Drug Formulary. A healthier you. A healthier community.

Transcription

1 Drug Formulary This Formulary is up to date through its date of publication, November 2, Please contact NextLevel Health at or with any mistakes in the formulary. A healthier you. A healthier community.

2 Step Therapy Information... 4 Prior Authorization Information... 6 ACE Inhibitors and ACE Inhibitor Combinations...15 Acne Therapy...16 Acne Therapy Topical...17 Alcoholism Treatment Agents Analgesic Narcotic Agonist Combinations Analgesic Narcotic Agonists and Combinations Analgesic, Anti-inflammatory or Antipyretic - Non-Narcotic Analgesics - Narcotic Androgen-Anabolic Anesthetics Angina Therapy...21 Angiotensin II Receptor Blocker (ARBs) and ARB Cominations...22 Anti-Infective Agents...23 Antiarrhythmics Antibacterial Agents...24 Anticoagulants Anticonvulsant...27 Antidepressant Combinations Antidepressants Antidiarrheals...27 Antidotes and other Reversal Agents Antiemetics Antifungals Antihyperlipidemic Combinations...29 Antihypertensive Therapy Agents Antihypertensive Therapy Combinations Antimycobacterial Agents Antineoplastic - Antibody/Antibody-Drug Complexes Antineoplastic - Protein-Tyrosine Kinase Inhibitors Antineoplastic - Systemic Enzyme Inhibitors Antineoplastics...31 Antiparasitics...32 Antiparkinson Therapy...32 Antiparkinson s Adjuvants...33 Antiprotozoal...33 Antiprotozoal-Antibacterial Agents...33 Antipsychotic - Atypical Agents, General Antipsychotic - Dopamine Antagonists Antipsychotics (Neuroleptics)...35 Antiretroviral - Entry Inhibitors...36 Antiretrovirals...36 Antithyroid Agents...38 Antitussive-Antihistamine Combinations...38 Antitussive-Antihistamine-Decongestant Combinations, All Antivirals Asthma/COPD Therapy Agents Beta Adrenergic Blockers BetaLactam Antibiotics Bone Resorption Inhibitors...43 Calcium Channel Blockers...43 Calcium Channel Blockers and Combinations...43 Cardiovascular Sympathomimetics and Combinations...45 Cardiovascular Therapy Agents...45 Central Nervous System Agents...47 Chemical Dependency, Agents to Treat Chemicals-Pharmaceutical Adjuvants CNS Stimulants...57 Cognitive Disorder Therapy Contraceptives...58 Contraceptives Oral Corticosteroids...64 Cough and Cold or Allergy Combinations...65 Dermatological...65 Dermatological - Anti-infective Combinations Dermatological - Anti-infectives Dermatological - Antiparasitics and Combinations Dermatological - Antipsoriatics

3 Dermatological - Hair Growth Agents Dermatological - Topical Local Anesthetics and Combinations Diabetic Therapy...69 Digestive Aids Disease Modifying Anti-Rheumatoid Drugs (DMARD)...70 Diuretic - Potassium Sparing (Single Agent), All...70 Diuretic - Potassium Sparing Diuretics and Combinations Diuretics...71 Eating Disorder Therapy Electrolyte Balance-Nutritional Products...72 Endocrine...72 Estrogens and Combinations...73 Fertility Enhancers Folate Antagonist Antibiotics...74 Gastrointestinal Antispasmodics...74 Gastrointestinal Therapy Agents...74 Genitourinary Therapy GI Antispasmodic Combinations...76 Gout and Hyperuricemia Therapy...77 Hematological Agents...77 Hematopoietic Agents...77 Hepatitis Agents...78 Hepatitis C Treatment Agents...79 Immunosuppressive Agents...79 Influenza Agents Insulin - Human and Analogs, Single Agent Insulin - Human and Analogs, Single Agents, and Combinations...80 Laxative Combinations...81 Medical Supplies and DME - Diabetic Supplies...81 Medical Supplies and Durable Medical Equipment (DME) Metabolic Disease Enzyme Replacement Agents Migraine Therapy...82 Minerals and Electrolytes - Potassium and Combinations...83 Mouth-Throat-Dental - Preparations Multiple Sclerosis Agents...83 Musculoskeletal Therapy Agents Nasal Preparations Neuromuscular Therapy Agents NSAID Analgesics...85 NSAID Analgesics and NSAID Combinations...85 Ophthalmic - Anti-infectives Ophthalmic - Intraocular Pressure Reducing Agents...87 Ophthalmic Agents...88 Ophthalmic Combinations...89 Oral Antidiabetic Agents Otic...90 Otic - Anti-infectives Passive Immunizing Agents...90 Penicillin Antibiotic Combinations Peptic Ulcer Therapy Pharmaceutical Adjuvants Prolactin Inhibitors Prostatic Hypertrophy Agents Quinolone Antibiotics Renin-Angiotensin-Aldosterone System (RAAS) Blocking Agents Respiratory Therapy Agents Salicylate Analgesic and Salicylate Combinations...95 Sedative-Hypnotics...95 Skeletal Muscle Relaxant Combinations...96 Smoking Deterrents, Systemic...96 Thyroid Therapy...97 Urinary Anti-infectives Urinary ph Modifiers Vaccines Vaccines - Viral...98 Vaginal Anti-infectives...99 Vaginal Antifungals Vaginal Products...99 Vitamin Combinations

4 Vitamins Vitamins - Water Soluble Acne Therapy Alternative Therapy Analgesic, Anti-inflammatory or Antipyretic - Non-Narcotic Anorectal Preparations Antacid Combinations Antacids and Combinations Antidiarrheals Antiemetics Antiparasitics Antiseptics and Disinfectants Chemicals-Pharmaceutical Adjuvants Contraceptives Contraceptives Intravaginal Cough and Cold or Allergy Combinations Dermatological Dermatological - Anti-infective Combinations Dermatological - Anti-infectives Dermatological - Antiparasitics and Combinations Dermatological - Emollients and Combinations Dermatological - Topical Local Anesthetics and Combinations Diabetic Therapy Electrolyte Balance-Nutritional Products Gastrointestinal Therapy Agents Genitourinary Therapy Hematological Agents Insulin - Human and Analogs, Single Agent Insulin - Human and Analogs, Single Agents, and Combinations Laxative Combinations Laxatives Medical Supplies and DME - Contraceptives Medical Supplies and DME - Diabetic Supplies Medical Supplies and DME-Glucose Monitoring and Insulin Admin Supplies Medical Supplies and Durable Medical Equipment (DME) Minerals and Electrolytes Mouth-Throat-Dental - Preparations Nasal Preparations NSAID Analgesics and NSAID Combinations Ophthalmic - Decongestants and Combinations Ophthalmic Agents Otic Peptic Ulcer Therapy Respiratory Therapy Agents Salicylate Analgesic and Salicylate Combinations Sedative-Hypnotics Smoking Deterrents and Combinations Vaginal Antifungals Vitamin Combinations Vitamins Vitamins - Water Soluble

5 Introduction Meridian Health Plan is pleased to provide an updated 2016 Medicaid Formulary as a reference and informational tool for physicians, pharmacists and patients. The Meridian Formulary is designed to assist practitioners in selecting clinically appropriate and cost-effective products for their patients. The MeridianRx Pharmacy and Therapeutics Committee (P&T) The medications on this formulary have been reviewed by the MeridianRx P&T Committee. The Committee includes physicians, pharmacists and health professionals. The clinical information within the formulary is primarily derived from medical literature and is reviewed and approved by the P&T Committee. Notice The information contained in this formulary is provided by Meridian, solely for the convenience of medical providers. This formulary is not intended to be a substitute for the knowledge, expertise, skill and judgment of the medical provider in their choice of prescription drugs. Meridian Health Plan assumes no responsibility for the actions or omissions of any medical provider based upon reliance, in whole or in part, on the information contained herein. The medical provider should consult the drug manufacturer s product literature or standard references for more detailed information. Preface The Meridian formulary is organized by sections. Each section includes therapeutic groups identified by either drug class or disease state. Products are listed by generic name. Brand and common names are included as a reference to assist in product recognition. Meridian will not cover prescription drugs that are prescribed for experimental, investigational or non FDA approved indications, dosages, or routes of administration. Meridian does not cover any medication excluded by Illinois Medicaid. Product Selection Criteria The MeridianRx P&T Committee considers clinical information on new to market drugs that are typically included in an outpatient pharmacy benefit. The primary goal of the MeridianRx P&T Committee is to preserve and evaluate the Meridian formulary based upon an objective analysis of the safety, efficacy, approved indications, adverse effects, contraindications, patient administration/compliance considerations and cost effectiveness. When a new drug is considered for formulary inclusion, it will be reviewed relative to similar drugs currently included in the Meridian Formulary. Formulary decisions are communicated quarterly on the Meridian Health Plan website. Formulary Components The Meridian Formulary contains the following components: Covered medications without authorization, medications that must meet Step Therapy Protocol, medications that require Prior Authorization, Specialty medications and medications that are subject to Quantity Limits. Members will not be charged a co-pay when Meridian covers a medication. Generic Substitution Meridian is a mandatory generic plan. The brand and common names listed in the formulary are for reference only. Generic medication will be dispensed where available. Covered Medications without Authorization Meridian covers many medications without any authorization required. These medications include many prescription and over-the-counter medications(when ordered by a physician). 4

