Comprehensive PREFERRED DRUG LIST. HRI-New York

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1 Comprehensive PREFERRED DRUG LIST HRI-New York GE 1 LAST UPDATED 09/2014

2 LEGEND TIER DESCRIPTION 0 Preventative 1 Preferred Generics 2 Preferred Brands 3 Non-Preferred Brands 4 Specialty TYPE QL Quantity Limit DESCRIPTION There is a limit on the amount of drug covered per prescription, or within a specific time frame. Prior Authorization Prior Authorization required before prescription can be filled. ST Step Therapy Requires trial and failure of one or more preferred products prior to coverage. Age Limit Drug is limited to specific age. Max Daily Dose A limit on the number of times the drug can be taken per day MPL Max Package Limit A limit on the amount of drug covered per prescription. MFL Max Fill Limit There is a limit on the number of times this drug can be refilled. GE 2 LAST UPDATED 09/2014

3 LIST OF COVERED PRESCRIPTION MEDICATIONS Analgesics Nonsteroidal Anti-inflammatory Drugs anexsia mg generic 3 6 per day CELEBREX 100 MG celecoxib ST 2 per day CELEBREX 200 MG celecoxib ST 2 per day CELEBREX 400 MG celecoxib ST CELEBREX 50 MG celecoxib ST 2 per day co-gesic mg generic 1 8 per day diclofenac potassium 50 mg generic 1 diclofenac sodium 25 mg generic 1 diclofenac sodium 50 mg generic 1 diclofenac sodium 75 mg generic 1 diclofenac sodium er 100 mg generic 1 diflunisal 500 mg generic 1 etodolac 200 mg generic 1 etodolac 300 mg generic 1 etodolac 400 mg generic 1 etodolac 500 mg generic 1 etodolac er 400 mg generic 1 fenoprofen calcium 600 mg generic 1 FENOPROFEN CCIUM 600 MG fenoprofen calcium flurbiprofen 100 mg generic 1 flurbiprofen 50 mg generic 1 hydrocodone-acetaminophen mg generic 1 13 per day hydrocodone-acetaminophen mg generic 1 12 per day GE 3 LAST UPDATED 09/2014

4 hydrocodone-acetaminophen mg generic 1 8 per day hydrocodone-acetaminophen mg generic 1 6 per day hydrocodone-acetaminophen mg generic 1 6 per day hydrocodone-acetaminophen mg generic 1 5 per day HYDROCODONE-ACETAMINOPHEN MG hydrocodone-acetaminophen 5 per day hydrocodone-acetaminophen mg generic 1 HYDROCODONE-ACETAMINOPHEN MG hydrocodone-acetaminophen hydrocodone-acetaminophen mg generic 1 8 per day hydrocodone-acetaminophen mg generic 1 13 per day hydrocodone-acetaminophen mg generic 1 12 per day hydrocodone-acetaminophen mg generic 1 8 per day hydrocodone-acetaminophen mg generic 1 13 per day hydrocodone-acetaminophen mg generic 1 12 per day hydrocodone-acetaminophen mg generic 1 8 per day HYDROCODONE-ACETAMINOPHEN MG hydrocodone-acetaminophen 8 per day hydrocodone-acetaminophen mg generic 1 6 per day HYDROCODONE-ACETAMINOPHEN MG hydrocodone-acetaminophen 6 per day hydrocodone-acetaminophen mg generic 1 5 per day ibu 800 mg generic 1 ibuprofen 400 mg generic 1 ibuprofen 600 mg generic 1 ibuprofen 800 mg generic 1 INDOCIN 25 MG/5ML indomethacin indomethacin 25 mg generic 1 1 GE 4 LAST UPDATED 09/2014

5 indomethacin 50 mg generic indomethacin er 75 mg generic 1 ketoprofen 50 mg generic 1 ketoprofen 75 mg generic 1 ketorolac tromethamine 10 mg generic 1 QL 20 / 30 days lorcet mg generic 1 12 per day lorcet hd mg generic 1 12 per day lorcet plus mg generic 1 12 per day lortab mg generic 1 12 per day lortab mg generic 3 8 per day lortab mg generic 1 12 per day lortab mg generic 1 12 per day meclofenamate sodium 100 mg generic 1 meclofenamate sodium 50 mg generic 1 mefenamic acid 250 mg generic 1 meloxicam 15 mg generic 1 meloxicam 7.5 mg generic 1 meloxicam 7.5 mg/5ml generic 1 MOBIC 7.5 MG/5ML meloxicam nabumetone 500 mg generic 1 nabumetone 750 mg generic 1 naprosyn 250 mg generic 3 naprosyn 375 mg generic 3 naproxen 125 mg/5ml generic 1 naproxen 250 mg generic 1 naproxen 375 mg generic 1 naproxen 500 mg generic 1 naproxen dr 375 mg generic 1 naproxen dr 500 mg generic 1 naproxen sodium 550 mg generic 1 GE 5 LAST UPDATED 09/2014

6 oxaprozin 600 mg generic 1 oxycodone-ibuprofen mg generic 1 QL 28 / 30 days piroxicam 10 mg generic 1 piroxicam 20 mg generic 1 sulindac 150 mg generic 1 sulindac 200 mg generic 1 tolmetin sodium 200 mg generic 1 tolmetin sodium 400 mg generic 1 tolmetin sodium 600 mg generic 1 verdrocet mg generic 1 vicodin mg generic 1 13 per day vicodin es mg generic 1 13 per day vicodin hp mg generic 1 13 per day vicodin hp mg generic 1 6 per day Opioid Analgesics, Long-acting BUTRANS 10 MCG/HR buprenorphine BUTRANS 15 MCG/HR buprenorphine BUTRANS 20 MCG/HR buprenorphine BUTRANS 5 MCG/HR buprenorphine QL 4 / 30 days QL 4 / 30 days QL 4 / 30 days QL 4 / 30 days fentanyl 100 mcg/hr generic 1 QL 30 / 30 days fentanyl 12 mcg/hr generic per day fentanyl 25 mcg/hr generic 1 QL 30 / 30 days fentanyl 50 mcg/hr generic 1 QL 30 / 30 days fentanyl 75 mcg/hr generic 1 QL 30 / 30 days fentanyl citrate 1200 mcg generic 1 4 per day fentanyl citrate 1600 mcg generic 1 4 per day fentanyl citrate 200 mcg generic 1 4 per day 1 GE 6 LAST UPDATED 09/2014

7 fentanyl citrate 400 mcg generic 4 per day fentanyl citrate 600 mcg generic 1 4 per day fentanyl citrate 800 mcg generic 1 4 per day levorphanol tartrate 2 mg generic 1 methadone hcl 10 mg generic 1 6 per day methadone hcl 10 mg/5ml generic 1 50 per day methadone hcl 10 mg/ml generic 1 10 per day methadone hcl 40 mg generic 1 2 per day methadone hcl 5 mg generic 1 6 per day methadone hcl 5 mg/5ml generic per day methadone hcl intensol 10 mg/ml generic 1 10 per day methadose 10 mg generic 1 6 per day methadose 40 mg generic 1 2 per day morphine sulfate 15 mg generic 1 4 per day MORPHINE SULFATE 15 MG morphine sulfate 4 per day morphine sulfate 30 mg generic 1 4 per day MORPHINE SULFATE 30 MG morphine sulfate 4 per day morphine sulfate er 10 mg generic 1 morphine sulfate er 100 mg generic 1 3 per day morphine sulfate er 15 mg generic 1 3 per day morphine sulfate er 20 mg generic 1 morphine sulfate er 200 mg generic 1 3 per day morphine sulfate er 30 mg generic 1 3 per day morphine sulfate er 50 mg generic 1 morphine sulfate er 60 mg generic 1 3 per day morphine sulfate er 80 mg generic 1 morphine sulfate er beads 120 mg generic 1 GE 7 LAST UPDATED 09/2014

8 morphine sulfate er beads 30 mg generic 1 morphine sulfate er beads 45 mg generic 1 morphine sulfate er beads 60 mg generic 1 morphine sulfate er beads 75 mg generic 1 morphine sulfate er beads 90 mg generic 1 NUCYNTA ER 100 MG tapentadol hcl 2 per day NUCYNTA ER 150 MG tapentadol hcl 2 per day NUCYNTA ER 200 MG tapentadol hcl 2 per day NUCYNTA ER 250 MG tapentadol hcl 2 per day NUCYNTA ER 50 MG tapentadol hcl 2 per day ONA ER 10 MG oxymorphone hcl 2 per day ONA ER 15 MG oxymorphone hcl 2 per day ONA ER 20 MG oxymorphone hcl 2 per day ONA ER 30 MG oxymorphone hcl 2 per day ONA ER 40 MG oxymorphone hcl 4 per day ONA ER 5 MG oxymorphone hcl 2 per day ONA ER 7.5 MG oxymorphone hcl 2 per day GE 8 LAST UPDATED 09/2014

