4-TIER HIGH DEDUCTIBLE HEALTH PLAN FORMULARY Effective May 2018

Transcription

1 4-TIER HIGH DEDUCTIBLE HEALTH PLAN FORMULARY Effective May 2018 Provided by EnvisionRx Introduction The Total Health Care (THC) 4-Tier High Deductible Health Plan Formulary was developed to serve as a guide for physicians, pharmacists, health care professionals and members in the selection of cost-effective drug therapy. Total Health Care recognizes that drug therapy is an integral part of effective health management. Total Health Care continually reviews new and existing medications to ensure the Formulary remains responsive to the needs of our members and health professionals. Criteria used to evaluate drug selection for the formulary includes, but is not limited to: safety, efficacy and cost-effectiveness data, as well as comparison of relevant benefits of similar prescription or over-the counter (OTC) agents while minimizing potential duplications. Notice The information contained in this formulary is provided by THC & EnvisionRx, solely for the convenience of medical providers and members. THC does not warrant or assure accuracy of this information, nor is it intended to be comprehensive in nature. This formulary is not intended to be a substitute for the knowledge, expertise, skill or judgment of the medical provider in their choice of prescription drugs. Total Health Care assumes no responsibility for the actions or omissions of any medical provider based upon reliance, in whole or in part, on the information contained herein. The medical provider should consult the drug manufacturer s product literature or standard references for more detailed information. How to Read the Formulary All formulary drugs are listed either by their generic names (in lowercase) or by their brand names (in uppercase). Drugs are grouped together by their therapeutic drug category. Specific drug listings may be accessed by using the index, using the covered generic name or the covered brand name of the drug. Any drug not found in this Formulary listing shall be considered a non-formulary drug. 0

2 Tier Guidelines Generic Tier 1 Preferred Brand Tier 2 Non-Preferred Brand Tier 3 Non- Preferred Generic Specialty Tier 4 Preventive Tier 5 $0 co-pay at in-network pharmacies The Certificate of Coverage provided upon enrollment has specific information regarding co-payments, coinsurance, annual deductible requirements and maximum out of pocket limits associated with the corresponding pharmacy benefit. Prescribing Guidelines Prescribing guidelines may apply to select drugs on the THC formulary. Prescribing guidelines may vary by benefit design but may include: Prior Authorization Required () Over the Counter Drugs (OTC) Specialty Drugs (SP) Quantity Limit (QL) Age Limit (AL) Gender Restriction (GR) Step Therapy Required (ST) Custom (C) Drug requires prior authorization through a specific physician request process. Drug coverage is available for drugs that are available OTC with an authorized prescription from your provider. Drug requires processing through THC s contracted specialty pharmacy, Envision Specialty Pharmacy. Drug coverage may be limited to specific quantities per prescription and/or time period. Drug coverage may depend on patient age. Drug coverage may depend on patient gender. Drug coverage requires that an alternative or trial of another drug be used before the medication is covered. Drug coverage has unique restrictions. 1

3 Saving on Out-Of-Pocket Costs Total Health Care has designed its prescription drug plan to encourage the use of generic and preferred brand name drugs. Choosing non-preferred drugs may mean paying higher out-of-pocket expenses (such as coinsurance and co-payments) or not receiving coverage at all. Members may also pay less for generic drugs or they may be asked to pay the cost difference between brand name drugs and their generic alternatives, which are preferred by the plan. Benefit Coverage and Limitations This formulary does not define benefit coverage and limitations. Many members have specific benefit inclusions, exclusions, copayments, coinsurance or a lack of coverage, which are not reflected in the THC 4- Tier High Deductible Health Plan Formulary. Members should contact Total Health Care at if they have questions regarding their coverage. Please note that the formulary process is evolutionary and changes can occur throughout the year. Preventive Medications Total Health Care covers certain preventive services for $0 co-pay when delivered by in-network pharmacies. These drugs are indicated on the THC 4-Tier High Deductible Health Plan Formulary under Drug Tier 5. Examples of preventive medications include aspirin, contraceptives, iron supplementations, smoking cessation products and Vitamin D drugs. These drugs are available with standard drug coverage recommendations and are only available for certain populations. Prior Authorization () Drugs indicated with a require Prior Authorization for coverage. A prescriber may complete a Prior Authorization form that can be found on the Total Health Care website at You may also request a form by calling Total Health Care at Completed prior authorization forms should be faxed to Prior Authorization review of prescribing guidelines will be evaluated utilizing the established drug review criteria approved by Total Health Care. If the request does not meet the approved criteria, the request will not be approved and alternative therapy may be recommended along with the proper course of alternative action. The requesting provider will be provided written notification of Total Health Care review decisions. THC s website has a contact link where members can contact THC s Pharmacy Department to ask for an exception request. Non-Formulary Agents Drugs not located on the Total Health Care 4-Tier High Deductible Health Plan Formulary, or any updates published by Total Health Care, shall be considered a non-formulary drug. Requests for coverage of nonformulary agents may be requested by the health professional depending on specific coverage parameters. Review for non-formulary drug requests will require a Prior Authorization request with documentation of medical necessity. Generally, the following basic medical necessity guidelines are used in conducting a review: The patient has failed an appropriate trial of formulary or preferred agents. The use of preferred or formulary agent is contraindicated in the patient. 2

4 The formulary drug or preferred agents are not suited for the present patient care need, and the drug selected is required for patient safety. If the request does not meet the established guidelines request, it will not be approved and alternative therapy may be recommended along with the proper course of alternative action. Common Drug Exclusions The member s plan design may exclude certain drug classes. Prior authorization is generally not available for drugs that are specifically excluded by benefit design. Common excluded coverages may include, but are not limited to: OTC medications or their equivalents unless otherwise specified in the Formulary listing. Drug products used for cosmetic purposes. Drug products for sexual dysfunction. Experimental drug products, or any drug product used in an experimental manner. Foreign drugs or drugs not approved by the United States Food & Drug Administration (FDA). Mandated Generic Substitution Total Health Care advocates the use of cost-effective generic drugs where FDA-approved generic equivalent drugs are available. Generic products are listed in the Formulary and noted in lowercase lettering wherever an FDA-approved generic drug product is available. If a member or physician requests a brand name product in lieu of an approved generic, the member, based upon their coverage, will be required to pay the difference in cost between the brand/non-preferred brand and the generic drug, plus the brand/non-preferred brand copay. Total Health Care Pharmacy and Therapeutics (P&T) Committee Total Health Care s Pharmacy & Therapeutics Committee meets quarterly to review and recommend medications for formulary consideration. The Committee considers clinical information on drugs that are new to the market and drugs that are typically included in an outpatient pharmacy benefit. This assures that the formulary remains responsive to patient and physician needs. The Committee is composed of physicians, pharmacists, and health care professionals. The Committee also uses reference materials from our Pharmacy Benefits Manager's Pharmacy and Therapeutics Advisory Panel. Product Selection Criteria The primary goal of the THC Pharmacy & Therapeutics Committee is to maintain and update the formulary based upon an objective analysis of the safety, efficacy, approved indications, adverse effects, contraindications, patient administration/compliance considerations and cost effectiveness of available drugs. When a drug is considered for formulary inclusion, it will be reviewed relative to similar drugs including those currently in the THC Formulary. Physicians may request a copy of THC s drug criteria by calling the Pharmacy Department at Diabetic Testing Supplies Total Health Care works with J&B Medical Supply to provide diabetic testing supplies to our members. Covered diabetic testing supplies include Glucocard Vital glucometer, Glucocard Expression glucometer, and SD Biosensor GlucoNavii glucometer, Glucocard Vital test strips, Glucocard Expression test strips, SD 3

5 Biosensor GlucoNavii test strips, lancets, insulin syringes, alcohol swabs and ketone strips. These supplies are to be filled through J&B Medical Supply. If you have any questions about our diabetic supply program, please contact J&B Medical Supply at Specialty Bio-Pharmaceutical Pharmacy Program Total Health Care works with Envision Specialty Pharmacy to provide Specialty Bio-Pharmaceutical Pharmacy products to our members. These medications are to be filled exclusively through Envision Specialty Pharmacy. A Specialty Drug Prior Authorization Request form must be completed and faxed to EnvisionRx at with supporting documentation and the prescription. A prescriber may obtain a Specialty Drug Prior Authorization Request form found on the Total Health Care website at Once the order is received, EnvisionRx obtains authorization from Total Health Care. If the specialty prior authorization is approved, Total Health Care notifies Envision Specialty Pharmacy. Then, Envision Specialty Pharmacy staff ships the medication directly to the physician's office or the patient s home. All packages are individually marked for each patient and refrigerated items are shipped in insulated containers. Where appropriate, each shipment includes needles, syringes and alcohol swabs. If you have any questions about our Specialty Bio-Pharmaceutical Pharmacy program, please contact EnvisionRx at or Envision Specialty Pharmacy at Contact Information The Total Health Care 4-Tier High Deductible Health Plan Formulary is designed to assist physicians, members and other health care professionals in the selection of cost-effective agents. Total Health Care encourages your input and feedback on how we can assist in improving this document and the formulary management process. You may contact THC at Medication Limitations Quantity Limitations Quantity Limitations are on medications throughout the formulary and are indicated with a "QL" notation. These are medications that have a daily dose restriction, quantity/days supply limitation, and/or a limitation on the duration of therapy. Age Limitations Age Limitations are on medications throughout the formulary and are indicated with an "AL" notation. Coverage for a medication is indicated by the age limitation. This could be a minimum age, maximum age, and/or the combination of a minimum and maximum age edit. Gender Restrictions Gender restrictions are indicated with a GR on the formulary and require the member to be a specific gender for coverage. Step Therapy Criteria 4

6 Step Therapy medications are indicated with a ST on the formulary and require that an alternative, first line medication be tried and failed before the requested medication can be covered. The online claims adjudication system will automatically allow for the requested medication to be filled based on electronic claims history indicating that the first line medication was filled. *Formulary Disclaimer: Coverage for some drugs may be limited to specific dosage forms and/or strengths. The benefit design determines what is covered and the applicable co-payment. The medications listed on this formulary are subject to change pursuant to the formulary management activities of EnvisionRx. The presence of a medication on this formulary list does not guarantee coverage. 5

7 lowercase italics = Generic drugs UPPERCASE BOLD = Brand name drugs CURRENT AS OF 5/1/2018 Status = Generic = Preferred Brand = Non-Preferred Brand / Non- Preferred Generic = Specialty = Preventive Drug Status Notes *Adhd/Anti-Narcolepsy/Anti- Obesity/Anorexiants* amphetamine-dextroamphet er oral capsule extended release 24 hour 10, 15, 20, 25, 30, 5 amphetamine-dextroamphetamine oral tablet 10, 12.5, 15, 20, 30, 5, 7.5 armodafinil oral tablet 150, 200, 50 atomoxetine hcl oral capsule 10, 100, 18, 25, 40, 60, 80 caffeine citrate intravenous solution 60 /3ml caffeine citrate oral solution 20 /ml DAYTRANA TRANSDERMAL TCH 10 MG/9HR, 15 MG/9HR, 20 MG/9HR, 30 MG/9HR dexmethylphenidate hcl er oral capsule extended release 24 hour 10, 15, 20, 25, 30, 35, 40 dexmethylphenidate hcl oral tablet 10, 2.5, 5 dextroamphetamine sulfate er oral capsule extended release 24 hour 10, 15, 5 dextroamphetamine sulfate oral tablet 10, 5 diethylpropion hcl oral tablet 25 doxapram hcl intravenous solution 20 /ml guanfacine hcl er oral tablet extended release 24 hour 1, 2, 3, 4 methamphetamine hcl oral tablet 5 methylphenidate hcl er (cd) oral capsule extended release 10, 20, 30, 40, 50, 60 Notes AL = Age Limit C = Custom Restriction GR-F = Female Only GR-M = Male Only = Prior Authorization QL = Quantity Limit ST = Step Therapy QL (30 EA per 30 days); AL (Min 6 Years and Max 17 Years) AL (Min 6 Years and Max 17 Years) ; AL (Min 6 Years and Max 17 Years) ; QL (30 EA per 30 days); AL (Min 6 Years and Max 17 Years) QL (30 EA per 30 days); AL (Min 6 Years and Max 17 Years) AL (Min 6 Years and Max 17 Years) AL (Min 6 Years and Max 17 Years) AL (Min 6 Years and Max 17 Years) QL (30 EA per 30 days); AL (Min 6 Years and Max 17 Years) AL (Min 6 Years and Max 17 Years) QL (30 EA per 30 days); AL (Min 6 Years and Max 17 Years) 1

8 methylphenidate hcl er (la) oral capsule extended release 24 hour 20, 30, 40 methylphenidate hcl er oral tablet extended release 10, 20 methylphenidate hcl er oral tablet extended release 18, 27, 36, 54 methylphenidate hcl oral solution 10 /5ml, 5 /5ml methylphenidate hcl oral tablet 10, 20, 5 QL (30 EA per 30 days); AL (Min 6 Years and Max 17 Years) QL (30 EA per 30 days); AL (Min 6 Years and Max 17 Years) QL (30 EA per 30 days); AL (Min 6 Years and Max 17 Years) AL (Min 6 Years and Max 17 Years) AL (Min 6 Years and Max 17 Years) modafinil oral tablet 100, 200 ; QL (30 EA per 30 days) phentermine hcl oral capsule 15, 30, 37.5 phentermine hcl oral tablet 37.5 VYVANSE ORAL CAPSULE 10 MG, 20 MG, 30 MG, 40 MG, 50 MG, 60 MG, 70 MG *Aminoglycosides* KITABIS K INHALATION NEBULIZATION SOLUTION 300 MG/5ML neomycin sulfate oral tablet 500 paromomycin sulfate oral capsule 250 *Analgesics - Anti-Inflammatory* ACTEMRA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 162 MG/0.9ML ARCALYST SUBCUTANEOUS SOLUTION RECONSTITUTED 220 MG celecoxib oral capsule 100, 200, 400, 50 diclofenac potassium oral tablet 50 diclofenac sodium er oral tablet extended release 24 hour 100 diclofenac sodium oral tablet delayed release 25, 50, 75 diclofenac-misoprostol oral tablet delayed release , ENBREL SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 50 MG/ML ENBREL SUBCUTANEOUS SOLUTION RECONSTITUTED 25 MG ENBREL SURECLICK SUBCUTANEOUS SOLUTION AUTO-INJECTOR 50 MG/ML ; QL (30 EA per 30 days); AL (Min 6 Years and Max 17 Years) QL (30 EA per 30 days) 2

9 etodolac er oral tablet extended release 24 hour 400, 500, 600 etodolac oral capsule 200, 300 etodolac oral tablet 400, 500 flurbiprofen oral tablet 100, 50 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 ibuprofen childrens oral suspension 100 /5ml ibuprofen oral capsule 200 ibuprofen oral tablet 200, 400, 600, 800 indomethacin er oral capsule extended release 75 AL (Max 64 Years) indomethacin oral capsule 25, 50 AL (Max 64 Years) ketoprofen er oral capsule extended release 24 hour 200 QL (30 EA per 30 days) ketoprofen oral capsule 50 QL (180 EA per 30 days) ketoprofen oral capsule 75 QL (120 EA per 30 days) ketorolac tromethamine oral tablet 10 QL (20 EA per 5 days) KINERET SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 100 MG/0.67ML leflunomide oral tablet 10, 20 meclofenamate sodium oral capsule 100, 50 meloxicam oral suspension 7.5 /5ml meloxicam oral tablet 15, 7.5 nabumetone oral tablet 500 QL (120 EA per 30 days) nabumetone oral tablet 750 QL (60 EA per 30 days) naproxen dr oral tablet delayed release 375, 500 naproxen oral suspension 125 /5ml naproxen oral tablet 250, 375, 500 naproxen sodium oral capsule 220 naproxen sodium oral tablet 220 naproxen sodium oral tablet 275, 550 ORENCIA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 125 MG/ML oxaprozin oral tablet 600 3

10 piroxicam oral capsule 10, 20 RIDAURA ORAL CAPSULE 3 MG sulindac oral tablet 150, 200 tolmetin sodium oral capsule 400 tolmetin sodium oral tablet 200, 600 XELJANZ ORAL TABLET 5 MG *Analgesics - Nonnarcotic* acetaminophen er oral tablet extended release 650 acetaminophen oral capsule 500 acetaminophen oral elixir 160 /5ml acetaminophen oral tablet 325, 500 acetaminophen oral tablet chewable 80 acetaminophen rectal suppository 120, 325 adult aspirin low strength oral tablet dispersible 81 aspirin ec low strength oral tablet delayed release 81 aspirin ec oral tablet delayed release 325 aspirin low dose oral tablet 81 aspirin low dose oral tablet chewable 81 aspirin oral tablet 325 aspirin rectal suppository 300, 600 aspirin-acetaminophen-caffeine oral tablet aspirtab maximum strength oral tablet 500 butalbital-acetaminophen oral tablet butalbital-apap-caffeine oral capsule butalbital-apap-caffeine oral tablet butalbital-asa-caffeine oral capsule choline-mag trisalicylate oral liquid 500 /5ml diflunisal oral tablet 500 q-pap childrens oral suspension 160 /5ml q-pap infants oral solution 80 /0.8ml 4 QL (30 EA per 30 days); AL (Min 40 Years and Max 79 Years) QL (60 EA per 30 days); AL (Min 40 Years and Max 79 Years) QL (30 EA per 30 days); AL (Min 40 Years and Max 79 Years) QL (60 EA per 30 days); AL (Min 40 Years and Max 79 Years) QL (60 EA per 30 days); AL (Min 40 Years and Max 79 Years) QL (30 EA per 30 days); AL (Min 40 Years and Max 79 Years)

11 q-pap oral liquid 160 /5ml salsalate oral tablet 500, 750 tgt acetaminophen infants oral suspension 80 /0.8ml tri-buffered aspirin oral tablet 325 ZEBUTAL ORAL CAPSULE MG *Analgesics - Opioid* QL (30 EA per 30 days); AL (Min 40 Years and Max 79 Years) acetaminophen-codeine #3 oral tablet QL (390 EA per 30 days) acetaminophen-codeine #4 oral tablet QL (390 EA per 30 days) acetaminophen-codeine oral solution /5ml acetaminophen-codeine oral tablet QL (390 EA per 30 days) buprenorphine hcl injection solution 0.3 /ml buprenorphine hcl sublingual tablet sublingual 2, 8 buprenorphine hcl-naloxone hcl sublingual tablet sublingual 2-0.5, 8-2 buprenorphine transdermal patch weekly 10 mcg/hr, 20 mcg/hr, 5 mcg/hr butalbital-apap-caff-cod oral capsule , butalbital-asa-caff-codeine oral capsule butorphanol tartrate injection solution 1 /ml, 2 /ml butorphanol tartrate nasal solution 10 /ml BUTRANS TRANSDERMAL TCH WEEKLY 10 MCG/HR, 20 MCG/HR, 5 MCG/HR codeine sulfate oral tablet 15, 30 fentanyl transdermal patch 72 hour 100 mcg/hr, 12 mcg/hr, 25 mcg/hr, 50 mcg/hr, 75 mcg/hr hydrocodone-acetaminophen oral solution /15ml, /15ml hydrocodone-acetaminophen oral tablet , 5-300, hydrocodone-acetaminophen oral tablet , , 5-325, hydrocodone-ibuprofen oral tablet , , 5-200, ; QL (90 EA per 30 days) ; QL (10 EA per 30 days) QL (180 EA per 30 days) QL (180 EA per 30 days) QL (180 EA per 30 days) 5

12 hydromorphone hcl er oral tablet er 24 hour abuse-deterrent 12, 16, 32, 8 hydromorphone hcl oral liquid 1 /ml hydromorphone hcl oral tablet 2, 4, 8 QL (240 EA per 30 days) hydromorphone hcl rectal suppository 3 levorphanol tartrate oral tablet 2 meperidine hcl injection solution 10 /ml, 100 /ml, 25 /ml, 50 /ml meperidine hcl oral solution 50 /5ml meperidine hcl oral tablet 100, 50 methadone hcl injection solution 10 /ml methadone hcl oral concentrate 10 /ml methadone hcl oral solution 10 /5ml, 5 /5ml methadone hcl oral tablet 5 methadone hcl oral tablet soluble 40 METHADOSE ORAL TABLET 10 MG QL (240 EA per 30 days) morphine sulfate (concentrate) oral solution 100 /5ml morphine sulfate (pf) intravenous solution 10 /ml, 15 /ml, 2 /ml, 4 /ml, 8 /ml morphine sulfate er oral tablet extended release 100, 15, 30, 60 morphine sulfate injection solution 10 /ml, 15 /ml, 8 /ml morphine sulfate intramuscular device 10 /0.7ml morphine sulfate intravenous solution 1 /ml, 150 /30ml, 25 /ml, 50 /ml morphine sulfate oral solution 10 /5ml, 20 /5ml QL (90 EA per 30 days) morphine sulfate oral tablet 15, 30 QL (180 EA per 30 days) morphine sulfate rectal suppository 10, 20, 30, 5 nalbuphine hcl injection solution 10 /ml, 20 /ml NUCYNTA ER ORAL TABLET EXTENDED RELEASE 12 HOUR 100 MG, 150 MG, 200 MG, 250 MG, 50 MG oxycodone hcl oral capsule 5 QL (180 EA per 30 days) oxycodone hcl oral concentrate 100 /5ml oxycodone hcl oral solution 5 /5ml 6

