AETNA BETTER HEALTH Formulary Guide. Aetna Better Health Of Virginia Formulary Guide 201

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1 AETNA BETTER HEALTH Formulary Guide Aetna Better Health Of Virginia Formulary Guide 201

2 AETNA BETTER HEALTH Formulary Guide What is the Aetna Better Health of Virginia Formulary? Can the Plan s Drug List change? How do I use the Plan s Formulary? Column #1 Column #2 brand drugs are not covered if generic equivalent is available. Column #3: What are generic drugs? Are Over-The-Counter (OTC) drugs covered? Are there Medication Copays? 2

3 AETNA BETTER HEALTH Formulary Guide What are some types of coverage rules? Prior Approval (PA): Quantity Level Limits (QLL): Step Therapy (ST): What if my drug is not on the plan s Formulary? 3

4 Table of Contents *ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS*... 3 *AMINOGLYCOSIDES*... 6 *ANALGESICS - ANTI-INFLAMMATORY*... 7 *ANALGESICS - NONNARCOTIC*... 9 *ANALGESICS - OPIOID*... 9 *ANDROGENS-ANABOLIC* *ANORECTAL AGENTS* *ANTHELMINTICS* *ANTIANGINAL AGENTS* *ANTIANXIETY AGENTS* *ANTIARRHYTHMICS* *ANTIASTHMATIC AND BRONCHODILATOR AGENTS* *ANTICOAGULANTS* *ANTICONVULSANTS* *ANTIDEPRESSANTS* *ANTIDIABETICS* *ANTIDIARRHEALS* *ANTIDOTES* *ANTIEMETICS* *ANTIFUNGALS* *ANTIHISTAMINES* *ANTIHYPERLIPIDEMICS* *ANTIHYPERTENSIVES* *ANTI-INFECTIVE AGENTS - MISC.* *ANTIMALARIALS* *ANTIMYASTHENIC AGENTS* *ANTIMYASTHENIC/CHOLINERGIC AGENTS* *ANTIMYCOBACTERIAL AGENTS* *ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES* *ANTI-OBESITY AGENT COMBINATIONS** *ANTIPARKINSON AGENTS* *ANTIPSYCHOTICS/ANTIMANIC AGENTS* *ANTIRETROVIRALS ADJUVANTS*** *ANTISEPTICS & DISINFECTANTS* *ANTIVIRALS* *ASSORTED CLASSES* *BETA BLOCKERS* *CALCIUM CHANNEL BLOCKERS* *CARDIOTONICS* *CARDIOVASCULAR AGENTS - MISC.* *CEPHALOSPORINS* *CHEMICALS* *CONTRACEPTIVES* *CORTICOSTEROIDS* *COUGH/COLD/ALLERGY* *DERMATOLOGICALS*

5 Table of Contents *DIAGNOSTIC PRODUCTS* *DIGESTIVE AIDS* *DIURETICS* *ENDOCRINE AND METABOLIC AGENTS - MISC.* *ESTROGENS* *FLUOROQUINOLONES* *GASTROINTESTINAL AGENTS - MISC.* *GENITOURINARY AGENTS - MISCELLANEOUS* *GOUT AGENTS* *HEMATOLOGICAL AGENTS - MISC.* *HEMATOPOIETIC AGENTS* *HEPATITIS C AGENT - COMBINATIONS*** *HYPNOTICS* *LAXATIVES* *MACROLIDES* *MEDICAL DEVICES* *MIGRAINE PRODUCTS* *MINERALS & ELECTROLYTES* *MOUTH/THROAT/DENTAL AGENTS* *MULTIVITAMINS* *MUSCULOSKELETAL THERAPY AGENTS* *NASAL AGENTS - SYSTEMIC AND TOPICAL* *NEPRILYSIN INHIB (ARNI)-ANGIOTENSIN II RECEPT ANTAG COMB*** *NEUROMUSCULAR AGENTS* *OPHTHALMIC AGENTS* *OTIC AGENTS* *PASSIVE IMMUNIZING AGENTS* *PENICILLINS* *POTASSIUM REMOVING AGENTS*** *PROGESTINS* *PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.* *RESPIRATORY AGENTS - MISC.* *SEROTONIN MODULATORS*** *SODIUM-GLUCOSE CO-TRANSPORTER 2 INHIBITOR-BIGUANIDE COMB*** *SULFONAMIDES* *TETRACYCLINES* *THYROID AGENTS* *ULCER DRUGS* *URINARY ANTI-INFECTIVES* *URINARY ANTISPASMODICS* *VAGINAL PRODUCTS* *VASOPRESSORS* *VITAMINS*

6 amphetamine-dextroamphet er oral capsule extended release 24 hour 10 mg, 15 mg, 20 mg, 25 mg, 5 mg amphetamine-dextroamphet er oral capsule extended release 24 hour 30 mg amphetamine-dextroamphetamine oral tablet 10 mg, 12.5 mg, 15 mg, 20 mg, 5 mg, 7.5 mg amphetamine-dextroamphetamine oral tablet 30 mg dextroamphetamine sulfate er oral capsule extended release 24 hour 10 mg, 15 mg dextroamphetamine sulfate er oral capsule extended release 24 hour 5 mg Adderall XR Adderall XR Adderall Adderall Dexedrine Dexedrine PA; Additional prior authorization may be required if prescribed with buprenorphine containing products.; QLL (30 EA per 30 days) PA; QLL (30EA per 30 days for members under the age of 12, 60EA per 30 days for members age 12 and older); Additional prior authorization may be required if prescribed with buprenorphine containing products. PA; Additional prior authorization may be required if prescribed with buprenorphine containing products.; QLL (90 EA per 30 days) PA; Additional prior authorization may be required if prescribed with buprenorphine containing products.; QLL (60 EA per 30 days) PA; Additional prior authorization may be required if prescribed with buprenorphine containing products.; QLL (120 EA per 30 days) PA; Additional prior authorization may be required if prescribed with buprenorphine containing products.; QLL (90 EA per 30 days) 3

