Aetna Better Health of Louisiana

Transcription

1 AETNA BETTER HEALTH Formulary Guide Aetna Better Health of Louisiana Formulary Guide January

2 AETNA BETTER HEALTH Formulary Guide What is the Aetna Better Health in Louisiana Formulary? This is a drug list created by Aetna Better Health in Louisiana ( 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 s 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 at least 30 days before the change is made. Utilizing members 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: lists the brand name of the drug when a generic is covered Column #3: 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 (OTC) drugs covered? The plan will cover OTC drugs on the formulary. Some OTC drugs may have coverage rules. If the rules for that OTC drug are met, the plan will cover the OTC drug. Like other drugs, OTC drugs need a prescription from a doctor if they are to be covered by the plan. Are there Medication Copays? Copays for brand drugs are $0 and copays for generic drugs are $0. 2

3 AETNA BETTER HEALTH Formulary Guide 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. 3

4 Aetna Better Health Louisiana Table of Contents *Adhd/Anti-Narcolepsy/Anti-Obesity/Anorexiants*...3 *Aminoglycosides*...5 *Analgesics - Anti-Inflammatory*...6 *Analgesics - Nonnarcotic*... 8 *Analgesics - Opioid*...9 *Androgens-Anabolic* *Anorectal Agents*...12 *Anthelmintics* *Antianginal Agents*...13 *Antianxiety Agents*...14 *Antiarrhythmics*...15 *Antiasthmatic And Bronchodilator Agents*...15 *Anticoagulants*...18 *Anticonvulsants*...19 *Antidepressants* *Antidiabetics*...24 *Antidiarrheals*...27 *Antidotes* *Antiemetics*...27 *Antifungals*...28 *Antihistamines*...28 *Antihyperlipidemics*...29 *Antihypertensives*...30 *Anti-Infective Agents - Misc.*...33 *Antimalarials* *Antimyasthenic Agents* *Antimyasthenic/Cholinergic Agents* *Antimycobacterial Agents*...34 *Antineoplastics And Adjunctive Therapies*...35 *Antiparkinson Agents*...37 *Antipsychotics/Antimanic Agents*...39 *Antiretrovirals Adjuvants***...41 *Antiseptics & Disinfectants*...41 *Antivirals*...41 *Assorted Classes*...45 *Beta Blockers* *Bulk Chemicals - Ny***...48 *Calcium Channel Blockers*...48 *Cardiotonics* *Cardiovascular Agents - Misc.*...50 *Cephalosporins*...50 *Chemicals*...51 *Contraceptives*...52 *Corticosteroids* *Cough/Cold/Allergy*...60 *Dermatologicals* *Diagnostic Products*

5 *Dietary Products/Dietary Management Products*...69 *Digestive Aids*...70 *Diuretics* *Endocrine And Metabolic Agents - Misc.*...71 *Estrogens* *Fluoroquinolones*...73 *Gastrointestinal Agents - Misc.*...73 *Genitourinary Agents - Miscellaneous*...75 *Gout Agents*...76 *Hematological Agents - Misc.*...76 *Hematopoietic Agents*...77 *Hepatitis C Agent - Combinations*** *Hypnotics* *Laxatives* *Macrolides*...79 *Medical Devices*...80 *Migraine Products* *Minerals & Electrolytes* *Mouth/Throat/Dental Agents* *Multivitamins* *Musculoskeletal Therapy Agents*...90 *Nasal Agents - Systemic And Topical* *Neprilysin Inhib (Arni)-Angiotensin Ii Recept Antag Comb***...91 *Neuromuscular Agents*...92 *Ophthalmic Agents*...92 *Otic Agents*...95 *Passive Immunizing Agents*...96 *Penicillins*...96 *Pharmaceutical Adjuvants*...97 *Potassium Removing Agents*** *Progestins* *Psychotherapeutic And Neurological Agents - Misc.* *Respiratory Agents - Misc.* *Serotonin Modulators*** *Sinus Node Inhibitors** *Sodium-Glucose Co-Transporter 2 Inhibitor-Biguanide Comb*** *Sulfonamides* *Tetracyclines* *Thyroid Agents* *Ulcer Drugs* *Urinary Anti-Infectives* *Urinary Antispasmodics* *Vaccines* *Vaginal Products* *Vasopressors* *Vitamins*

6 Aetna Better Health Louisiana lowercase italics = Generic drugs UPPERCASE BOLD = Brand name drugs Notes = NO required for greater than or equal to 6 y/o and less than or equal to 18 y/o = QLL: 1 capsule per day for under age 12 and 2 capsules per day for age 12 and older * = required for all members less than 6 years AND over 18 years for all medications used to treat ADHD * = Prior Authorization required for quantities greater than 21 days supply AL = Age Limits Apply OTC = Over the Counter = Prior Authorization Applies QLL = Quantity Level Limits Apply ST = Step Therapy Applies Drug Reference Notes *Adhd/Anti-Narcolepsy/Anti- Obesity/Anorexiants* *Adhd Agent - Selective Alpha Adrenergic Agonists*** guanfacine hcl er oral tablet extended release 24 hour 1, 2, 3, 4 *Amphetamine Mixtures*** amphetamine-dextroamphet er oral capsule extended release 24 hour 10, 15, 20, 25, 5 amphetamine-dextroamphet er oral capsule extended release 24 hour 30 amphetamine-dextroamphetamine oral tablet 10, 12.5, 15, 20, 5, 7.5 amphetamine-dextroamphetamine oral tablet 30 Intuniv Adderall XR Adderall XR Adderall Adderall QLL (30 EA per 30 days); AL (Min 6 Years) QLL (30 EA per 30 days); AL (Min 6 Years and Max 18 Years) QLL: 1 capsule per day for under age 12 and 2 capsules per day for age 12 and older; AL (Min 6 Years and Max 18 Years) QLL (90 EA per 30 days); AL (Min 6 Years and Max 18 Years) QLL (60 EA per 30 days); AL (Min 6 Years and Max 18 Years) 3

7 *Amphetamines*** dextroamphetamine sulfate er oral capsule extended release 24 hour 10, 15 dextroamphetamine sulfate er oral capsule extended release 24 hour 5 dextroamphetamine sulfate oral tablet 10, 5 Dexedrine Dexedrine Zenzedi QLL (120 EA per 30 days); AL (Min 6 Years and Max 18 Years) QLL (90 EA per 30 days); AL (Min 6 Years and Max 18 Years) QLL (180 EA per 30 days); AL (Min 6 Years and Max 18 Years) *Analeptics*** caffeine citrate oral solution 20 /ml, 60 /3ml caffeine citrated powder *Lipase Inhibitors*** ALLI ORAL CAPSULE 60 MG ; OTC *Stimulants - Misc.*** armodafinil oral tablet 150, 200, 250 Nuvigil ; QLL (30 EA per 30 days) armodafinil oral tablet 50 Nuvigil ; QLL (60 EA per 30 days) dexmethylphenidate hcl er oral capsule extended release 24 hour 10, 15, 20, 25, 30, 35, 40, 5 dexmethylphenidate hcl oral tablet 10, 2.5, 5 METADATE ER ORAL TABLET EXTENDED RELEASE 20 MG METHYLIN ORAL SOLUTION 10 MG/5ML METHYLIN ORAL SOLUTION 5 MG/5ML methylphenidate hcl er (cd) oral capsule extended release 10, 20, 30, 40, 50, 60 methylphenidate hcl er (la) oral capsule extended release 24 hour 20, 40 methylphenidate hcl er (la) oral capsule extended release 24 hour 30 4 Focalin XR Focalin Metadate ER Methylin Methylin Ritalin LA Ritalin LA QLL (30 EA per 30 days); AL (Min 6 Years and Max 18 Years) QLL (60 EA per 30 days); AL (Min 6 Years and Max 18 Years) QLL (90 EA per 30 days); AL (Min 6 Years and Max 18 Years) QLL (900 ml per 30 days); AL (Min 6 Years and Max 18 Years) QLL (900 ML per 30 days); AL (Min 6 Years and Max 18 Years) QLL (30 EA per 30 days); AL (Min 6 Years and Max 18 Years) QLL (30 EA per 30 days); AL (Min 6 Years and Max 18 Years) QLL (60 EA per 30 days); AL (Min 6 Years and Max 18 Years)

