Louisiana Healthcare Connections MEMBER Preferred Drug List. Effective November 2012

Transcription

1 Louisiana Healthcare Connections MEMBER Preferred Drug List Last Updated November 2012 Effective November 2012 Preferred Drug List Medication Locator Instructions: 1. With the PDF open, on the Edit menu, click Find. 2. In the Find box type the name of the medication you want to find. 3. Click Find Next button until you find the medication you are looking for.

2 Pharmacy Program Louisiana Healthcare Connections covers certain prescription drugs and over-the-counter (OTC) drugs when written on a prescription by a doctor in the Louisiana Healthcare Connections provider network. The pharmacy program does not cover all drugs. Louisiana Healthcare Connections works with doctors and pharmacists to make sure that Louisiana Healthcare Connections covers the drugs you may need. Some drugs have limits or require prior authorization. You should use a generic instead of brand whenever possible. In general, when generic drugs are available, the brand name drug will not be covered without prior authorization from Louisiana Healthcare Connections. If you and your doctor feel a brand-name drug is medically necessary, your doctor can ask for prior authorization. Preferred Drug List Louisiana Healthcare Connections has a list of covered drugs. This is called the Preferred Drug List (PDL). Louisiana Healthcare Connections watches for new drugs to put on the list of covered drugs. For the most current Louisiana Healthcare Connections PDL, you can call Member Services at (TDD/TTY ) or visit the Louisiana Healthcare Connections website Over-the-Counter Drugs The Louisiana Healthcare Connections pharmacy program covers a variety of OTC drugs. A list of covered OTC drugs can be found in the Over-the-Counter section. This is on the page after the copayment table. Your doctor must write a prescription for an OTC drug to be covered by Louisiana Healthcare Connections. If you want to get OTC drugs and don t have a prescription from a doctor in the Louisiana Healthcare Connections provider network, you will have to pay for them. Tobacco Cessation Drugs Louisiana Healthcare Connections covers some drugs to help you quit smoking. A doctor in the Louisiana Healthcare Connections provider network must write a prescription for these drugs. These drugs include: Generic nicotine replacement products (gum, lozenges, and patches) Bupropion SR (Zyban)

3 Excluded Drugs Some drugs are not covered by Louisiana Healthcare Connections. This includes, but is not limited to drugs for: Infertility or impotence Cosmetic purposes or hair growth Vitamins (except those listed in the PDL) Step Therapy Some drugs listed on the Louisiana Healthcare Connections PDL may require other drugs to be tried first. The step therapy requirements can be found in the last column of the drug listing. If Louisiana Healthcare Connections has a record that you have already tired the required drugs, then the step therapy drugs will automatically be covered. If we do not have a record that the other drugs were tried, your doctor may need to send us a medical reason for using the step therapy drug. This requires a prior authorization. If Louisiana Healthcare Connections does not grant prior authorization, we will notify you and your doctor and tell you how to file an appeal. Quantity Limits Some drugs on the Louisiana Healthcare Connections PDL have limits on the amount you can take. This is to make sure the drugs you take are safe. These limits can be found in the last column of the drug listing. If your doctor feels you have a medical reason for getting a greater amount, they can ask Louisiana Healthcare Connections for prior authorization. If Louisiana Healthcare Connections does not grant the prior authorization, we will notify you and your doctor and tell you how to file an appeal. Age Limits Some drugs on the Louisiana Healthcare Connections PDL may have age limits. These are set for certain drugs based on the U.S. Food and Drug Administration (FDA) approval for safety and quality. The age limits can be found in the Limitations/Restrictions column of the drug listing.

4 Gender Limits Some drugs on the Louisiana Healthcare Connections PDL may be limited to one gender. The gender limits can be found in the Limitations/Restrictions column of the drug listing. These limits are set for certain drugs based on FDA approval for safety and quality. Filling a Prescription You can have your prescriptions filled at a network pharmacy. If you need help finding a pharmacy near you, call Member Services at (TDD/TTY ). At the pharmacy, you will need to give the pharmacist your prescription and your Louisiana Healthcare Connections ID. Specialty Drugs Louisiana Healthcare Connections covers many specialty drugs. Prior authorization requirements are different for each drug. Your doctor can ask for prior authorization for these drugs. Copayments The table below lists the copayment for the drugs according to the actual cost of the drug. Copayments are not required for children under the age of 21, pregnant women, family planning supplies, members in the hospital or a nursing home, Alaskan Eskimo members, or American Indian members. Actual Cost of Prescription Member Copayment Less than $10.01 $0.50 Between $10.01 and $25.00 $1.00 Between $25.01 and $50.00 $2.00 More than $50.01 $3.00

5 Over-the-Counter Drugs L ouisiana Healthcare Connections covers a variety of OTC drugs. The drugs listed below are covered when you have a prescription from a doctor in the Louisiana Healthcare Connections provider network and you have it filled at a Louisiana Healthcare Connections network pharmacy. You can get a one month supply of covered drugs. All OTC drugs that are not included in the list require prior authorization. Generic drugs must be used when available. ANALGESICS & ANTIPYRETICS Acetaminophen generic tablets, elixir, drops, suppositories Aspirin generic tablets ANTACIDS Maalox generic tablets, liquid Mylanta DS generic liquid ANTHELMINTICS Pin-X Pyrantel pamoate tablets/chewable/suspension ANTI-DIARRHEALS Imodium A-D generic (loperamide) capsules Kaopectate (attapulgite) suspension Pepto-Bismol generic (pink bismuth) chewable/liquid ANTI-EMETIC Antivert generic (meclizine) ANTI-FLATULENTS Gas-X chewables generic simethicone 80mg Mylicon drops** generic simethicone 40 mg/0.6ml ANTI-HISTAMINES Benadryl generic (diphenhydramine) capsules, liquid Chlor-Trimeton generic (chlorpheniramine) tablets, liquid Claritin generic (loratadine) tablets, syrup Claritin-D generic (loratadine/ pseudoephedrine) tablets Zyrtec generic (cetirizxine) tablets/chewables/liquid CONTRACEPTIVES Condoms lubricated COUGH/EXPECTORANT/DECONGESTANT Dallergy drops (chlorpheniramine & phenylephrine liquid) 1-2 mg/ml Decon A drops (brompheniramine & phenylephrine liquid) 2-5 mg/ml Delsym DM Polistirex Liquid CR Dimetapp generic (brompheniramine & phenylephrine elixir) mg/5ml Mucinex generic (guaifenesin) tablets Robitussin generic (guaifenesin) syrup

6 COUGH/EXPECTORANT/DECONGESTANT (continued) Robitussin DM generic (guaifenesin DM) syrup Sudafed generic (pseudoephedrine) tablets, liquid Triaminic generic AM, Night, soft chewable tablets DILUENTS Sodium chloride generic aerosol solution DME PRODUCTS Diabetic testing supplies (TRUEtest preferred) Gauze pad 2 x2, 3 x3, 4 x4 Peak Flow Meters Spacers OTIC PREPARATIONS Debrox drops generic (carbamide peroxide 6.5%) ELECTROLYTES Electrolyte solutions generic H2-RECEPTOR ANTAGONISTS Pepcid generic (famotidine) 10mg tablets Tagamet generic (cimetidine) 200mg tablets Zantac generic (ranitidine) 75mg tablets IRON PREPERATIONS Ferrous fumarate generic tablets Ferrous gluconate generic tablets Ferrous sulfate generic tablets, elixir, drops Polysaccharide Iron Complex generic capsules 150mg LAXATIVES Citrate of magnesium generic Colace generic (docusate sodium) capsules Dulcolax generic (bisacodyl) tablets, suppositories Fleet enema generic Metamucil generic (psyllium) Milk Of Magnesium generic MOM Miralax OTC Pediatric glycerin suppositories generic Senokot generic (senna) tablets Sorbitol oral solution 70% MINERALS Citracal generic (calcium citrate) - tablets Citracal+D generic (calcium citrate+d) tablets Magnesium oxide generic Neutra-phos/K powder generic Oscal 500+Vit D generic (calcium carbonate+d) tablets Tums Chew Tabs generic (calcium carbonate)

7 MINERALS (continued) Zinc sulfate generic capsules 220mg NASAL Nasalcrom spray generic Saline nasal spray/gel/solution NSAIDS Ibuprofen generic tablets, chewable, liquid, drops Naproxen generic tablets NUTRITIONAL SUPPLEMENTS Omega-3 fatty acid capsules 1000mg, 1200mg OPHTHALMIC PREPARATIONS Alaway (ketotifen 0.025%) Artificial tears generic polyvinyl alcohol drops Lacri-lube generic (artificial tears) ointment Naphcon-A generic (naphazoline/pheniramine 0.025/0.3) Zaditor-OTC (ketotifen 0.025%) PEDICULICIDES NIX generic (permethrin) RID generic (pyrethrins/piperonyl butoxide) PROTON PUMP INHIBITORS (PPIS) Prevacid 24 HR capsules Prilosec OTC tablets SLEEPING AIDS Nytol generic (diphenhydramine sleep) tablets/capsules Unisom generic (doxylamine sleep) tablets SMOKING DETERRENTS Commit Lozenges NicoDerm CQ transdermal patch generic Nicorette DS gum generic Nicorette gum generic Nicotrol transdermal patch generic TOPICALS AmLactin generic Bacitracin ointment generic Benzoyl peroxide generic liquid/gel/lotion Calamine generic Capsaicin cream/gel/lotion generic Clotrimazole generic cream, vaginal cream/inserts Hibiclens generic (chlorhexidine gluconate liquid) 4% Hydrocortisone generic cream, lotion, ointment, solution Miconazole generic cream, vaginal cream/inserts Polysporin generic ointment

