6-Tier Drug Formulary

Transcription

1 6-Tier Drug Formulary 2018

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3 Avera Health Plans Tier Drug Formulary Effective January 1, 2018 PLEASE READ: THIS DOCUMENT HAS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN. Please refer to your Certificate of Coverage, Master Contract, Plan Document or other plan materials to determine if your drug is covered. The Drug Formulary does not guarantee coverage and is subject to change. The Drug Formulary is subject to change without notice. Members must use participating pharmacies to fill their prescription drugs. 1

4 What is the Avera Health Plans Drug Formulary? The Drug Formulary is a list of covered prescription drugs, which are approved for use for specific treatments and dispensed through participating pharmacies. Avera Health Plans works with a team of health care providers to choose drugs that provide quality treatment. Avera Health Plans covers drugs on the Drug Formulary that are: Medically necessary Approved by the United States Food and Drug Administration (FDA) Filled at a participating pharmacy For more information on how to fill your prescriptions and determine if your drug is covered, please review your Certificate of Coverage, Master Contract, Plan Document or other plan materials. Can the Drug Formulary change? The Drug Formulary may change from time to time as described in the Certificate of Coverage, Master Contract, Plan Document or other plan materials. The enclosed Drug Formulary is the most current Drug Formulary covered by Avera Health Plans. To get updated information about the drugs covered by Avera Health Plans, please visit us online at AveraHealthPlans.com or call our Service Center at or tollfree at , 8 a.m. to 5 p.m. CT, Monday through Friday. How do I use the Drug Formulary? There are two ways to find your drug on the drug list: 1. Medical Condition The Drug Formulary starts on page 5. The drugs on this Drug Formulary are grouped by the type of medical conditions they are used to treat. For example, drugs used to treat a heart condition are listed under CARDIOVASCULAR. If you know what your drug is used for, look for the category name in the list that starts on page 5. Then look under the category name for your drug 2. Alphabetical Listing If you are not sure what category to look under, look for your drug in the Index that starts on page 132. The Index is an alphabetical list of all the drugs in this document. Both brand-name drugs and generic drugs are in the Index. Look in the Index and find your drug Next to your drug, see the page number where you can find coverage information Turn to the page listed in the Index and find the name of your drug in the first column of the list For more information about your Avera Health Plans prescription drug coverage, please look at your Certificate of Coverage, Master Contract, Plan Document or other plan materials. If you have questions about this Drug Formulary, please call our Service Center at or toll-free at , 8 a.m. to 5 p.m. CT, Monday through Friday. You may also visit us online at AveraHealthPlans.com. Avera Health Plans Drug Formulary The Drug Formulary that starts on the page 5, gives you information about the drugs covered by Avera Health Plans. A generic drug is a drug that has the same active ingredients as its brand-name counterpart, and has been approved by the FDA as being interchangeable with the brand-name drug as approved by your provider. Upon release of a generic drug to the market, the generic drug will generally be added to the formulary and the associated brand drug will be considered non-preferred or not covered. However, some generic drugs do not cost less than brand-name drugs and may not be added to your formulary. 2

5 The first column of the chart lists the drug name. Brand-name drugs are capitalized (e.g., LIPITOR). Generic drugs are listed in lower-case italics (e.g., atorvastatin). The second column (labeled Drug Tier) will list what tier the drug is placed on in the Drug Formulary. Refer to your Summary of Benefits and Coverage to find the associated co-pay for that drug tier. The information in the Requirements/Limits column tells you if Avera Health Plans has any special requirements for coverage of your drug. These requirements and limits may include: Preauthorization: Avera Health Plans needs your healthcare provider to get preauthorization for certain drugs. This means that approval from Avera Health Plans must be obtained before you fill your prescription. If you don't get approval, Avera Health Plans will not cover the cost of the drug. Additional information can be found online at AveraHealthPlans.com. Quantity Limits: For certain drugs, Avera Health Plans limits the amount of the drug that it will cover. For example, Avera Health Plans only covers 18 tablets of sumatriptan 50 per 30 days. Avera Health Plans also limits the amount of drugs you may receive within a class of drugs. These classes have an " " next to them on the drug list. For these classes, only one drug should be taken at a time for safety reasons. This may be in addition to a standard one-month or three-month supply. Step Therapy: Avera Health Plans utilizes step therapy to provide the most cost-effective and safest drugs available for a specific medical condition. Step therapy programs require your healthcare provider to prescribe a step-one drug before a step-two drug will be covered. If the step-one drugs do not work for you, Avera Health Plans will cover the step-two drugs. Visit us online at AveraHealthPlans.com to review a list of Step Therapy Programs. Age Limits: Certain drugs approved by the FDA or other prescribing guidelines are not appropriate based on age. Gender Limits: Certain drugs approved by the FDA or other prescribing guidelines are not appropriate based on gender. What if my drug is not on the Drug Formulary? If your drug is not on this Drug Formulary, you have two choices: Your healthcare provider can prescribe a drug that is similar that is covered on the Drug Formulary. Similar drugs that are preferred and covered on the Drug Formulary may be easier to obtain and lower cost to you. You can request a formulary exception if you believe the drug you take should be covered because other treatment options on the Drug Formulary do not work for you. To request a formulary exception, you or your healthcare provider must provide written documentation to include the following: Why no other prescription on the Drug Formulary will work as well as the requested drug A list of other drugs that have been tried and how you responded to these drugs Medical documentation to support the medical necessity How likely is it that I will get the formulary exception? We will review the information and when a decision has been made, you and your healthcare provider will receive a letter that states the decision. If a formulary exception is approved, the non-preferred co-pay (for the applicable drug type) will be applied. The prescription must be a covered benefit on your plan. Formulary exceptions do not include reductions on prescriptions co-pays. 3

6 What do the tiers mean on the Drug Formulary? Tier Type of Drugs Included Tier 1 Preventive drugs (covered at no cost to you) Tier 2 Preferred generic drugs Tier 3 Non-preferred generic drugs Tier 4 Preferred brand drugs Tier 5 Non-preferred brand drugs Tier 6 Specialty drugs (brand and generic) 4

7 ANALGESICS COX-II INHIBITORS CELEBREX CAP 50MG 5 QL CELEBREX CAP 100MG 5 QL CELEBREX CAP 200MG 5 QL CELEBREX CAP 400MG 5 QL celecoxib cap 50 2 QL celecoxib cap QL celecoxib cap QL celecoxib cap QL GOUT allopurinol tab allopurinol tab colchicine cap QL colchicine tab QL colchicine w/ probenecid tab COLCRYS TAB 0.6MG 5 QL probenecid tab ULORIC TAB 40MG 4 QL ULORIC TAB 80MG 4 QL ZURAMPIC TAB 200MG 5 QL; ST NON-OPIOID ANALGESICS butalbital-acetaminophen tab QL butalbital-acetaminophen tab QL butalbital-acetaminophen-caffeine cap 50-2 QL butalbital-acetaminophen-caffeine cap 50-2 QL butalbital-aspirin-caffeine cap ESGIC TAB 2 QL NSAIDS diclofenac potassium tab 50 2 diclofenac sodium tab delayed release 75 2 diclofenac sodium tab er 24hr diflunisal tab EC-NAPROSYN TAB 375MG 2 etodolac tab etodolac tab etodolac tab er 24hr etodolac tab er 24hr

8 etodolac tab er 24hr FELDENE CAP 10MG 5 FELDENE CAP 20MG 5 fenoprofen calcium cap FENOPROFEN CAP 200MG 3 FENORTHO CAP 200MG 3 flurbiprofen tab ibuprofen tab INDOCIN SUP 50MG 4 INDOCIN SUS 25MG/5ML 4 indomethacin cap 25 2 QL indomethacin cap 50 2 QL indomethacin cap er 75 2 ketoprofen cap 75 2 ketorolac tromethamine tab 10 2 QL LODINE TAB 400MG 2 meloxicam tab meloxicam tab 15 2 nabumetone tab nabumetone tab NAPRELAN TAB 750MG CR 5 naproxen sodium tab naproxen sodium tab naproxen sodium tab er 24hr (base equiv) naproxen sodium tab er 24hr (base equiv) naproxen susp 125 /5ml 2 naproxen tab naproxen tab ec oxaprozin tab PONSTEL CAP 250MG 5 salsalate tab salsalate tab sulindac tab tolmetin sodium tab tolmetin sodium tab ZIPSOR CAP 25MG 5 NSAIDS, COMBINATIONS diclofenac w/ misoprostol tab delayed 3 release diclofenac w/ misoprostol tab delayed release

