2016 Allegian Choice Preferred Drug List (formulary)

Transcription

1 2016 Allegian Choice Preferred Drug List (formulary) The Allegian Choice Formulary is a list of drugs covered by Allegian Health Plans, Inc. for its Allegian Choice plans. The drug list is updated often and may change. To get the most up-to-date information, you may view the latest drug list on our website at or you may call us at the telephone number listed on your Allegian Choice ID card. What is the Formulary? Welcome to Allegian Choice The Allegian Choice Formulary or preferred drug list is a list of covered drugs used to treat health problems or common diseases. This list can help your doctor in selecting clinically appropriate and cost effective medications for you. The formulary is selected by a committee of doctors and pharmacists who meet regularly to decide which drugs should be included. The committee reviews new drugs and new information about existing drugs and chooses drugs based on: Safety Effectiveness Side effects Value (If two drugs are equally effective, the less costly drug is preferred) The Allegian Choice Formulary is updated throughout the year to add important new medications as they become available. How much will I pay for my drugs? To figure out how much you will pay for a drug, the table below lists the Tier for each medication category. Your copayment amount is based on the Tier level, and is defined in your Summary of Benefits or other plan documents.

2 Tier Tier 0 Tier 1 Tier 2 Tier 3 Tier 4 Tier 5 Tier 6 Category Preventive -zero cost share Generic preferred Generic non-preferred Brand preferred Brand non-preferred Specialty Specialty non-preferred How do I use this Formulary? The formulary is organized by drug category, which will show you all medications in a certain category. For example, you will see all blood pressure medications listed together under ANTIHYPERTENSIVES, with their respective tiers and restrictions (See Are there any limits on my drug coverage? below for restrictions.). BRANDS are listed in capital letters, and generics are listed in small letters. You can also look up your drug using the alphabetical list using the index in the back of the formulary contained in this document. What is a generic drug? Generic drugs contain the same active ingredient and work the same way as the brand name drug. Generic drugs are safe, effective, and generally cost less. You will pay less for generic drugs almost every time. Preferred generic drugs are available on the formulary as Tier 1. If you request a brand name drug that has an available preferred generic version, you will pay the cost difference between the generic and the brand plus the applicable brand copay. What if my drug is not on this list? If you do not see your drug on the drug list, please call us at the telephone number on your Allegian Choice ID card and ask if your drug is covered. If your drug is not covered, you can ask your doctor to prescribe a similar drug that is covered. If your doctor feels you need to have the drug that is not covered, your doctor can ask us to make an exception. Are there any limits on my drug coverage? Some drugs have limits on coverage. The table below gives a description of abbreviations that may appear in the limits column on the drug list: Quantity Limits (QL) Prior Authorization (PA) Some drugs have a limit on how many doses you may receive. You may need approval first if your doctor prescribes more than what is recommended. Some drugs will require authorization before they can be dispensed by your pharmacy. This requirement ensures that the medication

3 Step Therapy (ST) prescribed meets medical criteria for you. Your doctor will need to submit a request for prior authorization when prescribing a drug in this category. Step therapy is a clinical program that only applies to certain types of medications. With step therapy, you will receive drug coverage for a medication after first trying an alternative medication that has been determined to be safe, effective, and less costly. Your provider can ask us to review coverage of a medication when it is different that the limits noted in our drug list. For example, if your drug has a quantity limit of 1 tablet per day, your doctor can ask us to cover more. To request an exception, or to request a prior authorization for a medication, your doctor can fax a prior authorization form along with a written statement supporting the request to us at or call Where can I pick up my medications? To get the best benefit, you should use pharmacies that are in network. Most chain pharmacies and many independent pharmacies are in the network. To find a pharmacy near you, visit our website at or call us at the telephone number on your Allegian Choice ID card. If you fill a prescription at an out-of-network pharmacy, you may end up paying the full cost of your drug. Some injectable medications or high-cost drugs may be considered specialty. Unless otherwise noted, you must obtain these drugs from CVS Caremark Specialty Pharmacy, the specialty pharmacy in the Allegian Choice network. You may find out more information by going to CVS Caremark Specialty Pharmacy website at URL or by calling them at You may use the mail order pharmacy, CVS Caremark Mail Service Pharmacy to get home delivery of most maintenance medications. Maintenance drugs are ones that you take every day and are needed to treat a long-term condition. Your doctor will need to give you a new prescription for up to a 90-day supply of your drug or drugs. If you would like to obtain a mail order form, visit the Caremark website at and click on Print Plan Forms, you may also call the mail order pharmacy, directly at , or you may call us at the telephone number listed on your Allegian Choice ID card to request a form.

4 EXCHANGES_CVSC EXCH_CVSC 6T TX STND eff 03/01/2016 ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS Amphetamines amphetamine-dextroamphetamine cap sr 2 QL (90 caps / 25 days) 24hr 5 amphetamine-dextroamphetamine cap sr 2 QL (90 caps / 25 days) 24hr 10 amphetamine-dextroamphetamine cap sr 2 QL (30 caps / 25 days) 24hr 15 amphetamine-dextroamphetamine cap sr 2 QL (30 caps / 25 days) 24hr 20 amphetamine-dextroamphetamine cap sr 2 QL (30 caps / 25 days) 24hr 25 amphetamine-dextroamphetamine cap sr 2 QL (30 caps / 25 days) 24hr 30 amphetamine-dextroamphetamine tab 5 2 QL (90 tabs / 25 days) amphetamine-dextroamphetamine tab QL (90 tabs / 25 days) amphetamine-dextroamphetamine tab 10 2 QL (90 tabs / 25 days) amphetamine-dextroamphetamine tab 2 QL (90 tabs / 25 days) 12.5 amphetamine-dextroamphetamine tab 15 2 QL (60 tabs / 25 days) amphetamine-dextroamphetamine tab 20 2 QL (60 tabs / 25 days) amphetamine-dextroamphetamine tab 30 2 QL (30 tabs / 25 days) dextroamphetamine sulfate cap sr 24hr 5 2 QL (120 caps / 25 days) dextroamphetamine sulfate cap sr 24hr 10 2 QL (120 caps / 25 days) dextroamphetamine sulfate cap sr 24hr 15 2 QL (60 caps / 25 days) dextroamphetamine sulfate oral solution 5 2 QL (1,200 ml / 25 days) /5ml dextroamphetamine sulfate tab 5 2 QL (120 tabs / 25 days) dextroamphetamine sulfate tab 10 2 QL (120 tabs / 25 days) methamphetamine hcl tab 5 2 QL (150 tabs / 25 days) VYVANSE CAP 10MG 3 VYVANSE CAP 20MG 3 VYVANSE CAP 30MG 3 VYVANSE CAP 40MG 3 VYVANSE CAP 50MG 3 VYVANSE CAP 60MG 3 1

5 VYVANSE CAP 70MG 3 zenzedi tab QL (120 tabs / 25 days) zenzedi tab QL (120 tabs / 25 days) zenzedi tab 15 2 QL (60 tabs / 25 days) zenzedi tab 20 2 QL (60 tabs / 25 days) zenzedi tab 30 2 QL (30 tabs / 25 days) Attention-Deficit/Hyperactivity Disorder (ADHD) Agents guanfacine hcl tab sr 24hr 1 (base 2 ST; PA** equiv) guanfacine hcl tab sr 24hr 2 (base 2 ST; PA** equiv) guanfacine hcl tab sr 24hr 3 (base 2 ST; PA** equiv) guanfacine hcl tab sr 24hr 4 (base 2 ST; PA** equiv) STRATTERA CAP 10MG 3 STRATTERA CAP 18MG 3 STRATTERA CAP 25MG 3 STRATTERA CAP 40MG 3 STRATTERA CAP 60MG 3 STRATTERA CAP 80MG 3 STRATTERA CAP 100MG 3 Stimulants - Misc. dexmethylphenidate hcl cap sr 24 hr 5 2 QL (60 caps / 25 days) dexmethylphenidate hcl cap sr 24 hr 10 2 QL (60 caps / 25 days) dexmethylphenidate hcl cap sr 24 hr 15 2 QL (60 caps / 25 days) dexmethylphenidate hcl cap sr 24 hr 20 2 QL (60 caps / 25 days) dexmethylphenidate hcl cap sr 24 hr 30 2 QL (30 caps / 25 days) dexmethylphenidate hcl cap sr 24 hr 40 2 QL (30 caps / 25 days) dexmethylphenidate hcl tab QL (120 tabs / 25 days) dexmethylphenidate hcl tab 5 2 QL (120 tabs / 25 days) dexmethylphenidate hcl tab 10 2 QL (60 tabs / 25 days) methylphenidate hcl cap cr 10 2 QL (60 caps / 25 days) methylphenidate hcl cap cr 20 2 QL (60 caps / 25 days) methylphenidate hcl cap cr 30 2 QL (60 caps / 25 days) methylphenidate hcl cap cr 40 2 QL (30 caps / 25 days) methylphenidate hcl cap cr 50 2 QL (30 caps / 25 days) methylphenidate hcl cap cr 60 2 QL (30 caps / 25 days) methylphenidate hcl cap sr 24hr 20 2 QL (60 caps / 25 days) (la) methylphenidate hcl cap sr 24hr 30 (la) 2 QL (60 caps / 25 days) 2