8 TOPICALS (continued) Nupercainal generic (dibucaine rectal ointment) 1% Selsun Blue generic (selenium shampoo) 1% Tolnaftate generic cream Triple antibiotic ointment Vagistat generic (tioconazole vaginal ointment) 6.5% Xylocaine generic (lidocaine) gel 2% Zinc oxide ointment generic VITAMINS Folic acid generic Multi-vitamins with iron generic tablets, liquid, chewable Multi-vitamins generic tablets, liquid, chewable Niacin generic Prenatal vitamins generic tablets Pyridoxine generic tablets Slo-Niacin CR tablets Thiamine generic tablets

9 PENICILLINS Penicillin V Potassium Tab 250 Penicillin V Potassium Tab 500 Penicillin V Potassium For Soln 125 /5ML (Generic: AMOXIL) Penicillin V Potassium For Soln 250 /5ML Amoxicillin (Trihydrate) Cap 250 Amoxicillin (Trihydrate) Cap 500 Amoxicillin (Trihydrate) Tab 875 Amoxicillin (Trihydrate) Chew Tab 125 AMOXICILLIN Amoxicillin (Trihydrate) Chew Tab 250 (Generic: AMOXIL) Amoxicillin (Trihydrate) Chew Tab 400 Amoxicillin (Trihydrate) For Susp 50 /ML Amoxicillin (Trihydrate) For Susp 125 /5ML Amoxicillin (Trihydrate) For Susp 200 /5ML Amoxicillin (Trihydrate) For Susp 250 /5ML Amoxicillin (Trihydrate) For Susp 400 /5ML Ampicillin Cap 250 Ampicillin Cap 500 Ampicillin For Susp 125 /5ML Ampicillin For Susp 250 /5ML Dicloxacillin Sodium Cap 250 Dicloxacillin Sodium Cap 500 AMOXICILLIN AMOXIL AMPICILLIN AMPICILLIN (Generic: AUGMENTIN) Amoxicillin & K Clavulanate Tab 250 Max Qty=30/claim (Generic: AUGMENTIN) Amoxicillin & K Clavulanate Tab 500 Max Qty=20/claim (Generic: AUGMENTIN) Amoxicillin & K Clavulanate Tab 875 Max Qty=20/claim (Generic: AUGMENTIN) Amoxicillin & K Clavulanate Chew Tab 200 Max Qty=20/claim Amoxicillin & K Clavulanate Chew Tab 250 AUGMENTIN Max Qty=30/claim Amoxicillin & K Clavulanate Chew Tab 400 (Generic: AUGMENTIN) Max Qty=20/claim Amoxicillin & K Clavulanate For Susp 125 /5ML AUGMENTIN Amoxicillin & K Clavulanate For Susp 200 (Generic: AUGMENTIN) /5ML (Generic: AUGMENTIN) Amoxicillin & K Clavulanate For Susp 250 /5ML AUGMENTIN

10 (Generic: AUGMENTIN) (Generic: AUGMENTIN) (Generic: AUGMENTIN XR) CEPHALOSPORINS (Generic: KEFLEX) (Generic: KEFLEX) Pkg Size 50: Package Limit=1/claim; Pkg Size 75: Package Limit=2/claim; Pkg Amoxicillin & K Clavulanate For Susp 400 /5ML Size 100: Package Limit=2/claim Amoxicillin & K Clavulanate For Susp 600 /5ML Package Limit=2/claim Amoxicillin & K Clavulanate Tab SR 12HR AUGMENTIN XR Max Qty=40/30 days Cephalexin Cap 250 Cephalexin Cap 500 Cephalexin For Susp 125 /5ML Cephalexin For Susp 250 /5ML Cefaclor Cap 250 Cefaclor Cap 500 Cefaclor For Susp 125 /5ML CEFACLOR Cefaclor For Susp 250 /5ML CEFACLOR Cefaclor For Susp 375 /5ML CEFACLOR (Generic: CEFZIL) Cefprozil Tab 250 Max Qty=20/claim (Generic: CEFZIL) Cefprozil Tab 500 Max Qty=20/claim (Generic: CEFZIL) Cefprozil For Susp 125 /5ML Pkg Size 50, Limited to Ages 12 and Under; Pkg Size 75, Limited to Ages 12 and Under; Pkg Size 100, Limited to Ages 12 and Under; Pkg Size 75: Package Limit=2/claim; Pkg Size 100: Package Limit=2/claim (Generic: CEFZIL) Cefprozil For Susp 250 /5ML Pkg Size 50, Limited to Ages 12 and Under; Pkg Size 75, Limited to Ages 12 and Under; Pkg Size 100, Limited to Ages 12 and Under; Pkg Size 50: Package Limit=1/claim (Generic: CEFTIN) Cefuroxime Axetil Tab 250 Max Qty=20/claim (Generic: CEFTIN) Cefuroxime Axetil Tab 500 Max Qty=20/claim (Generic: CEFTIN) Cefuroxime Axetil For Susp 125 /5ML Limited to Ages 12 and Under; Max Qty=100/claim (Generic: OMNI-PAC, OMNICEF) (Generic: OMNICEF) (Generic: OMNICEF) (Generic: ROCEPHIN) Cefuroxime Axetil For Susp 250 /5ML Cefdinir Cap 300 Cefdinir For Susp 125 /5ML Cefdinir For Susp 250 /5ML Ceftriaxone Sodium For Inj 250 CEFTIN Limited to Ages 12 and Under; Max Qty=100/claim PA; Max Qty=20/claim; Step Therapy ; Step Therapy ; Step Therapy Max Qty=3/claim; Max Fills=1/30 days

11 (Generic: ROCEPHIN) (Generic: ROCEPHIN) MACROLIDES Ceftriaxone Sodium For Inj 500 Ceftriaxone Sodium For Inj 1 GM Erythromycin Tab 250 Erythromycin Tab 500 ERYTHROMYCIN ERYTHROMYCIN Max Qty=3/claim; Max Fills=1/30 days Max Qty=3/claim; Max Fills=1/30 days Erythromycin Tab Delayed Release 250 Erythromycin Tab Delayed Release 333 E-MYCIN, ERY-TAB ERY-TAB, ERYTHROMYCIN (Generic: ERYC) Erythromycin Tab Delayed Release 500 ERY-TAB Erythromycin w/ Enteric Coated Particles Cap 250 ERYTHROMYCIN Erythromycin w/ Enteric Coated Particles Tab 333 PCE Erythromycin w/ Enteric Coated Particles Tab 500 PCE ERYTHROCIN, Erythromycin Stearate Tab 250 ERYTHROM ST ERYTHROCIN, Erythromycin Stearate Tab 500 ERYTHROM ST Erythromycin Ethylsuccinate Tab 400 Erythromycin Ethylsuccinate Susp 200 /5ML Erythromycin Ethylsuccinate Susp 400 /5ML Erythromycin Ethylsuccinate For Susp 100 /2.5ML ERYPED Erythromycin Ethylsuccinate For Susp 200 /5ML E.E.S. GRAN, ERYPED 200 Erythromycin Ethylsuccinate For Susp 400 /5ML ERYPED 400 (Generic: ZITHROMAX) Azithromycin Tab 250 Max Qty=6/claim (Generic: ZITHROMAX) Azithromycin Tab 500 Daily Dosage=4 (Generic: ZITHROMAX) Azithromycin Tab 600 Max Qty=8/28 days (Generic: ZITHROMAX) Azithromycin For Susp 100 /5ML Max Qty=15/claim (Generic: ZITHROMAX) Azithromycin For Susp 200 /5ML ZITHROMAX Pkg Size 15: Package Limit=1/claim; Pkg Size 30: Package Limit=2/claim; Pkg Size 22.5: Package Limit=2/claim Azithromycin Powd Pack for Susp 1 GM AZITHROMYCIN, ZITHROMAX Max Qty=2/claim (Generic: BIAXIN) Clarithromycin Tab 250 Max Qty=28/claim (Generic: BIAXIN) Clarithromycin Tab 500 Max Qty=28/claim (Generic: BIAXIN) Clarithromycin For Susp 125 /5ML (Generic: BIAXIN) Clarithromycin For Susp 250 /5ML Pkg Size 50: Package Limit=1/claim; Pkg Size 100: Package Limit=2/claim (Generic: BIAXIN XL) Clarithromycin Tab SR 24HR 500 Max Qty=14/claim