9 DUEXIS TAB VIMOVO TAB MG 5 QL NSAIDS, TOPICAL diclofenac sodium gel 1% 3 QL diclofenac sodium soln 1.5% 3 QL FLECTOR DIS 1.3% 5 QL PENNSAID SOL 2% 5 QL OPIOID ANALGESICS ABSTRAL SUB 100MCG 5 QL ABSTRAL SUB 200MCG 5 QL ABSTRAL SUB 300MCG 5 QL ABSTRAL SUB 400MCG 5 QL ABSTRAL SUB 600MCG 5 QL ABSTRAL SUB 800MCG 5 QL acetaminophen w/ codeine soln /5ml 2 Covered for ages 12 acetaminophen w/ codeine tab QL; Covered for ages 12 acetaminophen w/ codeine tab QL; Covered for ages 12 acetaminophen w/ codeine tab QL; Covered for ages 12 ACTIQ LOZ 200MCG 5 QL ACTIQ LOZ 400MCG 5 QL ACTIQ LOZ 600MCG 5 QL ACTIQ LOZ 800MCG 5 QL ACTIQ LOZ 1200MCG 5 QL ACTIQ LOZ 1600MCG 5 QL aspirin-caffeine-dihydrocodeine cap Covered for ages BELBUCA MIS 75MCG 5 PA; QL BELBUCA MIS 150MCG 5 PA; QL BELBUCA MIS 300MCG 5 PA; QL BELBUCA MIS 450MCG 5 PA; QL BELBUCA MIS 600MCG 5 PA; QL BELBUCA MIS 750MCG 5 PA; QL BELBUCA MIS 900MCG 5 PA; QL buprenorphine td patch weekly 5 mcg/hr 3 QL buprenorphine td patch weekly 7.5 mcg/hr 3 QL buprenorphine td patch weekly 10 mcg/hr 3 QL buprenorphine td patch weekly 15 mcg/hr 3 QL buprenorphine td patch weekly 20 mcg/hr 3 QL 7

10 butalbital-acetaminophen-caff w/ cod cap QL; Covered for ages 12 butalbital-acetaminophen-caff w/ cod cap QL; Covered for ages 12 butalbital-aspirin-caff w/ codeine cap QL; Covered for ages 12 butorphanol tartrate nasal soln 10 /ml 3 QL codeine sulfate tab 15 2 QL; Covered for ages 12 codeine sulfate tab 30 2 QL; Covered for ages 12 codeine sulfate tab 60 2 QL; Covered for ages 12 EMBEDA CAP MG 5 QL; ST EMBEDA CAP MG 5 QL; ST EMBEDA CAP 50-2MG 5 QL; ST EMBEDA CAP MG 5 QL; ST EMBEDA CAP MG 5 QL; ST EMBEDA CAP 100-4MG 5 QL; ST fentanyl citrate lozenge on a handle QL mcg fentanyl citrate lozenge on a handle QL mcg fentanyl citrate lozenge on a handle QL mcg fentanyl citrate lozenge on a handle QL mcg fentanyl citrate lozenge on a handle QL mcg fentanyl citrate lozenge on a handle QL mcg FENTANYL DIS 37.5MCG 3 QL FENTANYL DIS 62.5MCG 3 QL FENTANYL DIS 87.5MCG 3 QL fentanyl td patch 72hr 12 mcg/hr 3 QL fentanyl td patch 72hr 25 mcg/hr 3 QL fentanyl td patch 72hr 50 mcg/hr 3 QL fentanyl td patch 72hr 75 mcg/hr 3 QL fentanyl td patch 72hr 100 mcg/hr 3 QL FENTORA TAB 100MCG 5 QL FENTORA TAB 200MCG 5 QL FENTORA TAB 400MCG 5 QL FENTORA TAB 600MCG 5 QL FENTORA TAB 800MCG 5 QL 8

11 HYCET SOL QL hydrocodone-acetaminophen soln /15ml 3 QL hydrocodone-acetaminophen tab QL hydrocodone-acetaminophen tab QL hydrocodone-acetaminophen tab QL hydrocodone-acetaminophen tab QL hydrocodone-acetaminophen tab QL hydrocodone-acetaminophen tab QL hydrocodone-ibuprofen tab QL hydrocodone-ibuprofen tab QL hydrocodone-ibuprofen tab QL hydrocodone-ibuprofen tab QL HYDROMORPHON SUP 3MG 3 QL hydromorphone hcl liqd 1 /ml 3 QL hydromorphone hcl tab 2 3 QL hydromorphone hcl tab 4 3 QL hydromorphone hcl tab 8 3 QL hydromorphone hcl tab er 24hr deter 8 3 QL hydromorphone hcl tab er 24hr deter 12 3 QL hydromorphone hcl tab er 24hr deter 16 3 QL hydromorphone hcl tab er 24hr deter 32 3 QL HYSINGLA ER TAB 20 MG 5 QL; ST HYSINGLA ER TAB 30 MG 5 QL; ST HYSINGLA ER TAB 40 MG 5 QL; ST HYSINGLA ER TAB 60 MG 5 QL; ST HYSINGLA ER TAB 80 MG 5 QL; ST HYSINGLA ER TAB 100 MG 5 QL; ST HYSINGLA ER TAB 120 MG 5 QL; ST KADIAN CAP 40MG ER 5 QL; ST KADIAN CAP 200MG ER 5 QL; ST LAZANDA SPR 100MCG 5 QL LAZANDA SPR 300MCG 5 QL LAZANDA SPR 400MCG 5 QL levorphanol tartrate tab 2 3 QL LORTAB ELX MG 3 QL 9

12 meperidine hcl oral soln 50 /5ml 3 QL meperidine hcl tab 50 3 QL meperidine hcl tab QL methadone hcl conc 10 /ml 3 QL methadone hcl soln 10 /5ml 3 QL methadone hcl tab 10 3 QL methadone hcl tab for oral susp 40 3 QL morphine sulfate beads cap er 24hr 30 3 morphine sulfate beads cap er 24hr 45 3 morphine sulfate beads cap er 24hr 60 3 morphine sulfate beads cap er 24hr 75 3 morphine sulfate beads cap er 24hr 90 3 morphine sulfate beads cap er 24hr morphine sulfate cap er 24hr 80 3 QL morphine sulfate oral soln 10 /5ml 3 QL morphine sulfate oral soln 20 /5ml 3 QL morphine sulfate oral soln 100 /5ml (20 3 QL /ml) morphine sulfate suppos 5 3 QL morphine sulfate tab 15 3 QL morphine sulfate tab 30 3 QL morphine sulfate tab er 15 3 QL NORCO TAB 5-325MG 2 QL NORCO TAB QL NORCO TAB MG 2 QL NUCYNTA ER TAB 50MG 5 QL; ST NUCYNTA ER TAB 100MG 5 QL; ST NUCYNTA ER TAB 150MG 5 QL; ST NUCYNTA ER TAB 200MG 5 QL; ST NUCYNTA ER TAB 250MG 5 QL; ST NUCYNTA TAB 50MG 5 QL NUCYNTA TAB 75MG 5 QL NUCYNTA TAB 100MG 5 QL oxycodone hcl cap 5 3 QL oxycodone hcl conc 100 /5ml (20 3 QL /ml) oxycodone hcl soln 5 /5ml 3 QL oxycodone hcl tab 5 3 QL oxycodone hcl tab 10 3 QL oxycodone hcl tab 15 3 QL oxycodone hcl tab 20 3 QL oxycodone hcl tab 30 3 QL 10

13 oxycodone hcl tab er 12hr deter 10 3 QL oxycodone hcl tab er 12hr deter 15 3 QL oxycodone hcl tab er 12hr deter 20 3 QL oxycodone hcl tab er 12hr deter 30 3 QL oxycodone hcl tab er 12hr deter 40 3 QL oxycodone hcl tab er 12hr deter 60 3 QL oxycodone hcl tab er 12hr deter 80 3 QL oxycodone w/ acetaminophen soln /5ml 2 QL oxycodone w/ acetaminophen tab QL oxycodone w/ acetaminophen tab QL oxycodone w/ acetaminophen tab QL oxycodone w/ acetaminophen tab QL oxycodone-aspirin tab QL oxycodone-ibuprofen tab QL OXYCONTIN TAB 10MG CR 4 QL; ST OXYCONTIN TAB 15MG CR 4 QL; ST OXYCONTIN TAB 20MG CR 4 QL; ST OXYCONTIN TAB 30MG CR 4 QL; ST OXYCONTIN TAB 40MG CR 4 QL; ST OXYCONTIN TAB 60MG CR 4 QL; ST OXYCONTIN TAB 80MG CR 4 QL; ST oxymorphone hcl tab 5 3 QL oxymorphone hcl tab 10 3 QL oxymorphone hcl tab er 12hr 5 3 oxymorphone hcl tab er 12hr oxymorphone hcl tab er 12hr 10 3 oxymorphone hcl tab er 12hr 15 3 oxymorphone hcl tab er 12hr 20 3 oxymorphone hcl tab er 12hr 30 3 oxymorphone hcl tab er 12hr 40 3 pentazocine w/ naloxone tab QL SUBSYS SPR 100MCG 5 SUBSYS SPR 200MCG 5 SUBSYS SPR 400MCG 5 SUBSYS SPR 600MCG 5 SUBSYS SPR 800MCG 5 SUBSYS SPR 1200MCG 5 SUBSYS SPR 1600MCG 5 11

