Commonwealth Care Alliance (Medicare-Medicaid Plan) One Care Plan

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1 2018 List of Covered Drugs (Formulary) Commonwealth Care Alliance (Medicare-Medicaid Plan) One Care Plan 30 Winter Street Boston, MA PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN If you have questions, please call Commonwealth Care Alliance at (TTY 711), 8 a.m. 8 p.m., 7 days a week. The call is free. For more information, visit H0137_CF2018_FINAL Approved Formulary: ID , Version 19, Update 10/01/2018

2 Commonwealth Care Alliance 2018 List of Covered Drugs (Formulary) This is a list of drugs that members can get in Commonwealth Care Alliance. Commonwealth Care Alliance (Medicare-Medicaid Plan) is a health plan that contracts with both Medicare and MassHealth to provide benefits of both programs to enrollees. The List of Covered Drugs and/or pharmacy and provider networks may change throughout the year. We will send you a notice before we make a change that affects you. Benefits may change on January 1 of each year. You can always check Commonwealth Care Alliance s up-to-date List of Covered Drugs online at or by calling (TTY: call MassRelay at 711). Limitations and restrictions may apply. For more information, call Commonwealth Care Alliance Member Services or read the Commonwealth Care Alliance Member Handbook. If you speak Spanish, language assistance services, free of charge, are available to you. Call (TTY: call MassRelay at 711), 8 a.m. 8 p.m., 7 days a week. The call is free. Si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al (TTY: llamar a MassRelay al 711), 8 a.m. 8 p.m., 7 días a la semana. Este es un servicio gratuito. You can get this document for free in other formats, such as large print, braille, or audio. Call (TTY: call MassRelay at 711), 8 a.m. 8 p.m., 7 days a week. The call is free. For purposes of future mailings, we will keep your request for alternative formats and/or special languages on file. Note to existing members: This formulary has changed since last year. Please review this document to make sure that it still contains the drugs you take. Commonwealth Care Alliance complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Commonwealth Care Alliance cumple con las leyes federales de derechos civiles aplicables y no discrimina por motivos de raza, color, nacionalidad, edad, discapacidad o sexo. H0137_CF2018 Approved? If you have questions, please call Commonwealth Care Alliance at (TTY: call MassRelay at 711), 8 a.m. 8 p.m., 7 days a week. The call is free. For more information, visit i

3 Frequently Asked Questions (FAQ) Find answers here to questions you have about this List of Covered Drugs. You can read all of the FAQ to learn more, or look for a question and answer. 1. What prescription drugs are on the List of Covered Drugs? (We call the List of Covered Drugs the Drug List for short.) The drugs on the List of Covered Drugs that starts on page 3 are the drugs covered by Commonwealth Care Alliance. The drugs are available at pharmacies within our network. A pharmacy is in our network if we have an agreement with them to work with us and provide you services. We refer to these pharmacies as network pharmacies. Commonwealth Care Alliance will cover all drugs on the Drug List if: your doctor or other prescriber says you need them to get better or stay healthy, Commonwealth Care Alliance agrees that the drug is medically necessary for you, and you fill the prescription at a Commonwealth Care Alliance network pharmacy. In some cases, you have to do something before you can get a drug (see question 7 below). You can also see an up-to-date list of drugs that we cover on our website at or call Member Services at (TTY: call MassRelay at 711). 2. Does the Drug List ever change? Yes. Commonwealth Care Alliance may add or remove drugs on the Drug List during the year. Generally, the Drug List will only change if: a new drug comes along that works as well as a drug on the Drug List now, or we learn that a drug is not safe. We may also change our rules about drugs. For example, we could: Decide to require or not require prior approval for a drug. (Prior approval is permission from Commonwealth Care Alliance before you can get a drug.) Add or change the amount of a drug you can get (called quantity limits ). Add or change step therapy restrictions on a drug. (Step therapy means you must try one drug before we will cover another drug.) (For more information on these drug rules, see page iv.) We will tell you when a drug you are taking is removed from the Drug List. We will also tell you when we change our rules for covering a drug. Questions 3, 4 and 9 below have more information on what happens when the Drug List changes. ii

4 You can always check Commonwealth Care Alliance s up to date Drug List online at You can also call Member Services to check the current Drug List at (TTY: call MassRelay at 711). 3. What happens when a drug is removed from the Drug List or we change our rules for getting a drug? If a cheaper drug becomes available that works as well as a drug on the Drug List now, the drug you get may change because: Your pharmacist may give you the cheaper drug the next time you fill your prescription. If you and your doctor decide that the cheaper drug is not right for you, your doctor can tell the pharmacist to give you the drug you take now. Commonwealth Care Alliance may decide to take the older drug off of the Drug List. If you are taking a drug that we decide to remove from the Drug List because a cheaper drug that works just as well comes along, we will tell you. We will tell you at least 60 days before we remove it from the Drug List or when you ask for a refill. Then you can get a 60-day supply of the drug before the change to the Drug List is made. If there is a change to coverage for a drug you are taking, we will send you a notice to tell you. We will tell you if you are taking a drug and we change our rules for covering it. For example, if you are taking a drug, and we add prior authorization (approval), quantity limits, and/or step therapy, we will tell you. We must tell you of this change at least 60 days before it becomes effective, or when you ask for a refill of the drug. If we tell you when you refill your drug, you will get a 60-day supply of the drug. This means that if your prescription is for a 30-day supply, you will get two 30-day refills. If your prescription is for a 60-day or 90-day supply, you will get one 60-day refill. For more information on these drug rules, see page iv. 4. What happens if we find out a drug is not safe? If the Food and Drug Administration (FDA) says a drug you are taking is not safe, we will take it off the Drug List right away. We will also send you a letter and call you to tell you that the drug is not safe and that we have taken it off the drug list. Your provider will also know about this change, and can work with you to find another drug for your condition.? If you have questions, please call Commonwealth Care Alliance at (TTY: call MassRelay at 711), 8 a.m. 8 p.m., 7 days a week. The call is free. For more information, visit iii

5 5. What is your copay? Commonwealth Care Alliance members have no copays for prescription and OTC drugs as long as the member follows the plan s rules. 6. What are drug tiers? Tiers are groups of drugs on our Drug List. Every drug on the plan s Drug List is in one of three tiers. Tier 1 includes generic drugs, tier 2 includes preferred brand drugs, and tier 3 includes nonpreferred brand drugs. All three tiers consist of both part D drugs and non-medicare covered drugs, and /or non-medicare covered OTC drugs. All tiers have no copay. As a member of our plan, you pay nothing for all covered drugs no matter what tier they are in. 7. Are there any restrictions or limits on drug coverage? Or are there any required actions to take in order to get certain drugs? Yes, some drugs have coverage rules or have limits on the amount you can get. In some cases you or your doctor or other prescriber must do something before you can get the drug. For example: Prior approval (or prior authorization): For some drugs, you or your doctor or other prescriber must get approval from Commonwealth Care Alliance before you fill your prescription. If you don t get approval, Commonwealth Care Alliance may not cover the drug. Quantity limits: Sometimes Commonwealth Care Alliance limits the amount of a drug you can get. Step therapy: Sometimes Commonwealth Care Alliance requires you to do step therapy. This means you will have to try drugs in a certain order for your medical condition. You might have to try one drug before we will cover another drug. If your doctor thinks the first drug doesn t work for you, then we will cover the second. You can find out if your drug has any additional requirements or limits by looking in the les beginning on page 3. You can also get more information by visiting our web site at We have posted online documents that explain our prior authorization and step therapy restrictions. You may also ask us to send you a copy. You can ask for an exception from these limits. Please see question 12 for more information on exceptions. iv

