MEDICAID FORMULARY Effective November 2017

MEDICAID FORMULARY Effective November 2017 Provided by EnvisionRx Introduction The Total Health Care (THC) Medicaid Formulary was developed to serve as a guide for physicians, pharmacists, health care professionals and members in the selection of cost-effective drug therapy. Total Health Care recognizes that drug therapy is an integral part of effective health management. In order to streamline drug coverage policies for Medicaid members and providers, the Michigan Department of Health and Human Services (MDHHS) has worked with Medicaid health plan providers, including Total Health Care, to create a formulary that is common across all contracted Medicaid Health. This is known as the Michigan Medicaid Managed Care Common Formulary. Total Health Care continually reviews new and existing medications to ensure the Formulary remains responsive to the needs of our members and health professionals. Criteria used to evaluate drug selection for the formulary includes, but is not limited to: safety, efficacy and cost-effectiveness data, as well as comparison of relevant benefits of similar prescription or over-the counter (OTC) agents while minimizing potential duplications. Notice The information contained in this formulary is provided by THC, solely for the convenience of medical providers and members. THC does not warrant or assure accuracy of this information, nor is it intended to be comprehensive in nature. This formulary is not intended to be a substitute for the knowledge, expertise, skill or judgment of the medical provider in their choice of prescription drugs. Total Health Care assumes no responsibility for the actions or omissions of any medical provider based upon reliance, in whole or in part, on the information contained herein. The medical provider should consult the drug manufacturer s product literature or standard references for more detailed information. How to Read the Formulary Drug Name All formulary drugs are listed either by their generic names (in lowercase) or by their brand names (in uppercase). Drugs are grouped together by their therapeutic drug category. Specific drug listings may be accessed by using the index, using the covered generic name or the covered brand name of the drug. The i

brand names listed are for reference use only, and do not denote coverage, unless specifically noted. Any drug not found in this Formulary listing shall be considered a non-formulary drug. Requirements/Limits This field includes potential limitations to the formulary drug. It also may contain additional information about the coverage of the drug such as applicable quantity limits (QL). For certain agents within the Medicaid Formulary, a recommended prescribing guideline may apply. Prescribing Guidelines Prescribing guidelines may apply to select drugs on the THC formulary. Prescribing guidelines may vary by benefit design but may include: Prior Authorization Required () Over the Counter Drugs (OTC) Specialty Drugs (SP) Quantity Limit (QL) Age Limit (AL) Drug requires prior authorization through a specific physician request process. Drug coverage is available for drugs that are available OTC with an authorized prescription from your provider. Drug requires processing through THC s contracted specialty pharmacy, Envision Specialty Pharmacy. Drug coverage may be limited to specific quantities per prescription and/or time period. Drug coverage may depend on patient age. Gender Restriction (GR) Drug coverage may depend on patient gender. Step Therapy Required (ST) Custom (C) Drug coverage requires that an alternative or trial of another drug be used before the medication is covered. Drug coverage has unique restrictions. Benefit Coverage and Limitations This formulary does not define benefit coverage and limitations. Members should contact Total Health Care at 1-800-826-2862 if they have questions regarding their coverage. Please note that the formulary process is evolutionary and changes can occur throughout the year. Prior Authorization () Drugs indicated with a require Prior Authorization for coverage. A prescriber may complete a Prior Authorization form that can be found on the Total Health Care website at www.thcmi.com. You may also request a form by calling Total Health Care at 1-844-222-5584. Completed prior authorization forms should be faxed to 1-866-422-9119. Prior Authorization review of prescribing guidelines will be evaluated utilizing the established drug review criteria approved by Total Health Care. If the request does not meet the approved ii

criteria, the request will not be approved and alternative therapy may be recommended along with the proper course of alternative action. The requesting provider will be provided written notification of Total Health Care review decisions. THC s website has a contact link where members can contact THC s Pharmacy Department to ask for an exception request. Non-Formulary Agents Drugs not found on the Total Health Care Medicaid Formulary, or any updates published by Total Health Care, shall be considered a non-formulary drug. Requests for coverage of non-formulary agents may be requested by the health professional depending on specific coverage parameters. Review for non-formulary drug requests will require a Prior Authorization request with documentation of medical necessity. Generally, the following basic medical necessity guidelines are used in conducting a review: The patient has failed an appropriate trial of formulary or preferred agents. The use of preferred or formulary agent is contraindicated in the patient. The formulary drug or preferred agents are not suited for the present patient care need, and the drug selected is required for patient safety. If the request does not meet the established guidelines request, it will not be approved and alternative therapy may be recommended along with the proper course of alternative action. Common Drug Exclusions The member s plan design may exclude certain drug classes. Prior authorization is generally not available for drugs that are specifically excluded by benefit design. Common excluded coverage may include, but are not limited to: Drug products used for cosmetic purposes. Drug products for erectile dysfunction. Drug products for infertility treatment. Experimental drug products or any drug product used in an experimental manner. Drug products identified by the Drug Efficacy Study Implementation (DESI) as being category 5 (less-than-effective for all indications) or category 6 (removed from the market). Foreign drugs or drugs not approved by the United States Food & Drug Administration (FDA). Medicaid Fee-For-Service Carve Out List The State of Michigan has a carve-out list for the Medicaid formulary. The carve-out drugs include mental health, HIV/AIDS, Oncology, Hemophilia and other miscellaneous drugs that have been added to the State's 100% carve-out list. These drugs must be billed directly by the pharmacies at point-of-sale to the Michigan Department of Community Health's contracted Pharmacy Benefits Manager (PBM). A list of the carve-out drugs can be found at https://michigan.fhsc.com/providers/druginfo.asp. Mandated Generic Substitution Total Health Care advocates the use of cost-effective generic drugs where FDA- approved generic equivalent drugs are available. Generic products are listed in the Formulary and noted as generic wherever an FDAapproved generic drug product is available. The brand names listed in the formulary are for reference only. iii

Total Health Care Pharmacy and Therapeutics (P&T) Committee Total Health Care s Pharmacy & Therapeutics Committee meets quarterly to review and recommend medications for formulary consideration. The Committee considers clinical information on drugs that are new to the market and drugs that are typically included in an outpatient pharmacy benefit. This assures that the formulary remains responsive to patient and physician needs. The Committee is composed of physicians, pharmacists, and health care professionals. The Committee also uses reference materials from our Pharmacy Benefits Manager's Pharmacy and Therapeutics Advisory Panel. Product Selection Criteria The primary goal of the THC Pharmacy & Therapeutics Committee is to maintain and update the formulary based upon an objective analysis of the safety, efficacy, approved indications, adverse effects, contraindications, patient administration/compliance considerations and cost effectiveness of available drugs. When a drug is considered for formulary inclusion, it will be reviewed relative to similar drugs including those currently in the THC Formulary. Physicians may request a copy of THC s drug criteria by calling the Pharmacy Department at 1-800-826-2862. Diabetic Testing Supplies Total Health Care works with J&B Medical Supply to provide diabetic testing supplies to our members. Covered diabetic testing supplies include Glucocard Vital glucometer, Glucocard Expression glucometer, and SD Biosensor GlucoNavii glucometer, Glucocard Vital test strips, Glucocard Expression test strips, SD Biosensor GlucoNavii test strips, lancets, insulin syringes, alcohol swabs and ketone strips. These supplies are to be filled through J&B Medical Supply. If you have any questions about our diabetic supply program, please contact J&B Medical Supply at 1-844-236-7933. Specialty Bio-Pharmaceutical Pharmacy Program Total Health Care works with Envision Specialty Pharmacy to provide Specialty Bio-Pharmaceutical Pharmacy products to our members. These medications are to be filled exclusively through Envision Specialty Pharmacy. A Specialty Drug Prior Authorization Request form must be completed and faxed to EnvisionRx at 1-866- 422-9119 with supporting documentation and the prescription. A prescriber may obtain a Specialty Drug Prior Authorization Request form found on the Total Health Care website at www.thcmi.com. Once the order is received, EnvisionRx obtains authorization from Total Health Care. If the specialty prior authorization is approved, Total Health Care notifies Envision Specialty Pharmacy. Then, Envision Specialty Pharmacy staff ships the medication directly to the physician's office or the patient s home. All packages are individually marked for each patient and refrigerated items are shipped in insulated containers. Where appropriate, each shipment includes needles, syringes and alcohol swabs. If you have any questions about our Specialty Bio-Pharmaceutical Pharmacy program, please contact EnvisionRx at 1-844-222-5584 or Envision Specialty Pharmacy at 1-866-909-5170. Contact Information The Total Health Care Medicaid formulary is designed to assist physicians, members and other health care professionals in the selection of cost-effective agents. Total Health Care encourages your input and feedback on how we can assist in improving this document and the formulary management process. You may contact THC at 1-800-826-2862. iv

