AETNA BETTER HEALTH Formulary Guide 2017 Aetna Better Health Pennsylvania Formulary Guide May 2017
AETNA BETTER HEALTH Formulary Guide 2017 What is the Aetna Better Health in Pennsylvania Formulary? This is a drug list created by Aetna Better Health in Pennsylvania ( plan ). The plan will cover drugs on this list. Some drugs may have coverage rules. If the rules for that drug are met, the plan will cover the drug. Drugs must also be filled at a plan s network pharmacy. This list is for drugs covered under you prescription benefit. Drugs may not be listed here if they are covered under your medical benefit. Drugs covered under your medical benefit are usually those a health care professional gives to you, like an IV infusion or other injection, and not typically a medication you would take on your own. Can the Plan s Drug List change? The plan may add or remove drugs on the list. All drug removals from the formulary will be sent to the state for review at least 30 days before the change is made. Utilizing members will be notified at least www.aetnabetterhealth.com/pennsylvania PA 10 03 03A 2
AETNA BETTER HEALTH Formulary Guide 2017 30 days before a drug is removed from the formulary. All changes to the formulary will be posted on the plan s website. How do I use the Plan s Formulary? Column #1: lists the covered drug. Brand drugs are in upper case letters (e.g., DRUG). Generics are in lower case letters (e.g., drug). Column #2: lists the brand name of the drug when a generic is covered Column #3: shows coverage rules for the drug Drugs are also grouped by the type of condition they treat. Drugs used to treat an earache are listed under the section, Ear Nose Throat Medications. If you know what your drug is used for, please look for that section name on the drug list. Then look under that section for your drug. What are generic drugs? Generic drugs are copies of brand-name drugs. They are the same as those brand name drugs in dosage form, safety, strength, route of administration, quality, and intended use. When a drug is available as a generic, you will be required to use the generic version for your prescription. If your provider feels it is medically necessary that you take only the brand, then your provider must request a prior authorization from the plan before the brand will be covered. Are Over The Counter (OTC) drugs covered? The plan will cover OTC drugs on the formulary. Some OTC drugs may have coverage rules. If the rules for that OTC drug are met, the plan will cover the OTC drug. Like other drugs, OTC drugs need a prescription from a doctor if they are to be covered by the plan. How much will I pay for covered drugs? s There are no copays for: Pregnant women Children under 21 years of age Members in a nursing home or other facility (Intermediate Care Facility for Mental Retardation) Family planning drugs Emergency situation (condition in which emergency medical care is needed to prevent death or serious injury of a member) www.aetnabetterhealth.com/pennsylvania PA 10 03 03A 3
AETNA BETTER HEALTH Formulary Guide 2017 Certain drug groups listed below do not have copays. For those drug groups that will not require a copay the drug group will be marked with a * on the formulary. High blood pressure drugs Cancer drugs Diabetes drugs Epilepsy drugs Heart disease drugs Antipsychotic drugs (except for those anti anxiety drugs that are controlled substances, like alprazolam or diazepam) Anti Parkinson drugs Anti glaucoma drugs Drugs used only to treat HIV/AIDS Drugs, including immunizations, which you get in a health care provider s office. Copays Members 21 years of age and older: generic drugs on formulary are $1; brand drugs on formulary are $3 per prescription. Services cannot be denied if the member cannot afford the copay. What are some types of coverage rules? Prior Approval (PA): This means your doctor will need to get approval from the plan first before the drug can be filled at the pharmacy. If it is not approved, the plan will not cover the drug. Quantity Level Limits (QLL): This means there is a limit on the amount of drug the plan will cover. For example, the plan provides 60 pills in 30 days for some drugs. Your doctor will need to get approval from the plan first before the drug can be filled for more than the plans limits. Step Therapy (ST): This means you may need to try certain drugs first to treat your condition. After the first drug is tried, the plan will then cover the other drug for that same condition. For example, Drug A and Drug B may treat your condition. The plan may not cover Drug B unless you try Drug A first. If Drug A does not work for you, then Drug B will be covered. What if my drug is not on the plan s Formulary? First, please call your doctor and ask if your drug is covered. If the plan does not cover the drug, then: Ask your doctor for a similar drug that is covered. Your doctor can ask the plan to cover your drug through the prior approval process. www.aetnabetterhealth.com/pennsylvania PA 10 03 03A 4
AETNA BETTER HEALTH Formulary Guide 2017 Where can I fill my prescriptions? You can fill your prescriptions at any network pharmacy. You can find the location of an in network pharmacy by visiting the CVS Caremark pharmacy locator. http://www.aetnabetterhealth.com/pennsylvania/providers/pharmacy This allows you to search for a pharmacy by zip code so you can find a location close to you. F AL Names in Italics LA PA QL SP ST Definition of Symbols Formulary Age Restriction: We require that the appropriate dose of medication based on age (e.g., pediatric and elderly populations) and indication AND Dosage requested must be based on national established/ recognized guidelines pertaining to the treatment and management of the diagnosis and age for which the medication is being used to treat. OR FDA-approved age limitations - Click this symbol for more information. Generic Drug - The plan covers both brand and generic drugs. Generic drugs have the same active ingredient formula as a brand name drug. Generic drugs usually cost less than brand name drugs and are rated by the Food and Drug Administration (FDA) to be as safe and effective as brand name drugs. Limited Access This means your doctor will need to get approval from the plan first before the drug can be filled at the pharmacy. If it is not approved, the plan will not cover the drug. This means there is a limit on the amount of drug the plan will cover. For example, the plan provides 60 pills in 30 days for some drugs. Specialty Pharmacy - All specialty medications require Prior Authorization. This means you may need to try certain drugs first to treat your condition. After the first drug is tried, the plan will then cover the other drug for that same condition. For example, Drug A and Drug B may treat your condition. The plan may not cover Drug B unless you try Drug A first. If Drug A does not work for you, then Drug B will be covered. For a complete list of all drugs requiring step therapy; click on the following -http://www.aetnabetterhealth.com/pennsylvania/assets/pdf/pharmacy/pharmacy-info/prior-authguidelines/step-therapy.pdf www.aetnabetterhealth.com/pennsylvania PA 10 03 03A 5
