letters (e.g., drug). Column #2: shows coverage rules for the drug Drugs are also grouped by the type of condition they treat. Drugs used to treat an earache are listed under the section, Ear-Nose-Throat Medications. If you know what your drug is used for, please look for that section name on the drug list. Then look under that section for your drug. What are generic drugs? The plan covers both brand and generic drugs. Generic drugs cost less and are approved by the Food and Drug Administration (FDA). Are Over-The-Counter () drugs covered? The plan will cover drugs on the formulary. Some drugs may have coverage rules. If the rules for that drug are met, the plan will cover the drug. Like other drugs, drugs need a prescription from a doctor if they are to be covered by the plan. Updated: 12/01/2017 Page 2

3 AETNA BETTER HEALTH Formulary Guide Are there Medication Copays? Copays for brand drugs are $0 and copays for generic drugs are $0. What are some types of coverage rules? Prior Approval (): This means your doctor will need to get approval from the plan first before the drug can be filled at the pharmacy. If it is not approved, the plan will not cover the drug. Quantity Level Limits (QLL): This means there is a limit on the amount of drug the plan will cover. For example, the plan provides 60 pills in 30 days for some drugs. Step Therapy (ST): This means you may need to try certain drugs first to treat your condition. After the first drug is tried, the plan will then cover the other drug for that same condition. For example, Drug A and Drug B may treat your condition. The plan may not cover Drug B unless you try Drug A first. If Drug A does not work for you, then Drug B will be covered. What if my drug is not on the plan s Formulary? First, please call your doctor and ask if your drug is covered. If the plan does not cover the drug, then: Ask your doctor for a similar drug that is covered. Your doctor can ask the plan to cover your drug through the prior approval process. Updated: 12/01/2017 Page 3

4 Aetna Better Health Michigan Table of Contents *Adhd/Anti-Narcolepsy/Anti-Obesity/Anorexiants*... 3 *Alternative Medicines*...3 *Aminoglycosides*... 3 *Analgesics - Anti-Inflammatory*... 4 *Analgesics - Nonnarcotic*...5 *Analgesics - Opioid*... 6 *Androgens-Anabolic*... 9 *Anorectal Agents*...9 *Antacids*... 9 *Anthelmintics* *Antianginal Agents*...10 *Antianxiety Agents*...10 *Antiarrhythmics* *Antiasthmatic And Bronchodilator Agents* *Anticoagulants* *Antidiabetics* *Antidiarrheals*...17 *Antidotes*...18 *Antiemetics*...18 *Antifungals*...18 *Antihistamines*...19 *Antihyperlipidemics* *Antihypertensives* *Anti-Infective Agents - Misc.*...23 *Antimalarials*...24 *Antimycobacterial Agents* *Antineoplastics And Adjunctive Therapies*...25 *Antiparkinson Agents* *Antipsychotics/Antimanic Agents* *Antivirals*...28 *Assorted Classes* *Beta Blockers*...30 *Calcium Channel Blockers* *Cardiotonics* *Cardiovascular Agents - Misc.*...33 *Cephalosporins*...34 *Chemicals* *Contraceptives*...34 *Corticosteroids* *Cough/Cold/Allergy* *Dermatologicals* *Diagnostic Products* *Dietary Products/Dietary Management Products*...44 *Digestive Aids* *Diuretics*...45 *Endocrine And Metabolic Agents - Misc.*

5 *Estrogens*...47 *Fluoroquinolones* *Gastrointestinal Agents - Misc.* *Genitourinary Agents - Miscellaneous* *Gout Agents* *Hematological Agents - Misc.*...51 *Hematopoietic Agents* *Hypnotics* *Laxatives* *Macrolides*...57 *Medical Devices* *Migraine Products*...60 *Minerals & Electrolytes* *Mouth/Throat/Dental Agents*...65 *Multivitamins* *Musculoskeletal Therapy Agents*...76 *Nasal Agents - Systemic And Topical*...77 *Neprilysin Inhib (Arni)-Angiotensin Ii Recept Antag Comb*** *Nutrients* *Ophthalmic Agents*...78 *Otic Agents*...82 *Passive Immunizing Agents* *Penicillins* *Pharmaceutical Adjuvants*...83 *Phosphodiesterase 4 (Pde4) Inhibitors*** *Potassium Removing Agents*** *Progestins* *Psychotherapeutic And Neurological Agents - Misc.*...84 *Respiratory Agents - Misc.*...86 *Sodium-Glucose Co-Transporter 2 Inhibitor-Biguanide Comb*** *Tetracyclines*...86 *Thyroid Agents*...87 *Ulcer Drugs*...88 *Urinary Anti-Infectives* *Urinary Antispasmodics*...90 *Vaginal Products* *Vasopressors*...91 *Vitamins*

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

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

8 indomethacin er oral capsule extended release 75 AL (Max 64 Years) indomethacin oral capsule 25, 50 AL (Max 64 Years) ketoprofen oral capsule 50, 75 ketorolac tromethamine oral tablet 10 AL (Max 64 Years) meloxicam oral tablet 15, 7.5 Mobic nabumetone oral tablet 500, 750 QLL (60 EA per 30 naproxen dr oral tablet delayed release 375, 500 EC-Naprosyn naproxen oral tablet 250, 500 Naprosyn naproxen oral tablet 375 naproxen sodium er oral tablet extended release 24 hour 500 Naprelan piroxicam oral capsule 10, 20 Feldene sulindac oral tablet 150, 200 *Pyrimidine Synthesis Inhibitors*** leflunomide oral tablet 10, 20 Arava *Soluble Tumor Necrosis Factor Receptor Agents*** ENBREL MINI SUBCUTANEOUS SOLUTION CARTRIDGE 50 MG/ML ENBREL SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 25 MG/0.5ML, 50 MG/ML ENBREL SURECLICK SUBCUTANEOUS SOLUTION AUTO- INJECTOR 50 MG/ML *Analgesics - Nonnarcotic* *Analgesics Other*** acetaminophen junior strength oral tablet dispersible 160 acetaminophen rapid tabs child oral tablet dispersible 80 *Analgesics-Sedatives*** butalbital-acetaminophen oral tablet Mapap Childrens Tencon ; QLL (3.92 ML per 28 QLL: cumulative acetaminophen limit of 4 grams per day; QLL (120 EA per 30 ; AL (Min 10 Years and Max 64 Years) 5

9 butalbital-apap-caffeine oral capsule butalbital-apap-caffeine oral tablet butalbital-aspirin-caffeine oral capsule CACET ORAL CAPSULE MG ESGIC ORAL CAPSULE MG marten-tab oral tablet TENCON ORAL TABLET MG ZEBUTAL ORAL CAPSULE MG *Salicylate Combinations*** choline-mag trisalicylate oral liquid 500 /5ml *Salicylates*** Capacet Esgic Fiorinal Capacet Capacet Tencon Tencon Capacet aspirin ec oral tablet delayed release 325 Bayer Aspirin Regimen aspirin ec oral tablet delayed release 81 aspirin oral tablet 325 aspirin oral tablet chewable 81 *Analgesics - Opioid* *Codeine Combinations*** acetaminophen-codeine #2 oral tablet Aspir-Low Bayer Advanced Aspirin Reg St Bayer Low Dose QLL (120 EA per 30 ; AL (Min 10 Years and Max 64 Years) QLL (120 EA per 30 ; AL (Min 10 Years and Max 64 Years) QLL (120 EA per 30 ; AL (Max 64 Years) QLL (120 EA per 30 ; AL (Min 10 Years and Max 64 Years) QLL (120 EA per 30 ; AL (Min 10 Years and Max 64 Years) QLL (120 EA per 30 ; AL (Min 10 Years and Max 64 Years) QLL (120 EA per 30 ; AL (Min 10 Years and Max 64 Years) QLL (120 EA per 30 ; AL (Min 10 Years and Max 64 Years) ; QLL (30 EA per 30 ; AL (Min 40 Years and Max 79 Years) ; QLL (30 EA per 30 ; QLL (30 EA per 30 ; AL (Min 40 Years and Max 79 Years) ; QLL (30 EA per 30 QLL (180 EA per 30 6