Medication Limitations Quantity Limitations Quantity Limitations are on medications throughout the formulary and are indicated with a "QL" notation. These are medications that have a daily dose restriction, quantity/days supply limitation, and/or a limitation on the duration of therapy. Age Limitations Age Limitations are on medications throughout the formulary and are indicated with an "AL" notation. Coverage for a medication is indicated by the age limitation. This could be a minimum age, maximum age, and/or the combination of a minimum and maximum age edit. Gender Restrictions Gender restrictions are indicated with a GR on the formulary and require the member to be a specific gender for coverage. Step Therapy Criteria Step Therapy medications are indicated with a ST on the formulary and require that an alternative, first line medication be tried and failed before the requested medication can be covered. The online claims adjudication system will automatically allow for the requested medication to be filled based on electronic claims history indicating that the first line medication was filled. Step-Therapy Criteria Therapy Class First Line Second Line Third Line Step Therapy Criteria 5-Aminosalicylic Acid Derivative Agents balsalazide sulfasalazine sulfasalazine dr APRISO, DELZICOL ASACOL HD, PENTASA Second Line: Prior use of balsalazide or sulfasalazine/dr within the last 180 days. Antiemetics Antimigraine Agents Immunosuppressant Agents ondansetron tablet, ondansetron odt, ondansetron solution naratriptan, rizatriptan, rizatriptan odt, sumatriptan tablet, sumatriptan injection ( required) mycophenolate tablet, capsule, suspension granisetron tablet zolmitriptan, zolmitriptan odt mycophenolic acid dr tablet Third Line: Prior use of APRISO or DELZICOL within the last 180 days. Prior use of ondansetron within the last 180 days. Prior use of TWO first line agents within the last 180 days. Prior use of mycophenolate tablet, capsule, or suspension within the last 180 days. v

Pediculicides permethrin 1% lotion, pyrethrins-piperonyl butoxide Urinary Antispasmodics oxybutynin tablet, oxybutynin er tablet, oxybutynin syrup malathion 0.5% lotion tolterodine ir tablet, tolterodine er capsule, trospium ir tablet Prior use of permethrin 1% lotion or pyrethrinspiperonyl butoxide in the last 180 days. Prior use of oxybutynin tablet/syrup in the last 180 days. *Formulary Disclaimer: Coverage for some drugs may be limited to specific dosage forms and/or strengths. The benefit design determines what is covered. The medications listed on this formulary are subject to change pursuant to the formulary management activities of EnvisionRx. The presence of a medication on this formulary list does not guarantee coverage. vi

lowercase italics = Generic drugs UPPERCASE BOLD = Brand name drugs Status = Covered Drug Status Notes *Adhd/Anti-Narcolepsy/Anti- Obesity/Anorexiants* Notes AL = Age Limit GR-F = Female Only GR-M = Male Only = Prior Authorization QL = Quantity Limit ST = Step Therapy caffeine citrate oral solution 20 /ml AL (Max 1 Years) *Aminoglycosides* BETHKIS INHALATION NEBULIZATION SOLUTION 300 MG/4ML KITABIS K INHALATION NEBULIZATION SOLUTION 300 MG/5ML neomycin sulfate oral tablet 500 paromomycin sulfate oral capsule 250 TOBI PODHALER INHALATION CAPSULE 28 MG tobramycin inhalation nebulization solution 300 /5ml *Analgesics - Anti-Inflammatory* celecoxib oral capsule 100, 200, 400, 50 diclofenac sodium er oral tablet extended release 24 hour 100 diclofenac sodium oral tablet delayed release 25, 50, 75 ENBREL SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 25 MG/0.5ML ENBREL SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 50 MG/ML ENBREL SUBCUTANEOUS SOLUTION RECONSTITUTED 25 MG ENBREL SURECLICK SUBCUTANEOUS SOLUTION AUTO-INJECTOR 50 MG/ML ; ; QL (2.04 ML per 28 days) ; QL (3.92 ML per 28 days) ; QL (4 EA per 28 days) ; QL (3.92 ML per 28 days) etodolac oral capsule 200, 300 QL (60 EA per 30 days) etodolac oral tablet 400, 500 QL (60 EA per 30 days) fenoprofen calcium oral tablet 600 flurbiprofen oral tablet 100, 50 HUMIRA PEN SUBCUTANEOUS PEN- INJECTOR KIT 40 MG/0.8ML ; QL (4 EA per 28 days) 1

HUMIRA SUBCUTANEOUS PREFILLED SYRINGE KIT 10 MG/0.2ML, 20 MG/0.4ML HUMIRA SUBCUTANEOUS PREFILLED SYRINGE KIT 40 MG/0.8ML ibuprofen junior strength oral tablet chewable 100 ; QL (2 EA per 28 days) ; QL (4 EA per 28 days) ibuprofen oral capsule 200 QL (60 EA per 30 days) ibuprofen oral suspension 100 /5ml QL (480 ML per 30 days) ibuprofen oral tablet 200, 400, 600, 800 INDOCIN ORAL SUSPENSION 25 MG/5ML AL (Max 12 Years) indomethacin er oral capsule extended release 75 AL (Max 64 Years) indomethacin oral capsule 25, 50 AL (Max 64 Years) infants ibuprofen oral suspension 50 /1.25ml ketoprofen oral capsule 50, 75 ketorolac tromethamine oral tablet 10 AL (Max 64 Years) leflunomide oral tablet 10, 20 meloxicam oral tablet 15, 7.5 nabumetone oral tablet 500, 750 QL (60 EA per 30 days) naproxen dr oral tablet delayed release 375, 500 naproxen oral tablet 250, 375, 500 naproxen sodium oral capsule 220 naproxen sodium oral tablet 220 QL (90 EA per 30 days) piroxicam oral capsule 10, 20 sm ibuprofen jr oral tablet 100 sulindac oral tablet 150, 200 *Analgesics - Nonnarcotic* ACEPHEN RECTAL SUPPOSITORY 325 MG acetaminophen 8 hour oral tablet 650 acetaminophen er oral tablet extended release 650 acetaminophen extra strength oral tablet 500 acetaminophen oral elixir 160 /5ml acetaminophen oral liquid 160 /5ml acetaminophen oral solution 160 /5ml acetaminophen oral suspension 160 /5ml acetaminophen oral tablet 325 2