6 methylphenidate hcl cap sr 24hr 40 2 QL (30 caps / 25 days) (la) methylphenidate hcl chew tab QL (180 chew tabs / 25 days) methylphenidate hcl chew tab 5 2 QL (180 chew tabs / 25 days) methylphenidate hcl chew tab 10 2 QL (180 chew tabs / 25 days) methylphenidate hcl soln 5 /5ml 2 QL (1800 ml / 25 days) methylphenidate hcl soln 10 /5ml 2 QL (900 ml / 25 days) methylphenidate hcl tab 5 2 QL (180 tabs / 25 days) methylphenidate hcl tab 10 2 QL (180 tabs / 25 days) methylphenidate hcl tab 20 2 QL (90 tabs / 25 days) methylphenidate hcl tab cr 10 2 QL (90 tabs / 25 days) methylphenidate hcl tab cr 20 2 QL (90 tabs / 25 days) methylphenidate hcl tab sa osm 18 2 QL (60 tabs / 25 days) methylphenidate hcl tab sa osm 27 2 QL (60 tabs / 25 days) methylphenidate hcl tab sa osm 36 2 QL (60 tabs / 25 days) methylphenidate hcl tab sa osm 54 2 QL (30 tabs / 25 days) methylphenidate hcl tab sr 24hr 18 2 QL (60 tabs / 25 days) methylphenidate hcl tab sr 24hr 27 2 QL (60 tabs / 25 days) methylphenidate hcl tab sr 24hr 36 2 QL (60 tabs / 25 days) methylphenidate hcl tab sr 24hr 54 2 QL (30 tabs / 25 days) modafinil tab PA modafinil tab PA NUVIGIL TAB 50MG 3 PA NUVIGIL TAB 150MG 3 PA NUVIGIL TAB 200MG 3 PA NUVIGIL TAB 250MG 3 PA AMINOGLYCOSIDES Aminoglycosides amikacin sulfate inj 1 gm/4ml (250 /ml) 2 amikacin sulfate inj 500 /2ml (250 2 /ml) GENTAM/NACL INJ 0.9MG/ML 4 GENTAM/NACL INJ 1.4MG/ML 4 gentamicin in saline inj 0.8 /ml 2 gentamicin in saline inj 1 /ml 2 gentamicin in saline inj 1.2 /ml 2 gentamicin in saline inj 1.6 /ml 2 gentamicin in saline inj 2 /ml 2 gentamicin sulfate inj 10 /ml 2 gentamicin sulfate inj 40 /ml 2 gentamicin sulfate iv soln 10 /ml 2 kanamycin sulfate inj 333 /ml 2 NEO-FRADIN SOL 125/5ML 4 3

7 neomycin sulfate tab paromomycin sulfate cap streptomycin sulfate for inj 1 gm 2 TOBRA/NACL INJ 80/0.9 4 tobramycin nebu soln 300 /5ml 2 PA tobramycin sulfate for inj 1.2 gm 2 tobramycin sulfate inj 1.2 gm/30ml (40 2 /ml) tobramycin sulfate inj 2 gm/50ml (40 2 /ml) tobramycin sulfate inj 10 /ml 2 tobramycin sulfate inj 80 /2ml (40 2 /ml) ANALGESICS - ANTI-INFLAMMATORY Anti-TNF-alpha - Monoclonal Antibodies HUMIRA INJ 10MG/0.2 5 PA HUMIRA KIT 20MG/0.4 5 PA HUMIRA KIT 40MG/0.8 5 PA HUMIRA PEN INJ CROHNS 5 PA SIMPONI ARIA SOL 50MG/4ML 6 PA, ST SIMPONI INJ 50/0.5ML 6 PA, ST SIMPONI INJ 100MG/ML 6 PA, ST Antirheumatic - Enzyme Inhibitors XELJANZ TAB 5MG 6 PA, ST Antirheumatic Antimetabolites RHEUMATREX TAB 2.5MG 4 Interleukin-1 Blockers ARCALYST INJ 220MG 5 PA Interleukin-1 Receptor Antagonist (IL-1Ra) KINERET INJ 6 PA, ST Interleukin-6 Receptor Inhibitors ACTEMRA INJ 80MG/4ML 6 PA, ST ACTEMRA INJ 162/0.9 6 PA, ST ACTEMRA INJ 200/10ML 6 PA, ST ACTEMRA INJ 400/20ML 6 PA, ST Nonsteroidal Anti-inflammatory Agents (NSAIDs) celecoxib cap 50 2 celecoxib cap celecoxib cap celecoxib cap diclofenac potassium tab 50 2 diclofenac sodium tab delayed release 25 2 diclofenac sodium tab delayed release

8 diclofenac sodium tab delayed release 75 2 diclofenac sodium tab sr 24hr diclofenac w/ misoprostol tab delayed 2 release diclofenac w/ misoprostol tab delayed 2 release etodolac cap etodolac cap etodolac tab etodolac tab etodolac tab sr 24hr etodolac tab sr 24hr etodolac tab sr 24hr fenoprofen calcium cap fenoprofen calcium tab flurbiprofen tab 50 2 flurbiprofen tab ibuprofen susp 100 /5ml 2 ibuprofen tab ibuprofen tab ibuprofen tab INDOCIN SUS 25MG/5ML 4 indomethacin cap 25 2 indomethacin cap 50 2 indomethacin cap cr 75 2 ketoprofen cap 50 2 ketoprofen cap 75 2 ketoprofen cap sr 24hr ketorolac tromethamine im inj 60 /2ml 2 (30 /ml) ketorolac tromethamine inj 15 /ml 2 ketorolac tromethamine inj 30 /ml 2 ketorolac tromethamine inj 60 /2ml (30 2 /ml) ketorolac tromethamine inj 300 /10ml 2 (30 /ml) ketorolac tromethamine tab 10 2 QL (20 tabs / 25 days) meclofenamate sodium cap 50 2 meclofenamate sodium cap mefenamic acid cap meloxicam susp 7.5 /5ml 2 meloxicam tab meloxicam tab 15 2 nabumetone tab nabumetone tab naproxen dr tab

9 naproxen dr tab naproxen sodium tab naproxen sodium tab naproxen susp 125 /5ml 2 naproxen tab naproxen tab naproxen tab oxaprozin tab piroxicam cap 10 2 piroxicam cap 20 2 sulindac tab sulindac tab tolmetin sodium cap tolmetin sodium tab tolmetin sodium tab Pyrimidine Synthesis Inhibitors leflunomide tab 10 2 leflunomide tab 20 2 Selective Costimulation Modulators ORENCIA INJ 125MG/ML 6 PA, ST ORENCIA INJ 250MG 6 PA, ST Soluble Tumor Necrosis Factor Receptor Agents ENBREL INJ 25/0.5ML 5 PA ENBREL INJ 25MG 5 PA ENBREL INJ 50MG/ML 5 PA ENBREL SRCLK INJ 50MG/ML 5 PA ANALGESICS - NonNarcotic Analgesic Combinations alagesic lq sol 2 QL (720 ml / 25 days) butalbital-acetaminophen-caffeine cap 2 QL (48 caps / 25 days) butalbital-acetaminophen-caffeine cap 2 QL (48 caps / 25 days) butalbital-acetaminophen-caffeine tab 2 QL (48 tabs / 25 days) butalbital-aspirin-caffeine cap QL (48 caps / 25 days) butalbital-aspirin-caffeine tab QL (48 tabs / 25 days) Salicylates aspirin chew tab 81 0 QL (100 tabs / 30 days); OTC; $0 copay-age restriction applies aspirin low tab 81 ec 0 QL (100 tabs / 30 days); OTC; $0 copay-age restriction applies 6