9 ORAMORPH SR 100 MG morphine sulfate ORAMORPH SR 15 MG morphine sulfate ORAMORPH SR 30 MG morphine sulfate ORAMORPH SR 60 MG morphine sulfate 3 per day 3 per day 3 per day 3 per day oxycodone hcl er 40 mg generic 1 2 per day OXYCONTIN 10 MG oxycodone hcl 2 per day OXYCONTIN 15 MG oxycodone hcl 2 per day OXYCONTIN 20 MG oxycodone hcl 2 per day OXYCONTIN 30 MG oxycodone hcl 2 per day OXYCONTIN 40 MG oxycodone hcl 2 per day OXYCONTIN 60 MG oxycodone hcl 2 per day OXYCONTIN 80 MG oxycodone hcl 2 per day oxymorphone hcl er 10 mg generic 3 oxymorphone hcl er 15 mg generic 3 oxymorphone hcl er 20 mg generic 3 oxymorphone hcl er 30 mg generic 3 oxymorphone hcl er 40 mg generic 3 2 per day 2 per day 2 per day 2 per day 4 per day GE 9 LAST UPDATED 09/2014

10 oxymorphone hcl er 5 mg generic 3 oxymorphone hcl er 7.5 mg generic 3 2 per day 2 per day tramadol hcl 50 mg generic 1 8 per day tramadol hcl er (biphasic) 100 mg generic 1 tramadol hcl er (biphasic) 200 mg generic 1 tramadol hcl er (biphasic) 300 mg generic 1 tramadol hcl er 100 mg generic 1 tramadol hcl er 200 mg generic 1 tramadol hcl er 300 mg generic 1 Opioid Analgesics, Short-acting astramorph 0.5 mg/ml generic 1 astramorph 1 mg/ml generic 1 buprenorphine hcl 0.3 mg/ml generic 1 butalbital-apap-caff-cod mg generic 1 butalbital-apap-caff-cod mg generic 1 6 per day butorphanol tartrate 1 mg/ml generic 1 butorphanol tartrate 10 mg/ml generic 1 QL 15 / 90 days butorphanol tartrate 2 mg/ml generic 1 codeine sulfate 15 mg generic 1 codeine sulfate 30 mg generic 1 6 per day codeine sulfate 60 mg generic 1 6 per day duramorph 0.5 mg/ml generic 1 duramorph 1 mg/ml generic 1 fentanyl 100 mcg/hr generic 1 QL 30 / 30 days fentanyl 12 mcg/hr generic per day fentanyl 25 mcg/hr generic 1 QL 30 / 30 days fentanyl 50 mcg/hr generic 1 QL 30 / 30 days GE 10 LAST UPDATED 09/2014

11 fentanyl 75 mcg/hr generic 1 QL 30 / 30 days fentanyl citrate 1200 mcg generic 1 4 per day fentanyl citrate 1600 mcg generic 1 4 per day fentanyl citrate 200 mcg generic 1 4 per day fentanyl citrate 400 mcg generic 1 4 per day fentanyl citrate 600 mcg generic 1 4 per day fentanyl citrate 800 mcg generic 1 4 per day hydromorphone hcl 1 mg/ml generic 1 hydromorphone hcl 2 mg generic 1 6 per day hydromorphone hcl 4 mg generic 1 6 per day hydromorphone hcl 8 mg generic 1 6 per day hydromorphone hcl pf 1 mg/ml generic 4 hydromorphone hcl pf 10 mg/ml generic 4 hydromorphone hcl pf 2 mg/ml generic 4 hydromorphone hcl pf 4 mg/ml generic 4 hydromorphone hcl pf 50 mg/5ml generic 4 hydromorphone hcl pf 500 mg/50ml generic 4 meperidine hcl 100 mg generic 1 6 per day meperidine hcl 100 mg/ml generic 1 meperidine hcl 25 mg/ml generic 1 meperidine hcl 50 mg generic 1 6 per day meperidine hcl 50 mg/5ml generic 1 QL 500 / claim meperidine hcl 50 mg/ml generic 1 meperitab 100 mg generic 1 6 per day meperitab 50 mg generic 1 6 per day methadone hcl 10 mg generic 1 6 per day methadone hcl 10 mg/5ml generic 1 50 per day methadone hcl 10 mg/ml generic 1 10 per day GE 11 LAST UPDATED 09/2014

12 methadone hcl 40 mg generic 1 2 per day methadone hcl 5 mg generic 1 6 per day methadone hcl 5 mg/5ml generic per day methadone hcl intensol 10 mg/ml generic 1 10 per day methadose 10 mg generic 1 6 per day methadose 40 mg generic 1 2 per day morphine sulfate (pf) 0.5 mg/ml generic 1 morphine sulfate (pf) 1 mg/ml generic 1 morphine sulfate 10 mg/5ml generic per day morphine sulfate 15 mg generic 1 4 per day MORPHINE SULFATE 15 MG morphine sulfate 4 per day morphine sulfate 20 mg/5ml generic 1 50 per day morphine sulfate 30 mg generic 1 4 per day MORPHINE SULFATE 30 MG morphine sulfate 4 per day nalbuphine hcl 10 mg/ml generic 1 nalbuphine hcl 20 mg/ml generic 3 nubain 10 mg/ml generic 3 8 per day 8 per day 8 per day NUCYNTA 100 MG tapentadol hcl 3 per day NUCYNTA 50 MG tapentadol hcl 3 per day NUCYNTA 75 MG tapentadol hcl 3 per day ONA ER 5 MG oxymorphone hcl 2 per day 1 GE 12 LAST UPDATED 09/2014

13 oxycodone hcl 10 mg generic 6 per day oxycodone hcl 15 mg generic 1 6 per day oxycodone hcl 20 mg generic 1 6 per day oxycodone hcl 30 mg generic 1 6 per day oxycodone hcl 5 mg generic 1 12 per day oxycodone hcl er 10 mg generic 1 2 per day OXYCODONE HCL ER 10 MG oxycodone hcl 2 per day oxycodone hcl er 20 mg generic 1 2 per day OXYCODONE HCL ER 20 MG oxycodone hcl 2 per day oxycodone hcl er 40 mg generic 1 2 per day oxycodone hcl er 80 mg generic 1 4 per day OXYCODONE HCL ER 80 MG oxycodone hcl 4 per day oxycodone-ibuprofen mg generic 1 QL 28 / 30 days oxymorphone hcl 10 mg generic 3 oxymorphone hcl 5 mg generic 3 4 per day 4 per day roxicodone 15 mg generic 3 6 per day roxicodone 30 mg generic 3 6 per day roxicodone 5 mg generic 3 12 per day TWIN 30 MG/ML pentazocine lactate tramadol hcl 50 mg generic 1 8 per day Anesthetics Local Anesthetics lidocaine 5 % generic 1 LIDOCAINE HCL (CARDIAC) 10 MG/ML lidocaine hcl (cardiac) GE 13 LAST UPDATED 09/2014

14 lidocaine hcl (cardiac) 20 mg/ml generic 1 lidocaine hcl (pf) 0.5 % generic 1 lidocaine hcl (pf) 1 % generic 1 lidocaine hcl (pf) 2 % generic 1 lidocaine hcl 0.5 % generic 1 lidocaine hcl 1 % generic 1 lidocaine hcl 1.5 % generic 1 lidocaine hcl 2 % generic 1 lidocaine hcl 4 % generic 1 lidocaine in d5w 4-5 mg/ml-% generic 1 lidocaine in d5w 8-5 mg/ml-% generic 1 lidocaine viscous 2 % generic 1 lidocaine-prilocaine % generic 1 LIDODERM 5 % lidocaine parcaine 0.5 % generic 1 proparacaine hcl 0.5 % generic 1 SYNERA MG lidocaine-tetracaine xylocaine (cardiac) 20 mg/ml generic 3 xylocaine 1 % generic 3 Anti-Addiction/Substance Abuse Treatment Agents Alcohol Deterrents/Anti-craving acamprosate calcium 333 mg generic 3 CAMPR DOSE K 333 MG acamprosate calcium depade 50 mg generic 1 disulfiram 250 mg generic 1 disulfiram 500 mg generic 1 naltrexone hcl 50 mg generic 1 VIVITROL 380 MG naltrexone GE 14 LAST UPDATED 09/2014