7 dextroamphetamine sulfate oral solution dextroamphetamine sulfate oral tablet caffeine citrate oral solution caffeine citrated powder benzphetamine hcl oral tablet diethylpropion hcl er oral tablet extended release 24 hour diethylpropion hcl oral tablet phendimetrazine tartrate er oral capsule extended release 24 hour phendimetrazine tartrate oral tablet phentermine hcl oral capsule 15 mg phentermine hcl oral capsule 30 mg phentermine hcl oral capsule 37.5 mg phentermine hcl oral tablet ProCentra Zenzedi Cafcit Regimex Bontril PDM Adipex-P Adipex-P Benzphetamine HCl Benzphetamine HCl PA; Additional prior authorization may be required if prescribed with buprenorphine containing products.; QLL (1800 ML per 30 days) PA; Additional prior authorization may be required if prescribed with buprenorphine containing products.; QLL (180 EA per 30 days) PA; ; AL (Min 18 Years) PA; QLL (90 EA per 30 days); AL (Min 12 Years) PA; ; AL (Min 17 Years) PA; QLL (90 EA per 30 days); AL (Min 17 Years) PA; ; AL (Min 17 Years) PA; QLL (90 EA per 30 days); AL (Min 17 Years) PA; QLL (60 EA per 30 days); AL (Min 16 Years) PA; ; AL (Min 16 Years) PA; ; AL (Min 16 Years) PA; ; AL (Min 16 Years) PA; QLL (90 EA per 30 days); AL (Min 12 Years) PA; QLL (90 EA per 30 days); AL (Min 12 Years) PA; OTC; QLL (180 EA per 30 days); AL (Min 12 Years) 4

8 dexmethylphenidate hcl er oral capsule extended release 24 hour 10 mg, 15 mg, 20 mg, 30 mg, 40 mg, 5 mg dexmethylphenidate hcl oral tablet methylphenidate hcl er (cd) oral capsule extended release methylphenidate hcl er (la) oral capsule extended release 24 hour 20 mg, 40 mg methylphenidate hcl er (la) oral capsule extended release 24 hour 30 mg methylphenidate hcl er oral tablet extended release 10 mg methylphenidate hcl er oral tablet extended release 18 mg, 27 mg, 54 mg methylphenidate hcl er oral tablet extended release 20 mg Focalin XR Focalin Metadate CD Ritalin LA Ritalin LA Concerta Ritalin SR PA; QLL (60 EA per 30 days); AL (Min 18 Years) PA; Additional prior authorization may be required if prescribed with buprenorphine containing products.; QLL (30 EA per 30 days) PA; Additional prior authorization may be required if prescribed with buprenorphine containing products.; QLL (60 EA per 30 days) PA; Additional prior authorization may be required if prescribed with buprenorphine containing products.; QLL (30 EA per 30 days) PA; Additional prior authorization may be required if prescribed with buprenorphine containing products.; QLL (30 EA per 30 days) PA; Additional prior authorization may be required if prescribed with buprenorphine containing products.; QLL (60 EA per 30 days) PA; Additional prior authorization may be required if prescribed with buprenorphine containing products.; QLL (90 EA per 30 days) PA; Additional prior authorization may be required if prescribed with buprenorphine containing products.; QLL (30 EA per 30 days) PA; Additional prior authorization may be required if prescribed with buprenorphine containing products.; QLL (90 EA per 30 days) 5

9 methylphenidate hcl er oral tablet extended release 24 hour 18 mg, 27 mg, 54 mg methylphenidate hcl er oral tablet extended release 24 hour 36 mg methylphenidate hcl er oral tablet extended release 36 mg methylphenidate hcl oral solution methylphenidate hcl oral tablet methylphenidate hcl oral tablet chewable 10 mg methylphenidate hcl oral tablet chewable 2.5 mg, 5 mg Concerta Methylin Ritalin Methylin Methylin PA; Additional prior authorization may be required if prescribed with buprenorphine containing products.; QLL (30 EA per 30 days) PA; Additional prior authorization may be required if prescribed with buprenorphine containing products.; QLL (60 EA per 30 days) PA; Additional prior authorization may be required if prescribed with buprenorphine containing products.; QLL (60 EA per 30 days) PA; Additional prior authorization may be required if prescribed with buprenorphine containing products.; QLL (900 ML per 30 days) PA; Additional prior authorization may be required if prescribed with buprenorphine containing products.; QLL (90 EA per 30 days) PA; Additional prior authorization may be required if prescribed with buprenorphine containing products.; QLL (180 EA per 30 days) PA; Additional prior authorization may be required if prescribed with buprenorphine containing products.; QLL (150 EA per 30 days) modafinil oral tablet Provigil PA; neomycin sulfate oral tablet paromomycin sulfate oral capsule tobramycin inhalation nebulization solution Tobi PA; QLL (280 ml Max Qty Per Fill Retail) 6