6 If you are in a nursing home or other long-term care facility and need a drug that is not on the Drug List, or if you cannot easily get the drug you need, we can help. We will cover a 31-day emergency supply of the drug you need (unless you have a prescription for fewer days), whether or not you are a new Commonwealth Care Alliance member. This will give you time to talk to your doctor or other prescriber. He or she can help you decide if there is a similar drug on the Drug List you can take instead or whether to ask for an exception. Please see question 13 for more information about exceptions. 8. How will you know if the drug you want has limitations or if there are required actions to take to get the drug? The List of Covered Drugs on page 3 has a column labeled restrictions, or limits on use. 9. What happens if we change our rules on how we cover some of the drugs? For example, if we add prior authorization (approval), quantity limits, and/or step therapy restrictions on a drug. We will tell you if we add prior approval, quantity limits, and/or step therapy restrictions on a drug. We will tell you at least 60 days before the restriction is added or when you next ask your pharmacy for a refill. Then, you can get a 60-day supply of the drug before the change to the Drug List is made. This gives you time to talk to your doctor or other prescriber about what to do next. 10. How can you find a drug on the Drug List? There are two ways to find a drug: You can search alphabetically (if you know how to spell the drug), or You can search by medical condition. To search alphabetically, you should look for your drug in the Index that begins on page 139. You can find it by looking in the index. Next to your drug, you will see the page number where you can find coverage information. Turn to the page listed in the Index and find the name of your drug in the first column of the list. To search by medical condition, find the section labeled List of drugs by medical condition on page 3. The drugs in this section are grouped into categories depending on the type of medical conditions they are used to treat. For example, if you have a heart condition, you should look in the category Cardiovascular Agents. That is where you will find drugs that treat heart conditions.? If you have questions, please call Commonwealth Care Alliance at (TTY: call MassRelay at 711), 8 a.m. 8 p.m., 7 days a week. The call is free. For more information, visit v

7 11. What if the drug you want to take is not on the Drug List? If you don t see your drug on the Drug List, call Member Services at (TTY: call MassRelay at 711) and ask about it. If you learn that Commonwealth Care Alliance will not cover the drug, you can do one of these things: Ask Member Services for a list of drugs like the one you want to take. Then show the list to your doctor or other prescriber. He or she can prescribe a drug on the Drug List that is like the one you want to take. Or You can ask the health plan to make an exception to cover your drug. Please see question 12 for more information about exceptions. 12. What if you are a new Commonwealth Care Alliance member and can t find your drug on the Drug List or have a problem getting your drug? We can help. We may cover a temporary 30-day supply of your drug during the first 90 days you are a member of Commonwealth Care Alliance. This will give you time to talk to your doctor or other prescriber. He or she can help you decide if there is a similar drug on the Drug List you can take instead or whether to ask for an exception. We will cover a 30-day supply of your drug if: you are taking a drug that is not on our Drug List, or health plan rules do not let you get the amount ordered by your prescriber, or the drug requires prior approval by Commonwealth Care Alliance, or you are taking a drug that is part of a step therapy restriction If you are taking a drug that Commonwealth Care Alliance does not consider to be a Part D drug, you have the right to get a one-time, 72-hour supply of the drug. You can find more information about getting a temporary supply of a drug in Chapter 5 of your Member Handbook. If you live in a nursing home or other long-term care facility, you may refill your prescription for as long as 98 days. You may refill the drug multiple times during your first 90 days in the plan. This gives your prescriber time to change your drugs to ones on the Drug List or ask for an exception. For current enrollees with level-of-care changes, we will provide an emergency supply of at least 31 days (unless the prescription is written for fewer days) for all non-formulary medications including those that may have step therapy or prior authorization requirements. An unplanned level of care transition could be any of the following: a discharge or admission to a Long Term Care facility a discharge or admission to a hospital, or vi

8 a nursing facility skilled level change. 13. Can you ask for an exception to cover your drug? Yes. You can ask Commonwealth Care Alliance to make an exception to cover a drug that is not on the Drug List. You can also ask us to change the rules on your drug. For example, Commonwealth Care Alliance may limit the amount of a drug we will cover. If your drug has a limit, you can ask us to change the limit and cover more. Other examples: You can ask us to drop step therapy restrictions or prior approval requirements. 14. How long does it take to get an exception? First, we must get a statement from your prescriber supporting your request for an exception. After we get the statement, we will give you a decision on your exception request within 72 hours. If you or your prescriber think your health may be harmed if you have to wait 72 hours for a decision, you can ask for an expedited exception. This is a faster decision. If your prescriber supports your request, we will give you a decision within 24 hours of getting your prescriber s supporting statement. 15. How can you ask for an exception? To ask for an exception, call your Care Team. Your Care Team will work with you and your provider to help you ask for an exception. 16. What are generic drugs? Generic drugs are made up of the same active ingredients as brand name drugs. They usually cost less than the brand name drug and usually don t have well-known names. Generic drugs are approved by the Food and Drug Administration (FDA). Commonwealth Care Alliance covers both brand name drugs and generic drugs. 17. What are OTC drugs? OTC stands for over-the-counter. Commonwealth Care Alliance covers some OTC drugs when they are written as prescriptions by your provider.? If you have questions, please call Commonwealth Care Alliance at (TTY: call MassRelay at 711), 8 a.m. 8 p.m., 7 days a week. The call is free. For more information, visit vii

9 You can read the Commonwealth Care Alliance Drug List to see what OTC drugs are covered. 18. Does Commonwealth Care Alliance cover OTC non-drug products? Commonwealth Care Alliance covers some OTC non-drug products, such as diabetic supplies, when they are written as prescriptions by your provider. You can read the Commonwealth Care Alliance Drug List to see what OTC non-drug products are covered. 19. Does Commonwealth Care Alliance cover long-term supplies of prescriptions? Mail-Order Programs. We offer a mail-order program that allows you to get up to a 90- day supply of your prescription maintenance drugs sent directly to your home. Maintenance drugs are prescription drugs that you use on an ongoing basis, for a chronic or long term medical condition. There is no copay for mail order drugs. 90-Day Retail Pharmacy Programs. Some retail pharmacies may also offer up to a 90- day supply of covered maintenance prescription drugs. Maintenance drugs are prescription drugs that you use on an ongoing basis, for a chronic or long term medical condition. There is no copay on a long-term supply of drugs. 20. Can I get prescriptions delivered to my home from my local pharmacy? Your local pharmacy may be able to deliver your prescription to your home. You can call your pharmacy to find out if they offer home delivery. viii

10 List of Covered Drugs The list of covered drugs that begins on the next page gives you information about the drugs covered by Commonwealth Care Alliance. If you have trouble finding your drug in the list, turn to the Index that begins on page 139. The first column of the chart lists the name of the drug. Brand name drugs are capitalized (e.g., EMEND) and generic drugs are listed in lower-case italics (e.g., cephalexin). The information in the column tells you if Commonwealth Care Alliance has any rules for covering your drug. Note: The DP next to a drug means the drug is not a Part D drug. These drugs have different rules for appeals. An appeal is a formal way of asking us to review a decision we made about your coverage and to change it if you think we made a mistake. For example, we might decide that a drug that you want is not covered or is no longer covered by Medicare or MassHealth. If you or your doctor disagrees with our decision, you can appeal. If you ever have a question, call Member Services at (TTY: call MassRelay at 711). You can also read the Member Handbook to learn how to appeal a decision. You can find information on what the symbols and abbreviations in this le mean by going to page 2 1