15 Opioid Antagonists buprenorphine hcl 0.3 mg/ml generic 1 buprenorphine hcl 2 mg generic 1 buprenorphine hcl 8 mg generic 1 buprenorphine hcl-naloxone hcl mg generic 1 buprenorphine hcl-naloxone hcl 8-2 mg generic 1 depade 50 mg generic 1 3 per day 3 per day 3 per day 3 per day naloxone hcl 0.4 mg/ml generic 1 NOXONE HCL 0.4 MG/ML naloxone hcl naltrexone hcl 50 mg generic 1 SUBOXONE 12-3 MG buprenorphine hcl-naloxone hcl dihydrate SUBOXONE MG buprenorphine hcl-naloxone hcl dihydrate 3 per day SUBOXONE 4-1 MG buprenorphine hcl-naloxone hcl dihydrate SUBOXONE 8-2 MG buprenorphine hcl-naloxone hcl dihydrate 3 per day VIVITROL 380 MG naltrexone Smoking Cessation Agents buproban 150 mg generic 0 2 per day CHANTIX 0.5 MG varenicline tartrate CHANTIX 1 MG varenicline tartrate CHANTIX CONTINUING MONTH K 1 MG varenicline tartrate QL 90 / 365 days QL 90 / 365 days QL 90 / 365 days CHANTIX STARTING MONTH K 0.5 MG X QL 53 / 365 days GE 15 LAST UPDATED 09/2014

16 11 & 1 MG X 42 varenicline tartrate nicotine 14 mg/24hr generic 0 QL 90 / 365 days nicotine 21 mg/24hr generic 0 QL 90 / 365 days nicotine 7 mg/24hr generic 0 QL 90 / 365 days NICOTROL 10 MG nicotine NICOTROL NS 10 MG/ML nicotine Anti-inflammatory Agents Glucocorticoids a-methapred 125 mg generic 4 a-methapred 40 mg generic 4 ala cort 1 % generic 1 alclometasone dipropionate 0.05 % generic 1 amcinonide 0.1 % generic 3 antibiotic ear generic 1 apexicon 0.05 % generic 1 asmalpred 15 mg/5ml generic 1 asmalpred plus 15 mg/5ml generic 1 beta-val 0.1 % generic 1 betamethasone dipropionate 0.05 % generic 1 betamethasone dipropionate aug 0.05 % generic 1 betamethasone valerate 0.1 % generic 1 BETAMETHASONE VERATE 0.1 % betamethasone valerate betamethasone valerate 0.12 % generic 1 clobetasol propionate 0.05 % generic 1 clobetasol propionate e 0.05 % generic 1 CLOBEX SPRAY 0.05 % clobetasol propionate clocortolone pivalate 0.1 % generic 3 clocortolone pivalate pump 0.1 % generic 3 GE 16 LAST UPDATED 09/2014

17 clodan 0.05 % generic 1 CLODERM 0.1 % clocortolone pivalate CLODERM PUMP 0.1 % clocortolone pivalate CORDRAN 0.05 % flurandrenolide CORDRAN 4 MCG/SQCM flurandrenolide cormax 0.05 % generic 1 cormax scalp application 0.05 % generic 1 cortisone acetate 25 mg generic 1 CORTISPORIN neomycin-polymyxin-hc cortomycin generic 1 DEPO-MEDROL 20 MG/ML methylprednisolone acetate DERMA-SMOOTHE/FS SCP 0.01 % fluocinolone acetonide desonide 0.05 % generic 1 desoximetasone 0.05 % generic 1 DESOXIMETASONE 0.05 % desoximetasone desoximetasone 0.25 % generic 1 dexamethasone sodium phosphate 10 mg/ml generic 1 DEXAMETHASONE SODIUM PHOSPHATE 10 MG/ML dexamethasone sodium phosphate dexamethasone sodium phosphate 100 mg/10ml dexamethasone sodium phosphate 120 mg/30ml generic 1 generic 1 dexamethasone sodium phosphate 20 mg/5ml generic 1 dexamethasone sodium phosphate 4 mg/ml generic 1 diflorasone diacetate 0.05 % generic 1 DIFLORASONE DIACETATE 0.05 % diflorasone diacetate GE 17 LAST UPDATED 09/2014

18 fludrocortisone acetate 0.1 mg generic 1 fluocinolone acetonide 0.01 % generic 1 fluocinolone acetonide % generic 1 fluocinolone acetonide body 0.01 % generic 1 fluocinolone acetonide scalp 0.01 % generic 1 fluocinonide 0.05 % generic 1 fluocinonide 0.1 % generic 1 fluocinonide-e 0.05 % generic 1 fluticasone propionate % generic 1 fluticasone propionate 0.05 % generic 1 halobetasol propionate 0.05 % generic 1 HOG 0.1 % halcinonide hydrocortisone 1 % generic 1 hydrocortisone 2.5 % generic 1 hydrocortisone 2.5 % generic 1 hydrocortisone butyr lipo base 0.1 % generic 1 hydrocortisone butyrate 0.1 % generic 1 isovate 0.05 % generic 1 LUXIQ 0.12 % betamethasone valerate MEDROL 2 MG methylprednisolone methylprednisolone (pak) 4 mg generic 1 methylprednisolone 16 mg generic 1 methylprednisolone 32 mg generic 1 methylprednisolone 4 mg generic 1 methylprednisolone 8 mg generic 1 methylprednisolone sodium succ 1000 mg generic 4 methylprednisolone sodium succ 125 mg generic 4 methylprednisolone sodium succ 40 mg generic 4 methylprednisolone sodium succ 500 mg generic 4 MILLIPRED 10 MG/5ML GE 18 LAST UPDATED 09/2014

19 prednisolone sodium phosphate MILLIPRED 5 MG prednisolone MILLIPRED DP 12-DAY 5 MG prednisolone MILLIPRED DP 5 MG prednisolone neomycin-polymyxin-hc 1 % generic 1 neomycin-polymyxin-hc generic 1 nystatin-triamcinolone unit/gm-% generic 1 NYSTATIN-TRIAMCINOLONE UNIT/GM-% nystatin-triamcinolone oralone 0.1 % generic 1 ORAPRED ODT 10 MG prednisolone sodium phosphate ORAPRED ODT 15 MG prednisolone sodium phosphate ORAPRED ODT 30 MG prednisolone sodium phosphate prednisolone 15 mg/5ml generic 1 prednisolone sodium phosphate 15 mg/5ml generic 1 PREDNISOLONE SODIUM PHOSPHATE 25 MG/5ML prednisolone sodium phosphate prednisolone sodium phosphate 6.7 (5 base) mg/5ml generic 1 prednisone (pak) 10 mg generic 1 PREDNISONE (K) 10 MG prednisone prednisone (pak) 5 mg generic 1 PREDNISONE (K) 5 MG prednisone prednisone 1 mg generic 1 prednisone 10 mg generic 1 prednisone 2.5 mg generic 1 prednisone 20 mg generic 1 prednisone 5 mg generic 1 GE 19 LAST UPDATED 09/2014

20 prednisone 5 mg/5ml generic 1 prednisone 50 mg generic 1 PREDNISONE INTENSOL 5 MG/ML prednisone proctocare-hc 2.5 % generic 1 proctocream hc 2.5 % generic 1 proctosol hc 2.5 % generic 1 proctozone-hc 2.5 % generic 1 scalacort 2 % generic 1 SOLU-MEDROL 2 GM methylprednisolone sod succ TOPICORT 0.05 % desoximetasone triamcinolone acetonide % generic 1 triamcinolone acetonide 0.1 % generic 1 triamcinolone acetonide 0.1 % generic 1 TRIAMCINOLONE ACETONIDE 0.5 % triamcinolone acetonide (topical) triamcinolone acetonide 0.5 % generic 1 TRIAMCINOLONE IN ABSORBASE 0.05 % triamcinolone acetonide (topical) triderm 0.1 % generic 1 VERDESO 0.05 % desonide VERIPRED MG/5ML prednisolone sodium phosphate Nonsteroidal Anti-inflammatory Drugs CELEBREX 100 MG celecoxib ST 2 per day CELEBREX 200 MG celecoxib ST 2 per day CELEBREX 400 MG celecoxib ST CELEBREX 50 MG celecoxib ST 2 per day GE 20 LAST UPDATED 09/2014