12 TETRACYCLINES (Generic: VIBRAMYCIN) (Generic: VIBRATAB) (Generic: MINOCIN) (Generic: MINOCIN) FLUOROQUINOLONES Doxycycline Hyclate Cap 50 Doxycycline Hyclate Cap 100 Doxycycline Hyclate Tab 100 Minocycline HCl Cap 50 Minocycline HCl Cap 75 Minocycline HCl Cap 100 Tetracycline HCl Cap 250 Tetracycline HCl Cap 500 TETRACYCLINE Ciprofloxacin HCl Tab 100 (Base Equiv) Max Qty=6/claim (Generic: CIPRO) Ciprofloxacin HCl Tab 250 (Base Equiv) (Generic: CIPRO) Ciprofloxacin HCl Tab 500 (Base Equiv) CIPRO (Generic: CIPRO) Ciprofloxacin HCl Tab 750 (Base Equiv) (Generic: LEVAQUIN) Levofloxacin Tab 250 LEVAQUIN (Generic: LEVAQUIN) Levofloxacin Tab 500 LEVAQUIN (Generic: LEVAQUIN) Levofloxacin Tab 750 LEVAQUIN Ofloxacin Tab 200 Ofloxacin Tab 300 Ofloxacin Tab 400 AMINOGLYCOSIDES Neomycin Sulfate Tab 500 SULFONAMIDES Sulfisoxazole Acetyl Susp 500 /5ML GANTRIS PED ANTIMYCOBACTERIAL AGENTS Max Qty=14/claim; Daily Dosage=1 Max Qty=14/claim; Daily Dosage=1 Max Qty=14/claim; Daily Dosage=1 Max Qty=56/claim Max Qty=56/claim Max Qty=56/claim (Generic: MYAMBUTOL) Ethambutol HCl Tab 100 (Generic: MYAMBUTOL) (Generic: RIFADIN) (Generic: RIFADIN) ANTIFUNGALS Ethambutol HCl Tab 400 Ethionamide Tab 250mg Isoniazid Tab 100 Isoniazid Tab 300 Isoniazid Syrup 50 /5ML Pyrazinamide Tab 500 Rifampin Cap 150 Rifampin Cap 300 Griseofulvin Microsize Tab 500 TRECATOR ISONIAZID GRIFULVIN V (Generic: GRIFULVIN V) (Generic: LAMISIL) Griseofulvin Microsize Susp 125 /5ML Griseofulvin Ultramicrosize Tab 125 Griseofulvin Ultramicrosize Tab 250 Nystatin Tab U Terbinafine HCl Tab 250 Ketoconazole Tab 200 GRIS-PEG GRIS-PEG, GRISEOFULVIN Daily Dosage=6 Max Qty=90/120 days; Daily Dosage=1 Daily Dosage=2

13 (Generic: DIFLUCAN) Fluconazole Tab 50 Max Qty=7/claim (Generic: DIFLUCAN) Fluconazole Tab 100 (Generic: DIFLUCAN) Fluconazole Tab 150 Max Qty=2/claim (Generic: DIFLUCAN) Fluconazole Tab 200 Daily Dosage=2 (Generic: DIFLUCAN) Fluconazole For Susp 10 /ML Max Qty=70/claim (Generic: DIFLUCAN) Fluconazole For Susp 40 /ML Max Qty=70/claim (Generic: SPORANOX) Itraconazole Cap 100 PA; ANTIVIRALS Maraviroc Tab 150 SELZENTRY Daily Dosage=2 Maraviroc Tab 300 SELZENTRY Daily Dosage=4 Raltegravir Potassium Tab 400 (Base Equiv) ISENTRESS Daily Dosage=2 Amprenavir Oral Soln 15 /ML AGENERASE Atazanavir Sulfate Cap 100 (Base Equiv) REYATAZ Daily Dosage=2 Atazanavir Sulfate Cap 150 (Base Equiv) REYATAZ Daily Dosage=2 Atazanavir Sulfate Cap 200 (Base Equiv) REYATAZ Daily Dosage=2 Atazanavir Sulfate Cap 300 (Base Equiv) REYATAZ Daily Dosage=2 Darunavir Ethanolate Tab 75 (Base Equiv) PREZISTA Daily Dosage=2 Darunavir Ethanolate Tab 150 (Base Equiv) PREZISTA Daily Dosage=3 Darunavir Ethanolate Tab 300 (Base Equiv) PREZISTA Daily Dosage=4 Darunavir Ethanolate Tab 400 (Base Equiv) PREZISTA Daily Dosage=2 Darunavir Ethanolate Tab 600 (Base Equiv) PREZISTA Daily Dosage=2 Fosamprenavir Calcium Tab 700 (Base Equiv) LEXIVA Daily Dosage=4 Fosamprenavir Calcium Susp 50 /ML (Base Equiv) LEXIVA Daily Dosage=56 Indinavir Sulfate Cap 100 CRIXIVAN Daily Dosage=6 Indinavir Sulfate Cap 200 CRIXIVAN Daily Dosage=9 Indinavir Sulfate Cap 333 CRIXIVAN Indinavir Sulfate Cap 400 CRIXIVAN Daily Dosage=6 Nelfinavir Mesylate Tab 250 VIRACEPT Daily Dosage=9 Nelfinavir Mesylate Tab 625 VIRACEPT Daily Dosage=4 Nelfinavir Mesylate Oral Powder 50 /GM VIRACEPT Daily Dosage=36 Ritonavir Cap 100 NORVIR 2 Ritonavir Tab 100 NORVIR 2 Ritonavir Oral Soln 80 /ML NORVIR 5 Saquinavir Mesylate Cap 200 INVIRASE 0 Saquinavir Mesylate Tab 500 INVIRASE Daily Dosage=4 Tipranavir Cap 250 APTIVUS Daily Dosage=4 Tipranavir Oral Soln 100 /ML APTIVUS 0 Abacavir Sulfate Tab 300 (Base Equiv) ZIAGEN Daily Dosage=2 Abacavir Sulfate Soln 20 /ML (Base Equiv) ZIAGEN Daily Dosage=30 Didanosine For Soln 2 GM VIDEX Daily Dosage=20

14 Didanosine For Soln 4 GM VIDEX Daily Dosage=20 (Generic: VIDEX EC) Didanosine Delayed Release Capsule 125 (Generic: VIDEX EC) Didanosine Delayed Release Capsule 200 (Generic: VIDEX EC) Didanosine Delayed Release Capsule 250 (Generic: VIDEX EC) Didanosine Delayed Release Capsule 400 Emtricitabine Caps 200 EMTRIVA Emtricitabine Soln 10 /ML EMTRIVA Daily Dosage=24 (Generic: EPIVIR) Lamivudine Tab 150 EPIVIR Daily Dosage=2 (Generic: EPIVIR) Lamivudine Tab 300 EPIVIR Lamivudine Oral Soln 10 /ML EPIVIR Daily Dosage=30 (Generic: ZERIT) Stavudine Cap 15 Daily Dosage=2 (Generic: ZERIT) Stavudine Cap 20 Daily Dosage=2 (Generic: ZERIT) Stavudine Cap 30 Daily Dosage=2 (Generic: ZERIT) Stavudine Cap 40 Daily Dosage=2 (Generic: ZERIT) Stavudine For Oral Soln 1 /ML Daily Dosage=30 (Generic: RETROVIR) Zidovudine Cap 100 Daily Dosage=6 (Generic: RETROVIR) Zidovudine Tab 300 Daily Dosage=2 (Generic: RETROVIR) Zidovudine Syrup 10 /ML Daily Dosage=60 Tenofovir Disoproxil Fumarate Tab 300 VIREAD Delavirdine Mesylate Tab 100 RESCRIPTOR 2 Delavirdine Mesylate Tab 200 RESCRIPTOR Daily Dosage=6 Efavirenz Cap 50 SUSTIVA Daily Dosage=2 Efavirenz Cap 200 SUSTIVA Efavirenz Tab 600 SUSTIVA Etravirine Tab 100 INTELENCE Daily Dosage=4 Etravirine Tab 200 INTELENCE Daily Dosage=2 Nevirapine Tab 200 VIRAMUNE Daily Dosage=2 Nevirapine Susp 50 /5ML VIRAMUNE Daily Dosage=40 Nevirapine Tab SR 24HR Viramune XR Rilpivirine HCl Tab 25 (Base Equivalent) EDURANT Abacavir Sulfate-Lamivudine Tab EPZICOM Emtricitabine-Tenofovir Disoproxil Fumarate Tab TRUVADA (Generic: COMBIVIR) Lamivudine-Zidovudine Tab COMBIVIR Daily Dosage=2 Lopinavir-Ritonavir Cap KALETRA Daily Dosage=6 Lopinavir-Ritonavir Tab KALETRA Daily Dosage=4 Lopinavir-Ritonavir Tab KALETRA Daily Dosage=4 Lopinavir-Ritonavir Soln /5ML (80-20 /ML) KALETRA Max Qty=320/32 days Abacavir Sulfate-Lamivudine-Zidovudine Tab TRIZIVIR Daily Dosage=2 Efavirenz-Emtricitabine-Tenofovir DF Tab ATRIPLA EMTRICITABINE; RILPIVIRINE HCL; Complera TENOFOVIR DISOPROXIL FUMARATE 200/25/300 Ganciclovir Cap 250 Daily Dosage=6 Ganciclovir Cap 500 GANCICLOVIR Daily Dosage=6