acetaminophen oral tablet chewable 80 acetaminophen rapid tabs child oral tablet dispersible 80 acetaminophen rectal suppository 120, 650 apap 500 oral liquid 500 /5ml aspirin ec low dose oral tablet delayed release 81 aspirin ec oral tablet delayed release 325 aspirin oral tablet 325 ; AL (Min 40 Years and Max 79 Years) ; AL (Min 40 Years and Max 79 Years) aspirin oral tablet chewable 81 aspirin rectal suppository 300, 600 buffered aspirin oral tablet 325 butalbital-acetaminophen oral tablet 50-325 butalbital-apap-caffeine oral capsule 50-325-40 butalbital-apap-caffeine oral tablet 50-325-40 butalbital-aspirin-caffeine oral capsule 50-325- 40 choline-mag trisalicylate oral liquid 500 /5ml eq acetaminophen junior oral tablet dispersible 160 extra strength acetaminophen oral capsule 500 infants pain relief oral suspension 80 /0.8ml non-aspirin extra strength oral tablet dispersible 500 pain relief childrens oral suspension 160 /5ml q-pap infants oral solution 80 /0.8ml *Analgesics - Opioid* AL (Min 40 Years and Max 79 Years) QL (120 EA per 30 days); AL (Min 10 Years and Max 64 Years) QL (120 EA per 30 days); AL (Min 10 Years and Max 64 Years) QL (120 EA per 30 days); AL (Min 10 Years and Max 64 Years) QL (120 EA per 30 days); AL (Max 64 Years) acetaminophen-codeine #2 oral tablet 300-15 QL (180 EA per 30 days) acetaminophen-codeine #3 oral tablet 300-30 QL (180 EA per 30 days) acetaminophen-codeine #4 oral tablet 300-60 QL (180 EA per 30 days) acetaminophen-codeine oral solution 120-12 /5ml butalbital-apap-caff-cod oral capsule 50-325-40-30 QL (240 ML per 30 days) QL (120 EA per 30 days) 3

butalbital-asa-caff-codeine oral capsule 50-325- 40-30 QL (120 EA per 30 days) codeine sulfate oral tablet 15, 30, 60 QL (180 EA per 30 days) fentanyl transdermal patch 72 hour 100 mcg/hr, 12 mcg/hr, 25 mcg/hr, 50 mcg/hr, 75 mcg/hr hydrocodone-acetaminophen oral solution 7.5-325 /15ml hydrocodone-acetaminophen oral tablet 10-325, 7.5-325 ; QL (10 EA per 30 days) QL (480 ML per 30 days) QL (180 EA per 30 days) hydrocodone-acetaminophen oral tablet 5-325 QL (360 EA per 30 days) hydromorphone hcl oral liquid 1 /ml QL (960 ML per 30 days) hydromorphone hcl oral tablet 2, 4, 8 QL (240 EA per 30 days) hydromorphone hcl rectal suppository 3 QL (120 EA per 30 days) meperidine hcl oral solution 50 /5ml meperidine hcl oral tablet 100, 50 METHADONE HCL INTENSOL ORAL CONCENTRATE 10 MG/ML QL (300 ML per 30 days); AL (Max 64 Years) QL (180 EA per 30 days); AL (Max 64 Years) QL (240 ML per 30 days) methadone hcl oral solution 10 /5ml QL (600 ML per 30 days) methadone hcl oral solution 5 /5ml QL (900 ML per 30 days) methadone hcl oral tablet 10, 5 QL (240 EA per 30 days) methadone hcl oral tablet soluble 40 QL (90 EA per 30 days) morphine sulfate (concentrate) oral solution 100 /5ml morphine sulfate er oral tablet extended release 100, 15, 200, 30, 60 morphine sulfate oral solution 10 /5ml, 20 /5ml QL (240 ML per 30 days) QL (90 EA per 30 days) QL (240 ML per 30 days) morphine sulfate oral tablet 15, 30 QL (180 EA per 30 days) oxycodone hcl oral solution 5 /5ml QL (600 ML per 30 days) oxycodone hcl oral tablet 10, 15, 20, 30, 5 oxycodone-acetaminophen oral tablet 10-325, 7.5-325 QL (180 EA per 30 days) QL (180 EA per 30 days) oxycodone-acetaminophen oral tablet 5-325 QL (360 EA per 30 days) pentazocine-naloxone hcl oral tablet 50-0.5 QL (360 EA per 30 days) tramadol hcl oral tablet 50 QL (240 EA per 30 days) *Androgens-Anabolic* danazol oral capsule 100, 200, 50 4

testosterone cypionate intramuscular solution 100 /ml, 200 /ml *Anorectal Agents* hydrocortisone rectal cream 1 % hydrocortisone rectal enema 100 /60ml PROCTOZONE-HC RECTAL CREAM 2.5 % *Antacids* ACID GONE ORAL SUSPENSION 95-358 MG/15ML aluminum hydroxide gel oral suspension 320 /5ml antacid calcium extra strength oral tablet chewable 750 antacid plus anti-gas fast act oral suspension 200-200-20 /5ml antacid/simethicone ds oral suspension 400-400- 40 /5ml calcium antacid ultra oral tablet chewable 1000 calcium carbonate antacid oral tablet chewable 500 magnesium oxide oral capsule 400 magnesium oxide oral tablet 250, 400 MAOX ORAL TABLET 420 MG ri-mox oral suspension 225-200 /5ml sodium bicarbonate oral tablet 325, 650 URO-MAG ORAL CAPSULE 140 MG *Anthelmintics* ivermectin oral tablet 3 PIN-X ORAL SUSPENSION 50 MG/ML PIN-X ORAL TABLET CHEWABLE 720.5 MG *Antianginal Agents* isosorbide dinitrate er oral tablet extended release 40 isosorbide dinitrate oral tablet 10, 20, 30, 5 isosorbide mononitrate er oral tablet extended release 24 hour 120, 30, 60 isosorbide mononitrate oral tablet 10, 20 GR-M 5

NITRO-BID TRANSDERMAL OINTMENT 2 % nitroglycerin er oral capsule extended release 2.5, 6.5, 9 nitroglycerin sublingual tablet sublingual 0.3, 0.4, 0.6 nitroglycerin transdermal patch 24 hour 0.1 /hr, 0.2 /hr, 0.4 /hr, 0.6 /hr nitroglycerin translingual solution 0.4 /spray RANEXA ORAL TABLET EXTENDED RELEASE 12 HOUR 1000 MG, 500 MG *Antianxiety Agents* hydroxyzine hcl oral syrup 10 /5ml AL (Max 12 Years) hydroxyzine hcl oral tablet 10, 25, 50 AL (Max 64 Years) hydroxyzine pamoate oral capsule 100, 25, 50 *Antiarrhythmics* amiodarone hcl oral tablet 100, 200, 400 disopyramide phosphate oral capsule 100, 150 flecainide acetate oral tablet 100, 150, 50 mexiletine hcl oral capsule 150, 200, 250 propafenone hcl oral tablet 150, 225, 300 quinidine sulfate er oral tablet extended release 300 quinidine sulfate oral tablet 200, 300 *Antiasthmatic And Bronchodilator Agents* AEROSN INHALATION AEROSOL SOLUTION 80 MCG/ACT albuterol sulfate inhalation nebulization solution (2.5 /3ml) 0.083%, (5 /ml) 0.5% albuterol sulfate inhalation nebulization solution 0.63 /3ml, 1.25 /3ml albuterol sulfate oral syrup 2 /5ml ATROVENT HFA INHALATION AEROSOL SOLUTION 17 MCG/ACT AL (Max 64 Years) AL (Max 64 Years) QL (8.9 GM per 30 days) QL (225 ML per 30 days) QL (12.9 GM per 30 days) 6