10 aspirin tab 81 0 QL (100 tabs / 30 days); OTC; $0 copay-age restriction applies aspirin tab QL (100 tabs / 30 days); OTC; $0 copay-age restriction applies aspirin tab delayed release QL (100 tabs / 30 days); OTC; $0 copay-age restriction applies diflunisal tab ANALGESICS - OPIOID Opioid Agonists ABSTRAL SUB 100MCG 3 QL (120 Units per 25 days), PA ABSTRAL SUB 200MCG 3 QL (120 Units per 25 days), PA ABSTRAL SUB 300MCG 3 QL (120 Units per 25 days), PA ABSTRAL SUB 400MCG 3 QL (120 Units per 25 days), PA ABSTRAL SUB 600MCG 3 QL (120 Units per 25 days), PA ABSTRAL SUB 800MCG 3 QL (120 Units per 25 days), PA astramorph inj 1/2ml 2 astramorph inj 2/2ml 2 CODEINE SULF SOL 30MG/5ML 3 codeine sulfate tab 15 2 QL (42 tabs / 25 days) codeine sulfate tab 30 2 QL (42 tabs / 25 days) codeine sulfate tab 60 2 QL (42 tabs / 25 days) EMBEDA CAP MG 4 QL (60 caps / 25 days) EMBEDA CAP MG 4 QL (60 caps / 25 days) EMBEDA CAP 50-2MG 4 QL (60 caps / 25 days) EMBEDA CAP MG 4 QL (30 caps / 25 days) EMBEDA CAP MG 4 QL (30 caps / 25 days) EMBEDA CAP 100-4MG 4 QL (30 caps / 25 days) fentanyl citrate lozenge on a handle 200 mcg 2 QL (120 lozenges / 25 days), PA fentanyl citrate lozenge on a handle 400 mcg 2 QL (120 lozenges / 25 days), PA fentanyl citrate lozenge on a handle 600 mcg 2 QL (120 lozenges / 25 days), PA fentanyl citrate lozenge on a handle 800 mcg 2 QL (120 lozenges / 25 days), PA fentanyl citrate lozenge on a handle 1200 mcg 2 QL (120 lozenges / 25 days), PA fentanyl citrate lozenge on a handle 1600 mcg 2 QL (120 lozenges / 25 days), PA 7

11 fentanyl td patch 72hr 12 mcg/hr 2 QL (10 patches / 25 days) fentanyl td patch 72hr 25 mcg/hr 2 QL (10 patches / 25 days) fentanyl td patch 72hr 50 mcg/hr 2 QL (10 patches / 25 days) fentanyl td patch 72hr 75 mcg/hr 2 QL (10 patches / 25 days) fentanyl td patch 72hr 100 mcg/hr 2 QL (10 patches / 25 days) HYDROMORPHON SUP 3MG 4 QL (120 units / 25 days) hydromorphone hcl inj 1 /ml 2 hydromorphone hcl inj 2 /ml 2 hydromorphone hcl inj 4 /ml 2 hydromorphone hcl liqd 1 /ml 2 QL (600 ml / 25 days) hydromorphone hcl preservative free (pf) 2 inj 10 /ml hydromorphone hcl tab 2 2 QL (180 tabs / 25 days) hydromorphone hcl tab 4 2 QL (180 tabs / 25 days) hydromorphone hcl tab 8 2 QL (180 tabs / 25 days) hydromorphone hcl tab er 24hr deter 8 2 QL (30 tablets per 25 days) hydromorphone hcl tab er 24hr deter 12 2 QL (30 tablets per 25 days) hydromorphone hcl tab er 24hr deter 16 2 QL (30 tablets per 25 days) hydromorphone hcl tab er 24hr deter 32 2 QL (30 tablets per 25 days) levorphanol tartrate tab 2 2 QL (120 tabs / 25 days) meperidine hcl inj 10 /ml 2 meperidine hcl inj 25 /ml 2 meperidine hcl inj 50 /ml 2 meperidine hcl inj 100 /ml 2 meperidine hcl oral soln 50 /5ml 2 QL (90 ml / 25 days) meperidine hcl tab 50 2 QL (18 tabs / 25 days) meperidine hcl tab QL (18 tabs / 25 days) methadone hcl conc 10 /ml 2 QL (30mL / 25 days) methadone hcl soln 5 /5ml 2 QL (600 ml / 25 days) methadone hcl soln 10 /5ml 2 QL (300 ml / 25 days) methadone hcl tab 5 2 QL (120 tabs / 25 days) methadone hcl tab 10 2 QL (60 tabs / 25 days) methadone hcl tab for oral susp 40 2 QL (9 tabs / 25 days) METHADONE INJ 10MG/ML 4 methadose tab 40 2 QL (9 tabs / 25 days) MORPHINE SUL INJ 2MG/ML 4 MORPHINE SUL INJ 4MG/ML 4 MORPHINE SUL INJ 5MG/ML 4 8

12 MORPHINE SUL INJ 8MG/ML 4 MORPHINE SUL INJ 150/30ML 4 MORPHINE SUL SUP 30MG 3 QL (180 supp / 25 days) morphine sulfate beads cap sr 24hr 30 2 QL (60 caps / 25 days) morphine sulfate beads cap sr 24hr 45 2 QL (60 caps / 25 days) morphine sulfate beads cap sr 24hr 60 2 QL (60 caps / 25 days) morphine sulfate beads cap sr 24hr 75 2 QL (30 caps / 25 days) morphine sulfate beads cap sr 24hr 90 2 QL (30 caps / 25 days) morphine sulfate beads cap sr 24hr QL (30 caps / 25 days) morphine sulfate cap sr 24hr 10 2 QL (60 caps / 25 days) morphine sulfate cap sr 24hr 20 2 QL (60 caps / 25 days) morphine sulfate cap sr 24hr 30 2 QL (60 caps / 25 days) morphine sulfate cap sr 24hr 50 2 QL (60 caps / 25 days) morphine sulfate cap sr 24hr 60 2 QL (60 caps / 25 days) morphine sulfate cap sr 24hr 80 2 QL (60 caps / 25 days) morphine sulfate cap sr 24hr QL (60 caps / 25 days) morphine sulfate inj 8 /ml 2 morphine sulfate inj 10 /ml 2 morphine sulfate inj 15 /ml 2 morphine sulfate inj pf 1 /ml 2 morphine sulfate iv soln 1 /ml 2 morphine sulfate iv soln 25 /ml 2 morphine sulfate iv soln 50 /ml 2 morphine sulfate iv soln pf 4 /ml 2 morphine sulfate iv soln pf 8 /ml 2 morphine sulfate iv soln pf 10 /ml 2 morphine sulfate iv soln pf 15 /ml 2 morphine sulfate oral soln 10 /5ml 2 QL (900 ml / 25 days) morphine sulfate oral soln 20 /5ml 2 QL (900 ml / 25 days) morphine sulfate oral soln 100 /5ml (20 2 QL (180 ml / 25 days) /ml) morphine sulfate suppos 5 2 QL (180 supp / 25 days) morphine sulfate suppos 10 2 QL (180 supp / 25 days) morphine sulfate suppos 20 2 QL (180 supp / 25 days) morphine sulfate tab 15 2 QL (180 tabs / 25 days) morphine sulfate tab 30 2 QL (180 tabs / 25 days) morphine sulfate tab cr 15 2 QL (120 tabs / 25 days) morphine sulfate tab cr 30 2 QL (120 tabs / 25 days) morphine sulfate tab cr 60 2 QL (120 tabs / 25 days) morphine sulfate tab cr QL (60 tabs / 25 days) morphine sulfate tab cr QL (60 tabs / 25 days) NUCYNTA ER TAB 50MG 3 QL (120 tabs / 25 days) NUCYNTA ER TAB 100MG 3 QL (120 tabs / 25 days) NUCYNTA ER TAB 150MG 3 QL (60 tabs / 25 days) NUCYNTA ER TAB 200MG 3 QL (60 tabs / 25 days) 9