21 diclofenac potassium 50 mg generic 1 diclofenac sodium 25 mg generic 1 diclofenac sodium 50 mg generic 1 diclofenac sodium 75 mg generic 1 diclofenac sodium er 100 mg generic 1 diflunisal 500 mg generic 1 etodolac 200 mg generic 1 etodolac 300 mg generic 1 etodolac 400 mg generic 1 etodolac 500 mg generic 1 etodolac er 400 mg generic 1 fenoprofen calcium 600 mg generic 1 FENOPROFEN CCIUM 600 MG fenoprofen calcium flurbiprofen 100 mg generic 1 flurbiprofen 50 mg generic 1 hydrocodone-acetaminophen mg generic 1 12 per day ibu 800 mg generic 1 ibuprofen 400 mg generic 1 ibuprofen 600 mg generic 1 ibuprofen 800 mg generic 1 INDOCIN 25 MG/5ML indomethacin indomethacin 25 mg generic 1 indomethacin 50 mg generic 1 indomethacin er 75 mg generic 1 ketoprofen 50 mg generic 1 ketoprofen 75 mg generic 1 ketorolac tromethamine 10 mg generic 1 QL 20 / 30 days meclofenamate sodium 100 mg generic 1 meclofenamate sodium 50 mg generic 1 mefenamic acid 250 mg generic 1 meloxicam 7.5 mg generic 1 GE 21 LAST UPDATED 09/2014

22 meloxicam 7.5 mg/5ml generic 1 MOBIC 7.5 MG/5ML meloxicam nabumetone 500 mg generic 1 nabumetone 750 mg generic 1 naprosyn 375 mg generic 3 naproxen 125 mg/5ml generic 1 naproxen 250 mg generic 1 naproxen 375 mg generic 1 naproxen 500 mg generic 1 naproxen dr 375 mg generic 1 naproxen dr 500 mg generic 1 naproxen sodium 550 mg generic 1 oxaprozin 600 mg generic 1 oxycodone-ibuprofen mg generic 1 QL 28 / 30 days piroxicam 10 mg generic 1 piroxicam 20 mg generic 1 sulindac 150 mg generic 1 sulindac 200 mg generic 1 tolmetin sodium 200 mg generic 1 tolmetin sodium 400 mg generic 1 tolmetin sodium 600 mg generic 1 Antibacterials Aminoglycosides amikacin sulfate 1 gm/4ml generic 1 amikacin sulfate 50 mg/ml generic 1 AMIKACIN SULFATE 50 MG/ML amikacin sulfate amikacin sulfate 500 mg/2ml generic 1 BETHKIS 300 MG/4ML tobramycin 1 GE 22 LAST UPDATED 09/2014

23 garamycin 0.3 % generic gentak 0.3 % generic 1 gentamicin in saline mg/ml-% generic 1 gentamicin in saline mg/ml-% generic 1 GENTAMICIN IN SINE MG/ML-% gentamicin in saline gentamicin in saline mg/ml-% generic 1 gentamicin in saline mg/ml-% generic 1 GENTAMICIN IN SINE MG/ML-% gentamicin in saline gentamicin in saline mg/ml-% generic 1 gentamicin in saline mg/ml-% generic 1 GENTAMICIN SULFATE 0.1 % gentamicin sulfate (topical) gentamicin sulfate 0.1 % generic 1 gentamicin sulfate 0.3 % generic 1 gentamicin sulfate 10 mg/ml generic 1 gentamicin sulfate 40 mg/ml generic 1 gentasol 0.3 % generic 1 kanamycin sulfate 333 mg/ml generic 1 NEO-FRADIN 25 MG/ML neomycin sulfate neomycin sulfate 500 mg generic 1 paromomycin sulfate 250 mg generic 3 streptomycin sulfate 1 gm generic 3 TOBI PODHER 28 MG tobramycin TOBRADEX % tobramycin-dexamethasone tobramycin 0.3 % generic 1 tobramycin 300 mg/5ml generic 1 tobramycin sulfate 1.2 gm generic 1 tobramycin sulfate 1.2 gm/30ml generic 1 GE 23 LAST UPDATED 09/2014

24 tobramycin sulfate 10 mg/ml generic 1 tobramycin sulfate 2 gm/50ml generic 1 tobramycin sulfate 80 mg/2ml generic 1 TOBRAMYCIN SULFATE IN SINE MG/ML-% tobramycin sulfate in saline TOBRAMYCIN SULFATE IN SINE MG/ML-% tobramycin sulfate in saline tobrasol 0.3 % generic 1 Antibacterials, Other acetasol hc 2-1 % generic 1 acetic acid 2 % generic 1 TABAX 1 % retapamulin baciim unit generic 1 bacitracin 500 unit/gm generic 2 bacitracin unit generic 1 BACTROBAN 2 % mupirocin calcium (topical) CENTANY 2 % mupirocin chlorhexidine gluconate 0.12 % generic 1 clindacin etz 1 % generic 1 At least 12 yrs old clindacin-p 1 % generic 1 At least 12 yrs old CLINDAGEL 1 % clindamycin phosphate (topical) At least 12 yrs old clindamycin hcl 150 mg generic 1 clindamycin hcl 300 mg generic 1 clindamycin hcl 75 mg generic 1 clindamycin palmitate hcl 75 mg/5ml generic 1 clindamycin phosphate 1 % generic 1 At least 12 yrs old clindamycin phosphate 2 % generic 1 GE 24 LAST UPDATED 09/2014

25 clindamycin phosphate 300 mg/2ml generic 1 CLINDAMYCIN PHOSPHATE 300 MG/2ML clindamycin phosphate clindamycin phosphate 600 mg/4ml generic 1 clindamycin phosphate 9 gm/60ml generic 1 clindamycin phosphate 900 mg/6ml generic 1 clindamycin phosphate 9000 mg/60ml generic 1 clindamycin phosphate in d5w 300 mg/50ml generic 1 clindamycin phosphate in d5w 600 mg/50ml generic 1 clindamycin phosphate in d5w 900 mg/50ml generic 1 CUBICIN 500 MG daptomycin CYCLOSERINE 250 MG cycloserine hydrocortisone-acetic acid 1-2 % generic 1 LINCOCIN 300 MG/ML lincomycin hcl macrobid 100 mg generic 3 mafenide acetate 5 % generic 1 methenamine hippurate 1 gm generic 1 methenamine mandelate 0.5 gm generic 1 methenamine mandelate 1 gm generic 1 metronidazole 0.75 % generic 1 metronidazole 0.75 % generic 1 metronidazole 1 % generic 1 metronidazole 250 mg generic 1 metronidazole 375 mg generic 1 metronidazole 500 mg generic 1 metronidazole in nacl mg/ml-% generic 4 metronidazole in nacl mg/100ml-% generic 4 MONUROL 3 GM fosfomycin tromethamine 1 GE 25 LAST UPDATED 09/2014

26 mupirocin 2 % generic mupirocin calcium 2 % generic 1 nitrofurantoin 25 mg/5ml generic 1 nitrofurantoin macrocrystal 100 mg generic 1 nitrofurantoin macrocrystal 50 mg generic 1 nitrofurantoin monohyd macro 100 mg generic 1 paroex 0.12 % generic 1 periogard 0.12 % generic 1 polymyxin b sulfate unit generic 1 rosadan 0.75 % generic 1 SEROMYCIN 250 MG cycloserine trimethoprim 100 mg generic 1 TYGACIL 50 MG tigecycline vancomycin hcl 10 gm generic 3 vancomycin hcl 1000 mg generic 3 vancomycin hcl 125 mg generic 3 QL 40 / 30 days vancomycin hcl 250 mg generic 3 QL 40 / 30 days vancomycin hcl 500 mg generic 3 vancomycin hcl 5000 mg generic 3 VANCOMYCIN HCL 750 MG vancomycin hcl VANCOMYCIN HCL IN DEXTROSE 1 GM/200ML vancomycin hcl in dextrose VANCOMYCIN HCL IN DEXTROSE 500 MG/100ML vancomycin hcl in dextrose VANCOMYCIN HCL IN DEXTROSE 750 MG/150ML vancomycin hcl in dextrose vandazole 0.75 % generic 1 VIBATIV 250 MG telavancin hcl GE 26 LAST UPDATED 09/2014

27 VIBATIV 750 MG telavancin hcl vitazol 0.75 % generic 1 XIFAXAN 200 MG rifaximin At least 12 yrs old XIFAXAN 550 MG rifaximin ZYVOX 100 MG/5ML linezolid ZYVOX 2 MG/ML linezolid ZYVOX 600 MG linezolid Beta-lactam, Cephalosporins CEDAX 400 MG ceftibuten cefaclor 125 mg/5ml generic 1 cefaclor 250 mg generic 1 cefaclor 250 mg/5ml generic 1 cefaclor 375 mg/5ml generic 1 cefaclor 500 mg generic 1 CEFACLOR ER 500 MG cefaclor monohydrate cefaclor er 500 mg generic 1 cefadroxil 1 gm generic 1 cefadroxil 250 mg/5ml generic 1 cefadroxil 500 mg generic 1 cefadroxil 500 mg/5ml generic 1 cefazolin sodium 1 gm generic 1 CEFAZOLIN SODIUM 1-5 GM-% cefazolin in d5w cefazolin sodium 10 gm generic 1 cefazolin sodium 20 gm generic 1 cefazolin sodium 500 mg generic 1 CEFAZOLIN SODIUM-DEXTROSE 1-4 GM-% GE 27 LAST UPDATED 09/2014