10 PA; QLL (1 Kit per 28 days) PA; QLL (1 Kit per 28 days) PA; QLL (1 Kit per 28 days) PA; QLL (1 Kit per 28 days) PA; QLL (2 Syringes per 28 days) PA; QLL (1 Kit per 28 days) PA; QLL (1 Kit per 28 days) PA; QLL (1 Kit per 28 days) PA; QLL (1 Kit per 28 days) PA; QLL (1 Kit per 28 days) PA; QLL (2 Syringes per 28 days) PA; QLL (1 Kit per 28 days) celecoxib oral capsule CeleBREX ST; diclofenac potassium oral tablet diclofenac sodium er oral tablet extended release 24 hour Cataflam Voltaren-XR 7

11 diclofenac sodium oral tablet delayed release etodolac er oral tablet extended release 24 hour etodolac oral capsule etodolac oral tablet fenoprofen calcium oral tablet flurbiprofen oral tablet ibuprofen oral tablet 400 mg, 600 mg, 800 mg indomethacin er oral capsule extended release indomethacin oral capsule ketoprofen oral capsule ketorolac tromethamine oral tablet meclofenamate sodium oral capsule Lodine Max Limit (Max 2 fills/90 days.); QLL (20 Tablets per 30 days); AL (Min 16 Years) meloxicam oral tablet Mobic nabumetone oral tablet naproxen dr oral tablet delayed release naproxen oral suspension naproxen oral tablet naproxen sodium oral tablet 275 mg EC-Naprosyn Naprosyn Naprosyn Anaprox QLL (120 EA per 30 days) oxaprozin oral tablet Daypro QLL (90 EA per 30 days) piroxicam oral capsule sulindac oral tablet tolmetin sodium oral capsule tolmetin sodium oral tablet Feldene QLL (90 EA per 30 days) QLL (90 EA per 30 days) leflunomide oral tablet Arava PA; QLL (4 Vials per 30 days) PA; QLL (204 Mgs per 28 days) PA; QLL (204 Mgs per 28 days) 8

12 butalbital-acetaminophen oral tablet Tencon QLL (180 EA per 30 days) butalbital-apap-caffeine oral capsule butalbital-apap-caffeine oral tablet mg butalbital-aspirin-caffeine oral capsule marten-tab oral tablet choline & mag trisalicylate oral tablet 1000 mg choline-mag trisalicylate oral liquid diflunisal oral tablet salsalate oral tablet acetaminophen-codeine #2 oral tablet Esgic Fioricet Fiorinal Tencon Margesic Margesic Marten-Tab Margesic Disalcid Max Limit (Max 240 tabs or caps/year.); QLL (180 EA per 30 days) Max Limit (Max 240 tabs or caps/year.); QLL (180 EA per 30 days) Max Limit (Max 240 tabs or caps/year.); QLL (180 EA per 30 days) Max Limit (Max 240 tabs or caps/year.); QLL (180 EA per 30 days) Max Limit (Max 240 tabs or caps/year.); QLL (180 EA per 30 days) Max Limit (Max 240 tabs or caps/year.); QLL (180 EA per 30 days) Prior authorization is required if the days supply exceeds 14 days, or a max of 28 days in the past 60. Drug may also be subject to 120 cumulative morphine equivalents per day.; QLL (300 EA per 30 days) 9

13 acetaminophen-codeine #3 oral tablet Tylenol with Codeine #3 acetaminophen-codeine #4 oral tablet Tylenol with Codeine #4 acetaminophen-codeine oral solution acetaminophen-codeine oral tablet butalbital-apap-caff-cod oral capsule butalbital-asa-caff-codeine oral capsule Fioricet/Codeine Ascomp-Codeine Prior authorization is required if the days supply exceeds 14 days, or a max of 28 days in the past 60. Drug may also be subject to 120 cumulative morphine equivalents per day.; QLL (300 EA per 30 days) Prior authorization is required if the days supply exceeds 14 days, or a max of 28 days in the past 60. Drug may also be subject to 120 cumulative morphine equivalents per day.; QLL (300 EA per 30 days) Prior authorization is required if the days supply exceeds 14 days, or a max of 28 days in the past 60. Drug may also be subject to 120 cumulative morphine equivalents per day.; QLL (4500 ML per 30 days) Prior authorization is required if the days supply exceeds 14 days, or a max of 28 days in the past 60. Drug may also be subject to 120 cumulative morphine equivalents per day.; QLL (300 EA per 30 days) Max Limit (Max 240 tabs or caps/year.); Prior authorization is required if the days supply exceeds 14 days, or a max of 28 days in the past 60. Drug may also be subject to 120 cumulative morphine equivalents per day.; QLL (180 EA per 30 days) Max Limit (Max 240 tabs or caps/year.); Prior authorization is required if the days supply exceeds 14 days, or a max of 28 days in the past 60. Drug may also be subject to 120 cumulative morphine equivalents per day.; QLL (180 EA per 30 days) 10