6 Non-Covered Benefits The following categories are not covered benefits: Medications used for cosmetic purposes, to promote fertility, for sexual dysfunction, to treat gender identity conditions, for experimental or investigational purposes, or medications that are not licensed for use in the United States. Prior Authorization Drugs indicated with "PA" require Prior Authorization for coverage. Details of the PA criteria are listed next to the drug name. Please call the MeridianRx Help Desk at or fax a completed Prior Authorization form to All Prior Authorization requests will be reviewed within 24 hours. Step Therapy Drugs indicated with a "ST" require Step Therapy for coverage. The required step is listed next to the drug name. Specialty Medications All specialty medications noted as "SP" are handled by MeridianRx. To order a specialty medication by fax, send the prescription and a completed prior authorization form to or call MeridianRx s Help Desk at Quantity Limits Drugs indicated with a "QL" have a set quantity limit imposed. These limits are based on FDA recommended dosing guidelines. The quantity limit is listed next to the drug name. All medications are subject to a maximum of 30 days per prescription. Benefit Exception The process for requesting non formulary medication(s) requires faxing of a completed Formulary Exception form indicating the request for an exception to the formulary. This request will need to include pertinent clinical documentation showing trial and failure of all formulary agents. It should also contain information showing the medication is the standard of care for the indication provided (Peer reviewed journal articles may be required). Please call the MeridianRx Help Desk at or fax a completed Formulary Exception form to Pharmacy Benefit Management Meridian Health Plan utilizes MeridianRx to manage each member s pharmacy benefit. MeridianRx provides Meridian with a pharmacy network, pharmacy claims management services, and claims adjudication. MeridianRx s Help Desk can be contacted at

7 Step Therapy Information Nasal Preparations PATANASE 665 MCG NASAL SPRAY PATANASE ST For patients over the age of 18, must show trial and failure of Cetirizine, Fexofendine, Desloratadine, or Levocetirizine within the past 360 days. Smoking Deterrents, Systemic CHANTIX 0.5 MG TABLET CHANTIX ST Limited to 90 days therapy per rolling 365 days; Must have tried and failed three consecutive fills of Nicotine Patches along with Nicotine Lozenges or Gum, and three consecutive fills of Buproban. CHANTIX 1 MG CONT MONTH BOX CHANTIX ST Limited to 90 days therapy per rolling 365 days; Must have tried and failed three consecutive fills of Nicotine Patches along with Nicotine Lozenges or Gum, and three consecutive fills of Buproban. CHANTIX 1 MG TABLET CHANTIX ST Limited to 90 days therapy per rolling 365 days; Must have tried and failed three consecutive fills of Nicotine Patches along with Nicotine Lozenges or Gum, and three consecutive fills of Buproban. CHANTIX STARTING MONTH BOX CHANTIX ST Limited to 90 days therapy per rolling 365 days; Must have tried and failed three consecutive fills of Nicotine Patches along with Nicotine Lozenges or Gum, and three consecutive fills of Buproban. Acne Therapy ADAPALENE 0.1% CREAM ADAPALENE ST Must have trial and failure of generic tretinoin products within the past 360 days. ADAPALENE 0.1% GEL ADAPALENE ST Must have trial and failure of generic tretinoin products within the past 360 days. ADAPALENE 0.1% LOTION ADAPALENE ST Must have trial and failure of generic tretinoin products within the past 360 days. AVITA 0.025% CREAM AVITA ST Must have trial and failure of generic tretinoin products within the past 360 days. AVITA 0.025% GEL AVITA ST Must have trial and failure of generic tretinoin products within the past 360 days. 6

8 Step Therapy Information Acne Therapy RETIN-A 0.01% GEL RETIN-A ST Must have trial and failure of generic tretinoin products within the past 360 days. RETIN-A 0.025% CREAM RETIN-A ST Must have trial and failure of generic tretinoin products within the past 360 days. RETIN-A 0.025% GEL RETIN-A ST Must have trial and failure of generic tretinoin products within the past 360 days. RETIN-A 0.05% CREAM RETIN-A ST Must have trial and failure of generic tretinoin products within the past 360 days. RETIN-A 0.1% CREAM RETIN-A ST Must have trial and failure of generic tretinoin products within the past 360 days. RETIN-A MICRO 0.04% GEL RETIN-A MICRO ST Must have trial and failure of generic tretinoin products within the past 360 days. RETIN-A MICRO 0.1% GEL RETIN-A MICRO ST Must have trial and failure of generic tretinoin products within the past 360 days. RETIN-A MICRO PUMP 0.04% GEL RETIN-A MICRO PUMP ST Must have trial and failure of generic tretinoin products within the past 360 days. RETIN-A MICRO PUMP 0.08% GEL RETIN-A MICRO PUMP ST Must have trial and failure of generic tretinoin products within the past 360 days. RETIN-A MICRO PUMP 0.1% GEL RETIN-A MICRO PUMP ST Must have trial and failure of generic tretinoin products within the past 360 days. Dermatological TACROLIMUS 0.1% OINTMENT TACROLIMUS ST Must have trail and failure of generic topical corticosteroids within the past 360 days. ELIDEL 1% CREAM ELIDEL ST Must have trail and failure of generic topical corticosteroids within the past 360 days. TACROLIMUS 0.03% OINTMENT TACROLIMUS ST Must have trail and failure of generic topical corticosteroids within the past 360 days. 7

9 Prior Authorization Information Multiple Sclerosis Agents AVONEX 30 MCG VIAL KIT AVONEX PA,SP Prior Authorization Required AVONEX PEN 30 MCG/0.5 ML KIT AVONEX PEN PA,SP Prior Authorization Required AVONEX PREFILLED SYR 30 MCG AVONEX PA,SP Prior Authorization Required BETASERON 0.3 MG KIT BETASERON PA,SP Prior Authorization Required COPAXONE 20 MG/ML SYRINGE COPAXONE PA,SP Prior Authorization Required GLATOPA 20 MG/ML SYRINGE GLATOPA PA,SP Prior Authorization Required REBIF 22 MCG/0.5 ML SYRINGE REBIF PA,SP Prior Authorization Required REBIF 44 MCG/0.5 ML SYRINGE REBIF PA,SP Prior Authorization Required REBIF REBIDOSE 44 MCG/0.5 ML REBIF REBIDOSE PA,SP Prior Authorization Required REBIF TITRATION PACK REBIF PA,SP Prior Authorization Required Passive Immunizing Agents HYPERRHO S-D 1500 UNITS SYR HYPERRHO S-D PA,SP Prior Authorization Required HYPERRHO S-D 250 UNITS SYRINGE HYPERRHO S-D PA,SP Prior Authorization Required MICRHOGAM ULTRA-FILTD PLUS SYR RHOGAM ULTRA-FILTERED PLUS SYR MICRHOGAM ULTRA-FILTERED PLUS RHOGAM ULTRA-FILTERED PLUS PA,SP PA,SP Prior Authorization Required Prior Authorization Required RHOPHYLAC 300 MCG/2 ML SYRINGE RHOPHYLAC PA,SP Prior Authorization Required WINRHO SDF 1,500 UNITS VIAL WINRHO SDF PA,SP Prior Authorization Required WINRHO SDF 15,000 UNITS VIAL WINRHO SDF PA,SP Prior Authorization Required WINRHO SDF 2,500 UNITS VIAL WINRHO SDF PA,SP Prior Authorization Required WINRHO SDF 5,000 UNITS VIAL WINRHO SDF PA,SP Prior Authorization Required Respiratory Therapy Agents PULMOZYME 1 MG/ML AMPUL PULMOZYME PA,SP PA required, must meet clinical criteria Vaccines GARDASIL SYRINGE GARDASIL PA,SP Prior Authorization Required GARDASIL VIAL GARDASIL PA,SP Prior Authorization Required Vitamins MEPHYTON 5 MG TABLET MEPHYTON PA PA required, must meet clinical criteria Anticoagulants ELIQUIS 2.5 MG TABLET ELIQUIS PA Prior authorization required; restricted to knee/hip replacement, atrial fibrillation, deep vein thrombosis, and pulmonary embolism) 8