8 methylphenidate hcl er oral tablet extended release 10 methylphenidate hcl er oral tablet extended release 18, 27, 54 methylphenidate hcl er oral tablet extended release 20 methylphenidate hcl er oral tablet extended release 24 hour 18, 27, 36 methylphenidate hcl er oral tablet extended release 24 hour 54 methylphenidate hcl er oral tablet extended release 36 methylphenidate hcl oral solution 10 /5ml methylphenidate hcl oral solution 5 /5ml methylphenidate hcl oral tablet 10, 20, 5 methylphenidate hcl oral tablet chewable 10 methylphenidate hcl oral tablet chewable 2.5, 5 modafinil oral tablet 100, 200 *Aminoglycosides* *Aminoglycosides*** KITABIS K INHALATION NEBULIZATION SOLUTION 300 MG/5ML neomycin sulfate oral tablet 500 paromomycin sulfate oral capsule 250 Concerta Metadate ER Concerta Methylin Methylin Ritalin Provigil Kitabis Pak QLL (90 EA per 30 days); AL (Min 6 Years and Max 18 Years) QLL (30 EA per 30 days); AL (Min 6 Years and Max 18 Years) QLL (90 EA per 30 days); AL (Min 6 Years and Max 18 Years) QLL (60 EA per 30 days); AL (Min 6 Years and Max 18 Years) AL (Min 6 Years and Max 18 Years) QLL (60 EA per 30 days); AL (Min 6 Years and Max 18 Years) QLL (900 ml per 30 days); AL (Min 6 Years and Max 18 Years) QLL (900 ML per 30 days); AL (Min 6 Years and Max 18 Years) QLL (90 EA per 30 days); AL (Min 6 Years and Max 18 Years) QLL (180 EA per 30 days); AL (Min 6 Years and Max 18 Years) QLL (150 EA per 30 days); AL (Min 6 Years and Max 18 Years) ; * ( required for all members less than 6 years AND over 18 years for all medications used to treat ADHD); QLL (30 EA per 30 Days); AL (Min 6 Years and Max 18 Years) 5

9 tobramycin inhalation nebulization solution 300 /5ml *Analgesics - Anti-Inflammatory* *Anti-Tnf-Alpha - Monoclonal 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 20 MG/0.4ML, 40 MG/0.8ML *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 20 MG/0.4ML, 40 MG/0.8ML *Cyclooxygenase 2 (Cox-2) Inhibitors*** celecoxib oral capsule 100, 200, 400, 50 *Gold Compounds*** RIDAURA ORAL CAPSULE 3 MG Kitabis Pak CeleBREX ST 6

10 *Nonsteroidal Anti-Inflammatory Agents (Nsaids)*** childrens ibuprofen 100 oral suspension 100 /5ml Childrens Advil OTC 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 er oral tablet extended release 24 hour 400, 500, 600 etodolac oral capsule 200, 300 etodolac oral tablet 400 Lodine etodolac oral tablet 500 fenoprofen calcium oral tablet 600 ProFeno flurbiprofen oral tablet 100, 50 flurbiprofen powder ibuprofen junior strength oral tablet chewable Advil Junior Strength 100 OTC ibuprofen oral tablet 200 Advil OTC ibuprofen oral tablet 400, 600, 800 ibuprofen powder indomethacin er oral capsule extended release 75 indomethacin oral capsule 25, 50 indomethacin powder infants ibuprofen oral suspension 50 /1.25ml Infants Advil OTC ketoprofen oral capsule 50, 75 ketoprofen powder ketorolac tromethamine oral tablet 10 QLL (20 EA per 30 days) meclofenamate sodium oral capsule 100, 50 meclofenamate sodium powder meloxicam oral tablet 15, 7.5 Mobic nabumetone oral tablet 500, 750 naproxen dr oral tablet delayed release 375, 500 EC-Naprosyn naproxen oral suspension 125 /5ml Naprosyn naproxen oral tablet 250, 500 Naprosyn 7

11 naproxen oral tablet 375 naproxen powder naproxen sodium oral tablet 275 naproxen sodium oral tablet 550 Anaprox DS naproxen sodium powder oxaprozin oral tablet 600 Daypro piroxicam oral capsule 10, 20 Feldene piroxicam powder sulindac oral tablet 150, 200 sulindac powder tolmetin sodium oral capsule 400 tolmetin sodium oral tablet 200, 600 *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 SUBCUTANEOUS SOLUTION RECONSTITUTED 25 MG ENBREL SURECLICK SUBCUTANEOUS SOLUTION AUTO-INJECTOR 50 MG/ML *Analgesics - Nonnarcotic* *Analgesics Other*** acetaminophen oral liquid 160 /5ml Little Remedies for Fever OTC acetaminophen oral tablet 500 Healthy Mama Shake That Ache OTC acetaminophen rectal suppository 120, 650 Acephen OTC eq acetaminophen junior oral tablet dispersible 160 OTC *Analgesics-Sedatives*** butalbital-acetaminophen oral tablet Tencon butalbital-apap-caffeine oral capsule Fioricet 8

12 butalbital-apap-caffeine oral capsule Capacet butalbital-apap-caffeine oral tablet Esgic butalbital-aspirin-caffeine oral capsule Fiorinal CACET ORAL CAPSULE MG Capacet ESGIC ORAL CAPSULE MG Capacet marten-tab oral tablet Tencon TENCON ORAL TABLET MG Tencon ZEBUTAL ORAL CAPSULE MG Capacet *Salicylate Combinations*** choline-mag trisalicylate oral liquid 500 /5ml *Salicylates*** acetyl salicylic acid powder aspirin adult low dose oral tablet delayed release 81 Aspir-Low OTC aspirin ec oral tablet delayed release 325 Bayer Aspirin Regimen OTC aspirin oral tablet 325 Bayer Advanced Aspirin Reg St OTC aspirin rectal suppository 300, 600 OTC diflunisal oral tablet 500 ra aspirin oral tablet 500 Bayer Advanced Aspirin Ex St OTC salsalate oral tablet 500, 750 *Analgesics - Opioid* *Codeine Combinations*** acetaminophen-codeine #2 oral tablet QLL (28 EA per 7 days) acetaminophen-codeine #3 oral tablet Tylenol with Codeine #3 QLL (28 EA per 7 days) acetaminophen-codeine #4 oral tablet Tylenol with Codeine #4 QLL (28 EA per 7 days) acetaminophen-codeine oral solution /5ml acetaminophen-codeine oral tablet QLL (28 EA per 7 days) acetaminophen-codeine oral tablet Tylenol with Codeine #4 QLL (28 EA per 7 days) ASCOMP-CODEINE ORAL CAPSULE MG Ascomp-Codeine 9