28 cefazolin sodium and dextrose CEFAZOLIN SODIUM-DEXTROSE 2-3 GM-% cefazolin sodium and dextrose cefdinir 125 mg/5ml generic 1 cefdinir 250 mg/5ml generic 1 cefdinir 300 mg generic 1 cefepime hcl 1 gm generic 1 CEFEPIME HCL 1 GM/50ML cefepime hcl cefepime hcl 2 gm generic 1 CEFEPIME HCL 2 GM/100ML cefepime hcl CEFEPIME-DEXTROSE 1 GM/50ML cefepime hcl and dextrose CEFEPIME-DEXTROSE 2 GM/50ML cefepime hcl and dextrose cefotaxime sodium 1 gm generic 1 cefotaxime sodium 10 gm generic 1 cefotaxime sodium 2 gm generic 1 cefotaxime sodium 500 mg generic 1 cefoxitin sodium 1 gm generic 1 cefoxitin sodium 10 gm generic 1 cefoxitin sodium 2 gm generic 1 CEFOXITIN SODIUM-DEXTROSE 1-4 GM-% cefoxitin sodium and dextrose CEFOXITIN SODIUM-DEXTROSE GM-% cefoxitin sodium and dextrose cefpodoxime proxetil 100 mg generic 1 cefpodoxime proxetil 100 mg/5ml generic 1 cefpodoxime proxetil 200 mg generic 1 cefpodoxime proxetil 50 mg/5ml generic 1 cefprozil 125 mg/5ml generic 1 cefprozil 250 mg generic 1 GE 28 LAST UPDATED 09/2014

29 cefprozil 250 mg/5ml generic 1 cefprozil 500 mg generic 1 CEFTIBUTEN 400 MG ceftibuten cefuroxime axetil 125 mg/5ml generic 1 cefuroxime axetil 250 mg generic 1 cefuroxime axetil 500 mg generic 1 cefuroxime sodium 1.5 gm generic 1 cefuroxime sodium 7.5 gm generic 1 CEFUROXIME SODIUM 7.5 GM cefuroxime sodium cefuroxime sodium 750 mg generic 1 CEFUROXIME SODIUM-DEXTROSE MG-% cefuroxime sodium and dextrose CEFUROXIME-DEXTROSE GM-% cefuroxime sodium and dextrose cephalexin 125 mg/5ml generic 1 cephalexin 250 mg generic 1 cephalexin 250 mg/5ml generic 1 cephalexin 500 mg generic 1 CEPHEXIN 500 MG cephalexin keflex 250 mg generic 3 SUPRAX 100 MG cefixime SUPRAX 100 MG/5ML cefixime SUPRAX 200 MG cefixime SUPRAX 200 MG/5ML cefixime SUPRAX 400 MG cefixime SUPRAX 500 MG/5ML cefixime ST ST ST ST ST ST Beta-lactam, Other GE 29 LAST UPDATED 09/2014

30 AZACTAM IN DEXTROSE 1 GM aztreonam in dextrose AZACTAM IN DEXTROSE 2 GM aztreonam in dextrose aztreonam 1 gm generic 1 aztreonam 2 gm generic 1 CAYSTON 75 MG aztreonam lysine DORIBAX 250 MG doripenem DORIBAX 500 MG doripenem Beta-lactam, Penicillins amoxicillin 125 mg generic 1 amoxicillin 125 mg/5ml generic 1 amoxicillin 200 mg/5ml generic 1 amoxicillin 250 mg generic 1 AMOXICILLIN 250 MG amoxicillin amoxicillin 250 mg/5ml generic 1 amoxicillin 400 mg/5ml generic 1 amoxicillin 500 mg generic 1 amoxicillin 875 mg generic 1 amoxicillin-pot clavulanate mg generic 1 amoxicillin-pot clavulanate mg/5ml generic 1 amoxicillin-pot clavulanate mg generic 1 amoxicillin-pot clavulanate mg/5ml generic 1 amoxicillin-pot clavulanate mg generic 1 amoxicillin-pot clavulanate mg/5ml generic 1 amoxicillin-pot clavulanate mg generic 1 amoxicillin-pot clavulanate mg/5ml generic 1 amoxicillin-pot clavulanate mg generic 1 amoxicillin-pot clavulanate er mg generic 1 ampicillin 125 mg/5ml generic 2 1 GE 30 LAST UPDATED 09/2014

31 ampicillin 250 mg generic ampicillin 250 mg/5ml generic 2 ampicillin 500 mg generic 1 ampicillin sodium 1 gm generic 1 ampicillin sodium 10 gm generic 1 AMPICILLIN SODIUM 10 GM ampicillin sodium ampicillin sodium 125 mg generic 1 ampicillin sodium 2 gm generic 1 ampicillin sodium 250 mg generic 1 ampicillin sodium 500 mg generic 1 ampicillin-sulbactam 3 (2-1) gm generic 1 ampicillin-sulbactam sodium 1.5 (1-0.5) gm generic 1 ampicillin-sulbactam sodium 15 (10-5) gm generic 1 ampicillin-sulbactam sodium 3 (2-1) gm generic 1 BICILLIN C-R UNIT/2ML penicillin g benzathine & procaine BICILLIN C-R 900/ UNIT/2ML penicillin g benzathine & procaine BICILLIN L-A UNIT/2ML penicillin g benzathine BICILLIN L-A UNIT/4ML penicillin g benzathine BICILLIN L-A UNIT/ML penicillin g benzathine nafcillin sodium 1 gm generic 1 nafcillin sodium 10 gm generic 1 nafcillin sodium 2 gm generic 1 oxacillin sodium 1 gm generic 3 oxacillin sodium 10 gm generic 3 oxacillin sodium 2 gm generic 3 GE 31 LAST UPDATED 09/2014

32 penicillin g pot in dextrose unit/ml generic 1 penicillin g pot in dextrose unit/ml generic 1 penicillin g pot in dextrose unit/ml generic 1 penicillin g potassium unit generic 1 penicillin g potassium unit generic 1 PENICILLIN G PROCAINE UNIT/ML penicillin g procaine penicillin g sodium unit generic 1 penicillin v potassium 125 mg/5ml generic 1 penicillin v potassium 250 mg generic 1 penicillin v potassium 250 mg/5ml generic 1 penicillin v potassium 500 mg generic 1 pfizerpen-g unit generic 1 TIMENTIN 3.1 GM ticarcillin & pot clavulanate TIMENTIN 3.1 GM/100ML ticarcillin & pot clavulanate TIMENTIN 31 GM ticarcillin & pot clavulanate Macrolides AZASITE 1 % azithromycin (ophth) azithromycin 1 gm generic 2 azithromycin 100 mg/5ml generic 1 azithromycin 200 mg/5ml generic 1 azithromycin 250 mg generic 1 azithromycin 500 mg generic 1 azithromycin 600 mg generic 1 azithromycin hydrogencitrate 2.5 gm generic 1 clarithromycin 125 mg/5ml generic 1 clarithromycin 250 mg generic 1 clarithromycin 250 mg/5ml generic 1 clarithromycin 500 mg generic 1 GE 32 LAST UPDATED 09/2014

33 clarithromycin er 500 mg generic 1 DIFICID 200 MG fidaxomicin E.E.S MG erythromycin ethylsuccinate e.e.s mg generic 1 e.e.s. granules 200 mg/5ml generic 3 ery 2 % generic 1 At least 12 yrs old ERY-TAB 250 MG erythromycin base ERY-TAB 333 MG erythromycin base ERY-TAB 500 MG erythromycin base eryped mg/5ml generic 3 ERYPED MG/5ML erythromycin ethylsuccinate ERYTHROCIN LACTOBIONATE 1000 MG erythromycin lactobionate ERYTHROCIN LACTOBIONATE 500 MG erythromycin lactobionate ERYTHROCIN STEARATE 250 MG erythromycin stearate ERYTHROCIN STEARATE 500 MG erythromycin stearate ERYTHROMYCIN 2 % erythromycin (acne aid) At least 12 yrs old erythromycin 2 % generic 1 At least 12 yrs old erythromycin 5 mg/gm generic 1 erythromycin base 250 mg generic 1 ERYTHROMYCIN BASE 250 MG erythromycin base ERYTHROMYCIN BASE 333 MG erythromycin base erythromycin base 500 mg generic 1 ERYTHROMYCIN BASE 500 MG erythromycin base erythromycin ethylsuccinate 400 mg generic 1 GE 33 LAST UPDATED 09/2014