10 Prior Authorization Information Anticoagulants ELIQUIS 5 MG TABLET ELIQUIS PA Prior authorization required; restricted to knee/hip replacement, atrial fibrillation, deep vein thrombosis, and pulmonary embolism) FONDAPARINUX 10 MG/0.8 ML SYR FONDAPARINUX SODIUM PA,SP Prior Authorization Required FONDAPARINUX 2.5 MG/0.5 ML SYR FONDAPARINUX SODIUM PA,SP Prior Authorization Required FONDAPARINUX 5 MG/0.4 ML SYR FONDAPARINUX SODIUM PA,SP Prior Authorization Required FRAGMIN 10,000 UNITS/ML SYRING FRAGMIN PA,SP Prior Authorization Required FRAGMIN 12,500 UNITS/0.5 ML FRAGMIN PA,SP Prior Authorization Required FRAGMIN 15,000 UNITS/0.6 ML FRAGMIN PA,SP Prior Authorization Required FRAGMIN 18,000 UNITS/0.72 ML FRAGMIN PA,SP Prior Authorization Required FRAGMIN 2,500 UNITS/0.2 ML SYR FRAGMIN PA,SP Prior Authorization Required FRAGMIN 5,000 UNITS/0.2 ML SYR FRAGMIN PA,SP Prior Authorization Required FRAGMIN 7,500 UNITS/0.3 ML SYR FRAGMIN PA,SP Prior Authorization Required FRAGMIN 95,000 UNITS/3.8 ML VL FRAGMIN PA,SP Prior Authorization Required XARELTO 10 MG TABLET XARELTO PA Prior authorization required; restricted to knee/hip replacement, atrial fibrillation, deep vein thrombosis, and pulmonary embolism) XARELTO 15 MG TABLET XARELTO PA Prior authorization required; restricted to knee/hip replacement, atrial fibrillation, deep vein thrombosis, and pulmonary embolism) XARELTO 20 MG TABLET XARELTO PA Prior authorization required; restricted to knee/hip replacement, atrial fibrillation, deep vein thrombosis, and pulmonary embolism) XARELTO STARTER PACK XARELTO PA Prior authorization required; restricted to knee/hip replacement, atrial fibrillation, deep vein thrombosis, and pulmonary embolism) Antidotes and other Reversal Agents EXJADE 125 MG TABLET EXJADE PA,SP PA required, must meet clinical criteria EXJADE 250 MG TABLET EXJADE PA,SP PA required, must meet clinical criteria EXJADE 500 MG TABLET EXJADE PA,SP PA required, must meet clinical criteria Antihypertensive Therapy Agents ADCIRCA 20 MG TABLET ADCIRCA PA,SP Prior authorization required for all covered PAH Drugs 9

11 Prior Authorization Information Antihypertensive Therapy Agents EPOPROSTENOL SODIUM 0.5 MG VL EPOPROSTENOL SODIUM PA,SP Prior authorization required for all covered PAH Drugs EPOPROSTENOL SODIUM 1.5 MG VL EPOPROSTENOL SODIUM PA,SP Prior authorization required for all covered PAH Drugs LETAIRIS 10 MG TABLET LETAIRIS PA,SP Prior authorization required for all covered PAH Drugs LETAIRIS 5 MG TABLET LETAIRIS PA,SP Prior authorization required for all covered PAH Drugs SILDENAFIL 20 MG TABLET SILDENAFIL PA,SP Prior authorization required for all covered PAH Drugs TRACLEER 125 MG TABLET TRACLEER PA,SP Prior authorization required for all covered PAH Drugs TRACLEER 62.5 MG TABLET TRACLEER PA,SP Prior authorization required for all covered PAH Drugs Antineoplastic - Antibody/Antibody-Drug Complexes AVASTIN 100 MG/4 ML VIAL AVASTIN PA,SP Prior Authorization Required AVASTIN 400 MG/16 ML VIAL AVASTIN PA,SP Prior Authorization Required RITUXAN 10 MG/ML VIAL RITUXAN PA,SP PA required, must meet clinical criteria Antineoplastic - Protein-Tyrosine Kinase Inhibitors TARCEVA 100 MG TABLET TARCEVA PA,SP Prior Authorization Required TARCEVA 150 MG TABLET TARCEVA PA,SP Prior Authorization Required TARCEVA 25 MG TABLET TARCEVA PA,SP Prior Authorization Required Antineoplastic - Systemic Enzyme Inhibitors TYKERB 250 MG TABLET TYKERB PA,SP Prior Authorization Required Antineoplastics CAPECITABINE 150 MG TABLET CAPECITABINE PA,SP Prior Authorization Required CAPECITABINE 500 MG TABLET CAPECITABINE PA,SP Prior Authorization Required GEMCITABINE HCL 1 GRAM VIAL GEMCITABINE HCL PA,SP Prior Authorization Required GEMCITABINE HCL 200 MG VIAL GEMCITABINE HCL PA,SP Prior Authorization Required GEMZAR 1 GRAM VIAL GEMZAR PA,SP Prior Authorization Required GEMZAR 200 MG VIAL GEMZAR PA,SP Prior Authorization Required GLEEVEC 100 MG TABLET GLEEVEC PA,SP Prior Authorization Required GLEEVEC 400 MG TABLET GLEEVEC PA,SP Prior Authorization Required LEUKERAN 2 MG TABLET LEUKERAN PA,SP Prior Authorization Required SPRYCEL 100 MG TABLET SPRYCEL PA,SP Prior Authorization Required SPRYCEL 140 MG TABLET SPRYCEL PA,SP Prior Authorization Required SPRYCEL 20 MG TABLET SPRYCEL PA,SP Prior Authorization Required SPRYCEL 50 MG TABLET SPRYCEL PA,SP Prior Authorization Required SPRYCEL 70 MG TABLET SPRYCEL PA,SP Prior Authorization Required 10

12 Prior Authorization Information Antineoplastics SPRYCEL 80 MG TABLET SPRYCEL PA,SP Prior Authorization Required SUTENT 12.5 MG CAPSULE SUTENT PA,SP Prior Authorization Required SUTENT 25 MG CAPSULE SUTENT PA,SP Prior Authorization Required SUTENT 50 MG CAPSULE SUTENT PA,SP Prior Authorization Required TEMODAR 100 MG CAPSULE TEMODAR PA,SP Prior Authorization Required TEMODAR 100 MG VIAL TEMODAR PA,SP Prior Authorization Required TEMODAR 140 MG CAPSULE TEMODAR PA,SP Prior Authorization Required TEMODAR 180 MG CAPSULE TEMODAR PA,SP Prior Authorization Required TEMODAR 20 MG CAPSULE TEMODAR PA,SP Prior Authorization Required TEMODAR 250 MG CAPSULE TEMODAR PA,SP Prior Authorization Required TEMODAR 5 MG CAPSULE TEMODAR PA,SP Prior Authorization Required TEMOZOLOMIDE 100 MG CAPSULE TEMOZOLOMIDE PA,SP Prior Authorization Required TEMOZOLOMIDE 140 MG CAPSULE TEMOZOLOMIDE PA,SP Prior Authorization Required TEMOZOLOMIDE 180 MG CAPSULE TEMOZOLOMIDE PA,SP Prior Authorization Required TEMOZOLOMIDE 20 MG CAPSULE TEMOZOLOMIDE PA,SP Prior Authorization Required TEMOZOLOMIDE 250 MG CAPSULE TEMOZOLOMIDE PA,SP Prior Authorization Required TEMOZOLOMIDE 5 MG CAPSULE TEMOZOLOMIDE PA,SP Prior Authorization Required XELODA 150 MG TABLET XELODA PA,SP Prior Authorization Required XELODA 500 MG TABLET XELODA PA,SP Prior Authorization Required Antiparasitics ATOVAQUONE 750 MG/5 ML SUSP ATOVAQUONE PA,SP Prior Authorization Required Antipsychotic - Atypical Agents, General ABILIFY MAINTENA ER 300 MG SYR ABILIFY MAINTENA PA PA required, must meet clinical criteria ABILIFY MAINTENA ER 300 MG VL ABILIFY MAINTENA PA PA required, must meet clinical criteria ABILIFY MAINTENA ER 400 MG SYR ABILIFY MAINTENA PA PA required, must meet clinical criteria ABILIFY MAINTENA ER 400 MG VL ABILIFY MAINTENA PA PA required, must meet clinical criteria ARISTADA ER 441 MG/1.6 ML SYRN ARISTADA PA PA required, must meet clinical criteria ARISTADA ER 662 MG/2.4 ML SYRN ARISTADA PA PA required, must meet clinical criteria ARISTADA ER 882 MG/3.2 ML SYRN ARISTADA PA PA required, must meet clinical criteria INVEGA SUSTENNA 117 MG/0.75 ML INVEGA SUSTENNA PA PA required, must meet clinical criteria INVEGA SUSTENNA 156 MG/ML SYRG INVEGA SUSTENNA PA PA required, must meet clinical criteria INVEGA SUSTENNA 234 MG/1.5 ML INVEGA SUSTENNA PA PA required, must meet clinical criteria 11