10 acetaminophen-codeine #3 oral tablet Tylenol with Codeine #3 acetaminophen-codeine #4 oral tablet Tylenol with Codeine #4 acetaminophen-codeine oral solution /5ml acetaminophen-codeine oral tablet acetaminophen-codeine oral tablet Tylenol with Codeine #4 ASCOMP-CODEINE ORAL CAPSULE Ascomp-Codeine MG butalbital-apap-caff-cod oral capsule butalbital-asa-caff-codeine oral capsule 50- Ascomp-Codeine *Hydrocodone Combinations*** QLL (180 EA per 30 QLL (180 EA per 30 QLL (240 ML per 30 QLL (180 EA per 30 QLL (180 EA per 30 QLL (120 EA per 30 QLL (120 EA per 30 QLL (120 EA per 30 hydrocodone-acetaminophen oral solution /5ml, /10ml Hycet QLL (1800 ML per 30 hydrocodone-acetaminophen oral solution /15ml Hycet QLL (480 ML per 30 hydrocodone-acetaminophen oral tablet Lorcet HD QLL (120 EA per 30 hydrocodone-acetaminophen oral tablet Lorcet QLL (120 EA per 30 hydrocodone-acetaminophen oral tablet Lorcet Plus QLL (120 EA per 30 hydrocodone-ibuprofen oral tablet QLL (240 EA per 30 LORCET HD ORAL TABLET MG Lorcet HD QLL (120 EA per 30 LORCET ORAL TABLET MG Lorcet QLL (120 EA per 30 LORCET PLUS ORAL TABLET MG Lorcet Plus QLL (120 EA per 30 *Opioid Agonists*** codeine sulfate oral tablet 15, 30, 60 DEMEROL ORAL TABLET 100 MG, 50 MG fentanyl citrate buccal lozenge on a handle 1200 mcg, 1600 mcg, 200 mcg, 400 mcg, 600 mcg, 800 mcg fentanyl transdermal patch 72 hour 100 mcg/hr Meperidine HCl Actiq Duragesic-100 QLL (90 EA per 30 ; AL (Max 64 Years) ; QLL (120 EA per 30 7

11 fentanyl transdermal patch 72 hour 12 mcg/hr Duragesic-12 fentanyl transdermal patch 72 hour 25 mcg/hr Duragesic-25 fentanyl transdermal patch 72 hour 50 mcg/hr Duragesic-50 fentanyl transdermal patch 72 hour 75 mcg/hr Duragesic-75 hydromorphone hcl oral tablet 2, 4 Dilaudid QLL (120 EA per 30 hydromorphone hcl rectal suppository 3 QLL (120 EA per 30 meperidine hcl oral solution 50 /5ml QLL (300 ML per 30 ; AL (Max 64 Years) METHADONE HCL INTENSOL ORAL CONCENTRATE 10 MG/ML Methadone HCl Intensol QLL (240 ML per 30 methadone hcl oral concentrate 10 /ml Methadone HCl Intensol QLL (240 ML per 30 methadone hcl oral solution 10 /5ml QLL (600 ML per 30 methadone hcl oral solution 5 /5ml QLL (900 ML per 30 methadone hcl oral tablet 10, 5 Dolophine QLL (120 EA per 30 methadone hcl oral tablet soluble 40 Methadose QLL (90 EA per 30 METHADOSE ORAL TABLET SOLUBLE 40 MG Methadose QLL (90 EA per 30 morphine sulfate (concentrate) oral solution 100 /5ml QLL (240 ML per 30 morphine sulfate er oral tablet extended MS Contin release 100, 15, 200, 30, 60 morphine sulfate oral solution 10 /5ml, 20 /5ml morphine sulfate oral tablet 15, 30 oxycodone hcl oral solution 5 /5ml QLL (60 EA per 30 QLL (240 ML per 30 QLL (120 EA per 30 oxycodone hcl oral tablet 5 Roxicodone QLL (120 EA per 30 tramadol hcl oral tablet 50 Ultram QLL (120 EA per 30 *Opioid Combinations*** ENDOCET ORAL TABLET MG, MG, MG oxycodone-acetaminophen oral tablet , 5-325, *Opioid Partial Agonists*** pentazocine-naloxone hcl oral tablet Endocet Endocet QLL (120 EA per 30 QLL (120 EA per 30 QLL (12 Tablets Max Qty Per Fill Retail) 8

12 *Tramadol Combinations*** tramadol-acetaminophen oral tablet *Androgens-Anabolic* *Androgens*** Ultracet danazol oral capsule 100, 200, 50 testosterone cypionate intramuscular solution Depo-Testosterone 100 /ml, 200 /ml *Anorectal Agents* *Rectal Anesthetic/Steroids*** lidocaine-hydrocortisone ace rectal cream % *Rectal Steroids*** PROCTO-K RECTAL CREAM 1 % *Antacids* *Antacid & Simethicone*** E-Z-GAS II ORAL CKET GM *Antacid Combinations*** ALKA-SELTZER HEARTBURN ORAL TABLET EFFERVESCENT MG antacid ultra strength oral tablet chewable DEWEES CARMINATIVE ORAL LIQUID GAVISCON EXTRA RELIEF FORMULA ORAL SUSPENSION MG/10ML GAVISCON ORAL TABLET CHEWABLE MG mag-al oral liquid /5ml *Antacids - Aluminum Salts*** aluminum hydroxide gel oral suspension 320 /5ml *Antacids - Magnesium Salts*** magnesium oxide oral capsule 400 URO-MAG ORAL CAPSULE 140 MG Hydrocortisone QLL (240 EA per 30 CVS Heartburn Relief Ex St 9

13 *Anthelmintics* *Anthelmintics*** ivermectin oral tablet 3 reeses pinworm medicine oral suspension 144 /ml *Antianginal Agents* *Antianginals-Other*** RANEXA ORAL TABLET EXTENDED RELEASE 12 HOUR 1000 MG, 500 MG *Nitrates*** isosorbide dinitrate er oral tablet extended release 40 isosorbide dinitrate oral tablet 10, 20, 30 isosorbide dinitrate oral tablet 5 isosorbide mononitrate er oral tablet extended release 24 hour 120 isosorbide mononitrate er oral tablet extended release 24 hour 30, 60 isosorbide mononitrate oral tablet 10, 20 MINITRAN TRANSDERMAL TCH 24 HOUR 0.1 MG/HR, 0.2 MG/HR, 0.4 MG/HR, 0.6 MG/HR NITRO-BID TRANSDERMAL OINTMENT 2 % nitroglycerin er oral capsule extended release 2.5, 6.5, 9 nitroglycerin transdermal patch 24 hour 0.1 /hr, 0.2 /hr, 0.4 /hr, 0.6 /hr nitroglycerin translingual solution 0.4 /spray NITROSTAT SUBLINGUAL TABLET SUBLINGUAL 0.3 MG, 0.4 MG, 0.6 MG NITRO-TIME ORAL CAPSULE EXTENDED RELEASE 2.5 MG, 6.5 MG, 9 MG *Antianxiety Agents* *Antianxiety Agents - Misc.*** hydroxyzine hcl oral syrup 10 /5ml 10 Stromectol Isordil Titradose Minitran Nitro-Time Minitran Nitrolingual Nitroglycerin Nitro-Time QLL (60 EA per 30 AL (Max 12 Years)