11 List of Abbreviations Dual Demonstration Plan (DP): This item is covered under your MassHealth benefits. The DP next to a drug means the drug is not a "Part D drug." The amount you pay when you fill a prescription for this drug does not count towards your total drug costs (that is, the amount you pay does not help you qualify for catastrophic coverage). These drugs also have different rules for appeals. An appeal is a formal way of asking us to review a decision we made about your coverage and to change it if you think we made a mistake. For example, we might decide that a drug that you want is not covered or is no longer covered by Medicare or MassHealth. If you or your doctor disagrees with our decision, you can appeal. If you ever have a question, call Member Services. You can also read the Member Handbook to learn how to appeal a decision. Limited Distribution (LD): Limited Availability. The symbol [LD] next to a drug name indicates that the drug has been noted as being restricted to certain pharmacies by the Food and Drug Administration. These drugs can only be obtained at specialty designated pharmacies able to appropriately handle the drugs. Non-Extended Day Supply (NDS): You may be able to receive greater than a 1-month supply of most of the drugs on your Formulary via retail or mail order. Drugs noted with NDS are limited to a 1-month supply for both Retail and Mail Order. Prior Authorization (PA): Commonwealth Care Alliance (CCA) requires a provider to submit a request for coverage based on a member s medical need for a particular drug. This means that you will need to get approval from CCA before you fill your prescription(s). If you don t get approval, CCA may not cover the drug. Prior Authorization Restriction for Part B vs Part D Determination (PA_BvD): This drug may be eligible for payment under Medicare Part B or Medicare Part D. You [or your physician] are required to get prior authorization from Commonwealth Care Alliance (CCA) to determine that this drug is covered under Medicare Part D before you fill your prescription for this drug. Without prior approval, CCA may not cover this drug. Prior Authorization Restriction for New Starts Only (PA_NSO): If this drug is new to the member, you [or your physician] are required to get prior authorization from CCA before you fill your prescription for this drug. Without prior approval, CCA may not cover this drug. Quantity Limits (QL): For certain drugs, Commonwealth Care Alliance (CCA) limits the amount of the drug that it will cover due to potential safety and utilization concerns. Due to these concerns, CCA has placed dispensing limits on some drugs. This means that only a certain quantity of drug can be dispensed by the pharmacy within a given time period. This could include a: per fill, daily, monthly, or yearly limitation. These quantities are based on standards of care from organizations such as the Food and Drug Administration. You can find information on what the symbols and abbreviations in this le mean by going to page 2 2

12 Step Therapy (ST): In some cases, Commonwealth Care Alliance (CCA) requires you to first try certain drugs to treat your medical condition before we will cover another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, CCA may not cover Drug B unless you try Drug A first. If Drug A does not work for you, CCA will then cover Drug B. You can find information on what the symbols and abbreviations in this le mean by going to page 2

13 List of Drugs by Medical Condition The drugs in this section are grouped into categories depending on the type of medical conditions they are used to treat. For example, if you have a heart condition, you should look in the category, "Cardiovascular Agents". That is where you will find drugs that treat heart conditions. Name of drug ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS - Drugs to treat ADHD, sleep disorders, and weight loss AMPHETAMINES - Drugs to treat ADHD, sleep disorders, and weight loss amphetamine 10mg er cap $0 (Tier 1) amphetamine 10mg $0 (Tier 1) amphetamine 12.5mg $0 (Tier 1) amphetamine 15mg er cap $0 (Tier 1) amphetamine 15mg $0 (Tier 1) amphetamine 20mg er cap $0 (Tier 1) amphetamine 20mg $0 (Tier 1) amphetamine 25mg er cap $0 (Tier 1) amphetamine 30mg er cap $0 (Tier 1) amphetamine 30mg $0 (Tier 1) amphetamine 5mg er cap $0 (Tier 1) amphetamine 5mg $0 (Tier 1) amphetamine 7.5mg $0 (Tier 1) dextroamphetamine sulfate 10mg er cap $0 (Tier 1) dextroamphetamine sulfate 10mg $0 (Tier 1) dextroamphetamine sulfate 15mg er cap $0 (Tier 1) dextroamphetamine sulfate 5mg er cap $0 (Tier 1) dextroamphetamine sulfate 5mg $0 (Tier 1) methamphetamine 5mg $0 (Tier 1) PA VYVANSE 10MG CAP $0 (Tier 2) VYVANSE 10MG CHEW $0 (Tier 2) VYVANSE 20MG CAP $0 (Tier 2) VYVANSE 20MG CHEW $0 (Tier 2) VYVANSE 30MG CAP $0 (Tier 2) VYVANSE 30MG CHEW $0 (Tier 2) VYVANSE 40MG CAP $0 (Tier 2) VYVANSE 40MG CHEW $0 (Tier 2) VYVANSE 50MG CAP $0 (Tier 2) VYVANSE 50MG CHEW $0 (Tier 2) VYVANSE 60MG CAP $0 (Tier 2) VYVANSE 60MG CHEW $0 (Tier 2) VYVANSE 70MG CAP $0 (Tier 2) ATTENTION-DEFICIT/HYPERACTIVITY DISORDER (ADHD) AGENTS - Drugs to treat ADHD and sleep disorders You can find information on what the symbols and abbreviations in this le mean by going to the beginning of this le. 3

14 atomoxetine 100mg cap $0 (Tier 1) QL=60 EA/30 Days atomoxetine 10mg cap $0 (Tier 1) QL=60 EA/30 Days atomoxetine 18mg cap $0 (Tier 1) QL=60 EA/30 Days atomoxetine 25mg cap $0 (Tier 1) QL=60 EA/30 Days atomoxetine 40mg cap $0 (Tier 1) QL=60 EA/30 Days atomoxetine 60mg cap $0 (Tier 1) QL=60 EA/30 Days atomoxetine 80mg cap $0 (Tier 1) QL=60 EA/30 Days guanfacine 1mg er $0 (Tier 1) guanfacine 2mg er $0 (Tier 1) guanfacine 3mg er $0 (Tier 1) guanfacine 4mg er $0 (Tier 1) STIMULANTS - MISC. - Miscellaneous stimulant drugs armodafinil 150mg $0 (Tier 1) PA QL=30 EA/30 Days armodafinil 200mg $0 (Tier 1) PA QL=30 EA/30 Days armodafinil 250mg $0 (Tier 1) PA QL=30 EA/30 Days armodafinil 50mg $0 (Tier 1) PA QL=30 EA/30 Days dexmethylphenidate 10mg er cap $0 (Tier 1) dexmethylphenidate 10mg $0 (Tier 1) dexmethylphenidate 15mg er cap $0 (Tier 1) dexmethylphenidate 2.5mg $0 (Tier 1) dexmethylphenidate 20mg er cap $0 (Tier 1) dexmethylphenidate 30mg er cap $0 (Tier 1) dexmethylphenidate 40mg er cap $0 (Tier 1) dexmethylphenidate 5mg er cap $0 (Tier 1) dexmethylphenidate 5mg $0 (Tier 1) metadate 20mg er $0 (Tier 1) methylphenidate 10mg cd cap $0 (Tier 1) methylphenidate 10mg chew $0 (Tier 1) methylphenidate 10mg er $0 (Tier 1) methylphenidate 10mg la cap $0 (Tier 1) methylphenidate 10mg $0 (Tier 1) METHYLPHENIDATE 18MG SR $0 (Tier 1) methylphenidate 1mg/ml oral soln $0 (Tier 1) methylphenidate 2.5mg chew $0 (Tier 1) methylphenidate 20mg cd cap $0 (Tier 1) methylphenidate 20mg er $0 (Tier 1) methylphenidate 20mg la cap $0 (Tier 1) methylphenidate 20mg $0 (Tier 1) METHYLPHENIDATE 27MG SR $0 (Tier 1) methylphenidate 2mg/ml oral soln $0 (Tier 1) methylphenidate 30mg cd cap $0 (Tier 1) methylphenidate 30mg la cap $0 (Tier 1) METHYLPHENIDATE 36MG SR $0 (Tier 1) You can find information on what the symbols and abbreviations in this le mean by going to the beginning of this le. 4