13 butalbital-apap-caff-cod oral capsule Fioricet/Codeine butalbital-apap-caff-cod oral capsule butalbital-asa-caff-codeine oral capsule Ascomp-Codeine *Hydrocodone Combinations*** hydrocodone-acetaminophen oral solution /5ml, /10ml, Hycet QLL (240 ML per 30 days) /15ml hydrocodone-acetaminophen oral tablet Lorcet HD QLL (28 EA per 7 days) hydrocodone-acetaminophen oral tablet Verdrocet QLL (28 EA per 7 days) hydrocodone-acetaminophen oral tablet Lorcet QLL (28 EA per 7 days) hydrocodone-acetaminophen oral tablet Lorcet Plus QLL (28 EA per 7 days) hydrocodone-ibuprofen oral tablet QLL (28 EA per 7 days) LORCET HD ORAL TABLET MG Lorcet HD QLL (28 EA per 7 days) LORCET ORAL TABLET MG Lorcet QLL (28 EA per 7 days) LORCET PLUS ORAL TABLET MG Lorcet Plus QLL (28 EA per 7 days) *Opioid Agonists*** codeine sulfate oral tablet 15, 30, 60 fentanyl citrate buccal lozenge on a handle 1200 mcg, 1600 mcg, 200 mcg, 400 mcg, 600 Actiq ; QLL (120 EA per 30 days) mcg, 800 mcg fentanyl citrate powder fentanyl transdermal patch 72 hour 100 mcg/hr Duragesic-100 ; QLL (20 EA per 30 days) fentanyl transdermal patch 72 hour 12 mcg/hr Duragesic-12 ; QLL (10 EA per 30 days) fentanyl transdermal patch 72 hour 25 mcg/hr Duragesic-25 ; QLL (10 EA per 30 days) fentanyl transdermal patch 72 hour 37.5 mcg/hr, 62.5 mcg/hr, 87.5 mcg/hr ; QLL (10 EA per 30 days) fentanyl transdermal patch 72 hour 50 mcg/hr Duragesic-50 ; QLL (10 EA per 30 days) fentanyl transdermal patch 72 hour 75 mcg/hr Duragesic-75 ; QLL (20 EA per 30 days) hydromorphone hcl oral tablet 2, 4, 8 Dilaudid QLL (28 EA per 7 days) hydromorphone hcl powder hydromorphone hcl rectal suppository 3 10

14 meperidine hcl oral solution 50 /5ml meperidine hcl oral tablet 100, 50 Demerol QLL (28 EA per 7 days) METHADONE HCL INTENSOL ORAL CONCENTRATE 10 MG/ML Methadone HCl Intensol methadone hcl oral concentrate 10 /ml Methadone HCl Intensol methadone hcl oral solution 10 /5ml, 5 /5ml methadone hcl oral tablet 10, 5 Dolophine ; QLL (45 EA per 30 days) methadone hcl oral tablet soluble 40 Methadose QLL (540 EA per 30 days) methadone hcl powder METHADOSE ORAL TABLET SOLUBLE 40 MG Methadose QLL (540 EA per 30 days) morphine sulfate (concentrate) oral solution 100 /5ml morphine sulfate er oral capsule extended release 24 hour 10, 100, 20, 30, Kadian QLL (30 EA per 30 days) 50, 60, 80 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 morphine sulfate powder morphine sulfate rectal suppository 10, 20, 30, 5 oxycodone hcl oral capsule 5 oxycodone hcl oral concentrate 100 /5ml oxycodone hcl oral solution 5 /5ml oxycodone hcl oral tablet 10, 20 oxycodone hcl oral tablet 15, 30, 5 Roxicodone oxycodone hcl powder oxymorphone hcl er oral tablet extended release 12 hour 10, 15, 20, 30, 40, 5, 7.5 tramadol hcl oral tablet 50 *Opioid Combinations*** ENDOCET ORAL TABLET MG, MG, MG, MG oxycodone-acetaminophen oral tablet , , 5-325, Ultram Endocet Endocet ; QLL (30 EA per 30 days) QLL (28 EA per 7 days) QLL (28 EA per 7 days) QLL (28 EA per 7 days) QLL (28 EA per 7 days) ; QLL (30 EA per 30 days) QLL (28 EA per 7 days); AL (Min 16 Years) QLL (28 EA per 7 days) QLL (28 EA per 7 days) 11

15 oxycodone-aspirin oral tablet QLL (28 EA per 7 days) *Opioid Partial Agonists*** buprenorphine hcl-naloxone hcl sublingual tablet sublingual 2-0.5, 8-2 butorphanol tartrate nasal solution 10 /ml QLL (2.5 ML per 30 days) pentazocine-naloxone hcl oral tablet *Tramadol Combinations*** tramadol-acetaminophen oral tablet *Androgens-Anabolic* *Androgens*** ANDROGEL PUMP TRANSDERMAL GEL MG/ACT (1.62%) danazol oral capsule 100, 200, 50 danazol powder methyltestosterone oral capsule 10 testosterone cypionate intramuscular solution 100 /ml, 200 /ml testosterone enanthate intramuscular solution 200 /ml testosterone transdermal gel 10 /act (2%) Ultracet Android Depo-Testosterone Fortesta testosterone transdermal gel 12.5 /act (1%) Vogelxo Pump testosterone transdermal gel 25 /2.5gm AndroGel (1%) testosterone transdermal gel 50 /5gm (1%) AndroGel *Anorectal Agents* *Intrarectal Steroids*** COLOCORT RECTAL ENEMA 100 Colocort MG/60ML CORTIFOAM RECTAL FOAM 10 % hydrocortisone rectal enema 100 /60ml Colocort *Nitrate Vasodilating Agents*** RECTIV RECTAL OINTMENT 0.4 % *Rectal Anesthetic/Steroids*** lidocaine-hydrocortisone ace rectal cream % QLL (28 EA per 7 days); AL (Min 16 Years) ; QLL (10 ML per 90 days) ; QLL (5 ML per 60 days) ; QLL (2 canisters per 30 days) ; QLL (4 canisters per 30 days) ; QLL (1 pack per 1 day) ; QLL (60 GM per 30 days) ; QLL (30 Grams per 30 days) 12

16 lidocaine-hydrocortisone ace rectal kit %, 3-1 % PROCTOFOAM HC RECTAL FOAM 1-1 % *Rectal Steroids*** HEMMOREX-HC RECTAL SUPPOSITORY 30 MG Hemmorex-HC hydrocortisone acetate rectal suppository 30 Hemmorex-HC PROCTO-K RECTAL CREAM 1 % Hydrocortisone PROCTOSOL HC RECTAL CREAM 2.5 % Hydrocortisone PROCTOZONE-HC RECTAL CREAM 2.5 % Hydrocortisone *Anthelmintics* *Anthelmintics*** ALBENZA ORAL TABLET 200 MG ST BILTRICIDE ORAL TABLET 600 MG ivermectin oral tablet 3 Stromectol reeses pinworm medicine oral suspension 144 /ml OTC reeses pinworm medicine oral tablet 180 OTC *Antianginal Agents* *Nitrates*** isosorbide dinitrate er oral tablet extended release 40 isosorbide dinitrate oral tablet 10, 20, 30 isosorbide dinitrate oral tablet 5 Isordil Titradose isosorbide mononitrate er oral tablet extended release 24 hour 120, 30, 60 isosorbide mononitrate oral tablet 10, 20 MINITRAN TRANSDERMAL TCH 24 HOUR 0.1 MG/HR, 0.2 MG/HR, 0.4 Minitran MG/HR, 0.6 MG/HR NITRO-BID TRANSDERMAL OINTMENT 2 % nitroglycerin er oral capsule extended release Nitro-Time 2.5, 6.5, 9 13