Aetna Better Health Pennsylvania Table of Contents *ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS*...3 *AMINOGLYCOSIDES*... 4 *ANALGESICS - ANTI-INFLAMMATORY*... 4 *ANALGESICS - NONNARCOTIC*...6 *ANALGESICS - OPIOID*... 6 *ANDROGENS-ANABOLIC*... 10 *ANORECTAL AGENTS*...10 *ANTHELMINTICS*... 11 *ANTIANGINAL AGENTS*... 11 *ANTIANXIETY AGENTS*...12 *ANTIARRHYTHMICS*... 12 *ANTIASTHMATIC AND BRONCHODILATOR AGENTS*... 13 *ANTICOAGULANTS*... 15 *ANTICONVULSANTS*...16 *ANTIDEPRESSANTS*...18 *ANTIDIABETICS*... 20 *ANTIDIARRHEALS*...24 *ANTIDOTES*... 24 *ANTIEMETICS*... 24 *ANTIFUNGALS*...25 *ANTIHISTAMINES*... 25 *ANTIHYPERLIPIDEMICS*...26 *ANTIHYPERTENSIVES*... 27 *ANTI-INFECTIVE AGENTS - MISC.*... 30 *ANTIMALARIALS*...30 *ANTIMYASTHENIC AGENTS*... 31 *ANTIMYCOBACTERIAL AGENTS*... 31 *ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES*...31 *ANTIPARKINSON AGENTS*...33 *ANTIPSYCHOTICS/ANTIMANIC AGENTS*... 34 *ANTIRETROVIRALS ADJUVANTS***... 36 *ANTISEPTICS & DISINFECTANTS*...36 *ANTIVIRALS*...36 *ASSORTED CLASSES*... 40 *BETA BLOCKERS*... 41 *CALCIUM CHANNEL BLOCKERS*... 42 *CARDIOTONICS*... 43 *CARDIOVASCULAR AGENTS - MISC.*... 44 *CEPHALOSPORINS*...44 *CONTRACEPTIVES*...45 *CORTICOSTEROIDS*... 51 *COUGH/COLD/ALLERGY*...52 *DERMATOLOGICALS*... 53 *DIAGNOSTIC PRODUCTS*...59 1
*DIGESTIVE AIDS*...59 *DIURETICS*...59 *ENDOCRINE AND METABOLIC AGENTS - MISC.*...60 *ESTROGENS*...61 *FLUOROQUINOLONES*... 62 *GASTROINTESTINAL AGENTS - MISC.*...63 *GENITOURINARY AGENTS - MISCELLANEOUS*... 64 *GOUT AGENTS*...64 *HEMATOLOGICAL AGENTS - MISC.*... 65 *HEMATOPOIETIC AGENTS*...65 *HEPATITIS C AGENT - COMBINATIONS***... 66 *HYPNOTICS*... 66 *LAXATIVES*... 66 *MACROLIDES*...67 *MEDICAL DEVICES*...67 *MIGRAINE PRODUCTS*...70 *MINERALS & ELECTROLYTES*...71 *MOUTH/THROAT/DENTAL AGENTS*...72 *MULTIVITAMINS*...73 *MUSCULOSKELETAL THERAPY AGENTS*...75 *NASAL AGENTS - SYSTEMIC AND TOPICAL*... 76 *NEPRILYSIN INHIB (ARNI)-ANGIOTENSIN II RECEPT ANTAG COMB***... 77 *NEUROMUSCULAR AGENTS*... 77 *OPHTHALMIC AGENTS*...77 *OTIC AGENTS*...80 *PASSIVE IMMUNIZING AGENTS*...80 *PENICILLINS*...81 *PHARMACEUTICAL ADJUVANTS*... 81 *POTASSIUM REMOVING AGENTS***...82 *PROGESTINS*...82 *PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.*...82 *SODIUM-GLUCOSE CO-TRANSPORTER 2 INHIBITOR-BIGUANIDE COMB***... 84 *SULFONAMIDES*...84 *TETRACYCLINES*... 84 *THYROID AGENTS*... 85 *ULCER DRUGS*... 86 *URINARY ANTI-INFECTIVES*...88 *URINARY ANTISPASMODICS*...88 *VACCINES*...88 *VAGINAL PRODUCTS*...89 *VASOPRESSORS*... 89 *VITAMINS*... 89 2
Aetna Better Health Pennsylvania Drug Name Reference Restrictions *ADHD/ANTI- NARCOLEPSY/ANTI- OBESITY/ANOREXIANTS* *Amphetamine Mixtures*** amphetamine-dextroamphet er oral capsule extended release 24 hour 10, 15, 20, 25, 30, 5 amphetamine-dextroamphetamine oral tablet 10, 12.5, 15, 20, 5, 7.5 amphetamine-dextroamphetamine oral tablet 30 *Amphetamines*** dextroamphetamine sulfate er oral capsule extended release 24 hour 10, 15 dextroamphetamine sulfate er oral capsule extended release 24 hour 5 dextroamphetamine sulfate oral solution 5 /5ml Adderall XR Adderall Adderall Dexedrine Dexedrine ProCentra PA; QLL (30 EA per 30 PA; QLL (90 EA per 30 PA; QLL (60 EA per 30 PA; QLL (120 EA per 30 PA; QLL (90 EA per 30 PA; QLL (1800 ML per 30 dextroamphetamine sulfate oral tablet 10 Zenzedi PA; QLL (180 EA per 30 dextroamphetamine sulfate oral tablet 5 Dexedrine PA; QLL (180 EA per 30 methamphetamine hcl oral tablet 5 Desoxyn PA; QLL (150 EA per 30 *Analeptics*** caffeine citrate oral solution 20 /ml, 60 /3ml *Stimulants - Misc.*** dexmethylphenidate hcl er oral capsule extended release 24 hour 10, 15, 20 Focalin XR PA; QLL (30 EA per 30, 25, 30, 35, 5 dexmethylphenidate hcl er oral capsule extended release 24 hour 40 Focalin XR QLL (30 EA per 30 dexmethylphenidate hcl oral tablet 10, 2.5, 5 Focalin PA; QLL (60 EA per 30 3
methylphenidate hcl er (cd) oral capsule extended release 10, 20, 30, 40, Metadate CD PA; QLL (30 EA per 30 50, 60 methylphenidate hcl er (la) oral capsule extended release 24 hour 20, 40 Ritalin LA PA; QLL (30 EA per 30 methylphenidate hcl er (la) oral capsule extended release 24 hour 30 Ritalin LA PA; QLL (60 EA per 30 methylphenidate hcl er (la) oral capsule extended release 24 hour 60 PA; QLL (30 EA per 30 methylphenidate hcl er oral tablet extended release 10 PA; QLL (90 EA per 30 methylphenidate hcl er oral tablet extended release 18, 27, 54 Concerta PA; QLL (30 EA per 30 methylphenidate hcl er oral tablet extended release 20 Metadate ER PA; QLL (90 EA per 30 methylphenidate hcl er oral tablet extended release 24 hour 18, 27, 36, 54 methylphenidate hcl er oral tablet extended release 36 Concerta PA; QLL (60 EA per 30 methylphenidate hcl oral solution 10 /5ml, 5 /5ml Methylin PA; QLL (900 ML per 30 methylphenidate hcl oral tablet 10, 20, Ritalin 5 PA; QLL (90 EA per 30 methylphenidate hcl oral tablet chewable 10 PA; QLL (180 EA per 30 methylphenidate hcl oral tablet chewable 2.5, 5 PA; QLL (150 EA per 30 modafinil oral tablet 100, 200 Provigil PA; QLL (30 EA per 30 *AMINOGLYCOSIDES* *Aminoglycosides*** neomycin sulfate oral tablet 500 paromomycin sulfate oral capsule 250 tobramycin inhalation nebulization solution 300 /5ml Tobi *ANALGESICS - ANTI- INFLAMMATORY* *Anti-Tnf-Alpha - Monoclonoal Antibodies*** HUMIRA PEN-CROHNS STARTER SUBCUTANEOUS PEN-INJECTOR KIT 40 MG/0.8ML PA 4