14 hydroxyzine hcl oral tablet 10, 25, 50 hydroxyzine pamoate oral capsule 100 hydroxyzine pamoate oral capsule 25, 50 *Antiarrhythmics* *Antiarrhythmics Type I-A*** disopyramide phosphate oral capsule 100, 150 quinidine sulfate oral tablet 200 quinidine sulfate oral tablet 300 *Antiarrhythmics Type I-B*** mexiletine hcl oral capsule 150, 200, 250 *Antiarrhythmics Type I-C*** flecainide acetate oral tablet 100, 150, 50 propafenone hcl oral tablet 150, 225, 300 *Antiarrhythmics Type Iii*** amiodarone hcl oral tablet 100, 200, 400 CERONE ORAL TABLET 100 MG, 200 MG, 400 MG *Antiasthmatic And Bronchodilator Agents* *Adrenergic Combinations*** ADVAIR DISKUS INHALATION AEROSOL POWDER BREATH ACTIVATED MCG/DOSE, MCG/DOSE, MCG/DOSE ADVAIR HFA INHALATION AEROSOL MCG/ACT, MCG/ACT, MCG/ACT COMBIVENT RESPIMAT INHALATION AEROSOL SOLUTION MCG/ACT DULERA INHALATION AEROSOL MCG/ACT, MCG/ACT Vistaril Norpace Pacerone Pacerone AL (Max 64 Years) AL (Max 64 Years) AL (Max 64 Years) AL (Max 64 Years) QLL (49 EA per 365 QLL (13 GM per 30 11

15 fluticasone-salmeterol inhalation aerosol powder breath activated mcg/act fluticasone-salmeterol inhalation aerosol powder breath activated mcg/act fluticasone-salmeterol inhalation aerosol powder breath activated mcg/act ipratropium-albuterol inhalation solution (3) /3ml SYMBICORT INHALATION AEROSOL MCG/ACT, MCG/ACT *Anti-Inflammatory Agents*** cromolyn sodium inhalation nebulization solution 20 /2ml *Beta Adrenergics*** albuterol sulfate inhalation nebulization solution (2.5 /3ml) 0.083%, (5 /ml) 0.5% albuterol sulfate inhalation nebulization solution 0.63 /3ml, 1.25 /3ml albuterol sulfate oral syrup 2 /5ml metaproterenol sulfate oral tablet 10, 20 SEREVENT DISKUS INHALATION AEROSOL POWDER BREATH ACTIVATED 50 MCG/DOSE terbutaline sulfate oral tablet 2.5, 5 VENTOLIN HFA INHALATION AEROSOL SOLUTION 108 (90 BASE) MCG/ACT *Bronchodilators - Anticholinergics*** ATROVENT HFA INHALATION AEROSOL SOLUTION 17 MCG/ACT INCRUSE ELLIPTA INHALATION AEROSOL POWDER BREATH ACTIVATED 62.5 MCG/INH ipratropium bromide inhalation solution 0.02 % AirDuo RespiClick 113/14 AirDuo RespiClick 232/14 AirDuo RespiClick 55/14 QLL (1 EA per 30 QLL (1 EA per 30 QLL (1 EA per 30 QLL (90 ML per 30 QLL (225 ML per 30 QLL (60 EA per 30 QLL (18 GM per 30 12

16 *Leukotriene Receptor Antagonists*** montelukast sodium oral packet 4 montelukast sodium oral tablet 10 montelukast sodium oral tablet chewable 4 montelukast sodium oral tablet chewable 5 *Steroid Inhalants*** AEROSN INHALATION AEROSOL SOLUTION 80 MCG/ACT budesonide inhalation suspension 0.25 /2ml, 0.5 /2ml, 1 /2ml FLOVENT DISKUS INHALATION AEROSOL POWDER BREATH ACTIVATED 100 MCG/BLIST, 250 MCG/BLIST, 50 MCG/BLIST PULMICORT FLEXHALER INHALATION AEROSOL POWDER BREATH ACTIVATED 180 MCG/ACT, 90 MCG/ACT PULMICORT INHALATION SUSPENSION 1 MG/2ML QVAR INHALATION AEROSOL SOLUTION 40 MCG/ACT, 80 MCG/ACT *Xanthines*** ELIXOPHYLLIN ORAL ELIXIR 80 MG/15ML THEOCHRON ORAL TABLET EXTENDED RELEASE 12 HOUR 100 MG, 200 MG, 300 MG theophylline er oral tablet extended release 12 hour 100, 200, 300 theophylline er oral tablet extended release 12 hour 450 theophylline er oral tablet extended release 24 hour 400, 600 theophylline oral solution 80 /15ml Singulair Singulair Singulair Singulair Pulmicort Pulmicort Theochron Theochron ; AL (Max 5 Years) ; AL (Min 15 Years) ; AL (Max 5 Years) ; AL (Min 6 Years and Max 14 Years) QLL (18 GM per 30 QLL (60 ML per 30 ; AL (Max 6 Years) QLL (30 EA per 60 QLL (1 EA per 30 QLL (60 ML per 30 ; AL (Max 6 Years) 13

17 *Anticoagulants* *Coumarin Anticoagulants*** warfarin sodium oral tablet 1, 10, 2, 2.5, 3, 4, 5, 6, 7.5 *Direct Factor Xa Inhibitors*** XARELTO ORAL TABLET 10 MG, 15 MG, 20 MG *Heparins And Heparinoid-Like Agents*** heparin sodium (porcine) injection solution 1000 unit/ml, unit/ml, 5000 unit/ml *Low Molecular Weight Heparins*** enoxaparin sodium subcutaneous solution 100 /ml, 120 /0.8ml, 150 /ml, 30 /0.3ml, 40 /0.4ml, 60 /0.6ml, 80 /0.8ml *Antidiabetics* *Alpha-Glucosidase Inhibitors*** Coumadin Lovenox ; Max 7 day supply acarbose oral tablet 100 Precose QLL (120 EA per 30 acarbose oral tablet 25, 50 Precose QLL (90 EA per 30 *Biguanides*** metformin hcl er oral tablet extended release 24 hour 500, 750 metformin hcl oral tablet 1000, 500, 850 *Diabetic Other*** GLUCAGEN HYPOKIT INJECTION SOLUTION RECONSTITUTED 1 MG GLUCAGON EMERGENCY INJECTION KIT 1 MG *Dipeptidyl Peptidase-4 (Dpp-4) Inhibitors*** alogliptin benzoate oral tablet 12.5, 25, 6.25 JANUVIA ORAL TABLET 100 MG, 25 MG, 50 MG TRADJENTA ORAL TABLET 5 MG Glucophage XR Glucophage Nesina QLL (60 EA per 30 QLL (1 EA per 30 QLL (1 EA per 28 ST; ST; 14

18 *Dipeptidyl Peptidase-4 Inhibitor- Biguanide Combinations*** alogliptin-metformin hcl oral tablet , JANUMET ORAL TABLET MG, MG JANUMET XR ORAL TABLET EXTENDED RELEASE 24 HOUR MG, MG, MG JENTADUETO ORAL TABLET MG, MG, MG JENTADUETO XR ORAL TABLET EXTENDED RELEASE 24 HOUR MG JENTADUETO XR ORAL TABLET EXTENDED RELEASE 24 HOUR MG *Dpp-4 Inhibitor-Thiazolidinedione Combinations*** Kazano alogliptin-pioglitazone oral tablet , , , 25-15, Oseni, *Human Insulin*** APIDRA INJECTION SOLUTION 100 UNIT/ML APIDRA SOLOSTAR SUBCUTANEOUS SOLUTION PEN-INJECTOR 100 UNIT/ML BASAGLAR KWIKPEN SUBCUTANEOUS SOLUTION PEN- INJECTOR 100 UNIT/ML HUMALOG KWIKPEN SUBCUTANEOUS SOLUTION PEN- INJECTOR 100 UNIT/ML HUMALOG MIX 50/50 KWIKPEN SUBCUTANEOUS SUSPENSION PEN- INJECTOR (50-50) 100 UNIT/ML HUMALOG MIX 50/50 SUBCUTANEOUS SUSPENSION (50-50) 100 UNIT/ML ST; QLL (60 EA per 30 ST; ST; QLL (60 EA per 30 ST; QLL (60 EA per 30 ST; ; QLL (60 ML per 30 QLL (30 ML per 30 ; AL (Max 21 Years) QLL (30 ML per 30 QLL (30 ML per 30 ; AL (Max 21 Years) QLL (30 ML per 30 ; AL (Max 21 Years) QLL (60 ML per 30 15