15 methylphenidate 40mg cd cap $0 (Tier 1) methylphenidate 40mg la cap $0 (Tier 1) methylphenidate 50mg cd cap $0 (Tier 1) METHYLPHENIDATE 54MG SR $0 (Tier 1) methylphenidate 5mg chew $0 (Tier 1) methylphenidate 5mg $0 (Tier 1) methylphenidate 60mg cd cap $0 (Tier 1) modafinil 100mg $0 (Tier 1) PA QL=60 EA/30 Days modafinil 200mg $0 (Tier 1) PA QL=60 EA/30 Days ALTERNATIVE MEDICINES - Miscellaneous alternatives to conventional medicine ALTERNATIVE MEDICINE - C'S - Miscellaneous alternatives to conventional medicine CHEW Q 100MG CHEW $0 (Tier 3) DP CHEW Q 600MG CHEW $0 (Tier 3) DP CO Q MG CAP $0 (Tier 3) DP CO-ENZYME Q-10 15MG $0 (Tier 3) DP COENZYME Q10 100MG $0 (Tier 3) DP coenzyme Q10 10mg cap $0 (Tier 1) DP coenzyme Q10 150mg cap $0 (Tier 1) DP COENZYME Q10 200MG $0 (Tier 3) DP COENZYME Q10 25MG $0 (Tier 3) DP coenzyme Q10 300mg cap $0 (Tier 1) DP coenzyme Q10 30mg cap $0 (Tier 1) DP COENZYME Q10 30MG/5ML LIQUID $0 (Tier 3) DP coenzyme Q10 50mg cap $0 (Tier 1) DP COENZYME Q10 50MG $0 (Tier 3) DP coenzyme Q10 60mg cap $0 (Tier 1) DP COENZYME Q10 60MG CHEW $0 (Tier 3) DP coenzyme q10 60mg $0 (Tier 1) DP coenzyme Q10 cap 100mg $0 (Tier 1) DP coenzyme Q10 cap 200mg $0 (Tier 1) DP coenzyme Q10 cap 400mg $0 (Tier 1) DP coenzyme Q10 cap 75mg $0 (Tier 1) DP COENZYME Q10 CHEW $0 (Tier 3) DP COQ-10 TR 100MG CAP $0 (Tier 3) DP LIQSORB LIQUID 100MG/ML $0 (Tier 3) DP Q-GEL 15MG CAP $0 (Tier 3) DP ALTERNATIVE MEDICINE - M'S - Miscellaneous alternatives to conventional medicine melatonin 10mg cr $0 (Tier 1) DP melatonin 1mg $0 (Tier 1) DP melatonin 300mcg $0 (Tier 1) DP melatonin 3mg odt $0 (Tier 1) DP melatonin 3mg $0 (Tier 1) DP melatonin 5mg odt $0 (Tier 1) DP You can find information on what the symbols and abbreviations in this le mean by going to the beginning of this le. 5

16 melatonin 5mg $0 (Tier 1) DP melatonin cap $0 (Tier 1) DP melatonin liquid $0 (Tier 1) DP MELATONIN LIQUID $0 (Tier 3) DP ALTERNATIVE MEDICINE COMBINATIONS - Miscellaneous alternatives to conventional medicine MELATONIN/PYRIDOXINE 1-10MG $0 (Tier 3) DP melatonin/pyridoxine 10-10mg cr $0 (Tier 1) DP MELATONIN/PYRIDOXINE 3-10MG $0 (Tier 3) DP melatonin/pyridoxine 3-1mg $0 (Tier 1) DP melatonin/pyridoxine 3-2mg $0 (Tier 1) DP melatonin/pyridoxine 5-10mg $0 (Tier 1) DP melatonin/pyridoxine 5-1mg $0 (Tier 1) DP AMINOGLYCOSIDES - Drugs to treat bacterial infections AMINOGLYCOSIDES - Drugs to treat infections amikacin 250mg/ml inj $0 (Tier 1) gentamicin 1.2mg/ml inj $0 (Tier 1) gentamicin 40mg/ml inj $0 (Tier 1) gentamicin sulfate 0.8mg/ml inj $0 (Tier 1) gentamicin sulfate 1.6mg/ml inj $0 (Tier 1) gentamicin sulfate 1mg/ml inj $0 (Tier 1) neomycin sulfate 500mg $0 (Tier 1) paromomycin 250mg cap $0 (Tier 1) STREPTOMYCIN 100MG INJ $0 (Tier 3) TOBI PODHALER KIT 28MG PACK $0 (Tier 3) NDS PA TOBRAMYCIN 10MG/ML INJ $0 (Tier 1) tobramycin 40mg/ml inj $0 (Tier 1) tobramycin 60mg/ml inh soln $0 (Tier 1) NDS PA ANALGESICS - ANTI-INFLAMMATORY - Drugs to treat pain and inflammation ANTIRHEUMATIC - ENZYME INHIBITORS - Drugs to treat disorders of the immune system XELJANZ 10MG $0 (Tier 3) NDS PA QL=60 EA/30 Days XELJANZ 11MG ER $0 (Tier 3) NDS PA QL=30 EA/30 Days XELJANZ 5MG $0 (Tier 3) NDS PA QL=60 EA/30 Days ANTI-TNF-ALPHA - MONOCLONAL ANTIBODIES - Drugs to treat disorders of the immune system HUMIRA 10MG/0.1ML SYRINGE $0 (Tier 2) NDS PA HUMIRA 10MG/0.2ML SYRINGE $0 (Tier 2) NDS PA HUMIRA 20MG/0.2ML SYRINGE $0 (Tier 2) NDS PA HUMIRA 20MG/0.4ML SYRINGE $0 (Tier 2) NDS PA HUMIRA 40MG/0.4ML AUTO-INJECTOR $0 (Tier 2) NDS PA HUMIRA 40MG/0.4ML SYRINGE $0 (Tier 2) NDS PA HUMIRA 40MG/0.8ML AUTO-INJECTOR $0 (Tier 2) NDS PA HUMIRA 40MG/0.8ML SYRINGE $0 (Tier 2) NDS PA You can find information on what the symbols and abbreviations in this le mean by going to the beginning of this le. 6