budesonide inhalation suspension 0.25 /2ml, 0.5 /2ml, 1 /2ml COMBIVENT RESPIMAT INHALATION AEROSOL SOLUTION 20-100 MCG/ACT cromolyn sodium inhalation nebulization solution 20 /2ml DULERA INHALATION AEROSOL 100-5 MCG/ACT, 200-5 MCG/ACT fluticasone-salmeterol aerosol powder breath activated 113-14 mcg/act inhalation 113-14 mcg/act fluticasone-salmeterol aerosol powder breath activated 232-14 mcg/act inhalation 232-14 mcg/act fluticasone-salmeterol aerosol powder breath activated 55-14 mcg/act inhalation 55-14 mcg/act FORADIL AEROLIZER INHALATION CAPSULE 12 MCG INCRUSE ELLIPTA INHALATION AEROSOL POWDER BREATH ACTIVATED 62.5 MCG/INH ipratropium bromide inhalation solution 0.02 % ipratropium-albuterol inhalation solution 0.5-2.5 (3) /3ml metaproterenol sulfate oral tablet 10, 20 montelukast sodium oral packet 4 QL (120 ML per 30 days); AL (Max 6 Years) QL (4 GM per 30 days) QL (13 GM per 30 days) QL (1 EA per 30 days) QL (1 EA per 30 days) QL (1 EA per 30 days) QL (60 EA per 30 days) QL (90 ML per 30 days) ; AL (Max 5 Years) montelukast sodium oral tablet 10 montelukast sodium oral tablet chewable 4, 5 PULMICORT FLEXHALER INHALATION AEROSOL POWDER BREATH ACTIVATED 180 MCG/ACT, 90 MCG/ACT QVAR INHALATION AEROSOL SOLUTION 40 MCG/ACT, 80 MCG/ACT SEREVENT DISKUS INHALATION AEROSOL POWDER BREATH ACTIVATED 50 MCG/DOSE STRIVERDI RESPIMAT INHALATION AEROSOL SOLUTION 2.5 MCG/ACT SYMBICORT INHALATION AEROSOL 160-4.5 MCG/ACT, 80-4.5 MCG/ACT terbutaline sulfate oral tablet 2.5, 5 QL (1 EA per 30 days) QL (8.7 GM per 30 days) QL (60 EA per 30 days) QL (4 GM per 30 days) QL (10.2 GM per 30 days) 7

theophylline er oral tablet extended release 12 hour 100, 200, 300, 450 theophylline er oral tablet extended release 24 hour 600 theophylline oral elixir 80 /15ml theophylline oral solution 80 /15ml VENTOLIN HFA INHALATION AEROSOL SOLUTION 108 (90 BASE) MCG/ACT *Anticoagulants* enoxaparin sodium subcutaneous solution 100 /ml, 120 /0.8ml, 150 /ml, 30 /0.3ml, 40 /0.4ml, 60 /0.6ml, 80 /0.8ml heparin sodium (porcine) injection solution 10000 unit/ml, 20000 unit/ml, 5000 unit/ml heparin sodium (porcine) pf injection solution 5000 unit/0.5ml warfarin sodium oral tablet 1, 10, 2, 2.5, 3, 4, 5, 6, 7.5 XARELTO ORAL TABLET 10 MG, 15 MG, 20 MG *Antidiabetics* QL (18 GM per 25 days) ; acarbose oral tablet 100 QL (120 EA per 30 days) acarbose oral tablet 25, 50 QL (90 EA per 30 days) alogliptin benzoate oral tablet 12.5, 25, 6.25 alogliptin-metformin hcl oral tablet 12.5-1000, 12.5-500 alogliptin-pioglitazone oral tablet 12.5-15, 12.5-30, 12.5-45, 25-15, 25-30, 25-45 APIDRA INJECTION SOLUTION 100 UNIT/ML APIDRA SOLOSTAR SUBCUTANEOUS SOLUTION PEN-INJECTOR 100 UNIT/ML BASAGLAR KWIKPEN SOLUTION PEN- INJECTOR 100 UNIT/ML SUBCUTANEOUS 100 UNIT/ML ; QL (60 ML per 30 days) QL (60 ML per 30 days); AL (Max 21 Years) QL (30 ML per 30 days) chlorpropamide oral tablet 100, 250 AL (Max 64 Years) FARXIGA ORAL TABLET 10 MG, 5 MG ; glimepiride oral tablet 1, 2, 4 glipizide er oral tablet extended release 24 hour 10, 2.5, 5 8

glipizide oral tablet 10, 5 glipizide-metformin hcl oral tablet 2.5-250, 2.5-500, 5-500 GLUCAGEN HYPOKIT INJECTION SOLUTION RECONSTITUTED 1 MG GLUCAGON EMERGENCY INJECTION KIT 1 MG glyburide micronized oral tablet 1.5, 3, 6 glyburide oral tablet 1.25, 2.5, 5 glyburide-metformin oral tablet 1.25-250, 2.5-500, 5-500 HUMALOG KWIKPEN SUBCUTANEOUS SOLUTION PEN-INJECTOR 100 UNIT/ML HUMALOG MIX 50/50 KWIKPEN SUBCUTANEOUS SUSPENSION PEN- INJECTOR (50-50) 100 UNIT/ML HUMALOG MIX 50/50 SUBCUTANEOUS SUSPENSION (50-50) 100 UNIT/ML HUMALOG MIX 75/25 KWIKPEN SUBCUTANEOUS SUSPENSION PEN- INJECTOR (75-25) 100 UNIT/ML HUMALOG MIX 75/25 SUBCUTANEOUS SUSPENSION (75-25) 100 UNIT/ML HUMALOG SUBCUTANEOUS SOLUTION 100 UNIT/ML HUMALOG SUBCUTANEOUS SOLUTION CARTRIDGE 100 UNIT/ML HUMULIN 70/30 KWIKPEN SUBCUTANEOUS SUSPENSION PEN- INJECTOR (70-30) 100 UNIT/ML HUMULIN 70/30 SUBCUTANEOUS SUSPENSION (70-30) 100 UNIT/ML HUMULIN N KWIKPEN SUBCUTANEOUS SUSPENSION PEN-INJECTOR 100 UNIT/ML HUMULIN N SUBCUTANEOUS SUSPENSION 100 UNIT/ML HUMULIN R INJECTION SOLUTION 100 UNIT/ML HUMULIN R U-500 (CONCENTRATED) SUBCUTANEOUS SOLUTION 500 UNIT/ML INVOKANA ORAL TABLET 100 MG, 300 MG QL (1 EA per 30 days) QL (1 EA per 30 days) QL (60 ML per 30 days); AL (Max 21 Years) QL (30 ML per 30 days); AL (Max 21 Years) QL (60 ML per 30 days) QL (60 ML per 30 days); AL (Max 21 Years) QL (60 ML per 30 days) QL (60 ML per 30 days) QL (60 ML per 30 days) QL (60 ML per 30 days); AL (Max 21 Years) QL (60 ML per 30 days) QL (60 ML per 30 days); AL (Max 21 Years) QL (60 ML per 30 days) QL (60 ML per 30 days) ; 9

JANUMET ORAL TABLET 50-1000 MG, 50-500 MG JANUMET XR ORAL TABLET EXTENDED RELEASE 24 HOUR 100-1000 MG, 50-1000 MG, 50-500 MG JANUVIA ORAL TABLET 100 MG, 25 MG, 50 MG JENTADUETO ORAL TABLET 2.5-1000 MG, 2.5-500 MG, 2.5-850 MG LANTUS SOLOSTAR SOLUTION PEN- INJECTOR 100 UNIT/ML SUBCUTANEOUS 100 UNIT/ML LANTUS SUBCUTANEOUS SOLUTION 100 UNIT/ML metformin hcl er oral tablet extended release 24 hour 500, 750 metformin hcl oral tablet 1000, 500, 850 ; QL (60 EA per 30 days) ; ; ; QL (60 EA per 30 days) QL (60 ML per 30 days); AL (Max 21 Years) QL (60 ML per 30 days) nateglinide oral tablet 120, 60 QL (90 EA per 30 days) NOVOLIN 70/30 SUBCUTANEOUS SUSPENSION (70-30) 100 UNIT/ML NOVOLIN N SUBCUTANEOUS SUSPENSION 100 UNIT/ML NOVOLIN R 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 QL (60 ML per 30 days) QL (60 ML per 30 days) QL (60 ML per 30 days) QL (60 ML per 30 days); AL (Max 21 Years) QL (60 ML per 30 days); AL (Max 21 Years) QL (60 ML per 30 days) QL (60 ML per 30 days) QL (60 ML per 30 days) pioglitazone hcl oral tablet 15, 30, 45 repaglinide oral tablet 0.5, 1, 2 QL (120 EA per 30 days) TANZEUM SUBCUTANEOUS PEN- INJECTOR 30 MG, 50 MG tolazamide oral tablet 250, 500 tolbutamide oral tablet 500 ; QL (4 EA per 28 days) TRADJENTA ORAL TABLET 5 MG ; 10