14 SYNALGOS-DC CAP 5 Covered for ages 12 TRAMADOL HCL CAP 150MG ER 5 QL; Covered for ages 12 tramadol hcl cap er 24hr biphasic release 5 QL; Covered for ages tramadol hcl cap er 24hr biphasic release 5 QL; Covered for ages tramadol hcl cap er 24hr biphasic release 5 QL; Covered for ages tramadol hcl tab er 24hr QL; Covered for ages 12 tramadol hcl tab er 24hr QL; Covered for ages 12 tramadol hcl tab er 24hr QL; Covered for ages 12 tramadol hcl tab er 24hr biphasic release 3 QL; Covered for ages tramadol hcl tab er 24hr biphasic release 3 QL; Covered for ages tramadol hcl tab er 24hr biphasic release 3 QL; Covered for ages tramadol-acetaminophen tab QL; Covered for ages 12 TREZIX CAP 3 Covered for ages 12 XODOL TAB 5-300MG 2 QL XODOL TAB QL XODOL TAB MG 2 QL ZOHYDRO ER CAP 10MG 5 QL; ST ZOHYDRO ER CAP 15MG 5 QL; ST ZOHYDRO ER CAP 20MG 5 QL; ST ZOHYDRO ER CAP 30MG 5 QL; ST ZOHYDRO ER CAP 40MG 5 QL; ST ZOHYDRO ER CAP 50MG 5 QL; ST ANTI-INFECTIVES AMINOGLYCOSIDES neomycin sulfate tab paromomycin sulfate cap ANTIBACTERIALS, CEPHALOSPORINS, First Generation cefadroxil for susp 250 /5ml 2 cefadroxil for susp 500 /5ml 2 cefadroxil tab 1 gm 2 cephalexin cap

15 cephalexin tab ANTIBACTERIALS, CEPHALOSPORINS, Second Generation cefaclor for susp 375 /5ml 3 cefprozil for susp 125 /5ml 2 cefprozil for susp 250 /5ml 2 cefprozil tab cefprozil tab CEFTIN SUS 125/5ML 5 cefuroxime axetil tab ANTIBACTERIALS, CEPHALOSPORINS, Third Generation CEDAX CAP 400MG 5 cefdinir cap cefdinir for susp 250 /5ml 2 cefditoren pivoxil tab 200 (base 3 equivalent) cefditoren pivoxil tab 400 (base 3 equivalent) cefixime for susp 100 /5ml 3 cefixime for susp 200 /5ml 3 cefpodoxime proxetil for susp 50 /5ml 3 cefpodoxime proxetil for susp 100 /5ml 3 ceftibuten cap ceftibuten for susp 180 /5ml 3 SPECTRACEF TAB 400MG 5 SUPRAX CAP 400MG 5 SUPRAX CHW 100MG 5 SUPRAX CHW 200MG 5 SUPRAX SUS 100/5ML 5 SUPRAX SUS 200/5ML 5 SUPRAX SUS 500/5ML 5 ANTIBACTERIALS, ERYTHROMYCINS/MACROLIDES azithromycin for susp 100 /5ml 2 azithromycin for susp 200 /5ml 2 azithromycin powd pack for susp 1 gm 2 azithromycin tab clarithromycin for susp 125 /5ml 3 clarithromycin for susp 250 /5ml 3 clarithromycin tab clarithromycin tab DIFICID TAB 200MG 4 QL ERYPED SUS 400/5ML 5 13

16 erythromycin ethylsuccinate for susp /5ml erythromycin ethylsuccinate tab erythromycin stearate tab erythromycin tab erythromycin tab delayed release erythromycin tab delayed release erythromycin tab delayed release PCE TAB 333MG EC 5 PCE TAB 500MG EC 5 ZMAX SUS 2GM 5 ANTIBACTERIALS, FLUOROQUINOLONES ciprofloxacin for oral susp 500 /5ml 3 (10%) (10 gm/100ml) ciprofloxacin hcl tab 100 (base equiv) 2 ciprofloxacin hcl tab 250 (base equiv) 2 ciprofloxacin hcl tab 500 (base equiv) 2 ciprofloxacin hcl tab 750 (base equiv) 2 ciprofloxacin-ciprofloxacin hcl tab er 24hr (base eq) ciprofloxacin-ciprofloxacin hcl tab er 24hr (base eq) FACTIVE TAB 320MG 5 levofloxacin oral soln 25 /ml 3 levofloxacin tab levofloxacin tab levofloxacin tab moxifloxacin hcl tab 400 (base equiv) 3 ofloxacin tab ofloxacin tab ANTIBACTERIALS, PENICILLINS amoxicillin & k clavulanate chew tab amoxicillin & k clavulanate chew tab amoxicillin & k clavulanate for susp /5ml amoxicillin & k clavulanate for susp /5ml amoxicillin & k clavulanate for susp /5ml amoxicillin & k clavulanate for susp /5ml 14

17 amoxicillin & k clavulanate tab amoxicillin & k clavulanate tab amoxicillin & k clavulanate tab er 12hr amoxicillin (trihydrate) chew tab amoxicillin (trihydrate) chew tab ampicillin cap AUGMENTIN SUS 125/5ML 5 dicloxacillin sodium cap dicloxacillin sodium cap MOXATAG TAB 775MG 5 penicillin v potassium tab ANTIBACTERIALS, SULFONAMIDES SULFADIAZINE TAB 500MG 3 sulfamethoxazole-trimethoprim susp /5ml sulfamethoxazole-trimethoprim tab sulfamethoxazole-trimethoprim tab sulfatrim pd sus /5 2 ANTIBACTERIALS, TETRACYCLINES demeclocycline hcl tab demeclocycline hcl tab doxycycline hyclate cap 50 2 doxycycline hyclate cap doxycycline hyclate tab 20 3 doxycycline hyclate tab 75 3 doxycycline hyclate tab doxycycline hyclate tab delayed release 50 3 doxycycline hyclate tab delayed release 75 3 doxycycline hyclate tab delayed release doxycycline hyclate tab delayed release doxycycline hyclate tab delayed release doxycycline monohydrate cap 50 3 doxycycline monohydrate cap 75 2 doxycycline monohydrate cap doxycycline monohydrate cap

18 doxycycline monohydrate for susp 25 3 /5ml doxycycline monohydrate tab 50 3 doxycycline monohydrate tab 75 3 doxycycline monohydrate tab doxycycline monohydrate tab minocycline hcl cap 75 2 minocycline hcl tab 75 2 minocycline hcl tab er 24hr 45 3 minocycline hcl tab er 24hr 90 3 minocycline hcl tab er 24hr MORGIDOX KIT 1X50MG 2 MORGIDOX KIT 1X100MG 2 MORGIDOX KIT 2X100MG 2 okebo cap 75 3 okebo cap SOLODYN TAB 55MG 5 SOLODYN TAB 65MG 5 SOLODYN TAB 105MG 5 SOLODYN TAB 115MG 5 tetracycline hcl cap tetracycline hcl cap VIBRAMYCIN SYP 50MG/5ML 5 ANTIFUNGALS clotrimazole troche 10 3 CRESEMBA CAP 186 MG 5 QL; Restricted to infectious disease specialists fluconazole for susp 10 /ml 2 fluconazole for susp 40 /ml 2 fluconazole tab 50 2 fluconazole tab fluconazole tab fluconazole tab flucytosine cap flucytosine cap griseofulvin microsize susp 125 /5ml 3 itraconazole cap QL; Restricted to infectious disease specialists ketoconazole tab