19 HUMALOG MIX 75/25 KWIKPEN SUBCUTANEOUS SUSPENSION PEN- INJECTOR (75-25) 100 UNIT/ML HUMALOG MIX 75/25 SUBCUTANEOUS SUSPENSION (75-25) 100 UNIT/ML HUMALOG SUBCUTANEOUS SOLUTION 100 UNIT/ML HUMALOG SUBCUTANEOUS SOLUTION CARTRIDGE 100 UNIT/ML HUMULIN 70/30 KWIKPEN SUBCUTANEOUS SUSPENSION PEN- INJECTOR (70-30) 100 UNIT/ML HUMULIN N KWIKPEN SUBCUTANEOUS SUSPENSION PEN- INJECTOR 100 UNIT/ML HUMULIN R U-500 (CONCENTRATED) SUBCUTANEOUS SOLUTION 500 UNIT/ML NOVOLOG FLEXPEN SUBCUTANEOUS SOLUTION PEN- INJECTOR 100 UNIT/ML NOVOLOG MIX 70/30 FLEXPEN SUBCUTANEOUS SUSPENSION PEN- INJECTOR (70-30) 100 UNIT/ML NOVOLOG MIX 70/30 SUBCUTANEOUS SUSPENSION (70-30) 100 UNIT/ML NOVOLOG PENFILL SUBCUTANEOUS SOLUTION CARTRIDGE 100 UNIT/ML NOVOLOG SUBCUTANEOUS SOLUTION 100 UNIT/ML *Incretin Mimetic Agents (Glp-1 Receptor Agonists)*** TANZEUM SUBCUTANEOUS PEN- INJECTOR 30 MG, 50 MG TRULICITY SUBCUTANEOUS SOLUTION PEN-INJECTOR 0.75 MG/0.5ML, 1.5 MG/0.5ML VICTOZA SUBCUTANEOUS SOLUTION PEN-INJECTOR 18 MG/3ML 16 QLL (30 ML per 30 ; AL (Max 21 Years) QLL (60 ML per 30 QLL (60 ML per 30 QLL (30 ML per 30 ; AL (Max 21 Years) ; QLL (30 ML per 30 ; AL (Max 21 Years) ; QLL (30 ML per 30 ; AL (Max 21 Years) ; QLL (60 ML per 30 QLL (30 ML per 30 ; AL (Max 21 Years) QLL (30 ML per 30 ; AL (Max 21 Years) QLL (60 ML per 30 QLL (30 ML per 30 ; AL (Max 21 Years) QLL (60 ML per 30 ST; QLL (4 EA per 28 ST ST

20 *Meglitinide Analogues*** nateglinide oral tablet 120, 60 Starlix QLL (90 EA per 30 repaglinide oral tablet 0.5 QLL (120 EA per 30 repaglinide oral tablet 1, 2 Prandin QLL (120 EA per 30 *Sodium-Glucose Co-Transporter 2 (Sglt2) Inhibitors*** FARXIGA ORAL TABLET 10 MG, 5 MG INVOKANA ORAL TABLET 100 MG, 300 MG *Sulfonylurea-Biguanide Combinations*** glipizide-metformin hcl oral tablet , , glyburide-metformin oral tablet glyburide-metformin oral tablet , *Sulfonylureas*** chlorpropamide oral tablet 100 chlorpropamide oral tablet 250 glimepiride oral tablet 1, 2, 4 glipizide er oral tablet extended release 24 hour 10, 2.5, 5 glipizide oral tablet 10, 5 glipizide xl oral tablet extended release 24 hour 10, 2.5, 5 glyburide micronized oral tablet 1.5, 3, 6 glyburide oral tablet 1.25, 2.5, 5 tolazamide oral tablet 250, 500 tolbutamide oral tablet 500 *Thiazolidinediones*** pioglitazone hcl oral tablet 15, 30, 45 *Antidiarrheals* *Antiperistaltic Agents*** diphenoxylate-atropine oral liquid /5ml Glucovance Amaryl Glucotrol XL Glucotrol Glucotrol XL Glynase Actos ST; ST; QLL (120 EA per 30 ; AL (Max 64 Years) QLL (90 EA per 30 ; AL (Max 64 Years) 17

21 diphenoxylate-atropine oral tablet loperamide hcl oral capsule 2 *Antidotes* *Antidotes - Chelating Agents*** CHEMET ORAL CAPSULE 100 MG *Opioid Antagonists*** naloxone hcl injection solution 0.4 /ml NARCAN NASAL LIQUID 4 MG/0.1ML *Antiemetics* *5-Ht3 Receptor Antagonists*** Lomotil Imodium A-D QLL (2 ML per 90 QLL (4 EA per 90 granisetron hcl oral tablet 1 ST; QLL (4 EA per 30 ondansetron hcl oral solution 4 /5ml Zofran QLL (300 ML per 30 ; AL (Max 12 Years) ondansetron hcl oral tablet 24 ondansetron hcl oral tablet 4, 8 Zofran QLL (90 EA per 30 ondansetron oral tablet dispersible 4, 8 Zofran ODT QLL (90 EA per 30 *Antiemetics - Miscellaneous*** MARINOL ORAL CAPSULE 10 MG, 2.5 MG, 5 MG *Antifungals* *Antifungals*** Dronabinol griseofulvin microsize oral suspension 125 /5ml griseofulvin microsize oral tablet 500 griseofulvin ultramicrosize oral tablet 125, 250 Gris-PEG nystatin oral tablet unit terbinafine hcl oral tablet 250 LamISIL *Imidazoles*** ketoconazole oral tablet 200 *Triazoles*** fluconazole oral suspension reconstituted 10 /ml, 40 /ml fluconazole oral tablet 100, 150, 200, 50 itraconazole oral capsule Diflucan Diflucan Sporanox QLL (60 EA per 30 AL (Max 12 Years)

22 *Antihistamines* *Antihistamines - Alkylamines*** chlorpheniramine maleate oral tablet 4 Chlor-Trimeton *Antihistamines - Ethanolamines*** allergy childrens oral liquid 12.5 /5ml Banophen carbinoxamine maleate oral solution 4 /5ml carbinoxamine maleate oral tablet 4 clemastine fumarate oral tablet 2.68 diphenhydramine hcl oral capsule 50 Banophen AL (Max 64 Years) diphenhydramine hcl oral elixir 12.5 /5ml *Antihistamines - Non-Sedating*** cetirizine hcl oral solution 1 /ml loratadine allergy relief oral tablet dispersible 10 loratadine oral syrup 5 /5ml loratadine oral tablet 10 *Antihistamines - Phenothiazines*** promethazine hcl oral solution 6.25 /5ml promethazine hcl oral syrup 6.25 /5ml promethazine hcl oral tablet 12.5, 25, 50 promethazine hcl rectal suppository 12.5, 25 promethazine hcl rectal suppository 50 PROMETHEGAN RECTAL SUPPOSITORY 12.5 MG, 25 MG PROMETHEGAN RECTAL SUPPOSITORY 50 MG *Antihistamines - Piperidines*** cyproheptadine hcl oral syrup 2 /5ml cyproheptadine hcl oral tablet 4 KLS Aller-Tec Childrens Alavert Claritin Claritin Phenadoz Phenergan Phenadoz Phenergan QLL (300 ML per 30 ; AL (Max 12 Years) ; QLL (300 ML per 30 ; AL (Max 12 Years) ; QLL (30 EA per 30 AL (Min 2 Years and Max 64 Years) AL (Min 2 Years and Max 64 Years) AL (Min 2 Years and Max 64 Years) AL (Min 2 Years and Max 64 Years) AL (Min 2 Years and Max 64 Years) AL (Min 2 Years and Max 64 Years) AL (Min 2 Years and Max 64 Years) AL (Max 64 Years) AL (Max 64 Years) 19