17 nitroglycerin transdermal patch 24 hour 0.1 /hr, 0.2 /hr, 0.4 /hr, 0.6 /hr Minitran NITROSTAT SUBLINGUAL TABLET SUBLINGUAL 0.3 MG, 0.4 MG, 0.6 MG Nitroglycerin NITRO-TIME ORAL CAPSULE EXTENDED RELEASE 2.5 MG, 6.5 MG, 9 Nitro-Time MG *Antianxiety Agents* *Antianxiety Agents - Misc.*** buspirone hcl oral tablet 10, 15, 30, 5, 7.5 QLL (60 EA per 30 days) hydroxyzine hcl oral syrup 10 /5ml hydroxyzine hcl oral tablet 10, 25, 50 hydroxyzine pamoate oral capsule 100 hydroxyzine pamoate oral capsule 25, 50 Vistaril hydroxyzine pamoate powder meprobamate oral tablet 200, 400 *Benzodiazepines*** alprazolam er oral tablet extended release 24 hour 0.5, 1, 2, 3 Xanax XR ALPRAZOLAM INTENSOL ORAL CONCENTRATE 1 MG/ML alprazolam oral tablet 0.25, 0.5, 1, 2 Xanax alprazolam oral tablet dispersible 0.25, 0.5, 1, 2 alprazolam xr oral tablet extended release 24 hour 0.5, 1, 2, 3 Xanax XR chlordiazepoxide hcl oral capsule 10, 25, 5 clorazepate dipotassium oral tablet 15, 3.75 clorazepate dipotassium oral tablet 7.5 Tranxene-T diazepam oral solution 1 /ml diazepam oral tablet 10, 2, 5 Valium LORAZEM INTENSOL ORAL CONCENTRATE 2 MG/ML LORazepam Intensol lorazepam oral concentrate 2 /ml LORazepam Intensol lorazepam oral tablet 0.5, 1, 2 Ativan 14

18 oxazepam oral capsule 10, 15, 30 *Antiarrhythmics* *Antiarrhythmics Type I-A*** disopyramide phosphate oral capsule 100, Norpace 150 procainamide hcl powder quinidine gluconate er oral tablet extended release 324 quinidine sulfate oral tablet 200, 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 Pacerone MULTAQ ORAL TABLET 400 MG ; QLL (60 EA per 30 days) CERONE ORAL TABLET 100 MG, 200 Pacerone MG, 400 MG *Antiasthmatic And Bronchodilator Agents* *Adrenergic Combinations*** ANORO ELLIPTA INHALATION AEROSOL POWDER BREATH QLL (1 inhaler per 30 days) ACTIVATED MCG/INH BREO ELLIPTA INHALATION AEROSOL POWDER BREATH ACTIVATED MCG/INH, QLL (1 inhaler per 30 days) MCG/INH COMBIVENT RESPIMAT INHALATION AEROSOL SOLUTION MCG/ACT DULERA INHALATION AEROSOL MCG/ACT, MCG/ACT fluticasone-salmeterol inhalation aerosol powder breath activated mcg/act AirDuo RespiClick 113/14 QLL (1 inhaler per 30 days) fluticasone-salmeterol inhalation aerosol powder breath activated mcg/act AirDuo RespiClick 232/14 QLL (1 inhaler per 30 days) 15

19 fluticasone-salmeterol inhalation aerosol powder breath activated mcg/act AirDuo RespiClick 55/14 QLL (1 inhaler per 30 days) ipratropium-albuterol inhalation solution (3) /3ml STIOLTO RESPIMAT INHALATION AEROSOL SOLUTION MCG/ACT ST; QLL (1 inhaler per 30 days) *Anti-Inflammatory Agents*** cromolyn sodium inhalation nebulization solution 20 /2ml cromolyn sodium powder *Beta Adrenergics*** albuterol sulfate er oral tablet extended release 12 hour 4, 8 albuterol sulfate inhalation nebulization solution (2.5 /3ml) 0.083% QLL (390 ml per 30 days) albuterol sulfate inhalation nebulization solution (5 /ml) 0.5% QLL (390 EA per 30 days) albuterol sulfate inhalation nebulization solution 0.63 /3ml, 1.25 /3ml ST; QLL (390 ML per 30 days) albuterol sulfate oral syrup 2 /5ml albuterol sulfate oral tablet 2, 4 albuterol sulfate powder levalbuterol tartrate inhalation aerosol 45 mcg/act Xopenex HFA ST; QLL (2 INH per 30 days) metaproterenol sulfate oral syrup 10 /5ml metaproterenol sulfate oral tablet 10, 20 metaproterenol sulfate powder PROAIR HFA INHALATION AEROSOL SOLUTION 108 (90 BASE) MCG/ACT QLL (17 GM per 30 days) PROVENTIL HFA INHALATION AEROSOL SOLUTION 108 (90 BASE) QLL (13 GM per 30 days) MCG/ACT SEREVENT DISKUS INHALATION AEROSOL POWDER BREATH ACTIVATED 50 MCG/DOSE terbutaline sulfate oral tablet 2.5, 5 terbutaline sulfate powder VENTOLIN HFA INHALATION AEROSOL SOLUTION 108 (90 BASE) MCG/ACT QLL (36 Grams per 30 days) 16

20 *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 % ipratropium bromide powder *Leukotriene Receptor Antagonists*** montelukast sodium oral packet 4 Singulair QLL (30 EA per 30 days) montelukast sodium oral tablet 10 Singulair QLL (30 EA per 30 days) montelukast sodium oral tablet chewable 4, 5 Singulair QLL (30 EA per 30 days) zafirlukast oral tablet 10, 20 Accolate ST; QLL (60 EA per 30 days) *Steroid Inhalants*** budesonide inhalation suspension 0.25 /2ml, 0.5 /2ml Pulmicort ; QLL (120 ml per 30 days) FLOVENT DISKUS INHALATION AEROSOL POWDER BREATH ACTIVATED 100 MCG/BLIST, 250 MCG/BLIST, 50 MCG/BLIST FLOVENT HFA INHALATION AEROSOL 110 MCG/ACT, 220 MCG/ACT, 44 MCG/ACT PULMICORT FLEXHALER INHALATION AEROSOL POWDER BREATH ACTIVATED 180 MCG/ACT, 90 MCG/ACT PULMICORT INHALATION SUSPENSION 1 MG/2ML QVAR INHALATION AEROSOL SOLUTION 40 MCG/ACT, 80 MCG/ACT *Xanthines*** aminophylline anhydrous powder THEO-24 ORAL CAPSULE EXTENDED RELEASE 24 HOUR 100 MG, 200 MG, 300 MG, 400 MG THEOCHRON ORAL TABLET EXTENDED RELEASE 12 HOUR 100 MG, 200 MG, 300 MG Budesonide Theochron QLL (1 EA per 30 days); AL (Max 5 Years) QLL (120 ml per 30 days) 17