HUMIRA SUBCUTANEOUS PREFILLED SYRINGE KIT 10 MG/0.2ML, 20 PA MG/0.4ML, 40 MG/0.8ML *Cyclooxygenase 2 (Cox-2) Inhibitors*** celecoxib oral capsule 100, 200, 400, 50 CeleBREX ST *Gold Compounds*** RIDAURA ORAL CAPSULE 3 MG *Nonsteroidal Anti-Inflammatory Agents (Nsaids)*** diclofenac potassium oral tablet 50 diclofenac sodium er oral tablet extended release 24 hour 100 diclofenac sodium oral tablet delayed release 25, 50, 75 etodolac er oral tablet extended release 24 hour 400, 500, 600 etodolac oral capsule 200, 300 etodolac oral tablet 400 Lodine etodolac oral tablet 500 fenoprofen calcium oral tablet 600 flurbiprofen oral tablet 100, 50 ibuprofen oral tablet 400, 600, 800 indomethacin er oral capsule extended release 75 indomethacin oral capsule 25, 50 ketoprofen oral capsule 50, 75 ketorolac tromethamine oral tablet 10 QLL (20 Tablets per 30 meclofenamate sodium oral capsule 100, 50 meloxicam oral tablet 15, 7.5 Mobic nabumetone oral tablet 500, 750 naproxen dr oral tablet delayed release 375, 500 EC-Naprosyn naproxen oral suspension 125 /5ml Naprosyn naproxen oral tablet 250, 500 Naprosyn naproxen oral tablet 375 naproxen sodium oral tablet 275 oxaprozin oral tablet 600 Daypro 5
piroxicam oral capsule 10, 20 Feldene sulindac oral tablet 150, 200 tolmetin sodium oral capsule 400 tolmetin sodium oral tablet 200, 600 *Pyrimidine Synthesis Inhibitors*** leflunomide oral tablet 10, 20 Arava *Soluble Tumor Necrosis Factor Receptor Agents*** ENBREL SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 25 MG/0.5ML, 50 PA MG/ML ENBREL SURECLICK SUBCUTANEOUS SOLUTION AUTO-INJECTOR 50 PA MG/ML *ANALGESICS - NONNARCOTIC* *Analgesics-Sedatives*** butalbital-acetaminophen oral tablet 50-325 Tencon butalbital-apap-caffeine oral capsule 50-300- 40 Fioricet butalbital-apap-caffeine oral capsule 50-325- 40 Esgic butalbital-apap-caffeine oral tablet 50-325-40 Esgic butalbital-asa-caffeine oral capsule 50-325-40 Fiorinal *Salicylate Combinations*** choline & mag trisalicylate oral tablet 1000 choline-mag trisalicylate oral liquid 500 /5ml *Salicylates*** diflunisal oral tablet 500 salsalate oral tablet 500, 750 Disalcid *ANALGESICS - OPIOID* *Codeine Combinations*** acetaminophen-codeine #2 oral tablet 300-15 30 days supply allowed per 180 days. Maximum 15 days supply per fill. 6
acetaminophen-codeine #3 oral tablet 300-30 acetaminophen-codeine #4 oral tablet 300-60 acetaminophen-codeine oral solution 120-12 /5ml butalbital-apap-caff-cod oral capsule 50-300- 40-30 butalbital-apap-caff-cod oral capsule 50-325- 40-30 butalbital-asa-caff-codeine oral capsule 50-325-40-30 *Hydrocodone Combinations*** hydrocodone-acetaminophen oral solution 7.5-325 /15ml hydrocodone-acetaminophen oral tablet 10-325, 5-325 hydrocodone-acetaminophen oral tablet 2.5-325 hydrocodone-acetaminophen oral tablet 7.5-325 Tylenol with Codeine #3 Tylenol with Codeine #4 Fioricet/Codeine Ascomp-Codeine Hycet Lortab Verdrocet Lortab hydrocodone-ibuprofen oral tablet 10-200 Reprexain hydrocodone-ibuprofen oral tablet 5-200 hydrocodone-ibuprofen oral tablet 7.5-200 Reprexain 30 days supply allowed per 180 days. Maximum 15 days supply per fill. 30 days supply allowed per 180 days. Maximum 15 days supply per fill. PA; 30 days supply allowed per 180 days. Maximum 15 days supply per fill. 30 days supply allowed per 180 days. Maximum 15 days supply per fill. 30 days supply allowed per 180 days. Maximum 15 days supply per fill. PA; 30 days supply allowed per 180 days. Maximum 15 days supply per fill. 30 days supply allowed per 180 days. Maximum 15 days supply per fill. 30 days supply allowed per 180 days. Maximum 15 days supply per fill.; QLL (240 EA per 30 30 days supply allowed per 180 days. Maximum 15 days supply per fill. 30 days supply allowed per 180 days. Maximum 15 days supply per fill.; QLL (120 EA per 15 PA; 30 days supply allowed per 180 days. Maximum 15 days supply per fill. 30 days supply allowed per 180 days. Maximum 15 days supply per fill. PA; 30 days supply allowed per 180 days. Maximum 15 days supply per fill. 7
*Opioid Agonists*** codeine sulfate oral tablet 15, 30, 60 fentanyl citrate buccal lozenge on a handle 1200 mcg, 1600 mcg, 200 mcg, 400 mcg, 600 mcg, 800 mcg fentanyl transdermal patch 72 hour 100 mcg/hr Actiq Duragesic-100 fentanyl transdermal patch 72 hour 12 mcg/hr Duragesic-12 fentanyl transdermal patch 72 hour 25 mcg/hr Duragesic-25 fentanyl transdermal patch 72 hour 50 mcg/hr Duragesic-50 fentanyl transdermal patch 72 hour 75 mcg/hr Duragesic-75 30 days supply allowed per 180 days. Maximum 15 days supply per fill.; QLL (4 EA per 1 day) 30 days supply allowed per 180 days. Maximum 15 days supply per fill.; QLL (4 EA per 1 day) PA; QLL (10 Patches per 30 PA; QLL (10 Patches per 30 PA; QLL (10 Patches per 30 PA; QLL (10 Patches per 30 PA; QLL (10 Patches per 30 hydromorphone hcl injection solution 2 /ml Dilaudid hydromorphone hcl oral tablet 2, 4 Dilaudid 30 days supply allowed per 180 days. Maximum 15 days supply per fill. hydromorphone hcl oral tablet 8 Dilaudid 30 days supply allowed per 180 days. Maximum 15 days supply per fill.; QLL (120 EA per 30 hydromorphone hcl pf injection solution 10 /ml, 50 /5ml, 500 /50ml hydromorphone hcl rectal suppository 3 methadone hcl oral concentrate 10 /ml Methadose methadone hcl oral solution 10 /5ml, 5 /5ml PA methadone hcl oral tablet 10, 5 Dolophine PA; QLL (180 EA per 30 methadone hcl oral tablet soluble 40 Methadose QLL (180 EA per 30 morphine sulfate (concentrate) oral solution 100 /5ml, 20 /ml morphine sulfate er oral capsule extended release 24 hour 10, 100, 20, 30, 50, 60, 80 morphine sulfate er oral tablet extended release 100, 15, 200, 30, 60 morphine sulfate injection solution 2 /ml, 4 /ml, 5 /ml 8 Kadian MS Contin PA 30 days supply allowed per 180 days. Maximum 15 days supply per fill. PA 30 days supply allowed per 180 days. Maximum 15 days supply per fill.