34 ERYTHROMYCIN ETHYLSUCCINATE 400 MG erythromycin ethylsuccinate ERYTHROMYCIN STEARATE 250 MG erythromycin stearate ERYTHROMYCIN STEARATE 500 MG erythromycin stearate ilotycin 5 mg/gm generic 1 KETEK 300 MG telithromycin KETEK 400 MG telithromycin PCE 333 MG erythromycin base (coated) PCE 500 MG erythromycin base (coated) romycin 5 mg/gm generic 1 zithromax 1 gm generic 2 zithromax 250 mg generic 3 zithromax z-pak 250 mg generic 3 Quinolones AVELOX 400 MG moxifloxacin hcl AVELOX 400 MG/250ML moxifloxacin hcl in sodium chloride BESIVANCE 0.6 % besifloxacin hcl ciprofloxacin 1200 mg/120ml generic 1 ciprofloxacin 200 mg/20ml generic 1 ciprofloxacin 400 mg/40ml generic 1 ciprofloxacin hcl 0.3 % generic 1 ciprofloxacin hcl 100 mg generic 1 ciprofloxacin hcl 250 mg generic 1 ciprofloxacin hcl 500 mg generic 1 ciprofloxacin hcl 750 mg generic 1 ciprofloxacin in d5w 200 mg/100ml generic 1 GE 34 LAST UPDATED 09/2014

35 ciprofloxacin in d5w 400 mg/200ml generic 1 ciprofloxacin-ciproflox hcl er 1000 mg generic 1 ciprofloxacin-ciproflox hcl er 500 mg generic 1 FACTIVE 320 MG gemifloxacin mesylate gatifloxacin 0.5 % generic 1 levofloxacin 0.5 % generic 1 levofloxacin 25 mg/ml generic 1 levofloxacin 250 mg generic 1 levofloxacin 500 mg generic 1 levofloxacin 750 mg generic 1 levofloxacin in d5w 250 mg/50ml generic 1 levofloxacin in d5w 500 mg/100ml generic 1 levofloxacin in d5w 750 mg/150ml generic 1 moxifloxacin hcl 400 mg generic 1 NOROXIN 400 MG norfloxacin ofloxacin 0.3 % generic 1 ofloxacin 0.3 % generic 1 ofloxacin 200 mg generic 1 ofloxacin 300 mg generic 1 ofloxacin 400 mg generic 1 OFLOXACIN 400 MG ofloxacin VIGAMOX 0.5 % moxifloxacin hcl (ophth) Sulfonamides bleph % generic 3 silver sulfadiazine 1 % generic 1 smz-tmp ds mg generic 1 ssd 1 % generic 1 ssd af 1 % generic 1 sulfacetamide sodium (acne) 10 % generic 1 At least 12 yrs old GE 35 LAST UPDATED 09/2014

36 sulfacetamide sodium 10 % generic 1 At least 12 yrs old sulfacetamide sodium 10 % generic 1 sulfadiazine 500 mg generic 1 sulfamethoxazole-tmp ds mg generic 1 sulfamethoxazole-trimethoprim mg/5ml generic 1 sulfamethoxazole-trimethoprim mg generic 1 sulfamethoxazole-trimethoprim mg/5ml generic 1 sulfamethoxazole-trimethoprim mg/20ml generic 1 sulfatrim pediatric mg/5ml generic 1 thermazene 1 % generic 1 Tetracyclines avidoxy 100 mg generic 1 demeclocycline hcl 150 mg generic 1 demeclocycline hcl 300 mg generic 1 doxy mg generic 1 doxycycline hyclate 100 mg generic 1 doxycycline hyclate 150 mg generic 1 doxycycline hyclate 20 mg generic 1 doxycycline hyclate 50 mg generic 1 doxycycline hyclate 75 mg generic 1 doxycycline monohydrate 100 mg generic 1 doxycycline monohydrate 150 mg generic 1 doxycycline monohydrate 50 mg generic 1 doxycycline monohydrate 75 mg generic 1 minocycline hcl 100 mg generic 1 minocycline hcl 50 mg generic 1 minocycline hcl 75 mg generic 1 morgidox 100 mg generic 1 tetracycline hcl 250 mg generic 1 TETRACYCLINE HCL 250 MG tetracycline hcl 1 GE 36 LAST UPDATED 09/2014

37 tetracycline hcl 500 mg TETRACYCLINE HCL 500 MG tetracycline hcl generic Anticonvulsants Anticonvulsants, Other acetazolamide 125 mg generic 2 acetazolamide 250 mg generic 1 levetiracetam 100 mg/ml generic 1 30 per day levetiracetam 1000 mg generic 1 3 per day levetiracetam 250 mg generic 1 4 per day levetiracetam 500 mg generic 1 4 per day levetiracetam 500 mg/5ml generic 1 levetiracetam 750 mg generic 1 4 per day levetiracetam er 500 mg generic 1 4 per day levetiracetam er 750 mg generic 1 4 per day POTIGA 200 MG ezogabine 3 per day POTIGA 300 MG ezogabine 3 per day POTIGA 400 MG ezogabine 3 per day POTIGA 50 MG ezogabine 3 per day primidone 250 mg generic 1 primidone 50 mg generic 1 Calcium Channel Modifying Agents CELONTIN 300 MG methsuximide ethosuximide 250 mg generic 1 6 per day ethosuximide 250 mg/5ml generic 1 30 per day LYRICA 100 MG GE 37 LAST UPDATED 09/2014

38 pregabalin 3 per day LYRICA 150 MG pregabalin 3 per day LYRICA 20 MG/ML pregabalin LYRICA 200 MG pregabalin 3 per day LYRICA 225 MG pregabalin 3 per day LYRICA 25 MG pregabalin 3 per day LYRICA 300 MG pregabalin 3 per day LYRICA 50 MG pregabalin 3 per day LYRICA 75 MG pregabalin 3 per day zonisamide 100 mg generic 1 6 per day zonisamide 25 mg generic 1 6 per day zonisamide 50 mg generic 1 6 per day Gamma-aminobutyric Acid (GABA) Augmenting Agents divalproex sodium 125 mg generic 1 divalproex sodium 250 mg generic 1 divalproex sodium 500 mg generic 1 divalproex sodium er 250 mg generic 1 divalproex sodium er 500 mg generic 1 gabapentin 100 mg generic 1 gabapentin 250 mg/5ml generic 1 60 per day gabapentin 300 mg generic 1 gabapentin 400 mg generic 1 GE 38 LAST UPDATED 09/2014

39 gabapentin 600 mg generic 1 gabapentin 800 mg generic 1 GABITRIL 12 MG tiagabine hcl GABITRIL 16 MG tiagabine hcl GRISE 300 MG gabapentin (phn) GRISE 600 MG gabapentin (phn) HORIZANT 300 MG gabapentin enacarbil HORIZANT 600 MG gabapentin enacarbil SABRIL 500 MG vigabatrin 6 per day tiagabine hcl 2 mg generic 1 tiagabine hcl 4 mg generic 1 valproate sodium 100 mg/ml generic 1 valproate sodium 500 mg/5ml generic 1 valproic acid 250 mg generic 1 valproic acid 250 mg/5ml generic 1 Glutamate Reducing Agents felbamate 400 mg generic 3 9 per day felbamate 600 mg generic 3 6 per day felbamate 600 mg/5ml generic per day lamotrigine 100 mg generic 1 lamotrigine 150 mg generic 1 lamotrigine 200 mg generic 1 lamotrigine 25 mg generic 1 lamotrigine 5 mg generic 1 lamotrigine er 100 mg generic 1 lamotrigine er 200 mg generic 1 2 per day lamotrigine er 25 mg generic 1 GE 39 LAST UPDATED 09/2014

40 lamotrigine er 250 mg generic 1 2 per day lamotrigine er 300 mg generic 1 2 per day lamotrigine er 50 mg generic 1 topiragen 100 mg generic 1 3 per day topiragen 200 mg generic 1 8 per day topiragen 25 mg generic 1 4 per day topiragen 50 mg generic 1 4 per day topiramate 100 mg generic 1 3 per day topiramate 15 mg generic 1 6 per day topiramate 200 mg generic 1 8 per day topiramate 25 mg generic 1 8 per day topiramate 50 mg generic 1 4 per day Sodium Channel Agents BANZEL 200 MG rufinamide BANZEL 40 MG/ML rufinamide BANZEL 400 MG rufinamide 2 per day 80 per day 8 per day carbamazepine 100 mg generic 1 carbamazepine 100 mg/5ml generic 1 carbamazepine 200 mg generic 1 carbamazepine er 100 mg generic 1 carbamazepine er 200 mg generic 1 6 per day carbamazepine er 300 mg generic 1 4 per day carbamazepine er 400 mg generic 1 4 per day DILANTIN 30 MG phenytoin sodium extended DILANTIN INFATABS 50 MG phenytoin epitol 200 mg generic 1 3 GE 40 LAST UPDATED 09/2014