13 Prior Authorization Information Antipsychotic - Atypical Agents, General INVEGA SUSTENNA 39 MG/0.25 ML INVEGA SUSTENNA PA PA required, must meet clinical criteria INVEGA SUSTENNA 78 MG/0.5 ML INVEGA SUSTENNA PA PA required, must meet clinical criteria Antivirals GANCICLOVIR 500 MG VIAL GANCICLOVIR SODIUM PA,SP Prior Authorization Required VALGANCICLOVIR 450 MG TABLET VALGANCICLOVIR HCL PA,SP Prior Authorization Required CNS Stimulants CAFFEINE CIT 60 MG/3 ML ORAL CAFFEINE CITRATE PA,SP Prior Authorization Required Dermatological - Antipsoriatics ACITRETIN 10 MG CAPSULE ACITRETIN PA PA required, must meet clinical criteria ACITRETIN 17.5 MG CAPSULE ACITRETIN PA PA required, must meet clinical criteria ACITRETIN 25 MG CAPSULE ACITRETIN PA PA required, must meet clinical criteria Disease Modifying Anti-Rheumatoid Drugs (DMARD) ENBREL 25 MG KIT ENBREL PA,SP Prior authorization required for all Biologic Response Modifiers. ENBREL 25 MG/0.5 ML SYRINGE ENBREL PA,SP Prior authorization required for all Biologic Response Modifiers. ENBREL 50 MG/ML SURECLICK SYR ENBREL PA,SP Prior authorization required for all Biologic Response Modifiers. ENBREL 50 MG/ML SYRINGE ENBREL PA,SP Prior authorization required for all Biologic Response Modifiers. HUMIRA 10 MG/0.2 ML SYRINGE HUMIRA PA,SP Prior authorization required for all covered Biologic Response Modifiers. HUMIRA 20 MG/0.4 ML SYRINGE HUMIRA PA,SP Prior authorization required for all covered Biologic Response Modifiers. HUMIRA 40 MG/0.8 ML PEN HUMIRA PEN PA,SP Prior authorization required for all Biologic Response Modifiers. HUMIRA 40 MG/0.8 ML SYRINGE HUMIRA PA,SP Prior authorization required for all covered Biologic Response Modifiers. HUMIRA PEDIATRIC CROHN S START HUMIRA PEDIATRIC CROHN S PA,SP Prior authorization required for all covered Biologic Response Modifiers. HUMIRA PEN CROHN-UC-HS STARTER HUMIRA PEN PSORIASIS-UVEITIS STARTER HUMIRA PEN CROHN-UC-HS STARTER HUMIRA PEN PSORIASIS- UVEITIS PA,SP PA,SP Prior authorization required for all Biologic Response Modifiers. Prior authorization required for all Biologic Response Modifiers. 12

14 Prior Authorization Information Endocrine LUPRON DEPOT 3.75 MG (LUPANETA) LUPRON DEPOT (LUPANETA) PA,SP Prior Authorization Required LUPRON DEPOT 3.75 MG KIT LUPRON DEPOT PA,SP Prior Authorization Required LUPRON DEPOT-PED MG KIT LUPRON DEPOT-PED PA,SP Prior Authorization Required LUPRON DEPOT-PED 15 MG KIT LUPRON DEPOT-PED PA,SP Prior Authorization Required LUPRON DEPOT-PED 7.5 MG KIT LUPRON DEPOT-PED PA,SP Prior Authorization Required MIACALCIN 400 UNIT/2 ML VIAL MIACALCIN PA,SP Prior Authorization Required OMNITROPE 10 MG/1.5 ML CRTG OMNITROPE PA,SP Prior authorization required for all covered Growth Hormones. OMNITROPE 5 MG/1.5 ML CRTG OMNITROPE PA,SP Prior authorization required for all covered Growth Hormones. OMNITROPE 5.8 MG VIAL OMNITROPE PA,SP Prior authorization required for all covered Growth Hormones. Gastrointestinal Therapy Agents CIMZIA 200 MG VIAL KIT CIMZIA PA,SP Prior authorization required for all covered Biologic Response Modifiers. CIMZIA 200 MG/ML STARTER KIT CIMZIA PA,SP Prior authorization required for all covered Biologic Response Modifiers. CIMZIA 200 MG/ML SYRINGE KIT CIMZIA PA,SP Prior authorization required for all covered Biologic Response Modifiers. EMEND 80 MG CAPSULE EMEND PA,SP Prior Authorization Required EMEND TRIPACK EMEND PA,SP Prior Authorization Required Hematological Agents ANAGRELIDE HCL 0.5 MG CAPSULE ANAGRELIDE HCL PA,SP Prior Authorization Required ANAGRELIDE HCL 1 MG CAPSULE ANAGRELIDE HCL PA,SP Prior Authorization Required Hematopoietic Agents ARANESP 10 MCG/0.4 ML SYRINGE ARANESP PA,SP Prior authorization required for all covered Erythropoietins ARANESP 100 MCG/0.5 ML SYRINGE ARANESP PA,SP Prior authorization required for all covered Erythropoietins ARANESP 100 MCG/ML VIAL ARANESP PA,SP Prior authorization required for all covered Erythropoietins ARANESP 150 MCG/0.3 ML SYRINGE ARANESP PA,SP Prior authorization required for all covered Erythropoietins ARANESP 150 MCG/0.75 ML VIAL ARANESP PA,SP Prior authorization required for all covered Erythropoietins ARANESP 200 MCG/0.4 ML SYRINGE ARANESP PA,SP Prior authorization required for all covered Erythropoietins ARANESP 200 MCG/ML VIAL ARANESP PA,SP Prior authorization required for all covered Erythropoietins ARANESP 25 MCG/0.42 ML SYRING ARANESP PA,SP Prior authorization required for all covered Erythropoietins 13