21 theophylline er oral tablet extended release 12 Theochron 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 *Anticoagulants* *Coumarin Anticoagulants*** JANTOVEN ORAL TABLET 1 MG, 10 MG, 2 MG, 2.5 MG, 3 MG, 4 MG, 5 MG, 6 Coumadin MG, 7.5 MG warfarin sodium oral tablet 1, 10, 2, 2.5, 3, 4, 5, 6, 7.5 Coumadin warfarin sodium powder *Direct Factor Xa Inhibitors*** ELIQUIS ORAL TABLET 2.5 MG, 5 MG ; QLL (60 EA per 30 days) XARELTO ORAL TABLET 10 MG, 15 MG, 20 MG ; QLL (30 EA per 30 days) XARELTO STARTER CK ORAL TABLET THERAPY CK 15 & 20 MG ; QLL (1 FILL per 90 days) *Heparins And Heparinoid-Like Agents*** heparin lock flush intravenous solution 1 unit/ml heparin sodium (porcine) injection solution 1000 unit/ml, unit/ml, unit/ml, 5000 unit/ml heparin sodium (porcine) pf injection solution 5000 unit/0.5ml *Low Molecular Weight Heparins*** enoxaparin sodium injection solution 300 /3ml Lovenox QLL (20 ml per 1 Year) enoxaparin sodium subcutaneous solution 100 Lovenox /ml, 150 /ml QLL (20 ml per 1 Year) enoxaparin sodium subcutaneous solution 120 Lovenox /0.8ml, 80 /0.8ml QLL (16 ml per 1 Year) enoxaparin sodium subcutaneous solution 30 /0.3ml Lovenox QLL (6 ml per 1 Year) enoxaparin sodium subcutaneous solution 40 /0.4ml Lovenox QLL (8 ml per 1 Year) 18

22 enoxaparin sodium subcutaneous solution 60 /0.6ml FRAGMIN SUBCUTANEOUS SOLUTION UNIT/ML FRAGMIN SUBCUTANEOUS SOLUTION UNIT/0.5ML FRAGMIN SUBCUTANEOUS SOLUTION UNIT/0.6ML FRAGMIN SUBCUTANEOUS SOLUTION UNT/0.72ML FRAGMIN SUBCUTANEOUS SOLUTION 2500 UNIT/0.2ML, 5000 UNIT/0.2ML FRAGMIN SUBCUTANEOUS SOLUTION 7500 UNIT/0.3ML *Synthetic Heparinoid-Like Agents*** fondaparinux sodium subcutaneous solution 10 /0.8ml, 2.5 /0.5ml, 5 /0.4ml, 7.5 /0.6ml *Anticonvulsants* *Anticonvulsants - Benzodiazepines*** clonazepam oral tablet 0.5, 1, 2 clonazepam oral tablet dispersible 0.125, 0.25, 0.5, 1, 2 DIASTAT ACUDIAL RECTAL GEL 10 MG, 20 MG DIASTAT PEDIATRIC RECTAL GEL 2.5 MG *Anticonvulsants - Misc.*** carbamazepine er oral capsule extended release 12 hour 100, 200, 300 carbamazepine er oral tablet extended release 12 hour 200, 400 carbamazepine oral suspension 100 /5ml carbamazepine oral tablet 200 carbamazepine oral tablet chewable 100 carbamazepine powder CARBATROL ORAL CAPSULE EXTENDED RELEASE 12 HOUR 100 MG, 200 MG, 300 MG Lovenox Arixtra KlonoPIN DiazeM DiazeM Carbatrol TEGretol-XR TEGretol Epitol Carbatrol QLL (12 ml per 1 Year) QLL (10 ml per 1 Year) QLL (5 ml per 1 Year) QLL (6 ml per 1 Year) QLL (7.2 ml per 1 Year) QLL (2 ml per 1 Year) QLL (3 ml per 1 Year) ; * (Prior Authorization required for quantities greater than 21 days supply) QLL (2 EA per 30 days) QLL (400 EA per 100 days) 19

23 EPITOL ORAL TABLET 200 MG Epitol gabapentin oral capsule 100, 300, 400 gabapentin oral solution 250 /5ml gabapentin oral tablet 600, 800 Neurontin Neurontin Neurontin QLL (3600 MG (cumulative) per 1 day) QLL (3600 MG (cumulative) per 1 day) QLL (3600 MG (cumulative) per 1 day) lamotrigine oral tablet 100, 150, 200, 25 LaMICtal lamotrigine oral tablet chewable 25, 5 LaMICtal levetiracetam er oral tablet extended release 24 hour 500, 750 Keppra XR levetiracetam oral solution 100 /ml Keppra levetiracetam oral tablet 1000, 250, 500, 750 Keppra oxcarbazepine oral suspension 300 /5ml Trileptal oxcarbazepine oral tablet 150, 300, 600 Trileptal primidone oral tablet 250, 50 Mysoline topiramate oral capsule sprinkle 15, 25 Topamax Sprinkle QLL (120 EA per 30 days) topiramate oral tablet 100, 200, 25, Topamax 50 QLL (120 EA per 30 days) zonisamide oral capsule 100, 25 Zonegran QLL (180 EA per 30 days) zonisamide oral capsule 50 QLL (180 EA per 30 days) *Carbamates*** felbamate oral suspension 600 /5ml Felbatol felbamate oral tablet 400, 600 Felbatol *Gaba Modulators*** GABITRIL ORAL TABLET 12 MG, 16 MG QLL (60 EA per 30 days) tiagabine hcl oral tablet 2, 4 Gabitril QLL (60 EA per 30 days) *Hydantoins*** DILANTIN INFATABS ORAL TABLET CHEWABLE 50 MG Dilantin Infatabs DILANTIN ORAL CAPSULE 100 MG Dilantin DILANTIN ORAL CAPSULE 30 MG PHENYTEK ORAL CAPSULE 200 MG, 300 MG Phenytek PHENYTOIN INFATABS ORAL TABLET Dilantin Infatabs CHEWABLE 50 MG phenytoin oral suspension 125 /5ml Dilantin 20

24 phenytoin oral tablet chewable 50 Dilantin Infatabs phenytoin sodium extended oral capsule 100 Dilantin phenytoin sodium extended oral capsule 200, 300 Phenytek *Succinimides*** CELONTIN ORAL CAPSULE 300 MG ethosuximide oral capsule 250 Zarontin ethosuximide oral solution 250 /5ml Zarontin *Valproic Acid*** DEKOTE ER ORAL TABLET EXTENDED RELEASE 24 HOUR 250 Depakote ER MG, 500 MG DEKOTE ORAL TABLET DELAYED RELEASE 125 MG, 250 MG, 500 MG Depakote DEKOTE SPRINKLES ORAL CAPSULE DELAYED RELEASE Depakote Sprinkles SPRINKLE 125 MG divalproex sodium er oral tablet extended release 24 hour 250, 500 Depakote ER divalproex sodium oral capsule delayed release sprinkle 125 Depakote Sprinkles divalproex sodium oral tablet delayed release 125, 250, 500 Depakote valproic acid oral capsule 250 Depakene valproic acid oral solution 250 /5ml Depakene *Antidepressants* *Alpha-2 Receptor Antagonists (Tetracyclics)*** mirtazapine oral tablet 15, 30, 45 Remeron QLL (30 EA per 30 days) mirtazapine oral tablet 7.5 QLL (30 EA per 30 days) mirtazapine oral tablet dispersible 15, 30, 45 Remeron SolTab QLL (30 EA per 30 days) *Antidepressants - Misc.*** bupropion hcl er (sr) oral tablet extended release 12 hour 100, 150, 200 Wellbutrin SR QLL (60 EA per 30 days) bupropion hcl er (xl) oral tablet extended release 24 hour 150, 300 Wellbutrin XL QLL (90 EA per 30 days) bupropion hcl oral tablet 100, 75 QLL (90 EA per 30 days) maprotiline hcl oral tablet 25 QLL (270 EA per 30 days) maprotiline hcl oral tablet 50 21