17 HUMIRA PEDIATRIC CROHN'S STARTER PACK (3) 40MG/0.8ML INJ HUMIRA PEDIATRIC CROHN'S STARTER PACK (3) 80MG/0.8ML INJ HUMIRA PEDIATRIC CROHN'S STARTER PACK (6) 40MG/0.8ML INJ HUMIRA PEDIATRIC CROHN'S STARTER PACK SYRINGE (2) 40MG/0.4ML, 80MG/0.8ML HUMIRA PEN - CROHN'S STARTER PACK 40MG/0.8ML INJ HUMIRA PEN - PSORIASIS STARTER PACK $0 (Tier 2) NDS PA $0 (Tier 2) NDS PA $0 (Tier 2) NDS PA $0 (Tier 2) NDS PA $0 (Tier 2) NDS PA $0 (Tier 2) NDS PA 40MG/0.8ML INJ SIMPONI ARIA 50MG/4ML INJ $0 (Tier 3) NDS PA GOLD COMPOUNDS - Drugs to treat disorders of the immune system RIDAURA 3MG CAP $0 (Tier 2) INTERLEUKIN-1 BLOCKERS - Drugs to treat disorders of the immune system ARCALYST 220MG INJ $0 (Tier 3) NDS PA INTERLEUKIN-1BETA BLOCKERS - Drugs to treat disorders of the immune system ILARIS 150MG/ML INJ $0 (Tier 3) NDS PA NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS) - Drugs to treat pain and inflammation celecoxib 100mg cap $0 (Tier 1) QL=60 EA/30 Days celecoxib 200mg cap $0 (Tier 1) QL=60 EA/30 Days celecoxib 400mg cap $0 (Tier 1) QL=60 EA/30 Days celecoxib 50mg cap $0 (Tier 1) QL=60 EA/30 Days diclofenac potassium 50mg $0 (Tier 1) diclofenac sodium 100mg er $0 (Tier 1) diclofenac sodium 25mg dr $0 (Tier 1) diclofenac sodium 50mg dr $0 (Tier 1) diclofenac sodium 50mg/misoprostol 0.2mg $0 (Tier 1) diclofenac sodium 75mg dr $0 (Tier 1) diclofenac sodium 75mg/misoprostol 0.2mg $0 (Tier 1) etodolac 200mg cap $0 (Tier 1) etodolac 300mg cap $0 (Tier 1) etodolac 400mg er $0 (Tier 1) etodolac 400mg $0 (Tier 1) etodolac 500mg er $0 (Tier 1) etodolac 500mg $0 (Tier 1) etodolac 600mg er $0 (Tier 1) FENOPROFEN 400MG CAP $0 (Tier 3) flurbiprofen 100mg $0 (Tier 1) flurbiprofen 50mg $0 (Tier 1) ibu 600mg $0 (Tier 1) You can find information on what the symbols and abbreviations in this le mean by going to the beginning of this le. 7

18 ibu 800mg $0 (Tier 1) ibuprofen 20mg/ml oral susp $0 (Tier 1) ibuprofen 20mg/ml susp $0 (Tier 1) DP ibuprofen 400mg $0 (Tier 1) ibuprofen 600mg $0 (Tier 1) ibuprofen 800mg $0 (Tier 1) ibuprofen cap 200mg $0 (Tier 1) DP ibuprofen chew 100mg $0 (Tier 1) DP ibuprofen susp 40mg/ml $0 (Tier 1) DP ibuprofen 100mg $0 (Tier 1) DP ibuprofen 200mg $0 (Tier 1) DP indomethacin 25mg cap $0 (Tier 1) indomethacin 50mg cap $0 (Tier 1) indomethacin 75mg er cap $0 (Tier 1) ketoprofen 75mg cap $0 (Tier 1) ketorolac tromethamine 10mg $0 (Tier 1) QL=20 EA/5 Days ketorolac tromethamine 15mg/ml inj $0 (Tier 1) ketorolac tromethamine 30mg/ml cartridge $0 (Tier 1) ketorolac tromethamine 30mg/ml inj $0 (Tier 1) MECLOFENAMATE 100MG CAP $0 (Tier 3) MECLOFENAMATE 50MG CAP $0 (Tier 3) mefenamic acid 250mg cap $0 (Tier 1) meloxicam 15mg $0 (Tier 1) meloxicam 7.5mg $0 (Tier 1) nabumetone 500mg $0 (Tier 1) nabumetone 750mg $0 (Tier 1) naproxen 250mg $0 (Tier 1) naproxen 25mg/ml oral susp $0 (Tier 1) naproxen 375mg dr $0 (Tier 1) naproxen 375mg $0 (Tier 1) naproxen 500mg dr $0 (Tier 1) naproxen 500mg $0 (Tier 1) naproxen sodium 275mg $0 (Tier 1) naproxen sodium 550mg $0 (Tier 1) naproxen sodium cap 220mg $0 (Tier 1) DP naproxen sodium 220mg $0 (Tier 1) DP oxaprozin 600mg $0 (Tier 1) piroxicam 10mg cap $0 (Tier 1) piroxicam 20mg cap $0 (Tier 1) sulindac 150mg $0 (Tier 1) sulindac 200mg $0 (Tier 1) PYRIMIDINE SYNTHESIS INHIBITORS - Drugs to treat disorders of the immune system leflunomide 10mg $0 (Tier 1) You can find information on what the symbols and abbreviations in this le mean by going to the beginning of this le. 8

19 leflunomide 20mg $0 (Tier 1) SELECTIVE COSTIMULATION MODULATORS - Drugs to treat disorders of the immune system ORENCIA 125MG/ML AUTO-INJECTOR $0 (Tier 3) NDS PA ORENCIA 125MG/ML SYRINGE $0 (Tier 3) NDS PA ORENCIA 250MG INJ $0 (Tier 3) NDS PA ORENCIA 50MG/0.4ML SYRINGE $0 (Tier 3) NDS PA ORENCIA 87.5MG/0.7ML SYRINGE $0 (Tier 3) NDS PA SOLUBLE TUMOR NECROSIS FACTOR RECEPTOR AGENTS - Drugs to treat disorders of the immune system ENBREL 25MG INJ $0 (Tier 2) NDS PA ENBREL 25MG/0.5ML SYRINGE $0 (Tier 2) NDS PA ENBREL 50MG/ML SURECLICK INJ $0 (Tier 2) NDS PA ENBREL 50MG/ML SYRINGE $0 (Tier 2) NDS PA ANALGESICS - NONNARCOTIC - Drugs to treat pain ANALGESIC COMBINATIONS - Drugs to treat pain EXCEDRIN EXTRA STRENGTH $0 (Tier 3) DP ANALGESICS OTHER - Drugs to treat pain ACETAMINOPHEN 950MG POWDER PACK $0 (Tier 3) DP acetaminophen cap 500mg $0 (Tier 1) DP acetaminophen chew 160mg $0 (Tier 1) DP acetaminophen chew 80mg $0 (Tier 1) DP acetaminophen CR 650mg $0 (Tier 1) DP acetaminophen dispersible 160mg $0 (Tier 1) DP acetaminophen dispersible 80mg $0 (Tier 1) DP acetaminophen elixir 160mg/5ml $0 (Tier 1) DP acetaminophen liquid 160mg/5ml $0 (Tier 1) DP acetaminophen liquid 167mg/5ml $0 (Tier 1) DP acetaminophen soln 160mg/5ml $0 (Tier 1) DP acetaminophen supp 120mg $0 (Tier 1) DP acetaminophen supp 325mg $0 (Tier 1) DP acetaminophen supp 650mg $0 (Tier 1) DP acetaminophen susp 160mg/5ml $0 (Tier 1) DP acetaminophen susp 80mg/0.8ml $0 (Tier 1) DP ACETAMINOPHEN SYRUP 160 MG/5ML $0 (Tier 3) DP acetaminophen 325mg $0 (Tier 1) DP acetaminophen 500mg $0 (Tier 1) DP ELIXSURE FEVER/PAIN 160MG/5ML GEL $0 (Tier 3) DP FEBROL 325MG/5ML ORAL SOLN $0 (Tier 3) DP SALICYLATES - Drugs to treat pain ALKA-SELTZER EXTRA STRENGTH $0 (Tier 3) DP ASCRIPTIN MAXIMUM STRENGT $0 (Tier 3) DP ASCRIPTIN 325MG $0 (Tier 3) DP You can find information on what the symbols and abbreviations in this le mean by going to the beginning of this le. 9

20 ASPIRIN 200MG SUPP $0 (Tier 3) DP aspirin 300mg supp $0 (Tier 1) DP aspirin 600mg supp $0 (Tier 1) DP aspirin buffered $0 (Tier 1) DP aspirin buffered 325mg $0 (Tier 1) DP aspirin chew 81mg $0 (Tier 1) DP aspirin EC 325mg $0 (Tier 1) DP aspirin EC 500mg $0 (Tier 1) DP aspirin EC 650mg $0 (Tier 1) DP aspirin EC 81mg $0 (Tier 1) DP aspirin effervescent $0 (Tier 1) DP ASPIRIN SUPP 120MG $0 (Tier 3) DP aspirin 325mg $0 (Tier 1) DP aspirin 500mg $0 (Tier 1) DP BUFFERIN EXTRA STRENGTH $0 (Tier 3) DP diflunisal 500mg $0 (Tier 1) ANALGESICS - OPIOID - Drugs to treat pain OPIOID AGONISTS - Drugs to treat pain codeine sulfate 15mg $0 (Tier 1) QL=240 EA/30 Days codeine sulfate 30mg $0 (Tier 1) QL=240 EA/30 Days codeine sulfate 60mg $0 (Tier 1) QL=180 EA/30 Days duramorph 0.5mg/ml inj $0 (Tier 1) B/D duramorph 1mg/ml inj $0 (Tier 1) B/D fentanyl 0.012mg/hr patch $0 (Tier 1) QL=10 EA/30 Days fentanyl 0.025mg/hr patch $0 (Tier 1) QL=10 EA/30 Days fentanyl 0.05mg/hr patch $0 (Tier 1) QL=10 EA/30 Days fentanyl 0.075mg/hr patch $0 (Tier 1) QL=10 EA/30 Days fentanyl 0.1mg/hr patch $0 (Tier 1) QL=10 EA/30 Days fentanyl 0.2mg lozenge $0 (Tier 1) PA QL=120 EA/30 Days fentanyl 0.4mg lozenge $0 (Tier 1) PA QL=120 EA/30 Days fentanyl 0.6mg lozenge $0 (Tier 1) PA QL=120 EA/30 Days fentanyl 0.8mg lozenge $0 (Tier 1) PA QL=120 EA/30 Days fentanyl 1.2mg lozenge $0 (Tier 1) PA QL=120 EA/30 Days fentanyl 1.6mg lozenge $0 (Tier 1) PA QL=120 EA/30 Days hydromorphone 10mg/ml (1ml) inj $0 (Tier 1) hydromorphone 10mg/ml (5ml) inj $0 (Tier 1) hydromorphone 12mg er $0 (Tier 1) QL=60 EA/30 Days hydromorphone 16mg er $0 (Tier 1) QL=60 EA/30 Days hydromorphone 1mg/ml oral soln $0 (Tier 1) QL=2400 ML/30 Days hydromorphone 2mg $0 (Tier 1) QL=450 EA/30 Days hydromorphone 2mg/ml syringe $0 (Tier 1) hydromorphone 32mg er $0 (Tier 1) QL=60 EA/30 Days hydromorphone 4mg $0 (Tier 1) QL=240 EA/30 Days You can find information on what the symbols and abbreviations in this le mean by going to the beginning of this le. 10

21 hydromorphone 8mg er $0 (Tier 1) QL=60 EA/30 Days hydromorphone 8mg $0 (Tier 1) QL=120 EA/30 Days LEVORPHANOL 2MG $0 (Tier 2) QL=240 EA/30 Days meperidine 100mg $0 (Tier 1) QL=360 EA/30 Days meperidine 50mg $0 (Tier 1) QL=720 EA/30 Days methadone 10mg $0 (Tier 1) QL=360 EA/30 Days methadone 1mg/ml oral soln $0 (Tier 1) QL=3600 ML/30 Days methadone 2mg/ml oral soln $0 (Tier 1) QL=1800 ML/30 Days methadone 5mg $0 (Tier 1) QL=360 EA/30 Days morphine sulfate 100mg er cap $0 (Tier 1) QL=60 EA/30 Days morphine sulfate 100mg er $0 (Tier 1) QL=120 EA/30 Days morphine sulfate 10mg er cap $0 (Tier 1) QL=60 EA/30 Days MORPHINE SULFATE 120MG ER (24HR) CAP $0 (Tier 3) QL=60 EA/30 Days morphine sulfate 15mg er $0 (Tier 1) QL=120 EA/30 Days morphine sulfate 15mg $0 (Tier 1) QL=180 EA/30 Days morphine sulfate 200mg er $0 (Tier 1) QL=120 EA/30 Days morphine sulfate 20mg er cap $0 (Tier 1) QL=60 EA/30 Days morphine sulfate 20mg/ml oral soln $0 (Tier 1) QL=180 ML/30 Days morphine sulfate 2mg/ml oral soln $0 (Tier 1) QL=1800 ML/30 Days MORPHINE SULFATE 2MG/ML SYRINGE $0 (Tier 3) MORPHINE SULFATE 30MG ER (24 HR) CAP $0 (Tier 3) QL=60 EA/30 Days morphine sulfate 30mg er cap $0 (Tier 1) QL=60 EA/30 Days morphine sulfate 30mg er $0 (Tier 1) QL=120 EA/30 Days morphine sulfate 30mg $0 (Tier 1) QL=180 EA/30 Days MORPHINE SULFATE 45MG ER (24HR) CAP $0 (Tier 3) QL=60 EA/30 Days morphine sulfate 4mg/ml oral soln $0 (Tier 1) QL=900 ML/30 Days morphine sulfate 50mg er cap $0 (Tier 1) QL=60 EA/30 Days MORPHINE SULFATE 5MG/ML SYRINGE $0 (Tier 3) MORPHINE SULFATE 60MG (24HR) ER CAP $0 (Tier 3) QL=60 EA/30 Days morphine sulfate 60mg er cap $0 (Tier 1) QL=60 EA/30 Days morphine sulfate 60mg er $0 (Tier 1) QL=120 EA/30 Days MORPHINE SULFATE 75MG ER (24HR) CAP $0 (Tier 3) QL=60 EA/30 Days morphine sulfate 80mg er cap $0 (Tier 1) QL=60 EA/30 Days MORPHINE SULFATE 90MG ER (24HR) CAP $0 (Tier 3) QL=60 EA/30 Days oxycodone 10mg $0 (Tier 1) QL=180 EA/30 Days oxycodone 15mg $0 (Tier 1) QL=180 EA/30 Days oxycodone 1mg/ml oral soln $0 (Tier 1) QL=5400 ML/30 Days oxycodone 20mg $0 (Tier 1) QL=180 EA/30 Days oxycodone 20mg/ml oral soln $0 (Tier 1) QL=270 ML/30 Days oxycodone 30mg $0 (Tier 1) QL=180 EA/30 Days oxycodone 5mg cap $0 (Tier 1) QL=360 EA/30 Days oxycodone 5mg $0 (Tier 1) QL=360 EA/30 Days OXYCONTIN 10MG ER $0 (Tier 2) QL=60 EA/30 Days You can find information on what the symbols and abbreviations in this le mean by going to the beginning of this le. 11