15 Valganciclovir HCl Tab 450 VALCYTE Daily Dosage=2 (Generic: ZOVIRAX) Acyclovir Cap 200 Max Qty=50/30 days (Generic: ZOVIRAX) Acyclovir Tab 400 Daily Dosage=2 (Generic: ZOVIRAX) Acyclovir Tab 800 Max Qty=50/30 days (Generic: ZOVIRAX) Acyclovir Susp 200 /5ML Max Qty=400/30 days (Generic: VALTREX) Valacyclovir HCl Tab 500 VALTREX Max Qty=42/21 days (Generic: VALTREX) Valacyclovir HCl Tab 1 GM VALTREX Max Qty=21/21 days Oseltamivir Phosphate Cap 30 (Base Equiv) TAMIFLU Max Qty=20/30 days Oseltamivir Phosphate Cap 45 (Base Equiv) TAMIFLU Max Qty=10/30 days Oseltamivir Phosphate Cap 75 (Base Equiv) TAMIFLU Max Qty=10/30 days Oseltamivir Phosphate For Susp 6 /ML (Base Equiv) TAMIFLU Max Qty=120/30 days Oseltamivir Phosphate For Susp 12 /ML (Base Equiv) TAMIFLU Max Qty=75/30 days Zanamivir Aero Powder Breath Activated 5 /BLISTER Limited to Ages 5 and Older; Package Limit=1/30 days RELENZA ANTIMALARIALS Chloroquine Phosphate Tab 250 Max Qty=60/30 days (Generic: ARALEN) Chloroquine Phosphate Tab 500 Max Qty=8/56 days (Generic: PLAQUENIL) Hydroxychloroquine Sulfate Tab 200 (Generic: LARIAM) Mefloquine HCl Tab 250 Primaquine Phosphate Tab 26.3 PRIMAQUINE Artemether-Lumefantrine Tab COARTEM Max Qty=24/claim ANTHELMINTICS (Generic: VERMOX) Mebendazole Chew Tab 100 MEBENDAZOLE Pyrantel Pamoate Tab 180 PINWORM Max Qty=16/claim; Max Fills=1/30 days Pyrantel Pamoate Chew Tab (250 Base Equiv) PIN-X Max Qty=4/claim; Max Fills=1/30 days Pyrantel Pamoate Susp 250 /5ML (50 /ML Base Equiv) Max Qty=60/claim; Max Fills=1/30 days ANTI-INFECTIVE AGENTS - MISC. (Generic: FLAGYL) Metronidazole Tab 250 (Generic: FLAGYL) Metronidazole Tab 500 (Generic: TRIMPEX) Trimethoprim Tab 100 Vancomycin HCl For Inj 500 Max Qty=14/30 days (Generic: VANCOCIN HCL) Vancomycin HCl For Inj 1000 Max Qty=14/claim (Generic: CLEOCIN) Clindamycin HCl Cap 150 (Generic: CLEOCIN) Clindamycin HCl Cap 300 (Generic: CLEOCIN PED) Clindamycin Palmitate HCl For Soln 75 /5ML (Base Equiv) Max Qty=300/claim Dapsone Tab 25 DAPSONE Dapsone Tab 100 DAPSONE Erythromycin & Sulfisoxazole For Susp 200- (Generic: PEDIAZOLE) 600 /5ML (Generic: BACTRIM, SEPTRA) Sulfamethoxazole-Trimethoprim Tab (Generic: BACTRIM DS, SEPTRA DS) Sulfamethoxazole-Trimethoprim Tab

16 Sulfamethoxazole-Trimethoprim Susp /5ML PASSIVE IMMUNIZING AGENTS Rho D Immune Globulin (Human) IM Inj 300 MCG ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES Busulfan Tab 2 Chlorambucil Tab 2 Cyclophosphamide Tab 25 Cyclophosphamide Tab 50 Melphalan Tab 2 HYPERRHO S/D, RHOGAM PLUS MYLERAN LEUKERAN CYCLOPHOSPH CYCLOPHOSPH ALKERAN (Generic: PURINETHOL) Mercaptopurine Tab 50 Methotrexate Sodium Tab 2.5 (Base Equiv) Methotrexate Sodium Tab 5 (Base Equiv) Methotrexate Sodium Tab 7.5 (Base Equiv) Methotrexate Sodium Tab 10 (Base Equiv) TREXALL TREXALL TREXALL Methotrexate Sodium Tab 15 (Base Equiv) TREXALL Methotrexate Sodium Inj 25 /ML Methotrexate Sodium Inj PF 25 /ML (Generic: CASODEX) Bicalutamide Tab 50 Flutamide Cap 125 Tamoxifen Citrate Tab 10 (Base Equivalent) Tamoxifen Citrate Tab 20 (Base Equivalent) Toremifene Citrate Tab 60 (Base Equivalent) FARESTON (Generic: ARIMIDEX) Anastrozole Tab 1 ARIMIDEX (Generic: AROMASIN) Exemestane Tab 25 AROMASIN Step Therapy (Generic: FEMARA) Letrozole Tab 2.5 Step Therapy Megestrol Acetate Tab 20 Megestrol Acetate Tab 40 (Generic: MEGACE ORAL) Megestrol Acetate Susp 40 /ML (Generic: HYDREA) Hydroxyurea Cap 500 Leucovorin Calcium Tab 5 Leucovorin Calcium Tab 10 Leucovorin Calcium Tab 15 Leucovorin Calcium Tab 25 CORTICOSTEROIDS Cortisone Acetate Tab 25 Dexamethasone Tab 0.5 Dexamethasone Tab 0.75 Dexamethasone Tab 1 Dexamethasone Tab 1.5 Dexamethasone Tab 2 Dexamethasone Tab 4 Dexamethasone Tab 6 Dexamethasone Elixir 0.5 /5ML Dexamethasone Conc 1 /ML LEUCOVOR CA DEXAMETHASON DEXAMETHASON DEXAMETHASON

17 (Generic: CORTEF) (Generic: CORTEF) (Generic: CORTEF) (Generic: MEDROL) (Generic: MEDROL) (Generic: MEDROL) (Generic: PRELONE) (Generic: ORAPRED) (Generic: PEDIAPRED) (Generic: STERAPRED) Dexamethasone Soln 0.5 /5ML DEXAMETHASON Hydrocortisone Tab 5 Hydrocortisone Tab 10 Hydrocortisone Tab 20 Methylprednisolone Tab 4 Methylprednisolone Tab 8 Testosterone TD Patch 2/24HR Androderm Testosterone TD Patch 4/24HR Androderm Methylprednisolone Tab 4 Dose Pack Prednisolone Tab 5 MILLIPRED Prednisolone Syrup 5 /5ML Prednisolone Syrup 15 /5ML Prednisolone Sod Phosphate Oral Soln 15 /5ML (Base Equiv) Max Qty=240/claim Prednisolone Sod Phosph Oral Soln 6.7 /5ML (5 /5ML Base) Prednisolone Sod Phosphate Oral Soln 20 /5ML (Base Equiv) VERIPRED 20 Max Qty=150/claim Prednisone Tab 1 PREDNISONE Prednisone Tab 2.5 Prednisone Tab 5 Prednisone Tab 10 Prednisone Tab 20 Prednisone Tab 50 PREDNISONE Prednisone Conc 5 /ML PREDNISONE Prednisone Oral Soln 5 /5ML PREDNISONE Prednisone Tab 5 Dose Pack (Generic: STERAPRED DS) Prednisone Tab 10 Dose Pack Fludrocortisone Acetate Tab 0.1 ANDROGENS-ANABOLIC Fluoxymesterone Tab 10 Methyltestosterone Oral Tab 10 ANDROXY METHITEST Testosterone TD Patch 24HR 2.5 /24HR ANDRODERM Daily Dosage=2 Testosterone TD Patch 24HR 5 /24HR ANDRODERM (Generic: DEPO-TESTOST) Testosterone Cypionate IM in Oil 200 /ML Max Qty=4/30 days ESTROGENS Estrogens, Conjugated Tab 0.3 PREMARIN Limited to Female; Daily Dosage=1 Estrogens, Conjugated Tab 0.45 PREMARIN Limited to Female; Daily Dosage=1 Estrogens, Conjugated Tab PREMARIN Limited to Female; Daily Dosage=1 Estrogens, Conjugated Tab 0.9 PREMARIN Limited to Female; Daily Dosage=1 Estrogens, Conjugated Tab 1.25 PREMARIN Limited to Female; Daily Dosage=1 (Generic: ESTRACE) Estradiol Tab 0.5 Limited to Female (Generic: ESTRACE) Estradiol Tab 1 Limited to Female (Generic: ESTRACE) Estradiol Tab 2 Limited to Female