19 NOXAFIL SUS 40MG/ML 4 QL; Restricted to oncologists and infectious disease specialists NOXAFIL TAB 100MG 4 QL; Restricted to oncologists and infectious disease specialists nystatin susp unit/ml 4 nystatin tab unit 2 ONMEL TAB 200MG 5 ORAVIG TAB 50MG 5 SPORANOX SOL 10MG/ML 5 QL; Restricted to infectious disease specialists terbinafine hcl tab QL voriconazole for susp 40 /ml 3 QL; Restricted to infectious disease specialists voriconazole tab 50 3 QL; Restricted to infectious disease specialists voriconazole tab QL; Restricted to infectious disease specialists ANTIMALARIALS atovaquone-proguanil hcl tab atovaquone-proguanil hcl tab chloroquine phosphate tab chloroquine phosphate tab COARTEM TAB MG 4 QL DARAPRIM TAB 25MG 5 mefloquine hcl tab PRIMAQUINE TAB 26.3MG 3 quinine sulfate cap QL ANTIRETROVIRALS, ANTIRETROVIRAL ADJUVANTS TYBOST TAB 150MG 5 QL ANTIRETROVIRALS, ANTIRETROVIRAL COMBINATIONS abacavir sulfate-lamivudine tab abacavir sulfate-lamivudine-zidovudine tab ATRIPLA TAB 6 COMBIVIR TAB

20 COMPLERA TAB 6 QL DESCOVY TAB 200/25 6 QL EPZICOM TAB EVOTAZ TAB QL GENVOYA TAB 6 lamivudine-zidovudine tab PREZCOBIX TAB QL STRIBILD TAB 6 QL TRIUMEQ TAB 6 QL TRIZIVIR TAB 6 TRUVADA TAB TRUVADA TAB TRUVADA TAB TRUVADA TAB ANTIRETROVIRALS, CHEMOKINE RECEPTOR ANTAGONISTS SELZENTRY SOL 20MG/ML 6 QL SELZENTRY TAB 150MG 6 QL SELZENTRY TAB 300MG 6 QL ANTIRETROVIRALS, FUSION INHIBITORS FUZEON INJ 90MG 6 QL ANTIRETROVIRALS, INTEGRASE INHIBITORS ISENTRESS CHW 25MG 6 QL ISENTRESS CHW 100MG 6 QL ISENTRESS HD TAB 600MG 6 QL ISENTRESS POW 100MG 6 QL ISENTRESS TAB 400MG 6 QL TIVICAY TAB 10MG 6 QL TIVICAY TAB 25MG 6 QL TIVICAY TAB 50MG 6 QL ANTIRETROVIRALS, NON-NUCLEOSIDE REVERSE TRANSCRIPTASE INHIBITORS EDURANT TAB 25MG 6 QL INTELENCE TAB 25MG 6 QL INTELENCE TAB 100MG 6 QL INTELENCE TAB 200MG 6 QL nevirapine tab nevirapine tab er 24hr QL nevirapine tab er 24hr QL RESCRIPTOR TAB 100 MG 6 RESCRIPTOR TAB 200MG 6 SUSTIVA CAP 50MG 6 SUSTIVA CAP 200MG 6 18

21 SUSTIVA TAB 600MG 6 VIRAMUNE SUS 50MG/5ML 6 VIRAMUNE TAB 200MG 6 VIRAMUNE XR TAB 100MG 6 QL VIRAMUNE XR TAB 400MG 6 QL ANTIRETROVIRALS, NUCLEOSIDE REVERSE TRANSCRIPTASE INHIBITORS abacavir sulfate soln 20 /ml (base 6 equiv) abacavir sulfate tab 300 (base equiv) 6 didanosine delayed release capsule didanosine delayed release capsule didanosine delayed release capsule didanosine delayed release capsule EMTRIVA CAP 200MG 6 QL EMTRIVA SOL 10MG/ML 6 QL EPIVIR SOL 10MG/ML 6 EPIVIR TAB 150MG 6 EPIVIR TAB 300MG 6 lamivudine oral soln 10 /ml 6 lamivudine tab lamivudine tab RETROVIR CAP 100MG 6 RETROVIR SYP 50MG/5ML 6 stavudine cap 15 6 stavudine cap 20 6 stavudine cap 30 6 stavudine cap 40 6 VIDEX EC CAP 125MG 6 VIDEX EC CAP 200MG 6 VIDEX EC CAP 250MG 6 VIDEX EC CAP 400MG 6 VIDEX SOL 2GM 6 VIDEX SOL 4GM 6 ZERIT CAP 15MG 6 ZERIT CAP 20MG 6 ZERIT CAP 30MG 6 ZERIT CAP 40MG 6 ZERIT SOL 1MG/ML 6 ZIAGEN SOL 20MG/ML 6 ZIAGEN TAB 300MG 6 zidovudine cap

22 zidovudine syrup 10 /ml 6 ANTIRETROVIRALS, PROTEASE INHIBITORS APTIVUS CAP 250MG 6 APTIVUS SOL 6 CRIXIVAN CAP 200MG 6 CRIXIVAN CAP 400MG 6 fosamprenavir calcium tab 700 (base 6 equiv) INVIRASE CAP 200MG 6 INVIRASE TAB 500MG 6 KALETRA TAB MG 6 KALETRA TAB MG 6 LEXIVA SUS 50MG/ML 6 LEXIVA TAB 700MG 6 lopinavir-ritonavir soln /5ml 6 (80-20 /ml) NORVIR CAP 100MG 6 NORVIR SOL 80MG/ML 6 NORVIR TAB 100MG 6 PREZISTA SUS 100MG/ML 6 PREZISTA TAB 75MG 6 QL PREZISTA TAB 150MG 6 QL PREZISTA TAB 600MG 6 QL PREZISTA TAB 800MG 6 QL REYATAZ CAP 150MG 6 REYATAZ CAP 200MG 6 REYATAZ CAP 300MG 6 REYATAZ POW 50MG 6 VIRACEPT TAB 250MG 6 VIRACEPT TAB 625MG 6 ANTIRETROVIRALS, REVERSE TRANSCRIPTASE INHIBITORS - NUCLEOTIDE VIREAD POW 40MG/GM 6 VIREAD TAB 150MG 6 VIREAD TAB 200MG 6 VIREAD TAB 250MG 6 VIREAD TAB 300MG 6 ANTITUBERCULAR AGENTS cycloserine cap ethambutol hcl tab ethambutol hcl tab isoniazid syrup 50 /5ml 2 20

23 isoniazid tab isoniazid tab PASER GRA 4GM 3 PRIFTIN TAB 150MG 5 pyrazinamide tab RIFAMATE CAP 5 RIFATER TAB 5 SIRTURO TAB 100MG 6 TRECATOR TAB 250MG 5 ANTIVIRALS, CYTOMEGALOVIRUS AGENTS VALCYTE SOL 50MG/ML 6 VALCYTE TAB 450MG 6 valganciclovir hcl for soln 50 /ml (base 6 equiv) valganciclovir hcl tab 450 (base 6 equivalent) ANTIVIRALS, HEPATITIS AGENTS, Hepatitis B adefovir dipivoxil tab 10 6 BARACLUDE SOL.05MG/ML 6 BARACLUDE TAB 0.5MG 6 BARACLUDE TAB 1MG 6 entecavir tab entecavir tab 1 6 EPIVIR HBV SOL 5MG/ML 6 EPIVIR HBV TAB 100MG 6 HEPSERA TAB 10MG 6 lamivudine tab 100 (hbv) 6 ANTIVIRALS, HEPATITIS AGENTS, Hepatitis C DAKLINZA TAB 30MG 6 PA; QL DAKLINZA TAB 60MG 6 PA; QL DAKLINZA TAB 90MG 6 PA; QL EPCLUSA TAB PA; QL HARVONI TAB MG 6 PA; QL MAVYRET TAB MG 6 PA OLYSIO CAP 150MG 6 PA; QL ribavirin cap ribavirin tab SOVALDI TAB 400MG 6 PA; QL TECHNIVIE TAB 6 PA; QL VIEKIRA PAK TAB 6 PA; QL VIEKIRA XR TAB 6 PA; QL VOSEVI TAB 6 PA 21

24 ZEPATIER TAB MG 6 PA; QL ANTIVIRALS, HERPES AGENTS acyclovir cap acyclovir susp 200 /5ml 2 famciclovir tab famciclovir tab famciclovir tab valacyclovir hcl tab 1 gm 3 valacyclovir hcl tab ANTIVIRALS, INFLUENZA AGENTS oseltamivir phosphate cap 30 (base 3 QL equiv) oseltamivir phosphate cap 45 (base 3 QL equiv) oseltamivir phosphate cap 75 (base 3 QL equiv) oseltamivir phosphate for susp 6 /ml 3 QL (base equiv) RELENZA MIS DISKHALE 5 QL rimantadine hydrochloride tab TAMIFLU SUS 6MG/ML 4 QL MISCELLANEOUS ALBENZA TAB 200MG 5 ALINIA SUS 100/5ML 4 ALINIA TAB 500MG 4 atovaquone susp 750 /5ml 3 BILTRICIDE TAB 600MG 5 clindamycin hcl cap 75 2 clindamycin hcl cap clindamycin hcl cap clindamycin palmitate hcl for soln 75 2 /5ml (base equiv) dapsone tab 25 2 dapsone tab IMPAVIDO CAP 50MG 6 QL ivermectin tab 3 2 linezolid for susp 100 /5ml 3 Restricted to infectious disease specialists linezolid tab QL; Restricted to infectious disease specialists methenamine hippurate tab 1 gm 3 methenamine mandelate tab 0.5 gm 3 22