13 NUCYNTA ER TAB 250MG 3 QL (60 tabs / 25 days) NUCYNTA TAB 50MG 3 QL (360 tabs / 25 days) NUCYNTA TAB 75MG 3 QL (240 tabs / 25 days) NUCYNTA TAB 100MG 3 QL (180 tabs / 25 days) oxycodone hcl cap 5 2 QL (180 caps / 25 days) oxycodone hcl conc 100 /5ml (20 2 QL (180 ml / 25 days) /ml) oxycodone hcl soln 5 /5ml 2 QL (900 ml / 25 days) oxycodone hcl tab 5 2 QL (180 tabs / 25 days) oxycodone hcl tab 10 2 QL (180 tabs / 25 days) oxycodone hcl tab 15 2 QL (180 tabs / 25 days) oxycodone hcl tab 20 2 QL (180 tabs / 25 days) oxycodone hcl tab 30 2 QL (180 tabs / 25 days) oxycodone hcl tab er 12hr deter 10 2 QL (120 tabs / 25 days) oxycodone hcl tab er 12hr deter 20 2 QL (120 tabs / 25 days) oxycodone hcl tab er 12hr deter 40 2 QL (120 tabs / 25 days) oxycodone hcl tab er 12hr deter 80 2 QL (60 tabs / 25 days) OXYCONTIN TAB 10MG ER 3 QL (120 tabs / 25 days) OXYCONTIN TAB 15MG CR 3 QL (120 tabs / 25 days) OXYCONTIN TAB 20MG ER 3 QL (120 tabs / 25 days) OXYCONTIN TAB 30MG CR 3 QL (120 tabs / 25 days) OXYCONTIN TAB 40MG ER 3 QL (120 tabs / 25 days) OXYCONTIN TAB 60MG ER 3 QL (60 tabs / 25 days) OXYCONTIN TAB 80MG ER 3 QL (60 tabs / 25 days) oxymorphone hcl tab 5 2 QL (180 tabs / 25 days) oxymorphone hcl tab 10 2 QL (180 tabs / 25 days) oxymorphone hcl tab sr 12hr 5 2 QL (120 tabs / 25 days) oxymorphone hcl tab sr 12hr QL (120 tabs / 25 days) oxymorphone hcl tab sr 12hr 10 2 QL (120 tabs / 25 days) oxymorphone hcl tab sr 12hr 15 2 QL (120 tabs / 25 days) oxymorphone hcl tab sr 12hr 20 2 QL (120 tabs / 25 days) oxymorphone hcl tab sr 12hr 30 2 QL (60 tabs / 25 days) oxymorphone hcl tab sr 12hr 40 2 QL (60 tabs / 25 days) tramadol hcl tab 50 2 QL (240 tabs / 25 days) tramadol hcl tab sr 24hr QL (90 tabs / 25 days) tramadol hcl tab sr 24hr QL (30 tabs / 25 days) tramadol hcl tab sr 24hr QL (30 tabs / 25 days) Opioid Combinations acetaminophen w/ codeine soln /5ml 2 QL (5000 ml / 25 days) acetaminophen w/ codeine tab QL (400 tabs / 25 days) acetaminophen w/ codeine tab QL (400 tabs / 25 days) acetaminophen w/ codeine tab QL (400 tabs / 25 days) CAPITAL/COD SUS /5 4 QL (5000 ml / 25 days) endocet tab QL (375 tabs / 25 days) endocet tab QL (375 tabs / 25 days) 10

14 endocet tab QL (375 tabs / 25 days) hydrocodone-acetaminophen soln QL (5540 ml / 25 days) /15ml hydrocodone-acetaminophen tab QL (375 tabs / 25 days) hydrocodone-acetaminophen tab QL (400 tabs / 25 days) hydrocodone-acetaminophen tab QL (375 tabs / 25 days) hydrocodone-acetaminophen tab QL (400 tabs / 25 days) hydrocodone-acetaminophen tab QL (375 tabs / 25 days) hydrocodone-acetaminophen tab QL (400 tabs / 25 days) hydrocodone-acetaminophen tab QL (375 tabs / 25 days) oxycodone w/ acetaminophen tab QL (375 tabs / 25 days) oxycodone w/ acetaminophen tab QL (375 tabs / 25 days) oxycodone w/ acetaminophen tab QL (375 tabs / 25 days) oxycodone w/ acetaminophen tab QL (375 tabs / 25 days) oxycodone-aspirin tab QL (375 tabs / 25 days) oxycodone-ibuprofen tab QL (28 tabs / 25 days) PRIMLEV TAB 5-300MG 4 QL (400 tabs / 25 days) PRIMLEV TAB QL (400 tabs / 25 days) PRIMLEV TAB MG 4 QL (400 tabs / 25 days) ROXICET SOL 5-325/5 4 QL (1850 ml / 25 days) roxicet tab QL (375 tabs / 25 days) vicodin es tab QL (400 tabs / 25 days) vicodin hp tab QL (400 tabs / 25 days) vicodin tab QL (400 tabs / 25 days) zamicet sol QL (5540 ml / 25 days) Opioid Partial Agonists buprenorphine hcl inj 0.3 /ml (base equiv) 2 buprenorphine hcl sl tab 2 (base equiv) 2 QL (120 tablets per 25 days), PA buprenorphine hcl sl tab 8 (base equiv) 2 QL (120 tablets per 25 days), PA buprenorphine hcl-naloxone hcl sl tab (base equiv) 2 QL (120 tablets per 25 days), PA buprenorphine hcl-naloxone hcl sl tab 8-2 (base equiv) 2 QL (120 tablets per 25 days), PA butorphanol tartrate inj 1 /ml 2 butorphanol tartrate inj 2 /ml 2 11

15 butorphanol tartrate nasal soln 10 /ml 2 QL (2 bottles / 25 days) BUTRANS DIS 5MCG/HR 4 QL (8 patches/25 days), PA BUTRANS DIS 7.5/HR 4 QL (8 patches/25 days), PA BUTRANS DIS 10MCG/HR 4 QL (8 patches/25 days), PA BUTRANS DIS 15MCG/HR 4 QL (4 patches/25 days), PA BUTRANS DIS 20MCG/HR 4 QL (4 patches/25 days), PA nalbuphine hcl inj 10 /ml 2 nalbuphine hcl inj 20 /ml 2 SUBOXONE MIS 2-0.5MG 3 QL (120 units per 25 days), PA SUBOXONE MIS 4-1MG 3 QL (120 units per 25 days), PA SUBOXONE MIS 8-2MG 3 QL (120 units per 25 days), PA SUBOXONE MIS 12-3MG 3 QL (60 films per 25 days), PA ANDROGENS-ANABOLIC Anabolic Steroids ANADROL-50 TAB 50MG 4 PA oxandrolone tab PA oxandrolone tab 10 2 PA Androgens ANDROXY TAB 10MG 4 PA danazol cap 50 2 danazol cap danazol cap methyltestosterone cap 10 2 PA testosterone cypionate im inj in oil PA /ml testosterone cypionate im inj in oil PA /ml testosterone enanthate im inj in oil PA /ml testosterone td gel 10/act (2%) 2 PA testosterone td gel 25 /2.5gm (1%) 2 PA ANORECTAL AGENTS Intrarectal Steroids colocort ene Rectal Steroids procto-pak cre 1% 2 proctosol hc cre 2.5% 2 12

16 proctozone cre -hc 2.5% 2 Vasodilating Agents RECTIV OIN 0.4% 4 ANTHELMINTICS Anthelmintics ALBENZA TAB 200MG 3 BILTRICIDE TAB 600MG 4 ivermectin tab 3 2 ANTI-INFECTIVE AGENTS - MISC. Anti-infective Agents - Misc. AZACTAM/DEX INJ 1GM 4 AZACTAM/DEX INJ 2GM 4 aztreonam for inj 1 gm 2 aztreonam for inj 2 gm 2 CAYSTON INH 75MG 5 PA FLAGYL ER TAB 750MG 4 metronidazole cap metronidazole in nacl 0.79% iv soln /100ml metronidazole tab metronidazole tab NEBUPENT INH 300MG 4 PENTAM 300 INJ 300MG 4 PRIMSOL SOL 50MG/5ML 3 tinidazole tab tinidazole tab trimethoprim tab vancomycin hcl cap ST; PA** vancomycin hcl cap ST; PA** vancomycin hcl for inj 10 gm 2 vancomycin hcl for inj vancomycin hcl for inj vancomycin hcl for inj VIBATIV INJ 250MG 4 VIBATIV INJ 750MG 4 XIFAXAN TAB 200MG 3 XIFAXAN TAB 550MG 3 PA Anti-infective Misc. - Combinations e.s.p. sus sulfamethoxazole-trimethoprim iv soln /5ml sulfamethoxazole-trimethoprim susp /5ml 2 sulfamethoxazole-trimethoprim tab

