Your Guide to Prescription Drug Benefits

Transcription

1 Your Guide to Prescription Drug Benefits 2018 ESSENTIAL FORMULARY GUIDE FOR INDIVIDUAL AND SMALL GROUP* PLANS *Does not apply to the following Small Group plans. For these plans, please refer to the 2018 Essential Formulary with Preventive Drug Copays: BlueCross SG Bronze 19 BlueCross SG Silver 25 BlueCross SG Gold 24 BlueCross SG Bronze 20 BlueCross SG Silver 41 BlueCross SG Gold 25 BlueCross SG Silver 23 BlueCross SG Silver 52 BlueCross SG Gold 26

2 2018 Essential Formulary for Individual and Small Groups Table of Contents Abbreviations and Key to Drug Tiers...2 Drug Classes: Anti - Infectives... 6 Antineoplastic & Immunosuppressant Drugs...15 Autonomic & Cns Drugs, Neurology & Psych...18 Cardiovascular, Hypertension & Lipids...36 Dermatologicals/Topical Therapy...46 Diagnostics & Miscellaneous Agents...55 Ear, Nose & Throat Medications...60 Endocrine/Diabetes Gastroenterology Immunology, Vaccines & Biotechnology...84 Musculoskeletal & Rheumatology...91 Obstetrics & Gynecology Ophthalmology Respiratory, Allergy, Cough & Cold Urologicals Vitamins, Hematinics & Electrolytes Index of Drugs

3 Requirements/Limits AGE-A = Age edit is applicable. Prior authorization is required for members 17 years of age and younger. Your network provider must call Express Scripts at to request a coverage review. = Affordable Care Act. The products with the indicator are available to you at no out-of-pocket cost based on the Affordable Care Act () $0 Copay Preventive List. LD = Limited Distribution. This medication may be available only at certain pharmacies. For more information, please call BlueCross BlueShield Member Services at the phone number listed on your BlueCross BlueShield of Tennessee member ID card. PA = Prior Authorization. The plan requires your physician to obtain prior authorization for certain drugs. This means that you will need to get approval before you may fill your prescription. Your network provider must call Express Scripts at to request a coverage review for a drug that requires prior authorization. QL = Quantity Limit. For certain drugs, the plan limits the amount of the drug that will be covered. SPRx = Specialty Medication. Includes high-cost medications for chronic, serious diseases such as hepatitis C, multiple sclerosis, arthritis, hemophilia and other conditions. Some plans may cover specialty medications at different benefit levels or may require the use of a preferred specialty pharmacy. ST = Step Therapy. In some cases, your plan requires you to first try certain drugs to treat your medical condition before we will cover another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, we may not cover Drug B unless you try Drug A first. If Drug A does not work for you, we will then cover Drug B. Your network provider must call Express Scripts at to request a coverage review. Please refer to the Step Therapy list included within this guidebook on page 3 for medications that require step therapy and the agents that are required to be taken first. lowercase italics= Generic drugs UPPERCASE BOLD= Brand name drugs

4 Step Therapy Medication(s) Requiring Step Therapy Step Therapy Requirements Edarbi Edarbyclor Non-preferred diabetic test strips (e.g., Accu- Chek, Freestyle) QL Trial and failure of generic ARB Trial and failure of preferred products made by Lifescan (OneTouch) QL or Ascensia (Contour or Breeze2) QL Zioptan Trial and failure of latanoprost, Lumigan, or Travatan Z Admelog Admelog SoloStar Apidra Apidra SoloStar Humalog Humalog KwikPen Humalog Junior KwikPen Trial and failure of Fiasp, Fiasp FlexTouch, or Novolog Humulin Trial and failure of Novolin Proventil HFA QL Ventolin HFA QL Xopenex HFA QL Trial and failure of ProAir HFA QL or ProAir Respiclick QL Nevanac Trial and failure of Prolensa Alocril Alomide Bepreve Trial and failure of Pazeo Emadine Lastacaft Azopt Betimol Betoptic S Cosopt PF Istalol Simbrinza Trial and failure of Alphagan P 0.1 % or Combigan Osphena Premarin Cream Trial and failure of Estrace 0.01% cream or estradiol 0.01% cream 3

5 For drugs used to treat various inflammatory immune conditions, preferred drugs are required to be used before other non-preferred drugs based on a specific medical condition. A trial of one or two preferred agents will be required before a non-preferred drug will be covered. Below is a table of preferred and non-preferred agents based on various medical conditions. Medical Condition Preferred Agents Non-Preferred Agents (directed to ONE Preferred agent) Non-Preferred Agents (directed to TWO Preferred agents) Rheumatoid arthritis Actemra SC Enbrel Humira Xeljanz/XR Cimzia Orencia SC Simponi SC Kevzara Kineret Ankylosing spondylitis Cosentyx Enbrel Humira Cimzia Simponi SC Juvenile idiopathic arthritis Enbrel Humira Orencia SC Psoriatic arthritis Cosentyx Enbrel Humira Stelara SC Otezla Cimzia Orencia SC Simponi SC Taltz Xeljanz/XR Psoriasis Cosentyx Humira Otezla Stelara SC Enbrel* Tremfya Siliq Taltz Crohn s disease Humira Stelara SC Cimzia Ulcerative colitis Humira Simponi SC SC subcutaneous * For the treatment of Psoriasis, you must try Humira first before Enbrel is approved. Cosentyx, Otezla or Stelara SC do not meet the requirement for coverage of Enbrel for Psoriasis. 4

6 Drug Tiers = Generic Drugs = Preferred Brand Drugs = Non-Preferred Brand Drugs = Specialty Drugs = Drugs with $0 Cost Share- per Affordable Care Act () $0 Copay Preventive List Pharmacy Appeals To appeal a denial based on the prior authorization criteria or to request a medical exception to the quantity limit, please FAX a written request to: Pharmacy Management Appeals BlueCross BlueShield of Tennessee 1 Cameron Hill Circle Chattanooga, TN Fax: Please provide the following information with your written request: 1. Patient name and cardholder ID number 2. Physician name and phone number 3. Drug and diagnosis information This list is subject to change. Please call Member Services at the phone number listed on your BlueCross BlueShield of Tennessee member ID card or visit our website at bcbst.com for the most up to date information. 5

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

8 acyclovir oral suspension 200 mg/5 ml acyclovir oral tablet adefovir oral tablet amantadine hcl oral capsule amantadine hcl oral solution amantadine hcl oral tablet APTIVUS ORAL CAPSULE APTIVUS ORAL SOLUTION atazanavir oral capsule SPRx ATRIPLA ORAL TABLET SPRx BARACLUDE ORAL SOLUTION COMPLERA ORAL TABLET SPRx CRIXIVAN ORAL CAPSULE 200 MG, 400 MG 7 DESCOVY ORAL TABLET SPRx didanosine oral capsule,delayed release(dr/ec) EDURANT ORAL TABLET efavirenz oral capsule efavirenz oral tablet EMTRIVA ORAL CAPSULE EMTRIVA ORAL SOLUTION entecavir oral tablet EPCLUSA ORAL TABLET PA; SPRx EPIVIR HBV ORAL SOLUTION EPZICOM ORAL TABLET SPRx EVOTAZ ORAL TABLET SPRx famciclovir oral tablet fosamprenavir oral tablet FUZEON SUBCUTANEOUS RECON SOLN SPRx GENVOYA ORAL TABLET SPRx HARVONI ORAL TABLET PA; SPRx INTELENCE ORAL TABLET