25 metronidazole cap MONUROL PAK GRANULES 5 nitrofurantoin macrocrystalline cap 25 3 nitrofurantoin macrocrystalline cap nitrofurantoin monohydrate 2 macrocrystalline cap 100 nitrofurantoin susp 25 /5ml 2 PRIMSOL SOL 50MG/5ML 5 rifabutin cap SIVEXTRO TAB 200MG 4 QL tinidazole tab tinidazole tab trimethoprim tab TRIMPEX SOL 50MG/5ML 5 vancomycin hcl cap PA; QL vancomycin hcl cap PA; QL vancomycin hcl for inj vancomycin hcl for inj vancomycin hcl for inj XIFAXAN TAB 200MG 5 XIFAXAN TAB 550MG 5 ANTINEOPLASTIC AGENTS ALKYLATING AGENTS CYCLOPHOSPH CAP 25MG 6 CYCLOPHOSPH CAP 50MG 6 EMCYT CAP 140MG 6 PA GLEOSTINE CAP 5MG 6 PA GLEOSTINE CAP 10MG 6 PA GLEOSTINE CAP 40MG 6 PA GLEOSTINE CAP 100MG 6 PA HEXALEN CAP 50MG 6 PA LEUKERAN TAB 2MG 4 PA melphalan tab 2 6 PA MYLERAN TAB 2MG 5 TEMODAR CAP 5MG 6 PA TEMODAR CAP 20MG 6 PA TEMODAR CAP 100MG 6 PA TEMODAR CAP 140MG 6 PA TEMODAR CAP 180MG 6 PA TEMODAR CAP 250MG 6 PA temozolomide cap 5 6 PA temozolomide cap 20 6 PA 23

26 temozolomide cap PA temozolomide cap PA temozolomide cap PA temozolomide cap PA VALCHLOR GEL 0.016% 6 ANTIMETABOLITES capecitabine tab PA capecitabine tab PA mercaptopurine tab 50 2 methotrexate sodium inj 50 /2ml (25 /ml) 2 methotrexate sodium inj 250 /10ml (25 2 /ml) methotrexate sodium inj pf 50 /2ml (25 2 /ml) methotrexate sodium inj pf 250 /10ml 2 (25 /ml) methotrexate sodium tab 2.5 (base 2 equiv) PURIXAN SUS 20MG/ML 5 TABLOID TAB 40MG 5 PA TREXALL TAB 5MG 4 TREXALL TAB 7.5MG 4 TREXALL TAB 10MG 4 TREXALL TAB 15MG 4 XELODA TAB 150MG 6 PA XELODA TAB 500MG 6 PA HORMONAL ANTINEOPLASTIC AGENTS, LUTEINIZING HORMONE- RELEASING HORMONE (LHRH) AGONISTS leuprolide acetate inj kit 5 /ml 6 PA HORMONAL ANTINEOPLASTICS, ANTIANDROGENS bicalutamide tab 50 2 QL flutamide cap NILANDRON TAB 150MG 6 PA nilutamide tab PA XTANDI CAP 40MG 6 PA; QL ZYTIGA TAB 250MG 6 PA; QL HORMONAL ANTINEOPLASTICS, ANTIESTROGENS FARESTON TAB 60MG 5 PA HORMONAL ANTINEOPLASTICS, AROMATASE INHIBITORS ARIMIDEX TAB 1MG 5 QL exemestane tab 25 3 PA 24

27 letrozole tab HORMONAL ANTINEOPLASTICS, PROGESTINS megestrol acetate tab 20 3 megestrol acetate tab 40 3 IMMUNOMODULATORS POMALYST CAP 1MG 6 PA; QL POMALYST CAP 2MG 6 PA; QL POMALYST CAP 3MG 6 PA; QL POMALYST CAP 4MG 6 PA; QL REVLIMID CAP 2.5MG 6 PA; QL REVLIMID CAP 5MG 6 PA; QL REVLIMID CAP 10MG 6 PA; QL REVLIMID CAP 15MG 6 PA; QL REVLIMID CAP 20MG 6 PA; QL REVLIMID CAP 25MG 6 PA; QL THALOMID CAP 50MG 6 PA; QL THALOMID CAP 100MG 6 PA; QL THALOMID CAP 150MG 6 PA; QL THALOMID CAP 200MG 6 PA; QL KINASE INHIBITORS AFINITOR DIS TAB 2MG 6 PA; QL AFINITOR DIS TAB 3MG 6 PA; QL AFINITOR DIS TAB 5MG 6 PA; QL AFINITOR TAB 2.5MG 6 PA; QL AFINITOR TAB 5MG 6 PA; QL AFINITOR TAB 7.5MG 6 PA; QL AFINITOR TAB 10MG 6 PA; QL ALECENSA CAP 150MG 6 PA; QL ALUNBRIG TAB 30MG 6 PA; QL BOSULIF TAB 100MG 6 PA; QL BOSULIF TAB 500MG 6 PA; QL CAPRELSA TAB 100MG 6 PA; QL CAPRELSA TAB 300MG 6 PA; QL COMETRIQ KIT 100MG 6 PA; QL COMETRIQ KIT 140MG 6 PA; QL COTELLIC TAB 20MG 6 PA; QL GILOTRIF TAB 20MG 6 PA; QL GILOTRIF TAB 30MG 6 PA; QL GILOTRIF TAB 40MG 6 PA; QL GLEEVEC TAB 100MG 6 PA; QL GLEEVEC TAB 400MG 6 PA; QL IBRANCE CAP 75MG 6 PA; QL 25

28 IBRANCE CAP 100MG 6 PA; QL IBRANCE CAP 125MG 6 PA; QL ICLUSIG TAB 15MG 6 PA; QL ICLUSIG TAB 45MG 6 PA; QL imatinib mesylate tab 100 (base 6 PA; QL equivalent) imatinib mesylate tab 400 (base 6 PA; QL equivalent) IMBRUVICA CAP 140MG 6 PA; QL INLYTA TAB 1MG 6 PA; QL INLYTA TAB 5MG 6 PA; QL JAKAFI TAB 5MG 6 PA; QL JAKAFI TAB 10MG 6 PA; QL JAKAFI TAB 15MG 6 PA; QL JAKAFI TAB 20MG 6 PA; QL JAKAFI TAB 25MG 6 PA; QL LENVIMA CAP 8 MG 6 PA; QL LENVIMA CAP 10 MG 6 PA; QL LENVIMA CAP 14 MG 6 PA; QL LENVIMA CAP 18 MG 6 PA; QL LENVIMA CAP 20 MG 6 PA; QL LENVIMA CAP 24 MG 6 PA; QL MEKINIST TAB 0.5MG 6 PA; QL MEKINIST TAB 2MG 6 PA; QL NEXAVAR TAB 200MG 6 PA; QL RYDAPT CAP 25MG 6 PA SPRYCEL TAB 20MG 6 PA SPRYCEL TAB 50MG 6 PA SPRYCEL TAB 70MG 6 PA SPRYCEL TAB 80MG 6 PA SPRYCEL TAB 100MG 6 PA SPRYCEL TAB 140MG 6 PA STIVARGA TAB 40MG 6 PA; QL SUTENT CAP 12.5MG 6 PA SUTENT CAP 25MG 6 PA SUTENT CAP 37.5MG 6 PA SUTENT CAP 50MG 6 PA TAFINLAR CAP 50MG 6 PA; QL TAFINLAR CAP 75MG 6 PA; QL TAGRISSO TAB 40MG 6 PA; QL TAGRISSO TAB 80MG 6 PA; QL TARCEVA TAB 25MG 6 PA; QL TARCEVA TAB 100MG 6 PA; QL 26