25 maprotiline hcl oral tablet 75 QLL (90 EA per 30 days) *Modified Cyclics*** trazodone hcl oral tablet 100 QLL (180 EA per 30 days) trazodone hcl oral tablet 150 QLL (120 EA per 30 days) trazodone hcl oral tablet 300 QLL (60 EA per 30 days) trazodone hcl oral tablet 50 QLL (360 EA per 30 days) trazodone hcl powder *Monoamine Oxidase Inhibitors (Maois)*** MARPLAN ORAL TABLET 10 MG QLL (180 EA per 30 days) phenelzine sulfate oral tablet 15 Nardil QLL (180 EA per 30 days) tranylcypromine sulfate oral tablet 10 Parnate QLL (180 EA per 30 days) *Selective Serotonin Reuptake Inhibitors (Ssris)*** citalopram hydrobromide oral solution 10 /5ml QLL (300 ml per 30 days) citalopram hydrobromide oral tablet 10, 20, 40 CeleXA QLL (30 EA per 30 days) escitalopram oxalate oral solution 5 /5ml QLL (300 ml per 30 days) escitalopram oxalate oral tablet 10, 20, Lexapro 5 QLL (30 EA per 30 days) fluoxetine hcl oral capsule 10 PROzac QLL (30 EA per 30 days) fluoxetine hcl oral capsule 20 PROzac QLL (120 EA per 30 days) fluoxetine hcl oral capsule 40 PROzac QLL (60 EA per 30 days) fluoxetine hcl oral solution 20 /5ml QLL (150 ml per 30 days) fluvoxamine maleate oral tablet 100 QLL (90 EA per 30 days) fluvoxamine maleate oral tablet 25 QLL (30 EA per 30 days) fluvoxamine maleate oral tablet 50 QLL (60 EA per 30 days) paroxetine hcl oral tablet 10, 20, 30, 40 Paxil QLL (30 EA per 30 days) sertraline hcl oral concentrate 20 /ml Zoloft sertraline hcl oral tablet 100, 50 Zoloft QLL (60 EA per 30 days) sertraline hcl oral tablet 25 Zoloft QLL (30 EA per 30 days) *Serotonin-Norepinephrine Reuptake Inhibitors (Snris)*** duloxetine hcl oral capsule delayed release particles 20, 30, 60 Cymbalta QLL (60 EA per 30 days) duloxetine hcl oral capsule delayed release particles 40 QLL (30 EA per 30 days) 22

26 venlafaxine hcl er oral capsule extended release 24 hour 150, 37.5, 75 Effexor XR QLL (30 EA per 30 days) venlafaxine hcl er oral tablet extended release 24 hour 150 venlafaxine hcl er oral tablet extended release 24 hour 225 QLL (30 EA per 30 days) venlafaxine hcl er oral tablet extended release 24 hour 37.5 QLL (120 EA per 30 days) venlafaxine hcl er oral tablet extended release 24 hour 75 QLL (90 EA per 30 days) venlafaxine hcl oral tablet 100 QLL (90 EA per 30 days) venlafaxine hcl oral tablet 25 QLL (270 EA per 30 days) venlafaxine hcl oral tablet 37.5 QLL (300 EA per 30 days) venlafaxine hcl oral tablet 50 QLL (210 EA per 30 days) venlafaxine hcl oral tablet 75 QLL (150 EA per 30 days) *Tricyclic Agents*** amitriptyline hcl oral tablet 10 QLL (900 EA per 30 days) amitriptyline hcl oral tablet 100 QLL (90 EA per 30 days) amitriptyline hcl oral tablet 150, 75 QLL (60 EA per 30 days) amitriptyline hcl oral tablet 25 Elavil QLL (360 EA per 30 days) amitriptyline hcl oral tablet 50 QLL (180 EA per 30 days) amoxapine oral tablet 100 QLL (180 EA per 30 days) amoxapine oral tablet 150 QLL (120 EA per 30 days) amoxapine oral tablet 25 QLL (720 EA per 30 days) amoxapine oral tablet 50 QLL (360 EA per 30 days) desipramine hcl oral tablet 10 Norpramin QLL (900 EA per 30 days) desipramine hcl oral tablet 100 QLL (90 EA per 30 days) desipramine hcl oral tablet 150 QLL (60 EA per 30 days) desipramine hcl oral tablet 25 Norpramin QLL (360 EA per 30 days) desipramine hcl oral tablet 50 QLL (180 EA per 30 days) desipramine hcl oral tablet 75 QLL (120 EA per 30 days) desipramine hcl powder doxepin hcl oral capsule 10 QLL (900 EA per 30 days) doxepin hcl oral capsule 100 QLL (90 EA per 30 days) doxepin hcl oral capsule 150 QLL (60 EA per 30 days) doxepin hcl oral capsule 25 QLL (360 EA per 30 days) doxepin hcl oral capsule 50 QLL (180 EA per 30 days) doxepin hcl oral capsule 75 QLL (120 EA per 30 days) doxepin hcl oral concentrate 10 /ml 23

27 doxepin hcl powder imipramine hcl oral tablet 10 Tofranil QLL (900 EA per 30 days) imipramine hcl oral tablet 25 Tofranil QLL (360 EA per 30 days) imipramine hcl oral tablet 50 Tofranil QLL (180 EA per 30 days) imipramine hcl powder nortriptyline hcl oral capsule 10 Pamelor QLL (450 EA per 30 days) nortriptyline hcl oral capsule 25 Pamelor QLL (180 EA per 30 days) nortriptyline hcl oral capsule 50 Pamelor QLL (90 EA per 30 days) nortriptyline hcl oral capsule 75 Pamelor QLL (60 EA per 30 days) nortriptyline hcl oral solution 10 /5ml nortriptyline hcl powder protriptyline hcl oral tablet 10 QLL (180 EA per 30 days) protriptyline hcl oral tablet 5 QLL (360 EA per 30 days) *Antidiabetics* *Alpha-Glucosidase Inhibitors*** acarbose oral tablet 100, 25, 50 Precose *Biguanides*** metformin hcl er oral tablet extended release 24 hour 500, 750 Glucophage XR metformin hcl oral tablet 1000, 500, 850 Glucophage *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 Nesina TRADJENTA ORAL TABLET 5 MG ST *Dipeptidyl Peptidase-4 Inhibitor- Biguanide Combinations*** alogliptin-metformin hcl oral tablet Kazano, JENTADUETO ORAL TABLET MG, MG, MG ST JENTADUETO XR ORAL TABLET EXTENDED RELEASE 24 HOUR ST; QLL (60 EA per 30 days) MG 24

28 JENTADUETO XR ORAL TABLET EXTENDED RELEASE 24 HOUR MG *Human Insulin*** BASAGLAR 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 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 SUBCUTANEOUS SUSPENSION (70-30) 100 UNIT/ML HUMULIN N SUBCUTANEOUS SUSPENSION 100 UNIT/ML HUMULIN R INJECTION SOLUTION 100 UNIT/ML HUMULIN R U-500 (CONCENTRATED) SUBCUTANEOUS SOLUTION 500 UNIT/ML NOVOLIN N SUBCUTANEOUS SUSPENSION 100 UNIT/ML NOVOLIN R INJECTION SOLUTION 100 UNIT/ML NOVOLOG MIX 70/30 SUBCUTANEOUS SUSPENSION (70-30) 100 UNIT/ML NOVOLOG SUBCUTANEOUS SOLUTION 100 UNIT/ML *Incretin Mimetic Agents (Glp-1 Receptor Agonists)*** TANZEUM SUBCUTANEOUS PEN- INJECTOR 30 MG, 50 MG ST; QLL (30 EA per 30 days) OTC OTC OTC OTC OTC ST; QLL (4 PENS per 28 days) 25