15 Prior Authorization Information Hematopoietic Agents ARANESP 25 MCG/ML VIAL ARANESP PA,SP Prior authorization required for all covered Erythropoietins ARANESP 300 MCG/0.6 ML SYRINGE ARANESP PA,SP Prior authorization required for all covered Erythropoietins ARANESP 300 MCG/ML VIAL ARANESP PA,SP Prior authorization required for all covered Erythropoietins ARANESP 40 MCG/0.4 ML SYRINGE ARANESP PA,SP Prior authorization required for all covered Erythropoietins ARANESP 40 MCG/ML VIAL ARANESP PA,SP Prior authorization required for all covered Erythropoietins ARANESP 500 MCG/1 ML SYRINGE ARANESP PA,SP Prior authorization required for all covered Erythropoietins ARANESP 60 MCG/0.3 ML SYRINGE ARANESP PA,SP Prior authorization required for all covered Erythropoietins ARANESP 60 MCG/ML VIAL ARANESP PA,SP Prior authorization required for all covered Erythropoietins NEUPOGEN 300 MCG/0.5 ML SYR NEUPOGEN PA,SP Prior Authorization Required NEUPOGEN 300 MCG/ML VIAL NEUPOGEN PA,SP Prior Authorization Required NEUPOGEN 480 MCG/0.8 ML SYR NEUPOGEN PA,SP Prior Authorization Required NEUPOGEN 480 MCG/1.6 ML VIAL NEUPOGEN PA,SP Prior Authorization Required PROCRIT 10,000 UNITS/ML VIAL PROCRIT PA,SP Prior authorization required for all covered Erythropoietins PROCRIT 2,000 UNITS/ML VIAL PROCRIT PA,SP Prior authorization required for all covered Erythropoietins PROCRIT 20,000 UNITS/ML VIAL PROCRIT PA,SP Prior authorization required for all covered Erythropoietins PROCRIT 3,000 UNITS/ML VIAL PROCRIT PA,SP Prior authorization required for all covered Erythropoietins PROCRIT 4,000 UNITS/ML VIAL PROCRIT PA,SP Prior authorization required for all covered Erythropoietins PROCRIT 40,000 UNITS/ML VIAL PROCRIT PA,SP Prior Authorization Required Hepatitis Agents ENTECAVIR 0.5 MG TABLET ENTECAVIR PA,SP Prior Authorization Required ENTECAVIR 1 MG TABLET ENTECAVIR PA,SP Prior Authorization Required PEGINTRON 120 MCG KIT PEGINTRON REDIPEN PA,SP Prior authorization required for all covered Hepatitis C Agents PEGINTRON 150 MCG KIT PEGINTRON REDIPEN PA,SP Prior authorization required for all covered Hepatitis C Agents PEGINTRON 50 MCG KIT PEGINTRON REDIPEN PA,SP Prior authorization required for all covered Hepatitis C Agents PEGINTRON 80 MCG KIT PEGINTRON REDIPEN PA,SP Prior authorization required for all covered Hepatitis C Agents PEGINTRON REDIPEN 120 MCG PEGINTRON REDIPEN PA,SP Prior authorization required for all covered Hepatitis C Agents PEGINTRON REDIPEN 120 MCG 4PK PEGINTRON REDIPEN PA,SP Prior authorization required for all covered Hepatitis C Agents 14

16 Prior Authorization Information Hepatitis Agents PEGINTRON REDIPEN 150 MCG PEGINTRON REDIPEN PA,SP Prior authorization required for all covered Hepatitis C Agents PEGINTRON REDIPEN 50 MCG PEGINTRON REDIPEN PA,SP Prior authorization required for all covered Hepatitis C Agents PEGINTRON REDIPEN 80 MCG PEGINTRON REDIPEN PA,SP Prior authorization required for all covered Hepatitis C Agents RIBAVIRIN 200 MG CAPSULE RIBAVIRIN PA,SP Prior authorization required for all covered Hepatitis C Agents RIBAVIRIN 200 MG TABLET RIBAVIRIN PA,SP Prior authorization required for all covered Hepatitis C Agents SOVALDI 400 MG TABLET SOVALDI PA,SP Prior authorization required for all Hepatitis C Agents Hepatitis C Treatment Agents EPCLUSA 400 MG-100 MG TABLET EPCLUSA PA,SP Preferred for Genotypes 2 and 3 HARVONI MG TABLET HARVONI PA,SP Prior authorization required for all Hepatitis C Agents ZEPATIER MG TABLET ZEPATIER PA,SP Preferred for Genotypes 1 and 4 Immunosuppressive Agents CELLCEPT 250 MG CAPSULE CELLCEPT PA,SP Prior Authorization Required CELLCEPT 500 MG TABLET CELLCEPT PA,SP Prior Authorization Required CYCLOSPORINE 100 MG CAPSULE CYCLOSPORINE PA,SP Prior Authorization Required CYCLOSPORINE 100 MG/ML SOLN CYCLOSPORINE PA,SP Prior Authorization Required CYCLOSPORINE 25 MG CAPSULE CYCLOSPORINE PA,SP Prior Authorization Required CYCLOSPORINE MODIFIED 100 MG CYCLOSPORINE MODIFIED PA,SP Prior Authorization Required CYCLOSPORINE MODIFIED 25 MG CYCLOSPORINE MODIFIED PA,SP Prior Authorization Required GENGRAF 100 MG CAPSULE GENGRAF PA,SP Prior Authorization Required GENGRAF 100 MG/ML SOLUTION GENGRAF PA,SP Prior Authorization Required GENGRAF 25 MG CAPSULE GENGRAF PA,SP Prior Authorization Required MYCOPHENOLATE 250 MG CAPSULE MYCOPHENOLATE MOFETIL PA,SP Prior Authorization Required MYCOPHENOLATE 500 MG TABLET MYCOPHENOLATE MOFETIL PA,SP Prior Authorization Required NEORAL 100 MG GELATIN CAPSULE NEORAL PA,SP Prior Authorization Required NEORAL 100 MG/ML SOLUTION NEORAL PA,SP Prior Authorization Required NEORAL 25 MG GELATIN CAPSULE NEORAL PA,SP Prior Authorization Required PROGRAF 0.5 MG CAPSULE PROGRAF PA,SP Prior Authorization Required PROGRAF 1 MG CAPSULE PROGRAF PA,SP Prior Authorization Required PROGRAF 5 MG CAPSULE PROGRAF PA,SP Prior Authorization Required SANDIMMUNE 100 MG CAPSULE SANDIMMUNE PA,SP Prior Authorization Required SANDIMMUNE 100 MG/ML SOLN SANDIMMUNE PA,SP Prior Authorization Required SANDIMMUNE 25 MG CAPSULE SANDIMMUNE PA,SP Prior Authorization Required Metabolic Disease Enzyme Replacement Agents 15

17 Prior Authorization Information Metabolic Disease Enzyme Replacement Agents CEREZYME 400 UNITS VIAL CEREZYME PA,SP PA required, must meet clinical criteria 16

18 Next Level Health ACE Inhibitors and ACE Inhibitor Combinations AMLODIPINE-BENAZEPRIL MG AMLODIPINE-BENAZEPRIL MG AMLODIPINE-BENAZEPRIL AMLODIPINE-BENAZEPRIL 5-10 MG AMLODIPINE-BENAZEPRIL 5-20 MG AMLODIPINE-BENAZEPRIL 5-40 MG BENAZEPRIL- HYDROCHLOROTHIAZIDE MG TAB BENAZEPRIL- HYDROCHLOROTHIAZIDE MG TAB BENAZEPRIL- HYDROCHLOROTHIAZIDE MG TAB BENAZEPRIL- HYDROCHLOROTHIAZIDE MG TAB CAPTOPRIL- HYDROCHLOROTHIAZIDE MG TABLET CAPTOPRIL- HYDROCHLOROTHIAZIDE MG TABLET CAPTOPRIL- HYDROCHLOROTHIAZIDE MG TABLET CAPTOPRIL- HYDROCHLOROTHIAZIDE MG TABLET ENALAPRIL-HYDROCHLOROTHIAZIDE MG TABLET ENALAPRIL-HYDROCHLOROTHIAZIDE MG TAB FOSINOPRIL- HYDROCHLOROTHIAZIDE MG TAB FOSINOPRIL- HYDROCHLOROTHIAZIDE MG TAB LISINOPRIL-HYDROCHLOROTHIAZIDE MG TAB LISINOPRIL-HYDROCHLOROTHIAZIDE MG TAB AMLODIPINE BESYLATE- BENAZEPRIL AMLODIPINE BESYLATE- BENAZEPRIL AMLODIPINE BESYLATE- BENAZEPRIL AMLODIPINE BESYLATE- BENAZEPRIL AMLODIPINE BESYLATE- BENAZEPRIL AMLODIPINE BESYLATE- BENAZEPRIL BENAZEPRIL- HYDROCHLOROTHIAZIDE BENAZEPRIL- HYDROCHLOROTHIAZIDE BENAZEPRIL- HYDROCHLOROTHIAZIDE BENAZEPRIL- HYDROCHLOROTHIAZIDE CAPTOPRIL- HYDROCHLOROTHIAZIDE CAPTOPRIL- HYDROCHLOROTHIAZIDE CAPTOPRIL- HYDROCHLOROTHIAZIDE CAPTOPRIL- HYDROCHLOROTHIAZIDE ENALAPRIL- HYDROCHLOROTHIAZIDE ENALAPRIL- HYDROCHLOROTHIAZIDE FOSINOPRIL- HYDROCHLOROTHIAZIDE FOSINOPRIL- HYDROCHLOROTHIAZIDE LISINOPRIL- HYDROCHLOROTHIAZIDE LISINOPRIL- HYDROCHLOROTHIAZIDE 17