29 TARCEVA TAB 150MG 6 PA; QL TASIGNA CAP 150MG 6 PA; QL TASIGNA CAP 200MG 6 PA; QL TYKERB TAB 250MG 6 PA; QL VOTRIENT TAB 200MG 6 PA; QL XALKORI CAP 200MG 6 PA; QL XALKORI CAP 250MG 6 PA; QL ZELBORAF TAB 240MG 6 PA; QL ZYDELIG TAB 100MG 6 PA; QL ZYDELIG TAB 150MG 6 PA; QL ZYKADIA CAP 150MG 6 PA; QL MISCELLANEOUS bexarotene cap 75 6 PA DROXIA CAP 200MG 5 DROXIA CAP 300MG 5 DROXIA CAP 400MG 5 ERIVEDGE CAP 150MG 6 PA; QL FARYDAK CAP 10MG 6 PA; QL FARYDAK CAP 15MG 6 PA; QL FARYDAK CAP 20MG 6 PA; QL hydroxyurea cap leucovorin calcium tab 5 3 leucovorin calcium tab 10 3 leucovorin calcium tab 15 3 leucovorin calcium tab 25 3 LONSURF TAB PA; QL LONSURF TAB PA; QL LYNPARZA CAP 50MG 6 PA; QL LYNPARZA TAB 100MG 6 PA LYNPARZA TAB 150MG 6 PA LYSODREN TAB 500MG 6 PA MATULANE CAP 50MG 6 PA MESNEX TAB 400MG 6 NINLARO CAP 2.3MG 6 PA; QL NINLARO CAP 3MG 6 PA; QL NINLARO CAP 4MG 6 PA; QL ODOMZO CAP 200MG 6 PA; QL RUBRACA TAB 200MG 6 PA; QL RUBRACA TAB 250MG 6 PA; QL RUBRACA TAB 300MG 6 PA; QL TARGRETIN CAP 75MG 6 PA TARGRETIN GEL 1% 6 27

30 tretinoin cap 10 6 PA VENCLEXTA TAB 10MG 6 PA; QL VENCLEXTA TAB 50MG 6 PA; QL VENCLEXTA TAB 100MG 6 PA; QL VENCLEXTA TAB START PK 6 PA; QL VISTOGARD PAK 10GM 6 QL ZEJULA CAP 100MG 6 PA, QL ZOLINZA CAP 100MG 6 PA; QL TOPOISOMERASE INHIBITORS HYCAMTIN CAP 0.25MG 6 PA HYCAMTIN CAP 1MG 6 PA CARDIOVASCULAR ACE INHIBITOR/CALCIUM CHANNEL BLOCKER COMBINATIONS amlodipine besylate-benazepril hcl cap amlodipine besylate-benazepril hcl cap amlodipine besylate-benazepril hcl cap amlodipine besylate-benazepril hcl cap amlodipine besylate-benazepril hcl cap amlodipine besylate-benazepril hcl cap trandolapril-verapamil hcl tab er trandolapril-verapamil hcl tab er trandolapril-verapamil hcl tab er trandolapril-verapamil hcl tab er ACE INHIBITOR/DIURETIC COMBINATIONS benazepril & hydrochlorothiazide tab benazepril & hydrochlorothiazide tab benazepril & hydrochlorothiazide tab benazepril & hydrochlorothiazide tab captopril & hydrochlorothiazide tab captopril & hydrochlorothiazide tab

31 captopril & hydrochlorothiazide tab captopril & hydrochlorothiazide tab enalapril maleate & hydrochlorothiazide tab enalapril maleate & hydrochlorothiazide tab fosinopril sodium & hydrochlorothiazide tab fosinopril sodium & hydrochlorothiazide tab lisinopril & hydrochlorothiazide tab lisinopril & hydrochlorothiazide tab moexipril-hydrochlorothiazide tab moexipril-hydrochlorothiazide tab moexipril-hydrochlorothiazide tab quinapril-hydrochlorothiazide tab quinapril-hydrochlorothiazide tab quinapril-hydrochlorothiazide tab ACE INHIBITORS ACCUPRIL TAB 5MG 5 ACCUPRIL TAB 10MG 5 ACCUPRIL TAB 20MG 5 ACCUPRIL TAB 40MG 5 benazepril hcl tab 5 2 benazepril hcl tab 10 2 benazepril hcl tab 20 2 benazepril hcl tab 40 2 captopril tab captopril tab 25 2 captopril tab 50 2 captopril tab enalapril maleate tab enalapril maleate tab 5 2 fosinopril sodium tab 10 2 fosinopril sodium tab

32 fosinopril sodium tab 40 2 lisinopril tab lisinopril tab 30 2 lisinopril tab 40 2 moexipril hcl tab moexipril hcl tab 15 2 perindopril erbumine tab 2 2 perindopril erbumine tab 8 2 QBRELIS SOL 1MG/ML 5 ramipril cap ramipril cap ramipril cap 5 2 ramipril cap 10 2 trandolapril tab 1 2 trandolapril tab 2 2 trandolapril tab 4 2 ADRENOLYTICS, CENTRAL clonidine hcl tab clonidine hcl tab clonidine hcl tab clonidine hcl td patch weekly 0.1 /24hr 3 QL clonidine hcl td patch weekly 0.2 /24hr 3 QL clonidine hcl td patch weekly 0.3 /24hr 3 QL guanfacine hcl tab 1 2 guanfacine hcl tab 2 2 ADRENOLYTICS, CENTRAL/DIURETIC COMBINATIONS clonidine & chlorthalidone tab clonidine & chlorthalidone tab clonidine & chlorthalidone tab AGENTS FOR PHEOCHROMOCYTOMA DEMSER CAP 250MG 5 phenoxybenzamine hcl cap 10 3 ALDOSTERONE RECEPTOR ANTAGONISTS ALDACTONE TAB 25MG 5 ALDACTONE TAB 50MG 5 ALDACTONE TAB 100MG 5 eplerenone tab 25 3 QL eplerenone tab 50 3 QL ALPHA BLOCKERS doxazosin mesylate tab 1 2 doxazosin mesylate tab 2 2 doxazosin mesylate tab

33 doxazosin mesylate tab 8 2 prazosin hcl cap 1 2 prazosin hcl cap 2 2 terazosin hcl cap 1 2 terazosin hcl cap 2 2 terazosin hcl cap 5 2 terazosin hcl cap 10 2 ANGIOTENSIN II RECEPTOR ANTAGONIST/BETA-BLOCKER COMBINATIONS BYVALSON TAB 5-80MG 5 QL ANGIOTENSIN II RECEPTOR ANTAGONIST/CALCIUM CHANNEL BLOCKER COMBINATIONS amlodipine besylate-olmesartan medoxomil 3 tab 5-20 amlodipine besylate-olmesartan medoxomil 3 tab 5-40 amlodipine besylate-olmesartan medoxomil 3 tab amlodipine besylate-olmesartan medoxomil 3 tab amlodipine besylate-valsartan tab amlodipine besylate-valsartan tab amlodipine besylate-valsartan tab amlodipine besylate-valsartan tab telmisartan-amlodipine tab telmisartan-amlodipine tab telmisartan-amlodipine tab telmisartan-amlodipine tab ANGIOTENSIN II RECEPTOR ANTAGONIST/CALCIUM CHANNEL BLOCKER/DIURETIC COMBINATIONS amlodipine-valsartan-hydrochlorothiazide 3 tab amlodipine-valsartan-hydrochlorothiazide 3 tab amlodipine-valsartan-hydrochlorothiazide 3 tab amlodipine-valsartan-hydrochlorothiazide 3 tab

34 amlodipine-valsartan-hydrochlorothiazide 3 tab olmesartan-amlodipine-hydrochlorothiazide 3 tab olmesartan-amlodipine-hydrochlorothiazide 3 tab olmesartan-amlodipine-hydrochlorothiazide 3 tab olmesartan-amlodipine-hydrochlorothiazide 3 tab olmesartan-amlodipine-hydrochlorothiazide 3 tab ANGIOTENSIN II RECEPTOR ANTAGONIST/DIURETIC COMBINATIONS candesartan cilexetil-hydrochlorothiazide 2 tab candesartan cilexetil-hydrochlorothiazide 2 tab candesartan cilexetil-hydrochlorothiazide 2 tab EDARBYCLOR TAB EDARBYCLOR TAB 40-25MG 5 irbesartan-hydrochlorothiazide tab irbesartan-hydrochlorothiazide tab losartan potassium & hydrochlorothiazide 2 tab losartan potassium & hydrochlorothiazide 2 tab losartan potassium & hydrochlorothiazide 2 tab olmesartan medoxomil-hydrochlorothiazide 3 tab olmesartan medoxomil-hydrochlorothiazide 3 tab olmesartan medoxomil-hydrochlorothiazide 3 tab telmisartan-hydrochlorothiazide tab telmisartan-hydrochlorothiazide tab telmisartan-hydrochlorothiazide tab