14 hydrocodone-acetaminophen oral solution mg/5ml, mg/10ml, mg/15ml hydrocodone-acetaminophen oral tablet mg hydrocodone-acetaminophen oral tablet mg hydrocodone-acetaminophen oral tablet mg, mg Butalbital Compound/Codeine Hycet Norco Verdrocet Norco hydrocodone-ibuprofen oral tablet mg Vicoprofen Max Limit (Max 240 tabs or caps/year.); Prior authorization is required if the days supply exceeds 14 days, or a max of 28 days in the past 60. Drug may also be subject to 120 cumulative morphine equivalents per day.; QLL (180 EA per 30 days) Prior authorization is required if the days supply exceeds 14 days, or a max of 28 days in the past 60. Drug may also be subject to 120 cumulative morphine equivalents per day.; QLL (5400 ML per 30 days) Prior authorization is required if the days supply exceeds 14 days, or a max of 28 days in the past 60. Drug may also be subject to 120 cumulative morphine equivalents per day.; QLL (270 EA per 30 days) Prior authorization is required if the days supply exceeds 14 days, or a max of 28 days in the past 60. Drug may also be subject to 120 cumulative morphine equivalents per day.; QLL (360 EA per 30 days) Prior authorization is required if the days supply exceeds 14 days, or a max of 28 days in the past 60. Drug may also be subject to 120 cumulative morphine equivalents per day.; QLL (360 EA per 30 days) Prior authorization is required if the days supply exceeds 14 days, or a max of 28 days in the past 60. Drug may also be subject to 120 cumulative morphine equivalents per day.; QLL (150 EA per 30 days) 11

15 codeine sulfate oral tablet 15 mg Hydrocodone-Acetaminophen Hydrocodone-Acetaminophen Hydrocodone-Acetaminophen Hydrocodone-Acetaminophen Hydrocodone-Acetaminophen Prior authorization is required if the days supply exceeds 14 days, or a max of 28 days in the past 60. Drug may also be subject to 120 cumulative morphine equivalents per day.; QLL (270 EA per 30 days) Prior authorization is required if the days supply exceeds 14 days, or a max of 28 days in the past 60. Drug may also be subject to 120 cumulative morphine equivalents per day.; QLL (360 EA per 30 days) Prior authorization is required if the days supply exceeds 14 days, or a max of 28 days in the past 60. Drug may also be subject to 120 cumulative morphine equivalents per day.; QLL (360 EA per 30 days) Prior authorization is required if the days supply exceeds 14 days, or a max of 28 days in the past 60. Drug may also be subject to 120 cumulative morphine equivalents per day.; QLL (270 EA per 30 days) Prior authorization is required if the days supply exceeds 14 days, or a max of 28 days in the past 60. Drug may also be subject to 120 cumulative morphine equivalents per day.; QLL (360 EA per 30 days) Prior authorization is required if the days supply exceeds 14 days, or a max of 28 days in the past 60. Drug may also be subject to 120 cumulative morphine equivalents per day.; QLL (720 EA per 30 days) 12

16 codeine sulfate oral tablet 30 mg codeine sulfate oral tablet 60 mg fentanyl transdermal patch 72 hour 100 mcg/hr Duragesic-100 fentanyl transdermal patch 72 hour 12 mcg/hr Duragesic-12 fentanyl transdermal patch 72 hour 25 mcg/hr Duragesic-25 fentanyl transdermal patch 72 hour 50 mcg/hr Duragesic-50 fentanyl transdermal patch 72 hour 75 mcg/hr Duragesic-75 hydromorphone hcl oral tablet 2 mg hydromorphone hcl oral tablet 4 mg Dilaudid Dilaudid Prior authorization is required if the days supply exceeds 14 days, or a max of 28 days in the past 60. Drug may also be subject to 120 cumulative morphine equivalents per day.; QLL (360 EA per 30 days) Prior authorization is required if the days supply exceeds 14 days, or a max of 28 days in the past 60. Drug may also be subject to 120 cumulative morphine equivalents per day.; QLL (180 EA per 30 days) PA; Drug may be subject to 120 cumulative morphine equivalents per day.; QLL (10 EA per 30 days) PA; Drug may be subject to 120 cumulative morphine equivalents per day.; QLL (10 EA per 30 days) PA; Drug may be subject to 120 cumulative morphine equivalents per day.; QLL (10 EA per 30 days) PA; Drug may be subject to 120 cumulative morphine equivalents per day.; QLL (10 EA per 30 days) PA; Drug may be subject to 120 cumulative morphine equivalents per day.; QLL (10 EA per 30 days) Prior authorization is required if the days supply exceeds 14 days, or a max of 28 days in the past 60. Drug may also be subject to 120 cumulative morphine equivalents per day.; QLL (330 EA per 30 days) Prior authorization is required if the days supply exceeds 14 days, or a max of 28 days in the past 60. Drug may also be subject to 120 cumulative morphine equivalents per day.; QLL (150 EA per 30 days) 13

17 hydromorphone hcl oral tablet 8 mg hydromorphone hcl rectal suppository Dilaudid Prior authorization is required if the days supply exceeds 14 days, or a max of 28 days in the past 60. Drug may also be subject to 120 cumulative morphine equivalents per day.; QLL (60 EA per 30 days) Prior authorization is required if the days supply exceeds 14 days, or a max of 28 days in the past 60. Drug may also be subject to 120 cumulative morphine equivalents per day.; QLL (120 EA per 30 days) methadone hcl oral concentrate Methadose PA; QLL (90 ML per 30 days) methadone hcl oral solution 10 mg/5ml methadone hcl oral solution 5 mg/5ml methadone hcl oral tablet 10 mg methadone hcl oral tablet 5 mg Dolophine Dolophine PA; Drug may be subject to 120 cumulative morphine equivalents per day.; QLL (450 ML per 30 days) PA; Drug may be subject to 120 cumulative morphine equivalents per day.; QLL (900 ML per 30 days) PA; Drug may be subject to 120 cumulative morphine equivalents per day.; QLL (90 EA per 30 days) PA; Drug may be subject to 120 cumulative morphine equivalents per day.; QLL (180 EA per 30 days) methadone hcl oral tablet soluble Methadose PA; QLL (22 EA per 30 days) morphine sulfate (concentrate) oral solution 100 mg/5ml morphine sulfate er oral capsule extended release 24 hour 10 mg, 20 mg morphine sulfate er oral capsule extended release 24 hour 100 mg, 50 mg, 60 mg, 80 mg 14 Kadian Kadian Prior authorization is required if the days supply exceeds 14 days, or a max of 28 days in the past 60. Drug may also be subject to 120 cumulative morphine equivalents per day.; QLL (120 ML per 30 days) PA; Drug may be subject to 120 cumulative morphine equivalents per day.; QLL (60 EA per 30 days) PA; Drug may be subject to 120 cumulative morphine equivalents per day.; QLL (30 EA per 30 days)