18 Estradiol TD Patch Biweekly /24HR ALORA, VIVELLE-DOT Daily Dosage=.29 Estradiol TD Patch Biweekly /24HR VIVELLE-DOT Daily Dosage=.29 Estradiol TD Patch Biweekly 0.05 /24HR ALORA, ESTRADERM, VIVELLE, VIVELLE-DOT Daily Dosage=.29 Estradiol TD Patch Biweekly /24HR ALORA, VIVELLE-DOT Daily Dosage=.29 (Generic: CLIMARA) (Generic: CLIMARA) (Generic: CLIMARA) (Generic: CLIMARA) (Generic: CLIMARA) (Generic: CLIMARA) (Generic: OGEN) (Generic: OGEN) (Generic: OGEN) (Generic: ESTRATEST HS) (Generic: ESTRATEST) (Generic: ACTIVELLA) CONTRACEPTIVES (Generic: NOR-QD, ORTHO MICRON) ALORA, ESTRADERM, Estradiol TD Patch Biweekly 0.1 /24HR VIVELLE, VIVELLE-DOT Daily Dosage=.29 Limited to Female; Max Estradiol TD Patch Weekly /24HR Qty=4/28 days Estradiol TD Patch Weekly /24HR Limited to Female; Max (37.5 MCG/24HR) Qty=4/28 days Limited to Female; Max Estradiol TD Patch Weekly 0.05 /24HR Qty=4/28 days Limited to Female; Max Estradiol TD Patch Weekly 0.06 /24HR Qty=4/28 days Limited to Female; Max Estradiol TD Patch Weekly /24HR Qty=4/28 days Limited to Female; Max Estradiol TD Patch Weekly 0.1 /24HR Qty=4/28 days Limited to Female; Daily Estropipate Tab 0.75 Dosage=1 Limited to Female; Daily Estropipate Tab 1.5 Dosage=1 Limited to Female; Daily Estropipate Tab 3 Dosage=2 Esterified Estrogens & Methyltestosterone Tab Esterified Estrogens & Methyltestosterone Tab Conjugated Estrogen-Medroxyprogest Acetate Limited to Female; Daily Tab PREMPRO Dosage=1 Conjugated Estrogen-Medroxyprogest Acetate Limited to Female; Daily Tab PREMPRO Dosage=1 Conjugated Estrogen-Medroxyprogest Acetate Limited to Female; Daily Tab PREMPRO Dosage=1 Conjugated Estrogen-Medroxyprogest Acetate Limited to Female; Daily Tab PREMPRO Dosage=1 Conj Est.625(14) & Conj Est-Medroxypro Ac Limited to Female; Max Tab (14) PREMPHASE Qty=28/28 days Estradiol & Norethindrone Acetate Tab Estradiol-Norethindrone Ace TD PTTW Limited to Female; Max 0.14/DAY COMBIPATCH Qty=8/28 days Estradiol-Norethindrone Ace TD PTTW Limited to Female; Max 0.25/DAY COMBIPATCH Qty=8/28 days Norethindrone Tab 0.35 Limited to Female; Daily Dosage=1

19 (Generic: DEPO- PROVERA) Medroxyprogesterone Acetate IM Susp 150 /ML Limited to Female; Max Qty=1/claim; Min DS=84 (Generic: PLAN B) (Generic: DESOGEN, DESOGEN-28, ORTHO- CEPT) Medroxyprogesterone Acetate Subcutaneous Susp 104 /0.65ML DEPO-SQ PROV Limited to Female; Max Qty=1/claim; Min DS=84 Limited to Female; Max Levonorgestrel Tab 0.75 Fills=4/365 days Limited to Female; Max Levonorgestrel Tab 1.5 PLAN B Fills=4/365 days Ulipristal Acetate Tab 30 ELLA Max Qty=4/365 days Norelgestromin-Ethinyl Estradiol TD PTWK Limited to Female; Max MCG/24HR ORTHO EVRA Qty=3/claim Etonogestrel-Ethinyl Estradiol VA Ring Limited to Female; Max /24HR NUVARING Qty=1/claim Desogestrel & Ethinyl Estradiol Tab MCG Limited to Female; Daily Dosage=1 (Generic: YAZ) Drospirenone-Ethinyl Estradiol Tab Limited to Female (Generic: YASMIN 28) Drospirenone-Ethinyl Estradiol Tab Limited to Female; Daily Dosage=1 Ethynodiol Diacetate & Ethinyl Estradiol Tab 1-35MCG Limited to Female; Daily Dosage=1 Ethynodiol Diacetate & Ethinyl Estradiol Tab 1 Limited to Female; Daily -50MCG ZOVIA 1/50E Dosage=1 Levonorgestrel & Ethinyl Estradiol Tab MCG Limited to Female; Daily Dosage=1 (Generic: NORDETTE, NORDETTE-28) Levonorgestrel & Ethinyl Estradiol Tab MCG Limited to Female; Daily Dosage=1 (Generic: OVCON-35) Norethindrone & Ethinyl Estradiol Tab MCG Limited to Female; Daily Dosage=1 (Generic: BREVICON, MODICON) Norethindrone & Ethinyl Estradiol Tab MCG Limited to Female; Daily Dosage=1 (Generic: NORINYL, ORTHO-NOVUM) Norethindrone & Ethinyl Estradiol Tab 1-35MCG Limited to Female; Daily Dosage=1 (Generic: LOESTRIN) Norethindrone Ace & Ethinyl Estradiol Tab 1-20MCG Limited to Female; Daily Dosage=1 (Generic: LOESTRIN 21) Norethindrone Ace & Ethinyl Estradiol Tab MCG Limited to Female; Daily Dosage=1 (Generic: ORTHO- NOVUM) Norethindrone & Mestranol Tab 1-50MCG NECON, NORINYL Limited to Female; Daily Dosage=1 (Generic: LO/OVRAL, LO/OVRAL-28) Norgestrel & Ethinyl Estradiol Tab MCG Limited to Female; Daily Dosage=2 Norgestrel & Ethinyl Estradiol Tab MCG OGESTREL Limited to Female; Daily Dosage=1 (Generic: ORTHO- CYCLEN) Norgestimate & Ethinyl Estradiol Tab MCG Limited to Female; Daily Dosage=1 (Generic: LOESTRIN FE) Norethindrone Ace & Ethinyl Estradiol-FE Tab 1-20MCG Limited to Female; Daily Dosage=1 (Generic: LOESTRIN FE) Norethindrone Ace & Ethinyl Estradiol-FE Tab MCG Limited to Female; Daily Dosage=1 (Generic: MIRCETTE) Desogest-Eth Estrad & Eth Estrad Tab /0.01 (21/5) Limited to Female; Daily Dosage=1

20 (Generic: CYCLESSA) (Generic: ORTHO- NOVUM) (Generic: TRI-NORINYL) (Generic: ORTHO TRI-) (Generic: SEASONALE) (Generic: SEASONIQUE) PROGESTINS (Generic: PROVERA) (Generic: PROVERA) Norethindrone-Eth Estradiol Tab /1-35 -MCG (10/11) NECON Desogest-Ethinyl Estrad Tab / / Levonorgestrel-Eth Estrad Tab.05-30/ / MCG Norethindrone-Eth Estradiol Tab / /1-35 -MCG ORTHO-NOVUM Norethindrone-Eth Estradiol Tab /1-35/ MCG Norgestimate-Eth Estrad Tab / / MCG Levonorgestrel & Ethinyl Estradiol (91-Day) Tab Levonorg-Eth Est Tab (84) & Eth Est Tab 0.01(7) Medroxyprogesterone Acetate Tab 2.5 Medroxyprogesterone Acetate Tab 5 Limited to Female; Daily Dosage=1 Limited to Female; Daily Dosage=1 Limited to Female; Daily Dosage=1 Limited to Female; Daily Dosage=1 Limited to Female; Daily Dosage=1 Limited to Female; Daily Dosage=1 Limited to Female; Max Qty=91/claim; Min DS=91 Limited to Female; Daily Dosage=1 (Generic: PROVERA) (Generic: AYGESTIN) ANTIDIABETICS Medroxyprogesterone Acetate Tab 10 Norethindrone Acetate Tab 5 PROGESTERONE Cap 100 PROGESTERONE Cap 200 Max Qty=30/30 days Max Qty=20/30 days Insulin Aspart Inj 100 U/ML NOVOLOG Max Qty=40/30 days Insulin Glargine Inj 100 U/ML LANTUS Max Qty=30/30 days Insulin Lispro (Human) Inj 100 U/ML HUMALOG Max Qty=40/30 days Insulin Regular (Human) Inj 100 U/ML HUMULIN R, NOVOLIN R Max Qty=40/30 days Insulin Isophane (Human) Inj 100 U/ML HUMULIN N, NOVOLIN N Max Qty=40/30 days Insulin Aspart & Aspart Prot (Human) Inj 100 U/ML (30-70) NOVOLOG MIX Max Qty=40/30 days Insulin Lispro Prot & Lispro (Human) Inj 100 Unit/ML (75-2 HUMALOG MIX Max Qty=40/30 days Insulin Lispro Prot & Lispro (Human) Inj 100 Unit/ML (50-5 HUMALOG MIX Max Qty=40/30 days Insulin Isophane & Regular (Human) Inj 100 U/ML (70-30) HUMULIN 70/30, NOVOLIN 70/30 Max Qty=40/30 days Insulin Isophane & Regular (Human) Inj 100 U/ML (50-50) HUMULIN Max Qty=40/30 days (Generic: AMARYL) Glimepiride Tab 1 (Generic: AMARYL) Glimepiride Tab 2 (Generic: AMARYL) Glimepiride Tab 4 Daily Dosage=2 (Generic: GLUCOTROL) Glipizide Tab 5 (Generic: GLUCOTROL) Glipizide Tab 10 (Generic: GLUCOTROL XL) Glipizide Tab SR 24HR 2.5 (Generic: GLUCOTROL XL) Glipizide Tab SR 24HR 5 (Generic: GLUCOTROL XL) Glipizide Tab SR 24HR 10