35 valsartan-hydrochlorothiazide tab valsartan-hydrochlorothiazide tab valsartan-hydrochlorothiazide tab valsartan-hydrochlorothiazide tab valsartan-hydrochlorothiazide tab ANGIOTENSIN II RECEPTOR ANTAGONISTS candesartan cilexetil tab 4 2 candesartan cilexetil tab 8 2 candesartan cilexetil tab 16 2 candesartan cilexetil tab 32 2 EDARBI TAB 40MG 5 EDARBI TAB 80MG 5 eprosartan mesylate tab irbesartan tab 75 2 irbesartan tab irbesartan tab losartan potassium tab 25 2 losartan potassium tab 50 2 losartan potassium tab olmesartan medoxomil tab 5 3 olmesartan medoxomil tab 20 3 olmesartan medoxomil tab 40 3 telmisartan tab 20 3 telmisartan tab 40 3 telmisartan tab 80 3 valsartan tab 40 2 valsartan tab 80 2 valsartan tab valsartan tab ANTIARRHYTHMICS amiodarone hcl tab amiodarone hcl tab amiodarone hcl tab disopyramide phosphate cap disopyramide phosphate cap dofetilide cap 125 mcg (0.125 ) 3 dofetilide cap 250 mcg (0.25 ) 3 dofetilide cap 500 mcg (0.5 ) 3 33

36 flecainide acetate tab 50 2 flecainide acetate tab flecainide acetate tab mexiletine hcl cap mexiletine hcl cap mexiletine hcl cap MULTAQ TAB 400MG 5 QL NORPACE CAP 100MG CR 5 NORPACE CAP 150MG CR 5 propafenone hcl cap er 12hr propafenone hcl cap er 12hr propafenone hcl cap er 12hr propafenone hcl tab propafenone hcl tab propafenone hcl tab quinidine gluconate tab er quinidine sulfate tab quinidine sulfate tab sotalol hcl (afib/afl) tab 80 2 sotalol hcl (afib/afl) tab sotalol hcl (afib/afl) tab sotalol hcl tab 80 2 sotalol hcl tab sotalol hcl tab sotalol hcl tab SOTYLIZE SOL 5MG/ML 5 TIKOSYN CAP 125MCG 5 TIKOSYN CAP 250MCG 5 TIKOSYN CAP 500MCG 5 ANTILIPEMICS, BILE ACID RESINS cholestyramine light powder 4 gm/dose 2 cholestyramine light powder packets 4 gm 2 cholestyramine powder 4 gm/dose 2 cholestyramine powder packets 4 gm 2 colestipol hcl granule packets 5 gm 3 colestipol hcl granules 5 gm 3 colestipol hcl tab 1 gm 3 WELCHOL PAK 3.75GM 4 WELCHOL TAB 625MG 4 ANTILIPEMICS, CHOLESTEROL ABSORPTION INHIBITORS ezetimibe tab 10 3 ANTILIPEMICS, FIBRATES 34

37 ANTARA CAP 30MG 5 ANTARA CAP 90MG 5 choline fenofibrate cap dr 45 (fenofibric 2 acid equiv) choline fenofibrate cap dr (fenofibric acid equiv) fenofibrate cap 50 2 fenofibrate cap fenofibrate micronized cap 43 2 fenofibrate micronized cap 67 2 fenofibrate micronized cap fenofibrate tab 40 3 fenofibrate tab 48 2 fenofibrate tab 54 2 fenofibrate tab fenofibrate tab fenofibrate tab fenofibric acid tab 35 2 fenofibric acid tab LOPID TAB 600MG 5 TRIGLIDE TAB 160MG 5 ANTILIPEMICS, HMG-COA REDUCTASE INHIBITORS/COMBINATIONS atorvastatin calcium tab 10 (base 1 equivalent) atorvastatin calcium tab 20 (base 1 equivalent) atorvastatin calcium tab 40 (base 2 QL equivalent) atorvastatin calcium tab 80 (base 2 QL equivalent) CRESTOR TAB 5MG 5 QL CRESTOR TAB 10MG 5 QL CRESTOR TAB 20MG 5 QL CRESTOR TAB 40MG 5 QL ezetimibe-simvastatin tab ezetimibe-simvastatin tab ezetimibe-simvastatin tab ezetimibe-simvastatin tab fluvastatin sodium cap 20 1 fluvastatin sodium cap 40 1 fluvastatin sodium tab er 24 hr 80 1 LIVALO TAB 1MG 5 QL 35

38 LIVALO TAB 2MG 5 QL LIVALO TAB 4MG 5 QL lovastatin tab 10 1 lovastatin tab 20 1 lovastatin tab 40 1 pravastatin sodium tab 10 1 pravastatin sodium tab 20 1 pravastatin sodium tab 40 1 pravastatin sodium tab 80 1 rosuvastatin calcium tab 5 1 rosuvastatin calcium tab 10 1 rosuvastatin calcium tab 20 3 QL rosuvastatin calcium tab 40 3 QL simvastatin tab 5 1 simvastatin tab 10 1 simvastatin tab 20 1 simvastatin tab 40 1 simvastatin tab 80 2 ANTILIPEMICS, MICROSOMAL TRIGLYCERIDE TRANSFER PROTEIN INHIBITORS JUXTAPID CAP 5MG 6 PA; QL JUXTAPID CAP 10MG 6 PA; QL JUXTAPID CAP 20MG 6 PA; QL JUXTAPID CAP 30MG 6 PA; QL JUXTAPID CAP 40MG 6 PA; QL JUXTAPID CAP 60MG 6 PA; QL ANTILIPEMICS, MISCELLANEOUS KYNAMRO INJ 200MG/ML 6 PA; QL ANTILIPEMICS, NIACINS/COMBINATIONS niacin (antihyperlipidemic) tab niacin tab er 500 (antihyperlipidemic) 3 QL niacin tab er 1000 (antihyperlipidemic) 3 QL ANTILIPEMICS, OMEGA-3 FATTY ACIDS omega-3-acid ethyl esters cap 1 gm 3 QL VASCEPA CAP 1GM 5 QL ANTILIPEMICS, PCSK9 INHIBITORS PRALUENT INJ 75MG/ML 6 PA; QL PRALUENT INJ 150MG/ML 6 PA; QL REPATHA INJ 140MG/ML 6 PA; QL REPATHA PUSH INJ 420/3.5 6 PA; QL REPATHA SURE INJ 140MG/ML 6 PA; QL BETA-BLOCKER/DIURETIC COMBINATIONS 36

39 atenolol & chlorthalidone tab bisoprolol & hydrochlorothiazide tab bisoprolol & hydrochlorothiazide tab bisoprolol & hydrochlorothiazide tab metoprolol & hydrochlorothiazide tab metoprolol & hydrochlorothiazide tab metoprolol & hydrochlorothiazide tab nadolol & bendroflumethiazide tab propranolol & hydrochlorothiazide tab propranolol & hydrochlorothiazide tab BETA-BLOCKERS acebutolol hcl cap acebutolol hcl cap atenolol tab 25 2 atenolol tab 50 2 atenolol tab betaxolol hcl tab 10 2 betaxolol hcl tab 20 2 bisoprolol fumarate tab 5 2 bisoprolol fumarate tab 10 2 BYSTOLIC TAB 2.5MG 5 QL BYSTOLIC TAB 5MG 5 QL BYSTOLIC TAB 10MG 5 QL BYSTOLIC TAB 20MG 5 QL carvedilol phosphate cap er 24hr 10 3 QL carvedilol phosphate cap er 24hr 20 3 QL carvedilol phosphate cap er 24hr 40 3 QL carvedilol phosphate cap er 24hr 80 3 QL carvedilol tab COREG CR CAP 10MG 5 QL COREG CR CAP 20MG 5 QL COREG CR CAP 40MG 5 QL COREG CR CAP 80MG 5 QL labetalol hcl tab