13 oxycodone hcl oral tablet 10, 15, 20, 30, 5 oxycodone-acetaminophen oral tablet , oxycodone-acetaminophen oral tablet QL (180 EA per 30 days) QL (180 EA per 30 days) oxycodone-acetaminophen oral tablet QL (360 EA per 30 days) oxycodone-aspirin oral tablet oxycodone-ibuprofen oral tablet QL (240 EA per 30 days) oxymorphone hcl er oral tablet extended release 12 hour 10, 15, 20, 30, 40, 5, 7.5 pentazocine-naloxone hcl oral tablet SUBOXONE SUBLINGUAL FILM 12-3 MG ; QL (30 EA per 30 days) SUBOXONE SUBLINGUAL FILM MG, 4-1 MG ; QL (90 EA per 30 days) SUBOXONE SUBLINGUAL FILM 8-2 MG ; QL (60 EA per 30 days) tramadol hcl er (biphasic) oral tablet extended release 24 hour 300 tramadol hcl er oral capsule extended release 24 hour 150 tramadol hcl er oral tablet extended release 24 hour 100, 200 QL (30 EA per 30 days) QL (30 EA per 30 days) QL (30 EA per 30 days) tramadol hcl oral tablet 50 QL (240 EA per 30 days) tramadol-acetaminophen oral tablet XARTEMIS XR ORAL TABLET EXTENDED RELEASE MG *Androgens-Anabolic* ANADROL-50 ORAL TABLET 50 MG ANDRODERM TRANSDERMAL TCH 24 HOUR 2 MG/24HR, 4 MG/24HR ANDROGEL PUMP TRANSDERMAL GEL MG/ACT (1.62%) ANDROGEL TRANSDERMAL GEL MG/1.25GM (1.62%), 40.5 MG/2.5GM (1.62%) ANDROXY ORAL TABLET 10 MG methitest oral tablet 10 oxandrolone oral tablet 10, 2.5 testosterone cypionate intramuscular solution 100 /ml, 200 /ml testosterone enanthate intramuscular solution 200 /ml GR-M GR-M 7

14 testosterone transdermal gel 25 /2.5gm (1%) *Anorectal Agents* ANALPRAM-HC RECTAL LOTION % anucort-hc suppository 25 rectal 25 QL (28 EA per 14 days) CORTIFOAM RECTAL FOAM 10 % HEMMOREX-HC RECTAL SUPPOSITORY 30 MG hemorrhoidal max str rectal cream % hemorrhoidal rectal suppository 51 % hydrocortisone ace-pramoxine rectal cream 1-1 %, % hydrocortisone ace-pramoxine rectal kit & 1 % hydrocortisone acetate suppository 25 rectal 25 hydrocortisone rectal cream 2.5 % hydrocortisone rectal enema 100 /60ml lidocaine-hydrocortisone ace rectal gel % PROCTOFOAM HC RECTAL FOAM 1-1 % RECTIV RECTAL OINTMENT 0.4 % *Antacids* ACID GONE ORAL SUSPENSION MG/15ML ALKA-SELTZER HEARTBURN ORAL TABLET EFFERVESCENT MG ALMACONE ORAL TABLET CHEWABLE MG aluminum-magnesium-simethicone oral suspension /5ml antacid advanced oral suspension /5ml antacid extra strength oral tablet chewable antacid multi-symptom oral tablet chewable antacid oral tablet chewable 1177, , 420, 500 calcium antacid ultra oral tablet chewable 1000 calcium carbonate antacid oral tablet QL (28 EA per 14 days)

15 calcium carbonate antacid oral tablet chewable 750 CHILDRENS SOOTHE ORAL TABLET CHEWABLE 400 MG CITROCARBONATE ORAL GRANULES EFFERVESCENT GM/DOSE cvs heartburn relief ex st oral suspension /5ml DEWEES CARMINATIVE ORAL LIQUID E-Z-GAS II ORAL CKET GM GAVISCON ORAL TABLET CHEWABLE MG geri-lanta supreme oral suspension /5ml gnp antacid & anti-gas oral tablet chewable gnp antacid extra strength oral tablet chewable gnp antacid oral tablet chewable mag-al oral liquid /5ml magnesium oxide oral capsule 400 magnesium oxide oral tablet 250, 400, 420 magnesium oxide powder MI-ACID ORAL TABLET CHEWABLE MG sm foaming antacid oral tablet chewable sodium bicarbonate oral powder sodium bicarbonate oral tablet 325, 650 URO-MAG ORAL CAPSULE 140 MG *Anthelmintics* ALBENZA ORAL TABLET 200 MG PIN-X ORAL SUSPENSION 50 MG/ML PIN-X ORAL TABLET CHEWABLE MG *Antianginal Agents* DILATRATE-SR ORAL CAPSULE EXTENDED RELEASE 40 MG 9

16 isosorbide dinitrate er oral tablet extended release 40 isosorbide dinitrate oral tablet 10, 20, 30, 5 isosorbide mononitrate er oral tablet extended release 24 hour 120, 30, 60 isosorbide mononitrate oral tablet 10, 20 NITRO-BID TRANSDERMAL OINTMENT 2 % NITRO-DUR TRANSDERMAL TCH 24 HOUR 0.3 MG/HR, 0.8 MG/HR nitroglycerin er oral capsule extended release 6.5, 9 nitroglycerin sublingual tablet sublingual 0.3, 0.4, 0.6 nitroglycerin transdermal patch 24 hour 0.1 /hr, 0.2 /hr, 0.4 /hr, 0.6 /hr nitroglycerin translingual solution 0.4 /spray NITRO-TIME ORAL CAPSULE EXTENDED RELEASE 2.5 MG RANEXA ORAL TABLET EXTENDED RELEASE 12 HOUR 1000 MG, 500 MG *Antianxiety Agents* alprazolam er oral tablet extended release 24 hour 0.5, 1, 2, 3 alprazolam oral tablet 0.25, 0.5, 1, 2 alprazolam oral tablet dispersible 0.25, 0.5, 1, 2 buspirone hcl oral tablet 10, 15, 30, 5, 7.5 chlordiazepoxide hcl oral capsule 10, 25, 5 clorazepate dipotassium oral tablet 15, 3.75, 7.5 QL (60 EA per 30 days) AL (Max 64 Years) AL (Max 64 Years) AL (Max 64 Years) AL (Max 64 Years) AL (Max 64 Years) diazepam injection solution 5 /ml AL (Max 64 Years) diazepam oral solution 1 /ml AL (Max 64 Years) diazepam oral tablet 10, 2, 5 AL (Max 64 Years) droperidol injection solution 2.5 /ml hydroxyzine hcl intramuscular solution 25 /ml, 50 /ml AL (Max 64 Years) hydroxyzine hcl oral syrup 10 /5ml AL (Max 64 Years) 10

17 hydroxyzine hcl oral tablet 10, 25, 50 AL (Max 64 Years) hydroxyzine pamoate oral capsule 100, 25, 50 lorazepam injection solution 2 /ml, 4 /ml lorazepam oral concentrate 2 /ml lorazepam oral tablet 0.5, 1, 2 AL (Max 64 Years) meprobamate oral tablet 200, 400 AL (Max 64 Years) oxazepam oral capsule 10, 15, 30 *Antiarrhythmics* amiodarone hcl oral tablet 100 amiodarone hcl oral tablet 200, 400 disopyramide phosphate oral capsule 100, 150 dofetilide oral capsule 125 mcg, 250 mcg, 500 mcg flecainide acetate oral tablet 100, 150, 50 mexiletine hcl oral capsule 150, 200, 250 MULTAQ ORAL TABLET 400 MG QL (60 EA per 30 days) NORCE CR ORAL CAPSULE EXTENDED RELEASE 12 HOUR 100 MG propafenone hcl er oral capsule extended release 12 hour 225, 325, 425 propafenone hcl oral tablet 150, 225, 300 quinidine gluconate er oral tablet extended release 324 quinidine sulfate er oral tablet extended release 300 quinidine sulfate oral tablet 200, 300 *Antiasthmatic And Bronchodilator Agents* ADVAIR DISKUS INHALATION AEROSOL POWDER BREATH ACTIVATED MCG/DOSE, MCG/DOSE, MCG/DOSE ADVAIR HFA INHALATION AEROSOL MCG/ACT, MCG/ACT, MCG/ACT AEROSN INHALATION AEROSOL SOLUTION 80 MCG/ACT QL (60 EA per 30 days) QL (12 GM per 30 days) QL (8.9 GM per 30 days) 11