18 morphine sulfate er oral capsule extended release 24 hour 30 mg morphine sulfate er oral tablet extended release 100 mg, 200 mg morphine sulfate er oral tablet extended release 15 mg, 30 mg, 60 mg morphine sulfate oral solution 10 mg/5ml morphine sulfate oral solution 20 mg/5ml morphine sulfate oral tablet 15 mg morphine sulfate oral tablet 30 mg morphine sulfate rectal suppository Kadian MS Contin MS Contin PA; Drug may be subject to 120 cumulative morphine equivalents per day.; QLL (90 EA per 30 days) PA; Drug may be subject to 120 cumulative morphine equivalents per day.; QLL (60 EA per 30 days) PA; Drug may be subject to 120 cumulative morphine equivalents per day.; QLL (90 EA per 30 days) Prior authorization is required if the days supply exceeds 14 days, or a max of 28 days in the past 60. Drug may also be subject to 120 cumulative morphine equivalents per day.; QLL (900 ML per 30 days) Prior authorization is required if the days supply exceeds 14 days, or a max of 28 days in the past 60. Drug may also be subject to 120 cumulative morphine equivalents per day.; QLL (660 ML per 30 days) Prior authorization is required if the days supply exceeds 14 days, or a max of 28 days in the past 60. Drug may also be subject to 120 cumulative morphine equivalents per day.; QLL (180 EA per 30 days) Prior authorization is required if the days supply exceeds 14 days, or a max of 28 days in the past 60. Drug may also be subject to 120 cumulative morphine equivalents per day.; QLL (90 EA per 30 days) Prior authorization is required if the days supply exceeds 14 days, or a max of 28 days in the past 60. Drug may also be subject to 120 cumulative morphine equivalents per day. 15

19 oxycodone hcl oral capsule oxycodone hcl oral concentrate 100 mg/5ml oxycodone hcl oral solution oxycodone hcl oral tablet 10 mg oxycodone hcl oral tablet 15 mg oxycodone hcl oral tablet 20 mg Roxicodone Prior authorization is required if the days supply exceeds 14 days, or a max of 28 days in the past 60. Drug may also be subject to 120 cumulative morphine equivalents per day.; QLL (180 EA per 30 days) Prior authorization is required if the days supply exceeds 14 days, or a max of 28 days in the past 60. Drug may also be subject to 120 cumulative morphine equivalents per day.; QLL (90 ML per 30 days) Prior authorization is required if the days supply exceeds 14 days, or a max of 28 days in the past 60. Drug may also be subject to 120 cumulative morphine equivalents per day.; QLL (900 ML per 30 days) Prior authorization is required if the days supply exceeds 14 days, or a max of 28 days in the past 60. Drug may also be subject to 120 cumulative morphine equivalents per day.; QLL (180 EA per 30 days) Prior authorization is required if the days supply exceeds 14 days, or a max of 28 days in the past 60. Drug may also be subject to 120 cumulative morphine equivalents per day.; QLL (120 EA per 30 days) Prior authorization is required if the days supply exceeds 14 days, or a max of 28 days in the past 60. Drug may also be subject to 120 cumulative morphine equivalents per day.; QLL (90 EA per 30 days) 16

20 oxycodone hcl oral tablet 30 mg oxycodone hcl oral tablet 5 mg oxymorphone hcl er oral tablet extended release 12 hour oxymorphone hcl oral tablet 10 mg oxymorphone hcl oral tablet 5 mg tramadol hcl oral tablet Roxicodone Roxicodone Opana Opana Ultram Methadone HCl Prior authorization is required if the days supply exceeds 14 days, or a max of 28 days in the past 60. Drug may also be subject to 120 cumulative morphine equivalents per day.; QLL (60 EA per 30 days) Prior authorization is required if the days supply exceeds 14 days, or a max of 28 days in the past 60. Drug may also be subject to 120 cumulative morphine equivalents per day.; QLL (180 EA per 30 days) PA; Drug may be subject to 120 cumulative morphine equivalents per day.; QLL (60 EA per 30 days) Prior authorization is required if the days supply exceeds 14 days, or a max of 28 days in the past 60. Drug may also be subject to 120 cumulative morphine equivalents per day.; QLL (90 EA per 30 days) Prior authorization is required if the days supply exceeds 14 days, or a max of 28 days in the past 60. Drug may also be subject to 120 cumulative morphine equivalents per day.; QLL (180 EA per 30 days) Prior authorization is required if the days supply exceeds 14 days, or a max of 28 days in the past 60. Drug may also be subject to 120 cumulative morphine equivalents per day.; QLL (240 EA per 30 days); AL (Min 16 Years) PA; QLL (90 ML per 30 days) 17