19 Next Level Health ACE Inhibitors and ACE Inhibitor Combinations LISINOPRIL-HYDROCHLOROTHIAZIDE MG TAB MOEXIPRIL-HYDROCHLOROTHIAZIDE MG TAB MOEXIPRIL-HYDROCHLOROTHIAZIDE MG TABLET MOEXIPRIL-HYDROCHLOROTHIAZIDE MG TAB QUINAPRIL-HYDROCHLOROTHIAZIDE MG TAB QUINAPRIL-HYDROCHLOROTHIAZIDE MG TAB QUINAPRIL-HYDROCHLOROTHIAZIDE MG TAB TRANDOLAPRIL-VERAPAMIL ER MG TABLET TRANDOLAPRIL-VERAPAMIL ER MG TABLET TRANDOLAPRIL-VERAPAMIL ER MG TABLET TRANDOLAPRIL-VERAPAMIL ER MG TABLET LISINOPRIL- HYDROCHLOROTHIAZIDE MOEXIPRIL- HYDROCHLOROTHIAZIDE MOEXIPRIL- HYDROCHLOROTHIAZIDE MOEXIPRIL- HYDROCHLOROTHIAZIDE QUINAPRIL- HYDROCHLOROTHIAZIDE QUINAPRIL- HYDROCHLOROTHIAZIDE QUINAPRIL- HYDROCHLOROTHIAZIDE TRANDOLAPRIL-VERAPAMIL ER TRANDOLAPRIL-VERAPAMIL ER TRANDOLAPRIL-VERAPAMIL ER TRANDOLAPRIL-VERAPAMIL ER Acne Therapy ADAPALENE 0.1% CREAM ADAPALENE ST Must have trial and failure of generic tretinoin products within the past 360 days. ADAPALENE 0.1% GEL ADAPALENE ST Must have trial and failure of generic tretinoin products within the past 360 days. ADAPALENE 0.1% LOTION ADAPALENE ST Must have trial and failure of generic tretinoin products within the past 360 days. AVITA 0.025% CREAM AVITA ST Must have trial and failure of generic tretinoin products within the past 360 days. AVITA 0.025% GEL AVITA ST Must have trial and failure of generic tretinoin products within the past 360 days. BENZOYL PEROXIDE 10% GEL ERYTHROMYCIN 2% GEL ERYTHROMYCIN 2% PLEDGETS ERYTHROMYCIN 2% SOLUTION INOVA 4% EASY PAD INOVA 8% EASY PAD METRONIDAZOLE 0.75% CREAM METRONIDAZOLE 0.75% LOTION BENZOYL PEROXIDE ERYTHROMYCIN ERYTHROMYCIN ERYTHROMYCIN INOVA INOVA METRONIDAZOLE METRONIDAZOLE 18

20 Next Level Health Acne Therapy RETIN-A 0.01% GEL RETIN-A ST Must have trial and failure of generic tretinoin products within the past 360 days. RETIN-A 0.025% CREAM RETIN-A ST Must have trial and failure of generic tretinoin products within the past 360 days. RETIN-A 0.025% GEL RETIN-A ST Must have trial and failure of generic tretinoin products within the past 360 days. RETIN-A 0.05% CREAM RETIN-A ST Must have trial and failure of generic tretinoin products within the past 360 days. RETIN-A 0.1% CREAM RETIN-A ST Must have trial and failure of generic tretinoin products within the past 360 days. RETIN-A MICRO 0.04% GEL RETIN-A MICRO ST Must have trial and failure of generic tretinoin products within the past 360 days. RETIN-A MICRO 0.1% GEL RETIN-A MICRO ST Must have trial and failure of generic tretinoin products within the past 360 days. RETIN-A MICRO PUMP 0.04% GEL RETIN-A MICRO PUMP ST Must have trial and failure of generic tretinoin products within the past 360 days. RETIN-A MICRO PUMP 0.08% GEL RETIN-A MICRO PUMP ST Must have trial and failure of generic tretinoin products within the past 360 days. RETIN-A MICRO PUMP 0.1% GEL RETIN-A MICRO PUMP ST Must have trial and failure of generic tretinoin products within the past 360 days. TRETINOIN 0.01% GEL TRETINOIN 0.025% CREAM TRETINOIN 0.025% GEL TRETINOIN 0.05% CREAM TRETINOIN 0.05% GEL TRETINOIN 0.1% CREAM TRETINOIN GEL MICRO 0.04% PUMP TRETINOIN GEL MICRO 0.04% TUBE TRETINOIN GEL MICRO 0.1% PUMP TRETINOIN GEL MICRO 0.1% TUBE TRETINOIN TRETINOIN TRETINOIN TRETINOIN TRETINOIN TRETINOIN TRETINOIN MICROSPHERE TRETINOIN MICROSPHERE TRETINOIN MICROSPHERE TRETINOIN MICROSPHERE Acne Therapy Topical INOVA 4-1 EASY PAD INOVA 4-1 INOVA 8-2 EASY PAD INOVA 8-2 Alcoholism Treatment Agents 19

21 Next Level Health Alcoholism Treatment Agents ACAMPROSATE CALC DR 333 MG TAB VIVITROL 380 MG VIAL VIVITROL 380 MG VIAL + DILUENT ACAMPROSATE CALCIUM VIVITROL VIVITROL Analgesic Narcotic Agonist Combinations HYDROCODONE-ACETAMINOPHEN 10 MG-325 MG/15 ML SOLUTION HYDROCODONE-ACETAMINOPHEN MG TABLET HYDROCODONE-ACETAMINOPHEN MG TABLET HYDROCODONE-ACETAMINOPHEN TABLET HYDROCODONE-ACETAMINOPHEN 2.5 MG-108 MG/5 ML SOLUTION HYDROCODONE-ACETAMINOPHEN 2.5 MG-167 MG/5 ML SOLUTION HYDROCODONE-ACETAMINOPHEN MG TABLET HYDROCODONE-ACETAMINOPHEN 5 MG-163 MG/7.5 ML SOLUTION HYDROCODONE-ACETAMINOPHEN 5 MG-217 MG/10 ML SOLUTION HYDROCODONE-ACETAMINOPHEN MG TABLET HYDROCODONE-ACETAMINOPHEN MG TABLET HYDROCODONE-ACETAMINOPHEN TABLET HYDROCODONE-ACETAMINOPHEN 7.5 MG-325 MG/15 ML SOLUTION HYDROCODONE-ACETAMINOPHEN MG TABLET HYDROCODONE-ACETAMINOPHEN MG TABLET HYDROCODONE-ACETAMINOPHEN TAB HYDROCODONE-IBUPROFEN OXYCODONE-ACETAMINOPHEN MG TAB OXYCODONE-ACETAMINOPHEN MG TABLET OXYCODONE-ACETAMINOPHEN MG TAB OXYCODONE-ACETAMINOPHEN MG TAB HYDROCODONE- ACETAMINOPHEN HYDROCODONE- ACETAMINOPHEN HYDROCODONE- ACETAMINOPHEN HYDROCODONE- ACETAMINOPHEN HYDROCODONE- ACETAMINOPHEN HYDROCODONE- ACETAMINOPHEN HYDROCODONE- ACETAMINOPHEN HYDROCODONE- ACETAMINOPHEN HYDROCODONE- ACETAMINOPHEN HYDROCODONE- ACETAMINOPHEN HYDROCODONE- ACETAMINOPHEN HYDROCODONE- ACETAMINOPHEN HYDROCODONE- ACETAMINOPHEN HYDROCODONE- ACETAMINOPHEN HYDROCODONE- ACETAMINOPHEN HYDROCODONE- ACETAMINOPHEN HYDROCODONE-IBUPROFEN OXYCODONE- ACETAMINOPHEN OXYCODONE- ACETAMINOPHEN OXYCODONE- ACETAMINOPHEN OXYCODONE- ACETAMINOPHEN QL QL QL QL QL QL QL QL QL QL 20