morphine sulfate oral solution 10 /5ml, 20 /5ml morphine sulfate oral tablet 15, 30 morphine sulfate rectal suppository 10, 20, 30, 5 oxycodone hcl oral capsule 5 oxycodone hcl oral concentrate 100 /5ml oxycodone hcl oral solution 5 /5ml oxycodone hcl oral tablet 10, 20 oxycodone hcl oral tablet 15, 30 oxycodone hcl oral tablet 5 oxymorphone hcl er oral tablet extended release 12 hour 10, 15, 20, 30, 40, 5, 7.5 oxymorphone hcl oral tablet 10, 5 tramadol hcl oral tablet 50 *Opioid Combinations*** oxycodone-acetaminophen oral tablet 10-325, 5-325, 7.5-325 Roxicodone Roxicodone Opana Ultram Endocet PA; 30 days supply allowed per 180 days. Maximum 15 days supply per fill. 30 days supply allowed per 180 days. Maximum 15 days supply per fill. 30 days supply allowed per 180 days. Maximum 15 days supply per fill. 30 days supply allowed per 180 days. Maximum 15 days supply per fill.; QLL (8 EA per 1 day) 30 days supply allowed per 180 days. Maximum 15 days supply per fill. 30 days supply allowed per 180 days. Maximum 15 days supply per fill. 30 days supply allowed per 180 days. Maximum 15 days supply per fill.; QLL (150 EA per 30 30 days supply allowed per 180 days. Maximum 15 days supply per fill.; QLL (150 EA per 30 30 days supply allowed per 180 days. Maximum 15 days supply per fill.; QLL (240 EA per 30 PA; ST 30 days supply allowed per 180 days. Maximum 15 days supply per fill. PA; 30 days supply allowed per 180 days. Maximum 15 days supply per fill.; QLL (240 EA per 30 30 days supply allowed per 180 days. Maximum 15 days supply per fill.; QLL (240 EA per 30 9
oxycodone-acetaminophen oral tablet 2.5-325 oxycodone-aspirin oral tablet 4.8355-325 *Opioid Partial Agonists*** buprenorphine hcl sublingual tablet sublingual 2, 8 buprenorphine hcl-naloxone hcl sublingual tablet sublingual 2-0.5, 8-2 pentazocine-naloxone hcl oral tablet 50-0.5 *Tramadol Combinations*** tramadol-acetaminophen oral tablet 37.5-325 *ANDROGENS-ANABOLIC* *Androgens*** danazol oral capsule 100, 200, 50 testosterone cypionate intramuscular solution 100 /ml, 200 /ml testosterone enanthate intramuscular solution 200 /ml testosterone transdermal gel 10 /act (2%) Percocet Ultracet Depo-Testosterone Fortesta testosterone transdermal gel 12.5 /act (1%) Vogelxo Pump testosterone transdermal gel 25 /2.5gm AndroGel (1%) testosterone transdermal gel 50 /5gm (1%) AndroGel ANDROID ORAL CAPSULE 10 MG MethylTESTOSTERone *ANORECTAL AGENTS* *Intrarectal Steroids*** hydrocortisone rectal enema 100 /60ml Cortenema CORTIFOAM RECTAL FOAM 10 % *Nitrate Vasodilating Agents*** RECTIV RECTAL OINTMENT 0.4 % 30 days supply allowed per 180 days. Maximum 15 days supply per fill.; QLL (240 EA per 30 30 days supply allowed per 180 days. Maximum 15 days supply per fill. PA; QLL (60 EA per 30 ; AL (Min 18 Years) PA; QLL (60 EA per 30 ; AL (Min 18 Years) 30 days supply allowed per 180 days. Maximum 15 days supply per fill. PA; 30 days supply allowed per 180 days. Maximum 15 days supply per fill.; QLL (240 EA per 30 PA; QLL (1 ML per 28 QLL (5 ML per 30 PA; QLL (2 canisters per 30 Days) PA; QLL (4 canisters per 30 PA PA; QLL (60 GM per 30 Days) PA; QLL (30 gm per 30 10
*Rectal Anesthetic/Steroids*** lidocaine-hydrocortisone ace rectal cream 3-0.5 % LidaZone HC lidocaine-hydrocortisone ace rectal kit 3-0.5 %, 3-1 % PROCTOFOAM HC RECTAL FOAM 1-1 % *Rectal Steroids*** PROCTO-PAK RECTAL CREAM 1 % Hydrocortisone PROCTOSOL HC RECTAL CREAM 2.5 % Hydrocortisone PROCTOZONE-HC RECTAL CREAM 2.5 % Hydrocortisone *ANTHELMINTICS* *Anthelmintics*** reeses pinworm medicine oral suspension 144 /ml OTC reeses pinworm medicine oral tablet 180 OTC ALBENZA ORAL TABLET 200 MG *ANTIANGINAL AGENTS* *Nitrates*** isosorbide dinitrate er oral tablet extended release 40 isosorbide dinitrate oral tablet 10, 20, 30 isosorbide dinitrate oral tablet 5 Isordil Titradose isosorbide mononitrate er oral tablet extended release 24 hour 120, 30, 60 isosorbide mononitrate oral tablet 10, 20 nitroglycerin er oral capsule extended release Nitro-Time 2.5, 6.5, 9 nitroglycerin sublingual tablet sublingual 0.3, 0.4, 0.6 Nitrostat nitroglycerin transdermal patch 24 hour 0.1 /hr, 0.4 /hr Nitro-Dur nitroglycerin transdermal patch 24 hour 0.2 /hr, 0.6 /hr Minitran nitroglycerin translingual solution 0.4 /spray Nitrolingual 11
NITRO-BID TRANSDERMAL OINTMENT 2 % NITRO-TIME ORAL CAPSULE EXTENDED RELEASE 2.5 MG, 6.5 MG, 9 Nitroglycerin ER MG *ANTIANXIETY AGENTS* *Antianxiety Agents - Misc.*** buspirone hcl oral tablet 10, 15, 5, 7.5 QLL (2 EA per 1 day) hydroxyzine hcl oral syrup 10 /5ml hydroxyzine hcl oral tablet 10, 25, 50 hydroxyzine pamoate oral capsule 100 hydroxyzine pamoate oral capsule 25, 50 Vistaril meprobamate oral tablet 200, 400 *Benzodiazepines*** alprazolam er oral tablet extended release 24 hour 0.5, 1, 2, 3 Xanax XR alprazolam oral tablet 0.25, 0.5, 1, 2 Xanax alprazolam oral tablet dispersible 0.25, 0.5, 1, 2 alprazolam xr oral tablet extended release 24 hour 0.5, 1, 2, 3 Xanax XR chlordiazepoxide hcl oral capsule 10, 25, 5 clorazepate dipotassium oral tablet 15, 3.75 clorazepate dipotassium oral tablet 7.5 Tranxene-T diazepam injection solution 5 /ml diazepam oral solution 1 /ml diazepam oral tablet 10, 2, 5 Valium lorazepam oral tablet 0.5, 1, 2 Ativan oxazepam oral capsule 10, 15, 30 LORAZEPAM INTENSOL ORAL CONCENTRATE 2 MG/ML LORazepam *ANTIARRHYTHMICS* *Antiarrhythmics Type I-A*** disopyramide phosphate oral capsule 100, Norpace 150 12
procainamide hcl injection solution 100 /ml quinidine gluconate er oral tablet extended release 324 quinidine sulfate oral tablet 200, 300 *Antiarrhythmics Type I-B*** mexiletine hcl oral capsule 150, 200, 250 *Antiarrhythmics Type I-C*** flecainide acetate oral tablet 100, 150, 50 propafenone hcl oral tablet 150, 225, 300 *Antiarrhythmics Type Iii*** amiodarone hcl oral tablet 100, 200, 400 *ANTIASTHMATIC AND BRONCHODILATOR AGENTS* *Adrenergic Combinations*** ipratropium-albuterol inhalation solution 0.5-2.5 (3) /3ml ANORO ELLIPTA INHALATION AEROSOL POWDER BREATH ACTIVATED 62.5-25 MCG/INH BREO ELLIPTA INHALATION AEROSOL POWDER BREATH ACTIVATED 100-25 MCG/INH, 200-25 MCG/INH COMBIVENT RESPIMAT INHALATION AEROSOL SOLUTION 20-100 MCG/ACT DULERA INHALATION AEROSOL 100-5 MCG/ACT, 200-5 MCG/ACT STIOLTO RESPIMAT INHALATION AEROSOL SOLUTION 2.5-2.5 MCG/ACT *Anti-Inflammatory Agents*** cromolyn sodium inhalation nebulization solution 20 /2ml *Beta Adrenergics*** albuterol sulfate er oral tablet extended release 12 hour 4, 8 albuterol sulfate inhalation nebulization solution (2.5 /3ml) 0.083% Pacerone VoSpire ER QLL (1 inhaler per 30 Days) QLL (1 EA per 30 QLL (1 EA per 30 ST; QLL (1 inhaler per 30 QLL (15 ML per 1 day) 13