17 sulfamethoxazole-trimethoprim tab Antiprotozoal Agents ALINIA SUS 100/5ML 3 ALINIA TAB 500MG 3 atovaquone susp 750 /5ml 2 Carbapenems DORIBAX INJ 250MG 4 DORIBAX INJ 500MG 4 imipenem-cilastatin intravenous for soln imipenem-cilastatin intravenous for soln INVANZ INJ 1GM 4 meropenem iv for soln 1 gm 2 meropenem iv for soln Chloramphenicols chloramphenicol sodium succinate for iv inj 2 1 gm Cyclic Lipopeptides CUBICIN SOL 500MG 4 Glycylcyclines TYGACIL INJ 50MG 4 Ketolides KETEK TAB 300MG 4 KETEK TAB 400MG 4 Leprostatics dapsone tab 25 2 dapsone tab Lincosamides clindamycin hcl cap 75 2 clindamycin hcl cap clindamycin hcl cap clindamycin palmitate hcl for soln 75 2 /5ml (base equiv) clindamycin phosphate inj 9 gm/60ml 2 clindamycin phosphate inj 300 /2ml 2 clindamycin phosphate inj 600 /4ml 2 clindamycin phosphate inj 900 /6ml 2 clindamycin phosphate iv soln 300 /2ml 2 clindamycin phosphate iv soln 600 /4ml 2 clindamycin phosphate iv soln 900 /6ml 2 LINCOCIN INJ 300MG/ML 4 Oxazolidinones linezolid for susp 100 /5ml 2 14

18 linezolid iv soln 2 /ml 2 linezolid tab ZYVOX SUS 100MG/5M 3 Polymyxins polymyxin b sulfate for inj unit 2 ANTIANGINAL AGENTS Antianginals-Other RANEXA TAB 500MG 3 ST; PA** RANEXA TAB 1000MG 3 ST; PA** Nitrates DILATRATE SR CAP 40MG 4 isoditrate tab 40 er 2 ISORDIL TAB 40MG 3 isosorbide dinitrate sl tab isosorbide dinitrate tab 5 2 isosorbide dinitrate tab 10 2 isosorbide dinitrate tab 20 2 isosorbide dinitrate tab 30 2 isosorbide dinitrate tab cr 40 2 isosorbide mononitrate tab 10 2 isosorbide mononitrate tab 20 2 isosorbide mononitrate tab sr 24hr 30 2 isosorbide mononitrate tab sr 24hr 60 2 isosorbide mononitrate tab sr 24hr minitran dis 0.1/hr 2 minitran dis 0.2/hr 2 minitran dis 0.4/hr 2 minitran dis 0.6/hr 2 NITRO-BID OIN 2% 4 NITRO-DUR DIS 0.3MG/HR 3 NITRO-DUR DIS 0.8MG/HR 3 NITROGLYCER INJ 5MG/ML 4 nitroglycerin cap cr nitroglycerin cap cr nitroglycerin cap cr 9 2 nitroglycerin iv soln 100 mcg/ml in d5w 2 nitroglycerin iv soln 200 mcg/ml in d5w 2 nitroglycerin iv soln 400 mcg/ml in d5w 2 nitroglycerin lingual aerosol 400 mcg/spray 2 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 nitroglycerin tl soln 0.4 /spray (400 2 mcg/spray) 15

19 NITROSTAT SUB 0.3MG 3 NITROSTAT SUB 0.4MG 3 NITROSTAT SUB 0.6MG 3 ANTIANXIETY AGENTS Antianxiety Agents - Misc. buspirone hcl tab 5 2 buspirone hcl tab buspirone hcl tab 10 2 buspirone hcl tab 15 2 buspirone hcl tab 30 2 hydroxyzine hcl im soln 25 /ml 2 PA; High Risk hydroxyzine hcl im soln 50 /ml 2 PA; High Risk hydroxyzine hcl syrup 10 /5ml 2 PA; High Risk hydroxyzine hcl tab 10 2 PA; High Risk hydroxyzine hcl tab 25 2 PA; High Risk hydroxyzine hcl tab 50 2 PA; High Risk hydroxyzine pamoate cap 25 2 PA; High Risk hydroxyzine pamoate cap 50 2 PA; High Risk hydroxyzine pamoate cap PA; High Risk meprobamate tab meprobamate tab

20 Benzodiazepines ALPRAZOLAM CON 1 MG/ML 3 QL (120 ml / 25 days) alprazolam orally disintegrating tab QL (90 tabs / 25 days) alprazolam orally disintegrating tab QL (90 tabs / 25 days) alprazolam orally disintegrating tab 1 2 QL (90 tabs / 25 days) alprazolam orally disintegrating tab 2 2 QL (60 tabs / 25 days) alprazolam tab QL (90 tabs / 25 days) alprazolam tab QL (90 tabs / 25 days) alprazolam tab 1 2 QL (90 tabs / 25 days) alprazolam tab 2 2 QL (60 tabs / 25 days) clorazepate dipotassium tab QL (120 tabs / 25 days) clorazepate dipotassium tab QL (120 tabs / 25 days) clorazepate dipotassium tab 15 2 QL (120 tabs / 25 days) diazepam con 5/ml 2 QL (240 ml / 25 days) diazepam soln 1 /ml 2 QL (1200 ml / 25 days) diazepam tab 2 2 QL (120 tabs / 25 days) diazepam tab 5 2 QL (120 tabs / 25 days) diazepam tab 10 2 QL (120 tabs / 25 days) lorazepam conc 2 /ml 2 QL (150 ml / 25 days) lorazepam tab QL (150 tabs / 25 days) lorazepam tab 1 2 QL (150 tabs / 25 days) lorazepam tab 2 2 QL (150 tabs / 25 days) oxazepam cap 10 2 QL (120 caps / 25 days) oxazepam cap 15 2 QL (120 caps / 25 days) oxazepam cap 30 2 QL (120 caps / 25 days) ANTIARRHYTHMICS Antiarrhythmics Type I-A disopyramide phosphate cap disopyramide phosphate cap NORPACE CAP 100MG CR 3 NORPACE CAP 150MG CR 3 procainamide hcl inj 100 /ml 2 PROCAINAMIDE INJ 500MG/ML 4 Antiarrhythmics Type I-B lidocaine hcl iv inj 10 /ml 2 lidocaine hcl iv inj 20 /ml 2 lidocaine iv infusion in d5w inj 4 /ml 2 lidocaine iv infusion in d5w inj 8 /ml 2 mexiletine hcl cap mexiletine hcl cap mexiletine hcl cap Antiarrhythmics Type I-C flecainide acetate tab 50 2 flecainide acetate tab

21 flecainide acetate tab propafenone hcl cap sr 12hr propafenone hcl cap sr 12hr propafenone hcl cap sr 12hr propafenone hcl tab propafenone hcl tab propafenone hcl tab Antiarrhythmics Type III amiodarone hcl inj 150 /3ml (50 2 /ml) amiodarone hcl inj 450 /9ml (50 2 /ml) amiodarone hcl inj 900 /18ml (50 2 /ml) amiodarone hcl tab amiodarone hcl tab MULTAQ TAB 400MG 4 PA NEXTERONE INJ 4 pacerone tab pacerone tab TIKOSYN CAP 125MCG 5 PA TIKOSYN CAP 250MCG 5 PA TIKOSYN CAP 500MCG 5 PA ANTIASTHMATIC AND BRONCHODILATOR AGENTS Anti-Inflammatory Agents cromolyn sodium soln nebu 20 /2ml 2 QL (2 boxes / 25 days) Bronchodilators - Anticholinergics ipratropium bromide inhal soln 0.02% 2 QL (5 boxes / 25 days) SPIRIVA AER RESPIMAT 3 SPIRIVA CAP HANDIHLR 3 SPIRIVA SPR RESPIMAT 3 Leukotriene Modulators montelukast sodium chew tab 4 (base 2 equiv) montelukast sodium chew tab 5 (base 2 equiv) montelukast sodium oral granules packet 4 2 (base equiv) montelukast sodium tab 10 (base 2 equiv) zafirlukast tab 10 2 zafirlukast tab 20 2 ZYFLO CR TAB 600MG 4 Selective Phosphodiesterase 4 (PDE4) Inhibitors DALIRESP TAB 500MCG 4 PA Steroid Inhalants 18