23 *Antihyperlipidemics* *Antihyperlipidemics - Misc.*** omega-3-acid ethyl esters oral capsule 1 gm Lovaza *Bile Acid Sequestrants*** cholestyramine light oral packet 4 gm Prevalite QLL (60 EA per 30 cholestyramine light oral powder 4 gm/dose Prevalite QLL (240 GM per 30 cholestyramine oral packet 4 gm Questran QLL (60 EA per 30 cholestyramine oral powder 4 gm/dose Questran QLL (378 GM per 30 colestipol hcl oral granules 5 gm Colestid colestipol hcl oral tablet 1 gm Colestid *Fibric Acid Derivatives*** fenofibrate micronized oral capsule 134, 67 Lofibra fenofibrate micronized oral capsule 200, 43 fenofibrate oral capsule 50 Lipofen fenofibrate oral tablet 145, 48 Tricor fenofibrate oral tablet 160 Triglide fenofibrate oral tablet 54 Lofibra fenofibric acid oral capsule delayed release 135, 45 Trilipix fenofibric acid oral tablet 105, 35 Fibricor gemfibrozil oral tablet 600 Lopid QLL (60 EA per 30 *H Coa Reductase Inhibitors*** atorvastatin calcium oral tablet 10, 20, 40, 80 Lipitor lovastatin oral tablet 10, 20 lovastatin oral tablet 40 Mevacor pravastatin sodium oral tablet 10 pravastatin sodium oral tablet 20, 40, Pravachol 80 rosuvastatin calcium oral tablet 10, 20, 40, 5 Crestor simvastatin oral tablet 10, 20, 40, 5, 80 Zocor *Intestinal Cholesterol Absorption Inhibitors*** ezetimibe oral tablet 10 Zetia 20

24 *Antihypertensives* *Ace Inhibitor & Calcium Channel Blocker Combinations*** amlodipine besy-benazepril hcl oral capsule 10-20, 10-40, 5-10, 5-20 amlodipine besy-benazepril hcl oral capsule , 5-40 *Ace Inhibitors & Thiazide/Thiazide- Like*** enalapril-hydrochlorothiazide oral tablet enalapril-hydrochlorothiazide oral tablet lisinopril-hydrochlorothiazide oral tablet , , quinapril-hydrochlorothiazide oral tablet , , *Ace Inhibitors*** Lotrel Vaseretic Zestoretic Accuretic QLL (60 EA per 30 QLL (60 EA per 30 QLL (60 EA per 30 benazepril hcl oral tablet 10, 20 Lotensin QLL (45 EA per 30 benazepril hcl oral tablet 40 Lotensin QLL (60 EA per 30 benazepril hcl oral tablet 5 QLL (45 EA per 30 captopril oral tablet 100, 12.5, 25, 50 enalapril maleate oral tablet 10, 2.5, 5 Vasotec QLL (45 EA per 30 enalapril maleate oral tablet 20 Vasotec QLL (60 EA per 30 ENED ORAL SOLUTION 1 MG/ML AL (Max 12 Years) fosinopril sodium oral tablet 10, 20 QLL (45 EA per 30 fosinopril sodium oral tablet 40 QLL (60 EA per 30 lisinopril oral tablet 10, 20, 5 Prinivil QLL (45 EA per 30 lisinopril oral tablet 2.5, 30 Zestril QLL (45 EA per 30 lisinopril oral tablet 40 Zestril QLL (60 EA per 30 perindopril erbumine oral tablet 2 QLL (45 EA per 30 perindopril erbumine oral tablet 4 Aceon QLL (45 EA per 30 quinapril hcl oral tablet 10, 20, 40, Accupril 5 ramipril oral capsule 1.25, 10, 2.5, Altace 5 trandolapril oral tablet 1, 2 21

25 trandolapril oral tablet 4 Mavik *Adrenolytics-Central & Thiazide/Thiazide-Like Comb*** methyldopa-hydrochlorothiazide oral tablet , *Angiotensin Ii Receptor Antag & Thiazide/Thiazide-Like*** candesartan cilexetil-hctz oral tablet , , irbesartan-hydrochlorothiazide oral tablet , losartan potassium-hctz oral tablet , , valsartan-hydrochlorothiazide oral tablet , , , , *Angiotensin Ii Receptor Antagonists*** Atacand HCT Avalide Hyzaar Diovan HCT candesartan cilexetil oral tablet 16, 32, 4, 8 Atacand irbesartan oral tablet 150, 300, 75 Avapro losartan potassium oral tablet 100, 25, 50 Cozaar valsartan oral tablet 160, 40, 80 Diovan QLL (60 EA per 30 valsartan oral tablet 320 Diovan *Antiadrenergics - Centrally Acting*** clonidine hcl oral tablet 0.1, 0.2, 0.3 guanfacine hcl oral tablet 1, 2 methyldopa oral tablet 250, 500 *Antiadrenergics - Peripherally Acting*** Catapres QLL (60 EA per 30 AL (Max 64 Years) doxazosin mesylate oral tablet 1, 2, 4 Cardura doxazosin mesylate oral tablet 8 Cardura QLL (60 EA per 30 prazosin hcl oral capsule 1, 2, 5 Minipress QLL (60 EA per 30 terazosin hcl oral capsule 1, 5 terazosin hcl oral capsule 10, 2 QLL (60 EA per 30 22

26 *Beta Blocker & Diuretic Combinations*** atenolol-chlorthalidone oral tablet Tenoretic 100 atenolol-chlorthalidone oral tablet Tenoretic 50 bisoprolol-hydrochlorothiazide oral tablet 10- Ziac 6.25 bisoprolol-hydrochlorothiazide oral tablet Ziac , metoprolol-hydrochlorothiazide oral tablet metoprolol-hydrochlorothiazide oral tablet Lopressor HCT *Direct Renin Inhibitors & Thiazide/Thiazide-Like Comb*** TEKTURNA HCT ORAL TABLET MG, MG, MG, MG *Direct Renin Inhibitors*** TEKTURNA ORAL TABLET 150 MG, 300 MG *Vasodilators*** hydralazine hcl injection solution 20 /ml hydralazine hcl oral tablet 10, 100, 50 hydralazine hcl oral tablet 25 minoxidil oral tablet 10, 2.5 *Anti-Infective Agents - Misc.* *Anti-Infective Agents - Misc.*** CAYSTON INHALATION SOLUTION RECONSTITUTED 75 MG metronidazole oral tablet 250, 500 tinidazole oral tablet 250 tinidazole oral tablet 500 trimethoprim oral tablet 100 vancomycin hcl intravenous solution reconstituted 10 gm, 1000, 500, 5000, 750 Flagyl Tindamax QLL (60 EA per 30 QLL (45 EA per 30 ; ; QLL (90 EA per 30 QLL (120 EA per 30 23