VICTOZA SUBCUTANEOUS SOLUTION PEN-INJECTOR 18 MG/3ML *Antidiarrheals* diphenoxylate-atropine oral liquid 2.5-0.025 /5ml diphenoxylate-atropine oral tablet 2.5-0.025 loperamide hcl oral capsule 2 loperamide hcl oral suspension 1 /7.5ml paregoric oral tincture 2 /5ml pink bismuth maximum strength oral suspension 525 /15ml pink bismuth oral suspension 262 /15ml pink bismuth oral tablet chewable 262 SOOTHE ORAL TABLET 262 MG *Antidotes* CHEMET ORAL CAPSULE 100 MG naloxone hcl injection solution 0.4 /ml, 1 /ml ; QL (6 ML per 30 days) QL (2 ML per 90 days) NARCAN NASAL LIQUID 4 MG/0.1ML QL (2 EA per 90 days) *Antiemetics* dimenhydrinate oral tablet 50 dronabinol oral capsule 10, 2.5, 5 granisetron hcl oral tablet 1 ST; QL (4 EA per 30 days) meclizine hcl oral tablet 12.5, 25 meclizine hcl oral tablet chewable 25 ondansetron hcl oral solution 4 /5ml QL (300 ML per 30 days); AL (Max 12 Years) ondansetron hcl oral tablet 24 ondansetron hcl oral tablet 4, 8 QL (90 EA per 30 days) ondansetron oral tablet dispersible 4, 8 QL (90 EA per 30 days) *Antifungals* fluconazole oral suspension reconstituted 10 /ml, 40 /ml fluconazole oral tablet 100, 150, 200, 50 griseofulvin microsize oral suspension 125 /5ml griseofulvin microsize oral tablet 500 griseofulvin ultramicrosize oral tablet 125, 250 AL (Max 12 Years) 11

itraconazole oral capsule 100 ketoconazole oral tablet 200 QL (60 EA per 30 days) nystatin oral tablet 500000 unit terbinafine hcl oral tablet 250 *Antihistamines* carbinoxamine maleate oral solution 4 /5ml carbinoxamine maleate oral tablet 4 cetirizine hcl allergy child oral solution 5 /5ml QL (300 ML per 30 days); AL (Max 12 Years) cetirizine hcl oral tablet 10, 5 childrens loratadine oral syrup 5 /5ml chlorpheniramine maleate er oral tablet extended release 12 chlorpheniramine maleate oral tablet 4 clemastine fumarate oral syrup 0.67 /5ml clemastine fumarate oral tablet 1.34, 2.68 QL (300 ML per 30 days); AL (Max 12 Years) cyproheptadine hcl oral syrup 2 /5ml AL (Max 64 Years) cyproheptadine hcl oral tablet 4 AL (Max 64 Years) diphenhydramine hcl injection solution 50 /ml AL (Max 64 Years) diphenhydramine hcl oral capsule 25, 50 AL (Max 64 Years) diphenhydramine hcl oral elixir 12.5 /5ml diphenhydramine hcl oral liquid 12.5 /5ml diphenhydramine hcl oral tablet 25 AL (Max 64 Years) loratadine oral tablet 10 promethazine hcl oral syrup 6.25 /5ml promethazine hcl oral tablet 12.5, 25, 50 promethazine hcl rectal suppository 12.5, 25, 50 *Antihyperlipidemics* atorvastatin calcium oral tablet 10, 20, 40, 80 AL (Min 2 Years and Max 64 Years) AL (Min 2 Years and Max 64 Years) AL (Min 2 Years and Max 64 Years) cholestyramine light oral packet 4 gm QL (60 EA per 30 days) cholestyramine oral packet 4 gm QL (60 EA per 30 days) cholestyramine oral powder 4 gm/dose QL (378 GM per 30 days) colestipol hcl oral granules 5 gm colestipol hcl oral tablet 1 gm ezetimibe oral tablet 10 ; 12

fenofibrate micronized oral capsule 134, 200, 43, 67 fenofibrate oral capsule 50 fenofibrate oral tablet 145, 160, 48, 54 fenofibric acid oral capsule delayed release 135, 45 fenofibric acid oral tablet 105, 35 gemfibrozil oral tablet 600 QL (60 EA per 30 days) lovastatin oral tablet 10, 20 lovastatin oral tablet 40 QL (60 EA per 30 days) omega-3-acid ethyl esters oral capsule 1 gm pravastatin sodium oral tablet 10, 20, 40, 80 PREVALITE ORAL POWDER 4 GM/DOSE QL (240 GM per 30 days) rosuvastatin calcium oral tablet 10, 20, 40, 5 simvastatin oral tablet 10, 20, 40, 5, 80 *Antihypertensives* amlodipine besy-benazepril hcl oral capsule 10-20, 10-40, 2.5-10, 5-10, 5-20, 5-40 amlodipine besylate-valsartan oral tablet 10-160, 10-320, 5-160, 5-320 atenolol-chlorthalidone oral tablet 100-25, 50-25 benazepril hcl oral tablet 10, 20, 5 QL (45 EA per 30 days) benazepril hcl oral tablet 40 QL (60 EA per 30 days) benazepril-hydrochlorothiazide oral tablet 10-12.5, 20-12.5, 20-25, 5-6.25 bisoprolol-hydrochlorothiazide oral tablet 10-6.25 bisoprolol-hydrochlorothiazide oral tablet 2.5-6.25, 5-6.25 captopril oral tablet 100, 12.5, 25, 50 captopril-hydrochlorothiazide oral tablet 25-15, 25-25, 50-15, 50-25 clonidine hcl oral tablet 0.1, 0.2, 0.3 QL (60 EA per 30 days) QL (45 EA per 30 days) doxazosin mesylate oral tablet 1, 2, 4 doxazosin mesylate oral tablet 8 QL (60 EA per 30 days) 13

enalapril maleate oral tablet 10, 2.5, 5 QL (45 EA per 30 days) enalapril maleate oral tablet 20 QL (60 EA per 30 days) enalapril-hydrochlorothiazide oral tablet 10-25, 5-12.5 QL (60 EA per 30 days) ENED ORAL SOLUTION 1 MG/ML AL (Max 12 Years) fosinopril sodium oral tablet 10, 20 QL (45 EA per 30 days) fosinopril sodium oral tablet 40 QL (60 EA per 30 days) guanfacine hcl oral tablet 1, 2 QL (60 EA per 30 days) hydralazine hcl injection solution 20 /ml hydralazine hcl oral tablet 10, 25, 50 QL (120 EA per 30 days) hydralazine hcl oral tablet 100 QL (90 EA per 30 days) irbesartan oral tablet 150, 300, 75 irbesartan-hydrochlorothiazide oral tablet 150-12.5, 300-12.5 lisinopril oral tablet 10, 2.5, 20, 30, 40, 5 lisinopril-hydrochlorothiazide oral tablet 10-12.5, 20-12.5, 20-25 losartan potassium oral tablet 100, 25, 50 losartan potassium-hctz oral tablet 100-12.5, 100-25, 50-12.5 methyldopa oral tablet 250, 500 AL (Max 64 Years) methyldopa-hydrochlorothiazide oral tablet 250-15, 250-25 metoprolol-hydrochlorothiazide oral tablet 100-25, 100-50, 50-25 minoxidil oral tablet 10, 2.5 perindopril erbumine oral tablet 2, 4 QL (45 EA per 30 days) prazosin hcl oral capsule 1, 2, 5 QL (60 EA per 30 days) quinapril hcl oral tablet 10, 20, 40, 5 quinapril-hydrochlorothiazide oral tablet 10-12.5, 20-12.5, 20-25 ramipril oral capsule 1.25, 10, 2.5, 5 TEKTURNA HCT ORAL TABLET 150-12.5 MG, 150-25 MG, 300-12.5 MG, 300-25 MG TEKTURNA ORAL TABLET 150 MG, 300 MG ; ; terazosin hcl oral capsule 1, 5 14