22 OXYCONTIN 15MG ER $0 (Tier 2) QL=60 EA/30 Days OXYCONTIN 20MG ER $0 (Tier 2) QL=60 EA/30 Days OXYCONTIN 30MG ER $0 (Tier 2) QL=60 EA/30 Days OXYCONTIN 40MG ER $0 (Tier 2) QL=60 EA/30 Days OXYCONTIN 60MG ER $0 (Tier 2) QL=60 EA/30 Days OXYCONTIN 80MG ER $0 (Tier 2) QL=120 EA/30 Days oxymorphone 10mg $0 (Tier 1) QL=360 EA/30 Days oxymorphone 5mg $0 (Tier 1) QL=360 EA/30 Days tramadol 100mg er $0 (Tier 1) QL=60 EA/30 Days tramadol 100mg er (matrix delivery) $0 (Tier 1) QL=60 EA/30 Days tramadol 200mg er $0 (Tier 1) QL=60 EA/30 Days tramadol 200mg er (matrix delivery) $0 (Tier 1) QL=60 EA/30 Days tramadol 300mg er $0 (Tier 1) QL=60 EA/30 Days tramadol 300mg er (matrix delivery) $0 (Tier 1) QL=60 EA/30 Days tramadol 50mg $0 (Tier 1) QL=240 EA/30 Days OPIOID COMBINATIONS - Drugs to treat pain acetaminophen 21.7mg/ml/hydrocodone bitartrate $0 (Tier 1) QL=5400 ML/30 Days 0.5mg/ml oral soln acetaminophen 24mg/ml/codeine phosphate 2.4mg/ml $0 (Tier 1) QL=4980 ML/30 Days oral soln acetaminophen 300mg/codeine phosphate 15mg $0 (Tier 1) QL=390 EA/30 Days acetaminophen 300mg/codeine phosphate 30mg $0 (Tier 1) QL=390 EA/30 Days acetaminophen 300mg/codeine phosphate 60mg $0 (Tier 1) QL=390 EA/30 Days acetaminophen 300mg/hydrocodone bitartrate 10mg $0 (Tier 1) QL=390 EA/30 Days acetaminophen 300mg/hydrocodone bitartrate 5mg $0 (Tier 1) QL=390 EA/30 Days acetaminophen 300mg/hydrocodone bitartrate 7.5mg $0 (Tier 1) QL=390 EA/30 Days acetaminophen 325mg/hydrocodone bitartrate 10mg $0 (Tier 1) QL=360 EA/30 Days acetaminophen 325mg/hydrocodone bitartrate 2.5mg $0 (Tier 1) QL=360 EA/30 Days acetaminophen 325mg/hydrocodone bitartrate 5mg $0 (Tier 1) QL=360 EA/30 Days acetaminophen 325mg/hydrocodone bitartrate 7.5mg $0 (Tier 1) QL=360 EA/30 Days acetaminophen 325mg/oxycodone 10mg $0 (Tier 1) QL=360 EA/30 Days acetaminophen 325mg/oxycodone 2.5mg $0 (Tier 1) QL=360 EA/30 Days acetaminophen 325mg/oxycodone 5mg $0 (Tier 1) QL=360 EA/30 Days acetaminophen 325mg/oxycodone 7.5mg $0 (Tier 1) QL=360 EA/30 Days acetaminophen 325mg/tramadol 37.5mg $0 (Tier 1) QL=360 EA/30 Days aspirin 325mg/oxycodone 4.84mg $0 (Tier 1) QL=360 EA/30 Days You can find information on what the symbols and abbreviations in this le mean by going to the beginning of this le. 12

23 endocet mg $0 (Tier 1) QL=360 EA/30 Days endocet 5-325mg $0 (Tier 1) QL=360 EA/30 Days endocet mg $0 (Tier 1) QL=360 EA/30 Days hydrocodone 10mg/ibuprofen 200mg $0 (Tier 1) QL=480 EA/30 Days hydrocodone 5mg/ibuprofen 200mg $0 (Tier 1) QL=480 EA/30 Days hydrocodone bitartrate 7.5mg/ibuprofen 200mg $0 (Tier 1) QL=480 EA/30 Days IBUPROFEN 400MG/OXYCODONE 5MG $0 (Tier 1) QL=240 EA/30 Days lorcet mg $0 (Tier 1) QL=360 EA/30 Days lorcet 5-325mg $0 (Tier 1) QL=360 EA/30 Days lorcet mg $0 (Tier 1) QL=360 EA/30 Days vicodin mg $0 (Tier 1) QL=390 EA/30 Days vicodin 5-300mg $0 (Tier 1) QL=390 EA/30 Days vicodin mg $0 (Tier 1) QL=390 EA/30 Days OPIOID PARTIAL AGONISTS - Drugs to treat pain BUNAVAIL MG FILM $0 (Tier 2) BUNAVAIL MG FILM $0 (Tier 2) BUNAVAIL 6.3-1MG FILM $0 (Tier 2) buprenorphine 0.3mg/ml cartridge $0 (Tier 1) buprenorphine 0.3mg/ml inj $0 (Tier 1) buprenorphine 2mg sl $0 (Tier 1) PA buprenorphine 2mg/naloxone 0.5mg sl $0 (Tier 1) QL=90 EA/30 Days buprenorphine 8mg sl $0 (Tier 1) PA buprenorphine 8mg/naloxone 2mg sl $0 (Tier 1) QL=90 EA/30 Days butorphanol tartrate 10mg/ml nasal spray $0 (Tier 1) QL=10 ML/30 Days BUTORPHANOL TARTRATE 1MG/ML INJ $0 (Tier 1) butorphanol tartrate 2mg/ml inj $0 (Tier 1) naloxone 0.5mg/pentazocine 50mg $0 (Tier 1) QL=360 EA/30 Days SUBOXONE 12-3MG STRIP $0 (Tier 2) SUBOXONE 2-0.5MG STRIP $0 (Tier 2) SUBOXONE 4-1MG STRIP $0 (Tier 2) SUBOXONE 8-2MG STRIP $0 (Tier 2) ZUBSOLV MG SL $0 (Tier 2) QL=60 EA/30 Days ZUBSOLV MG SL $0 (Tier 2) QL=90 EA/30 Days ZUBSOLV MG SL $0 (Tier 2) QL=90 EA/30 Days ZUBSOLV MG SL $0 (Tier 2) QL=90 EA/30 Days ZUBSOLV MG SL $0 (Tier 2) QL=60 EA/30 Days ANDROGENS-ANABOLIC - Drugs to regulate male hormones ANABOLIC STEROIDS - Drugs used to gain weight ANADROL-50 50MG $0 (Tier 3) oxandrolone 10mg $0 (Tier 1) PA oxandrolone 2.5mg $0 (Tier 1) PA ANDROGENS - Drugs to treat low testosterone level You can find information on what the symbols and abbreviations in this le mean by going to the beginning of this le. 13