27 *Anti-Infective Misc. - Combinations*** sulfamethoxazole-trimethoprim oral suspension /5ml sulfamethoxazole-trimethoprim oral tablet sulfamethoxazole-trimethoprim oral tablet *Antiprotozoal Agents*** Sulfatrim Pediatric Bactrim Bactrim DS atovaquone oral suspension 750 /5ml Mepron *Leprostatics*** dapsone oral tablet 100, 25 *Lincosamides*** clindamycin hcl oral capsule 150, 300, 75 clindamycin palmitate hcl oral solution reconstituted 75 /5ml *Oxazolidinones*** Cleocin Cleocin linezolid oral suspension reconstituted 100 /5ml Zyvox linezolid oral tablet 600 Zyvox *Antimalarials* *Antimalarials*** chloroquine phosphate oral tablet 250, 500 DARAPRIM ORAL TABLET 25 MG hydroxychloroquine sulfate oral tablet 200 mefloquine hcl oral tablet 250 primaquine phosphate oral tablet 26.3 *Antimycobacterial Agents* *Antimycobacterial Agents*** cycloserine oral capsule 250 ethambutol hcl oral tablet 100, 400 isoniazid oral syrup 50 /5ml isoniazid oral tablet 100, 300 pyrazinamide oral tablet 500 rifabutin oral capsule Plaquenil Seromycin Myambutol Mycobutin AL (Max 12 Years) AL (Max 12 Years)

28 rifampin oral capsule 150, 300 TRECATOR ORAL TABLET 250 MG *Antineoplastics And Adjunctive Therapies* *Alkylating Agents*** HEXALEN ORAL CAPSULE 50 MG MYLERAN ORAL TABLET 2 MG *Androgen Biosynthesis Inhibitors*** ZYTIGA ORAL TABLET 250 MG *Antiadrenals*** LYSODREN ORAL TABLET 500 MG *Antiandrogens*** Rifadin ; QLL (120 EA per 30 bicalutamide oral tablet 50 Casodex flutamide oral capsule 125 nilutamide oral tablet 150 Nilandron XTANDI ORAL CAPSULE 40 MG ; QLL (120 EA per 30 *Antiestrogens*** FARESTON ORAL TABLET 60 MG tamoxifen citrate oral tablet 10, 20 *Antimetabolites*** capecitabine oral tablet 150, 500 Xeloda mercaptopurine oral tablet 50 methotrexate oral tablet 2.5 TABLOID ORAL TABLET 40 MG *Antineoplastic - Hedgehog Pathway Inhibitors*** ERIVEDGE ORAL CAPSULE 150 MG *Antineoplastic - Histone Deacetylase Inhibitors*** FARYDAK ORAL CAPSULE 10 MG, 15 MG, 20 MG ZOLINZA ORAL CAPSULE 100 MG QLL (60 EA per 30 ; 25

29 *Antineoplastic - Immunomodulators*** POMALYST ORAL CAPSULE 1 MG, 2 MG, 3 MG, 4 MG *Antineoplastic - Mtor Kinase Inhibitors*** AFINITOR DISPERZ ORAL TABLET SOLUBLE 2 MG, 3 MG, 5 MG AFINITOR ORAL TABLET 10 MG AFINITOR ORAL TABLET 2.5 MG, 5 MG AFINITOR ORAL TABLET 7.5 MG *Antineoplastic Combinations*** LONSURF ORAL TABLET MG, MG *Antineoplastics Misc.*** hydroxyurea oral capsule 500 INTRON A INJECTION SOLUTION UNIT/ML, UNIT/ML MATULANE ORAL CAPSULE 50 MG *Aromatase Inhibitors*** anastrozole oral tablet 1 exemestane oral tablet 25 letrozole oral tablet 2.5 *Estrogens-Antineoplastic*** EMCYT ORAL CAPSULE 140 MG *Folic Acid Antagonists Rescue Agents*** leucovorin calcium oral tablet 10, 15, 25, 5 *Imidazotetrazines*** temozolomide oral capsule 100, 140, 180, 20, 250, 5 *Janus Associated Kinase (Jak) Inhibitors*** JAKAFI ORAL TABLET 10 MG, 15 MG, 20 MG, 25 MG, 5 MG Hydrea Arimidex Aromasin Femara Temodar ; QLL (60 EA per 30 ; QLL (60 EA per 30 ; ; AL (Min 18 Years) ; QLL (60 EA per 30 26

30 *Mitotic Inhibitors*** etoposide oral capsule 50 *Nitrogen Mustards*** cyclophosphamide oral capsule 25, 50 LEUKERAN ORAL TABLET 2 MG melphalan oral tablet 2 Alkeran *Nitrosoureas*** GLEOSTINE ORAL CAPSULE 10 MG, 100 MG, 40 MG *Progestins-Antineoplastic*** megestrol acetate oral suspension 40 /ml, 400 /10ml megestrol acetate oral tablet 20, 40 *Retinoids*** tretinoin oral capsule 10 *Selective Retinoid X Receptor Agonists*** bexarotene oral capsule 75 Targretin *Topoisomerase I Inhibitors*** HYCAMTIN ORAL CAPSULE 0.25 MG, 1 MG *Urinary Tract Protective Agents*** MESNEX ORAL TABLET 400 MG *Antiparkinson Agents* *Antiparkinson Dopaminergics*** amantadine hcl oral capsule 100 QLL (120 EA per 30 amantadine hcl oral syrup 50 /5ml QLL (240 ML per 30 amantadine hcl oral tablet 100 bromocriptine mesylate oral capsule 5 Parlodel bromocriptine mesylate oral tablet 2.5 Parlodel QLL (180 EA per 30 *Antiparkinson Monoamine Oxidase Inhibitors*** selegiline hcl oral capsule 5 Eldepryl QLL (60 EA per 30 *Levodopa Combinations*** carbidopa-levodopa er oral tablet extended release , Sinemet CR 27

31 carbidopa-levodopa oral tablet , , carbidopa-levodopa oral tablet dispersible , carbidopa-levodopa oral tablet dispersible *Nonergoline Dopamine Receptor Agonists*** pramipexole dihydrochloride oral tablet 0.125, 0.25, 0.5, 0.75, 1, 1.5 ropinirole hcl oral tablet 0.25, 0.5, 1, 2, 3, 4, 5 *Antipsychotics/Antimanic Agents* *Phenothiazines*** Sinemet Mirapex Requip prochlorperazine maleate oral tablet 10 QLL (150 EA per 30 prochlorperazine maleate oral tablet 5 QLL (120 EA per 30 prochlorperazine rectal suppository 25 Compro QLL (60 EA per 30 *Antivirals* *Cmv Agents*** valganciclovir hcl oral tablet 450 Valcyte ; QLL (60 EA per 30 *Hepatitis B Agents*** adefovir dipivoxil oral tablet 10 entecavir oral tablet 0.5, 1 lamivudine oral tablet 100 VEMLIDY ORAL TABLET 25 MG *Herpes Agents - Purine Analogues*** Hepsera Baraclude Epivir HBV ; acyclovir oral capsule 200 Zovirax QLL (60 EA per 30 acyclovir oral suspension 200 /5ml Zovirax AL (Max 12 Years) acyclovir oral tablet 400 Zovirax QLL (60 EA per 30 acyclovir oral tablet 800 Zovirax valacyclovir hcl oral tablet 1 gm Valtrex valacyclovir hcl oral tablet 500 Valtrex QLL (90 EA per 30 *Herpes Agents - Thymidine Analogues*** famciclovir oral tablet 125, 250 QLL (90 EA per 30 famciclovir oral tablet 500 Famvir QLL (90 EA per 30 28