albuterol sulfate inhalation nebulization solution (5 /ml) 0.5% QLL (15 EA per 1 day) albuterol sulfate inhalation nebulization solution 0.63 /3ml, 1.25 /3ml ST; AL (Max 17 Years) albuterol sulfate oral syrup 2 /5ml albuterol sulfate oral tablet 2, 4 levalbuterol tartrate inhalation aerosol 45 mcg/act Xopenex HFA ST; QLL (2 INH per 30 metaproterenol sulfate oral syrup 10 /5ml metaproterenol sulfate oral tablet 10, 20 terbutaline sulfate oral tablet 2.5, 5 ARCAPTA NEOHALER INHALATION CAPSULE 75 MCG QLL (1 Inhaler per 30 STRIVERDI RESPIMAT INHALATION AEROSOL SOLUTION 2.5 MCG/ACT QLL (1 Respimat per 30 VENTOLIN HFA INHALATION AEROSOL SOLUTION 108 (90 BASE) QLL (2 Inhaler per 30 MCG/ACT *Bronchodilators - Anticholinergics*** ipratropium bromide inhalation solution 0.02 % ATROVENT HFA INHALATION AEROSOL SOLUTION 17 MCG/ACT INCRUSE ELLIPTA INHALATION AEROSOL POWDER BREATH QLL (1 Inhaler per 30 ACTIVATED 62.5 MCG/INH *Leukotriene Receptor Antagonists*** montelukast sodium oral packet 4 Singulair AL (Max 2 Years) montelukast sodium oral tablet 10 Singulair montelukast sodium oral tablet chewable 4, 5 Singulair zafirlukast oral tablet 10, 20 Accolate ST *Steroid Inhalants*** budesonide inhalation suspension 0.25 /2ml, 0.5 /2ml Pulmicort QLL (120 ML per 30 budesonide inhalation suspension 1 /2ml Pulmicort 14
FLOVENT DISKUS INHALATION AEROSOL POWDER BREATH ACTIVATED 100 MCG/BLIST, 250 MCG/BLIST, 50 MCG/BLIST PULMICORT FLEXHALER INHALATION AEROSOL POWDER BREATH ACTIVATED 180 MCG/ACT, 90 QLL (1 Bottle per 30 MCG/ACT QVAR INHALATION AEROSOL SOLUTION 40 MCG/ACT, 80 MCG/ACT QLL (1 Inhaler per 30 *Xanthines*** theophylline er oral tablet extended release 12 Theochron hour 100, 200, 300 theophylline er oral tablet extended release 12 hour 450 theophylline er oral tablet extended release 24 hour 400, 600 theophylline oral solution 80 /15ml THEOCHRON ORAL TABLET EXTENDED RELEASE 12 HOUR 100 Theophylline ER MG, 200 MG, 300 MG *ANTICOAGULANTS* *Coumarin Anticoagulants*** warfarin sodium oral tablet 1, 2, 3, Coumadin 4, 5, 6 warfarin sodium oral tablet 10, 2.5, 7.5 Jantoven JANTOVEN ORAL TABLET 1 MG, 10 MG, 2 MG, 2.5 MG, 3 MG, 4 MG, 5 MG, 6 Warfarin Sodium MG, 7.5 MG *Direct Factor Xa Inhibitors*** XARELTO ORAL TABLET 10 MG, 15 MG, 20 MG PA; QLL (30 EA per 30 XARELTO STARTER PACK ORAL TABLET THERAPY PACK 15 & 20 MG PA; QLL (1 FILL per 90 *Heparins And Heparinoid-Like Agents*** heparin sodium (porcine) injection solution 1000 unit/ml, 10000 unit/ml, 20000 unit/ml, 5000 unit/ml heparin sodium (porcine) pf injection solution 5000 unit/0.5ml 15
*Low Molecular Weight Heparins*** enoxaparin sodium injection solution 300 /3ml Lovenox QLL (21 days per 180 enoxaparin sodium subcutaneous solution 100 /ml, 120 /0.8ml, 150 /ml, 30 /0.3ml, 40 /0.4ml, 60 /0.6ml, 80 Lovenox QLL (21 days per 180 /0.8ml FRAGMIN SUBCUTANEOUS SOLUTION 10000 UNIT/ML, 12500 UNIT/0.5ML, 15000 UNIT/0.6ML, 18000 UNT/0.72ML, 2500 UNIT/0.2ML, 5000 QLL (21 days per 180 UNIT/0.2ML, 7500 UNIT/0.3ML, 95000 UNIT/3.8ML *Synthetic Heparinoid-Like Agents*** fondaparinux sodium subcutaneous solution 10 /0.8ml, 2.5 /0.5ml, 5 /0.4ml, 7.5 Arixtra QLL (21 days per 180 /0.6ml *ANTICONVULSANTS* *Anticonvulsants - Benzodiazepines*** clonazepam oral tablet 0.5, 1, 2 KlonoPIN clonazepam oral tablet dispersible 0.125, 0.25, 0.5, 1, 2 diazepam rectal gel 10, 20 Diastat AcuDial QLL (2 Packages per 30 diazepam rectal gel 2.5 Diastat Pediatric QLL (2 Packages per 30 *Anticonvulsants - Misc.*** carbamazepine er oral capsule extended release 12 hour 100, 200, 300 Carbatrol carbamazepine er oral tablet extended release 12 hour 200, 400 TEGretol-XR carbamazepine oral suspension 100 /5ml TEGretol carbamazepine oral tablet 200 TEGretol carbamazepine oral tablet chewable 100 gabapentin oral capsule 100, 300, 400 Neurontin ; QLL (120 EA per 30 ; QLL (6 EA per 1 day) gabapentin oral solution 250 /5ml Neurontin gabapentin oral tablet 600 Neurontin ; QLL (6 EA per 1 day) gabapentin oral tablet 800 Neurontin ; QLL (4.5 EA per 1 day) 16
lamotrigine oral tablet 100, 150, 200, 25 LaMICtal lamotrigine oral tablet chewable 25, 5 LaMICtal levetiracetam er oral tablet extended release 24 hour 500, 750 Keppra XR levetiracetam oral solution 100 /ml Keppra levetiracetam oral tablet 1000, 250, 500, 750 Keppra oxcarbazepine oral suspension 300 /5ml Trileptal oxcarbazepine oral tablet 150, 300, 600 Trileptal primidone oral tablet 250, 50 Mysoline topiramate oral capsule sprinkle 15, 25 Topamax Sprinkle ; QLL (120 EA per 30 topiramate oral tablet 100, 200, 25, 50 Topamax ; QLL (120 EA per 30 zonisamide oral capsule 100, 25 Zonegran zonisamide oral capsule 50 ; QLL (6 EA per 1 day) *Carbamates*** felbamate oral suspension 600 /5ml Felbatol felbamate oral tablet 400, 600 Felbatol *Gaba Modulators*** tiagabine hcl oral tablet 2 Gabitril tiagabine hcl oral tablet 4 Gabitril ; QLL (60 EA per 30 GABITRIL ORAL TABLET 12 MG, 16 MG *Hydantoins*** phenytoin oral suspension 125 /5ml Dilantin phenytoin oral tablet chewable 50 Dilantin Infatabs phenytoin sodium extended oral capsule 100 Dilantin phenytoin sodium extended oral capsule 200, 300 Phenytek DILANTIN ORAL CAPSULE 100 MG Phenytoin Sodium Extended *Succinimides*** ethosuximide oral capsule 250 Zarontin ethosuximide oral solution 250 /5ml Zarontin 17
*Valproic Acid*** divalproex sodium er oral tablet extended release 24 hour 250, 500 Depakote ER divalproex sodium oral tablet delayed release 125, 250, 500 Depakote valproic acid oral capsule 250 Depakene valproic acid oral solution 250 /5ml Depakene *ANTIDEPRESSANTS* *Alpha-2 Receptor Antagonists (Tetracyclics)*** mirtazapine oral tablet 15 Remeron QLL (30 EA per 30 mirtazapine oral tablet 30 Remeron QLL (60 EA per 30 mirtazapine oral tablet 45 Remeron QLL (45 EA per 30 mirtazapine oral tablet 7.5 QLL (30 EA per 30 mirtazapine oral tablet dispersible 15, 45 Remeron SolTab QLL (30 EA per 30 mirtazapine oral tablet dispersible 30 Remeron SolTab QLL (60 EA per 30 *Antidepressants - Misc.*** bupropion hcl er (sr) oral tablet extended release 12 hour 100 Wellbutrin SR QLL (120 EA per 30 bupropion hcl er (sr) oral tablet extended release 12 hour 150 Wellbutrin SR QLL (2 EA per 1 day) bupropion hcl er (sr) oral tablet extended release 12 hour 200 Wellbutrin SR QLL (3 EA per 1 day) bupropion hcl er (xl) oral tablet extended release 24 hour 150 Wellbutrin XL QLL (90 EA per 30 bupropion hcl er (xl) oral tablet extended release 24 hour 300 Wellbutrin XL QLL (3 EA per 1 day) bupropion hcl oral tablet 100 QLL (135 EA per 30 bupropion hcl oral tablet 75 QLL (180 EA per 30 maprotiline hcl oral tablet 25 QLL (9 EA per 1 day) maprotiline hcl oral tablet 50 QLL (5 EA per 1 day) maprotiline hcl oral tablet 75 QLL (3 EA per 1 day) *Modified Cyclics*** trazodone hcl oral tablet 100 QLL (6 EA per 1 day); AL (Min 1 Years) trazodone hcl oral tablet 150 QLL (4 EA per 1 day) trazodone hcl oral tablet 50 QLL (12 EA per 1 day) 18