22 ASMANEX 30 AER 110MCG 3 QL (2 inhalers / 25 days) ASMANEX 60 AER 220MCG 3 QL (2 inhalers per 25 days) ASMANEX 120 AER 220MCG 3 QL (1 inhaler per 25 days) ASMANEX HFA AER 100 MCG 3 QL (1 inhaler per 25 days) ASMANEX HFA AER 200 MCG 3 QL (1 inhaler per 25 days) budesonide inhalation susp 0.5 /2ml 2 QL (2 boxes / 25 days) budesonide inhalation susp 0.25 /2ml 2 QL (3 boxes / 25 days) budesonide inhalation susp 1 /2ml 2 QL (1 box / 25 days) QVAR AER 40MCG 3 QVAR AER 80MCG 3 Sympathomimetics ADVAIR DISKU AER 100/50 3 ADVAIR DISKU AER 250/50 3 ADVAIR DISKU AER 500/50 3 ADVAIR HFA AER 45/21 3 ADVAIR HFA AER 115/21 3 ADVAIR HFA AER 230/21 3 albuterol sulfate soln nebu 0.5% (5 /ml)2 QL (3 boxes / 25 days) albuterol sulfate soln nebu 0.5% (5 /ml)2 QL (4 boxes / 25 days) albuterol sulfate soln nebu 0.63 /3ml 2 QL (5 boxes / 25 days) (base equiv) albuterol sulfate soln nebu 0.083% (2.5 2 QL (5 boxes / 25 days) /3ml) albuterol sulfate soln nebu 1.25 /3ml 2 QL (5 boxes / 25 days) (base equiv) albuterol sulfate syrup 2 /5ml 2 albuterol sulfate tab 2 2 albuterol sulfate tab 4 2 albuterol sulfate tab sr 12hr 4 2 albuterol sulfate tab sr 12hr 8 2 ARCAPTA CAP 75MCG 4 QL (30 caps / 25 days) BREO ELLIPTA INH QL (1 package / 25 days), PA BREO ELLIPTA INH QL (1 package / 25 days), PA BROVANA NEB 15MCG 4 QL (2 boxes / 25 days) COMBIVENT AER RESPIMAT 3 QL (2 inhalers / 25 days) epinephrine hcl inj 1 /ml 2 epinephrine hcl soln prefilled syringe /ml FORADIL CAP AEROLIZE 3 QL (60 caps / 25 days) 19

23 ipratropium-albuterol nebu soln (3) 2 QL (6 boxes / 25 days) /3ml levalbuterol hcl soln nebu 0.31 /3ml 2 QL (300 ml / 25 days) (base equiv) levalbuterol hcl soln nebu 0.63 /3ml 2 QL (300 ml / 25 days) (base equiv) levalbuterol hcl soln nebu 1.25 /3ml 2 QL (300 ml / 25 days) (base equiv) levalbuterol hcl soln nebu conc QL (90 ml / 25 days) /0.5ml (base equiv) metaproterenol sulfate syrup 10 /5ml 2 metaproterenol sulfate tab 10 2 metaproterenol sulfate tab 20 2 PERFOROMIST NEB 20MCG 3 QL (2 boxes / 25 days) PROAIR HFA AER 3 QL (2 inhalers / 25 days) PROVENTIL AER HFA 3 QL (2 inhalers / 25 days) SEREVENT DIS AER 50MCG 4 QL (1 inhaler / 25 days) terbutaline sulfate inj 1 /ml 2 terbutaline sulfate tab terbutaline sulfate tab 5 2 VENTOLIN HFA AER 3 QL (2 inhalers / 25 days) XOPENEX HFA AER 4 QL (2 inhalers per 25 days), ST; PA** Xanthines aminophylline inj 25 /ml 2 ELIXOPHYLLIN ELX 80/15ML 4 LUFYLLIN TAB 200MG 4 LUFYLLIN TAB 400MG 4 THEO-24 CAP 100MG CR 4 THEO-24 CAP 200MG CR 4 THEO-24 CAP 300MG CR 4 THEO-24 CAP 400MG ER 4 theochron tab 100 cr 2 theochron tab 200 er 2 theochron tab 300 cr 2 theophylline soln 80 /15ml 2 theophylline tab sr 12hr theophylline tab sr 24hr theophylline tab sr 24hr ANTICOAGULANTS Coumarin Anticoagulants COUMADIN INJ 5 MG 4 jantoven tab 1 2 jantoven tab

24 jantoven tab 2 2 jantoven tab 3 2 jantoven tab 4 2 jantoven tab 5 2 jantoven tab 6 2 jantoven tab jantoven tab 10 2 warfarin sodium tab 1 2 warfarin sodium tab 2 2 warfarin sodium tab warfarin sodium tab 3 2 warfarin sodium tab 4 2 warfarin sodium tab 5 2 warfarin sodium tab 6 2 warfarin sodium tab warfarin sodium tab 10 2 Direct Factor Xa Inhibitors ELIQUIS TAB 2.5MG 3 ELIQUIS TAB 5MG 3 XARELTO STAR TAB 15/20MG 3 XARELTO TAB 10MG 3 XARELTO TAB 15MG 3 XARELTO TAB 20MG 3 Heparins And Heparinoid-Like Agents enoxaparin sodium inj 30 /0.3ml 2 enoxaparin sodium inj 40 /0.4ml 2 enoxaparin sodium inj 60 /0.6ml 2 enoxaparin sodium inj 80 /0.8ml 2 enoxaparin sodium inj 100 /ml 2 enoxaparin sodium inj 120 /0.8ml 2 enoxaparin sodium inj 150 /ml 2 enoxaparin sodium inj 300 /3ml 2 fondaparinux sodium subcutaneous inj /0.5ml fondaparinux sodium subcutaneous inj 5 2 /0.4ml fondaparinux sodium subcutaneous inj /0.6ml fondaparinux sodium subcutaneous inj 10 2 /0.8ml FRAGMIN INJ 2500/0.2 4 FRAGMIN INJ 5000/0.2 4 FRAGMIN INJ 7500/0.3 4 FRAGMIN INJ 10000/ML 4 FRAGMIN INJ 12500UNT 4 FRAGMIN INJ 15000UNT 4 21

25 FRAGMIN INJ 18000UNT 4 FRAGMIN INJ 25000/ML 4 FRAGMIN INJ 95000UNT 4 heparin sodium (porcine) inj 1000 unit/ml 2 heparin sodium (porcine) inj 5000 unit/ml 2 heparin sodium (porcine) inj unit/ml 2 heparin sodium (porcine) inj unit/ml 2 heparin sodium (porcine) pf inj unit/0.5ml Thrombin Inhibitors ARGATROBAN INJ 125/125 4 argatroban inj 250 /2.5ml (concentrate 2 for iv infusion) ARGATROBAN INJ 250/250 4 ANTICONVULSANTS Anticonvulsants - Benzodiazepines clonazepam tab clonazepam tab 1 2 clonazepam tab 2 2 ONFI SUS 2.5MG/ML 4 PA ONFI TAB 5MG 4 PA ONFI TAB 10MG 4 PA ONFI TAB 20MG 4 PA Anticonvulsants - Misc. BANZEL SUS 40MG/ML 4 PA BANZEL TAB 200MG 4 PA BANZEL TAB 400MG 4 PA carbamazepine cap sr 12hr carbamazepine cap sr 12hr carbamazepine cap sr 12hr carbamazepine chew tab carbamazepine susp 100 /5ml 2 carbamazepine tab carbamazepine tab sr 12hr carbamazepine tab sr 12hr epitol tab gabapentin cap gabapentin cap gabapentin cap gabapentin oral soln 250 /5ml 2 gabapentin tab gabapentin tab LAMICTAL CHW 2MG 3 LAMICTAL KIT START 35 4 LAMICTAL KIT START 49 4 LAMICTAL KIT START