41 EQUETRO 100 MG carbamazepine (antipsychotic) BRAND 2 per day EQUETRO 200 MG carbamazepine (antipsychotic) EQUETRO 300 MG carbamazepine (antipsychotic) 8 per day 4 per day oxcarbazepine 150 mg generic 1 3 per day oxcarbazepine 300 mg generic 1 3 per day oxcarbazepine 300 mg/5ml generic 1 40 per day oxcarbazepine 600 mg generic 1 4 per day PEGANONE 250 MG ethotoin phenytoin 100 mg/4ml generic 1 phenytoin 125 mg/5ml generic 1 phenytoin 50 mg generic 1 phenytoin infatabs 50 mg generic 1 phenytoin sodium 50 mg/ml generic 1 phenytoin sodium extended 100 mg generic 1 phenytoin sodium extended 200 mg generic 1 phenytoin sodium extended 300 mg generic 1 TEGRETOL-XR 100 MG carbamazepine VIMT 10 MG/ML lacosamide 40 per day VIMT 100 MG lacosamide 2 per day VIMT 150 MG lacosamide 2 per day VIMT 200 MG lacosamide 2 per day VIMT 200 MG/20ML lacosamide VIMT 50 MG lacosamide 2 per day GE 41 LAST UPDATED 09/2014

42 zonisamide 100 mg generic 1 6 per day zonisamide 25 mg generic 1 6 per day zonisamide 50 mg generic 1 6 per day Antidementia Agents Antidementia Agents, Other ergoloid mesylates 1 mg generic 1 ERGOLOID MESYLATES 1 MG ergoloid mesylates Cholinesterase Inhibitors donepezil hcl 10 mg generic 1 donepezil hcl 23 mg generic 1 donepezil hcl 5 mg generic 1 EXELON 13.3 MG/24HR rivastigmine EXELON 2 MG/ML rivastigmine tartrate EXELON 4.6 MG/24HR rivastigmine EXELON 9.5 MG/24HR rivastigmine galantamine hydrobromide 12 mg generic 1 2 per day galantamine hydrobromide 4 mg generic 1 2 per day galantamine hydrobromide 4 mg/ml generic 1 galantamine hydrobromide 8 mg generic 1 2 per day galantamine hydrobromide er 16 mg generic 1 galantamine hydrobromide er 24 mg generic 1 galantamine hydrobromide er 8 mg generic 1 rivastigmine tartrate 1.5 mg generic 1 2 per day rivastigmine tartrate 3 mg generic 1 2 per day GE 42 LAST UPDATED 09/2014

43 rivastigmine tartrate 4.5 mg generic 1 2 per day rivastigmine tartrate 6 mg generic 1 2 per day N-methyl-D-aspartate (NMDA) Receptor Antagonist NAMENDA 10 MG memantine hcl NAMENDA 10 MG/5ML memantine hcl NAMENDA 5 MG memantine hcl NAMENDA TITRATION K 5 (28)-10 (21) MG memantine hcl NAMENDA XR 14 MG memantine hcl NAMENDA XR 21 MG memantine hcl NAMENDA XR 28 MG memantine hcl NAMENDA XR 7 MG memantine hcl 2 per day 2 per day Antidepressants Antidepressants, Other ABILIFY 1 MG/ML aripiprazole At least 6 yrs old 10 per day ABILIFY 10 MG aripiprazole At least 6 yrs old ABILIFY 15 MG aripiprazole At least 6 yrs old ABILIFY 2 MG aripiprazole At least 6 yrs old ABILIFY 20 MG aripiprazole At least 6 yrs old GE 43 LAST UPDATED 09/2014

44 ABILIFY 30 MG aripiprazole At least 6 yrs old ABILIFY 5 MG aripiprazole At least 6 yrs old ABILIFY 9.75 MG/1.3ML aripiprazole QL 8 / 28 days At least 6 yrs old ABILIFY DISCMELT 10 MG aripiprazole At least 6 yrs old ABILIFY DISCMELT 15 MG aripiprazole At least 6 yrs old budeprion sr 100 mg generic 1 2 per day budeprion sr 150 mg generic 1 2 per day budeprion xl 150 mg generic 1 2 per day budeprion xl 300 mg generic 1 2 per day bupropion hcl 100 mg generic 1 3 per day bupropion hcl 75 mg generic 1 3 per day bupropion hcl er (smoking det) 150 mg generic 0 2 per day bupropion hcl er (sr) 100 mg generic 1 2 per day bupropion hcl er (sr) 150 mg generic 1 2 per day bupropion hcl er (sr) 200 mg generic 1 2 per day bupropion hcl er (xl) 150 mg generic 1 2 per day bupropion hcl er (xl) 300 mg generic 1 2 per day maprotiline hcl 25 mg generic 1 maprotiline hcl 50 mg generic 1 maprotiline hcl 75 mg generic 1 GE 44 LAST UPDATED 09/2014

45 mirtazapine 15 mg generic 1 mirtazapine 30 mg generic 1 mirtazapine 45 mg generic 1 mirtazapine 7.5 mg generic 1 nefazodone hcl 100 mg generic 1 nefazodone hcl 150 mg generic 1 nefazodone hcl 200 mg generic 1 nefazodone hcl 250 mg generic 1 nefazodone hcl 50 mg generic 1 OLEPTRO 150 MG trazodone hcl OLEPTRO 300 MG trazodone hcl SEROQUEL XR 150 MG quetiapine fumarate At least 10 yrs old SEROQUEL XR 200 MG quetiapine fumarate At least 10 yrs old SEROQUEL XR 300 MG quetiapine fumarate At least 10 yrs old 2 per day SEROQUEL XR 400 MG quetiapine fumarate At least 10 yrs old 2 per day SEROQUEL XR 50 MG quetiapine fumarate At least 10 yrs old trazodone hcl 100 mg generic 1 trazodone hcl 150 mg generic 1 trazodone hcl 300 mg generic 1 1 GE 45 LAST UPDATED 09/2014

46 trazodone hcl 50 mg VIIBRYD 10 & 20 & 40 MG vilazodone hcl generic ST VIIBRYD 10 MG vilazodone hcl ST VIIBRYD 20 MG vilazodone hcl ST VIIBRYD 40 MG vilazodone hcl ST Monoamine Oxidase Inhibitors EMSAM 12 MG/24HR selegiline EMSAM 6 MG/24HR selegiline EMSAM 9 MG/24HR selegiline MARPLAN 10 MG isocarboxazid 6 per day phenelzine sulfate 15 mg generic 1 tranylcypromine sulfate 10 mg generic 1 Serotonin/Norepinephrine Reuptake Inhibitors citalopram hydrobromide 10 mg generic per day citalopram hydrobromide 10 mg/5ml generic 1 20 per day citalopram hydrobromide 20 mg generic per day citalopram hydrobromide 40 mg generic per day duloxetine hcl 20 mg generic 1 duloxetine hcl 30 mg generic 1 duloxetine hcl 60 mg generic 1 2 per day 2 per day 2 per day escitalopram oxalate 10 mg generic 1 escitalopram oxalate 20 mg generic 1 GE 46 LAST UPDATED 09/2014

47 escitalopram oxalate 5 mg generic 1 escitalopram oxalate 5 mg/5ml generic 1 fluoxetine hcl (pmdd) 10 mg generic 1 fluoxetine hcl (pmdd) 20 mg generic 1 fluoxetine hcl 10 mg generic 1 fluoxetine hcl 20 mg generic 1 3 per day fluoxetine hcl 20 mg/5ml generic 1 20 per day fluoxetine hcl 40 mg generic 1 2 per day fluoxetine hcl 60 mg generic 1 FLUOXETINE HCL 60 MG fluoxetine hcl fluoxetine hcl 90 mg generic 1 QL 4 / 28 days fluvoxamine maleate 100 mg generic 1 3 per day fluvoxamine maleate 25 mg generic 1 2 per day fluvoxamine maleate 50 mg generic 1 2 per day fluvoxamine maleate er 100 mg generic 1 fluvoxamine maleate er 150 mg generic 1 2 per day nefazodone hcl 100 mg generic 1 nefazodone hcl 150 mg generic 1 nefazodone hcl 200 mg generic 1 nefazodone hcl 250 mg generic 1 nefazodone hcl 50 mg generic 1 paroxetine hcl 10 mg generic per day paroxetine hcl 10 mg/5ml generic 1 30 per day paroxetine hcl 20 mg generic per day paroxetine hcl 30 mg generic per day paroxetine hcl 40 mg generic per day GE 47 LAST UPDATED 09/2014