18 albuterol sulfate er oral tablet extended release 12 hour 4, 8 albuterol sulfate inhalation nebulization solution (2.5 /3ml) 0.083%, (5 /ml) 0.5%, 0.63 /3ml, 1.25 /3ml albuterol sulfate oral syrup 2 /5ml aminophylline intravenous solution 25 /ml ARCAPTA NEOHALER INHALATION CAPSULE 75 MCG ASMANEX 120 METERED DOSES INHALATION AEROSOL POWDER BREATH ACTIVATED 220 MCG/INH ASMANEX 30 METERED DOSES INHALATION AEROSOL POWDER BREATH ACTIVATED 110 MCG/INH ATROVENT HFA INHALATION AEROSOL SOLUTION 17 MCG/ACT BREO ELLIPTA INHALATION AEROSOL POWDER BREATH ACTIVATED MCG/INH, MCG/INH BROVANA INHALATION NEBULIZATION SOLUTION 15 MCG/2ML budesonide inhalation suspension 0.25 /2ml, 0.5 /2ml budesonide inhalation suspension 1 /2ml COMBIVENT RESPIMAT INHALATION AEROSOL SOLUTION MCG/ACT QL (30 EA per 30 days) QL (2 EA per 30 days) QL (2 EA per 30 days) QL (12.9 GM per 30 days) QL (60 EA per 30 days) QL (120 ML per 30 days); AL (Max 6 Years) QL (120 ML per 30 days); AL (Max 6 Years) QL (4 GM per 30 days) DALIRESP ORAL TABLET 500 MCG QL (30 EA per 30 days) DULERA INHALATION AEROSOL MCG/ACT, MCG/ACT ELIXOPHYLLIN ORAL ELIXIR 80 MG/15ML epinephrine hcl injection solution prefilled syringe 0.1 /ml FLOVENT DISKUS INHALATION AEROSOL POWDER BREATH ACTIVATED 100 MCG/BLIST FLOVENT DISKUS INHALATION AEROSOL POWDER BREATH ACTIVATED 50 MCG/BLIST FLOVENT HFA INHALATION AEROSOL 110 MCG/ACT QL (13 GM per 30 days) QL (60 EA per 30 days) QL (60 EA per 30 days); AL (Min 4 Years and Max 11 Years) QL (12 GM per 30 days); AL (Max 12 Years) 12

19 FLOVENT HFA INHALATION AEROSOL 44 MCG/ACT fluticasone-salmeterol aerosol powder breath activated mcg/act inhalation mcg/act fluticasone-salmeterol aerosol powder breath activated mcg/act inhalation mcg/act fluticasone-salmeterol aerosol powder breath activated mcg/act inhalation mcg/act INCRUSE ELLIPTA INHALATION AEROSOL POWDER BREATH ACTIVATED 62.5 MCG/INH ipratropium bromide inhalation solution 0.02 % ipratropium-albuterol inhalation solution (3) /3ml levalbuterol hcl inhalation nebulization solution 0.31 /3ml, 0.63 /3ml, 1.25 /0.5ml levalbuterol tartrate inhalation aerosol 45 mcg/act metaproterenol sulfate oral syrup 10 /5ml metaproterenol sulfate oral tablet 10, 20 montelukast sodium oral packet 4 montelukast sodium oral tablet 10 montelukast sodium oral tablet chewable 4, 5 PERFOROMIST INHALATION NEBULIZATION SOLUTION 20 MCG/2ML PULMICORT FLEXHALER INHALATION AEROSOL POWDER BREATH ACTIVATED 180 MCG/ACT, 90 MCG/ACT QVAR INHALATION AEROSOL SOLUTION 40 MCG/ACT, 80 MCG/ACT QVAR REDIHALER INHALATION AEROSOL BREATH ACTIVATED 40 MCG/ACT, 80 MCG/ACT SEREVENT DISKUS INHALATION AEROSOL POWDER BREATH ACTIVATED 50 MCG/DOSE SPIRIVA HANDIHALER INHALATION CAPSULE 18 MCG STRIVERDI RESPIMAT INHALATION AEROSOL SOLUTION 2.5 MCG/ACT QL (10.6 GM per 30 days); AL (Max 12 Years) QL (1 EA per 30 days) QL (1 EA per 30 days) QL (1 EA per 30 days) QL (30 EA per 30 days) QL (15 GM per 30 days) QL (1 EA per 30 days) QL (8.7 GM per 30 days) QL (10.6 GM per 30 days) QL (30 EA per 30 days) QL (4 GM per 30 days) 13

20 SYMBICORT INHALATION AEROSOL MCG/ACT, MCG/ACT terbutaline sulfate injection solution 1 /ml terbutaline sulfate oral tablet 2.5, 5 theophylline er oral tablet extended release 12 hour 100, 200, 300, 450 theophylline er oral tablet extended release 24 hour 400, 600 theophylline oral solution 80 /15ml TUDORZA PRESSAIR INHALATION AEROSOL POWDER BREATH ACTIVATED 400 MCG/ACT VENTOLIN HFA INHALATION AEROSOL SOLUTION 108 (90 BASE) MCG/ACT XOLAIR SUBCUTANEOUS SOLUTION RECONSTITUTED 150 MG zafirlukast oral tablet 10, 20 zileuton er oral tablet extended release 12 hour 600 ZYFLO ORAL TABLET 600 MG *Anticoagulants* QL (10.2 GM per 30 days) QL (1 EA per 30 days) QL (36 GM per 30 days) ELIQUIS ORAL TABLET 2.5 MG, 5 MG QL (60 EA per 30 days) enoxaparin sodium injection solution 300 /3ml enoxaparin sodium subcutaneous solution 100 /ml, 120 /0.8ml, 150 /ml, 30 /0.3ml, 40 /0.4ml, 60 /0.6ml, 80 /0.8ml fondaparinux sodium subcutaneous solution 10 /0.8ml, 2.5 /0.5ml, 5 /0.4ml, 7.5 /0.6ml FRAGMIN SUBCUTANEOUS SOLUTION UNIT/ML, UNIT/0.5ML, UNIT/0.6ML, UNT/0.72ML, 2500 UNIT/0.2ML, 5000 UNIT/0.2ML, 7500 UNIT/0.3ML heparin lock flush intravenous solution 1 unit/ml, 10 unit/ml, 100 unit/ml heparin sod (porcine) in d5w intravenous solution 100 unit/ml heparin sodium (porcine) injection solution 1000 unit/ml, unit/ml, unit/ml, 5000 unit/ml ; C (Cover For 7 days supply per 30 days, requiring thereafter) ; C (Cover For 7 days supply per 30 days, requiring thereafter) 14

21 heparin sodium (porcine) pf injection solution 5000 unit/0.5ml PRADAXA ORAL CAPSULE 110 MG, 150 MG, 75 MG warfarin sodium oral tablet 1, 10, 2, 2.5, 3, 4, 5, 6, 7.5 QL (60 EA per 30 days) XARELTO ORAL TABLET 10 MG, 20 MG QL (30 EA per 30 days) XARELTO ORAL TABLET 15 MG QL (60 EA per 30 days) XARELTO STARTER CK ORAL TABLET THERAPY CK 15 & 20 MG *Anticonvulsants* APTIOM ORAL TABLET 200 MG, 400 MG, 600 MG, 800 MG BANZEL ORAL SUSPENSION 40 MG/ML carbamazepine er oral capsule extended release 12 hour 100, 200, 300 carbamazepine er oral tablet extended release 12 hour 100, 200, 400 carbamazepine oral suspension 100 /5ml carbamazepine oral tablet 200 carbamazepine oral tablet chewable 100 CELONTIN ORAL CAPSULE 300 MG 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 QL (51 EA per 365 days) QL (2 EA per 30 days) diazepam rectal gel 10, 2.5, 20 QL (2 EA per 30 days) DILANTIN ORAL CAPSULE 100 MG, 30 MG divalproex sodium er oral tablet extended release 24 hour 250, 500 divalproex sodium oral tablet delayed release 125, 250, 500 ethosuximide oral capsule 250 ethosuximide oral solution 250 /5ml felbamate oral suspension 600 /5ml felbamate oral tablet 400, 600 gabapentin oral capsule 100, 300, 400 gabapentin oral solution 300 /6ml gabapentin oral tablet 600,