26 LAMICTAL ODT KIT 4 LAMICTAL XR KIT 4 lamotrigine orally disintegrating tab 25 2 lamotrigine orally disintegrating tab 50 2 lamotrigine orally disintegrating tab lamotrigine orally disintegrating tab lamotrigine tab 25 2 lamotrigine tab lamotrigine tab lamotrigine tab lamotrigine tab chewable dispersible 5 2 lamotrigine tab chewable dispersible 25 2 lamotrigine tab disp 25 (14) & 50 (14) 2 & 100 (7) kit lamotrigine tab disp 25 (21) & 50 2 (7) titration kit lamotrigine tab disp 50 (42) & (14) titration kit lamotrigine tab sr 24hr 25 2 lamotrigine tab sr 24hr 50 2 lamotrigine tab sr 24hr lamotrigine tab sr 24hr lamotrigine tab sr 24hr lamotrigine tab sr 24hr LEVETIRACETA INJ 5MG/ML 4 LEVETIRACETA INJ 10MG/ML 4 LEVETIRACETA INJ 15MG/ML 4 levetiracetam inj 500 /5ml (100 /ml) 2 levetiracetam oral soln 100 /ml 2 levetiracetam tab levetiracetam tab levetiracetam tab levetiracetam tab levetiracetam tab sr 24hr levetiracetam tab sr 24hr LYRICA CAP 25MG 4 ST; PA** LYRICA CAP 50MG 4 ST; PA** LYRICA CAP 75MG 4 ST; PA** LYRICA CAP 100MG 4 ST; PA** LYRICA CAP 150MG 4 ST; PA** LYRICA CAP 200MG 4 ST; PA** LYRICA CAP 225MG 4 ST; PA** LYRICA CAP 300MG 4 ST; PA** LYRICA SOL 20MG/ML 4 ST; PA** 23

27 oxcarbazepine susp 300 /5ml (60 2 /ml) oxcarbazepine tab oxcarbazepine tab oxcarbazepine tab POTIGA TAB 50MG 4 PA POTIGA TAB 200MG 4 PA POTIGA TAB 300MG 4 PA POTIGA TAB 400MG 4 PA primidone tab 50 2 primidone tab TEGRETOL-XR TAB 100MG 3 topiragen tab 25 2 topiragen tab 50 2 topiragen tab topiragen tab topiramate sprinkle cap 15 2 topiramate sprinkle cap 25 2 topiramate tab 25 2 topiramate tab 50 2 topiramate tab topiramate tab VIMPAT INJ 200MG/20 4 PA VIMPAT SOL 10MG/ML 4 PA VIMPAT TAB 50MG 4 PA VIMPAT TAB 100MG 4 PA VIMPAT TAB 150MG 4 PA VIMPAT TAB 200MG 4 PA zonisamide cap 25 2 zonisamide cap 50 2 zonisamide cap Carbamates felbamate susp 600 /5ml 2 felbamate tab felbamate tab GABA Modulators GABITRIL TAB 12MG 3 GABITRIL TAB 16MG 3 SABRIL POW 500MG 5 PA SABRIL TAB 500MG 5 PA tiagabine hcl tab 2 2 tiagabine hcl tab 4 2 Hydantoins DILANTIN CAP 30MG 4 fosphenytoin sodium inj 100 /2ml (phenytoin equiv) 2 24

28 fosphenytoin sodium inj 500 /10ml 2 (phenytoin equiv) PEGANONE TAB 250MG 4 PHENYTEK CAP 200MG 2 PHENYTEK CAP 300MG 2 phenytoin chew tab 50 2 phenytoin sodium extended cap phenytoin sodium extended cap phenytoin sodium extended cap phenytoin sodium inj 50 /ml 2 phenytoin susp 125 /5ml 2 Succinimides CELONTIN CAP 300MG 4 ethosuximide cap ethosuximide soln 250 /5ml 2 Valproic Acid divalproex sodium cap sprinkle divalproex sodium tab delayed release divalproex sodium tab delayed release divalproex sodium tab delayed release divalproex sodium tab sr 24 hr divalproex sodium tab sr 24 hr STAVZOR CAP 125MG 4 STAVZOR CAP 250MG 4 STAVZOR CAP 500MG 4 valproate sodium inj 100 /ml 2 valproate sodium syrup 250 /5ml (base 2 equiv) valproic acid cap ANTIDEPRESSANTS Alpha-2 Receptor Antagonists (Tetracyclics) mirtazapine orally disintegrating tab 15 2 mirtazapine orally disintegrating tab 30 2 mirtazapine orally disintegrating tab 45 2 mirtazapine tab mirtazapine tab 15 2 mirtazapine tab 30 2 mirtazapine tab 45 2 Antidepressants - Misc. APLENZIN TAB 174MG 4 APLENZIN TAB 348MG 4 APLENZIN TAB 522MG 4 bupropion hcl tab

29 bupropion hcl tab bupropion hcl tab sr 12hr bupropion hcl tab sr 12hr bupropion hcl tab sr 12hr bupropion hcl tab sr 24hr bupropion hcl tab sr 24hr maprotiline hcl tab 25 2 maprotiline hcl tab 50 2 maprotiline hcl tab 75 2 Monoamine Oxidase Inhibitors (MAOIs) EMSAM DIS 6MG/24HR 4 EMSAM DIS 9MG/24HR 4 EMSAM DIS 12MG/24H 4 MARPLAN TAB 10MG 4 phenelzine sulfate tab 15 2 tranylcypromine sulfate tab 10 2 Selective Serotonin Reuptake Inhibitors (SSRIs) citalopram hydrobromide oral soln 10 2 /5ml citalopram hydrobromide tab 10 (base 2 equiv) citalopram hydrobromide tab 20 (base 2 equiv) citalopram hydrobromide tab 40 (base 2 equiv) escitalopram oxalate soln 5 /5ml (base 2 equiv) escitalopram oxalate tab 5 (base 2 equiv) escitalopram oxalate tab 10 (base 2 equiv) escitalopram oxalate tab 20 (base 2 equiv) fluoxetine hcl cap 10 2 fluoxetine hcl cap 20 2 fluoxetine hcl cap 40 2 fluoxetine hcl cap delayed release 90 2 fluoxetine hcl solution 20 /5ml 2 fluoxetine hcl tab 10 2 fluoxetine hcl tab 20 2 FLUOXETINE TAB 60MG 4 fluvoxamine maleate cap sr 24hr fluvoxamine maleate cap sr 24hr fluvoxamine maleate tab 25 2 fluvoxamine maleate tab 50 2 fluvoxamine maleate tab

30 paroxetine hcl tab 10 2 paroxetine hcl tab 20 2 paroxetine hcl tab 30 2 paroxetine hcl tab 40 2 paroxetine hcl tab sr 24hr paroxetine hcl tab sr 24hr 25 2 paroxetine hcl tab sr 24hr sertraline hcl oral conc 20 /ml 2 sertraline hcl tab 25 2 sertraline hcl tab 50 2 sertraline hcl tab Serotonin Modulators nefazodone hcl tab 50 2 nefazodone hcl tab nefazodone hcl tab nefazodone hcl tab nefazodone hcl tab trazodone hcl tab 50 2 trazodone hcl tab trazodone hcl tab trazodone hcl tab VIIBRYD KIT 4 ST; PA** VIIBRYD KIT STARTER 4 ST; PA** VIIBRYD TAB 10MG 4 ST; PA** VIIBRYD TAB 20MG 4 ST; PA** VIIBRYD TAB 40MG 4 ST; PA** Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs) duloxetine hcl cap 20 2 duloxetine hcl cap 30 2 duloxetine hcl cap 60 2 venlafaxine hcl cap sr 24hr 37.5 (base 2 equivalent) venlafaxine hcl cap sr 24hr 75 (base 2 equivalent) venlafaxine hcl cap sr 24hr 150 (base 2 equivalent) venlafaxine hcl tab 25 2 venlafaxine hcl tab venlafaxine hcl tab 50 2 venlafaxine hcl tab 75 2 venlafaxine hcl tab venlafaxine hcl tab sr 24hr 37.5 (base 2 equivalent) venlafaxine hcl tab sr 24hr 75 (base 2 equivalent) 27