32 *Influenza Agents*** rimantadine hcl oral tablet 100 Flumadine *Neuraminidase Inhibitors*** oseltamivir phosphate oral capsule 30, 45, 75 RELENZA DISKHALER INHALATION AEROSOL POWDER BREATH ACTIVATED 5 MG/BLISTER TAMIFLU ORAL SUSPENSION RECONSTITUTED 6 MG/ML *Assorted Classes* *Antileprotics*** THALOMID ORAL CAPSULE 100 MG, 150 MG, 200 MG, 50 MG *Cyclosporine Analogs*** Tamiflu Oseltamivir Phosphate QLL (10 EA Max Qty Per Fill Retail) QLL (20 EA per 180 ; AL (Min 5 Years) QLL (3 Bottles Max Qty Per Fill Retail); AL (Max 12 Years) cyclosporine modified oral capsule 100, 25 Gengraf cyclosporine modified oral capsule 50 Gengraf cyclosporine modified oral solution 100 /ml Gengraf AL (Max 12 Years) cyclosporine oral capsule 100 SandIMMUNE QLL (150 EA per 30 cyclosporine oral capsule 25 SandIMMUNE GENGRAF ORAL CAPSULE 100 MG, 25 Gengraf MG GENGRAF ORAL SOLUTION 100 MG/ML Gengraf AL (Max 12 Years) *Immunomodulators For Myelodysplastic Syndromes*** REVLIMID ORAL CAPSULE 10 MG, 15 MG, 25 MG, 5 MG REVLIMID ORAL CAPSULE 2.5 MG, 20 MG *Inosine Monophosphate Dehydrogenase Inhibitors*** ; mycophenolate mofetil oral capsule 250 CellCept mycophenolate mofetil oral suspension reconstituted 200 /ml CellCept AL (Max 12 Years) mycophenolate mofetil oral tablet 500 CellCept 29

33 *Irrigation Solutions*** sterile water for irrigation irrigation solution Argyle Sterile Water *Macrolide Immunosuppressants*** sirolimus oral tablet 0.5, 1, 2 tacrolimus oral capsule 0.5, 1, 5 *Potassium Removing Resins*** KIONEX ORAL POWDER sodium polystyrene sulfonate oral powder sodium polystyrene sulfonate oral suspension 15 gm/60ml sodium polystyrene sulfonate rectal suspension 30 gm/120ml, 50 gm/200ml *Purine Analogs*** Rapamune Prograf Kionex Kionex Kionex azathioprine oral tablet 50 Imuran QLL (240 EA per 30 *Beta Blockers* *Alpha-Beta Blockers*** carvedilol oral tablet 12.5, 25, 3.125, 6.25 labetalol hcl oral tablet 100, 200, 300 *Beta Blockers Cardio-Selective*** Coreg acebutolol hcl oral capsule 200, 400 atenolol oral tablet 100, 25, 50 Tenormin betaxolol hcl oral tablet 10, 20 bisoprolol fumarate oral tablet 10 bisoprolol fumarate oral tablet 5 metoprolol succinate er oral tablet extended Toprol XL release 24 hour 100, 25, 50 metoprolol succinate er oral tablet extended Toprol XL release 24 hour 200 metoprolol tartrate oral tablet 100, 50 Lopressor metoprolol tartrate oral tablet 25 *Beta Blockers Non-Selective*** HEMANGEOL ORAL SOLUTION 4.28 MG/ML nadolol oral tablet 20, 40, 80 pindolol oral tablet 10, 5 Corgard QLL (60 EA per 30 QLL (45 EA per 30 QLL (45 EA per 30 QLL (60 EA per 30 QLL (90 EA per 30 QLL (90 EA per 30 AL (Max 4 Years) 30

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

35 diltiazem hcl er coated beads oral capsule extended release 24 hour 120, 240 Cardizem CD diltiazem hcl er coated beads oral capsule extended release 24 hour 180 Cardizem CD QLL (60 EA per 30 diltiazem hcl er coated beads oral capsule extended release 24 hour 300 Cartia XT diltiazem hcl er coated beads oral tablet extended release 24 hour 180, 300 Cardizem LA diltiazem hcl er oral capsule extended release 24 hour 120, 180, 240 diltiazem hcl oral tablet 120, 30, 60 Cardizem diltiazem hcl oral tablet 90 dilt-xr oral capsule extended release 24 hour 120, 180, 240 felodipine er oral tablet extended release 24 hour 10 QLL (60 EA per 30 felodipine er oral tablet extended release 24 hour 2.5, 5 isradipine oral capsule 2.5, 5 QLL (60 EA per 30 MATZIM LA ORAL TABLET EXTENDED RELEASE 24 HOUR 180 Cardizem LA MG, 300 MG nicardipine hcl oral capsule 20, 30 NIFEDIAC CC ORAL TABLET Adalat CC EXTENDED RELEASE 24 HOUR 30 MG NIFEDICAL XL ORAL TABLET EXTENDED RELEASE 24 HOUR 60 MG nifedipine er oral tablet extended release 24 hour 30, 60, 90 nifedipine er osmotic release oral tablet extended release 24 hour 30, 90 nifedipine er osmotic release oral tablet extended release 24 hour 60 nifedipine oral capsule 10 nifedipine oral capsule 20 nimodipine oral capsule 30 TAZTIA XT ORAL CAPSULE EXTENDED RELEASE 24 HOUR 120 MG, 180 MG, 240 MG, 300 MG, 360 MG 32 Nifedical XL Adalat CC Procardia XL Nifedical XL Procardia Taztia XT QLL (120 EA per 30 ; AL (Max 64 Years) QLL (120 EA per 30 ; AL (Max 64 Years)

36 verapamil hcl er oral capsule extended release 24 hour 100, 200, 300 verapamil hcl er oral capsule extended release 24 hour 120, 180, 240, 360 verapamil hcl er oral tablet extended release 120, 180, 240 verapamil hcl oral tablet 120, 80 verapamil hcl oral tablet 40 VERELAN PM ORAL CAPSULE EXTENDED RELEASE 24 HOUR 100 MG, 200 MG *Cardiotonics* *Cardiac Glycosides*** DIGITEK ORAL TABLET 125 MCG, 250 MCG DIGOX ORAL TABLET 125 MCG, 250 MCG digoxin oral solution 0.05 /ml digoxin oral tablet 125 mcg, 250 mcg *Cardiovascular Agents - Misc.* *Peripheral Vasodilators*** niacin flush free oral capsule 500 NIACIN FLUSH-FREE EX ST ORAL CAPSULE 750 MG *Pulm Hyperten-Soluble Guanylate Cyclase Stimulator (Sgc)*** ADEMS ORAL TABLET 0.5 MG, 1 MG, 1.5 MG, 2 MG, 2.5 MG *Pulmonary Hypertension - Endothelin Receptor Antagonists*** LETAIRIS ORAL TABLET 10 MG, 5 MG TRACLEER ORAL TABLET 125 MG, 62.5 MG *Pulmonary Hypertension - Phosphodiesterase Inhibitors*** Verelan PM Verelan Calan SR Calan Verelan PM Digitek Digitek Digitek ; QLL (90 EA per 30 ; ; QLL (60 EA per 30 ADCIRCA ORAL TABLET 20 MG ; QLL (60 EA per 30 sildenafil citrate oral tablet 20 Revatio 33

37 *Cephalosporins* *Cephalosporins - 1St Generation*** cefadroxil oral capsule 500 cefadroxil oral suspension reconstituted 250 /5ml, 500 /5ml cefadroxil oral tablet 1 gm cephalexin oral capsule 250, 500 Keflex cephalexin oral suspension reconstituted 125 /5ml, 250 /5ml *Cephalosporins - 2Nd Generation*** cefaclor oral capsule 250, 500 cefaclor oral suspension reconstituted 125 /5ml, 250 /5ml, 375 /5ml cefprozil oral suspension reconstituted 125 /5ml, 250 /5ml cefprozil oral tablet 250, 500 cefuroxime axetil oral tablet 250, 500 Ceftin *Cephalosporins - 3Rd Generation*** cefdinir oral capsule 300 cefdinir oral suspension reconstituted 125 /5ml, 250 /5ml cefpodoxime proxetil oral suspension reconstituted 100 /5ml, 50 /5ml cefpodoxime proxetil oral tablet 100, 200 ceftriaxone sodium injection solution reconstituted 250, 500 *Chemicals* *Bulk Chemicals - Hy's*** hydroxyprogesterone caproate powder *Contraceptives* *Biphasic Contraceptives - Oral*** desogestrel-ethinyl estradiol oral tablet /0.01 (21/5) viorele oral tablet /0.01 (21/5) Azurette Azurette AL (Max 12 Years) AL (Max 12 Years) AL (Max 12 Years) AL (Max 12 Years) AL (Max 12 Years) QLL (2 Grams Max Qty Per Fill Retail) 34