*Monoamine Oxidase Inhibitors (Maois)*** phenelzine sulfate oral tablet 15 Nardil QLL (6 EA per 1 day) tranylcypromine sulfate oral tablet 10 Parnate QLL (6 EA per 1 day) MARPLAN ORAL TABLET 10 MG *Selective Serotonin Reuptake Inhibitors (Ssris)*** citalopram hydrobromide oral solution 10 /5ml QLL (600 ML per 30 citalopram hydrobromide oral tablet 10, 20, 40 CeleXA QLL (30 EA per 30 escitalopram oxalate oral solution 5 /5ml QLL (600 ML per 30 escitalopram oxalate oral tablet 10, 20, Lexapro 5 QLL (30 EA per 30 fluoxetine hcl oral capsule 10 PROzac QLL (30 EA per 30 fluoxetine hcl oral capsule 20 PROzac QLL (120 EA per 30 fluoxetine hcl oral capsule 40 PROzac QLL (60 EA per 30 fluoxetine hcl oral solution 20 /5ml QLL (600 ML per 30 fluoxetine hcl oral tablet 10 QLL (30 EA per 30 fluvoxamine maleate oral tablet 100 QLL (3 EA per 1 day) fluvoxamine maleate oral tablet 25 QLL (1 EA per 1 day) fluvoxamine maleate oral tablet 50 QLL (2 EA per 1 day) paroxetine hcl oral tablet 10, 20, 30, 40 Paxil QLL (1 EA per 1 day) sertraline hcl oral concentrate 20 /ml Zoloft QLL (300 ML per 30 sertraline hcl oral tablet 100 Zoloft QLL (75 EA per 30 sertraline hcl oral tablet 25 Zoloft QLL (30 Tablet per 30 sertraline hcl oral tablet 50 Zoloft QLL (60 Tablet per 30 *Serotonin-Norepinephrine Reuptake Inhibitors (Snris)*** duloxetine hcl oral capsule delayed release particles 20, 30, 60 Cymbalta QLL (2 EA per 1 day) venlafaxine hcl er oral capsule extended release 24 hour 150 Effexor XR QLL (60 EA per 30 venlafaxine hcl er oral capsule extended release 24 hour 37.5, 75 Effexor XR QLL (1 EA per 1 day) venlafaxine hcl oral tablet 100 QLL (3 EA per 1 day) venlafaxine hcl oral tablet 25 QLL (9 EA per 1 day) venlafaxine hcl oral tablet 37.5 QLL (10 EA per 1 day) venlafaxine hcl oral tablet 50 QLL (7 EA per 1 day) 19
venlafaxine hcl oral tablet 75 QLL (5 EA per 1 day) *Tricyclic Agents*** amitriptyline hcl oral tablet 10 QLL (30 Tablets per 1 day) amitriptyline hcl oral tablet 100 QLL (3 Tablets per 1 day) amitriptyline hcl oral tablet 150, 75 QLL (2 Tablets per 1 day) amitriptyline hcl oral tablet 25 Elavil QLL (12 Tablets per 1 day) amitriptyline hcl oral tablet 50 QLL (6 Tablets per 1 day) amoxapine oral tablet 100 QLL (6 EA per 1 day) amoxapine oral tablet 150 QLL (4 EA per 1 day) amoxapine oral tablet 25 QLL (24 EA per 1 day) amoxapine oral tablet 50 QLL (12 EA per 1 day) desipramine hcl oral tablet 10, 25 Norpramin desipramine hcl oral tablet 100, 150, 50, 75 doxepin hcl oral capsule 10 QLL (30 EA per 1 day) doxepin hcl oral capsule 100 QLL (3 EA per 1 day) doxepin hcl oral capsule 150 QLL (2 EA per 1 day) doxepin hcl oral capsule 25 QLL (12 EA per 1 day) doxepin hcl oral capsule 50 QLL (6 EA per 1 day) doxepin hcl oral capsule 75 QLL (4 EA per 1 day) doxepin hcl oral concentrate 10 /ml imipramine hcl oral tablet 10, 25, 50 Tofranil nortriptyline hcl oral capsule 10, 25, 50, 75 Pamelor nortriptyline hcl oral solution 10 /5ml protriptyline hcl oral tablet 10 QLL (6 EA per 1 day) protriptyline hcl oral tablet 5 QLL (12 EA per 1 day) *ANTIDIABETICS* *Alpha-Glucosidase Inhibitors*** acarbose oral tablet 100, 25, 50 Precose *Biguanides*** metformin hcl er oral tablet extended release 24 hour 500, 750 Glucophage XR metformin hcl oral tablet 1000, 500, 850 Glucophage *Diabetic Other*** GLUCAGEN HYPOKIT INJECTION SOLUTION RECONSTITUTED 1 MG 20
*Dipeptidyl Peptidase-4 (Dpp-4) Inhibitors*** alogliptin benzoate oral tablet 12.5, 25, 6.25 TRADJENTA ORAL TABLET 5 MG *Dipeptidyl Peptidase-4 Inhibitor- Biguanide Combinations*** alogliptin-metformin hcl oral tablet 12.5-1000, 12.5-500 JENTADUETO ORAL TABLET 2.5-1000 MG, 2.5-500 MG, 2.5-850 MG JENTADUETO XR ORAL TABLET EXTENDED RELEASE 24 HOUR 2.5-1000 MG JENTADUETO XR ORAL TABLET EXTENDED RELEASE 24 HOUR 5-1000 MG *Dpp-4 Inhibitor-Thiazolidinedione Combinations*** alogliptin-pioglitazone oral tablet 12.5-15, 12.5-30, 12.5-45, 25-15, 25-30, 25-45 *Human Insulin*** BASAGLAR KWIKPEN SUBCUTANEOUS SOLUTION PEN- INJECTOR 100 UNIT/ML HUMALOG KWIKPEN SUBCUTANEOUS SOLUTION PEN- INJECTOR 100 UNIT/ML, 200 UNIT/ML HUMALOG MIX 50/50 KWIKPEN SUBCUTANEOUS SUSPENSION PEN- INJECTOR (50-50) 100 UNIT/ML HUMALOG MIX 50/50 SUBCUTANEOUS SUSPENSION (50-50) 100 UNIT/ML HUMALOG MIX 75/25 KWIKPEN SUBCUTANEOUS SUSPENSION PEN- INJECTOR (75-25) 100 UNIT/ML HUMALOG MIX 75/25 SUBCUTANEOUS SUSPENSION (75-25) 100 UNIT/ML HUMALOG SUBCUTANEOUS SOLUTION 100 UNIT/ML Nesina Kazano Oseni ST; ; QLL (30 EA per 30 ST; ; QLL (60 EA per 30 ST; ; QLL (60 EA per 30 ST; ; QLL (30 EA per 30 ; QLL (15 ML per 30 PA; PA; 21
HUMULIN 70/30 SUBCUTANEOUS SUSPENSION (70-30) 100 UNIT/ML ; OTC HUMULIN R INJECTION SOLUTION 100 UNIT/ML ; OTC HUMULIN R U-500 (CONCENTRATED) SUBCUTANEOUS SOLUTION 500 UNIT/ML LANTUS SOLOSTAR SUBCUTANEOUS SOLUTION PEN-INJECTOR 100 UNIT/ML LANTUS SUBCUTANEOUS SOLUTION 100 UNIT/ML LEVEMIR FLEXTOUCH SUBCUTANEOUS SOLUTION PEN- INJECTOR 100 UNIT/ML LEVEMIR SUBCUTANEOUS SOLUTION 100 UNIT/ML NOVOLIN 70/30 RELION SUBCUTANEOUS SUSPENSION (70-30) 100 UNIT/ML NOVOLIN 70/30 SUBCUTANEOUS SUSPENSION (70-30) 100 UNIT/ML NOVOLIN N RELION SUBCUTANEOUS SUSPENSION 100 UNIT/ML NOVOLIN N SUBCUTANEOUS SUSPENSION 100 UNIT/ML NOVOLIN R INJECTION SOLUTION 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 PENFILL SUBCUTANEOUS SOLUTION CARTRIDGE 100 UNIT/ML NOVOLOG SUBCUTANEOUS SOLUTION 100 UNIT/ML ; QLL (15 ML per 30 ; OTC ; OTC ; OTC ; OTC ; OTC ; OTC PA; 22