29 TRULICITY SUBCUTANEOUS SOLUTION PEN-INJECTOR 0.75 ST MG/0.5ML, 1.5 MG/0.5ML VICTOZA SUBCUTANEOUS SOLUTION PEN-INJECTOR 18 MG/3ML *Meglitinide Analogues*** nateglinide oral tablet 120, 60 Starlix repaglinide oral tablet 0.5 repaglinide oral tablet 1, 2 Prandin *Sodium-Glucose Co-Transporter 2 (Sglt2) Inhibitors*** INVOKANA ORAL TABLET 100 MG, 300 MG ST *Sulfonylurea-Biguanide Combinations*** glipizide-metformin hcl oral tablet , , glyburide-metformin oral tablet glyburide-metformin oral tablet , Glucovance *Sulfonylureas*** chlorpropamide oral tablet 100, 250 glimepiride oral tablet 1, 2, 4 Amaryl glipizide er oral tablet extended release 24 hour 10, 2.5, 5 Glucotrol XL glipizide oral tablet 10, 5 Glucotrol glipizide powder glipizide xl oral tablet extended release 24 hour 10, 2.5, 5 Glucotrol XL glyburide micronized oral tablet 1.5, 3, Glynase 6 glyburide oral tablet 1.25, 2.5, 5 tolazamide oral tablet 250, 500 tolbutamide oral tablet 500 *Sulfonylurea-Thiazolidinedione Combinations*** DUETACT ORAL TABLET 30-2 MG, 30-4 Duetact MG QLL (30 EA per 30 days) pioglitazone hcl-glimepiride oral tablet 30-2, 30-4 Duetact QLL (30 EA per 30 days) 26

30 *Thiazolidinedione-Biguanide Combinations*** pioglitazone hcl-metformin hcl oral tablet , Actoplus Met QLL (90 EA per 30 days) *Thiazolidinediones*** AVANDIA ORAL TABLET 2 MG, 4 MG QLL (30 EA per 30 days) pioglitazone hcl oral tablet 15, 30, 45 Actos QLL (30 EA per 30 days) *Antidiarrheals* *Antiperistaltic Agents*** diphenoxylate-atropine oral liquid /5ml diphenoxylate-atropine oral tablet Lomotil loperamide hcl oral capsule 2 Imodium A-D loperamide hcl powder paregoric oral tincture 2 /5ml *Antidotes* *Antidotes - Chelating Agents*** CHEMET ORAL CAPSULE 100 MG *Opioid Antagonists*** naloxone hcl injection solution 0.4 /ml naltrexone hcl oral tablet 50 NARCAN NASAL LIQUID 4 MG/0.1ML *Antiemetics* *5-Ht3 Receptor Antagonists*** granisetron hcl oral tablet 1 ondansetron hcl oral solution 4 /5ml Zofran ondansetron hcl oral tablet 24 ondansetron hcl oral tablet 4, 8 Zofran ondansetron oral tablet dispersible 4, 8 Zofran ODT *Antiemetics - Anticholinergic*** meclizine hcl oral tablet 25 Dramamine Less Drowsy meclizine hcl powder trimethobenzamide hcl oral capsule 300 Tigan 27

31 *Substance P/Neurokinin 1 (Nk1) Receptor Antagonists*** EMEND INTRAVENOUS SOLUTION RECONSTITUTED 150 MG EMEND ORAL CAPSULE 125 MG, 40 MG, 80 MG Aprepitant *Antifungals* *Antifungals*** bio-statin oral powder griseofulvin microsize oral suspension 125 /5ml griseofulvin microsize oral tablet 500 griseofulvin ultramicrosize oral tablet 125, Gris-PEG 250 nystatin oral tablet unit terbinafine hcl oral tablet 250 LamISIL QLL (84 EA per 365 days) *Imidazoles*** ketoconazole oral tablet 200 *Triazoles*** fluconazole oral suspension reconstituted 10 /ml, 40 /ml Diflucan fluconazole oral tablet 100, 150, 200, 50 Diflucan itraconazole oral capsule 100 Sporanox SPORANOX ORAL SOLUTION 10 MG/ML *Antihistamines* *Antihistamines - Alkylamines*** brompheniramine tannate oral tablet chewable 12 chlorpheniramine maleate powder *Antihistamines - Ethanolamines*** carbinoxamine maleate oral tablet 4 clemastine fumarate oral tablet 2.68 clemastine fumarate powder diphenhydramine hcl injection solution 50 /ml diphenhydramine hcl powder 28

32 *Antihistamines - Non-Sedating*** cetirizine hcl oral solution 1 /ml KLS Aller-Tec Childrens QLL (150 ml per 30 days) loratadine oral solution 5 /5ml Claritin OTC loratadine oral tablet 10 Claritin OTC *Antihistamines - Phenothiazines*** PHENADOZ RECTAL SUPPOSITORY 12.5 MG, 25 MG Phenadoz PHENERGAN RECTAL SUPPOSITORY 12.5 MG, 25 MG Phenadoz PHENERGAN RECTAL SUPPOSITORY 50 MG Phenergan 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 Phenadoz promethazine hcl rectal suppository 50 Phenergan PROMETHEGAN RECTAL SUPPOSITORY 12.5 MG, 25 MG Phenadoz PROMETHEGAN RECTAL SUPPOSITORY 50 MG Phenergan *Antihistamines - Piperidines*** cyproheptadine hcl oral syrup 2 /5ml cyproheptadine hcl oral tablet 4 *Antihyperlipidemics* *Bile Acid Sequestrants*** cholestyramine light oral packet 4 gm Prevalite cholestyramine light oral powder 4 gm/dose Prevalite cholestyramine oral packet 4 gm Questran cholestyramine oral powder 4 gm/dose Questran colestipol hcl oral granules 5 gm Colestid colestipol hcl oral packet 5 gm Colestid colestipol hcl oral tablet 1 gm Colestid PREVALITE ORAL CKET 4 GM Prevalite PREVALITE ORAL POWDER 4 GM/DOSE Prevalite *Fibric Acid Derivatives*** fenofibrate micronized oral capsule 134, 67 Lofibra 29

33 fenofibrate micronized oral capsule 200 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 gemfibrozil oral tablet 600 Lopid QLL (60 EA per 30 days) gemfibrozil powder *H Coa Reductase Inhibitors*** atorvastatin calcium oral tablet 10, 20, Lipitor 40, 80 QLL (30 EA per 30 days) fluvastatin sodium oral capsule 20 Lescol QLL (60 EA per 30 days) fluvastatin sodium oral capsule 40 QLL (60 EA per 30 days) LESCOL XL ORAL TABLET EXTENDED RELEASE 24 HOUR 80 MG Fluvastatin Sodium ER QLL (30 EA per 30 days) lovastatin oral tablet 10, 20 QLL (30 EA per 30 days) lovastatin oral tablet 40 Mevacor QLL (60 EA per 30 days) pravastatin sodium oral tablet 10 QLL (30 EA per 30 days) pravastatin sodium oral tablet 20, 40, 80 Pravachol QLL (30 EA per 30 days) rosuvastatin calcium oral tablet 10, 20, Crestor 40, 5 ST simvastatin oral tablet 10, 20, 40, 5 Zocor, 80 QLL (30 EA per 30 days) *Intestinal Cholesterol Absorption Inhibitors*** ezetimibe oral tablet 10 Zetia ST *Nicotinic Acid Derivatives*** niacin er (antihyperlipidemic) oral tablet extended release 1000, 500, 750 Niaspan *Antihypertensives* *Ace Inhibitor & Calcium Channel Blocker Combinations*** amlodipine besy-benazepril hcl oral capsule 10-20, 10-40, 5-10, 5-20 Lotrel amlodipine besy-benazepril hcl oral capsule ,

34 *Ace Inhibitors & Thiazide/Thiazide- Like*** benazepril-hydrochlorothiazide oral tablet 10- Lotensin HCT 12.5, , benazepril-hydrochlorothiazide oral tablet captopril-hydrochlorothiazide oral tablet 25-15, 25-25, 50-15, enalapril-hydrochlorothiazide oral tablet Vaseretic enalapril-hydrochlorothiazide oral tablet fosinopril sodium-hctz oral tablet , lisinopril-hydrochlorothiazide oral tablet , , Zestoretic moexipril-hydrochlorothiazide oral tablet , 15-25, quinapril-hydrochlorothiazide oral tablet , , Accuretic *Ace Inhibitors*** benazepril hcl oral tablet 10, 20, 40 Lotensin benazepril hcl oral tablet 5 captopril oral tablet 100, 12.5, 25, 50 enalapril maleate oral tablet 10, 2.5, 20, 5 Vasotec fosinopril sodium oral tablet 10, 20, 40 lisinopril oral tablet 10, 20, 5 Prinivil QLL (30 EA per 30 days) lisinopril oral tablet 2.5, 30 Zestril QLL (30 EA per 30 days) lisinopril oral tablet 40 Zestril QLL (60 EA per 30 days) moexipril hcl oral tablet 15, 7.5 perindopril erbumine oral tablet 2, 4, 8 quinapril hcl oral tablet 10, 20, 40, Accupril 5 ramipril oral capsule 1.25, 10, 2.5, Altace 5 trandolapril oral tablet 1, 2 trandolapril oral tablet 4 Mavik 31

35 *Adrenolytics-Central & Thiazide/Thiazide-Like Comb*** methyldopa-hydrochlorothiazide oral tablet , *Angiotensin Ii Receptor Antag & Thiazide/Thiazide-Like*** candesartan cilexetil-hctz oral tablet , , Atacand HCT irbesartan-hydrochlorothiazide oral tablet , Avalide losartan potassium-hctz oral tablet , , Hyzaar valsartan-hydrochlorothiazide oral tablet , , , , Diovan HCT ST; QLL (30 EA per 30 days) *Angiotensin Ii Receptor Antagonists*** candesartan cilexetil oral tablet 16, 32, Atacand 4, 8 irbesartan oral tablet 150, 300, 75 Avapro losartan potassium oral tablet 100, 25, Cozaar 50 valsartan oral tablet 160, 320, 40, 80 Diovan ST; QLL (60 EA per 30 days) *Antiadrenergics - Centrally Acting*** clonidine hcl oral tablet 0.1, 0.2, 0.3 Catapres clonidine hcl powder clonidine hcl transdermal patch weekly 0.1 /24hr Catapres-TTS-1 clonidine hcl transdermal patch weekly 0.2 /24hr Catapres-TTS-2 clonidine hcl transdermal patch weekly 0.3 /24hr Catapres-TTS-3 guanfacine hcl oral tablet 1 QLL (240 EA per 30 days) guanfacine hcl oral tablet 2 QLL (120 EA per 30 days) methyldopa oral tablet 250, 500 *Antiadrenergics - Peripherally Acting*** doxazosin mesylate oral tablet 1, 2, 4, 8 Cardura QLL (30 EA per 30 days) 32

36 prazosin hcl oral capsule 1, 2, 5 Minipress terazosin hcl oral capsule 1, 2, 5 QLL (30 EA per 30 days) terazosin hcl oral capsule 10 QLL (60 EA per 30 days) *Beta Blocker & Diuretic Combinations*** atenolol-chlorthalidone oral tablet Tenoretic 100 atenolol-chlorthalidone oral tablet Tenoretic 50 bisoprolol-hydrochlorothiazide oral tablet , , Ziac metoprolol-hydrochlorothiazide oral tablet , metoprolol-hydrochlorothiazide oral tablet Lopressor HCT nadolol-bendroflumethiazide oral tablet 40-5, 80-5 Corzide propranolol-hctz oral tablet 40-25, *Reserpine*** reserpine powder *Vasodilators*** hydralazine hcl oral tablet 10, 100, 25, 50 minoxidil oral tablet 10, 2.5 *Anti-Infective Agents - Misc.* *Anti-Infective Agents - Misc.*** FIRST-VANCOMYCIN 25 ORAL SOLUTION 25 MG/ML FIRST-VANCOMYCIN 50 ORAL SOLUTION 50 MG/ML metronidazole oral capsule 375 Flagyl metronidazole oral tablet 250, 500 Flagyl trimethoprim oral tablet 100 trimethoprim powder vancomycin hcl intravenous solution reconstituted 10 gm, 1000, 500, 5000 vancomycin hcl oral capsule 125, 250 Vancocin HCl 33

37 *Anti-Infective Misc. - Combinations*** sulfamethoxazole-trimethoprim oral Sulfatrim Pediatric suspension /5ml sulfamethoxazole-trimethoprim oral tablet Bactrim sulfamethoxazole-trimethoprim oral tablet Bactrim DS SULFATRIM PEDIATRIC ORAL Sulfatrim Pediatric SUSPENSION MG/5ML *Leprostatics*** dapsone oral tablet 100, 25 *Lincosamides*** clindamycin hcl oral capsule 150, 300, Cleocin 75 clindamycin palmitate hcl oral solution Cleocin reconstituted 75 /5ml *Antimalarials* *Antimalarials*** chloroquine phosphate oral tablet 250, 500 chloroquine phosphate powder DARAPRIM ORAL TABLET 25 MG hydroxychloroquine sulfate oral tablet 200 Plaquenil mefloquine hcl oral tablet 250 *Antimyasthenic Agents* *Antimyasthenic Agents*** pyridostigmine bromide oral tablet 60 Mestinon *Antimyasthenic/Cholinergic Agents*** pyridostigmine bromide oral tablet 60 Mestinon *Antimyasthenic/Cholinergic Agents* pyridostigmine bromide oral tablet 60 Mestinon *Antimycobacterial Agents* *Antimycobacterial Agents*** ethambutol hcl oral tablet 100, 400 Myambutol ethambutol hcl powder isoniazid oral syrup 50 /5ml 34

38 isoniazid oral tablet 100, 300 isoniazid powder MYCOBUTIN ORAL CAPSULE 150 MG Mycobutin PRIFTIN ORAL TABLET 150 MG pyrazinamide oral tablet 500 rifabutin oral capsule 150 Mycobutin rifampin oral capsule 150, 300 Rifadin rifampin powder *Antineoplastics And Adjunctive Therapies* *Alkylating Agents*** HEXALEN ORAL CAPSULE 50 MG MYLERAN ORAL TABLET 2 MG *Antiadrenals*** LYSODREN ORAL TABLET 500 MG *Antiandrogens*** bicalutamide oral tablet 50 Casodex flutamide oral capsule 125 NILANDRON ORAL TABLET 150 MG Nilutamide *Antiestrogens*** FARESTON ORAL TABLET 60 MG SOLTAMOX ORAL SOLUTION 10 MG/5ML tamoxifen citrate oral tablet 10, 20 *Antimetabolites*** capecitabine oral tablet 150 Xeloda ; QLL (140 EA per 21 days) capecitabine oral tablet 500 Xeloda ; QLL (154 EA per 21 days) mercaptopurine oral tablet 50 methotrexate oral tablet 2.5 TABLOID ORAL TABLET 40 MG *Antineoplastic - Histone Deacetylase Inhibitors*** ZOLINZA ORAL CAPSULE 100 MG *Antineoplastic - Mtor Kinase Inhibitors*** AFINITOR ORAL TABLET 10 MG, 2.5 MG, 5 MG, 7.5 MG 35