21 oxycodone-acetaminophen oral tablet mg oxycodone-acetaminophen oral tablet mg, mg oxycodone-acetaminophen oral tablet mg oxycodone-aspirin oral tablet mg Endocet Percocet Percocet Percodan Oxycodone-Acetaminophen Oxycodone-Acetaminophen Prior authorization is required if the days supply exceeds 14 days, or a max of 28 days in the past 60. Drug may also be subject to 120 cumulative morphine equivalents per day.; QLL (180 EA per 30 days) Prior authorization is required if the days supply exceeds 14 days, or a max of 28 days in the past 60. Drug may also be subject to 120 cumulative morphine equivalents per day.; QLL (360 EA per 30 days) Prior authorization is required if the days supply exceeds 14 days, or a max of 28 days in the past 60. Drug may also be subject to 120 cumulative morphine equivalents per day.; QLL (240 EA per 30 days) Prior authorization is required if the days supply exceeds 14 days, or a max of 28 days in the past 60. Drug may also be subject to 120 cumulative morphine equivalents per day.; QLL (360 EA per 30 days) Prior authorization is required if the days supply exceeds 14 days, or a max of 28 days in the past 60. Drug may also be subject to 120 cumulative morphine equivalents per day.; QLL (180 EA per 30 days) Prior authorization is required if the days supply exceeds 14 days, or a max of 28 days in the past 60. Drug may also be subject to 120 cumulative morphine equivalents per day.; QLL (360 EA per 30 days) 18

22 buprenorphine hcl sublingual tablet sublingual 2 mg buprenorphine hcl sublingual tablet sublingual 8 mg buprenorphine hcl-naloxone hcl sublingual tablet sublingual mg buprenorphine hcl-naloxone hcl sublingual tablet sublingual 8-2 mg butorphanol tartrate nasal solution pentazocine-naloxone hcl oral tablet Oxycodone-Acetaminophen Suboxone Suboxone Prior authorization is required if the days supply exceeds 14 days, or a max of 28 days in the past 60. Drug may also be subject to 120 cumulative morphine equivalents per day.; QLL (240 EA per 30 days) PA; Two 7 day induction periods are permitted without prior authorization in 365 days, the induction periods must be at least 90 days apart.; QLL (90 EA per 30 days) PA; Two 7 day induction periods are permitted without prior authorization in 365 days, the induction periods must be at least 90 days apart.; QLL (60 EA per 30 days) PA; Two 7 day induction periods are permitted without prior authorization in 365 days, the induction periods must be at least 90 days apart.; QLL (90 EA per 30 days) PA; Two 7 day induction periods are permitted without prior authorization in 365 days, the induction periods must be at least 90 days apart.; QLL (60 EA per 30 days) QLL (1 Bottle per 30 days) Prior authorization is required if the days supply exceeds 14 days, or a max of 28 days in the past 60. Drug may also be subject to 120 cumulative morphine equivalents per day.; QLL (120 EA per 30 days) PA; Drug may be subject to 120 cumulative morphine equivalents per day.; QLL (8 EA per 28 days) 19

23 tramadol-acetaminophen oral tablet danazol oral capsule methyltestosterone oral capsule testosterone cypionate intramuscular solution 100 mg/ml, 200 mg/ml testosterone enanthate intramuscular solution testosterone transdermal gel 10 mg/act (2%) Ultracet Android Depo-Testosterone Fortesta testosterone transdermal gel 12.5 mg/act (1%) AndroGel Pump testosterone transdermal gel 25 mg/2.5gm (1%) AndroGel PA; Drug may be subject to 120 cumulative morphine equivalents per day.; QLL (4 EA per 28 days) Prior authorization is required if the days supply exceeds 14 days, or a max of 28 days in the past 60. Drug may also be subject to 120 cumulative morphine equivalents per day.; QLL (240 EA per 30 days); AL (Min 16 Years) PA PA PA; QLL (2 canisters per 30 days) PA; QLL (300 GM per 30 days) PA; QLL (30 pak per 30 days) testosterone transdermal gel 50 mg/5gm (1%) Testim PA; QLL (300 GM per 30 days) hydrocortisone rectal enema lidocaine-hydrocortisone ace rectal cream lidocaine-hydrocortisone ace rectal kit %, 3-1 % Cortenema Hydrocortisone LidaZone HC Lidocaine-Hydrocortisone Ace PA 20

24 hydrocortisone acetate rectal suppository 30 mg ivermectin oral tablet isosorbide dinitrate er oral tablet extended release isosorbide dinitrate oral tablet isosorbide mononitrate er oral tablet extended release 24 hour 120 mg isosorbide mononitrate er oral tablet extended release 24 hour 30 mg, 60 mg isosorbide mononitrate oral tablet Hemril-30 Hydrocortisone Acetate Hydrocortisone Hemorrhoidal-HC Hemorrhoidal-HC Stromectol Imdur Imdur nitroglycerin er oral capsule extended release Nitro-Time nitroglycerin sublingual tablet sublingual nitroglycerin transdermal patch 24 hour Nitrostat Nitro-Dur QLL (60 EA per 30 days) nitroglycerin translingual solution Nitrolingual QLL (12 Grams per 30 days) buspirone hcl oral tablet 10 mg, 5 mg, 7.5 mg buspirone hcl oral tablet 15 mg hydroxyzine hcl oral syrup hydroxyzine hcl oral tablet hydroxyzine pamoate oral capsule Nitroglycerin Nitroglycerin ER QLL (90 EA per 30 days) QLL (120 EA per 30 days) 21