terazosin hcl oral capsule 10, 2 QL (60 EA per 30 days) trandolapril oral tablet 1, 2, 4 valsartan oral tablet 160, 40, 80 QL (60 EA per 30 days) valsartan oral tablet 320 valsartan-hydrochlorothiazide oral tablet 160-12.5, 160-25, 320-12.5, 320-25, 80-12.5 *Anti-Infective Agents - Misc.* atovaquone oral suspension 750 /5ml CAYSTON INHALATION SOLUTION RECONSTITUTED 75 MG clindamycin hcl oral capsule 150, 300, 75 clindamycin palmitate hcl oral solution reconstituted 75 /5ml dapsone oral tablet 100, 25 FIRST-VANCOMYCIN 25 ORAL SOLUTION 25 MG/ML FIRST-VANCOMYCIN 50 ORAL SOLUTION 50 MG/ML linezolid oral suspension reconstituted 100 /5ml linezolid oral tablet 600 metronidazole oral tablet 250, 500 sulfamethoxazole-trimethoprim oral suspension 200-40 /5ml sulfamethoxazole-trimethoprim oral tablet 400-80, 800-160 tinidazole oral tablet 250, 500 trimethoprim oral tablet 100 vancomycin hcl intravenous solution reconstituted 10 gm, 1000, 500, 5000, 750 *Antimalarials* chloroquine phosphate oral tablet 250, 500 DARAPRIM ORAL TABLET 25 MG hydroxychloroquine sulfate oral tablet 200 mefloquine hcl oral tablet 250 primaquine phosphate oral tablet 26.3 *Antimyasthenic Agents* AL (Max 12 Years) MESTINON ORAL SYRUP 60 MG/5ML AL (Max 12 Years) 15

pyridostigmine bromide oral tablet 60 *Antimyasthenic/Cholinergic Agents* MESTINON ORAL SYRUP 60 MG/5ML AL (Max 12 Years) pyridostigmine bromide oral tablet 60 *Antimycobacterial Agents* cycloserine oral capsule 250 ethambutol hcl oral tablet 100, 400 isoniazid oral syrup 50 /5ml AL (Max 12 Years) isoniazid oral tablet 100, 300 pyrazinamide oral tablet 500 rifabutin oral capsule 150 rifampin oral capsule 150, 300 TRECATOR ORAL TABLET 250 MG *Antineoplastics And Adjunctive Therapies* AFINITOR DISPERZ ORAL TABLET SOLUBLE 2 MG, 3 MG, 5 MG ; QL (60 EA per 30 days) AFINITOR ORAL TABLET 10 MG ; QL (60 EA per 30 days) AFINITOR ORAL TABLET 2.5 MG, 5 MG ; AFINITOR ORAL TABLET 7.5 MG ALKERAN ORAL TABLET 2 MG anastrozole oral tablet 1 GR-F bexarotene oral capsule 75 bicalutamide oral tablet 50 ; GR-M capecitabine oral tablet 150, 500 cyclophosphamide oral capsule 25, 50 EMCYT ORAL CAPSULE 140 MG ; GR-M ERIVEDGE ORAL CAPSULE 150 MG ; etoposide oral capsule 50 exemestane oral tablet 25 FARESTON ORAL TABLET 60 MG FARYDAK ORAL CAPSULE 10 MG, 15 MG, 20 MG flutamide oral capsule 125 ; GR-M GLEOSTINE ORAL CAPSULE 10 MG, 100 MG, 40 MG HEXALEN ORAL CAPSULE 50 MG HYCAMTIN ORAL CAPSULE 0.25 MG, 1 MG 16

hydroxyurea oral capsule 500 INTRON A INJECTION SOLUTION 10000000 UNIT/ML, 6000000 UNIT/ML INTRON A INJECTION SOLUTION RECONSTITUTED 10000000 UNIT, 18000000 UNIT, 50000000 UNIT JAKAFI ORAL TABLET 10 MG, 15 MG, 20 MG, 25 MG, 5 MG letrozole oral tablet 2.5 leucovorin calcium oral tablet 10, 15, 25, 5 LEUKERAN ORAL TABLET 2 MG leuprolide acetate injection kit 1 /0.2ml LONSURF ORAL TABLET 15-6.14 MG, 20-8.19 MG LYSODREN ORAL TABLET 500 MG MATULANE ORAL CAPSULE 50 MG megestrol acetate oral suspension 400 /10ml megestrol acetate oral tablet 20, 40 GR-F mercaptopurine oral tablet 50 MESNEX ORAL TABLET 400 MG methotrexate oral tablet 2.5 methotrexate sodium (pf) injection solution 25 /ml methotrexate sodium injection solution 25 /ml MYLERAN ORAL TABLET 2 MG nilutamide oral tablet 150 POMALYST ORAL CAPSULE 1 MG, 2 MG, 3 MG, 4 MG TABLOID ORAL TABLET 40 MG ; QL (60 EA per 30 days) ; AL (Min 18 Years) tamoxifen citrate oral tablet 10, 20 GR-F; QL (60 EA per 30 days) temozolomide oral capsule 100, 140, 180, 20, 250, 5 tretinoin oral capsule 10 XTANDI ORAL CAPSULE 40 MG ZOLINZA ORAL CAPSULE 100 MG ZYTIGA ORAL TABLET 250 MG ; GR-M; QL (120 EA per 30 days) ; GR-M; QL (120 EA per 30 days) 17

*Antiparkinson Agents* amantadine hcl oral capsule 100 QL (120 EA per 30 days) amantadine hcl oral syrup 50 /5ml QL (1200 ML per 30 days) amantadine hcl oral tablet 100 bromocriptine mesylate oral capsule 5 bromocriptine mesylate oral tablet 2.5 QL (180 EA per 30 days) carbidopa-levodopa er oral tablet extended release 25-100, 50-200 carbidopa-levodopa oral tablet 10-100, 25-100, 25-250 carbidopa-levodopa oral tablet dispersible 10-100, 25-250 carbidopa-levodopa oral tablet dispersible 25-100 pramipexole dihydrochloride oral tablet 0.125, 0.25, 0.5, 0.75, 1, 1.5 ropinirole hcl oral tablet 0.25, 0.5, 1, 2, 3, 4, 5 QL (90 EA per 30 days) QL (90 EA per 30 days) selegiline hcl oral capsule 5 QL (60 EA per 30 days) *Antipsychotics/Antimanic Agents* prochlorperazine maleate oral tablet 10, 5 QL (120 EA per 30 days) prochlorperazine rectal suppository 25 QL (60 EA per 30 days) *Antiseptics & Disinfectants* povidone-iodine external solution 10 % *Antivirals* acyclovir oral capsule 200 acyclovir oral suspension 200 /5ml AL (Max 12 Years) acyclovir oral tablet 400, 800 adefovir dipivoxil oral tablet 10 entecavir oral tablet 0.5, 1 famciclovir oral tablet 125, 250, 500 QL (90 EA per 30 days) lamivudine oral tablet 100 oseltamivir phosphate oral capsule 30, 45, 75 RELENZA DISKHALER INHALATION AEROSOL POWDER BREATH ACTIVATED 5 MG/BLISTER rimantadine hcl oral tablet 100 TAMIFLU ORAL SUSPENSION RECONSTITUTED 6 MG/ML 18 QL (20 EA per 180 days) QL (20 EA per 180 days); AL (Min 5 Years) QL (120 ML per 180 days); AL (Max 12 Years)