*Incretin Mimetic Agents (Glp-1 Receptor Agonists)*** TANZEUM SUBCUTANEOUS PEN- INJECTOR 30 MG, 50 MG TRULICITY SUBCUTANEOUS SOLUTION PEN-INJECTOR 0.75 MG/0.5ML, 1.5 MG/0.5ML *Meglitinide Analogues*** ST; ; QLL (4 EA per 30 Days) ST; nateglinide oral tablet 120, 60 Starlix repaglinide oral tablet 0.5 repaglinide oral tablet 1, 2 Prandin *Meglitinide-Biguanide Combinations*** repaglinide-metformin hcl oral tablet 1-500, 2-500 *Sodium-Glucose Co-Transporter 2 (Sglt2) Inhibitors*** INVOKANA ORAL TABLET 100 MG, 300 MG *Sulfonylurea-Biguanide Combinations*** glipizide-metformin hcl oral tablet 2.5-250, 2.5-500, 5-500 glyburide-metformin oral tablet 1.25-250 glyburide-metformin oral tablet 2.5-500, 5-500 *Sulfonylureas*** chlorpropamide oral tablet 100, 250 Glucovance ST; ; QLL (30 EA per 30 glimepiride oral tablet 1, 2, 4 Amaryl glipizide er oral tablet extended release 24 hour 10, 2.5, 5 Glucotrol XL glipizide oral tablet 10, 5 Glucotrol glyburide micronized oral tablet 1.5, 3, Glynase 6 glyburide oral tablet 1.25, 2.5, 5 tolazamide oral tablet 250, 500 tolbutamide oral tablet 500 23
*Sulfonylurea-Thiazolidinedione Combinations*** pioglitazone hcl-glimepiride oral tablet 30-2, 30-4 Duetact *Thiazolidinedione-Biguanide Combinations*** pioglitazone hcl-metformin hcl oral tablet 15-500, 15-850 Actoplus Met *Thiazolidinediones*** pioglitazone hcl oral tablet 15, 30, 45 Actos AVANDIA ORAL TABLET 2 MG, 4 MG ST; *ANTIDIARRHEALS* *Antiperistaltic Agents*** diphenoxylate-atropine oral liquid 2.5-0.025 /5ml diphenoxylate-atropine oral tablet 2.5-0.025 Lomotil lofene oral tablet 2.5-0.025 Lomotil loperamide hcl oral capsule 2 Imodium A-D *ANTIDOTES* *Antidotes - Chelating Agents*** CHEMET ORAL CAPSULE 100 MG *Opioid Antagonists*** naloxone hcl injection solution 0.4 /ml QLL (2 ML Max Qty Per Fill Retail) naltrexone hcl oral tablet 50 NARCAN NASAL LIQUID 4 MG/0.1ML QLL (4 EA Max Qty Per Fill Retail) *ANTIEMETICS* *5-Ht3 Receptor Antagonists*** granisetron hcl oral tablet 1 ondansetron hcl oral solution 4 /5ml Zofran ondansetron hcl oral tablet 24 ondansetron hcl oral tablet 4, 8 Zofran ondansetron oral tablet dispersible 4, 8 Zofran ODT *Antiemetics - Anticholinergic*** trimethobenzamide hcl oral capsule 300 Tigan 24
*Substance P/Neurokinin 1 (Nk1) Receptor Antagonists*** EMEND ORAL CAPSULE 125 MG, 40 MG, 80 & 125 MG, 80 MG Aprepitant *ANTIFUNGALS* *Antifungals*** griseofulvin microsize oral suspension 125 /5ml griseofulvin microsize oral tablet 500 griseofulvin ultramicrosize oral tablet 125, Gris-PEG 250 nystatin oral tablet 500000 unit terbinafine hcl oral tablet 250 LamISIL QLL (84 EA per 365 *Imidazoles*** ketoconazole oral tablet 200 *Triazoles*** fluconazole oral suspension reconstituted 10 /ml, 40 /ml Diflucan fluconazole oral tablet 100, 150, 200, 50 Diflucan itraconazole oral capsule 100 Sporanox SPORANOX ORAL SOLUTION 10 MG/ML *ANTIHISTAMINES* *Antihistamines - Alkylamines*** brompheniramine tannate oral tablet chewable 12 *Antihistamines - Ethanolamines*** carbinoxamine maleate oral tablet 4 clemastine fumarate oral tablet 2.68 *Antihistamines - Non-Sedating*** cetirizine hcl oral syrup 1 /ml, 5 /5ml ZyrTEC Childrens Allergy QLL (150 ML per 30 *Antihistamines - Phenothiazines*** promethazine hcl oral solution 6.25 /5ml promethazine hcl oral syrup 6.25 /5ml promethazine hcl oral tablet 12.5, 25, 50 promethazine hcl rectal suppository 12.5, 25 Phenergan 25
*Antihistamines - Piperidines*** cyproheptadine hcl oral syrup 2 /5ml cyproheptadine hcl oral tablet 4 *ANTIHYPERLIPIDEMICS* *Bile Acid Sequestrants*** cholestyramine light oral packet 4 gm Prevalite cholestyramine oral packet 4 gm Questran colestipol hcl oral granules 5 gm Colestid colestipol hcl oral packet 5 gm Colestid colestipol hcl oral tablet 1 gm Colestid *Fibric Acid Derivatives*** fenofibrate micronized oral capsule 134, 200, 67 Lofibra fenofibrate oral tablet 145, 48 Tricor fenofibrate oral tablet 160, 54 Lofibra fenofibric acid oral capsule delayed release 135, 45 Trilipix gemfibrozil oral tablet 600 Lopid ; QLL (60 EA per 30 *H Coa Reductase Inhibitors*** atorvastatin calcium oral tablet 10, 20, 40, 80 fluvastatin sodium er oral tablet extended release 24 hour 80 fluvastatin sodium oral capsule 20 fluvastatin sodium oral capsule 40 lovastatin oral tablet 10, 20 lovastatin oral tablet 40 pravastatin sodium oral tablet 10 pravastatin sodium oral tablet 20, 40, 80 simvastatin oral tablet 10, 20, 40, 5 simvastatin oral tablet 80 Lipitor Lescol XL Lescol Mevacor Pravachol Zocor Zocor ; QLL (30 EA per 30 ; QLL (30 EA per 30 ; QLL (2 EA per 1 day) ; QLL (2 EA per 1 day) ; QLL (1 EA per 1 day) ; QLL (2 EA per 1 day) ; QLL (60 EA per 30 ; QLL (1 EA per 1 day) ; QLL (1 EA per 1 day) ; QLL (30 EA per 30 26
CRESTOR ORAL TABLET 10 MG, 20 MG, 40 MG, 5 MG *Intestinal Cholesterol Absorption Inhibitors*** Rosuvastatin Calcium ezetimibe oral tablet 10 Zetia ST; *ANTIHYPERTENSIVES* *Ace Inhibitor & Calcium Channel Blocker Combinations*** amlodipine besy-benazepril hcl oral capsule 10-20, 10-40, 5-10, 5-20 Lotrel amlodipine besy-benazepril hcl oral capsule 2.5-10, 5-40 *Ace Inhibitors & Thiazide/Thiazide- Like*** benazepril-hydrochlorothiazide oral tablet 10- Lotensin HCT 12.5, 20-12.5, 20-25 benazepril-hydrochlorothiazide oral tablet 5-6.25 captopril-hydrochlorothiazide oral tablet 25-15, 25-25, 50-15, 50-25 enalapril-hydrochlorothiazide oral tablet 10-25 Vaseretic enalapril-hydrochlorothiazide oral tablet 5-12.5 fosinopril sodium-hctz oral tablet 10-12.5, 20-12.5 lisinopril-hydrochlorothiazide oral tablet 10-12.5, 20-12.5, 20-25 Zestoretic moexipril-hydrochlorothiazide oral tablet 15-12.5, 15-25, 7.5-12.5 quinapril-hydrochlorothiazide oral tablet 10-12.5, 20-12.5, 20-25 Accuretic *Ace Inhibitors*** benazepril hcl oral tablet 10, 20, 40 Lotensin benazepril hcl oral tablet 5 captopril oral tablet 100, 12.5, 25, 50 enalapril maleate oral tablet 10, 2.5, 20, 5 Vasotec fosinopril sodium oral tablet 10, 20, 40 PA; ; QLL (30 gm per 30 27
lisinopril oral tablet 10, 2.5, 20, 30, 5 lisinopril oral tablet 40 Zestril Zestril moexipril hcl oral tablet 15, 7.5 perindopril erbumine oral tablet 2 perindopril erbumine oral tablet 4, 8 Aceon quinapril hcl oral tablet 10, 20, 40, Accupril 5 ramipril oral capsule 1.25, 10, 2.5, Altace 5 trandolapril oral tablet 1, 2, 4 Mavik *Adrenolytics-Central & Thiazide/Thiazide-Like Comb*** methyldopa-hydrochlorothiazide oral tablet 250-15, 250-25 *Angiotensin Ii Receptor Antag & Ca Channel Blocker Comb*** amlodipine besylate-valsartan oral tablet 10- Exforge 160, 10-320, 5-160, 5-320 *Angiotensin Ii Receptor Antag & Thiazide/Thiazide-Like*** candesartan cilexetil-hctz oral tablet 16-12.5 Atacand HCT, 32-12.5, 32-25 irbesartan-hydrochlorothiazide oral tablet Avalide 150-12.5, 300-12.5 losartan potassium-hctz oral tablet 100-12.5 Hyzaar, 100-25, 50-12.5 valsartan-hydrochlorothiazide oral tablet 160-12.5, 160-25, 320-12.5, 320-25, Diovan HCT 80-12.5 *Angiotensin Ii Receptor Antagonists*** candesartan cilexetil oral tablet 16, 32, Atacand 4, 8 irbesartan oral tablet 150, 300, 75 Avapro losartan potassium oral tablet 100, 25, Cozaar 50 valsartan oral tablet 160, 320, 40, Diovan 80 ; QLL (30 EA per 30 ; QLL (60 EA per 30 ; QLL (30 EA per 30 Days) ; QLL (1 EA per 1 day) ; QLL (60 EA per 30 28
*Angiotensin Ii Receptor Ant-Ca Channel Blocker-Thiazides*** amlodipine-valsartan-hctz oral tablet 10-160- 12.5, 10-160-25, 10-320-25, 5-160- 12.5, 5-160-25 *Antiadrenergics - Centrally Acting*** clonidine hcl oral tablet 0.1, 0.2, 0.3 clonidine hcl transdermal patch weekly 0.1 /24hr clonidine hcl transdermal patch weekly 0.2 /24hr clonidine hcl transdermal patch weekly 0.3 /24hr guanfacine hcl oral tablet 1 guanfacine hcl oral tablet 2 Exforge HCT Catapres Catapres-TTS-1 Catapres-TTS-2 Catapres-TTS-3 ST; ; QLL (30 EA per 30 methyldopa oral tablet 250, 500 *Antiadrenergics - Peripherally Acting*** doxazosin mesylate oral tablet 1, 2, 4, 8 Cardura prazosin hcl oral capsule 1, 2, 5 Minipress ; QLL (240 EA per 30 ; QLL (120 EA per 30 ; QLL (1 EA per 1 day) terazosin hcl oral capsule 1, 2, 5 ; QLL (1 EA per 1 day) terazosin hcl oral capsule 10 ; QLL (2 EA per 1 day) *Beta Blocker & Diuretic Combinations*** atenolol-chlorthalidone oral tablet 100-25 Tenoretic 100 atenolol-chlorthalidone oral tablet 50-25 Tenoretic 50 bisoprolol-hydrochlorothiazide oral tablet 10-6.25, 2.5-6.25, 5-6.25 Ziac metoprolol-hydrochlorothiazide oral tablet 100-25, 100-50 metoprolol-hydrochlorothiazide oral tablet 50-25 Lopressor HCT nadolol-bendroflumethiazide oral tablet 40-5, 80-5 Corzide 29
propranolol-hctz oral tablet 40-25, 80-25 *Vasodilators*** hydralazine hcl oral tablet 10, 100, 25, 50 minoxidil oral tablet 10, 2.5 *ANTI-INFECTIVE AGENTS - MISC.* *Anti-Infective Agents - Misc.*** metronidazole oral capsule 375 Flagyl metronidazole oral tablet 250, 500 Flagyl trimethoprim oral tablet 100 vancomycin hcl oral capsule 125 Vancocin HCl QLL (56 EA per 30 FIRST-VANCOMYCIN 25 ORAL SOLUTION 25 MG/ML FIRST-VANCOMYCIN 50 ORAL SOLUTION 50 MG/ML *Anti-Infective Misc. - Combinations*** sulfamethoxazole-trimethoprim oral suspension 200-40 /5ml Sulfatrim Pediatric sulfamethoxazole-trimethoprim oral tablet 400-80 Bactrim *Leprostatics*** dapsone oral tablet 100, 25 *Lincosamides*** clindamycin hcl oral capsule 150, 300, Cleocin 75 clindamycin palmitate hcl oral solution reconstituted 75 /5ml Cleocin *ANTIMALARIALS* *Antimalarials*** chloroquine phosphate oral tablet 250, 500 hydroxychloroquine sulfate oral tablet 200 Plaquenil mefloquine hcl oral tablet 250 primaquine phosphate oral tablet 26.3 DARAPRIM ORAL TABLET 25 MG PA 30
*ANTIMYASTHENIC AGENTS* *Antimyasthenic Agents*** pyridostigmine bromide oral tablet 60 Mestinon *ANTIMYCOBACTERIAL AGENTS* *Antimycobacterial Agents*** ethambutol hcl oral tablet 100, 400 Myambutol isoniazid injection solution 100 /ml isoniazid oral syrup 50 /5ml isoniazid oral tablet 100, 300 pyrazinamide oral tablet 500 rifabutin oral capsule 150 Mycobutin rifampin oral capsule 150, 300 Rifadin PRIFTIN ORAL TABLET 150 MG *ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES* *Alkylating Agents*** HEXALEN ORAL CAPSULE 50 MG MYLERAN ORAL TABLET 2 MG *Antiandrogens*** bicalutamide oral tablet 50 Casodex flutamide oral capsule 125 nilutamide oral tablet 150 Nilandron ; QLL (60 EA per 30 *Antiestrogens*** tamoxifen citrate oral tablet 10, 20 FARESTON ORAL TABLET 60 MG SOLTAMOX ORAL SOLUTION 10 MG/5ML *Antimetabolites*** capecitabine oral tablet 150 Xeloda PA; capecitabine oral tablet 500 Xeloda PA; ; QLL (154 EA per 21 floxuridine injection solution reconstituted 0.5 gm mercaptopurine oral tablet 50 methotrexate oral tablet 2.5 TABLOID ORAL TABLET 40 MG 31
*Antineoplastic - Tyrosine Kinase Inhibitors*** imatinib mesylate oral tablet 100, 400 Gleevec CABOMETYX ORAL TABLET 20 MG, 40 MG, 60 MG IMBRUVICA ORAL CAPSULE 140 MG TYKERB ORAL TABLET 250 MG VOTRIENT ORAL TABLET 200 MG *Antineoplastics - Photoactivated Agents*** UVADEX INJECTION SOLUTION 20 MCG/ML *Antineoplastics Misc.*** hydroxyurea oral capsule 500 Hydrea MATULANE ORAL CAPSULE 50 MG *Aromatase Inhibitors*** anastrozole oral tablet 1 Arimidex exemestane oral tablet 25 Aromasin letrozole oral tablet 2.5 Femara *Folic Acid Antagonists Rescue Agents*** leucovorin calcium oral tablet 10, 15, 25, 5 *Gonadotropin Releasing Hormone (Gnrh) Antagonists*** FIRMAGON SUBCUTANEOUS SOLUTION RECONSTITUTED 120 MG, 80 MG *Imidazotetrazines*** temozolomide oral capsule 100, 140, 180, 20, 250, 5 Temodar *Lhrh Analogs*** TRELSTAR MIXJECT INTRAMUSCULAR SUSPENSION PA; RECONSTITUTED 22.5 MG VANTAS SUBCUTANEOUS KIT 50 MG PA; PA; PA; ; QLL (30 EA per 30 Days) PA; ; QLL (120 EA per 30 PA; ; QLL (180 EA per 30 PA; ; QLL (120 EA per 30 Days) 32
*Mitotic Inhibitors*** etoposide oral capsule 50 *Nitrogen Mustards*** ALKERAN ORAL TABLET 2 MG LEUKERAN ORAL TABLET 2 MG *Progestins-Antineoplastic*** hydroxyprogesterone caproate intramuscular solution 1.25 gm/5ml megestrol acetate oral suspension 40 /ml, 400 /10ml Megace Oral megestrol acetate oral tablet 20, 40 *Retinoids*** tretinoin oral capsule 10 *Selective Retinoid X Receptor Agonists*** bexarotene oral capsule 75 Targretin *Urinary Tract Protective Agents*** MESNEX ORAL TABLET 400 MG *ANTIPARKINSON AGENTS* *Antiparkinson Anticholinergics*** benztropine mesylate oral tablet 0.5, 1, 2 trihexyphenidyl hcl oral elixir 0.4 /ml trihexyphenidyl hcl oral tablet 2, 5 *Antiparkinson Dopaminergics*** amantadine hcl oral capsule 100 amantadine hcl oral syrup 50 /5ml amantadine hcl oral tablet 100 bromocriptine mesylate oral capsule 5 Parlodel bromocriptine mesylate oral tablet 2.5 Parlodel *Antiparkinson Monoamine Oxidase Inhibitors*** selegiline hcl oral capsule 5 Eldepryl selegiline hcl oral tablet 5 *Levodopa Combinations*** carbidopa-levodopa er oral tablet extended release 25-100, 50-200 Sinemet CR 33