25 meprobamate oral tablet alprazolam er oral tablet extended release 24 hour alprazolam oral tablet alprazolam oral tablet dispersible alprazolam xr oral tablet extended release 24 hour chlordiazepoxide hcl oral capsule clorazepate dipotassium oral tablet diazepam oral solution 1 mg/ml diazepam oral tablet Xanax XR Xanax Niravam Xanax XR Tranxene-T Valium Prior authorization may be required if prescribed with opioids or buprenorphine containing products.; QLL (60 EA per 30 days); AL (Min 18 Years) Prior authorization may be required if prescribed with opioids or buprenorphine containing products.; AL (Min 18 Years) Prior authorization may be required if prescribed with opioids or buprenorphine containing products.; QLL (90 EA per 30 days); AL (Min 18 Years) Prior authorization may be required if prescribed with opioids or buprenorphine containing products.; QLL (60 EA per 30 days); AL (Min 18 Years) Prior authorization may be required if prescribed with opioids or buprenorphine containing products.; AL (Min 6 Years) Prior authorization may be required if prescribed with opioids or buprenorphine containing products.; QLL (60 EA per 30 days); AL (Min 9 Years) Prior authorization may be required if prescribed with opioids or buprenorphine containing products. Prior authorization may be required if prescribed with opioids or buprenorphine containing products. 22

26 lorazepam oral concentrate lorazepam oral tablet oxazepam oral capsule disopyramide phosphate oral capsule quinidine gluconate er oral tablet extended release quinidine sulfate oral tablet mexiletine hcl oral capsule flecainide acetate oral tablet propafenone hcl oral tablet amiodarone hcl oral tablet LORazepam Intensol Ativan LORazepam Norpace Tambocor Cordarone Amiodarone HCl Prior authorization may be required if prescribed with opioids or buprenorphine containing products. Prior authorization may be required if prescribed with opioids or buprenorphine containing products. Prior authorization may be required if prescribed with opioids or buprenorphine containing products.; AL (Min 6 Years) Prior authorization may be required if prescribed with opioids or buprenorphine containing products.; AL (Min 18 Years) Prior authorization may be required if prescribed with opioids or buprenorphine containing products. PA; QLL (60 EA per 30 days) ipratropium-albuterol inhalation solution DuoNeb QLL (180 Nebules per 30 days) 23

27 cromolyn sodium inhalation nebulization solution albuterol sulfate er oral tablet extended release 12 hour albuterol sulfate inhalation nebulization solution (2.5 mg/3ml) 0.083%, (5 mg/ml) 0.5% albuterol sulfate inhalation nebulization solution 0.63 mg/3ml, 1.25 mg/3ml albuterol sulfate oral syrup albuterol sulfate oral tablet metaproterenol sulfate oral syrup metaproterenol sulfate oral tablet terbutaline sulfate oral tablet ipratropium bromide inhalation solution VoSpire ER AccuNeb QLL (1 inhaler per 30 days) QLL (1 EA per 30 days) QLL (2 Inhaler per 30 days) QLL (1 Inhaler per 30 days) ST; QLL (1 ea per 30 days) QLL (360 Nebules per 30 days) ST; QLL (360 Nebules per 30 days) QLL (1 Inhaler per 30 days) QLL (2 Inhaler per 30 days) QLL (2 Inhaler per 30 days) 24

28 montelukast sodium oral packet Singulair PA; ; AL (Max 2 Years) montelukast sodium oral tablet Singulair montelukast sodium oral tablet chewable Singulair zafirlukast oral tablet 10 mg Accolate ST; QLL (60 EA per 30 days) zafirlukast oral tablet 20 mg Accolate QLL (60 EA per 30 days) budesonide inhalation suspension 0.25 mg/2ml, 0.5 mg/2ml theophylline er oral tablet extended release 12 hour theophylline er oral tablet extended release 24 hour theophylline oral solution warfarin sodium oral tablet Pulmicort Budesonide Theochron Theophylline ER Coumadin Warfarin Sodium QLL (120 ML per 30 days); AL (Max 5 Years) QLL (60 Blisters per 30 days) QLL (1 Inhaler per 30 days) QLL (120 ML per 30 days); AL (Max 5 Years) QLL (1 Inhaler per 30 days) QLL (2 Inhaler per 30 days) PA; PA; QLL (1 FILL per 90 days) 25

29 heparin sodium (porcine) injection solution 1000 unit/ml, unit/ml, unit/ml, 5000 unit/ml heparin sodium (porcine) pf injection solution enoxaparin sodium injection solution enoxaparin sodium subcutaneous solution fondaparinux sodium subcutaneous solution clonazepam oral tablet clonazepam oral tablet dispersible Lovenox Lovenox Arixtra KlonoPIN Max Limit (Total quantities are limited to a 21 days supply every 90 days. Quantities above this amount will require a Prior Authorization) Max Limit (Total quantities are limited to a 21 days supply every 90 days. Quantities above this amount will require a Prior Authorization) Max Limit (Total quantities are limited to a 21 days supply every 90 days. Quantities above this amount will require a Prior Authorization) Max Limit (Total quantities are limited to a 21 days supply every 90 days. Quantities above this amount will require a Prior Authorization) Prior authorization may be required if prescribed with opioids or buprenorphine containing products. Prior authorization may be required if prescribed with opioids or buprenorphine containing products. diazepam rectal gel Diastat AcuDial QLL (2 EA per 30 days) 26