22 lamotrigine er oral tablet extended release 24 hour 100, 200, 25, 250, 300, 50 lamotrigine oral kit 25 & 50 & 100, 25 (21)- 50 (7), 50 (42)-100(14) lamotrigine oral tablet 100, 150, 200, 25 lamotrigine oral tablet chewable 25, 5 levetiracetam er oral tablet extended release 24 hour 500, 750 levetiracetam intravenous solution 500 /5ml levetiracetam oral solution 100 /ml levetiracetam oral tablet 1000 QL (90 EA per 30 days) levetiracetam oral tablet 250 QL (360 EA per 30 days) levetiracetam oral tablet 500 QL (180 EA per 30 days) levetiracetam oral tablet 750 QL (120 EA per 30 days) LYRICA ORAL CAPSULE 100 MG, 150 MG, 200 MG, 225 MG, 25 MG, 300 MG, 50 MG, 75 MG LYRICA ORAL SOLUTION 20 MG/ML ONFI ORAL SUSPENSION 2.5 MG/ML ONFI ORAL TABLET 10 MG, 20 MG oxcarbazepine oral suspension 300 /5ml oxcarbazepine oral tablet 150, 300, 600 PEGANONE ORAL TABLET 250 MG phenytoin oral suspension 125 /5ml phenytoin oral tablet chewable 50 phenytoin sodium extended oral capsule 100, 200, 300 phenytoin sodium injection solution 50 /ml POTIGA ORAL TABLET 200 MG, 300 MG, 400 MG, 50 MG primidone oral tablet 250, 50 TEGRETOL-XR ORAL TABLET EXTENDED RELEASE 12 HOUR 100 MG tiagabine hcl oral tablet 12, 16, 2, 4 topiramate oral capsule sprinkle 15, 25 topiramate oral tablet 100, 200, 25, 50 16

23 valproate sodium oral syrup 250 /5ml valproic acid oral capsule 250 VIMT ORAL TABLET 100 MG, 150 MG, 200 MG, 50 MG zonisamide oral capsule 100 QL (180 EA per 30 days) zonisamide oral capsule 25, 50 QL (360 EA per 30 days) *Antidepressants* amitriptyline hcl oral tablet 10, 100, 150, 25, 50, 75 amoxapine oral tablet 100, 150, 25, 50 bupropion hcl er (sr) oral tablet extended release 12 hour 100, 150, 200 bupropion hcl er (xl) oral tablet extended release 24 hour 150, 300 bupropion hcl oral tablet 100, 75 citalopram hydrobromide oral solution 10 /5ml citalopram hydrobromide oral tablet 10, 20 AL (Max 64 Years) AL (Max 64 Years) citalopram hydrobromide oral tablet 40 QL (30 EA per 30 days) clomipramine hcl oral capsule 25, 50, 75 desipramine hcl oral tablet 10, 100, 150, 25, 50, 75 desvenlafaxine er oral tablet extended release 24 hour 100, 50 desvenlafaxine succinate er oral tablet extended release 24 hour 100, 25, 50 doxepin hcl oral capsule 10, 100, 150, 25, 50, 75 AL (Max 64 Years) QL (60 EA per 30 days) QL (30 EA per 30 days) QL (30 EA per 30 days) AL (Max 64 Years) doxepin hcl oral concentrate 10 /ml AL (Max 64 Years) duloxetine hcl oral capsule delayed release particles 20 duloxetine hcl oral capsule delayed release particles 30, 60 EMSAM TRANSDERMAL TCH 24 HOUR 12 MG/24HR, 6 MG/24HR, 9 MG/24HR escitalopram oxalate oral solution 5 /5ml QL (60 EA per 30 days) QL (30 EA per 30 days) QL (30 EA per 30 days) escitalopram oxalate oral tablet 10, 5 QL (45 EA per 30 days) escitalopram oxalate oral tablet 20 QL (30 EA per 30 days) fluoxetine hcl oral capsule 10, 20, 40 17

24 fluoxetine hcl oral capsule delayed release 90 QL (4 EA per 28 days) fluoxetine hcl oral solution 20 /5ml fluvoxamine maleate oral tablet 100, 25, 50 imipramine hcl oral tablet 10, 25, 50 AL (Max 64 Years) imipramine pamoate oral capsule 100, 125, 150, 75 maprotiline hcl oral tablet 25, 50, 75 MARPLAN ORAL TABLET 10 MG mirtazapine oral tablet 15, 30, 45, 7.5 mirtazapine oral tablet dispersible 15, 30, 45 nefazodone hcl oral tablet 100, 150, 200, 250, 50 nortriptyline hcl oral capsule 10, 25, 50, 75 nortriptyline hcl oral solution 10 /5ml paroxetine hcl er oral tablet extended release 24 hour 12.5, 25, 37.5 paroxetine hcl oral tablet 10, 20, 30, 40 XIL ORAL SUSPENSION 10 MG/5ML phenelzine sulfate oral tablet 15 protriptyline hcl oral tablet 10, 5 sertraline hcl oral concentrate 20 /ml sertraline hcl oral tablet 100, 25, 50 tranylcypromine sulfate oral tablet 10 trazodone hcl oral tablet 100, 150, 300, 50 trimipramine maleate oral capsule 100, 25, 50 venlafaxine hcl er oral capsule extended release 24 hour 150, 37.5, 75 venlafaxine hcl oral tablet 100, 25, 37.5, 50, 75 VIIBRYD ORAL TABLET 10 MG, 20 MG, 40 MG *Antidiabetics* acarbose oral tablet 100, 25, 50 AVANDIA ORAL TABLET 2 MG, 4 MG 18 AL (Max 64 Years) AL (Max 64 Years) AL (Max 64 Years)

25 chlorpropamide oral tablet 100, 250 CYCLOSET ORAL TABLET 0.8 MG glimepiride oral tablet 1, 2, 4 glipizide oral tablet 10, 5 glipizide xl oral tablet extended release 24 hour 10, 2.5, 5 glipizide-metformin hcl oral tablet , , GLUCAGEN HYPOKIT INJECTION SOLUTION RECONSTITUTED 1 MG GLUCAGON EMERGENCY INJECTION KIT 1 MG glucose oral tablet chewable 4-6 gm- glyburide micronized oral tablet 1.5, 3, 6 glyburide oral tablet 1.25, 2.5, 5 glyburide-metformin oral tablet , , HUMALOG MIX 50/50 SUBCUTANEOUS SUSPENSION (50-50) 100 UNIT/ML HUMALOG MIX 75/25 SUBCUTANEOUS SUSPENSION (75-25) 100 UNIT/ML HUMULIN R INJECTION SOLUTION 100 UNIT/ML HUMULIN R U-500 (CONCENTRATED) SUBCUTANEOUS SOLUTION 500 UNIT/ML INVOKANA ORAL TABLET 100 MG, 300 MG JANUMET ORAL TABLET MG, MG JANUMET XR ORAL TABLET EXTENDED RELEASE 24 HOUR MG, MG, MG JANUVIA ORAL TABLET 100 MG, 25 MG, 50 MG QL (60 EA per 30 days) QL (2 EA per 30 days) QL (2 EA per 30 days) QL (20 ML per 30 days) QL (30 EA per 30 days) QL (60 EA per 30 days) QL (30 EA per 30 days) QL (30 EA per 30 days) JARDIANCE ORAL TABLET 10 MG, 25 MG QL (30 EA per 30 days) LANTUS SOLOSTAR SUBCUTANEOUS SOLUTION PEN-INJECTOR 100 UNIT/ML LANTUS SUBCUTANEOUS SOLUTION 100 UNIT/ML LEVEMIR FLEXPEN SUBCUTANEOUS SOLUTION PEN-INJECTOR 100 UNIT/ML 19