38 *Combination Contraceptives - Oral*** ALTAVERA ORAL TABLET MG- Altavera MCG alyacen 1/35 oral tablet mcg Cyclafem 1/35 briellyn oral tablet mcg Balziva CHATEAL ORAL TABLET MG- Altavera MCG CRYSELLE-28 ORAL TABLET MG-MCG desogestrel-ethinyl estradiol oral tablet Apri 30 -mcg drospirenone-ethinyl estradiol oral tablet 3- Gianvi 0.02 drospirenone-ethinyl estradiol oral tablet 3- Ocella 0.03 ELINEST ORAL TABLET MG- MCG GILDESS FE 1.5/30 ORAL TABLET MG-MCG JUNEL 1.5/30 ORAL TABLET MG-MCG JUNEL FE 1.5/30 ORAL TABLET MG-MCG KELNOR 1/35 ORAL TABLET 1-35 MG- MCG LARIN 1.5/30 ORAL TABLET MG- MCG LARIN FE 1.5/30 ORAL TABLET MG-MCG levonorgestrel-ethinyl estrad oral tablet mcg levonorgestrel-ethinyl estrad oral tablet mcg LOW-OGESTREL ORAL TABLET MG-MCG marlissa oral tablet mcg MICROGESTIN 1.5/30 ORAL TABLET MG-MCG MICROGESTIN FE 1.5/30 ORAL TABLET MG-MCG Ethynodiol Diac-Eth Estradiol Aubra Altavera Altavera 35

39 NECON 0.5/35 (28) ORAL TABLET MG-MCG NECON 1/50 (28) ORAL TABLET 1-50 MG-MCG norethin ace-eth estrad-fe oral tablet mcg Blisovi FE 1/20 norethin ace-eth estrad-fe oral tablet chewable mcg(24) Melodetta 24 Fe norethindrone acet-ethinyl est oral tablet mcg Junel 1/20 norethin-eth estradiol-fe oral tablet chewable Generess FE mcg norgestimate-eth estradiol oral tablet Estarylla -mcg NORTREL 0.5/35 (28) ORAL TABLET MG-MCG OCELLA ORAL TABLET MG Ocella OGESTREL ORAL TABLET MG- MCG SYEDA ORAL TABLET MG Ocella WERA ORAL TABLET MG-MCG ZARAH ORAL TABLET MG Ocella ZOVIA 1/35E (28) ORAL TABLET 1-35 MG-MCG ZOVIA 1/50E (28) ORAL TABLET 1-50 MG-MCG *Combination Contraceptives - Transdermal*** XULANE TRANSDERMAL TCH WEEKLY MCG/24HR *Combination Contraceptives - Vaginal*** NUVARING VAGINAL RING MG/24HR *Continuous Contraceptives - Oral*** levonorgestrel-ethinyl estrad oral tablet mcg *Emergency Contraceptives*** ELLA ORAL TABLET 30 MG levonorgestrel oral tablet Ethynodiol Diac-Eth Estradiol Ethynodiol Diac-Eth Estradiol Aftera QLL (4 EA per 28

40 *Extended-Cycle Contraceptives - Oral*** levonorgest-eth estrad 91-day oral tablet *Progestin Contraceptives - Injectable*** medroxyprogesterone acetate intramuscular suspension 150 /ml *Progestin Contraceptives - Oral*** norethindrone oral tablet 0.35 *Triphasic Contraceptives - Oral*** alyacen 7/7/7 oral tablet 0.5/0.75/1-35 mcg ARANELLE ORAL TABLET 0.5/1/ MG-MCG CAZIANT ORAL TABLET 0.1/0.125/ MG CESIA ORAL TABLET 0.1/0.125/ MG LEENA ORAL TABLET 0.5/1/ MG- MCG levonorg-eth estrad triphasic oral tablet norgestim-eth estrad triphasic oral tablet 0.18/0.215/ mcg TILIA FE ORAL TABLET 1-20/1-30/1-35 MG-MCG TRI-LEGEST FE ORAL TABLET 1-20/1-30/1-35 MG-MCG VELIVET ORAL TABLET 0.1/0.125/ MG *Corticosteroids* *Glucocorticosteroids*** Introvale Depo-Provera Camila Cyclafem 7/7/7 Enpresse-28 DELTASONE ORAL TABLET 20 MG Deltasone dexamethasone oral elixir 0.5 /5ml dexamethasone oral solution 0.5 /5ml dexamethasone oral tablet 0.5, 0.75, 1, 1.5, 2, 4, 6 hydrocortisone oral tablet 10, 20, 5 Cortef Ortho Tri-Cyclen (28) QLL (1 ML per 75 37

41 methylprednisolone oral tablet 16, 32, Medrol 4, 8 prednisolone oral solution 15 /5ml prednisolone oral syrup 15 /5ml prednisolone sodium phosphate oral solution 15 /5ml, 25 /5ml prednisolone sodium phosphate oral solution Pediapred 6.7 (5 base) /5ml prednisone oral solution 5 /5ml prednisone oral tablet 1, 10, 2.5, 5, 50 prednisone oral tablet 20 Deltasone *Mineralocorticoids*** fludrocortisone acetate oral tablet 0.1 *Cough/Cold/Allergy* *Antitussive - Nonnarcotic*** benzonatate oral capsule 100 benzonatate oral capsule 200 *Antitussive - Opioid*** hydrocodone-homatropine oral syrup /5ml hydromet oral syrup /5ml *Misc. Respiratory Inhalants*** PULMOSAL INHALATION NEBULIZATION SOLUTION 7 % sodium chloride inhalation nebulization solution 0.9 % sodium chloride inhalation nebulization solution 7 % *Mucolytics*** acetylcysteine inhalation solution 10 %, 20 % *Non-Narc Antitussive- Antihistamine*** promethazine-dm oral syrup /5ml *Opioid Antitussive-Antihistamine*** promethazine-codeine oral syrup /5ml Tessalon Perles HyperSal HyperSal 38

42 *Dermatologicals* *Acne Antibiotics*** clindamycin phosphate external gel 1 % Cleocin-T clindamycin phosphate external lotion 1 % Cleocin-T clindamycin phosphate external solution 1 % Cleocin-T clindamycin phosphate external swab 1 % Cleocin-T erythromycin external solution 2 % *Acne Combinations*** sulfacetamide sodium-sulfur external emulsion 10-5 % *Acne Products*** Avar Cleanser adapalene external gel 0.1 % Differin ST; QLL (45 GM per 30 AVITA EXTERNAL CREAM % Tretinoin QLL (45 GM per 30 ; AL (Min 10 Years and Max 29 Years) AVITA EXTERNAL GEL % Tretinoin QLL (45 GM per 30 ; AL (Min 10 Years and Max 29 Years) benzoyl peroxide external gel 10 % Clean & Clear Persa-Gel Max St QLL (112 GM per 30 bp foaming wash external liquid 10 % Desquam-X Wash CLARAVIS ORAL CAPSULE 10 MG, 20 MG, 30 MG, 40 MG ; QLL (60 EA per 30 MYORISAN ORAL CAPSULE 10 MG, 20 MG, 40 MG ; QLL (60 EA per 30 OSCION CLEANSER EXTERNAL LOTION 6 % Benzoyl Peroxide Cleanser ZENATANE ORAL CAPSULE 10 MG, 20 MG, 30 MG, 40 MG ; QLL (60 EA per 30 *Antibiotics - Topical*** gentamicin sulfate external cream 0.1 % gentamicin sulfate external ointment 0.1 % gentamicin sulfate powder mupirocin external ointment 2 % Centany QLL (22 GM per 30 *Antifungals - Topical Combinations*** clotrimazole-betamethasone external cream % Lotrisone QLL (45 GM per 30 39