31 venlafaxine hcl tab sr 24hr 150 (base 2 equivalent) venlafaxine hcl tab sr 24hr 225 (base 2 equivalent) Tricyclic Agents amitriptyline hcl tab 10 2 QL (150 tabs / 25 days); QL applies to members age 65 and amitriptyline hcl tab 25 2 QL (30 tabs / 25 days); QL applies to members age 65 and amitriptyline hcl tab 50 2 QL (30 tabs / 25 days); QL applies to members age 65 and amitriptyline hcl tab 75 2 Members 65 and subject to PA amitriptyline hcl tab Members 65 and subject to PA amitriptyline hcl tab Members 65 and subject to PA amoxapine tab 25 2 QL (90 tabs / 25 days); QL applies to members age 65 and amoxapine tab 50 2 QL (90 tabs / 25 days); QL applies to members age 65 and amoxapine tab QL (90 tabs / 25 days); QL applies to members age 65 and amoxapine tab QL (60 tabs / 25 days); QL applies to members age 65 and clomipramine hcl cap 25 2 QL (150 caps / 25 days); QL applies to members age 65 and clomipramine hcl cap 50 2 QL (150 caps / 25 days); QL applies to members age 65 and clomipramine hcl cap 75 2 QL (90 caps / 25 days); QL applies to members age 65 and desipramine hcl tab 10 2 QL (90 tabs / 25 days); QL applies to members age 65 and desipramine hcl tab 25 2 QL (90 tabs / 25 days); QL applies to members age 65 and 28

32 desipramine hcl tab 50 2 QL (90 tabs / 25 days); QL applies to members age 65 and desipramine hcl tab 75 2 QL (60 tabs / 25 days); QL applies to members age 65 and desipramine hcl tab QL (30 tabs / 25 days); QL applies to members age 65 and desipramine hcl tab QL (30 tabs / 25 days); QL applies to members age 65 and doxepin hcl cap 10 2 QL (90 caps / 25 days); QL applies to members age 65 and doxepin hcl cap 25 2 QL (90 caps / 25 days); QL applies to members age 65 and doxepin hcl cap 50 2 QL (90 caps / 25 days); QL applies to members age 65 and doxepin hcl cap 75 2 QL (60 caps / 25 days); QL applies to members age 65 and doxepin hcl cap QL (30 caps / 25 days); QL applies to members age 65 and doxepin hcl cap QL (30 caps / 25 days); QL applies to members age 65 and doxepin hcl conc 10 /ml 2 QL (450 ml / 25 days); QL applies to members age 65 and imipramine hcl tab 10 2 QL (60 tabs / 25 days); QL applies to members age 65 and imipramine hcl tab 25 2 QL (60 tabs / 25 days); QL applies to members age 65 and imipramine hcl tab 50 2 QL (60 tabs / 25 days); QL applies to members age 65 and imipramine pamoate cap 75 2 QL (30 caps / 25 days); QL applies to members age 65 and imipramine pamoate cap QL (30 caps / 25 days); QL applies to members age 65 and 29

33 imipramine pamoate cap Members 65 and subject to PA imipramine pamoate cap Members 65 and subject to PA nortriptyline hcl cap 10 2 QL (150 caps / 25 days); QL applies to members age 65 and nortriptyline hcl cap 25 2 QL (60 caps / 25 days); QL applies to members age 65 and nortriptyline hcl cap 50 2 QL (30 caps / 25 days); QL applies to members age 65 and nortriptyline hcl cap 75 2 Members 65 and subject to PA nortriptyline hcl soln 10 /5ml 2 QL (750 ml / 25 days); QL applies to members age 65 and protriptyline hcl tab 5 2 QL (90 tabs / 25 days); QL applies to members age 65 and protriptyline hcl tab 10 2 QL (60 tabs / 25 days); QL applies to members age 65 and SURMONTIL CAP 25MG 4 QL (60 caps / 25 days); QL applies to members age 65 and SURMONTIL CAP 50MG 4 QL (60 caps / 25 days); QL applies to members age 65 and SURMONTIL CAP 100MG 4 QL (30 caps / 25 days); QL applies to members age 65 and trimipramine maleate cap 25 2 QL (60 caps / 25 days); QL applies to members age 65 and trimipramine maleate cap 50 2 QL (60 caps / 25 days); QL applies to members age 65 and trimipramine maleate cap QL (30 caps / 25 days); QL applies to members age 65 and ANTIDIABETICS Alpha-Glucosidase Inhibitors acarbose tab 25 2 acarbose tab 50 2 acarbose tab

34 GLYSET TAB 25MG 4 GLYSET TAB 50MG 4 GLYSET TAB 100MG 4 Antidiabetic - Amylin Analogs SYMLINPEN 60 INJ 1000MCG 4 PA SYMLNPEN 120 INJ 1000MCG 4 PA Antidiabetic Combinations glipizide-metformin hcl tab glipizide-metformin hcl tab glipizide-metformin hcl tab glyburide-metformin tab PA; High Risk glyburide-metformin tab PA; High Risk glyburide-metformin tab PA; High Risk JANUMET TAB MG 3 JANUMET TAB JANUMET XR TAB MG 3 JANUMET XR TAB JANUMET XR TAB JENTADUETO TAB JENTADUETO TAB JENTADUETO TAB pioglitazone hcl-glimepiride tab pioglitazone hcl-glimepiride tab pioglitazone hcl-metformin hcl tab pioglitazone hcl-metformin hcl tab repaglinide-metformin hcl tab repaglinide-metformin hcl tab Biguanides metformin hcl tab metformin hcl tab metformin hcl tab metformin hcl tab sr 24hr metformin hcl tab sr 24hr metformin hcl tab sr 24hr osmotic metformin hcl tab sr 24hr osmotic

35 Diabetic Other GLUCAGON KIT 1MG 3 PROGLYCEM SUS 50MG/ML 4 Dipeptidyl Peptidase-4 (DPP-4) Inhibitors JANUVIA TAB 25MG 3 JANUVIA TAB 50MG 3 JANUVIA TAB 100MG 3 TRADJENTA TAB 5MG 3 Dopamine Receptor Agonists - Antidiabetic CYCLOSET TAB 0.8MG 4 Incretin Mimetic Agents (GLP-1 Receptor Agonists) TRULICITY INJ 0.75/0.5 3 TRULICITY INJ 1.5/0.5 3 VICTOZA INJ 18MG/3ML 3 Insulin APIDRA INJ SOLOSTAR 3 APIDRA INJ U HUMALOG INJ 100/ML 4 HUMALOG KWIK INJ 100/ML 4 HUMALOG KWIK INJ 200/ML 4 HUMALOG MIX INJ 50/50 4 HUMALOG MIX INJ 50/50KWP 4 HUMALOG MIX INJ 75/25KWP 4 HUMALOG MIX SUS 75/25 4 HUMULIN INJ 70/30 4 OTC HUMULIN INJ 70/30KWP 4 OTC HUMULIN N INJ U OTC HUMULIN N INJ U-100KWP 4 OTC HUMULIN R INJ U OTC HUMULIN R INJ U LANTUS INJ 100/ML 3 LANTUS INJ SOLOSTAR 3 LEVEMIR INJ 3 LEVEMIR INJ FLEXTOUC 3 NOVOLIN INJ 70/30 3 OTC NOVOLIN N INJ U OTC NOVOLIN R INJ U OTC NOVOLOG INJ 100/ML 3 NOVOLOG INJ FLEXPEN 3 NOVOLOG INJ PENFILL 3 NOVOLOG MIX INJ 70/30 3 NOVOLOG MIX INJ FLEXPEN 3 Insulin Sensitizing Agents pioglitazone hcl tab 15 (base equiv) 1 pioglitazone hcl tab 30 (base equiv) 1 32

36 pioglitazone hcl tab 45 (base equiv) 1 Meglitinide Analogues nateglinide tab 60 1 nateglinide tab repaglinide tab repaglinide tab 1 1 repaglinide tab 2 1 Sodium-Glucose Co-Transporter 2 (SGLT2) Inhibitors FARXIGA TAB 5MG 3 FARXIGA TAB 10MG 3 JARDIANCE TAB 10MG 3 JARDIANCE TAB 25MG 3 Sulfonylureas chlorpropamide tab chlorpropamide tab glimepiride tab 1 1 glimepiride tab 2 1 glimepiride tab 4 1 glipizide tab 5 1 glipizide tab 10 1 glipizide tab sr 24hr glipizide tab sr 24hr 5 1 glipizide tab sr 24hr 10 1 glyburide micronized tab PA; High Risk glyburide micronized tab 3 1 PA; High Risk glyburide micronized tab 6 1 PA; High Risk glyburide tab PA; High Risk glyburide tab PA; High Risk glyburide tab 5 1 PA; High Risk 33