22 Next Level Health Analgesic Narcotic Agonist Combinations OXYCODONE-ACETAMINOPHEN MG TABLET OXYCODONE-ACETAMINOPHEN MG TAB OXYCODONE-ACETAMINOPHEN MG TABLET OXYCODONE- ACETAMINOPHEN OXYCODONE- ACETAMINOPHEN OXYCODONE- ACETAMINOPHEN QL QL QL Analgesic Narcotic Agonists and Combinations ACETAMINOPHEN-COD #2 TABLET ACETAMINOPHEN-CODEINE QL ACETAMINOPHEN-COD #3 TABLET ACETAMINOPHEN-CODEINE QL ACETAMINOPHEN-COD #4 TABLET ACETAMINOPHEN-CODEINE QL ACETAMINOPHEN-CODEINE 120 MG- 12 MG/5 ML SOLUTION ACETAMINOPHEN-CODEINE MG/5 ML ACETAMINOPHEN-CODEINE MG/10 ML ACETAMINOPHEN-CODEINE MG/12.5 ML ACETAMINOPHEN-CODEINE ACETAMINOPHEN-CODEINE ACETAMINOPHEN-CODEINE ACETAMINOPHEN-CODEINE Analgesic, Anti-inflammatory or Antipyretic - Non-Narcotic BUTALB-ACETAMINOPHEN-CAFF TAB BUTALBITAL-ACETAMINOPHEN MG TAB CHOLINE MAG TRISAL LIQUID SALSALATE 500 MG TABLET SALSALATE 750 MG TABLET BUTALBITAL-ACETAMINOPHEN- CAFFE BUTALBITAL-ACETAMINOPHEN CHOLINE MAG TRISALICYLATE SALSALATE SALSALATE Analgesics - Narcotic CODEINE SULFATE 15 MG TABLET CODEINE SULFATE 30 MG TABLET CODEINE SULFATE 60 MG TABLET EMBEDA ER MG CAPSULE EMBEDA ER MG CAPSULE EMBEDA ER MG CAPSULE EMBEDA ER 50-2 MG CAPSULE EMBEDA ER MG CAPSULE EMBEDA ER MG CAPSULE CODEINE SULFATE CODEINE SULFATE CODEINE SULFATE EMBEDA EMBEDA EMBEDA EMBEDA EMBEDA EMBEDA FENTANYL 100 MCG/HR PATCH FENTANYL QL FENTANYL 12 MCG/HR PATCH FENTANYL QL QL QL QL 21

23 Next Level Health Analgesics - Narcotic FENTANYL 25 MCG/HR PATCH FENTANYL QL FENTANYL 37.5 MCG/HR PATCH FENTANYL 50 MCG/HR PATCH FENTANYL 62.5 MCG/HR PATCH FENTANYL FENTANYL FENTANYL FENTANYL 75 MCG/HR PATCH FENTANYL QL FENTANYL 87.5 MCG/HR PATCH HYDROMORPHONE 0.5 MG/0.5 ML HYDROMORPHONE 1 MG/ML SOLUTION FENTANYL HYDROMORPHONE HCL HYDROMORPHONE HCL HYDROMORPHONE 2 MG TABLET HYDROMORPHONE HCL QL HYDROMORPHONE 4 MG TABLET HYDROMORPHONE HCL QL HYDROMORPHONE 5 MG/5 ML SOLN HYDROMORPHONE 8 MG TABLET HYDROMORPHONE HCL 110 MG/55 ML HYDROMORPHONE HCL 2 MG/1 ML HYDROMORPHONE HCL 60 MG/30 ML HYDROMORPHONE HCL HYDROMORPHONE HCL HYDROMORPHONE HCL HYDROMORPHONE HCL HYDROMORPHONE HCL MEPERIDINE 100 MG TABLET MEPERIDINE HCL QL MEPERIDINE 50 MG TABLET MEPERIDINE HCL QL MEPERIDINE 50 MG/5 ML SOLUTION MEPERIDINE HCL METHADONE 10 MG/5 ML SOLUTION METHADONE HCL QL METHADONE 10 MG/ML ORAL CONC METHADONE HCL QL METHADONE 40 MG TABLET DISPR METHADONE HCL METHADONE 5 MG/5 ML SOLUTION METHADONE HCL QL METHADONE HCL 10 MG TABLET METHADONE HCL QL METHADONE HCL 10 MG/ML SYRINGE METHADONE HCL 10 MG/ML SYRINGE (CMPD-RX) METHADONE HCL 10 MG/ML VIAL METHADONE HCL METHADONE HCL METHADONE HCL METHADONE HCL 5 MG TABLET METHADONE HCL QL METHADONE INTENSOL 10 MG/ML METHADONE-NS 1 MG/1 ML SYRINGE METHADONE INTENSOL METHADONE HCL MORPHINE SULF CR 100 MG TABLET MORPHINE SULFATE CR QL MORPHINE SULF CR 60 MG TABLET MORPHINE SULFATE CR QL MORPHINE SULF ER 100 MG TABLET MORPHINE SULFATE ER QL MORPHINE SULF ER 15 MG TABLET MORPHINE SULFATE ER QL MORPHINE SULF ER 200 MG TABLET MORPHINE SULFATE ER QL MORPHINE SULF ER 30 MG TABLET MORPHINE SULFATE ER QL MORPHINE SULF ER 60 MG TABLET MORPHINE SULFATE ER QL MORPHINE SULFATE IR 15 MG TAB MORPHINE SULFATE QL MORPHINE SULFATE IR 30 MG TAB MORPHINE SULFATE QL OXYCODONE HCL 10 MG TABLET OXYCODONE HCL 22

24 Next Level Health Analgesics - Narcotic OXYCODONE HCL 100 MG/5 ML SOLN OXYCODONE HCL 15 MG TABLET OXYCODONE HCL 20 MG TABLET OXYCODONE HCL 30 MG TABLET OXYCODONE HCL OXYCODONE HCL OXYCODONE HCL OXYCODONE HCL OXYCODONE HCL 5 MG CAPSULE OXYCODONE HCL QL OXYCODONE HCL 5 MG TABLET OXYCODONE HCL QL OXYCODONE HCL 5 MG/5 ML SOLN OXYCODONE HCL TRAMADOL HCL 50 MG TABLET TRAMADOL HCL QL Androgen-Anabolic TESTOSTERON CYP 1,000 MG/10 ML TESTOSTERON CYP 2,000 MG/10 ML TESTOSTERONE CYP 100 MG/ML TESTOSTERONE CYP 200 MG/ML TESTOSTERONE CYPIONATE TESTOSTERONE CYPIONATE TESTOSTERONE CYPIONATE TESTOSTERONE CYPIONATE Anesthetics LIDOCAINE HCL 4% SOLUTION LIDOCAINE HCL Angina Therapy ISOSORBIDE DN 10 MG TABLET ISOSORBIDE DN 20 MG TABLET ISOSORBIDE DN 30 MG TABLET ISOSORBIDE DN 5 MG TABLET ISOSORBIDE DN ER 40 MG TABLET ISOSORBIDE MN 20 MG TABLET ISOSORBIDE MN ER 120 MG TAB ISOSORBIDE MN ER 30 MG TABLET ISOSORBIDE MN ER 60 MG TABLET NITROGLYCERIN 0.1 MG/HR PATCH NITROGLYCERIN 0.2 MG/HR PATCH NITROGLYCERIN 0.4 MG TABLET SL NITROGLYCERIN 0.4 MG/HR PATCH NITROGLYCERIN 0.6 MG/HR PATCH NITROGLYCERIN ER 2.5 MG CAP NITROGLYCERIN ER 6.5 MG CAP NITROGLYCERIN ER 9 MG CAPSULE NITROSTAT 0.3 MG TABLET SL ISOSORBIDE DINITRATE ISOSORBIDE DINITRATE ISOSORBIDE DINITRATE ISOSORBIDE DINITRATE ISOSORBIDE DINITRATE ISOSORBIDE MONONITRATE ISOSORBIDE MONONITRATE ER ISOSORBIDE MONONITRATE ER ISOSORBIDE MONONITRATE ER NITROGLYCERIN PATCH NITROGLYCERIN PATCH NITROGLYCERIN NITROGLYCERIN PATCH NITROGLYCERIN PATCH NITROGLYCERIN NITROGLYCERIN NITROGLYCERIN NITROSTAT 23