24 ANDRODERM 2MG/24HR PATCH $0 (Tier 2) PA QL=60 EA/30 Days ANDRODERM 4MG/24HR PATCH $0 (Tier 2) PA QL=30 EA/30 Days ANDROGEL 1% (25MG) GEL $0 (Tier 2) PA QL=300 GM/30 Days ANDROGEL 1% (50MG) GEL $0 (Tier 2) PA QL=300 GM/30 Days ANDROGEL 1.62% (1.25GM) GEL $0 (Tier 2) PA QL=37.50 GM/30 Days ANDROGEL 1.62% (2.5GM) GEL $0 (Tier 2) PA QL=150 GM/30 Days ANDROGEL 1.62% GEL $0 (Tier 2) PA QL=150 GM/30 Days danazol 100mg cap $0 (Tier 1) danazol 200mg cap $0 (Tier 1) danazol 50mg cap $0 (Tier 1) testosterone 1% (25mg) gel $0 (Tier 1) PA QL=300 GM/30 Days testosterone 1% (50mg) gel $0 (Tier 1) PA QL=300 GM/30 Days testosterone 1% gel pump $0 (Tier 1) PA QL=300 GM/30 Days testosterone cypionate 100mg/ml inj $0 (Tier 1) testosterone cypionate 200mg/ml inj $0 (Tier 1) testosterone enanthate 200mg/ml inj $0 (Tier 1) ANORECTAL AGENTS - Drugs to treat problems related to the rectum INTRARECTAL STEROIDS - Drugs to treat systemic swelling conditions colocort 100mg/60ml enema $0 (Tier 1) hydrocortisone 1.67mg/ml enema $0 (Tier 1) UCERIS 2MG/ACT FOAM $0 (Tier 3) PA RECTAL COMBINATIONS - Drugs to treat systemic swelling conditions hydrocortisone/pramoxine 1-1% rectal cream $0 (Tier 1) RECTAL LOCAL ANESTHETICS - Drugs for numbing lidocaine anorectal cream 5% $0 (Tier 1) DP RECTAL STEROIDS - Drugs to treat systemic swelling conditions procto-med 2.5% cream $0 (Tier 1) procto-pak 1% rectal cream $0 (Tier 1) proctosol 2.5% cream $0 (Tier 1) proctozone hc 2.5% cream $0 (Tier 1) ANTACIDS - Drugs to treat ulcer and stomach acid ANTACID COMBINATIONS - Drugs to treat ulcer and stomach acid aluminum hydroxide/magnesium carbonate chew $0 (Tier 1) DP mg aluminum hydroxide/magnesium carbonate susp $0 (Tier 1) DP aluminum/magnesium hydroxide/simethicone susp $0 (Tier 1) DP mg/5ml aluminum/magnesium hydroxide/simethicone susp $0 (Tier 1) DP mg/5ml ANTACID CHEW MG $0 (Tier 3) DP CALCIUM CARBONATE CHEW $0 (Tier 3) DP calcium carbonate chew $0 (Tier 1) DP You can find information on what the symbols and abbreviations in this le mean by going to the beginning of this le. 14

25 calcium carbonate susp $0 (Tier 1) DP calcium carbonate/magnesium hydroxide chew $0 (Tier 1) DP GAVISCON EXTRA STRENGTH R SUSP $0 (Tier 3) DP MAG-AL LIQUID $0 (Tier 3) DP ANTACIDS - ALUMINUM SALTS - Drugs to treat ulcer and stomach acid ALUMINUM HYDROXIDE GEL SUSP 320MG/5ML $0 (Tier 3) DP ANTACIDS - BICARBONATE - Drugs to treat ulcer and stomach acid sodium bicarbonate 325mg $0 (Tier 1) DP SODIUM BICARBONATE POWDER $0 (Tier 3) DP sodium bicarbonate 650mg $0 (Tier 1) DP ANTACIDS - CALCIUM SALTS - Drugs to treat ulcer and stomach acid calcium carbonate (antacid) chew 1000mg $0 (Tier 1) DP calcium carbonate (antacid) chew 400mg $0 (Tier 1) DP calcium carbonate (antacid) chew 420mg $0 (Tier 1) DP calcium carbonate (antacid) chew 500mg $0 (Tier 1) DP calcium carbonate (antacid) chew 648mg $0 (Tier 1) DP calcium carbonate (antacid) chew 750mg $0 (Tier 1) DP CALCIUM CARBONATE CHEW $0 (Tier 3) DP TUMS CHEW $0 (Tier 3) DP ANTACIDS - MAGNESIUM SALTS - Drugs to treat ulcer and stomach acid MAGNESIUM OXIDE 400MG CAP $0 (Tier 3) DP magnesium oxide 250mg $0 (Tier 1) DP magnesium oxide 400mg $0 (Tier 1) DP magnesium oxide 420mg $0 (Tier 1) DP URO-MAG 140MG CAP $0 (Tier 3) DP ANTHELMINTICS - Drugs to treat worm infections ANTHELMINTICS - Drugs to treat parasites ALBENZA 200MG $0 (Tier 3) NDS ivermectin 3mg $0 (Tier 1) pyrantel pamoate susp $0 (Tier 3) DP REESE PINWORM 180MG $0 (Tier 3) DP ANTIANGINAL AGENTS - Drugs to treat chest pain ANTIANGINALS-OTHER - Drugs to treat chest pain RANEXA 1000MG ER $0 (Tier 2) RANEXA 500MG ER $0 (Tier 2) NITRATES - Drugs to treat chest pain isosorbide dinitrate 10mg $0 (Tier 1) isosorbide dinitrate 20mg $0 (Tier 1) isosorbide dinitrate 30mg $0 (Tier 1) ISOSORBIDE DINITRATE 40MG ER $0 (Tier 2) isosorbide dinitrate 5mg $0 (Tier 1) isosorbide mononitrate 10mg $0 (Tier 1) You can find information on what the symbols and abbreviations in this le mean by going to the beginning of this le. 15

26 isosorbide mononitrate 120mg er $0 (Tier 1) isosorbide mononitrate 20mg $0 (Tier 1) isosorbide mononitrate 30mg er $0 (Tier 1) isosorbide mononitrate 60mg er $0 (Tier 1) minitran 0.1mg/hr patch $0 (Tier 1) minitran 0.2mg/hr patch $0 (Tier 1) minitran 0.4mg/hr patch $0 (Tier 1) minitran 0.6mg/hr patch $0 (Tier 1) NITRO-BID 2% OINTMENT $0 (Tier 3) NITRO-DUR 0.3MG/HR PATCH $0 (Tier 3) NITRO-DUR 0.8MG/HR PATCH $0 (Tier 3) nitroglycerin 0.1mg/hr patch $0 (Tier 1) nitroglycerin 0.2mg/hr patch $0 (Tier 1) nitroglycerin 0.3mg sl $0 (Tier 1) nitroglycerin 0.4mg sl $0 (Tier 1) nitroglycerin 0.4mg/act pump spray $0 (Tier 1) nitroglycerin 0.4mg/hr patch $0 (Tier 1) nitroglycerin 0.6mg sl $0 (Tier 1) nitroglycerin 0.6mg/hr patch $0 (Tier 1) ANTIANXIETY AGENTS - Drugs to treat anxiety ANTIANXIETY AGENTS - MISC. - Miscellaneous anti-anxiety drugs buspirone 10mg $0 (Tier 1) buspirone 15mg $0 (Tier 1) buspirone 5mg $0 (Tier 1) hydroxyzine 10mg $0 (Tier 1) hydroxyzine 25mg $0 (Tier 1) HYDROXYZINE 25MG/ML INJ $0 (Tier 1) hydroxyzine 2mg/ml oral soln $0 (Tier 1) hydroxyzine 50mg $0 (Tier 1) hydroxyzine 50mg/ml inj $0 (Tier 1) HYDROXYZINE PAMOATE 100MG CAP $0 (Tier 1) hydroxyzine pamoate 25mg cap $0 (Tier 1) hydroxyzine pamoate 50mg cap $0 (Tier 1) meprobamate 200mg $0 (Tier 1) meprobamate 400mg $0 (Tier 1) BENZODIAZEPINES - Drugs to treat anxiety alprazolam 0.25mg odt $0 (Tier 1) alprazolam 0.25mg $0 (Tier 1) alprazolam 0.5mg er $0 (Tier 1) alprazolam 0.5mg odt $0 (Tier 1) alprazolam 0.5mg $0 (Tier 1) alprazolam 1mg er $0 (Tier 1) alprazolam 1mg odt $0 (Tier 1) You can find information on what the symbols and abbreviations in this le mean by going to the beginning of this le. 16

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