21 Glyburide Tab 1.25 DIABETA, GLYBURIDE (Generic: MICRONASE) Glyburide Tab 2.5 DIABETA, GLYBURIDE (Generic: MICRONASE) Glyburide Tab 5 DIABETA, GLYBURIDE (Generic: GLYNASE) Glyburide Micronized Tab 1.5 (Generic: GLYNASE) Glyburide Micronized Tab 3 (Generic: GLYNASE) Glyburide Micronized Tab 6 (Generic: GLUCOPHAGE) Metformin HCl Tab 500 Daily Dosage=5 (Generic: GLUCOPHAGE) Metformin HCl Tab 850 Daily Dosage=3 (Generic: GLUCOPHAGE) Metformin HCl Tab 1000 Daily Dosage=2 (Generic: GLUCOPHAGE) Metformin HCl Tab SR 24HR 500 Daily Dosage=4 (Generic: GLUCOPHAGE) Metformin HCl Tab SR 24HR 750 Daily Dosage=2 (Generic: STARLIX) NATEGLINIDE Tab 60 PA; Daily Dosage=3 (Generic: STARLIX) NATEGLINIDE Tab 120 PA; Daily Dosage=3 Glucagon (rdna) For Inj Kit 1 GLUCAGON Max Qty=1/claim Glucagon HCl (rdna) For Inj 1 (Base Equiv) GLUCAGEN Glucose Chew Tab 4 GM BL GLUCOSE, CVS GLUCOSE, DD GLUCOSE, DE GLUCOSE, DEX4 GLUCOSE... Max Qty=50/30 days Glucose Chew Tab 5 GM BD GLUCOSE Max Qty=50/30 days LINAGLIPTIN Tab 5 Tradjenta Age Limit =18 SAXAGLIPTIN HYDROCHLORIDE Tab 2.5 ONGLYZA Age Limit =18 SAXAGLIPTIN HYDROCHLORIDE Tab 5 ONGLYZA Age Limit =18 Pioglitazone HCl Tab 15 (Base Equiv) ACTOS Pioglitazone HCl Tab 30 (Base Equiv) ACTOS Pioglitazone HCl Tab 45 (Base Equiv) ACTOS Rosiglitazone Maleate Tab 2 (Base Equiv) AVANDIA Rosiglitazone Maleate Tab 4 (Base Equiv) AVANDIA Rosiglitazone Maleate Tab 8 (Base Equiv) AVANDIA LINAGLIPTIN; METFORMIN HYDROCHLORIDE Tab 2.5; 500 LINAGLIPTIN; METFORMIN HYDROCHLORIDE Tab 2.5; 850 JENTADUETO JENTADUETO Daily Dosage=2 Age Limit =18 Daily Dosage=2 Age Limit =18

22 LINAGLIPTIN; METFORMIN HYDROCHLORIDE Tab 2.5; 1000 METFORMIN HYDROCHLORIDE; SAXAGLIPTIN HYDROCHLORIDE Tab 1000; 2.5 METFORMIN HYDROCHLORIDE; SAXAGLIPTIN HYDROCHLORIDE Tab 500; 5 METFORMIN HYDROCHLORIDE; SAXAGLIPTIN HYDROCHLORIDE Tab 1000; 5 JENTADUETO KOMBIGLYZE XR KOMBIGLYZE XR KOMBIGLYZE XR Daily Dosage=2 Age Limit =18 Daily Dosage=2 Age Limit =18 Age Limit =18 Age Limit =18 (Generic: METAGLIP) (Generic: METAGLIP) (Generic: METAGLIP) (Generic: GLUCOVANCE) (Generic: GLUCOVANCE) (Generic: GLUCOVANCE) Glipizide-Metformin HCl Tab Glipizide-Metformin HCl Tab Glipizide-Metformin HCl Tab Glyburide-Metformin Tab Glyburide-Metformin Tab Glyburide-Metformin Tab Rosiglitazone Maleate-Glimepiride Tab 4-1 AVANDARYL Rosiglitazone Maleate-Glimepiride Tab 4-2 AVANDARYL Rosiglitazone Maleate-Glimepiride Tab 4-4 AVANDARYL Rosiglitazone Maleate-Glimepiride Tab 8-2 AVANDARYL THYROID AGENTS (Generic: SYNTHROID) (Generic: SYNTHROID) (Generic: SYNTHROID) (Generic: SYNTHROID) (Generic: SYNTHROID) (Generic: SYNTHROID) (Generic: SYNTHROID) (Generic: SYNTHROID) (Generic: SYNTHROID) Rosiglitazone Maleate-Glimepiride Tab 8-4 AVANDARYL Pioglitazone HCl-Metformin HCl Tab ACTOPLUS MET Daily Dosage=2 Pioglitazone HCl-Metformin HCl Tab ACTOPLUS MET Daily Dosage=2 Rosiglitazone Maleate-Metformin HCl Tab AVANDAMET Daily Dosage=2 Rosiglitazone Maleate-Metformin HCl Tab AVANDAMET Daily Dosage=2 Rosiglitazone Maleate-Metformin HCl Tab AVANDAMET Daily Dosage=2 Rosiglitazone Maleate-Metformin HCl Tab AVANDAMET Daily Dosage=2 Levothyroxine Sodium Tab Levothyroxine Sodium Tab 0.05 Levothyroxine Sodium Tab Levothyroxine Sodium Tab Levothyroxine Sodium Tab 0.1 Levothyroxine Sodium Tab Levothyroxine Sodium Tab Levothyroxine Sodium Tab Levothyroxine Sodium Tab 0.15

23 (Generic: SYNTHROID) Levothyroxine Sodium Tab (Generic: SYNTHROID) Levothyroxine Sodium Tab 0.2 (Generic: SYNTHROID) Levothyroxine Sodium Tab 0.3 (Generic: CYTOMEL) Liothyronine Sodium Tab 5 MCG (Generic: CYTOMEL) Liothyronine Sodium Tab 25 MCG (Generic: CYTOMEL) Liothyronine Sodium Tab 50 MCG Liotrix Tab 15 THYROLAR-1/4 Liotrix Tab 30 THYROLAR-1/2 Liotrix Tab 60 THYROLAR-1 Liotrix Tab 120 THYROLAR-2 Liotrix Tab 180 THYROLAR-3 Thyroid Tab 15 (1/4 Grain) ARMOUR THYRO (Generic: ARMOUR THYRO) Thyroid Tab 30 (1/2 Grain) ARMOUR THYRO Thyroid Tab 32.5 NATURE-THROI, WESTHROID (Generic: ARMOUR THYRO) Thyroid Tab 60 (1 Grain) ARMOUR THYRO Thyroid Tab 65 NATURE-THROI, WESTHROID (Generic: ARMOUR THYRO) Thyroid Tab 90 (1 1/2 Grain) Thyroid Tab 120 (2 Grain) ARMOUR THYRO Thyroid Tab 130 NATURE-THROI, WESTHROID Thyroid Tab 180 (3 Grain) ARMOUR THYRO Thyroid Tab 195 NATURE-THROI, WESTHROID Thyroid Tab 240 (4 Grain) ARMOUR THYRO Thyroid Tab 300 (5 Grain) ARMOUR THYRO (Generic: TAPAZOLE) (Generic: TAPAZOLE) OXYTOCICS Methimazole Tab 5 Methimazole Tab 10 Propylthiouracil Tab 50 (Generic: METHERGINE) Methylergonovine Maleate Tab 0.2 METHERGINE ENDOCRINE AND METABOLIC AGENTS - MISC. (Generic: FOSAMAX) Alendronate Sodium Tab 5 (Generic: FOSAMAX) Alendronate Sodium Tab 10 (Generic: FOSAMAX) Alendronate Sodium Tab 35 Daily Dosage=.15 (Generic: FOSAMAX) Alendronate Sodium Tab 40 (Generic: FOSAMAX) Alendronate Sodium Tab 70 Daily Dosage=.15 Alendronate Sodium Oral Soln 70 /75ML FOSAMAX 0.8 Risedronate Sodium Tab 5 ACTONEL PA; Risedronate Sodium Tab 30 ACTONEL PA; Risedronate Sodium Tab 35 ACTONEL PA; Max Qty=4/28 days Calcitonin (Salmon) Inj 200 IU/ML MIACALCIN Max Qty=2/30 days (Generic: MIACALCIN) Calcitonin (Salmon) Nasal Soln 200 IU/ACT FORTICAL Max Qty=4/30 days Raloxifene HCl Tab 60 EVISTA (Generic: DDAVP) Desmopressin Acetate Tab 0.1 Daily Dosage=3 (Generic: DDAVP) Desmopressin Acetate Tab 0.2 Daily Dosage=3 (Generic: DDAVP) Desmopressin Acetate Nasal Soln 0.01% (Refrigerated) PA; Max Qty=5/claim