25 Next Level Health Angina Therapy NITROSTAT 0.4 MG TABLET SL NITROSTAT Angiotensin II Receptor Blocker (ARBs) and ARB Cominations AMLODIPINE-VALSARTAN MG AMLODIPINE-VALSARTAN MG AMLODIPINE-VALSARTAN MG AMLODIPINE-VALSARTAN MG AMLODIPINE-VALSARTAN- HYDROCHLOROTHIAZIDE MG TAB AMLODIPINE-VALSARTAN- HYDROCHLOROTHIAZIDE MG TAB AMLODIPINE-VALSARTAN- HYDROCHLOROTHIAZIDE MG TAB AMLODIPINE-VALSARTAN- HYDROCHLOROTHIAZIDE MG TAB AMLODIPINE-VALSARTAN- HYDROCHLOROTHIAZIDE MG TAB IRBESARTAN- HYDROCHLOROTHIAZIDE MG TB IRBESARTAN- HYDROCHLOROTHIAZIDE MG TB LOSARTAN-HYDROCHLOROTHIAZIDE MG TAB LOSARTAN-HYDROCHLOROTHIAZIDE MG TAB LOSARTAN-HYDROCHLOROTHIAZIDE MG TAB TELMISARTAN-AMLODIPINE TELMISARTAN-AMLODIPINE 40-5 MG TELMISARTAN-AMLODIPINE TELMISARTAN-AMLODIPINE 80-5 MG VALSARTAN- HYDROCHLOROTHIAZIDE MG TAB VALSARTAN- HYDROCHLOROTHIAZIDE MG TAB VALSARTAN- HYDROCHLOROTHIAZIDE MG TAB AMLODIPINE-VALSARTAN AMLODIPINE-VALSARTAN AMLODIPINE-VALSARTAN AMLODIPINE-VALSARTAN AMLODIPINE-VALSARTAN- HCTZ AMLODIPINE-VALSARTAN- HCTZ AMLODIPINE-VALSARTAN- HCTZ AMLODIPINE-VALSARTAN- HCTZ AMLODIPINE-VALSARTAN- HCTZ IRBESARTAN- HYDROCHLOROTHIAZIDE IRBESARTAN- HYDROCHLOROTHIAZIDE LOSARTAN- HYDROCHLOROTHIAZIDE LOSARTAN- HYDROCHLOROTHIAZIDE LOSARTAN- HYDROCHLOROTHIAZIDE TELMISARTAN-AMLODIPINE TELMISARTAN-AMLODIPINE TELMISARTAN-AMLODIPINE TELMISARTAN-AMLODIPINE VALSARTAN- HYDROCHLOROTHIAZIDE VALSARTAN- HYDROCHLOROTHIAZIDE VALSARTAN- HYDROCHLOROTHIAZIDE QL QL QL 24

26 Next Level Health Angiotensin II Receptor Blocker (ARBs) and ARB Cominations VALSARTAN- HYDROCHLOROTHIAZIDE MG TAB VALSARTAN- HYDROCHLOROTHIAZIDE MG TAB VALSARTAN- HYDROCHLOROTHIAZIDE VALSARTAN- HYDROCHLOROTHIAZIDE Anti-Infective Agents CLINDAMYCIN 75 MG/5 ML SOLN CLINDAMYCIN PALMITATE HCL QL Medication is for pediatric members through age 8. CLINDAMYCIN HCL 150 MG CAPSULE CLINDAMYCIN HCL 300 MG CAPSULE CLINDAMYCIN HCL CLINDAMYCIN HCL CLINDAMYCIN PEDIATR 75 MG/5 ML CLINDAMYCIN PEDIATRIC QL Medication is for pediatric members through age 8. CLINDAMYCIN PEDIATRIC 75 MG/5 ML CLINDAMYCIN PEDIATRIC QL Medication is for pediatric members through age 8. FLUCYTOSINE 250 MG CAPSULE FLUCYTOSINE 500 MG CAPSULE GRISEOFULVIN 125 MG/5 ML SUSP GRISEOFULVIN MICRO 500 MG TAB GRISEOFULVIN ULTRA 125 MG TAB GRISEOFULVIN ULTRA 250 MG TAB NEOMYCIN 500 MG TABLET NYSTATIN 150,000,000 UNITS PWD NYSTATIN 50,000,000 UNITS PWD NYSTATIN 500,000 UNIT ORAL TAB NYSTATIN 500,000,000 UNITS PWD TERBINAFINE HCL 250 MG TABLET VANCOMYCIN HCL 125 MG CAPSULE FLUCYTOSINE FLUCYTOSINE GRISEOFULVIN GRISEOFULVIN GRISEOFULVIN ULTRAMICROSIZE GRISEOFULVIN ULTRAMICROSIZE NEOMYCIN SULFATE NYSTATIN NYSTATIN NYSTATIN NYSTATIN TERBINAFINE HCL VANCOMYCIN HCL Antiarrhythmics DISOPYRAMIDE 100 MG CAPSULE DISOPYRAMIDE 150 MG CAPSULE FLECAINIDE ACETATE 100 MG TAB FLECAINIDE ACETATE 150 MG TAB FLECAINIDE ACETATE 50 MG TAB MEXILETINE 150 MG CAPSULE MEXILETINE 200 MG CAPSULE MEXILETINE 250 MG CAPSULE PROPAFENONE HCL 150 MG TABLET DISOPYRAMIDE PHOSPHATE DISOPYRAMIDE PHOSPHATE FLECAINIDE ACETATE FLECAINIDE ACETATE FLECAINIDE ACETATE MEXILETINE HCL MEXILETINE HCL MEXILETINE HCL PROPAFENONE HCL QL QL 25

27 Next Level Health Antiarrhythmics PROPAFENONE HCL 225 MG TAB PROPAFENONE HCL 300 MG TAB QUINIDINE SULF ER 300 MG TAB QUINIDINE SULFATE 200 MG TAB QUINIDINE SULFATE 300 MG TAB PROPAFENONE HCL PROPAFENONE HCL QUINIDINE SULFATE QUINIDINE SULFATE QUINIDINE SULFATE Antibacterial Agents AZITHROMYCIN 1 GM PWD PACKET AZITHROMYCIN 100 MG/5 ML SUSP AZITHROMYCIN AZITHROMYCIN AZITHROMYCIN 200 MG/5 ML SUSP AZITHROMYCIN Medication is for pediatric members through age 8. AZITHROMYCIN 250 MG TABLET AZITHROMYCIN QL AZITHROMYCIN 500 MG TABLET AZITHROMYCIN QL AZITHROMYCIN 600 MG TABLET AZITHROMYCIN CLARITHROMYCIN 125 MG/5 ML SUS CLARITHROMYCIN Medication is for pediatric members through age 8. CLARITHROMYCIN 250 MG TABLET CLARITHROMYCIN CLARITHROMYCIN 250 MG/5 ML SUS CLARITHROMYCIN Medication is for pediatric members through age 8. CLARITHROMYCIN 500 MG TABLET CLARITHROMYCIN ER 500 MG TAB CLARITHROMYCIN CLARITHROMYCIN ER DEMECLOCYCLINE 150 MG TABLET DEMECLOCYCLINE HCL QL DEMECLOCYCLINE 300 MG TABLET DEMECLOCYCLINE HCL QL DOXYCYCLINE HYCLATE 100 MG CAP DOXYCYCLINE HYCLATE 100 MG TAB DOXYCYCLINE HYCLATE 50 MG CAP ERYTHROMYCIN 250 MG FILMTAB ERYTHROMYCIN 500 MG FILMTAB ERYTHROMYCIN DR 250 MG CAP ERYTHROMYCIN EC 250 MG CAP MINOCYCLINE 100 MG CAPSULE MINOCYCLINE 50 MG CAPSULE MINOCYCLINE 75 MG CAPSULE SULFADIAZINE 500 MG TABLET TETRACYCLINE 250 MG CAPSULE TETRACYCLINE 500 MG CAPSULE TRIMETHOPRIM 100 MG TABLET DOXYCYCLINE HYCLATE DOXYCYCLINE HYCLATE DOXYCYCLINE HYCLATE ERYTHROMYCIN ERYTHROMYCIN ERYTHROMYCIN ERYTHROMYCIN MINOCYCLINE HCL MINOCYCLINE HCL MINOCYCLINE HCL SULFADIAZINE TETRACYCLINE HCL TETRACYCLINE HCL TRIMETHOPRIM 26