26 LEVEMIR SUBCUTANEOUS SOLUTION 100 UNIT/ML metformin hcl er oral tablet extended release 24 hour 500, 750 metformin hcl oral tablet 1000, 500, 850 miglitol oral tablet 25 nateglinide oral tablet 120, 60 NOVOLIN 70/30 RELION SUSPENSION (70-30) 100 UNIT/ML SUBCUTANEOUS (70-30) 100 UNIT/ML NOVOLIN 70/30 SUSPENSION (70-30) 100 UNIT/ML SUBCUTANEOUS (70-30) 100 UNIT/ML NOVOLIN N RELION SUBCUTANEOUS SUSPENSION 100 UNIT/ML NOVOLIN R RELION INJECTION SOLUTION 100 UNIT/ML NOVOLOG FLEXPEN SUBCUTANEOUS SOLUTION PEN-INJECTOR 100 UNIT/ML NOVOLOG MIX 70/30 FLEXPEN SUBCUTANEOUS SUSPENSION PEN- INJECTOR (70-30) 100 UNIT/ML NOVOLOG MIX 70/30 SUBCUTANEOUS SUSPENSION (70-30) 100 UNIT/ML NOVOLOG SUBCUTANEOUS SOLUTION 100 UNIT/ML pioglitazone hcl oral tablet 15, 30, 45 QL (30 EA per 30 days) pioglitazone hcl-glimepiride oral tablet 30-2, 30-4 pioglitazone hcl-metformin hcl oral tablet , repaglinide oral tablet 0.5, 1, 2 SYMLINPEN 120 SUBCUTANEOUS SOLUTION PEN-INJECTOR 2700 MCG/2.7ML SYMLINPEN 60 SUBCUTANEOUS SOLUTION PEN-INJECTOR 1500 MCG/1.5ML TANZEUM SUBCUTANEOUS PEN- INJECTOR 30 MG, 50 MG tolazamide oral tablet 250, 500 tolbutamide oral tablet

27 TOUJEO SOLOSTAR SUBCUTANEOUS SOLUTION PEN-INJECTOR 300 UNIT/ML TRESIBA FLEXTOUCH SUBCUTANEOUS SOLUTION PEN-INJECTOR 100 UNIT/ML, 200 UNIT/ML VICTOZA SUBCUTANEOUS SOLUTION PEN-INJECTOR 18 MG/3ML *Antidiarrheal/Probiotic Agents* acidophilus plus pectin oral tablet acidophilus/pectin oral capsule bismuth oral tablet chewable 262 CULTURELLE DIGESTIVE HEALTH ORAL CAPSULE CULTURELLE DIGESTIVE HEALTH ORAL TABLET CHEWABLE pink bismuth maximum strength oral suspension 525 /15ml pink bismuth oral suspension 262 /15ml ra pink bismuth oral tablet 262 ra probiotic digestive care oral capsule *Antidiarrheals* acidophilus plus pectin oral tablet acidophilus/pectin oral capsule bismuth oral tablet chewable 262 CULTURELLE DIGESTIVE HEALTH ORAL CAPSULE CULTURELLE DIGESTIVE HEALTH ORAL TABLET CHEWABLE diphenoxylate-atropine oral liquid /5ml diphenoxylate-atropine oral tablet IMODIUM A-D ORAL TABLET CHEWABLE 2 MG loperamide hcl oral capsule 2 loperamide hcl oral liquid 1 /5ml loperamide hcl oral suspension 1 /7.5ml loperamide hcl oral tablet 2 pink bismuth maximum strength oral suspension 525 /15ml pink bismuth oral suspension 262 /15ml ra pink bismuth oral tablet 262 QL (6 ML per 30 days) 21

28 ra probiotic digestive care oral capsule *Antidotes And Specific Antagonists* acetylcysteine intravenous solution 200 /ml deferoxamine mesylate injection solution reconstituted 2 gm fomepizole intravenous solution 1.5 gm/1.5ml physostigmine salicylate injection solution 1 /ml *Antidotes* acetylcysteine intravenous solution 200 /ml CHEMET ORAL CAPSULE 100 MG deferoxamine mesylate injection solution reconstituted 2 gm EXJADE ORAL TABLET SOLUBLE 125 MG, 250 MG, 500 MG FERRIPROX ORAL TABLET 500 MG fomepizole intravenous solution 1.5 gm/1.5ml JADENU ORAL TABLET 180 MG, 360 MG, 90 MG naloxone hcl injection solution 0.4 /ml QL (2 ML per 90 days) naltrexone hcl oral tablet 50 pentetate calcium trisodium combination solution 200 /ml pentetate zinc trisodium combination solution 200 /ml physostigmine salicylate injection solution 1 /ml VIVITROL INTRAMUSCULAR SUSPENSION RECONSTITUTED 380 MG *Antiemetics* AKYNZEO ORAL CAPSULE MG ANZEMET ORAL TABLET 100 MG, 50 MG aprepitant oral capsule 125, 40, 80 CESAMET ORAL CAPSULE 1 MG dimenhydrinate injection solution 50 /ml dimenhydrinate oral tablet 50 DRAMAMINE ORAL TABLET CHEWABLE 50 MG dronabinol oral capsule 10, 2.5, 5 granisetron hcl oral tablet 1 QL (10 EA per 30 days) 22

29 meclizine hcl oral tablet 12.5, 25 meclizine hcl oral tablet chewable 25 ondansetron hcl oral solution 4 /5ml QL (50 ML per 30 days) ondansetron hcl oral tablet 24 QL (5 EA per 30 days) ondansetron hcl oral tablet 4, 8 QL (15 EA per 30 days) ondansetron oral tablet dispersible 4, 8 QL (10 EA per 30 days) trimethobenzamide hcl oral capsule 300 *Antifungals* CRESEMBA ORAL CAPSULE 186 MG fluconazole oral suspension reconstituted 10 /ml, 40 /ml fluconazole oral tablet 100, 150, 200, 50 flucytosine oral capsule 250, 500 griseofulvin microsize oral suspension 125 /5ml griseofulvin microsize oral tablet 500 griseofulvin ultramicrosize oral tablet 125, 250 itraconazole oral capsule 100 ketoconazole oral tablet 200 nystatin oral tablet unit terbinafine hcl oral tablet 250 voriconazole oral tablet 200, 50 *Antihistamines* aler-dryl oral tablet 50 aller-chlor oral syrup 2 /5ml QL (105 ML per 30 days) QL (30 EA per 30 days) carbinoxamine maleate oral tablet 4 AL (Max 64 Years) cetirizine hcl oral syrup 1 /ml QL (300 ML per 30 days); AL (Max 12 Years) cetirizine hcl oral tablet 10, 5 QL (30 EA per 30 days) chlorphen oral tablet 4 CHLORPHEN SR ORAL TABLET EXTENDED RELEASE 12 MG clemastine fumarate oral syrup 0.67 /5ml AL (Max 64 Years) clemastine fumarate oral tablet 1.34 clemastine fumarate oral tablet 2.68 AL (Max 64 Years) cvs allergy childrens oral tablet chewable 12.5 cyproheptadine hcl oral syrup 2 /5ml AL (Max 64 Years) 23