24 Desmopressin Acetate Nasal Spray Soln 0.01% (Refrigerated) PA; Max Qty=5/claim (Generic: DDAVP) Desmopressin Acetate Nasal Spray Soln 0.01% PA; Max Qty=5/claim (Generic: CARNITOR) Levocarnitine Tab 330 Daily Dosage=3 (Generic: CARNITOR, CARNITOR SF) Levocarnitine Oral Soln 1 GM/10ML (10%) Daily Dosage=30 (Generic: ROCALTROL) Calcitriol Cap 0.25 MCG (Generic: ROCALTROL) Calcitriol Cap 0.5 MCG CARDIOTONICS Digoxin Cap 0.1 LANOXICAPS (Generic: LANOXIN) (Generic: LANOXIN) ANTIANGINAL AGENTS (Generic: ISORDIL) Digoxin Tab Digoxin Tab 0.25 Digoxin Oral Soln 0.05 /ML Isosorbide Dinitrate Tab 5 Isosorbide Dinitrate Tab 10 Isosorbide Dinitrate Tab 20 Isosorbide Dinitrate Tab 30 Isosorbide Dinitrate Tab CR 40 Isosorbide Dinitrate SL Tab 2.5 Isosorbide Dinitrate SL Tab 5 ISOSORB DIN (Generic: MONOKET) Isosorbide Mononitrate Tab 10 Daily Dosage=2 (Generic: ISMO, MONOKET) Isosorbide Mononitrate Tab 20 Daily Dosage=2 (Generic: IMDUR) Isosorbide Mononitrate Tab SR 24HR 30 (Generic: IMDUR) Isosorbide Mononitrate Tab SR 24HR 60 (Generic: IMDUR) Isosorbide Mononitrate Tab SR 24HR 120 Nitroglycerin Cap CR 2.5 Nitroglycerin Cap CR 6.5 Nitroglycerin Cap CR 9 Nitroglycerin SL Tab 0.3 NITROSTAT Nitroglycerin SL Tab 0.4 NITROSTAT Nitroglycerin SL Tab 0.6 NITROSTAT NITRO-BID, Nitroglycerin Oint 2% NITROGLYCER (Generic: NITRO-DUR) (Generic: NITRO-DUR) (Generic: NITRO-DUR) Nitroglycerin TD Patch 24HR 0.1 /HR Nitroglycerin TD Patch 24HR 0.2 /HR Nitroglycerin TD Patch 24HR 0.4 /HR (Generic: NITRO-DUR) Nitroglycerin TD Patch 24HR 0.6 /HR BETA BLOCKERS (Generic: CORGARD) Nadolol Tab 20 Daily Dosage=2 (Generic: CORGARD) Nadolol Tab 40 Daily Dosage=2 (Generic: CORGARD) Nadolol Tab 80 Daily Dosage=2 Nadolol Tab 160 NADOLOL Daily Dosage=2 Pindolol Tab 5 PINDOLOL Pindolol Tab 10 Propranolol HCl Tab 10 Propranolol HCl Tab 20

25 Propranolol HCl Tab 40 Propranolol HCl Tab 60 Propranolol HCl Tab 80 Propranolol HCl Oral Soln 20 /5ML Propranolol HCl Oral Soln 40 /5ML (Generic: INDERAL LA) Propranolol HCl Cap SR 24HR 60 Daily Dosage=2 (Generic: INDERAL LA) Propranolol HCl Cap SR 24HR 80 Daily Dosage=2 (Generic: INDERAL LA) Propranolol HCl Cap SR 24HR 120 Daily Dosage=2 (Generic: INDERAL LA) Propranolol HCl Cap SR 24HR 160 Daily Dosage=2 (Generic: BETAPACE) Sotalol HCl Tab 80 Daily Dosage=2 (Generic: BETAPACE) Sotalol HCl Tab 120 Daily Dosage=2 (Generic: BETAPACE) Sotalol HCl Tab 160 Daily Dosage=2 (Generic: BETAPACE) Sotalol HCl Tab 240 (Generic: BETAPACE AF) Sotalol HCl (AFIB/AFL) Tab 80 Daily Dosage=2 (Generic: BETAPACE AF) Sotalol HCl (AFIB/AFL) Tab 120 Daily Dosage=2 (Generic: BETAPACE AF) Sotalol HCl (AFIB/AFL) Tab 160 Daily Dosage=2 Timolol Maleate Tab 5 Timolol Maleate Tab 10 Timolol Maleate Tab 20 (Generic: SECTRAL) Acebutolol HCl Cap 200 (Generic: SECTRAL) Acebutolol HCl Cap 400 (Generic: TENORMIN) Atenolol Tab 25 Daily Dosage=2 (Generic: TENORMIN) Atenolol Tab 50 Daily Dosage=2 (Generic: TENORMIN) Atenolol Tab 100 Daily Dosage=2 Bisoprolol Fumarate TAB 5 Bisoprolol Fumarate TAB 10 (Generic: TOPROL XL) Metoprolol Succinate Tab SR 24HR 25 (Generic: TOPROL XL) Metoprolol Succinate Tab SR 24HR 50 (Generic: TOPROL XL) Metoprolol Succinate Tab SR 24HR 100 (Generic: TOPROL XL) Metoprolol Succinate Tab SR 24HR 200 Daily Dosage=2 Metoprolol Tartrate Tab 25 Daily Dosage=2 (Generic: LOPRESSOR) Metoprolol Tartrate Tab 50 Daily Dosage=3 (Generic: LOPRESSOR) Metoprolol Tartrate Tab 100 Daily Dosage=2 (Generic: COREG) Carvedilol Tab Daily Dosage=3 (Generic: COREG) Carvedilol Tab 6.25 Daily Dosage=3 (Generic: COREG) Carvedilol Tab 12.5 Daily Dosage=3 (Generic: COREG) Carvedilol Tab 25 Daily Dosage=4 Carvedilol Phosphate Cap SR 24HR 10 COREG CR Carvedilol Phosphate Cap SR 24HR 20 COREG CR Carvedilol Phosphate Cap SR 24HR 40 COREG CR Carvedilol Phosphate Cap SR 24HR 80 COREG CR (Generic: TRANDATE) Labetalol HCl Tab 100 Daily Dosage=3 (Generic: TRANDATE) Labetalol HCl Tab 200 Daily Dosage=6 (Generic: TRANDATE) Labetalol HCl Tab 300 Daily Dosage=8 CALCIUM CHANNEL BLOCKERS