40 metoprolol succinate tab er 24hr 25 2 (tartrate equiv) metoprolol succinate tab er 24hr 50 2 (tartrate equiv) metoprolol succinate tab er 24hr (tartrate equiv) metoprolol tartrate tab 25 2 metoprolol tartrate tab metoprolol tartrate tab 75 2 nadolol tab 20 2 nadolol tab 40 2 nadolol tab 80 2 pindolol tab 5 2 pindolol tab 10 2 propranolol hcl cap er 24hr 60 2 propranolol hcl cap er 24hr 80 2 propranolol hcl cap er 24hr propranolol hcl cap er 24hr propranolol hcl oral soln 20 /5ml 2 propranolol hcl oral soln 40 /5ml 2 propranolol hcl tab 20 2 propranolol hcl tab 60 2 timolol maleate tab 5 2 timolol maleate tab 10 2 timolol maleate tab 20 2 CALCIUM CHANNEL BLOCKER/ANTILIPEMIC COMBINATIONS amlodipine besylate-atorvastatin calcium 3 tab amlodipine besylate-atorvastatin calcium 3 tab amlodipine besylate-atorvastatin calcium 3 tab amlodipine besylate-atorvastatin calcium 3 tab 5-10 amlodipine besylate-atorvastatin calcium 3 tab 5-20 amlodipine besylate-atorvastatin calcium 3 tab 5-40 amlodipine besylate-atorvastatin calcium 3 tab 5-80 amlodipine besylate-atorvastatin calcium 3 tab amlodipine besylate-atorvastatin calcium 3 tab

41 amlodipine besylate-atorvastatin calcium 3 tab amlodipine besylate-atorvastatin calcium 3 tab CALCIUM CHANNEL BLOCKERS, DIHYDROPYRIDINES amlodipine besylate tab amlodipine besylate tab 5 2 amlodipine besylate tab 10 2 felodipine tab er 24hr felodipine tab er 24hr 5 2 felodipine tab er 24hr 10 2 isradipine cap isradipine cap 5 2 nicardipine hcl cap 20 3 nicardipine hcl cap 30 3 nifedipine cap 20 3 nifedipine tab er 24hr 30 2 nifedipine tab er 24hr 60 2 nifedipine tab er 24hr 90 2 nifedipine tab er 24hr osmotic release 30 2 nifedipine tab er 24hr osmotic release 60 2 nifedipine tab er 24hr osmotic release 90 2 nimodipine cap 30 3 nisoldipine tab er 24hr nisoldipine tab er 24hr 17 3 nisoldipine tab er 24hr 20 3 nisoldipine tab er 24hr nisoldipine tab er 24hr 30 3 nisoldipine tab er 24hr 34 3 nisoldipine tab er 24hr 40 3 CALCIUM CHANNEL BLOCKERS, NON DIHYDROPYRIDINES CALAN SR TAB 120MG 5 CALAN SR TAB 180MG 5 CALAN SR TAB 240MG 5 CALAN TAB 80MG 5 CALAN TAB 120MG 5 CARDIZEM LA TAB 120MG 5 diltiazem hcl cap er 24hr diltiazem hcl cap er 24hr diltiazem hcl cap er 24hr

42 diltiazem hcl coated beads cap er 24hr diltiazem hcl coated beads cap er 24hr diltiazem hcl coated beads cap er 24hr diltiazem hcl coated beads cap er 24hr diltiazem hcl coated beads cap er 24hr diltiazem hcl coated beads tab er 24hr diltiazem hcl coated beads tab er 24hr diltiazem hcl coated beads tab er 24hr diltiazem hcl coated beads tab er 24hr diltiazem hcl coated beads tab er 24hr diltiazem hcl extended release beads cap 2 er 24hr 120 diltiazem hcl extended release beads cap 2 er 24hr 180 diltiazem hcl extended release beads cap 2 er 24hr 240 diltiazem hcl extended release beads cap 2 er 24hr 300 diltiazem hcl extended release beads cap 2 er 24hr 360 diltiazem hcl extended release beads cap 2 er 24hr 420 diltiazem hcl tab 30 2 diltiazem hcl tab 90 2 diltiazem hcl tab verapamil hcl cap er 24hr verapamil hcl cap er 24hr verapamil hcl cap er 24hr verapamil hcl cap er 24hr verapamil hcl tab er VERELAN CAP 120MG SR 5 VERELAN CAP 180MG SR 5 VERELAN CAP 240MG SR 5 VERELAN CAP 360MG SR 5 40

43 VERELAN PM CAP 100MG ER 5 VERELAN PM CAP 200MG ER 5 VERELAN PM CAP 300MG ER 5 DIGITALIS GLYCOSIDES digoxin oral soln 0.05 /ml 5 digoxin tab 125 mcg (0.125 ) 2 digoxin tab 250 mcg (0.25 ) 2 LANOXIN TAB MG 5 LANOXIN TAB MG 5 DIRECT RENIN INHIBITORS/DIURETIC COMBINATIONS TEKTURNA HCT TAB QL TEKTURNA HCT TAB MG 5 QL TEKTURNA HCT TAB QL TEKTURNA HCT TAB MG 5 QL TEKTURNA TAB 150MG 5 QL TEKTURNA TAB 300MG 5 QL DIURETICS, CARBONIC ANHYDRASE INHIBITORS acetazolamide cap er 12hr acetazolamide tab acetazolamide tab KEVEYIS TAB 50MG 6 PA; QL methazolamide tab 25 2 methazolamide tab 50 2 DIURETICS, DIURETIC COMBINATIONS ALDACTAZIDE TAB 50/50 5 amiloride & hydrochlorothiazide tab spironolactone & hydrochlorothiazide tab triamterene & hydrochlorothiazide cap triamterene & hydrochlorothiazide cap triamterene & hydrochlorothiazide tab triamterene & hydrochlorothiazide tab DIURETICS, LOOP bumetanide tab bumetanide tab 2 2 EDECRIN TAB 25MG 5 ethacrynic acid tab

44 furosemide oral soln 8 /ml 2 furosemide oral soln 10 /ml 2 furosemide tab 80 2 torsemide tab 5 2 torsemide tab 10 2 torsemide tab 20 2 torsemide tab DIURETICS, POTASSIUM-SPARING amiloride hcl tab 5 2 DYRENIUM CAP 50MG 5 DYRENIUM CAP 100MG 5 DIURETICS, THIAZIDES AND THIAZIDE-LIKE chlorothiazide tab chlorothiazide tab chlorthalidone tab 25 2 chlorthalidone tab 50 2 DIURIL SUS 250/5ML 5 hydrochlorothiazide cap hydrochlorothiazide tab hydrochlorothiazide tab 50 2 indapamide tab indapamide tab methyclothiazide tab 5 3 metolazone tab metolazone tab 10 2 HEART FAILURE CORLANOR TAB 5MG 5 QL CORLANOR TAB 7.5MG 5 QL ENTRESTO TAB 24-26MG 5 ENTRESTO TAB 49-51MG 5 ENTRESTO TAB MG 5 MISCELLANEOUS hydralazine hcl tab 10 2 hydralazine hcl tab 25 2 hydralazine hcl tab 50 2 hydralazine hcl tab methyldopa & hydrochlorothiazide tab methyldopa & hydrochlorothiazide tab methyldopa tab methyldopa tab

45 midodrine hcl tab midodrine hcl tab 5 3 midodrine hcl tab 10 3 minoxidil tab minoxidil tab 10 2 RANEXA TAB 500MG 4 QL RANEXA TAB 1000MG 4 QL NITRATES, ORAL DILATRATE SR CAP 40MG 4 ISORDIL TAB 40MG 5 isosorbide dinitrate tab 30 2 isosorbide mononitrate tab er 24hr 30 2 isosorbide mononitrate tab er 24hr 60 2 isosorbide mononitrate tab er 24hr NITRATES, SUBLINGUAL/TRANSLINGUAL nitroglycerin lingual aerosol 400 mcg/spray3 nitroglycerin sl tab nitroglycerin sl tab nitroglycerin tl soln 0.4 /spray (400 3 mcg/spray) NITRATES, TRANSDERMAL NITRO-BID OIN 2% 2 NITRO-DUR DIS 0.1MG/HR 5 NITRO-DUR DIS 0.2MG/HR 5 NITRO-DUR DIS 0.3MG/HR 5 NITRO-DUR DIS 0.4MG/HR 5 NITRO-DUR DIS 0.6MG/HR 5 NITRO-DUR DIS 0.8MG/HR 5 nitroglycerin td patch 24hr 0.1 /hr 2 nitroglycerin td patch 24hr 0.2 /hr 2 nitroglycerin td patch 24hr 0.4 /hr 2 nitroglycerin td patch 24hr 0.6 /hr 2 PULMONARY ARTERIAL HYPERTENSION, ENDOTHELIN RECEPTOR ANTAGONISTS LETAIRIS TAB 5MG 6 PA; QL LETAIRIS TAB 10MG 6 PA; QL OPSUMIT TAB 10MG 6 PA; QL TRACLEER TAB 32MG 6 PA; QL TRACLEER TAB 62.5MG 6 PA; QL TRACLEER TAB 125MG 6 PA; QL PULMONARY ARTERIAL HYPERTENSION, PHOSPHODIESTERASE INHIBITORS 43