30 cyproheptadine hcl oral tablet 4 AL (Max 64 Years) diphenhydramine cough oral syrup 12.5 /5ml diphenhydramine hcl injection solution 50 /ml AL (Max 64 Years) diphenhydramine hcl oral capsule 25 diphenhydramine hcl oral capsule 50 AL (Max 64 Years) diphenhydramine hcl oral elixir 12.5 /5ml AL (Max 64 Years) diphenhydramine hcl oral tablet 25 ED CHLORPED ORAL LIQUID 2 MG/ML eql allergy relief childrens oral tablet dispersible 12.5 fexofenadine hcl childrens oral suspension 30 /5ml fexofenadine hcl oral tablet 180 QL (30 EA per 30 days) fexofenadine hcl oral tablet 30, 60 QL (60 EA per 30 days) levocetirizine dihydrochloride oral tablet 5 QL (30 EA per 30 days) loratadine allergy relief oral tablet dispersible 10 loratadine childrens oral solution 5 /5ml QL (30 EA per 30 days) QL (300 ML per 30 days); AL (Max 12 Years) loratadine oral tablet 10 QL (30 EA per 30 days) PHENADOZ RECTAL SUPPOSITORY 12.5 MG, 25 MG PHENERGAN RECTAL SUPPOSITORY 50 MG promethazine hcl injection solution 25 /ml, 50 /ml QL (12 EA per 30 days); AL (Max 64 Years) QL (12 EA per 30 days); AL (Max 64 Years) AL (Max 64 Years) promethazine hcl oral solution 6.25 /5ml AL (Max 64 Years) promethazine hcl oral tablet 12.5, 25, 50 q-dryl oral liquid 12.5 /5ml TRIAMINIC COUGH/RUNNY NOSE ORAL STRIP 12.5 MG *Antihyperlipidemics* atorvastatin calcium oral tablet 10, 20, 40, 80 cholestyramine light oral powder 4 gm/dose colestipol hcl oral granules 5 gm colestipol hcl oral tablet 1 gm AL (Max 64 Years) QL (30 EA per 30 days) ezetimibe oral tablet 10 QL (30 EA per 30 days) ezetimibe-simvastatin oral tablet 10-10, 10-20, 10-40, QL (30 EA per 30 days)

31 fenofibrate micronized oral capsule 134, 200, 43, 67 fenofibrate oral tablet 145, 48 fenofibrate oral tablet 160, 54 fenofibric acid oral capsule delayed release 135, 45 FIBRICOR ORAL TABLET 105 MG, 35 MG fluvastatin sodium oral capsule 20, 40 gemfibrozil oral tablet 600 LIVALO ORAL TABLET 1 MG, 2 MG, 4 MG QL (30 EA per 30 days) lovastatin oral tablet 10, 20, 40 niacin er (antihyperlipidemic) oral tablet extended release 1000, 500, 750 NIACOR ORAL TABLET 500 MG omega-3-acid ethyl esters oral capsule 1 gm QL (120 EA per 30 days) pravastatin sodium oral tablet 10, 20, 40, 80 rosuvastatin calcium oral tablet 10, 20, 40, 5 simvastatin oral tablet 10, 20, 40, 5 QL (30 EA per 30 days) simvastatin oral tablet 80 QL (30 EA per 30 days) WELCHOL ORAL CKET 3.75 GM WELCHOL ORAL TABLET 625 MG *Antihypertensives* amlodipine besy-benazepril hcl oral capsule 10-20, 10-40, , 5-10, 5-20, 5-40 amlodipine besylate-valsartan oral tablet , , 5-160, amlodipine-olmesartan oral tablet 10-20, 10-40, 5-20, 5-40 atenolol-chlorthalidone oral tablet , benazepril hcl oral tablet 10, 20, 40, 5 benazepril-hydrochlorothiazide oral tablet , , 20-25, bisoprolol-hydrochlorothiazide oral tablet , , candesartan cilexetil oral tablet 16, 32 QL (30 EA per 30 days) 25

32 candesartan cilexetil-hctz oral tablet , , captopril oral tablet 100, 12.5, 25, 50 captopril-hydrochlorothiazide oral tablet 25-15, 25-25, 50-15, clonidine hcl oral tablet 0.1, 0.2, 0.3 clonidine hcl transdermal patch weekly 0.1 /24hr, 0.2 /24hr, 0.3 /24hr doxazosin mesylate oral tablet 1, 2, 4, 8 EDARBI ORAL TABLET 40 MG, 80 MG enalapril maleate oral tablet 10, 2.5, 20, 5 enalapril-hydrochlorothiazide oral tablet 10-25, eplerenone oral tablet 25, 50 eprosartan mesylate oral tablet 600 fosinopril sodium oral tablet 10, 20, 40 fosinopril sodium-hctz oral tablet , guanfacine hcl oral tablet 1, 2 hydralazine hcl oral tablet 10, 100, 25, 50 irbesartan oral tablet 150, 300, 75 irbesartan-hydrochlorothiazide oral tablet , lisinopril oral tablet 10, 2.5, 20, 30, 40, 5 lisinopril-hydrochlorothiazide oral tablet , , losartan potassium oral tablet 100, 25, 50 losartan potassium-hctz oral tablet , , methyldopa oral tablet 250, 500 metoprolol-hydrochlorothiazide oral tablet , , minoxidil oral tablet 10, 2.5 moexipril hcl oral tablet 15, 7.5 moexipril-hydrochlorothiazide oral tablet , 15-25, QL (30 EA per 30 days) AL (Max 64 Years) QL (30 EA per 30 days)

33 nadolol-bendroflumethiazide oral tablet 40-5, 80-5 olmesartan medoxomil oral tablet 20, 40, 5 olmesartan medoxomil-hctz oral tablet , , perindopril erbumine oral tablet 2, 4, 8 phenoxybenzamine hcl oral capsule 10 prazosin hcl oral capsule 1, 2, 5 propranolol-hctz oral tablet 40-25, quinapril hcl oral tablet 10, 20, 40, 5 quinapril-hydrochlorothiazide oral tablet , , ramipril oral capsule 1.25, 10, 2.5, 5 reserpine oral tablet 0.1, 0.25 TEKTURNA HCT ORAL TABLET MG, MG, MG, MG TEKTURNA ORAL TABLET 150 MG, 300 MG telmisartan oral tablet 20, 40, 80 telmisartan-hctz oral tablet , , terazosin hcl oral capsule 1, 10, 2, 5 QL (30 EA per 30 days) QL (30 EA per 30 days) AL (Max 64 Years) trandolapril oral tablet 1, 2, 4 QL (30 EA per 30 days) trandolapril-verapamil hcl er oral tablet extended release 1-240, 2-180, 2-240, valsartan oral tablet 160, 320, 40, 80 valsartan-hydrochlorothiazide oral tablet , , , , *Anti-Infective Agents - Misc.* ALINIA ORAL SUSPENSION RECONSTITUTED 100 MG/5ML ALINIA ORAL TABLET 500 MG QL (30 EA per 30 days) atovaquone oral suspension 750 /5ml QL (210 ML per 18 days) clindamycin hcl oral capsule 150, 300, 75 27