26 (Generic: NORVASC) Amlodipine Besylate Tab 2.5 (Generic: NORVASC) Amlodipine Besylate Tab 5 (Generic: NORVASC) Amlodipine Besylate Tab 10 (Generic: CARDIZEM) Diltiazem HCl Tab 30 Daily Dosage=3 (Generic: CARDIZEM) Diltiazem HCl Tab 60 Daily Dosage=3 (Generic: CARDIZEM) Diltiazem HCl Tab 90 Daily Dosage=3 (Generic: CARDIZEM) Diltiazem HCl Tab 120 Daily Dosage=3 Diltiazem HCl Cap SR 12HR 60 Daily Dosage=2 Diltiazem HCl Cap SR 12HR 90 Daily Dosage=2 Diltiazem HCl Cap SR 12HR 120 Daily Dosage=2 (Generic: DILACOR XR) Diltiazem HCl Cap SR 24HR 120 (Generic: DILACOR XR) Diltiazem HCl Cap SR 24HR 180 (Generic: DILACOR XR) Diltiazem HCl Cap SR 24HR 240 Daily Dosage=2 (Generic: TIAZAC) Diltiazem HCl Extended Release Beads Cap SR 24HR 120 (Generic: TIAZAC) Diltiazem HCl Extended Release Beads Cap SR 24HR 180 (Generic: TIAZAC) Diltiazem HCl Extended Release Beads Cap SR 24HR 240 (Generic: TIAZAC) Diltiazem HCl Extended Release Beads Cap SR 24HR 300 (Generic: TIAZAC) Diltiazem HCl Extended Release Beads Cap SR 24HR 360 (Generic: TIAZAC) Diltiazem HCl Extended Release Beads Cap SR 24HR 420 (Generic: CARDIZEM CD) Diltiazem HCl Coated Beads Cap SR 24HR 120 (Generic: CARDIZEM CD) Diltiazem HCl Coated Beads Cap SR 24HR 180 (Generic: CARDIZEM CD) Diltiazem HCl Coated Beads Cap SR 24HR 240 Daily Dosage=2 (Generic: CARDIZEM CD) Diltiazem HCl Coated Beads Cap SR 24HR 300 (Generic: PLENDIL) Felodipine Tab SR 24HR 2.5 (Generic: PLENDIL) Felodipine Tab SR 24HR 5 (Generic: PLENDIL) Felodipine Tab SR 24HR 10 Nicardipine HCl Cap 20 Nicardipine HCl Cap 30 (Generic: PROCARDIA) Nifedipine Cap 10 Daily Dosage=4 Nifedipine Cap 20 NIFEDIPINE Daily Dosage=4 (Generic: ADALAT CC) Nifedipine Tab SR 24HR 30 (Generic: ADALAT CC) Nifedipine Tab SR 24HR 60 Daily Dosage=2 (Generic: ADALAT CC) Nifedipine Tab SR 24HR 90 (Generic: PROCARDIA XL) Nifedipine Tab SR 24HR Osmotic 30 (Generic: PROCARDIA XL) Nifedipine Tab SR 24HR Osmotic 60 Daily Dosage=2 (Generic: PROCARDIA XL) Nifedipine Tab SR 24HR Osmotic 90 (Generic: CALAN) Verapamil HCl Tab 40 Daily Dosage=3 (Generic: CALAN) Verapamil HCl Tab 80 Daily Dosage=3 (Generic: CALAN) Verapamil HCl Tab 120 Daily Dosage=3 (Generic: CALAN SR, ISOPTIN SR) Verapamil HCl Tab CR 120 Daily Dosage=2

27 (Generic: CALAN SR, ISOPTIN SR) Verapamil HCl Tab CR 180 Daily Dosage=2 (Generic: CALAN SR, ISOPTIN SR) Verapamil HCl Tab CR 240 Daily Dosage=2 (Generic: VERELAN) Verapamil HCl Cap SR 24HR 120 Daily Dosage=2 (Generic: VERELAN) Verapamil HCl Cap SR 24HR 180 Daily Dosage=2 (Generic: VERELAN) Verapamil HCl Cap SR 24HR 240 Daily Dosage=2 (Generic: VERELAN) Verapamil HCl Cap SR 24HR 360 ANTIARRHYTHMICS Moricizine HCl Tab 200 ETHMOZINE Moricizine HCl Tab 250 ETHMOZINE Moricizine HCl Tab 300 ETHMOZINE (Generic: NORPACE) (Generic: NORPACE) (Generic: PRONESTYL) (Generic: TAMBOCOR) (Generic: TAMBOCOR) (Generic: TAMBOCOR) (Generic: RYTHMOL) (Generic: RYTHMOL) (Generic: RYTHMOL) Disopyramide Phosphate Cap 100 Disopyramide Phosphate Cap 150 Disopyramide Phosphate Cap SR 12HR 150 Procainamide HCl Cap 250 Procainamide HCl Tab CR 750 Quinidine Gluconate Tab CR 324 Quinidine Sulfate Tab 200 Quinidine Sulfate Tab 300 Quinidine Sulfate Tab CR 300 Mexiletine HCl Cap 150 Mexiletine HCl Cap 200 Mexiletine HCl Cap 250 Flecainide Acetate Tab 50 Flecainide Acetate Tab 100 Flecainide Acetate Tab 150 Propafenone HCl Tab 150 Propafenone HCl Tab 225 Propafenone HCl Tab 300 NORPACE PROCAINAMIDE MEXILETINE MEXILETINE MEXILETINE (Generic: CORDARONE) Amiodarone HCl Tab 200 Dofetilide Cap 125 MCG (0.125 ) TIKOSYN Dofetilide Cap 250 MCG (0.25 ) TIKOSYN Dofetilide Cap 500 MCG (0.5 ) TIKOSYN ANTIHYPERTENSIVES (Generic: LOTENSIN) Benazepril HCl Tab 5 (Generic: LOTENSIN) Benazepril HCl Tab 10 (Generic: LOTENSIN) Benazepril HCl Tab 20 LOTENSIN (Generic: LOTENSIN) Benazepril HCl Tab 40 Daily Dosage=2 (Generic: CAPOTEN) Captopril Tab 12.5 Daily Dosage=3 (Generic: CAPOTEN) Captopril Tab 25 Daily Dosage=3 (Generic: CAPOTEN) Captopril Tab 50 Daily Dosage=3 (Generic: CAPOTEN) Captopril Tab 100 Daily Dosage=3 (Generic: VASOTEC) Enalapril Maleate Tab 2.5 Daily Dosage=2 (Generic: VASOTEC) Enalapril Maleate Tab 5 Daily Dosage=2 (Generic: VASOTEC) Enalapril Maleate Tab 10 Daily Dosage=2 (Generic: VASOTEC) Enalapril Maleate Tab 20 Daily Dosage=2 (Generic: MONOPRIL) Fosinopril Sodium Tab 10 (Generic: MONOPRIL) Fosinopril Sodium Tab 20 (Generic: MONOPRIL) Fosinopril Sodium Tab 40 (Generic: ZESTRIL) Lisinopril Tab 2.5 (Generic: PRINIVIL, ZESTRIL) Lisinopril Tab 5 Daily Dosage=2

28 (Generic: PRINIVIL, ZESTRIL) Lisinopril Tab 10 PRINIVIL Daily Dosage=2 (Generic: PRINIVIL, ZESTRIL) Lisinopril Tab 20 Daily Dosage=2 (Generic: ZESTRIL) Lisinopril Tab 30 Daily Dosage=2 (Generic: ZESTRIL) Lisinopril Tab 40 Daily Dosage=2 (Generic: ACCUPRIL) Quinapril HCl Tab 5 (Generic: ACCUPRIL) Quinapril HCl Tab 10 (Generic: ACCUPRIL) Quinapril HCl Tab 20 (Generic: ACCUPRIL) Quinapril HCl Tab 40 (Generic: ALTACE) Ramipril Cap 1.25 Daily Dosage=2 (Generic: ALTACE) Ramipril Cap 2.5 Daily Dosage=2 (Generic: ALTACE) Ramipril Cap 5 Daily Dosage=2 (Generic: ALTACE) Ramipril Cap 10 Daily Dosage=2 (Generic: MAVIK) Trandolapril Tab 1 Daily Dosage=4 (Generic: MAVIK) Trandolapril Tab 2 Daily Dosage=4 (Generic: MAVIK) Trandolapril Tab 4 Daily Dosage=4 (Generic: COZAAR) Losartan Potassium Tab 25 COZAAR (Generic: COZAAR) Losartan Potassium Tab 50 COZAAR (Generic: COZAAR) Losartan Potassium Tab 100 COZAAR (Generic: DIOVAN) Valsartan Tab 40 ; Step Therapy (Generic: DIOVAN) Valsartan Tab 80 ; Step Therapy (Generic: DIOVAN) Valsartan Tab 160 ; Step Therapy (Generic: DIOVAN) Valsartan Tab 320 ; Step Therapy (Generic: CATAPRES) Clonidine HCl Tab 0.1 (Generic: CATAPRES) (Generic: CATAPRES) (Generic: TENEX) (Generic: TENEX) (Generic: CARDURA) (Generic: CARDURA) (Generic: CARDURA) (Generic: CARDURA) (Generic: MINIPRESS) (Generic: MINIPRESS) (Generic: MINIPRESS) (Generic: HYTRIN) (Generic: HYTRIN) (Generic: HYTRIN) (Generic: HYTRIN) Clonidine HCl Tab 0.2 Clonidine HCl Tab 0.3 Guanabenz Acetate Tab 4 Guanabenz Acetate Tab 8 Guanfacine HCl Tab 1 Guanfacine HCl Tab 2 Methyldopa Tab 250 Methyldopa Tab 500 Doxazosin Mesylate Tab 1 Doxazosin Mesylate Tab 2 Doxazosin Mesylate Tab 4 Doxazosin Mesylate Tab 8 Prazosin HCl Cap 1 Prazosin HCl Cap 2 Prazosin HCl Cap 5 Terazosin HCl Cap 1 Terazosin HCl Cap 2 Terazosin HCl Cap 5 Terazosin HCl Cap 10 Reserpine Tab 0.1 Reserpine Tab 0.25 Hydralazine HCl Tab 10 Hydralazine HCl Tab 25 (Generic: APRESOLINE) Hydralazine HCl Tab 50 Hydralazine HCl Tab 100 Minoxidil Tab 2.5