9 INVIRASE ORAL CAPSULE INVIRASE ORAL TABLET ISENTRESS HD ORAL TABLET SPRx ISENTRESS ORAL POWDER IN PACKET SPRx ISENTRESS ORAL TABLET SPRx ISENTRESS ORAL TABLET,CHEWABLE SPRx JULUCA ORAL TABLET SPRx KALETRA ORAL SOLUTION KALETRA ORAL TABLET lamivudine oral solution lamivudine oral tablet lamivudine-zidovudine oral tablet LEXIVA ORAL SUSPENSION LEXIVA ORAL TABLET lopinavir-ritonavir oral solution MAVYRET ORAL TABLET PA; SPRx nevirapine oral suspension nevirapine oral tablet nevirapine oral tablet extended release 24 hr NORVIR ORAL CAPSULE NORVIR ORAL SOLUTION NORVIR ORAL TABLET ODEFSEY ORAL TABLET SPRx oseltamivir oral capsule 30 mg QL (20 EA per 180 days) oseltamivir oral capsule 45 mg, 75 mg QL (10 EA per 180 days) oseltamivir oral suspension for reconstitution QL (180 ML per 180 days) PREZCOBIX ORAL TABLET SPRx PREZISTA ORAL SUSPENSION SPRx PREZISTA ORAL TABLET 150 MG, 600 MG, 75 MG, 800 MG RELENZA DISKHALER INHALATION BLISTER WITH DEVICE 8 RESCRIPTOR ORAL TABLET SPRx QL (20 EA per 180 days)

10 RESCRIPTOR ORAL TABLET, DISPERSIBLE REYATAZ ORAL CAPSULE 150 MG, 200 MG, 300 MG 9 SPRx REYATAZ ORAL POWDER IN PACKET SPRx rimantadine oral tablet ritonavir oral tablet SELZENTRY ORAL SOLUTION SELZENTRY ORAL TABLET stavudine oral capsule stavudine oral recon soln STRIBILD ORAL TABLET SPRx SUSTIVA ORAL CAPSULE SUSTIVA ORAL TABLET SYMFI LO ORAL TABLET SPRx TAMIFLU ORAL SUSPENSION FOR RECONSTITUTION tenofovir disoproxil fumarate oral tablet TIVICAY ORAL TABLET SPRx TRIUMEQ ORAL TABLET SPRx TRUVADA ORAL TABLET SPRx TYBOST ORAL TABLET TYZEKA ORAL TABLET valacyclovir oral tablet valganciclovir oral recon soln valganciclovir oral tablet VEMLIDY ORAL TABLET LD; SPRx VIDEX 2 GRAM PEDIATRIC ORAL RECON SOLN VIDEX 4 GRAM PEDIATRIC ORAL RECON SOLN VIRACEPT ORAL TABLET VIREAD ORAL POWDER VIREAD ORAL TABLET QL (180 ML per 180 days)

11 VITEKTA ORAL TABLET SPRx VOSEVI ORAL TABLET PA; SPRx ZIAGEN ORAL SOLUTION zidovudine oral capsule zidovudine oral syrup zidovudine oral tablet Cephalosporins cefaclor oral capsule cefaclor oral suspension for reconstitution 125 mg/5 ml, 250 mg/5 ml, 375 mg/5 ml 10 cefaclor oral tablet extended release 12 hr cefadroxil oral capsule cefadroxil oral suspension for reconstitution 250 mg/5 ml, 500 mg/5 ml cefadroxil oral tablet cefdinir oral capsule cefdinir oral suspension for reconstitution cefditoren pivoxil oral tablet cefixime oral suspension for reconstitution cefpodoxime oral suspension for reconstitution cefpodoxime oral tablet cefprozil oral suspension for reconstitution cefprozil oral tablet ceftibuten oral capsule ceftibuten oral suspension for reconstitution CEFTIN ORAL SUSPENSION FOR RECONSTITUTION cefuroxime axetil oral tablet cephalexin oral capsule cephalexin oral suspension for reconstitution cephalexin oral tablet SUPRAX ORAL CAPSULE SUPRAX ORAL TABLET,CHEWABLE

12 Erythromycins & Other Macrolides azithromycin oral packet azithromycin oral suspension for reconstitution azithromycin oral tablet clarithromycin oral suspension for reconstitution clarithromycin oral tablet clarithromycin oral tablet extended release 24 hr DIFICID ORAL TABLET e.e.s. 400 oral tablet E.E.S. GRANULES ORAL SUSPENSION FOR RECONSTITUTION ERYPED 200 ORAL SUSPENSION FOR RECONSTITUTION ERYPED 400 ORAL SUSPENSION FOR RECONSTITUTION ery-tab oral tablet,delayed release (dr/ec) 250 mg, 333 mg ERY-TAB ORAL TABLET,DELAYED RELEASE (DR/EC) 500 MG 11 erythrocin (as stearate) oral tablet 250 mg erythromycin ethylsuccinate oral tablet erythromycin oral capsule,delayed release(dr/ec) erythromycin oral tablet PCE ORAL TABLET, PARTICLES/CRYSTALS ZMAX ORAL SUSPENSION,EXTENDED REL RECON Miscellaneous Antiinfectives ALINIA ORAL SUSPENSION FOR RECONSTITUTION ALINIA ORAL TABLET atovaquone oral suspension atovaquone-proguanil oral tablet BILTRICIDE ORAL TABLET

13 CAYSTON INHALATION SOLUTION FOR NEBULIZATION 12 chloroquine phosphate oral tablet clindamycin hcl oral capsule clindamycin palmitate hcl oral recon soln clindamycin pediatric oral recon soln COARTEM ORAL TABLET cycloserine oral capsule dapsone oral tablet PA; SPRx DARAPRIM ORAL TABLET PA; LD; SPRx EMVERM ORAL TABLET,CHEWABLE ethambutol oral tablet FLAGYL ER ORAL TABLET EXTENDED RELEASE hydroxychloroquine oral tablet isoniazid oral solution isoniazid oral tablet ivermectin oral tablet KETEK ORAL TABLET KITABIS PAK INHALATION SOLUTION FOR NEBULIZATION SPRx; QL (56 ML per 30 days) linezolid oral suspension for reconstitution QL (14 day supply per 30 days) linezolid oral tablet QL (14 day supply per 30 days) mefloquine oral tablet MEPRON ORAL SUSPENSION metronidazole oral capsule metronidazole oral tablet NEBUPENT INHALATION RECON SOLN neomycin oral tablet paromomycin oral capsule PRIFTIN ORAL TABLET primaquine oral tablet pyrazinamide oral tablet

14 quinine sulfate oral capsule 13 rifabutin oral capsule RIFAMATE ORAL CAPSULE rifampin oral capsule RIFATER ORAL TABLET SIRTURO ORAL TABLET PA; SPRx tinidazole oral tablet tobramycin in % nacl inhalation solution for nebulization TRECATOR ORAL TABLET XIFAXAN ORAL TABLET 200 MG XIFAXAN ORAL TABLET 550 MG Penicillins amoxicillin oral capsule amoxicillin oral suspension for reconstitution amoxicillin oral tablet amoxicillin oral tablet,chewable 125 mg, 250 mg amoxicillin-pot clavulanate oral suspension for reconstitution amoxicillin-pot clavulanate oral tablet amoxicillin-pot clavulanate oral tablet extended release 12 hr amoxicillin-pot clavulanate oral tablet,chewable ampicillin oral capsule ampicillin oral suspension for reconstitution dicloxacillin oral capsule penicillin v potassium oral recon soln penicillin v potassium oral tablet Quinolones ciprofloxacin (mixture) oral tablet, er multiphase 24 hr ciprofloxacin hcl oral tablet ciprofloxacin oral suspension,microcapsule recon SPRx; QL (56 ML per 30 days)

15 FACTIVE ORAL TABLET 14 levofloxacin oral solution levofloxacin oral tablet moxifloxacin oral tablet ofloxacin oral tablet 400 mg Sulfa's & Related Agents sulfadiazine oral tablet sulfamethoxazole-trimethoprim oral suspension sulfamethoxazole-trimethoprim oral tablet mg sulfatrim oral suspension Tetracyclines demeclocycline oral tablet doxycycline hyclate oral capsule doxycycline hyclate oral tablet 100 mg, 20 mg doxycycline hyclate oral tablet,delayed release (dr/ec) 100 mg, 150 mg, 75 mg doxycycline monohydrate oral capsule doxycycline monohydrate oral suspension for reconstitution doxycycline monohydrate oral tablet minocycline oral capsule minocycline oral tablet tetracycline oral capsule VIBRAMYCIN ORAL SYRUP Urinary Tract Agents methenamine hippurate oral tablet methenamine mandelate oral tablet MONUROL ORAL PACKET nitrofurantoin macrocrystal oral capsule nitrofurantoin monohyd/m-cryst oral capsule nitrofurantoin oral suspension PRIMSOL ORAL SOLUTION

16 trimethoprim oral tablet Vancomycin FIRVANQ ORAL RECON SOLN vancomycin oral capsule Antineoplastic & Immunosuppressant Drugs Adjunctive Agents leucovorin calcium oral tablet MESNEX ORAL TABLET Antineoplastic & Immunosuppressant Drugs AFINITOR DISPERZ ORAL TABLET FOR SUSPENSION 15 PA; SPRx AFINITOR ORAL TABLET PA; SPRx ALECENSA ORAL CAPSULE PA; SPRx ALKERAN ORAL TABLET ALUNBRIG ORAL TABLET PA; SPRx ALUNBRIG ORAL TABLETS,DOSE PACK PA; SPRx anastrozole oral tablet ASTAGRAF XL ORAL CAPSULE,EXTENDED RELEASE 24HR azathioprine oral tablet SPRx bexarotene oral capsule SPRx bicalutamide oral tablet BOSULIF ORAL TABLET PA; SPRx CABOMETYX ORAL TABLET PA; SPRx CALQUENCE ORAL CAPSULE PA; LD; SPRx capecitabine oral tablet SPRx CAPRELSA ORAL TABLET PA; LD; SPRx COMETRIQ ORAL CAPSULE LD; SPRx COTELLIC ORAL TABLET PA; SPRx cyclophosphamide oral capsule cyclosporine modified oral capsule cyclosporine modified oral solution

17 cyclosporine oral capsule DROXIA ORAL CAPSULE EMCYT ORAL CAPSULE ERIVEDGE ORAL CAPSULE PA; SPRx etoposide oral capsule exemestane oral tablet FARESTON ORAL TABLET FARYDAK ORAL CAPSULE PA; SPRx flutamide oral capsule gengraf oral capsule 100 mg, 25 mg gengraf oral solution GILOTRIF ORAL TABLET PA; SPRx GLEOSTINE ORAL CAPSULE HEXALEN ORAL CAPSULE HYCAMTIN ORAL CAPSULE SPRx hydroxyurea oral capsule IBRANCE ORAL CAPSULE PA; SPRx ICLUSIG ORAL TABLET PA; LD; SPRx IDHIFA ORAL TABLET PA; LD; SPRx imatinib oral tablet SPRx IMBRUVICA ORAL CAPSULE PA; LD; SPRx IMBRUVICA ORAL TABLET PA; LD; SPRx INLYTA ORAL TABLET PA; SPRx IRESSA ORAL TABLET PA; SPRx JAKAFI ORAL TABLET PA; SPRx KISQALI ORAL TABLET PA; SPRx LENVIMA ORAL CAPSULE PA; SPRx letrozole oral tablet LEUKERAN ORAL TABLET leuprolide subcutaneous kit PA; SPRx LONSURF ORAL TABLET PA; SPRx LYNPARZA ORAL CAPSULE PA; SPRx 16

18 LYNPARZA ORAL TABLET PA; LD; SPRx LYSODREN ORAL TABLET MATULANE ORAL CAPSULE LD; SPRx megestrol oral suspension 400 mg/10 ml (40 mg/ml), 625 mg/5 ml 17 megestrol oral tablet MEKINIST ORAL TABLET PA; SPRx melphalan oral tablet mercaptopurine oral tablet methotrexate sodium (pf) injection recon soln methotrexate sodium (pf) injection solution methotrexate sodium injection solution methotrexate sodium oral tablet mycophenolate mofetil oral capsule mycophenolate mofetil oral suspension for reconstitution mycophenolate mofetil oral tablet mycophenolate sodium oral tablet,delayed release (dr/ec) MYLERAN ORAL TABLET NERLYNX ORAL TABLET PA; LD; SPRx NEXAVAR ORAL TABLET PA; SPRx nilutamide oral tablet SPRx NINLARO ORAL CAPSULE PA; SPRx octreotide acetate injection solution SPRx octreotide acetate injection syringe SPRx ODOMZO ORAL CAPSULE PA; SPRx PURIXAN ORAL SUSPENSION LD; SPRx RAPAMUNE ORAL SOLUTION RUBR ORAL TABLET PA; LD; SPRx SANDIMMUNE ORAL SOLUTION SIGNIFOR SUBCUTANEOUS SOLUTION PA; SPRx sirolimus oral tablet

19 SOLTAMOX ORAL SOLUTION SPRYCEL ORAL TABLET SPRx STIVARGA ORAL TABLET PA; SPRx SUTENT ORAL CAPSULE PA; SPRx TABLOID ORAL TABLET tacrolimus oral capsule TAFINLAR ORAL CAPSULE PA; SPRx TAGRISSO ORAL TABLET PA; SPRx tamoxifen oral tablet TARCEVA ORAL TABLET PA; SPRx TARGRETIN TOPICAL GEL SPRx TASIGNA ORAL CAPSULE 150 MG, 200 MG SPRx temozolomide oral capsule PA; SPRx THALOMID ORAL CAPSULE PA; SPRx tretinoin (chemotherapy) oral capsule TYKERB ORAL TABLET PA; SPRx VENCLEXTA ORAL TABLET PA; LD; SPRx VENCLEXTA STARTING PACK ORAL TABLETS,DOSE PACK 18 PA; LD; SPRx VERZENIO ORAL TABLET PA; SPRx VOTRIENT ORAL TABLET PA; SPRx XALKORI ORAL CAPSULE PA; SPRx XERMELO ORAL TABLET PA; LD; SPRx XTANDI ORAL CAPSULE SPRx ZEJULA ORAL CAPSULE PA; LD; SPRx ZELBORAF ORAL TABLET PA; SPRx ZOLINZA ORAL CAPSULE SPRx ZORTRESS ORAL TABLET SPRx ZYDELIG ORAL TABLET PA; LD; SPRx ZYKADIA ORAL CAPSULE PA; SPRx ZYTIGA ORAL TABLET SPRx Autonomic & Cns Drugs, Neurology & Psych

20 Agents For Narcotic Withdrawal BUNAVAIL BUCCAL FILM QL (90 EA per 30 days) buprenorphine hcl injection syringe buprenorphine-naloxone sublingual tablet QL (90 EA per 30 days) SUBOXONE SUBLINGUAL FILM QL (90 EA per 30 days) ZUBSOLV SUBLINGUAL TABLET QL (90 EA per 30 days) Anticonvulsants APTIOM ORAL TABLET BANZEL ORAL SUSPENSION BANZEL ORAL TABLET carbamazepine oral capsule, er multiphase 12 hr carbamazepine oral suspension carbamazepine oral tablet carbamazepine oral tablet extended release 12 hr carbamazepine oral tablet,chewable CARBATROL ORAL CAPSULE, ER MULTIPHASE 12 HR CELONTIN ORAL CAPSULE 300 MG clonazepam oral tablet clonazepam oral tablet,disintegrating DEPAKENE ORAL CAPSULE DEPAKENE ORAL SOLUTION DEPAKOTE ER ORAL TABLET EXTENDED RELEASE 24 HR DEPAKOTE ORAL TABLET,DELAYED RELEASE (DR/EC) DEPAKOTE SPRINKLES ORAL CAPSULE, DELAYED REL SPRINKLE DIASTAT ACUDIAL RECTAL KIT DIASTAT RECTAL KIT diazepam rectal kit DILANTIN EXTENDED ORAL CAPSULE 19

21 DILANTIN INFATABS ORAL TABLET,CHEWABLE 20 DILANTIN KAPSEAL ORAL CAPSULE DILANTIN ORAL CAPSULE DILANTIN-125 ORAL SUSPENSION divalproex oral capsule, delayed rel sprinkle divalproex oral tablet extended release 24 hr divalproex oral tablet,delayed release (dr/ec) epitol oral tablet EQUETRO ORAL CAPSULE, ER MULTIPHASE 12 HR ethosuximide oral capsule ethosuximide oral solution felbamate oral suspension felbamate oral tablet FELBATOL ORAL SUSPENSION FELBATOL ORAL TABLET FYCOMPA ORAL TABLET gabapentin oral capsule gabapentin oral solution gabapentin oral tablet 600 mg, 800 mg GABITRIL ORAL TABLET KEPPRA ORAL SOLUTION KEPPRA ORAL TABLET KEPPRA XR ORAL TABLET EXTENDED RELEASE 24 HR KLONOPIN ORAL TABLET LAMICTAL ODT ORAL TABLET,DISINTEGRATING LAMICTAL ODT STARTER (BLUE) ORAL TABLET DISINTEGRATING, DOSE PK LAMICTAL ODT STARTER (GREEN) ORAL TABLET DISINTEGRATING, DOSE PK

22 LAMICTAL ODT STARTER (ORANGE) ORAL TABLET DISINTEGRATING, DOSE PK 21 LAMICTAL ORAL TABLET LAMICTAL ORAL TABLET, CHEWABLE DISPERSIBLE 25 MG, 5 MG LAMICTAL STARTER (BLUE) KIT ORAL TABLETS,DOSE PACK LAMICTAL STARTER (GREEN) KIT ORAL TABLETS,DOSE PACK LAMICTAL STARTER (ORANGE) KIT ORAL TABLETS,DOSE PACK LAMICTAL XR ORAL TABLET EXTENDED RELEASE 24HR LAMICTAL XR STARTER (BLUE) ORAL TABLET EXTENDED REL,DOSE PACK LAMICTAL XR STARTER (GREEN) ORAL TABLET EXTENDED REL,DOSE PACK LAMICTAL XR STARTER (ORANGE) ORAL TABLET EXTENDED REL,DOSE PACK lamotrigine oral tablet lamotrigine oral tablet disintegrating, dose pk lamotrigine oral tablet extended release 24hr lamotrigine oral tablet, chewable dispersible lamotrigine oral tablet,disintegrating lamotrigine oral tablets,dose pack levetiracetam oral solution levetiracetam oral tablet levetiracetam oral tablet extended release 24 hr LYRICA CR ORAL TABLET EXTENDED RELEASE 24 HR LYRICA ORAL CAPSULE LYRICA ORAL SOLUTION MYSOLINE ORAL TABLET NEURONTIN ORAL CAPSULE

23 NEURONTIN ORAL SOLUTION 22 NEURONTIN ORAL TABLET ONFI ORAL SUSPENSION ONFI ORAL TABLET 10 MG, 20 MG oxcarbazepine oral suspension oxcarbazepine oral tablet OXTELLAR XR ORAL TABLET EXTENDED RELEASE 24 HR PEGANONE ORAL TABLET phenobarbital oral elixir phenobarbital oral tablet PHENYTEK ORAL CAPSULE phenytoin oral suspension phenytoin oral tablet,chewable phenytoin sodium extended oral capsule POTIGA ORAL TABLET primidone oral tablet QUDEXY XR ORAL CAPSULE,SPRINKLE,ER 24HR roweepra oral tablet roweepra xr oral tablet extended release 24 hr SABRIL ORAL POWDER IN PACKET SABRIL ORAL TABLET SPRITAM ORAL TABLET FOR SUSPENSION TEGRETOL ORAL SUSPENSION TEGRETOL ORAL TABLET TEGRETOL XR ORAL TABLET EXTENDED RELEASE 12 HR tiagabine oral tablet TOPAMAX ORAL CAPSULE, SPRINKLE TOPAMAX ORAL TABLET topiramate oral capsule, sprinkle

24 TOPIRAMATE ORAL CAPSULE,SPRINKLE,ER 24HR topiramate oral tablet TRILEPTAL ORAL SUSPENSION TRILEPTAL ORAL TABLET TROKENDI XR ORAL CAPSULE,EXTENDED RELEASE 24HR valproic acid (as sodium salt) oral solution valproic acid oral capsule vigabatrin oral powder in packet VIMPAT ORAL SOLUTION VIMPAT ORAL TABLET ZARONTIN ORAL CAPSULE ZARONTIN ORAL SOLUTION ZONEGRAN ORAL CAPSULE 100 MG, 25 MG zonisamide oral capsule Antiparkinsonism Agents APOKYN SUBCUTANEOUS CARTRIDGE SPRx benztropine oral tablet bromocriptine oral capsule bromocriptine oral tablet carbidopa oral tablet carbidopa-levodopa oral tablet carbidopa-levodopa oral tablet extended release carbidopa-levodopa oral tablet,disintegrating carbidopa-levodopa-entacapone oral tablet DUOPA J-TUBE INTESTINAL PUMP SUSPENSION entacapone oral tablet NEUPRO TRANSDERMAL PATCH 24 HOUR pramipexole oral tablet PA; SPRx 23

25 pramipexole oral tablet extended release 24 hr rasagiline oral tablet ropinirole oral tablet ropinirole oral tablet extended release 24 hr selegiline hcl oral capsule selegiline hcl oral tablet tolcapone oral tablet trihexyphenidyl oral elixir trihexyphenidyl oral tablet ZELAPAR ORAL TABLET,DISINTEGRATING Migraine & Cluster Headache Therapy 24 almotriptan malate oral tablet QL (18 EA per 30 days) dihydroergotamine injection solution dihydroergotamine nasal spray,non-aerosol QL (8 ML per 30 days) eletriptan hbr oral tablet QL (18 EA per 30 days) ergotamine-caffeine oral tablet frovatriptan oral tablet isometh-dichloral-acetaminophn oral capsule MIGERGOT RECTAL SUPPOSITORY naratriptan oral tablet QL (18 EA per 30 days) nodolor oral capsule RELPAX ORAL TABLET QL (18 EA per 30 days) rizatriptan oral tablet QL (18 EA per 30 days) rizatriptan oral tablet,disintegrating QL (18 EA per 30 days) sumatriptan nasal spray,non-aerosol QL (12 EA per 30 days) sumatriptan succinate oral tablet QL (18 EA per 30 days) sumatriptan succinate subcutaneous cartridge 4 mg/0.5 ml sumatriptan succinate subcutaneous cartridge 6 mg/0.5 ml sumatriptan succinate subcutaneous pen injector 4 mg/0.5 ml QL (12 ML per 30 days) QL (8 ML per 30 days) QL (12 ML per 30 days)

26 sumatriptan succinate subcutaneous pen injector 6 mg/0.5 ml 25 QL (8 ML per 30 days) sumatriptan succinate subcutaneous solution QL (8 ML per 30 days) sumatriptan succinate subcutaneous syringe 6 mg/0.5 ml SUMAVEL DOSEPRO SUBCUTANEOUS NEEDLE-FREE INJECTOR 4 MG/0.5 ML SUMAVEL DOSEPRO SUBCUTANEOUS NEEDLE-FREE INJECTOR 6 MG/0.5 ML QL (8 ML per 30 days) QL (12 ML per 30 days) QL (8 ML per 30 days) zolmitriptan oral tablet QL (18 EA per 30 days) zolmitriptan oral tablet,disintegrating QL (18 EA per 30 days) ZOMIG NASAL SPRAY,NON-AEROSOL Miscellaneous Neurological Therapy AMPYRA ORAL TABLET EXTENDED RELEASE 12 HR PA; SPRx AUSTEDO ORAL TABLET PA; LD; SPRx donepezil oral tablet donepezil oral tablet,disintegrating galantamine oral capsule,ext rel. pellets 24 hr galantamine oral solution galantamine oral tablet HORIZANT ORAL TABLET EXTENDED RELEASE KEVEYIS ORAL TABLET PA; LD; SPRx memantine oral capsule,sprinkle,er 24hr memantine oral solution memantine oral tablet MEMANTINE ORAL TABLETS,DOSE PACK NAMENDA TITRATION PAK ORAL TABLETS,DOSE PACK NAMENDA XR ORAL CAP,SPRINKLE,ER 24HR DOSE PACK NAMENDA XR ORAL CAPSULE,SPRINKLE,ER 24HR

27 NAMZARIC ORAL CAP,SPRINKLE,ER 24HR DOSE PACK NAMZARIC ORAL CAPSULE,SPRINKLE,ER 24HR 26 NUEDEXTA ORAL CAPSULE rivastigmine tartrate oral capsule rivastigmine transdermal patch 24 hour tetrabenazine oral tablet PA; SPRx Muscle Relaxants & Antispasmodic Therapy baclofen oral tablet carisoprodol oral tablet carisoprodol-asa-codeine oral tablet carisoprodol-aspirin oral tablet chlorzoxazone oral tablet cyclobenzaprine oral tablet dantrolene oral capsule meprobamate oral tablet MESTINON ORAL SYRUP metaxalone oral tablet 800 mg methocarbamol oral tablet orphenadrine citrate oral tablet extended release pyridostigmine bromide oral tablet pyridostigmine bromide oral tablet extended release tizanidine oral capsule tizanidine oral tablet Narcotic Analgesics acetaminophen-caff-dihydrocod oral capsule QL (120 EA per 30 days) acetaminophen-codeine oral solution mg/5 ml QL (4500 ML per 30 days) acetaminophen-codeine oral tablet QL (180 EA per 30 days) ascomp with codeine oral capsule QL (120 EA per 30 days) aspirin-caffeine-dihydrocodein oral capsule QL (240 EA per 30 days)

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

29 hydrocodone-acetaminophen oral tablet mg, mg, mg, mg, mg, mg, mg hydrocodone-ibuprofen oral tablet mg, mg, mg QL (120 EA per 30 days) QL (120 EA per 30 days) hydromorphone oral liquid QL (30 ML per 30 days) hydromorphone oral tablet QL (120 EA per 30 days) hydromorphone rectal suppository QL (60 EA per 30 days) ibuprofen-oxycodone oral tablet QL (28 EA per 30 days) KADIAN ORAL CAPSULE,EXTEND.RELEASE PELLETS 200 MG, 40 MG PA; QL (60 EA per 30 days) levorphanol tartrate oral tablet QL (120 EA per 30 days) lorcet (hydrocodone) oral tablet QL (120 EA per 30 days) lorcet hd oral tablet QL (120 EA per 30 days) lorcet plus oral tablet mg QL (120 EA per 30 days) LORTAB ELIXIR ORAL SOLUTION MG/15 ML QL (480 ML per 30 days) meperidine oral solution QL (480 ML per 30 days) meperidine oral tablet QL (120 EA per 30 days) methadone intensol oral concentrate PA; QL (120 ML per 30 days) methadone oral concentrate PA; QL (120 ML per 30 days) methadone oral solution 10 mg/5 ml PA; QL (480 ML per 30 days) methadone oral solution 5 mg/5 ml PA; QL (960 ML per 30 days) methadone oral tablet PA; QL (120 EA per 30 days) methadone oral tablet,soluble PA; QL (50 EA per 30 days) methadose oral concentrate PA; QL (120 ML per 30 days) methadose oral tablet,soluble PA; QL (50 EA per 30 days) morphine concentrate oral solution QL (300 ML per 30 days) morphine oral capsule, er multiphase 24 hr 120 mg morphine oral capsule, er multiphase 24 hr 30 mg, 45 mg, 60 mg, 75 mg, 90 mg PA; QL (50 EA per 30 days) PA; QL (60 EA per 30 days) morphine oral capsule,extend.release pellets PA; QL (60 EA per 30 days) 28

30 morphine oral solution QL (900 ML per 30 days) morphine oral tablet QL (120 EA per 30 days) morphine oral tablet extended release 100 mg, 15 mg, 30 mg, 60 mg 29 PA; QL (60 EA per 30 days) morphine oral tablet extended release 200 mg PA; QL (30 EA per 30 days) morphine rectal suppository QL (120 EA per 30 days) NUCYNTA ER ORAL TABLET EXTENDED RELEASE 12 HR PA; QL (60 EA per 30 days) NUCYNTA ORAL TABLET QL (120 EA per 30 days) oxycodone oral capsule QL (120 EA per 30 days) oxycodone oral concentrate QL (120 ML per 30 days) oxycodone oral solution QL (480 ML per 30 days) oxycodone oral tablet QL (120 EA per 30 days) oxycodone-acetaminophen oral solution QL (480 ML per 30 days) oxycodone-acetaminophen oral tablet mg, mg, mg, mg QL (120 EA per 30 days) oxycodone-aspirin oral tablet QL (120 EA per 30 days) OXYCONTIN ORAL TABLET,ORAL ONLY,EXT.REL.12 HR 10 MG, 15 MG, 20 MG, 30 MG, 40 MG, 60 MG OXYCONTIN ORAL TABLET,ORAL ONLY,EXT.REL.12 HR 80 MG PA; QL (60 EA per 30 days) PA; QL (50 EA per 30 days) oxymorphone oral tablet QL (120 EA per 30 days) oxymorphone oral tablet extended release 12 hr PA; QL (60 EA per 30 days) pentazocine-naloxone oral tablet QL (120 EA per 30 days) phrenilin forte(with caffeine) oral capsule QL (120 EA per 30 days) reprexain oral tablet QL (120 EA per 30 days) tencon oral tablet mg QL (120 EA per 30 days) tramadol oral tablet QL (240 EA per 30 days) tramadol oral tablet extended release 24 hr PA; QL (30 EA per 30 days) tramadol oral tablet, er multiphase 24 hr PA; QL (30 EA per 30 days) tramadol-acetaminophen oral tablet QL (240 EA per 30 days) verdrocet oral tablet QL (120 EA per 30 days) vicodin es oral tablet QL (120 EA per 30 days)

31 vicodin hp oral tablet QL (120 EA per 30 days) vicodin oral tablet QL (120 EA per 30 days) xylon 10 oral tablet QL (150 EA per 30 days) zamicet oral solution QL (480 ML per 30 days) zebutal oral capsule mg QL (120 EA per 30 days) Non-Narcotic Analgesics celecoxib oral capsule diclofenac potassium oral tablet diclofenac sodium oral tablet extended release 24 hr diclofenac sodium oral tablet,delayed release (dr/ec) 30 diclofenac sodium topical gel 1 % QL (500 GM per 30 days) diclofenac-misoprostol oral tablet,ir,delayed rel,biphasic diflunisal oral tablet etodolac oral capsule etodolac oral tablet etodolac oral tablet extended release 24 hr fenoprofen oral tablet flurbiprofen oral tablet ibu oral tablet ibuprofen oral suspension ibuprofen oral tablet 400 mg, 600 mg, 800 mg INDOCIN ORAL SUSPENSION indomethacin oral capsule indomethacin oral capsule, extended release ketoprofen oral capsule ketoprofen oral capsule,ext rel. pellets 24 hr 200 mg ketorolac oral tablet meclofenamate oral capsule mefenamic acid oral capsule

32 meloxicam oral suspension meloxicam oral tablet nabumetone oral tablet naproxen oral suspension naproxen oral tablet naproxen oral tablet,delayed release (dr/ec) naproxen sodium oral tablet 275 mg, 550 mg oxaprozin oral tablet piroxicam oral capsule salsalate oral tablet SPRIX NASAL SPRAY,NON-AEROSOL LD; SPRx sulindac oral tablet tolmetin oral capsule tolmetin oral tablet Opiate/Narcotic Reversal Agents - Opiate Antagonists naloxone injection solution QL (2 units per 1 claim) naloxone injection syringe QL (2 units per 1 claim) naltrexone oral tablet NARCAN NASAL SPRAY,NON-AEROSOL 4 MG/ACTUATION Psychotherapeutic Drugs ABILIFY MAINTENA INTRAMUSCULAR SUSPENSION,EXTENDED REL RECON ABILIFY MAINTENA INTRAMUSCULAR SUSPENSION,EXTENDED REL SYRING 31 alprazolam intensol oral concentrate alprazolam oral tablet alprazolam oral tablet extended release 24 hr alprazolam oral tablet,disintegrating amitriptyline oral tablet amitriptyline-chlordiazepoxide oral tablet amoxapine oral tablet QL (2 units per 1 claim) SPRx; AGE-A SPRx; AGE-A aripiprazole oral solution AGE-A

33 aripiprazole oral tablet AGE-A aripiprazole oral tablet,disintegrating AGE-A ARISTADA INTRAMUSCULAR SUSPENSION,EXTENDED REL SYRING 32 armodafinil oral tablet PA atomoxetine oral capsule bupropion hcl oral tablet bupropion hcl oral tablet extended release 12 hr bupropion hcl oral tablet extended release 24 hr buspirone oral tablet chlordiazepoxide hcl oral capsule chlorpromazine oral tablet citalopram oral solution citalopram oral tablet clomipramine oral capsule clonidine hcl oral tablet extended release 12 hr clorazepate dipotassium oral tablet clozapine oral tablet AGE-A clozapine oral tablet,disintegrating 100 mg, 12.5 mg, 25 mg clozapine oral tablet,disintegrating 150 mg, 200 mg DAYTRANA TRANSDERMAL PATCH 24 HOUR desipramine oral tablet desvenlafaxine succinate oral tablet extended release 24 hr dexedrine oral tablet dexmethylphenidate oral capsule,er biphasic dexmethylphenidate oral tablet dextroamphetamine oral capsule, extended release dextroamphetamine oral solution dextroamphetamine oral tablet LD; SPRx; AGE-A AGE-A AGE-A

34 dextroamphetamine-amphetamine oral capsule,extended release 24hr 20 mg, 25 mg, 30 mg 33 dextroamphetamine-amphetamine oral tablet diazepam intensol oral concentrate diazepam oral solution 5 mg/5 ml (1 mg/ml) diazepam oral tablet doxepin oral capsule doxepin oral concentrate duloxetine oral capsule,delayed release(dr/ec) EMSAM TRANSDERMAL PATCH 24 HOUR ergoloid oral tablet escitalopram oxalate oral solution escitalopram oxalate oral tablet estazolam oral tablet eszopiclone oral tablet FANAPT ORAL TABLET AGE-A FANAPT ORAL TABLETS,DOSE PACK AGE-A FAZACLO ORAL TABLET,DISINTEGRATING 150 MG, 200 MG fluoxetine oral capsule fluoxetine oral capsule,delayed release(dr/ec) fluoxetine oral solution fluoxetine oral tablet fluphenazine hcl oral concentrate fluphenazine hcl oral elixir fluphenazine hcl oral tablet flurazepam oral capsule fluvoxamine oral capsule,extended release 24hr fluvoxamine oral tablet guanfacine oral tablet extended release 24 hr guanidine oral tablet AGE-A

35 haloperidol lactate oral concentrate haloperidol oral tablet imipramine hcl oral tablet imipramine pamoate oral capsule INVEGA SUSTENNA INTRAMUSCULAR SYRINGE INVEGA TRINZA INTRAMUSCULAR SYRINGE 34 SPRx; AGE-A SPRx; AGE-A LATUDA ORAL TABLET AGE-A lithium carbonate oral capsule lithium carbonate oral tablet lithium carbonate oral tablet extended release lithium citrate oral solution 8 meq/5 ml lorazepam intensol oral concentrate lorazepam oral concentrate lorazepam oral tablet loxapine succinate oral capsule maprotiline oral tablet MARPLAN ORAL TABLET metadate er oral tablet extended release methamphetamine oral tablet methylphenidate hcl oral capsule, er biphasic methylphenidate hcl oral capsule,er biphasic methylphenidate hcl oral solution methylphenidate hcl oral tablet methylphenidate hcl oral tablet extended release methylphenidate hcl oral tablet extended release 24hr 18 mg, 27 mg, 36 mg, 54 mg methylphenidate hcl oral tablet,chewable midazolam oral syrup 2 mg/ml mirtazapine oral tablet mirtazapine oral tablet,disintegrating

36 modafinil oral tablet PA molindone oral tablet nefazodone oral tablet nortriptyline oral capsule nortriptyline oral solution NUPLAZID ORAL TABLET PA; SPRx olanzapine oral tablet AGE-A olanzapine oral tablet,disintegrating AGE-A olanzapine-fluoxetine oral capsule AGE-A oxazepam oral capsule paliperidone oral tablet extended release 24hr AGE-A paroxetine hcl oral tablet paroxetine hcl oral tablet extended release 24 hr PAXIL ORAL SUSPENSION perphenazine oral tablet perphenazine-amitriptyline oral tablet phenelzine oral tablet pimozide oral tablet procentra oral solution protriptyline oral tablet quazepam oral tablet quetiapine oral tablet AGE-A quetiapine oral tablet extended release 24 hr AGE-A QUILLIVANT XR ORAL SUSPENSION,EXT REL 24HR,RECON RISPERDAL CONSTA INTRAMUSCULAR SYRINGE 35 SPRx; AGE-A risperidone oral solution AGE-A risperidone oral tablet AGE-A risperidone oral tablet,disintegrating AGE-A ROZEREM ORAL TABLET SAPHRIS (BLACK CHERRY) SUBLINGUAL TABLET AGE-A

37 SARAFEM ORAL TABLET 10 MG, 20 MG sertraline oral concentrate sertraline oral tablet STRATTERA ORAL CAPSULE temazepam oral capsule thioridazine oral tablet thiothixene oral capsule tranylcypromine oral tablet trazodone oral tablet triazolam oral tablet trifluoperazine oral tablet trimipramine oral capsule TRINTELLIX ORAL TABLET venlafaxine oral capsule,extended release 24hr venlafaxine oral tablet VIIBRYD ORAL TABLET VIIBRYD ORAL TABLETS,DOSE PACK 10 MG (7)- 20 MG (23) 36 VRAYLAR ORAL CAPSULE AGE-A VRAYLAR ORAL CAPSULE,DOSE PACK AGE-A VYVANSE ORAL CAPSULE VYVANSE ORAL TABLET,CHEWABLE XYREM ORAL SOLUTION PA; LD; SPRx zaleplon oral capsule zenzedi oral tablet 10 mg, 5 mg ZENZEDI ORAL TABLET 15 MG, 2.5 MG, 20 MG, 30 MG, 7.5 MG ziprasidone hcl oral capsule AGE-A zolpidem oral tablet zolpidem oral tablet,ext release multiphase ZYPREXA RELPREVV INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION Cardiovascular, Hypertension & Lipids SPRx; AGE-A

38 Antiarrhythmic Agents amiodarone oral tablet disopyramide phosphate oral capsule dofetilide oral capsule flecainide oral tablet mexiletine oral capsule MULTAQ ORAL TABLET NORPACE CR ORAL CAPSULE, EXTENDED RELEASE 37 pacerone oral tablet 100 mg, 200 mg, 400 mg propafenone oral capsule,extended release 12 hr propafenone oral tablet quinidine gluconate oral tablet extended release quinidine sulfate oral tablet sorine oral tablet sotalol af oral tablet sotalol oral tablet SOTYLIZE ORAL SOLUTION Antihypertensive Therapy acebutolol oral capsule afeditab cr oral tablet extended release amiloride oral tablet amiloride-hydrochlorothiazide oral tablet amlodipine oral tablet amlodipine-benazepril oral capsule amlodipine-olmesartan oral tablet amlodipine-valsartan oral tablet amlodipine-valsartan-hcthiazid oral tablet atenolol oral tablet atenolol-chlorthalidone oral tablet benazepril oral tablet benazepril-hydrochlorothiazide oral tablet

39 betaxolol oral tablet 38 BIDIL ORAL TABLET bisoprolol fumarate oral tablet bisoprolol-hydrochlorothiazide oral tablet bumetanide oral tablet BYSTOLIC ORAL TABLET candesartan oral tablet candesartan-hydrochlorothiazid oral tablet captopril oral tablet captopril-hydrochlorothiazide oral tablet CARDIZEM LA ORAL TABLET EXTENDED RELEASE 24 HR 120 MG CARDURA XL ORAL TABLET EXTENDED RELEASE 24HR cartia xt oral capsule,extended release 24hr carvedilol oral tablet carvedilol phosphate oral capsule, er multiphase 24 hr chlorothiazide oral tablet chlorthalidone oral tablet 25 mg, 50 mg clonidine hcl oral tablet clonidine transdermal patch weekly clorpres oral tablet mg, mg CLORPRES ORAL TABLET MG COREG CR ORAL CAPSULE, ER MULTIPHASE 24 HR diltiazem hcl oral capsule,ext.rel 24h degradable diltiazem hcl oral capsule,extended release 12 hr diltiazem hcl oral capsule,extended release 24 hr diltiazem hcl oral capsule,extended release 24hr diltiazem hcl oral tablet diltiazem hcl oral tablet extended release 24 hr dilt-xr oral capsule,ext.rel 24h degradable

40 DIURIL ORAL SUSPENSION doxazosin oral tablet DUTOPROL ORAL TABLET EXTENDED RELEASE 24 HR 39 DYRENIUM ORAL CAPSULE EDARBI ORAL TABLET ST EDARBYCLOR ORAL TABLET ST enalapril maleate oral tablet enalapril-hydrochlorothiazide oral tablet EPANED ORAL RECON SOLN EPANED ORAL SOLUTION eplerenone oral tablet epoprostenol (glycine) intravenous recon soln PA; SPRx eprosartan oral tablet ethacrynic acid oral tablet felodipine oral tablet extended release 24 hr FLOLAN INTRAVENOUS RECON SOLN PA; SPRx fosinopril oral tablet fosinopril-hydrochlorothiazide oral tablet furosemide oral solution 10 mg/ml, 40 mg/5 ml (8 mg/ml) furosemide oral tablet guanfacine oral tablet hydralazine oral tablet hydrochlorothiazide oral capsule hydrochlorothiazide oral tablet indapamide oral tablet irbesartan oral tablet irbesartan-hydrochlorothiazide oral tablet isradipine oral capsule labetalol oral tablet LEVATOL ORAL TABLET lisinopril oral tablet

41 lisinopril-hydrochlorothiazide oral tablet 40 losartan oral tablet losartan-hydrochlorothiazide oral tablet matzim la oral tablet extended release 24 hr methyclothiazide oral tablet methyldopa oral tablet methyldopa-hydrochlorothiazide oral tablet metolazone oral tablet metoprolol succinate oral tablet extended release 24 hr metoprolol ta-hydrochlorothiaz oral tablet metoprolol tartrate oral tablet minoxidil oral tablet moexipril oral tablet moexipril-hydrochlorothiazide oral tablet nadolol oral tablet nadolol-bendroflumethiazide oral tablet nicardipine oral capsule nifedical xl oral tablet extended release 24hr nifedipine oral capsule nifedipine oral tablet extended release nifedipine oral tablet extended release 24hr nimodipine oral capsule nisoldipine oral tablet extended release 24 hr olmesartan oral tablet olmesartan-amlodipin-hcthiazid oral tablet olmesartan-hydrochlorothiazide oral tablet ORENITRAM ORAL TABLET EXTENDED RELEASE MG, 0.25 MG, 1 MG, 2.5 MG ORENITRAM ORAL TABLET EXTENDED RELEASE 5 MG perindopril erbumine oral tablet phenoxybenzamine oral capsule PA; SPRx PA; LD; SPRx

42 pindolol oral tablet 41 prazosin oral capsule propranolol oral capsule,extended release 24 hr propranolol oral solution propranolol oral tablet propranolol-hydrochlorothiazid oral tablet quinapril oral tablet quinapril-hydrochlorothiazide oral tablet ramipril oral capsule REMODULIN INJECTION SOLUTION PA; SPRx reserpine oral tablet spironolactone oral tablet spironolacton-hydrochlorothiaz oral tablet taztia xt oral capsule,extended release 24 hr TEKTURNA HCT ORAL TABLET TEKTURNA ORAL TABLET telmisartan oral tablet telmisartan-amlodipine oral tablet telmisartan-hydrochlorothiazid oral tablet terazosin oral capsule timolol maleate oral tablet torsemide oral tablet trandolapril oral tablet trandolapril-verapamil oral tablet, ir - er, biphasic 24hr triamterene-hydrochlorothiazid oral capsule triamterene-hydrochlorothiazid oral tablet valsartan oral tablet valsartan-hydrochlorothiazide oral tablet VELETRI INTRAVENOUS RECON SOLN PA; SPRx verapamil oral capsule, 24 hr er pellet ct verapamil oral capsule,ext rel. pellets 24 hr