48 paroxetine hcl er 12.5 mg generic 1 paroxetine hcl er 25 mg generic 1 paroxetine hcl er 37.5 mg generic 1 XIL 10 MG/5ML paroxetine hcl 30 per day PRISTIQ 100 MG desvenlafaxine succinate ST 4 per day PRISTIQ 50 MG desvenlafaxine succinate ST selfemra 10 mg generic 1 selfemra 20 mg generic 1 sertraline hcl 100 mg generic 1 2 per day sertraline hcl 20 mg/ml generic 1 sertraline hcl 25 mg generic 1 2 per day sertraline hcl 50 mg generic 1 2 per day venlafaxine hcl 100 mg generic 1 3 per day venlafaxine hcl 25 mg generic 1 3 per day venlafaxine hcl 37.5 mg generic 1 3 per day venlafaxine hcl 50 mg generic 1 3 per day venlafaxine hcl 75 mg generic 1 3 per day venlafaxine hcl er 150 mg generic 1 VENLAFAXINE HCL ER 225 MG venlafaxine hcl venlafaxine hcl er 37.5 mg generic 1 venlafaxine hcl er 75 mg generic 1 Tricyclics amitriptyline hcl 10 mg generic 1 amitriptyline hcl 100 mg generic 1 amitriptyline hcl 150 mg generic 1 amitriptyline hcl 25 mg generic 1 GE 48 LAST UPDATED 09/2014

49 amitriptyline hcl 50 mg generic 1 amitriptyline hcl 75 mg generic 1 amoxapine 100 mg generic 1 amoxapine 150 mg generic 1 amoxapine 25 mg generic 1 amoxapine 50 mg generic 1 clomipramine hcl 25 mg generic 1 clomipramine hcl 50 mg generic 1 clomipramine hcl 75 mg generic 1 desipramine hcl 10 mg generic 1 desipramine hcl 100 mg generic 1 desipramine hcl 150 mg generic 1 desipramine hcl 25 mg generic 1 desipramine hcl 50 mg generic 1 desipramine hcl 75 mg generic 1 doxepin hcl 10 mg generic 1 doxepin hcl 10 mg/ml generic 1 doxepin hcl 100 mg generic 1 doxepin hcl 150 mg generic 1 doxepin hcl 25 mg generic 1 doxepin hcl 50 mg generic 1 doxepin hcl 75 mg generic 1 DOXEPIN HCL 75 MG doxepin hcl imipramine hcl 10 mg generic 1 imipramine hcl 25 mg generic 1 imipramine hcl 50 mg generic 1 imipramine pamoate 100 mg generic 1 imipramine pamoate 125 mg generic 1 imipramine pamoate 150 mg generic 1 imipramine pamoate 75 mg generic 1 nortriptyline hcl 10 mg generic 1 nortriptyline hcl 10 mg/5ml generic 1 GE 49 LAST UPDATED 09/2014

50 nortriptyline hcl 25 mg generic 1 nortriptyline hcl 50 mg generic 1 nortriptyline hcl 75 mg generic 1 protriptyline hcl 10 mg generic 1 protriptyline hcl 5 mg generic 1 SURMONTIL 100 MG trimipramine maleate SURMONTIL 25 MG trimipramine maleate SURMONTIL 50 MG trimipramine maleate trimipramine maleate 100 mg generic 1 trimipramine maleate 25 mg generic 1 trimipramine maleate 50 mg generic 1 Antiemetics Antiemetics, Other OXI 0.25 MG/5ML palonosetron hcl chlorpromazine hcl 10 mg generic 1 chlorpromazine hcl 100 mg generic 1 chlorpromazine hcl 200 mg generic 1 chlorpromazine hcl 25 mg generic 1 chlorpromazine hcl 25 mg/ml generic 1 chlorpromazine hcl 50 mg generic 1 compazine 25 mg generic 1 compro 25 mg generic 1 diphenhydramine hcl 50 mg/ml generic 1 hydroxyzine hcl 10 mg generic 1 hydroxyzine hcl 10 mg/5ml generic 1 hydroxyzine hcl 25 mg generic 1 hydroxyzine hcl 25 mg/ml generic 1 hydroxyzine hcl 50 mg generic 1 hydroxyzine hcl 50 mg/ml generic 1 hydroxyzine pamoate 100 mg generic 1 GE 50 LAST UPDATED 09/2014

51 HYDROXYZINE MOATE 100 MG hydroxyzine pamoate hydroxyzine pamoate 25 mg generic 1 hydroxyzine pamoate 50 mg generic 1 meclizine hcl 12.5 mg generic 1 meclizine hcl 25 mg generic 1 metoclopramide hcl 1 mg/ml generic 1 metoclopramide hcl 10 mg generic 1 metoclopramide hcl 10 mg/10ml generic 1 metoclopramide hcl 5 mg generic 1 metoclopramide hcl 5 mg/5ml generic 1 metoclopramide hcl 5 mg/ml generic 1 perphenazine 16 mg generic 1 perphenazine 2 mg generic 1 perphenazine 4 mg generic 1 perphenazine 8 mg generic 1 phenadoz 12.5 mg generic 1 phenadoz 25 mg generic 1 phenergan 12.5 mg generic 1 phenergan 25 mg generic 1 phenergan 25 mg/ml generic 3 phenergan 50 mg generic 1 prochlorperazine 25 mg generic 1 prochlorperazine edisylate 5 mg/ml generic 1 prochlorperazine maleate 10 mg generic 1 prochlorperazine maleate 5 mg generic 1 promethazine hcl 12.5 mg generic 1 promethazine hcl 25 mg generic 1 promethazine hcl 25 mg/ml generic 1 promethazine hcl 50 mg generic 1 promethazine hcl 50 mg/ml generic 1 promethazine hcl 6.25 mg/5ml generic 1 GE 51 LAST UPDATED 09/2014

52 promethegan 12.5 mg generic 1 promethegan 25 mg generic 1 promethegan 50 mg generic 1 TIGAN 100 MG/ML trimethobenzamide hcl TRANSDERM-SCOP 1.5 MG scopolamine trimethobenzamide hcl 100 mg/ml generic 1 trimethobenzamide hcl 300 mg generic 1 Emetogenic Therapy Adjuncts OXI 0.25 MG/5ML palonosetron hcl ANZEMET 100 MG dolasetron mesylate QL 10 / 90 days ANZEMET 20 MG/ML dolasetron mesylate ANZEMET 50 MG dolasetron mesylate QL 10 / 90 days CESAMET 1 MG nabilone dronabinol 10 mg generic 1 dronabinol 2.5 mg generic 1 dronabinol 5 mg generic 1 EMEND 125 MG aprepitant EMEND 40 MG aprepitant EMEND 80 & 125 MG aprepitant EMEND 80 MG aprepitant QL 2 / 30 days QL 2 / 30 days QL 6 / 30 days QL 4 / 30 days granisetron hcl 0.1 mg/ml generic 1 granisetron hcl 1 mg generic 1 QL 30 / 90 days granisetron hcl 1 mg/ml generic 1 ondansetron 4 mg generic 1 QL 90 / 30 days GE 52 LAST UPDATED 09/2014

53 ondansetron 8 mg generic 1 QL 90 / 30 days ondansetron hcl 24 mg generic 1 QL 30 / 30 days ondansetron hcl 4 mg generic 1 QL 90 / 30 days ondansetron hcl 4 mg/2ml generic 1 ondansetron hcl 4 mg/5ml generic 1 QL 300 / 90 days ondansetron hcl 40 mg/20ml generic 1 ondansetron hcl 8 mg generic 1 QL 90 / 30 days ondansetron hcl-dextrose 32 mg/50ml generic 4 ONDANSETRON HCL-DEXTROSE 32 MG/50ML ondansetron hcl and dextrose ONDANSETRON HCL-NACL 32 MG/50ML ondansetron hcl and sodium chloride Antifungals ABELCET 5 MG/ML amphotericin b lipid AMBISOME 50 MG amphotericin b liposome AMPHOTEC 100 MG amphotericin b cholesteryl sulfate complex AMPHOTEC 50 MG amphotericin b cholesteryl sulfate complex amphotericin b 50 mg generic 1 AMPHOTERICIN B 50 MG amphotericin b CANCIDAS 50 MG caspofungin acetate CANCIDAS 70 MG caspofungin acetate ciclodan 0.77 % generic 1 ciclodan 8 % generic 1 ciclopirox 0.77 % generic 1 ciclopirox 1 % generic 1 ciclopirox 8 % generic 1 1 GE 53 LAST UPDATED 09/2014

2018 Formulary. (List of Covered Drugs)

2018 Formulary. (List of Covered Drugs) Capital Health Plan Advantage Plus (HMO) Capital Health Plan Preferred Advantage (HMO) 2018 Formulary (List of Covered Drugs) PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN