2015 CoventryOne Prescription Drug List

Transcription

1 This Prescription Drug List applies to 2015 Individual Health InsuranceMarketplace benefit plans This is not meant to be a complete list of the drugs covered under your plan. Not all dosage forms of the drugs listed below are covered. We periodically review our Prescription Drug List. This is the most current list at the time of printing and is subject to change. Some medications may require prior authorization or have quantity limits. Please call Customer Service at the number on your member ID card with any questions about your coverage or for more information. Specialty Medications Specialty medications are typically high-cost drugs, including but not limited to the oral, topical, inhaled, inserted or implanted, and injected routes of administration used to treat rare and complex diseases. Specialty medications require prior authorization unless otherwise indicated. Your doctor should contact Coventry s Pharmacy Call Center at to request prior authorization. Except in urgent situations, all specialty medications are distributed through a participating specialty pharmacy. Specialty drugs are limited to a 30 day supply at a time or the quantity prescribed in the prescription order, whichever is less. Please call Customer Service at the number on your member ID card for a referral to a participating specialty pharmacy or with questions regarding your pharmacy benefit. Please refer to your health plan documents regarding coverage of and any limitations or exclusions that may apply to your specialty drug benefit. Prior authorization Coventry Health Care has two broad goals for the prescription drug benefit we offer. One is to never compromise the quality or effectiveness of treatment. The second is to provide a comprehensive, affordable pharmacy benefit. One of the tools we use to help control prescription drug costs is to require prior approval, or authorization, before we will cover the cost of certain medications. These medications include those that (1) are not suggested for first-line therapy, (2) may require special tests before starting them or (3) have very limited approval for use. Step Therapy is an automated form of Prior Authorization based on past drug treatment. Drugs designated as stepped therapy will require prior authorization if the condition is not met when the pharmacist would attempt to transmit a prescription claim. Only your physician can provide the information necessary to complete the prior authorization process. If you have been prescribed a drug that requires prior authorization, make sure your doctor knows that this medicationrequires prior authorization. Your doctor should contact Coventry s Pharmacy Call Center at

2 This Formulary Applies to 2015 Individual Health Insurance Marketplace benefit plans Table of Contents Analgesic, Anti-Inflammatory Or Antipyretic... 3 Anesthetics... 8 Anorectal Preparations... 8 Antidotes And Other Reversal Agents... 8 Anti-Infective Agents... 9 Antineoplastics Antiseptics & Disinfectants Biologicals Cardiovascular Therapy Agents Central Nervous System Agents Chemical Dependency, Agents To Treat Chemicals-Pharmaceutical Adjuvants Cognitive Disorder Therapy Contraceptives Dermatological Diagnostic Agents Drugs To Treat Erectile Dysfunction Eating Disorder Therapy Electrolyte Balance-Nutritional Products Endocrine Gastrointestinal Therapy Agents Genitourinary Therapy Gout And Hyperuricemia Therapy Hematological Agents Immunosuppressive Agents Locomotor System Medical Supplies And Durable Medical Equipment (Dme) Medical Supply, Fdb Superset Metabolic Disease Enzyme Replacement Agents Metabolic Modifiers Mouth-Throat-Dental - Preparations Multiple Sclerosis Agents Ophthalmic Agents Otic Respiratory Therapy Agents Vaginal Products

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4 This Formulary Applies to 2015 Individual Health Insurance Marketplace benefit plans lowercase = Generic drugs UPPERCASE = Brand name drugs Tier = = = Copay Exception: Available to some members at no cost with a prescription from your provider when obtained at an in-network pharmacy LA = Limited Acces - Coverage varies by benefit N/A = = Tier 2 = Tier 2 = Tier 4 = Specialty Notes AL = Age Limit PA = Prior Authorization Applies QL = Quantity Limit Applies ST = Step Therapy Applies Medication Name Tier Notes Analgesic, Anti-Inflammatory Or Antipyretic acetaminophen-codeine oral solution 120 mg-12 mg /5 ml (5 ml), mg/5 ml, 240 mg-24 mg /10 ml (10 ml), 300 mg-30 mg /12.5 ml acetaminophen-codeine oral tablet ADULT LOW DOSE ASPIRIN ARCALYST Tier 4 PA ASCOMP WITH CODEINE ASPIR-81 ASPIR-LOW ASPIR-TRIN aspirin oral tablet 325 mg aspirin oral tablet,chewable aspirin oral tablet,delayed release (dr/ec) 325 mg, 500 mg, 81 mg ASPIRIN CHILDRENS ASPIRIN LOW DOSE ASPIRIN LOW-STRENGTH AZASAN Tier 2 3

5 azathioprine BAYER ADVAND BAYER ASPIRIN BAYER CHEWABLE ASPIRIN BAYER CHILDRENS ASPIRIN BENLYSTA Tier 4 PA BUTALBITAL COMPOUND W/CODEINE BUTALBITAL COMPOUND-CODEINE butalbital-acetaminop-caf-cod oral capsule mg butalbital-acetaminophen butalbital-acetaminophen-caff oral capsule mg butalbital-acetaminophen-caff oral tablet mg butalbital-aspirin-caffeine oral capsule butorphanol tartrate nasal QL BUTRANS TRANSDERMAL PATCH WEEKLY 10 MCG/HOUR, 20 MCG/HOUR, 5 MCG/HOUR CAPAT PA; QL LEBREX ST; QL LLPT ORAL SUSPENSION FOR RECONSTITUTION CHILD ASPIRIN CHILDREN'S ASPIRIN Tier 4 choline,magnesium salicylate oral liquid CIMZIA Tier 4 PA; QL CIMZIA POWDER FOR RECONST Tier 4 PA; QL CIMZIA STARTER KIT Tier 4 PA; QL codeine sulfate oral tablet codeine-butalbital-asa-caff CUPRIMINE cyclophosphamide oral capsule Tier 4 cyclophosphamide oral tablet Tier 4 cyclosporine oral capsule Tier 4 cyclosporine modified oral capsule Tier 4 cyclosporine modified oral solution Tier 4 diclofenac potassium diclofenac sodium oral tablet extended release 24 hr diclofenac sodium oral tablet,delayed release (dr/ec) diclofenac-misoprostol 4

6 diflunisal DISKETS E.C. PRIN ECOTRIN ECOTRIN LOW STRENGTH ENBREL SUBCUTANEOUS KIT Tier 4 PA; QL ENBREL SUBCUTANEOUS SYRINGE 25 MG/0.5ML (0.51), 50 MG/ML (0.98 ML) Tier 4 PA; QL ENBREL SURECLICK Tier 4 PA; QL ENDOT ORAL TABLET MG, MG, MG ENDODAN ENTERIC COATED ASPIRIN etodolac EXTRA STRENGTH BAYER fenoprofen oral tablet fentanyl QL fentanyl citrate PA; QL flurbiprofen GENGRAF ORAL CAPSULE Tier 4 GENGRAF ORAL SOLUTION Tier 4 HUMIRA SUBCUTANEOUS SYRINGE KIT 20 MG/0.4 ML, 40 MG/0.8 ML Tier 4 PA; QL HUMIRA CROHN'S DIS START PCK Tier 4 PA; QL HUMIRA PEN Tier 4 PA; QL HUMIRA PSORIASIS STARTER PACK Tier 4 PA; QL hydrocodone-acetaminophen oral solution mg/5 ml, mg/15 ml hydrocodone-acetaminophen oral tablet mg, mg, mg, mg, mg, mg, mg hydrocodone-ibuprofen hydromorphone oral tablet hydromorphone oral tablet extended release 24 hr QL hydromorphone rectal hydroxychloroquine oral ibuprofen oral tablet 400 mg, 600 mg, 800 mg ibuprofen-oxycodone QL ILARIS (PF) Tier 4 PA INDOCIN ORAL INDOCIN RECTAL indomethacin oral 5

7 KADIAN ORAL CAPSULE,EXTEND.RELEASE PELLETS 200 MG, 40 MG ketoprofen oral capsule ketorolac oral QL PA; QL KINERET Tier 4 PA; QL leflunomide QL levorphanol tartrate LITE COAT ASPIRIN LO-DOSE ASPIRIN MARGESIC MARTEN-TAB meclofenamate oral mefenamic acid meloxicam meperidine oral tablet MEPERITAB ORAL TABLET 100 MG methadone oral concentrate methadone oral solution methadone oral tablet methadone oral tablet,soluble METHADONE INTENSOL METHADOSE ORAL CONNTRATE METHADOSE ORAL TABLET,SOLUBLE methotrexate sodium oral minocycline oral capsule morphine oral capsule, er multiphase 24 hr 120 mg, 30 mg, 45 mg, 60 mg, 90 mg PA; QL morphine oral capsule, er multiphase 24 hr 75 mg Tier 4 PA; QL morphine oral capsule,extend.release pellets 10 mg QL morphine oral capsule,extend.release pellets 100 mg, 20 mg, 30 mg, 50 mg, 60 mg, 80 mg morphine oral solution morphine oral tablet morphine oral tablet extended release 100 mg, 15 mg, 200 mg morphine oral tablet extended release 30 mg, 60 mg morphine rectal morphine concentrate oral solution mycophenolate mofetil Tier 4 nabumetone nalbuphine injection Tier 4 6 PA; QL QL

8 NALFON ORAL CAPSULE 400 MG naproxen oral suspension naproxen oral tablet naproxen oral tablet,delayed release (dr/ec) naproxen sodium oral tablet 275 mg, 550 mg NUCYNTA PA; QL NUCYNTA ER PA; QL OPANA ER ORAL TABLET,ORAL ONLY,EXT.REL.12 HR 10 MG, 15 MG, 20 MG, 30 MG, 40 MG, 5 MG, 7.5 MG PA; QL ORENCIA Tier 4 PA; QL oxaprozin oxycodone oral capsule oxycodone oral concentrate oxycodone oral solution oxycodone oral tablet oxycodone-acetaminophen oral tablet mg, mg, mg oxycodone-acetaminophen oral tablet mg oxycodone-aspirin OXYCONTIN PA; QL oxymorphone oral tablet PA oxymorphone oral tablet extended release 12 hr 10 mg, 20 mg, 30 mg, 40 mg, 5 mg oxymorphone oral tablet extended release 12 hr 15 mg, 7.5 mg pentazocine-naloxone piroxicam REMICADE Tier 4 PA REPREXAIN RHEUMATREX RIDAURA RITUXAN Tier 4 PA ROXIT ORAL TABLET salsalate SIMPONI SUBCUTANEOUS PEN INJECTOR 100 MG/ML, 50 MG/0.5 ML SIMPONI SUBCUTANEOUS SYRINGE 100 MG/ML, 50 MG/0.5 ML ST. JOSEPH ASPIRIN Tier 4 Tier 4 sulfasalazine QL SULFAZINE QL PA; QL QL PA; QL PA; QL 7

9 SULFAZINE EC QL sulindac oral TALWIN tolmetin tramadol oral tablet tramadol oral tablet extended release 24 hr ST; QL tramadol oral tablet, er multiphase 24 hr ST; QL tramadol-acetaminophen QL TREXALL VICODIN ORAL TABLET MG VICODIN ES ORAL TABLET MG VICODIN HP ORAL TABLET MG XELJANZ Tier 4 PA; QL Anesthetics lidocaine topical ointment lidocaine hcl laryngotracheal LTA PRE-ATTACHED Anorectal Preparations ANALPRAM ADVAND ANUCORT-HC hydrocortisone rectal cream hydrocortisone acetate rectal suppository hydrocortisone-pramox-e-pram#1 hydrocortisone-pramoxine rectal lidocaine hcl-hydrocortison ac rectal cream % lidocaine hcl-hydrocortison ac rectal kit lidocaine-hydrocortisone-aloe PRAMCORT PROCORT PROCTO-PAK PROCTOFOAM HC PROCTOSOL HC PROCTOZONE-HC RECTACORT-HC RECTIV QL Antidotes And Other Reversal Agents acetylcysteine solution CHEMET CUPRIMINE DEPADE 8

10 ENTEREG EXJADE Tier 4 PA FERRIPROX Tier 4 PA GALZIN naltrexone oral RELISTOR PA SYPRINE Anti-Infective Agents abacavir Tier 4 abacavir-lamivudine-zidovudine Tier 4 ACTIMMUNE Tier 4 PA acyclovir oral acyclovir sodium Tier 4 adefovir Tier 4 QL ALBENZA ALINIA ORAL SUSPENSION FOR RECONSTITUTION ALINIA ORAL TABLET QL amikacin injection solution 1,000 mg/4 ml, 500 mg/2 ml Tier 4 amoxicillin oral capsule 250 mg, 500 mg amoxicillin oral suspension for reconstitution amoxicillin oral tablet amoxicillin oral tablet,chewable 125 mg, 250 mg, 400 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 amphotericin b Tier 4 ampicillin ampicillin sodium Tier 4 ampicillin-sulbactam Tier 4 APTIVUS Tier 4 atovaquone QL atovaquone-proguanil PA; QL ATRIPLA Tier 4 QL azithromycin oral packet azithromycin oral suspension for reconstitution QL QL QL 9

11 azithromycin oral tablet 250 mg, 500 mg, 600 mg QL BACIIM Tier 4 bacitracin intramuscular Tier 4 BARACLUDE ORAL SOLUTION Tier 4 BARACLUDE ORAL TABLET Tier 4 QL BICILLIN C-R Tier 4 BICILLIN L-A Tier 4 BILTRICIDE CANCIDAS Tier 4 CAPASTAT Tier 4 CAYSTON Tier 4 PA; QL DAX ORAL SUSPENSION FOR RECONSTITUTION 90 MG/5 ML cefaclor oral capsule cefaclor oral suspension for reconstitution 125 mg/5 ml, 250 mg/5 ml, 375 mg/5 ml cefaclor oral tablet extended release 12 hr QL cefadroxil oral capsule cefadroxil oral suspension for reconstitution 250 mg/5 ml, 500 mg/5 ml cefadroxil oral tablet cefazolin injection recon soln 1 gram, 10 gram, 20 gram, 500 mg Tier 4 cefazolin in 0.9% sod chloride Tier 4 cefazolin in dextrose 5 % Tier 4 cefazolin in sterile water Tier 4 cefdinir cefditoren pivoxil cefepime Tier 4 cefotaxime Tier 4 cefotetan Tier 4 cefoxitin Tier 4 cefpodoxime cefprozil ceftazidime injection recon soln 1 gram, 2 gram, 6 gram Tier 4 ceftibuten ceftriaxone injection recon soln 1 gram, 10 gram, 2 gram, 250 mg, 500 mg Tier 4 ceftriaxone intravenous recon soln Tier 4 cefuroxime axetil oral suspension for reconstitution 125 mg/5 ml 10

12 cefuroxime axetil oral tablet cefuroxime sodium injection recon soln 1.5 gram, 750 mg Tier 4 cephalexin oral capsule 250 mg, 500 mg cephalexin oral suspension for reconstitution cephalexin oral tablet chloramphenicol sod succinate Tier 4 chloroquine phosphate oral cidofovir Tier 4 ciprofloxacin oral suspension,microcapsule recon ciprofloxacin oral tablet CLAFORAN INJECTION Tier 4 CLAFORAN INTRAVENOUS RECON SOLN Tier 4 clarithromycin oral suspension for reconstitution QL clarithromycin oral tablet clarithromycin oral tablet extended release 24 hr QL CLEOCIN INJECTION Tier 4 clindamycin hcl clindamycin palmitate hcl CLINDAMYCIN PEDIATRIC clindamycin phosphate injection Tier 4 COARTEM PA; QL colistin (colistimethate na) Tier 4 COLY-MYCIN M PARENTERAL Tier 4 COMPLERA Tier 4 QL CRIXIVAN ORAL CAPSULE 200 MG, 400 MG Tier 4 CUBICIN Tier 4 cycloserine CYTOVENE Tier 4 dapsone DARAPRIM demeclocycline oral dicloxacillin didanosine Tier 4 DIFICID PA; QL DORIBAX Tier 4 doxycycline hyclate oral capsule doxycycline hyclate oral tablet 100 mg doxycycline monohydrate oral capsule 100 mg, 50 mg E.E.S

13 E.E.S. 400 ORAL TABLET E.E.S. GRANULES EDURANT Tier 4 QL EMTRIVA ORAL CAPSULE Tier 4 QL EMTRIVA ORAL SOLUTION Tier 4 EPIVIR ORAL SOLUTION Tier 4 EPIVIR HBV ORAL SOLUTION Tier 4 EPZICOM Tier 4 PA ERAXIS(WATER DILUENT) Tier 4 ERY-TAB ORAL TABLET,DELAYED RELEASE (DR/EC) 250 MG, 333 MG, 500 MG ERYPED 200 ERYPED 400 ERYTHROCIN (AS STEARATE) ORAL TABLET 250 MG erythromycin oral capsule,delayed release(dr/ec) erythromycin oral tablet erythromycin ethylsuccinate oral suspension for reconstitution erythromycin ethylsuccinate oral tablet erythromycin stearate oral tablet 250 mg ethambutol FACTIVE QL famciclovir QL FIRST-BXN FIRST-DUKE'S FIRST-MARY'S MOUTHWASH FLAGYL ER fluconazole oral suspension for reconstitution fluconazole oral tablet 100 mg, 200 mg, 50 mg fluconazole oral tablet 150 mg QL flucytosine FORTAZ INJECTION RECON SOLN 1 GRAM, 2 GRAM Tier 4 FORTAZ INTRAVENOUS Tier 4 foscarnet Tier 4 FOSCAVIR Tier 4 FUZEON SUBCUTANEOUS RECON SOLN Tier 4 ganciclovir sodium Tier 4 gentamicin injection Tier 4 gentamicin sulfate (ped) (pf) Tier 4 12

14 griseofulvin microsize griseofulvin ultramicrosize hydroxychloroquine oral imipenem-cilastatin Tier 4 INCIVEK Tier 4 PA; QL INTELEN ORAL TABLET 100 MG, 200 MG, 25 MG Tier 4 INVANZ Tier 4 INVIRASE Tier 4 ISENTRESS ORAL POWDER IN PACKET Tier 4 ISENTRESS ORAL TABLET Tier 4 QL ISENTRESS ORAL TABLET,CHEWABLE Tier 4 QL isoniazid oral itraconazole PA; QL KALETRA Tier 4 KETEK ketoconazole oral QL LAMISIL ORAL GRANULES IN PACKET 125 MG, MG lamivudine oral tablet 100 mg, 150 mg, 300 mg Tier 4 lamivudine-zidovudine Tier 4 PA levofloxacin oral tablet QL LEXIVA Tier 4 LINCOCIN Tier 4 MAXIPIME Tier 4 mefloquine QL meropenem Tier 4 MERREM Tier 4 metronidazole oral capsule metronidazole oral tablet minocycline oral capsule MORGIDOX moxifloxacin QL MYCAMINE Tier 4 nafcillin Tier 4 nebupent Tier 4 neomycin nevirapine oral suspension Tier 4 nevirapine oral tablet Tier 4 nevirapine oral tablet extended release 24 hr Tier 4 PA; QL NOROXIN QL QL QL 13

15 NORVIR Tier 4 NORVIR SOFT GELATIN Tier 4 NOXAFIL ORAL SUSPENSION PA; QL nystatin oral powder nystatin oral tablet ofloxacin oral tablet 400 mg QL ORAVIG PA; QL oxacillin injection Tier 4 paromomycin PASER P PEGASYS Tier 4 PA PEGASYS PROCLICK Tier 4 PA PEGINTRON Tier 4 PA PEGINTRON REDIPEN Tier 4 PA penicillin g potassium Tier 4 penicillin v potassium PENTAM Tier 4 PFIZERPEN-G Tier 4 piperacillin-tazobactam intravenous recon soln 40.5 gram Tier 4 polymyxin b sulfate Tier 4 PREZISTA ORAL SUSPENSION Tier 4 PREZISTA ORAL TABLET 150 MG, 400 MG, 600 MG, 75 MG, 800 MG Tier 4 PRIFTIN primaquine PRIMAXIN IV Tier 4 PRIMSOL pyrazinamide quinine sulfate PA; QL RELENZA DISKHALER QL RESCRIPTOR Tier 4 REYATAZ ORAL CAPSULE 150 MG, 200 MG, 300 MG Tier 4 RIBASPHERE ORAL CAPSULE Tier 4 PA RIBASPHERE ORAL TABLET 200 MG, 400 MG, 600 MG Tier 4 ribavirin oral capsule Tier 4 PA ribavirin oral tablet 200 mg Tier 4 PA rifabutin 14 QL QL PA

16 rifampin oral RIFATER rimantadine ROPHIN INJECTION RECON SOLN 1 GRAM Tier 4 SELZENTRY Tier 4 QL SPORANOX ORAL SOLUTION PA stavudine Tier 4 streptomycin intramuscular Tier 4 STRIBILD Tier 4 PA; QL STROMECTOL sulfadiazine oral sulfamethoxazole-trimethoprim oral tablet SUPRAX ORAL SUSPENSION FOR RECONSTITUTION 100 MG/5 ML, 200 MG/5 ML SUPRAX ORAL TABLET,CHEWABLE QL SUSTIVA Tier 4 SYNERCID Tier 4 TAMIFLU ORAL CAPSULE QL TAMIFLU ORAL SUSPENSION FOR RECONSTITUTION 6 MG/ML TAZIF INJECTION Tier 4 TEFLARO Tier 4 terbinafine hcl oral tetracycline THALOMID Tier 4 PA TIMENTIN INTRAVENOUS RECON SOLN Tier 4 tinidazole oral tablet 250 mg, 500 mg QL tobramycin in % nacl Tier 4 PA tobramycin sulfate Tier 4 TRECATOR trimethoprim TRUVADA Tier 4 PA TYGACIL Tier 4 TYZEKA Tier 4 QL UNASYN INJECTION Tier 4 valacyclovir oral tablet 1 gram, 500 mg QL VALCYTE ORAL RECON SOLN PA VALCYTE ORAL TABLET PA vancomycin intravenous recon soln 10 gram, 5 gram Tier 4 vancomycin oral capsule 125 mg QL vancomycin oral capsule 250 mg ST; QL QL 15

17 vancomycin in 0.9% sodium cl intravenous solution 1 gram/150 ml, 1 gram/250 ml, 1.25 gram/150 ml, 1.25 gram/250 ml, 1.5 gram/150 ml, 1.5 gram/250 ml, 1.75 gram/500 ml, 2 gram/250 ml, 2 gram/500 ml, 750 mg/150 ml Tier 4 vancomycin in d5w intravenous solution Tier 4 VIBRAMYCIN ORAL SYRUP VICTRELIS Tier 4 PA; QL VIDEX 2 GRAM PEDIATRIC Tier 4 VIDEX 4 GRAM PEDIATRIC Tier 4 VIRAPT ORAL TABLET Tier 4 VIRAMUNE XR ORAL TABLET EXTENDED RELEASE 24 HR 100 MG Tier 4 VIREAD ORAL POWDER Tier 4 VIREAD ORAL TABLET Tier 4 QL VISTIDE Tier 4 voriconazole oral tablet PA XIFAXAN ORAL TABLET 200 MG QL XIFAXAN ORAL TABLET 550 MG PA; QL ZIAGEN ORAL SOLUTION Tier 4 zidovudine Tier 4 ZINAF INJECTION Tier 4 ZMAX QL ZOSYN Tier 4 ZYVOX ORAL SUSPENSION FOR RECONSTITUTION PA PA; QL ZYVOX ORAL TABLET PA; QL Antineoplastics AFINITOR Tier 4 PA; QL ALIMTA Tier 4 PA ALKERAN INTRAVENOUS Tier 4 ALKERAN ORAL Tier 4 amifostine crystalline Tier 4 anastrozole PA ARRANON Tier 4 ARZERRA Tier 4 PA azacitidine Tier 4 bicalutamide QL bleomycin Tier 4 BOSULIF Tier 4 PA; QL BUSULFEX Tier 4 CAMPTOSAR Tier 4 16

18 capecitabine Tier 4 PA CAPRELSA ORAL TABLET 100 MG, 300 MG Tier 4 PA; QL carboplatin Tier 4 cisplatin Tier 4 COMETRIQ Tier 4 PA; QL COSMEGEN Tier 4 cromolyn oral cyclophosphamide oral capsule Tier 4 cyclophosphamide oral tablet Tier 4 cytarabine Tier 4 cytarabine (pf) injection solution Tier 4 DACOGEN Tier 4 PA daunorubicin Tier 4 decitabine Tier 4 PA dexrazoxane hcl Tier 4 DOFREZ Tier 4 docetaxel Tier 4 DOXIL Tier 4 doxorubicin Tier 4 doxorubicin, peg-liposomal Tier 4 ELLEN Tier 4 ELOXATIN INTRAVENOUS SOLUTION 100 MG/20 ML, 50 MG/10 ML (5 MG/ML) Tier 4 ELSPAR Tier 4 EMCYT epirubicin Tier 4 ERIVEDGE Tier 4 PA; QL etoposide intravenous Tier 4 etoposide oral Tier 4 exemestane PA; QL FARESTON fludarabine Tier 4 flutamide GLEEVEC Tier 4 PA HALAVEN Tier 4 PA HEXALEN Tier 4 HYCAMTIN INTRAVENOUS Tier 4 HYCAMTIN ORAL Tier 4 PA hydroxyurea ICLUSIG ORAL TABLET 15 MG Tier 4 PA 17

19 ICLUSIG ORAL TABLET 45 MG Tier 4 PA; QL IDAMYCIN PFS Tier 4 idarubicin Tier 4 INLYTA Tier 4 PA; QL INTRON A INJECTION Tier 4 PA irinotecan Tier 4 ISTODAX Tier 4 PA JAKAFI Tier 4 PA; QL JEVTANA Tier 4 PA letrozole PA leucovorin calcium oral LEUKERAN Tier 4 leuprolide Tier 4 PA; QL LIPODOX Tier 4 LIPODOX 50 Tier 4 lomustine Tier 4 LYSODREN MATULANE Tier 4 megestrol oral tablet melphalan Tier 4 mercaptopurine mesna Tier 4 MESNEX Tier 4 methotrexate sodium methotrexate sodium (pf) injection solution mitomycin Tier 4 MYLERAN Tier 4 NAVELBINE Tier 4 NEXAVAR Tier 4 PA; QL NILANDRON oxaliplatin Tier 4 paclitaxel Tier 4 POMALYST Tier 4 PA; QL PROLEUKIN Tier 4 PA REVLIMID ORAL CAPSULE 10 MG, 15 MG, 2.5 MG, 25 MG, 5 MG Tier 4 REVLIMID ORAL CAPSULE 20 MG Tier 4 PA RITUXAN Tier 4 PA SPRYL ORAL TABLET 100 MG, 140 MG, 20 MG, 50 MG, 70 MG, 80 MG Tier 4 PA; QL PA; QL STIVARGA Tier 4 PA; QL 18

20 SUTENT ORAL CAPSULE 12.5 MG, 25 MG, 37.5 MG, 50 MG Tier 4 SYLATRON Tier 4 PA SYLATRON 4-PACK SUBCUTANEOUS KIT 296 MCG, 444 MCG Tier 4 SYNRIBO Tier 4 PA TABLOID tamoxifen PA; QL TARVA Tier 4 PA; QL TARGRETIN ORAL Tier 4 PA TASIGNA Tier 4 PA; QL TAXOTERE INTRAVENOUS SOLUTION 20 MG/ML (1 ML), 80 MG/4 ML (20 MG/ML) Tier 4 temozolomide Tier 4 PA THALOMID Tier 4 PA thioguanine (bulk) TOPOSAR Tier 4 topotecan Tier 4 TORISEL Tier 4 PA TOTECT Tier 4 tretinoin (chemotherapy) Tier 4 TREXALL TRISENOX Tier 4 TYKERB Tier 4 PA VECTIBIX Tier 4 PA VELCADE Tier 4 PA VIDAZA Tier 4 VINCASAR PFS INTRAVENOUS SOLUTION 2 MG/2 ML Tier 4 vincristine Tier 4 vinorelbine Tier 4 VORAXAZE Tier 4 VOTRIENT Tier 4 PA; QL XALKORI Tier 4 PA; QL XTANDI Tier 4 PA; QL YERVOY Tier 4 PA ZANOSAR Tier 4 ZELBORAF Tier 4 PA; QL ZINECARD Tier 4 ZOLINZA Tier 4 PA; QL ZYTIGA Tier 4 PA; QL PA 19

21 Antiseptics & Disinfectants FORMA-RAY FORMADON formaldehyde IODOFLEX IODOSORB Biologicals AFLURIA Tier 2 AFLURIA (PF) Tier 2 ATGAM Tier 4 BIVIGAM Tier 4 PA CARIMUNE NF NANOFILTERED INTRAVENOUS RECON SOLN 12 GRAM, 6 GRAM RVARIX VACCINE (PF) INTRAMUSCULAR SYRINGE CYTOGAM INTRAVENOUS SOLUTION 50 MG/ML FLEBOGAMMA DIF INTRAVENOUS SOLUTION 10 % FLEBOGAMMA DIF INTRAVENOUS SOLUTION 5 % Tier 4 Tier 2 Tier 4 Tier 4 Tier 4 FLULAVAL Tier 2 FLULAVAL QUAD Tier 2 FLUVIRIN Tier 2 FLUVIRIN (PF) Tier 2 FLUZONE Tier 2 FLUZONE (PF) Tier 2 FLUZONE HIGH-DOSE (PF) Tier 2 FLUZONE INTRADERM (PF) Tier 2 FLUZONE QUAD Tier 2 FLUZONE QUAD (PF) Tier 2 FLUZONE QUAD PEDI (PF) Tier 2 GAMMAGARD LIQUID Tier 4 PA GAMMAKED Tier 4 PA GAMMAPLEX Tier 4 PA GAMUNEX-C INJECTION SOLUTION 1 GRAM/10 ML (10 %), 10 GRAM/100 ML (10 %), 2.5 GRAM/25 ML (10 %), 5 GRAM/50 ML (10 %) GAMUNEX-C INJECTION SOLUTION 20 GRAM/200 ML (10 %) Tier 4 Tier 4 GARDASIL (PF) Tier 2 HEPAGAM B Tier 4 20 PA PA PA

22 HIZENTRA SUBCUTANEOUS SOLUTION 1 GRAM/5 ML (20 %), 10 GRAM/50 ML (20 %), 2 GRAM/10 ML (20 %), 4 GRAM/20 ML (20 %) Tier 4 HYPERHEP B S-D NEONATAL Tier 4 HYPERHEP B S/D Tier 4 HYPERRAB S/D (PF) Tier 4 HYPERRHO S/D INTRAMUSCULAR SYRINGE 1,500 UNIT (300 MCG), 250 UNIT (50 MCG) Tier 4 HYPERTET S/D (PF) Tier 4 IMOGAM RABIES-HT (PF) Tier 4 NABI-HB Tier 4 OCTAGAM INTRAVENOUS SOLUTION 5 % Tier 4 PA PNEUMOVAX 23 INJECTION INJECTABLE Tier 2 PNEUMOVAX 23 INJECTION SYRINGE Tier 2 PRIVIGEN Tier 4 PA RHOGAM ULTRA-FILTERED PLUS Tier 4 RHOPHYLAC Tier 4 SYNAGIS Tier 4 PA THYMOGLOBULIN Tier 4 WINRHO SDF Tier 4 ZOSTAVAX (PF) Tier 2 Cardiovascular Therapy Agents acebutolol oral acetazolamide oral ADCIRCA Tier 4 PA; QL ADVICOR ORAL TABLET, ER MULTIPHASE 24 HR 1, MG, 1, MG, MG, MG AFEDITAB CR ORAL TABLET EXTENDED RELEASE 30 MG, 60 MG ALDACTAZIDE ORAL TABLET MG ALTOPREV QL amiloride oral amiloride-hydrochlorothiazide amiodarone oral amlodipine amlodipine-benazepril QL ammonium chloride PA ST; QL AMTURNIDE PA; QL atenolol atenolol-chlorthalidone atorvastatin QL QL 21

23 ATROPEN INTRAMUSCULAR PEN INJECTOR 0.5 MG/0.7 ML, 1 MG/0.7 ML, 2 MG/0.7 ML AUVI-Q Tier 2 QL AZOR PA; QL benazepril benazepril-hydrochlorothiazide BENICAR PA; QL BENICAR HCT PA; QL betaxolol oral BIDIL bisoprolol fumarate bisoprolol-hydrochlorothiazide bumetanide oral BYSTOLIC ORAL TABLET 10 MG, 2.5 MG, 20 MG, 5 MG candesartan PA; QL candesartan-hydrochlorothiazid PA; QL captopril captopril-hydrochlorothiazide CARDENE SR ORAL CAPSULE, EXTENDED RELEASE 30 MG CARDURA XL ORAL TABLET EXTENDED RELEASE 24HR 4 MG CARDURA XL ORAL TABLET EXTENDED RELEASE 24HR 8 MG CARTIA XT ORAL CAPSULE,EXTENDED RELEASE 24HR 120 MG, 240 MG, 300 MG CARTIA XT ORAL CAPSULE,EXTENDED RELEASE 24HR 180 MG carvedilol chlorothiazide chlorthalidone oral tablet 25 mg, 50 mg cholestyramine (with sugar) CHOLESTYRAMINE LIGHT clonidine QL clonidine hcl oral tablet CLORPRES colestipol COREG CR ST; QL CRESTOR ST; QL DEMSER DIBENZYLINE 22 QL QL QL

24 digoxin oral solution digoxin oral tablet DILATRATE-SR DILT-XR diltiazem hcl oral capsule, extended release 120 mg, 180 mg, 240 mg, 300 mg, 360 mg, 420 mg diltiazem hcl oral capsule,ext release degradable diltiazem hcl oral capsule,extended release 12 hr diltiazem hcl oral capsule,extended release 24hr 120 mg, 240 mg, 300 mg, 360 mg diltiazem hcl oral capsule,extended release 24hr 180 mg diltiazem hcl oral tablet diltiazem hcl oral tablet extended release 24 hr 180 mg diltiazem hcl oral tablet extended release 24 hr 240 mg, 300 mg, 360 mg, 420 mg disopyramide phosphate oral capsule DIURIL doxazosin DUTOPROL DYRENIUM EDARBI PA; QL EDARBYCLOR PA; QL EDECRIN enalapril maleate enalapril-hydrochlorothiazide eplerenone oral tablet 25 mg, 50 mg QL epoprostenol (glycine) Tier 4 PA eprosartan PA; QL EXFORGE PA; QL EXFORGE HCT PA; QL felodipine QL fenofibrate oral tablet QL fenofibrate micronized oral capsule 130 mg, 43 mg fenofibrate micronized oral capsule 134 mg, 200 mg, 67 mg fenofibrate nanocrystallized QL fenofibric acid oral tablet 105 mg QL fenofibric acid oral tablet 35 mg FENOGLIDE QL FIRAZYR Tier 4 PA; QL QL QL QL 23

25 flecainide FLOLAN Tier 4 PA fluvastatin ST; QL fosinopril fosinopril-hydrochlorothiazide furosemide oral solution 40 mg/4 ml, 40 mg/5 ml furosemide oral tablet gemfibrozil oral guanfacine hydralazine oral hydrochlorothiazide indapamide irbesartan QL irbesartan-hydrochlorothiazide QL ISORDIL isosorbide dinitrate oral isosorbide mononitrate isoxsuprine oral tablet 10 mg isradipine JUXTAPID ORAL CAPSULE 10 MG, 20 MG, 5 MG Tier 4 PA; QL labetalol oral LESCOL XL ST; QL LETAIRIS Tier 4 PA LEVATOL LIPOFEN QL lisinopril lisinopril-hydrochlorothiazide LIVALO ST; QL losartan losartan-hydrochlorothiazide lovastatin QL MATZIM LA ORAL TABLET EXTENDED RELEASE 24 HR 180 MG MATZIM LA ORAL TABLET EXTENDED RELEASE 24 HR 240 MG, 300 MG, 360 MG, 420 MG methazolamide oral methyclothiazide methyldopa methyldopa-hydrochlorothiazide metolazone 24 QL

26 metoprolol succinate oral tablet extended release 24 hr 100 mg, 200 mg, 25 mg, 50 mg metoprolol ta-hydrochlorothiaz metoprolol tartrate oral mexiletine midodrine minoxidil oral moexipril moexipril-hydrochlorothiazide MULTAQ QL nadolol nadolol-bendroflumethiazide niacin oral tablet extended release 24 hr nicardipine oral NIFEDICAL XL ORAL TABLET EXTENDED RELEASE 24HR 30 MG, 60 MG nifedipine oral capsule nifedipine oral tablet extended release 30 mg, 60 mg, 90 mg nifedipine oral tablet extended release 24hr 30 mg, 60 mg, 90 mg nimodipine nisoldipine oral tablet extended release 24 hr 17 mg, 20 mg, 25.5 mg, 30 mg, 34 mg, 40 mg, 8.5 mg NITRO-BID NITRO-DUR TRANSDERMAL PATCH 24 HOUR 0.3 MG/HR, 0.8 MG/HR NITRO-TIME nitroglycerin oral nitroglycerin transdermal patch 24 hour nitroglycerin translingual aerosol,spray nitroglycerin translingual spray,non-aerosol QL NITROSTAT norepinephrine bitartrate NORPA CR omega-3 acid ethyl esters PA; QL PARONE ORAL TABLET 100 MG, 200 MG, 400 MG perindopril erbumine oral tablet 2 mg, 4 mg, 8 mg QL pindolol pravastatin QL prazosin oral QL QL QL QL QL 25

27 PREVALITE procainamide injection propafenone oral capsule,extended release 12 hr QL propafenone oral tablet propranolol oral capsule,extended release 24 hr propranolol oral solution propranolol oral tablet propranolol-hydrochlorothiazid quinapril quinapril-hydrochlorothiazide quinidine gluconate oral quinidine sulfate ramipril RANEXA QL REMODULIN Tier 4 PA reserpine SAMSCA ORAL TABLET 15 MG, 30 MG Tier 4 PA; QL sildenafil Tier 4 PA; QL SIMCOR ORAL TABLET, ER MULTIPHASE 24 HR 1, MG, 1, MG, MG, MG, MG simvastatin oral tablet 10 mg, 20 mg, 40 mg, 5 mg, 80 mg SORINE sotalol oral SOTALOL AF spironolacton-hydrochlorothiaz spironolactone TAZTIA XT ORAL CAPSULE, EXTENDED RELEASE 120 MG, 180 MG, 240 MG, 300 MG, 360 MG ST; QL TEKAMLO PA; QL TEKTURNA PA; QL TEKTURNA HCT PA; QL telmisartan QL telmisartan-amlodipine PA; QL telmisartan-hydrochlorothiazid terazosin TEVETEN HCT PA; QL TIKOSYN timolol maleate oral QL QL 26

28 torsemide oral TRACLEER Tier 4 PA trandolapril triamterene-hydrochlorothiazid oral capsule mg triamterene-hydrochlorothiazid oral capsule mg triamterene-hydrochlorothiazid oral tablet TRIBENZOR PA; QL TYVASO Tier 4 PA; QL TYVASO REFILL KIT Tier 4 PA TYVASO STARTER KIT Tier 4 PA valsartan QL valsartan-hydrochlorothiazide QL VELETRI Tier 4 PA VENTAVIS Tier 4 PA verapamil oral capsule, 24 hr er pellet ct QL verapamil oral capsule,ext rel. pellets 24 hr verapamil oral tablet verapamil oral tablet extended release VYTORIN ST; QL VYTORIN ST; QL VYTORIN ST; QL VYTORIN ST; QL WELCHOL ORAL POWDER IN PACKET QL WELCHOL ORAL TABLET ZETIA ST; QL Central Nervous System Agents ABILIFY ORAL SOLUTION ST; QL ABILIFY ORAL TABLET PA; QL ABILIFY DISCMELT ST; QL alprazolam oral tablet AL alprazolam oral tablet extended release 24 hr 0.5 mg, 1 mg, 2 mg, 3 mg alprazolam oral tablet,disintegrating AL ALPRAZOLAM INTENSOL AL amantadine hcl oral amitriptyline amitriptyline-chlordiazepoxide amoxapine QL; AL 27

29 AMPHETAMINE SALT COMBO ORAL TABLET 10 MG, 12.5 MG, 15 MG, 20 MG, 30 MG, 5 MG, 7.5 MG APOKYN Tier 4 AXERT ST; QL AZILECT QL BANZEL ORAL SUSPENSION PA BANZEL ORAL TABLET PA; QL benztropine injection Tier 4 benztropine oral bromocriptine bupropion hcl oral tablet QL bupropion hcl oral tablet extended release 100 mg, 200 mg bupropion hcl oral tablet extended release 150 mg QL bupropion hcl oral tablet extended release 24 hr QL buspirone oral tablet 10 mg, 5 mg buspirone oral tablet 15 mg, 30 mg, 7.5 mg BUTISOL 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 carbidopa-levodopa oral tablet carbidopa-levodopa oral tablet extended release carbidopa-levodopa oral tablet,disintegrating carbidopa-levodopa-entacapone LONTIN ORAL CAPSULE 300 MG REBYX Tier 4 chlordiazepoxide hcl AL chlorpromazine oral citalopram oral solution citalopram oral tablet 10 mg, 20 mg, 40 mg QL clomipramine clonazepam oral tablet clonazepam oral tablet,disintegrating clonidine hcl oral tablet extended release 12 hr ST clorazepate dipotassium AL clozapine oral tablet 100 mg, 25 mg, 50 mg QL clozapine oral tablet 200 mg QL 28 QL QL

30 clozapine oral tablet,disintegrating 100 mg, 12.5 mg, 25 mg COGENTIN Tier 4 DAYTRANA PA; QL; AL desipramine oral dexmethylphenidate oral capsule,er biphasic PA; QL dexmethylphenidate oral tablet QL dextroamphetamine oral capsule, extended release 10 mg, 15 mg, 5 mg dextroamphetamine oral solution QL dextroamphetamine oral tablet 5 mg dextroamphetamine-amphetamine oral capsule,extended release 24hr dextroamphetamine-amphetamine oral tablet QL diazepam injection syringe diazepam oral diazepam rectal QL DIAZEPAM INTENSOL dihydroergotamine injection QL DILANTIN DILANTIN INFATABS DILANTIN KAPSEAL ORAL CAPSULE 30 MG diphenhydramine hcl oral capsule 25 mg diphenhydramine hcl oral capsule 50 mg diphenhydramine hcl oral tablet 25 mg diphenhydramine hcl oral tablet 50 mg divalproex oral capsule, sprinkle divalproex oral tablet extended release 24 hr divalproex oral tablet,delayed release (dr/ec) DORAL AL doxepin oral capsule doxepin oral concentrate duloxetine oral capsule,delayed release(dr/ec) 20 mg, 30 mg, 60 mg QL QL PA; QL; AL PA; QL EMSAM PA; QL entacapone EPITOL EQUETRO ERGOMAR escitalopram oxalate oral solution escitalopram oxalate oral tablet 10 mg, 20 mg, 5 mg QL 29

31 estazolam AL eszopiclone QL; AL ethosuximide FANAPT ORAL TABLET ST; QL FANAPT ORAL TABLETS,DOSE PACK ST; QL FAZACLO ORAL TABLET,DISINTEGRATING 150 MG, 200 MG felbamate fluoxetine oral capsule 10 mg, 20 mg, 40 mg QL fluoxetine oral capsule,delayed release(dr/ec) QL fluoxetine oral solution fluoxetine oral tablet 10 mg QL fluoxetine oral tablet 20 mg QL fluphenazine hcl oral flurazepam oral capsule 15 mg, 30 mg AL fluvoxamine oral tablet 100 mg, 25 mg, 50 mg QL FOCALIN XR ORAL CAPSULE,ER BIPHASIC MG, 20 MG, 25 MG, 35 MG, 5 MG fosphenytoin Tier 4 QL PA; QL; AL FROVA ST; QL gabapentin oral capsule QL gabapentin oral solution 250 mg/5 ml, 300 mg/6 ml (6 ml) gabapentin oral tablet 600 mg, 800 mg QL GRALISE ORAL TABLET EXTENDED RELEASE 24 HR 300 MG, 600 MG ST; QL GRALISE 30-DAY STARTER PACK ST; QL haloperidol HETLIOZ Tier 4 PA hydroxyzine hcl oral hydroxyzine pamoate imipramine hcl imipramine pamoate INTUNIV ER ST; QL INVEGA ORAL TABLET EXTENDED RELEASE 24HR 1.5 MG, 3 MG, 6 MG, 9 MG isometh-dichloral-acetaminophn ST; QL KHEDEZLA PA; QL LAMICTAL ODT ORAL TABLET,DISINTEGRATING 100 MG, 200 MG, 25 MG, 50 MG LAMICTAL ODT STARTER (BLUE) PA 30 PA; QL

32 LAMICTAL ODT STARTER (GREEN) PA LAMICTAL ODT STARTER (ORANGE) PA LAMICTAL STARTER (GREEN) KIT LAMICTAL STARTER (ORANGE) KIT LAMICTAL XR STARTER (BLUE) LAMICTAL XR STARTER (GREEN) LAMICTAL XR STARTER (ORANGE) lamotrigine oral tablet lamotrigine oral tablet extended release 24hr 100 mg, 200 mg, 25 mg, 250 mg, 300 mg, 50 mg lamotrigine oral tablet, chewable dispersible lamotrigine oral tablets,dose pack 25 mg (35) PA; QL LATUDA ST; QL levetiracetam oral solution levetiracetam oral tablet levetiracetam oral tablet extended release 24 hr 500 mg, 750 mg lithium carbonate oral capsule lithium carbonate oral tablet lithium carbonate oral tablet extended release lithium citrate LODOSYN lorazepam oral tablet loxapine succinate LYRICA ORAL CAPSULE 100 MG, 150 MG, 200 MG, 225 MG, 25 MG, 300 MG, 50 MG, 75 MG ST; QL PA; QL LYRICA ORAL SOLUTION PA; QL maprotiline MARPLAN meprobamate METADATE ER QL methamphetamine QL METHYLIN ORAL TABLET,CHEWABLE methylphenidate oral capsule, er biphasic mg, 20 mg, 30 mg, 40 mg methylphenidate oral capsule, er biphasic mg, 60 mg methylphenidate oral capsule,er biphasic mg, 30 mg, 40 mg methylphenidate oral solution QL methylphenidate oral tablet 10 mg QL methylphenidate oral tablet 20 mg, 5 mg QL PA; QL; AL PA; QL PA; QL 31

33 methylphenidate oral tablet extended release PA; QL; AL methylphenidate oral tablet extended release 24hr 18 mg, 27 mg, 36 mg methylphenidate oral tablet extended release 24hr 54 mg midazolam oral syrup 2 mg/ml MIGERGOT MIGRAGESIC IDA PA; QL; AL PA; QL MIRAPEX ER ST; QL mirtazapine oral tablet mirtazapine oral tablet,disintegrating modafinil PA; QL naratriptan QL nefazodone NEUPRO ST; QL NODOLOR nortriptyline oral capsule nortriptyline oral solution NUEDEXTA PA; QL NUVIGIL ORAL TABLET 150 MG, 200 MG, 250 MG, 50 MG olanzapine oral tablet 10 mg, 15 mg, 2.5 mg, 20 mg, 5 mg, 7.5 mg olanzapine oral tablet,disintegrating QL PA; QL olanzapine-fluoxetine ST; QL OLEPTRO ER ST; QL ONFI ORAL TABLET 10 MG, 20 MG QL ORAP oxazepam AL oxcarbazepine OXTELLAR XR ORAL TABLET EXTENDED RELEASE 24 HR 150 MG, 300 MG, 600 MG paroxetine hcl oral tablet 10 mg, 20 mg, 30 mg, 40 mg QL paroxetine hcl oral tablet extended release 24 hr 12.5 mg, 25 mg, 37.5 mg PEGANONE perphenazine perphenazine-amitriptyline phenelzine phenobarbital phenytoin oral suspension phenytoin oral tablet,chewable 32 QL QL ST; QL

34 phenytoin sodium extended POTIGA ORAL TABLET 200 MG, 300 MG, 400 MG, 50 MG pramipexole primidone PRISTIQ PA; QL protriptyline quetiapine oral tablet 100 mg, 200 mg, 25 mg, 300 mg, 400 mg, 50 mg QUILLIVANT XR PA; QL RELPAX ST; QL risperidone oral solution ST risperidone oral tablet 0.25 mg, 0.5 mg, 1 mg, 2 mg, 3 mg, 4 mg risperidone oral tablet,disintegrating 0.25 mg, 0.5 mg, 1 mg, 2 mg, 3 mg, 4 mg RITALIN ORAL TABLET 5 MG QL rizatriptan QL ropinirole oral tablet ropinirole oral tablet extended release 24 hr 12 mg, 2 mg, 4 mg, 6 mg, 8 mg QL QL QL ST; QL ST; QL ROZEREM PA; QL SABRIL Tier 4 PA; QL SAPHRIS ST; QL SAPHRIS (BLACK CHERRY) ST; QL SARAFEM ORAL TABLET 10 MG, 20 MG QL SAVELLA ORAL TABLET PA; QL SAVELLA ORAL TABLETS,DOSE PACK PA; QL SECONAL SODIUM selegiline hcl SEROQUEL XR ORAL TABLET EXTENDED RELEASE 24 HR 150 MG, 200 MG, 300 MG, 400 MG, 50 MG sertraline oral concentrate QL sertraline oral tablet 100 mg, 25 mg, 50 mg QL STAVZOR PA PA; QL STRATTERA ST; QL sumatriptan nasal spray,non-aerosol 20 mg/actuation, 5 mg/actuation sumatriptan succinate oral QL sumatriptan succinate subcutaneous cartridge QL sumatriptan succinate subcutaneous pen injector QL QL 33

35 sumatriptan succinate subcutaneous solution QL TASMAR ORAL TABLET 100 MG TEGRETOL XR ORAL TABLET EXTENDED RELEASE 12 HR 100 MG temazepam oral capsule 15 mg, 30 mg AL temazepam oral capsule 22.5 mg, 7.5 mg QL; AL thioridazine thiothixene tiagabine oral tablet 2 mg, 4 mg QL TOPIRAGEN ORAL TABLET 100 MG, 200 MG, 50 MG topiramate oral capsule, sprinkle QL topiramate oral tablet tranylcypromine trazodone triazolam AL trifluoperazine trihexyphenidyl valproic acid valproic acid (as sodium salt) venlafaxine oral capsule,extended release 24hr venlafaxine oral tablet 100 mg, 25 mg, 37.5 mg, 50 mg, 75 mg VIIBRYD ORAL TABLET PA; QL VIIBRYD ORAL TABLETS,DOSE PACK PA; QL VIMPAT ORAL TABLET QL VYVANSE ORAL CAPSULE 20 MG, 30 MG, 40 MG, 60 MG, 70 MG QL PA; ST; QL; AL VYVANSE ORAL CAPSULE 50 MG PA; QL; AL XYREM Tier 4 PA zaleplon QL; AL ZELAPAR ST; QL ziprasidone hcl QL zolmitriptan ST zolpidem oral tablet QL; AL zolpidem oral tablet,ext release multiphase ST; QL; AL ZOMIG NASAL SPRAY,NON-AEROSOL 2.5 MG, 5 MG zonisamide Chemical Dependency, Agents To Treat acamprosate ST; QL 34

36 buprenorphine hcl sublingual PA buprenorphine-naloxone PA; QL BUPROBAN bupropion hcl oral tablet extended release 150 mg QL CAMPRAL QL CHANTIX CHANTIX CONTINUING MONTH BOX CHANTIX CONTINUING MONTH PAK CHANTIX STARTING MONTH BOX CHANTIX STARTING MONTH PAK disulfiram NICODERM CQ nicotine transdermal patch 24 hour 14 mg/24 hr, 21 mg/24 hr, 7 mg/24 hr NICOTROL NICOTROL NS NTS STEP 1 SUBOXONE SUBLINGUAL FILM PA; QL Chemicals-Pharmaceutical Adjuvants kanamycin (bulk) Tier 4 magnesium citrate sodium chloride inhalation solution for nebulization 0.9 %, 10 %, 3 % sodium chloride inhalation solution for nebulization 7 % thioguanine (bulk) Cognitive Disorder Therapy donepezil oral tablet 10 mg, 5 mg AL donepezil oral tablet 23 mg ST; QL; AL donepezil oral tablet,disintegrating AL ergoloid EXELON TRANSDERMAL QL; AL galantamine oral capsule,ext rel. pellets 24 hr QL; AL galantamine oral solution AL galantamine oral tablet AL NAMENDA ORAL SOLUTION Tier 2 AL NAMENDA ORAL TABLET QL; AL NAMENDA TITRATION PAK QL; AL NAMENDA XR Tier 2 AL rivastigmine tartrate QL; AL Contraceptives 35

37 ALTAVERA (28) QL ALYAN 1/35 (28) ALYAN 7/7/7 (28) AMETHIA QL AMETHIA LO QL AMETHYST QL APRI QL ARANELLE (28) QL AUBRA QL AVIANE QL AZURETTE (28) QL BALZIVA (28) QL BEYAZ QL BREVICON (28) QL BRIELLYN QL CAMILA CAMRESE QL CAMRESE LO QL CAZIANT (28) QL CHATEAL QL CRYSELLE (28) QL CYCLAFEM 1/35 (28) CYCLAFEM 7/7/7 (28) CYCLESSA (28) QL DASETTA 1/35 (28) DASETTA 7/7/7 (28) daysee DEPO-PROVERA INTRAMUSCULAR SUSPENSION DEPO-PROVERA INTRAMUSCULAR SYRINGE QL DEPO-SUBQ PROVERA 104 PA; QL desogestrel-ethinyl estradiol QL ELINEST QL ELLA QL EMOQUETTE ENPRESSE QL ENSKY QL ERRIN ESTARYLLA ESTROSTEP FE-28 QL 36 QL

38 FALMINA (28) QL FEMCON FE QL GENERESS FE QL GIANVI (28) GILDAGIA QL GILDESS QL GILDESS FE QL HEATHER introvale QL JENCYCLA jolessa QL JOLIVETTE JUNEL 1.5/30 (21) QL JUNEL 1/20 (21) QL JUNEL FE 1.5/30 (28) QL JUNEL FE 1/20 (28) QL KARIVA (28) QL KELNOR 1/35 (28) QL KURVELO QL l norgest&e estradiol-e estrad QL LARIN FE QL LEENA 28 QL LESSINA QL LEVONEST (28) QL levonorgestrel oral tablet 0.75 mg QL levonorgestrel oral tablet 1.5 mg QL levonorgestrel-ethinyl estrad oral tablet mg-mcg levonorgestrel-ethinyl estrad oral tablet mg-mcg levonorgestrel-ethinyl estrad oral tablets,dose pack,3 month LEVORA 0.15/30 (28) QL LEVORA-28 QL LOESTRIN 1.5/30 (21) QL LOESTRIN 1/20 (21) QL LOESTRIN FE 1.5/30 (28) QL LOESTRIN FE 1/20 (28) QL LOMEDIA 24 FE QL LORYNA (28) LOSEASONIQUE QL QL QL QL 37

39 LOW-OGESTREL (28) QL LUTERA (28) QL LYZA MARLISSA QL medroxyprogesterone intramuscular QL MICROGESTIN 1.5/30 (21) QL MICROGESTIN 1/20 (21) QL MICROGESTIN FE 1.5/30 (28) QL MICROGESTIN FE 1/20 (28) QL MIRTTE (28) QL MIRENA QL MODICON (28) QL MONO-LINYAH MONONESSA (28) MY WAY QL MYZILRA QL NATAZIA NECON 0.5/35 (28) QL NECON 1/35 (28) NECON 1/50 (28) QL NECON 10/11 (28) QL NEXPLANON QL NEXT CHOI ONE DOSE QL NOR-QD QL NORA-BE norgestimate-ethinyl estradiol norgestrel-ethinyl estradiol oral tablet mg-mcg QL NORINYL 1+50 (28) QL NORTREL 0.5/35 (28) QL NORTREL 1/35 (21) NORTREL 1/35 (28) OLLA OGESTREL (28) QL ORSYTHIA QL ORTHO MICRONOR ORTHO TRI-CYCLEN (28) ORTHO TRI-CYCLEN LO (28) ORTHO-PT (28) ORTHO-CYCLEN (28) ORTHO-NOVUM 1/35 (28) 38

40 ORTHO-NOVUM 7/7/7 (28) OVCON-35 (28) QL PARAGARD T 380A PHILITH QL PIRMELLA ORAL TABLET 1-35 MG-MCG PLAN B ONE-STEP QL PORTIA QL PREVIFEM quasense QL RECLIPSEN (28) SAFYRAL QL SEASONIQUE QL SPRINTEC (28) SRONYX QL SYEDA TILIA FE QL TODAY CONTRAPTIVE SPONGE TRI-ESTARYLLA TRI-LEGEST FE QL TRI-LINYAH TRI-NORINYL (28) QL TRI-PREVIFEM (28) TRI-SPRINTEC (28) TRINESSA (28) TRIVORA (28) QL VAGINAL CONTRAPTIVE FILM VAGINAL CONTRAPTIVE FOAM VCF CONTRAPTIVE FILM VELIVET TRIPHASIC REGIMEN (28) QL VESTURA (28) VIORELE (28) QL WERA (28) QL WYMZYA FE QL XULANE QL YASMIN (28) YAZ (28) ZARAH ZENCHENT (28) QL ZENCHENT FE QL ZEOSA QL 39

41 ZOVIA 1/35E (28) QL ZOVIA 1/50E (28) QL Dermatological 8-MOP ABREVA acitretin ACZONE adapalene topical cream adapalene topical gel 0.1 %, 0.3 % AKNE-MYCIN alclometasone ALCORTIN A TOPICAL GEL IN PACKET ALOQUIN ALTABAX aluminum acetate topical aluminum chloride topical amcinonide ammonium lactate topical cream AMNESTEEM ST; QL ANACAINE ANTI-ITCH (HC) TOPICAL OINTMENT ANTIFUNGAL (CLOTRIMAZOLE) APEXICON E ATHLETIC FOOT CREAM ATRALIN ST; QL ATRAPRO HYDROGEL AVAGE AVAR TOPICAL CLEANSER AVITA TOPICAL CREAM QL AVITA TOPICAL GEL ST; QL AVO CREAM AZELEX BENZAMYCINPAK benzoyl peroxide topical cleanser 4 %, 6 %, 7 % BETA-HC betamethasone dipropionate betamethasone valerate betamethasone, augmented BIONECT TOPICAL CREAM BIONECT TOPICAL GEL 40

42 BP 10-1 BP WASH TOPICAL CLEANSER 7 % BPO TOPICAL GEL calcipotriene ST calcipotriene-betamethasone ST CALCITRENE ST calcitriol topical CAPEX CARAC NTANY AT CICLODAN ciclopirox topical cream ciclopirox topical gel ciclopirox topical shampoo ciclopirox topical solution ciclopirox topical suspension CLARAVIS ST; QL CLARIS CLARIFYING WASH CLEANSING WASH TOPICAL CLEANSER CLINDACIN P clindamycin phosphate topical foam clindamycin phosphate topical gel clindamycin phosphate topical lotion clindamycin phosphate topical solution clindamycin phosphate topical swab clindamycin-benzoyl peroxide topical gel 1-5 % QL clindamycin-benzoyl peroxide topical gel 1.2 %(1 % base) -5 % clobetasol topical cream clobetasol topical foam clobetasol topical gel clobetasol topical lotion clobetasol topical ointment clobetasol topical shampoo clobetasol topical solution clobetasol-emollient CLOBEX TOPICAL SPRAY,NON-AEROSOL CLODERM CLOTRIM ANTIFUNGAL clotrimazole topical 41

43 CLOTRIMAZOLE AF CLOTRIMAZOLE FOOT clotrimazole-betamethasone CONDYLOX TOPICAL GEL CORDRAN TOPICAL LOTION CORMAX TOPICAL SOLUTION CORTISPORIN TOPICAL CORTIZONE-10 TOPICAL OINTMENT DENAVIR ST DERMAZENE desonide desoximetasone diclofenac sodium topical gel ST DIFFERIN TOPICAL LOTION ST diflorasone DRITHOCREME HP econazole topical ELIDEL PA; QL EMULSION SB EPIDUO ST; QL EPIFOAM ERTACZO ERY PADS erythromycin with ethanol erythromycin-benzoyl peroxide ethyl chloride EURAX EXELDERM FABIOR ST FINAA FIRST-HYDROCORTISONE fluocinolone fluocinolone-shower cap fluocinonide topical cream 0.05 % fluocinonide topical cream 0.1 % ST fluocinonide topical gel fluocinonide topical ointment fluocinonide topical solution FLUOCINONIDE-E fluocinonide-emollient 42

44 FLUOROPLEX fluorouracil topical cream 5 % fluorouracil topical solution fluticasone topical cream fluticasone topical lotion fluticasone topical ointment gentamicin topical GERI-HYDROLAC TOPICAL CREAM halobetasol propionate HALOG HYDRO SKIN TOPICAL LOTION hydrocortisone topical cream 0.5 % hydrocortisone topical cream 2.5 % hydrocortisone topical lotion 2.5 % hydrocortisone topical ointment 1 % hydrocortisone topical ointment 2.5 % hydrocortisone valerate hydrocortisone-min oil-wht pet hydrocortisone-pramoxine topical HYPERCARE imiquimod QL iodoquinol-hc JOCK ITCH TOPICAL CREAM KENALOG TOPICAL ketoconazole topical cream ketoconazole topical shampoo KETODAN lactic acid topical lotion LEVULAN lidocaine topical adhesive patch,medicated lidocaine topical ointment lidocaine hcl mucous membrane gel lidocaine hcl mucous membrane jelly in applicator lidocaine hcl topical cream lidocaine hcl topical lotion lidocaine hcl-hydrocortison ac topical lidocaine-prilocaine topical cream LIDOVIR lindane QL mafenide acetate 43

45 malathion QL MENTAX methoxsalen rapid methyl salicylate topical metronidazole topical cream metronidazole topical gel 0.75 % metronidazole topical gel 1 % ST metronidazole topical lotion MIRVASO ST mometasone mupirocin mupirocin calcium MYORISAN ST; QL NAFTIN ST NORITATE NOVACORT PA NYAMYC nystatin topical nystatin-triamcinolone NYSTOP OVA PLUS WASH OXISTAT PAIN EASE PANOXYL-4 PANRETIN PEDIADERM AF PEDIADERM TA permethrin topical cream PICATO QL podofilox PRAMOSONE TOPICAL LOTION PRAMOSONE TOPICAL OINTMENT PRAMOSONE E prednicarbate PROTOPIC PA; QL PRUTECT RADIAGEL RADIAPLEXRX REGRANEX RETIN-A MICRO ST 44

46 RETIN-A MICRO PUMP TOPICAL GEL WITH PUMP 0.04 %, 0.1 % RINGWORM ROSADAN TOPICAL CREAM ROSADAN TOPICAL GEL SALACYN TOPICAL CREAM salicylic acid topical cream salicylic acid topical film forming liquid w/appl salicylic acid topical gel salicylic acid topical liquid 26 % salicylic acid topical shampoo salicylic acid sr-ceramides SALJET SALINE RINSE SANTYL SCALACORT SCALACORT DK SEB-PREV selenium sulfide topical shampoo selenium sulfide topical suspension 2.5 % SILVASORB silver nitrate topical silver nitrate applicators silver sulfadiazine SILVERMED TOPICAL GEL,EXTENDED RELEASE SKLI SONAFINE spinosad SPRAY AND STRETCH SSD SSS 10-5 STELARA SUBCUTANEOUS SYRINGE Tier 4 PA; QL sulfacetamide sod-sulfur-urea sulfacetamide sodium topical cleanser sulfacetamide sodium topical shampoo sulfacetamide sodium (acne) sulfacetamide sodium-sulfur topical cleanser 10-2 %, 10-5 % (w/w), 9-4 %, % sulfacetamide sodium-sulfur topical cream 10-2 %, 10-5 % (w/w) sulfacetamide sodium-sulfur topical foam ST 45

47 sulfacetamide sodium-sulfur topical lotion sulfacetamide sodium-sulfur topical pads, medicated 10-4 % sulfacetamide sodium-sulfur topical pads, medicated 10-5 % sulfacetamide sodium-sulfur topical suspension 10-5 %, 8-4 % SULFACLEANSE 8-4 SULFAMYLON SYNERA TARGRETIN TOPICAL Tier 4 TAZORAC ST TERSI FOAM TEXACORT THERMAZENE TL-RMIDE TRETIN-X TOPICAL CREAM % ST; QL tretinoin topical cream QL tretinoin topical gel 0.01 %, % QL triamcinolone acetonide topical cream triamcinolone acetonide topical lotion triamcinolone acetonide topical ointment %, 0.1 %, 0.5 % TRIANEX TRIDERM TOPICAL CREAM ULESFIA QL ULTRAVATE X urea topical cream 45 % VASOLEX VELTIN ST VERDESO VEREGEN VIRTI-SULF VOLTAREN TOPICAL QL VUSION WOUND GEL XERAC AC XERESE XOLEGEL ZENATANE ST; QL ZENCIA 46 QL

48 ZIANA ST ZOVIRAX TOPICAL CREAM ST Diagnostic Agents ACCU-CHEK ACTIVE TEST PA ACCU-CHEK AVIVA PA ACCU-CHEK AVIVA PLUS TEST STRP PA ACCU-CHEK COMFORT CURVE TEST PA ACCU-CHEK COMPACT TEST PA ACCU-CHEK SMARTVIEW TEST STRIP PA BREEZE 2 TEST STRIPS PA CHEK-STIX CONTROL CHEMSTRIP 10 MD CHEMSTRIP 10/SG CHEMSTRIP 2 GP CHEMSTRIP 50B CHEMSTRIP 7 CHEMSTRIP 9 CHEMSTRIP K CHEMSTRIP UGK COMBISTIX REAGENT DIASCREEN 1B REAGENT DIASCREEN 1K REAGENT DMSA EASY TOUCH STRIP QL FREESTYLE INSULINX STRIP Tier 2 FREESTYLE INSULINX TEST STRIPS Tier 2 FREESTYLE LITE STRIPS Tier 2 FREESTYLE TEST Tier 2 GLUCAGEN DIAGNOSTIC KIT QL HEMA-COMBISTIX KETO-DIASTIX KETONE CARE KETONE URINE TEST KETOSTIX LABSTIX REAGENT MULTISTIX MULTISTIX 10 SG MULTISTIX 5 MULTISTIX 7 MULTISTIX 8 SG 47

49 MULTISTIX 9 MULTISTIX 9 SG ONE TOUCH ULTRA TEST PA ONE TOUCH VERIO PA PRECISION XTRA B-KETONE Tier 2 PRECISION XTRA TEST Tier 2 URISTIX 4 URISTIX REAGENT Drugs To Treat Erectile Dysfunction CAVERJECT QL CAVERJECT IMPULSE QL CIALIS ORAL TABLET 10 MG, 20 MG QL CIALIS ORAL TABLET 5 MG PA; QL EDEX QL LEVITRA QL MUSE QL STAXYN QL STENDRA QL VIAGRA QL Eating Disorder Therapy benzphetamine LA BONTRIL PDM LA DIDREX LA diethylpropion LA phendimetrazine tartrate LA phentermine LA QSYMIA LA QL REGIMEX LA SUPRENZA LA XENICAL LA Electrolyte Balance-Nutritional Products ammonium molybdate BAL-CARE DHA BAL-CARE DHA ESSENTIAL BD POSIFLUSH NORMAL SALINE BD POSIFLUSH SALINE BLUNT CANN BD PRE-FILLED NORMAL SALINE BD PRE-FILLED SALINE BLUNT CAN C-NATE DHA 48

50 CALCARB 600 WITH VITAMIN D ORAL TABLET 600 MG(1,500MG) -200 UNIT calcitriol oral capsule calcitriol oral solution CALCIUM D ORAL TABLET 500 MG(1,250MG) -200 UNIT CALCIUM D ORAL TABLET,CHEWABLE CALCIUM D (D3) CALCIUM D(3) ORAL CAPSULE CALCIUM D(3) ORAL TABLET 600 MG(1,500MG) -200 UNIT, 600 MG(1,500MG) -400 UNIT CALCIUM 600 WITH VITAMIN D3 ORAL CAPSULE 600 MG(1,500MG) -400 UNIT CALCIUM 600 WITH VITAMIN D3 ORAL TABLET CALCIUM 600 WITH VITAMIN D3 ORAL TABLET,CHEWABLE calcium acetate oral tablet calcium carbonate-vitamin d2 calcium carbonate-vitamin d3 oral capsule 600 mg(1,500mg) -400 unit calcium carbonate-vitamin d3 oral tablet 500 mg(1,250mg) -200 unit, mg-unit, 600 mg(1,500mg) -200 unit, 600 mg(1,500mg) -400 unit calcium carbonate-vitamin d3 oral tablet,chewable 500 mg(1,250mg) -400 unit calcium chloride intravenous solution CALCIUM CITRATE + CALCIUM CITRATE + D calcium citrate-vitamin d2 calcium citrate-vitamin d3 oral tablet 200 mg calcium -250 unit, mg-unit, mg-unit, mg-unit calcium gluconate intravenous CALCIUM WITH VITAMIN D CALCIUM+D CALVITE P CHILDREN'S IRON CHILDREN'S VITAMIN D cholecalciferol (vitamin d3) oral capsule 1,000 unit, 400 unit cholecalciferol (vitamin d3) oral drops 400 unit/ml 49