43 verapamil oral tablet 42 verapamil oral tablet extended release Cardiac Glycosides digitek oral tablet digox oral tablet digoxin oral solution digoxin oral tablet LANOXIN ORAL TABLET Coagulation Therapy ADVATE INTRAVENOUS RECON SOLN SPRx ALPHANATE INTRAVENOUS RECON SOLN ALPHANINE SD INTRAVENOUS RECON SOLN SPRx SPRx ALPROLIX INTRAVENOUS RECON SOLN SPRx AMICAR ORAL SOLUTION AMICAR ORAL TABLET aspirin-dipyridamole oral capsule, er multiphase 12 hr BEBULIN INTRAVENOUS RECON SOLN SPRx BENEFIX INTRAVENOUS RECON SOLN SPRx BRILINTA ORAL TABLET cilostazol oral tablet clopidogrel oral tablet COAGADEX INTRAVENOUS RECON SOLN LD; SPRx CORIFACT INTRAVENOUS RECON SOLN SPRx COUMADIN ORAL TABLET dipyridamole oral tablet ELIQUIS ORAL TABLET ELIQUIS ORAL TABLETS,DOSE PACK enoxaparin subcutaneous solution QL (42 ML per 365 days) enoxaparin subcutaneous syringe QL (42 ML per 365 days) FEIBA NF INTRAVENOUS RECON SOLN SPRx

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

45 NOVOEIGHT INTRAVENOUS RECON SOLN NOVOSEVEN RT INTRAVENOUS RECON SOLN pentoxifylline oral tablet extended release PRADAXA ORAL CAPSULE prasugrel oral tablet PROFILNINE INTRAVENOUS RECON SOLN SPRx SPRx SPRx PROMACTA ORAL TABLET SPRx RECOMBINATE INTRAVENOUS RECON SOLN SPRx RIXUBIS INTRAVENOUS RECON SOLN SPRx ticlopidine oral tablet warfarin oral tablet WILATE INTRAVENOUS RECON SOLN SPRx XARELTO ORAL TABLET XARELTO ORAL TABLETS,DOSE PACK XYNTHA INTRAVENOUS SOLUTION SPRx XYNTHA SOLOFUSE INTRAVENOUS SYRINGE ZONTIVITY ORAL TABLET Lipid/Cholesterol Lowering Agents amlodipine-atorvastatin oral tablet ANTARA ORAL CAPSULE 30 MG, 90 MG SPRx atorvastatin oral tablet 10 mg, 20 mg atorvastatin oral tablet 40 mg, 80 mg cholestyramine (with sugar) oral powder cholestyramine (with sugar) oral powder in packet cholestyramine light oral powder cholestyramine light oral powder in packet COLESTID FLAVORED ORAL PACKET colestipol oral granules 44

46 colestipol oral packet colestipol oral tablet ezetimibe oral tablet ezetimibe-simvastatin oral tablet fenofibrate micronized oral capsule fenofibrate nanocrystallized oral tablet fenofibrate oral tablet fenofibric acid (choline) oral capsule,delayed release(dr/ec) 45 fenofibric acid oral tablet fluvastatin oral capsule fluvastatin oral tablet extended release 24 hr gemfibrozil oral tablet KYNAMRO SUBCUTANEOUS SYRINGE PA; SPRx LIPOFEN ORAL CAPSULE LIVALO ORAL TABLET lovastatin oral tablet niacin oral tablet extended release 24 hr NIACOR ORAL TABLET PRALUENT PEN SUBCUTANEOUS PEN INJECTOR PRALUENT SYRINGE SUBCUTANEOUS SYRINGE PA; SPRx PA; SPRx pravastatin oral tablet prevalite oral powder prevalite oral powder in packet REPATHA PUSHTRONEX SUBCUTANEOUS WEARABLE INJECTOR REPATHA SURECLICK SUBCUTANEOUS PEN INJECTOR REPATHA SYRINGE SUBCUTANEOUS SYRINGE PA; SPRx PA; SPRx PA; SPRx rosuvastatin oral tablet 10 mg, 5 mg rosuvastatin oral tablet 20 mg, 40 mg

47 simvastatin oral tablet 10 mg, 20 mg, 40 mg, 5 mg simvastatin oral tablet 80 mg TRIGLIDE ORAL TABLET 160 MG WELCHOL ORAL POWDER IN PACKET WELCHOL ORAL TABLET Miscellaneous Cardiovascular Agents CORLANOR ORAL TABLET ENTRESTO ORAL TABLET RANEXA ORAL TABLET EXTENDED RELEASE 12 HR Nitrates DILATRATE-SR ORAL CAPSULE, EXTENDED RELEASE 46 ISORDIL ORAL TABLET isosorbide dinitrate oral tablet isosorbide dinitrate oral tablet extended release isosorbide mononitrate oral tablet isosorbide mononitrate oral tablet extended release 24 hr MINITRAN TRANSDERMAL PATCH 24 HOUR nitro-bid transdermal ointment NITRO-DUR TRANSDERMAL PATCH 24 HOUR nitroglycerin oral capsule, extended release nitroglycerin sublingual tablet nitroglycerin transdermal patch 24 hour nitroglycerin translingual aerosol,spray nitroglycerin translingual spray,non-aerosol NITROSTAT SUBLINGUAL TABLET nitro-time oral capsule, extended release Dermatologicals/Topical Therapy Antipsoriatic / Antiseborrheic

48 acitretin oral capsule calcipotriene scalp solution calcipotriene topical cream calcipotriene topical ointment calcipotriene-betamethasone topical ointment calcitrene topical ointment calcitriol topical ointment COSENTYX (2 SYRINGES) SUBCUTANEOUS SYRINGE COSENTYX PEN (2 PENS) SUBCUTANEOUS PEN INJECTOR COSENTYX PEN SUBCUTANEOUS PEN INJECTOR PA; SPRx PA; SPRx PA; SPRx COSENTYX SUBCUTANEOUS SYRINGE PA; SPRx drithocreme hp topical cream ENSTILAR TOPICAL FOAM hydrocortisone-pramoxine topical cream seb-prev topical cleanser selenium sulfide topical lotion selenium sulfide topical shampoo 2.25 % SILIQ SUBCUTANEOUS SYRINGE PA; SPRx STELARA SUBCUTANEOUS SYRINGE PA; LD; SPRx sulfacetamide sodium topical cleanser sulfacetamide sodium topical shampoo TACLONEX TOPICAL SUSPENSION TALTZ AUTOINJECTOR (2 PACK) SUBCUTANEOUS AUTO-INJECTOR TALTZ AUTOINJECTOR (3 PACK) SUBCUTANEOUS AUTO-INJECTOR TALTZ AUTOINJECTOR SUBCUTANEOUS AUTO-INJECTOR TALTZ SYRINGE (2 PACK) SUBCUTANEOUS SYRINGE PA; SPRx PA; SPRx PA; SPRx PA; SPRx 47

49 TALTZ SYRINGE (3 PACK) SUBCUTANEOUS SYRINGE TALTZ SYRINGE SUBCUTANEOUS SYRINGE 48 PA; SPRx PA; SPRx TREMFYA SUBCUTANEOUS SYRINGE PA; SPRx Burn Therapy silver sulfadiazine topical cream ssd topical cream thermazene topical cream Keratolytics PODOCON TOPICAL LIQUID POTASSIUM HYDROXIDE TOPICAL SOLUTION salicylic acid er-ceramides topical combo pack salicylic acid topical cream salicylic acid topical cream,extended release salicylic acid topical film forming liquid w/appl salicylic acid topical liquid 26 % salicylic acid topical lotion salicylic acid topical shampoo Miscellaneous Dermatologicals ammonium lactate topical cream diclofenac sodium topical gel 3 % QL (100 GM per 30 days) doxepin topical cream DUPIXENT SUBCUTANEOUS SYRINGE PA; LD; SPRx; QL (2 ML per 30 days) ELIDEL TOPICAL CREAM EUCRISA TOPICAL OINTMENT fluorouracil topical cream 5 % fluorouracil topical solution methoxsalen oral capsule,liqd-filled,rapid rel PICATO TOPICAL GEL podofilox topical solution