valacyclovir hcl oral tablet 1 gm QL (90 EA per 30 days) valacyclovir hcl oral tablet 500 valganciclovir hcl oral tablet 450 ; QL (60 EA per 30 days) VEMLIDY ORAL TABLET 25 MG ; *Assorted Classes* azathioprine oral tablet 50 QL (240 EA per 30 days) cyclosporine modified oral capsule 100, 25, 50 cyclosporine modified oral solution 100 /ml AL (Max 12 Years) cyclosporine oral capsule 100, 25 mycophenolate mofetil oral capsule 250 mycophenolate mofetil oral suspension reconstituted 200 /ml mycophenolate mofetil oral tablet 500 mycophenolic acid oral tablet delayed release 180, 360 REVLIMID ORAL CAPSULE 10 MG, 15 MG, 25 MG, 5 MG REVLIMID ORAL CAPSULE 2.5 MG, 20 MG sirolimus oral tablet 0.5, 1, 2 sodium polystyrene sulfonate oral powder sodium polystyrene sulfonate rectal suspension 30 gm/120ml SPS ORAL SUSPENSION 15 GM/60ML sterile water for irrigation irrigation solution tacrolimus oral capsule 0.5, 1, 5 THALOMID ORAL CAPSULE 100 MG, 150 MG, 200 MG, 50 MG *Beta Blockers* acebutolol hcl oral capsule 200, 400 atenolol oral tablet 100, 25, 50 betaxolol hcl oral tablet 10, 20 AL (Max 12 Years) ST ; bisoprolol fumarate oral tablet 10 QL (60 EA per 30 days) bisoprolol fumarate oral tablet 5 QL (45 EA per 30 days) carvedilol oral tablet 12.5, 25, 3.125, 6.25 HEMANGEOL ORAL SOLUTION 4.28 MG/ML labetalol hcl oral tablet 100, 200, 300 AL (Max 4 Years) 19

metoprolol succinate er oral tablet extended release 24 hour 100, 25, 50 metoprolol succinate er oral tablet extended release 24 hour 200 metoprolol tartrate oral tablet 100, 25, 50 nadolol oral tablet 20, 40, 80 pindolol oral tablet 10, 5 propranolol hcl er oral capsule extended release 24 hour 120, 160 propranolol hcl er oral capsule extended release 24 hour 60 propranolol hcl er oral capsule extended release 24 hour 80 propranolol hcl oral solution 20 /5ml, 40 /5ml propranolol hcl oral tablet 10, 20, 40, 60, 80 QL (45 EA per 30 days) QL (60 EA per 30 days) QL (60 EA per 30 days) QL (120 EA per 30 days) QL (90 EA per 30 days) sotalol hcl (af) oral tablet 120, 160, 80 QL (60 EA per 30 days) sotalol hcl oral tablet 120, 160, 240, 80 timolol maleate oral tablet 10, 20, 5 *Calcium Channel Blockers* amlodipine besylate oral tablet 10, 2.5, 5 CARTIA XT ORAL CAPSULE EXTENDED RELEASE 24 HOUR 120 MG, 240 MG, 300 MG CARTIA XT ORAL CAPSULE EXTENDED RELEASE 24 HOUR 180 MG diltiazem hcl er beads oral capsule extended release 24 hour 420 diltiazem hcl er oral capsule extended release 24 hour 120, 180 diltiazem hcl oral tablet 120, 30, 60, 90 dilt-xr oral capsule extended release 24 hour 240 felodipine er oral tablet extended release 24 hour 10 felodipine er oral tablet extended release 24 hour 2.5, 5 QL (60 EA per 30 days) QL (60 EA per 30 days) QL (60 EA per 30 days) isradipine oral capsule 2.5, 5 QL (60 EA per 30 days) 20

MATZIM LA ORAL TABLET EXTENDED RELEASE 24 HOUR 180 MG, 300 MG nicardipine hcl oral capsule 20, 30 NIFEDICAL XL ORAL TABLET EXTENDED RELEASE 24 HOUR 30 MG, 60 MG nifedipine er oral tablet extended release 24 hour 30, 60, 90 nifedipine er osmotic release oral tablet extended release 24 hour 90 nifedipine oral capsule 10, 20 nimodipine oral capsule 30 TAZTIA XT ORAL CAPSULE EXTENDED RELEASE 24 HOUR 120 MG, 180 MG, 240 MG, 300 MG, 360 MG verapamil hcl er oral capsule extended release 24 hour 100, 120, 180, 200, 240, 300 verapamil hcl er oral tablet extended release 120, 180, 240 verapamil hcl oral tablet 120, 40, 80 *Cardiotonics* digoxin oral tablet 125 mcg, 250 mcg *Cardiovascular Agents - Misc.* QL (120 EA per 30 days); AL (Max 64 Years) ADCIRCA ORAL TABLET 20 MG ; QL (60 EA per 30 days) ADEMS ORAL TABLET 0.5 MG, 1 MG, 1.5 MG, 2 MG, 2.5 MG ; QL (90 EA per 30 days) LETAIRIS ORAL TABLET 10 MG, 5 MG ; niacin flush free oral capsule 500 NIACIN FLUSH-FREE EX ST ORAL CAPSULE 750 MG sildenafil citrate oral tablet 20 TRACLEER ORAL TABLET 125 MG, 62.5 MG *Cephalosporins* cefaclor oral capsule 250, 500 cefaclor oral suspension reconstituted 125 /5ml, 250 /5ml, 375 /5ml cefadroxil oral capsule 500 cefadroxil oral suspension reconstituted 250 /5ml, 500 /5ml ; QL (60 EA per 30 days) AL (Max 12 Years) AL (Max 12 Years) 21

cefadroxil oral tablet 1 gm cefdinir oral capsule 300 cefdinir oral suspension reconstituted 125 /5ml, 250 /5ml cefixime oral suspension reconstituted 100 /5ml, 200 /5ml cefpodoxime proxetil oral suspension reconstituted 100 /5ml, 50 /5ml cefpodoxime proxetil oral tablet 100, 200 cefprozil oral suspension reconstituted 125 /5ml, 250 /5ml cefprozil oral tablet 250, 500 ceftriaxone sodium injection solution reconstituted 250 cefuroxime axetil oral tablet 250, 500 cephalexin oral capsule 250, 500 cephalexin oral suspension reconstituted 125 /5ml, 250 /5ml SUPRAX ORAL CAPSULE 400 MG SUPRAX ORAL SUSPENSION RECONSTITUTED 500 MG/5ML *Contraceptives* AMETHYST ORAL TABLET 90-20 MCG GR-F ARANELLE ORAL TABLET 0.5/1/0.5-35 MG-MCG AL (Max 12 Years) AL (Max 12 Years) AL (Max 12 Years) QL (1 EA per 30 days) AL (Max 12 Years) GR-F AVIANE ORAL TABLET 0.1-20 MG-MCG GR-F BALZIVA ORAL TABLET 0.4-35 MG-MCG GR-F drospirenone-ethinyl estradiol oral tablet 3-0.03 GR-F ELLA ORAL TABLET 30 MG GR-F GIANVI ORAL TABLET 3-0.02 MG GR-F JUNEL 1/20 ORAL TABLET 1-20 MG-MCG GR-F KAITLIB FE ORAL TABLET CHEWABLE 0.8-25 MG-MCG KARIVA ORAL TABLET 0.15-0.02/0.01 MG (21/5) GR-F GR-F levonorgestrel oral tablet 0.75, 1.5 GR-F LEVORA 0.15/30 (28) ORAL TABLET 0.15-30 MG-MCG LOMEDIA 24 FE ORAL TABLET 1-20 MG- MCG(24) 22 GR-F GR-F

LOW-OGESTREL ORAL TABLET 0.3-30 MG-MCG medroxyprogesterone acetate intramuscular suspension 150 /ml MICROGESTIN 1.5/30 ORAL TABLET 1.5-30 MG-MCG MICROGESTIN FE 1.5/30 ORAL TABLET 1.5-30 MG-MCG MICROGESTIN FE 1/20 ORAL TABLET 1-20 MG-MCG NECON 0.5/35 (28) ORAL TABLET 0.5-35 MG-MCG NECON 1/35 (28) ORAL TABLET 1-35 MG- MCG GR-F GR-F; QL (1 ML per 75 days) GR-F GR-F GR-F GR-F GR-F NECON 10/11 (28) ORAL TABLET 35 MCG GR-F NORA-BE ORAL TABLET 0.35 MG GR-F norethin ace-eth estrad-fe oral tablet chewable 1-20 -mcg(24) NORTREL 7/7/7 ORAL TABLET 0.5/0.75/1-35 MG-MCG NUVARING VAGINAL RING 0.12-0.015 MG/24HR OGESTREL ORAL TABLET 0.5-50 MG- MCG ; GR-F GR-F GR-F; QL (3 EA per 84 days) GR-F QUASENSE ORAL TABLET 0.15-0.03 MG GR-F RECLIPSEN ORAL TABLET 0.15-30 MG- MCG SPRINTEC 28 ORAL TABLET 0.25-35 MG- MCG TRI-LEGEST FE ORAL TABLET 1-20/1-30/1-35 MG-MCG TRINESSA LO ORAL TABLET 0.18/0.215/0.25 MG-25 MCG TRI-SPRINTEC ORAL TABLET 0.18/0.215/0.25 MG-35 MCG GR-F GR-F GR-F GR-F GR-F TRIVORA (28) ORAL TABLET GR-F VELIVET ORAL TABLET 0.1/0.125/0.15-0.025 MG WYMZYA FE ORAL TABLET CHEWABLE 0.4-35 MG-MCG XULANE TRANSDERMAL TCH WEEKLY 150-35 MCG/24HR GR-F ; GR-F GR-F; QL (9 EA per 84 days) 23

ZOVIA 1/35E (28) ORAL TABLET 1-35 MG- MCG ZOVIA 1/50E (28) ORAL TABLET 1-50 MG- MCG *Corticosteroids* dexamethasone oral elixir 0.5 /5ml dexamethasone oral solution 0.5 /5ml dexamethasone oral tablet 0.5, 0.75, 1, 1.5, 2, 4, 6 fludrocortisone acetate oral tablet 0.1 hydrocortisone oral tablet 10, 20, 5 methylprednisolone oral tablet 16, 32, 4, 8 methylprednisolone oral tablet therapy pack 4 prednisolone oral solution 15 /5ml prednisolone sodium phosphate oral solution 15 /5ml, 6.7 (5 base) /5ml prednisone (pak) oral tablet 5 prednisone oral solution 5 /5ml prednisone oral tablet 1, 10, 2.5, 20, 5, 50 prednisone oral tablet therapy pack 10 (21), 5 (21) *Cough/Cold/Allergy* acetylcysteine inhalation solution 10 %, 20 % GR-F GR-F cheratussin ac oral solution 100-10 /5ml QL (240 ML per 30 days) cheratussin dac oral solution 30-10-100 /5ml QL (240 ML per 30 days) dextromethorphan-guaifenesin oral solution 10-100 /5ml guaifenesin oral solution 100 /5ml guaifenesin oral syrup 100 /5ml guaifenesin oral tablet 200, 400 QL (240 ML per 30 days) guaifenesin-dm oral syrup 100-10 /5ml QL (240 ML per 30 days) loratadine-d 12hr oral tablet extended release 12 hour 5-120 loratadine-d 24hr oral tablet extended release 24 hour 10-240 promethazine-dm oral syrup 6.25-15 /5ml QL (240 ML per 30 days) pseudoeph-bromphen-dm oral syrup 30-2-10 /5ml QL (120 ML per 30 days) 24

sodium chloride inhalation nebulization solution 0.9 %, 7 % tussin dm max adult oral liquid 10-200 /5ml QL (240 ML per 30 days) *Dermatologicals* ABREVA EXTERNAL CREAM 10 % acitretin oral capsule 10, 17.5, 25 alclometasone dipropionate external cream 0.05 % alclometasone dipropionate external ointment 0.05 % ammonium lactate external cream 12 % ammonium lactate external lotion 12 % ASPERCREME LIDOCAINE TCH 4 % EXTERNAL 4 % bacitracin external ointment 500 unit/gm bacitracin zinc external ointment 500 unit/gm benzoyl peroxide creamy wash external liquid 4 % QL (45 GM per 30 days) QL (45 GM per 30 days) benzoyl peroxide external gel 10 % QL (113.4 GM per 30 days) benzoyl peroxide external gel 2.5 %, 5 % benzoyl peroxide wash external liquid 10 %, 5 % betamethasone dipropionate aug external cream 0.05 % betamethasone dipropionate aug external gel 0.05 % betamethasone dipropionate aug external lotion 0.05 % betamethasone dipropionate aug external ointment 0.05 % betamethasone dipropionate external cream 0.05 % betamethasone dipropionate external lotion 0.05 % betamethasone dipropionate external ointment 0.05 % QL (50 GM per 30 days) QL (50 GM per 30 days) QL (60 ML per 30 days) QL (50 GM per 30 days) QL (60 GM per 30 days) QL (60 ML per 30 days) QL (45 GM per 30 days) betamethasone valerate external cream 0.1 % QL (454 GM per 30 days) betamethasone valerate external lotion 0.1 % QL (60 ML per 30 days) betamethasone valerate external ointment 0.1 % QL (45 GM per 30 days) calcipotriene external ointment 0.005 % ; QL (120 GM per 30 days) calcipotriene external solution 0.005 % ; QL (60 ML per 30 days) 25

capsaicin external cream 0.025 %, 0.075 %, 0.1 % ciclopirox external solution 8 % QL (6.6 ML per 28 days) CLARAVIS ORAL CAPSULE 10 MG, 20 MG, 30 MG, 40 MG clindamycin phosphate external solution 1 % clindamycin phosphate external swab 1 % ; QL (60 EA per 30 days) clobetasol propionate external cream 0.05 % ; QL (60 GM per 30 days) clobetasol propionate external ointment 0.05 % ; QL (60 GM per 30 days) clobetasol propionate external solution 0.05 % ; QL (50 ML per 30 days) clotrimazole external cream 1 % clotrimazole external solution 1 % clotrimazole-betamethasone external cream 1-0.05 % CORTIZONE-10/ALOE EXTERNAL CREAM 1 % QL (45 GM per 30 days) desonide external ointment 0.05 % QL (30 GM per 30 days) diclofenac sodium transdermal gel 3 % DIFFERIN GEL 0.1 % EXTERNAL (OTC) 0.1 % DRYSOL EXTERNAL SOLUTION 20 % QL (45 GM per 30 days) econazole nitrate external cream 1 % QL (30 GM per 30 days) ELIDEL EXTERNAL CREAM 1 % ; QL (30 GM per 30 days) erythromycin external solution 2 % fluocinolone acetonide external cream 0.01 % QL (45 GM per 30 days) fluocinolone acetonide external cream 0.025 % QL (60 GM per 30 days) fluocinolone acetonide external ointment 0.025 % QL (60 GM per 30 days) fluocinonide external cream 0.05 % QL (30 GM per 30 days) fluocinonide external ointment 0.05 % QL (30 GM per 30 days) fluocinonide external solution 0.05 % QL (60 ML per 30 days) fluocinonide-e external cream 0.05 % QL (30 GM per 30 days) fluorouracil external cream 0.5 %, 5 % fluticasone propionate external cream 0.05 % QL (60 GM per 30 days) fluticasone propionate external ointment 0.005 % QL (60 GM per 30 days) gentamicin sulfate external cream 0.1 % gentamicin sulfate external ointment 0.1 % halobetasol propionate external cream 0.05 % QL (50 GM per 30 days) halobetasol propionate external ointment 0.05 % QL (50 GM per 30 days) hydrocortisone external cream 0.5 %, 1 %, 2.5 % 26