30 carbamazepine er oral capsule extended release 12 hour carbamazepine er oral tablet extended release 12 hour 100 mg carbamazepine er oral tablet extended release 12 hour 200 mg carbamazepine er oral tablet extended release 12 hour 400 mg carbamazepine oral suspension carbamazepine oral tablet carbamazepine oral tablet chewable Carbatrol TEGretol XR TEGretol XR TEGretol XR TEGretol TEGretol QLL (120 EA per 30 days) QLL (300 EA per 30 days); AL (Min 6 Years) QLL (150 EA per 30 days); AL (Min 6 Years) QLL (2.5 EA per 1 day); AL (Min 6 Years) gabapentin oral capsule Neurontin QLL (180 EA per 30 days) gabapentin oral solution 250 mg/5ml Neurontin gabapentin oral tablet 600 mg Neurontin QLL (180 EA per 30 days) gabapentin oral tablet 800 mg Neurontin QLL (135 EA per 30 days) lamotrigine oral tablet 100 mg, 200 mg LaMICtal QLL (60 EA per 30 days) lamotrigine oral tablet 150 mg LaMICtal QLL (90 EA per 30 days) lamotrigine oral tablet 25 mg LaMICtal QLL (180 EA per 30 days) lamotrigine oral tablet chewable 25 mg LaMICtal QLL (180 EA per 30 days) lamotrigine oral tablet chewable 5 mg LaMICtal QLL (240 EA per 30 days) levetiracetam er oral tablet extended release 24 hour 500 mg levetiracetam er oral tablet extended release 24 hour 750 mg levetiracetam oral solution Keppra XR Keppra XR Keppra QLL (180 EA per 30 days) QLL (120 EA per 30 days) levetiracetam oral tablet 1000 mg Keppra QLL (90 EA per 30 days) levetiracetam oral tablet 250 mg Keppra QLL (60 EA per 30 days) levetiracetam oral tablet 500 mg Keppra QLL (180 EA per 30 days) levetiracetam oral tablet 750 mg Keppra QLL (120 EA per 30 days) oxcarbazepine oral suspension oxcarbazepine oral tablet primidone oral tablet Trileptal Trileptal Mysoline topiramate oral capsule sprinkle Topamax Sprinkle QLL (120 EA per 30 days) topiramate oral tablet 100 mg Topiragen QLL (90 EA per 30 days) topiramate oral tablet 200 mg Topiragen QLL (60 EA per 30 days) topiramate oral tablet 25 mg, 50 mg Topiragen QLL (120 EA per 30 days) zonisamide oral capsule Zonegran QLL (180 EA per 30 days) CarBAMazepine ST 27

31 felbamate oral suspension felbamate oral tablet Felbatol Felbatol tiagabine hcl oral tablet 2 mg Gabitril tiagabine hcl oral tablet 4 mg Gabitril QLL (120 EA per 30 days) phenytoin oral suspension 125 mg/5ml phenytoin oral tablet chewable phenytoin sodium extended oral capsule Dilantin Dilantin Infatabs Dilantin Phenytoin ethosuximide oral capsule ethosuximide oral solution divalproex sodium er oral tablet extended release 24 hour divalproex sodium oral tablet delayed release valproic acid oral capsule valproic acid oral solution Zarontin Zarontin Depakote ER Depakote Depakene Depakene ST QLL (120 EA per 30 days) QLL (90 EA per 30 days) mirtazapine oral tablet 15 mg Remeron mirtazapine oral tablet 30 mg Remeron QLL (60 EA per 30 days) mirtazapine oral tablet 45 mg Remeron QLL (45 EA per 30 days) mirtazapine oral tablet 7.5 mg mirtazapine oral tablet dispersible 15 mg, 45 mg Remeron SolTab mirtazapine oral tablet dispersible 30 mg Remeron SolTab QLL (60 EA per 30 days) 28

32 bupropion hcl er (sr) oral tablet extended release 12 hour 100 mg bupropion hcl er (sr) oral tablet extended release 12 hour 150 mg bupropion hcl er (sr) oral tablet extended release 12 hour 200 mg bupropion hcl er (xl) oral tablet extended release 24 hour 150 mg bupropion hcl er (xl) oral tablet extended release 24 hour 300 mg Budeprion SR Budeprion SR Wellbutrin SR Wellbutrin XL Wellbutrin XL QLL (120 EA per 30 days) QLL (60 EA per 30 days) QLL (60 EA per 30 days) QLL (90 EA per 30 days) bupropion hcl oral tablet 100 mg Wellbutrin QLL (135 EA per 30 days) bupropion hcl oral tablet 75 mg Wellbutrin QLL (180 EA per 30 days) maprotiline hcl oral tablet trazodone hcl oral tablet 100 mg, 150 mg, 50 mg phenelzine sulfate oral tablet tranylcypromine sulfate oral tablet citalopram hydrobromide oral solution citalopram hydrobromide oral tablet 10 mg, 20 mg Nardil Parnate CeleXA QLL (600 ML per 30 days) QLL (45 EA per 30 days) citalopram hydrobromide oral tablet 40 mg CeleXA escitalopram oxalate oral solution Lexapro QLL (600 ML per 30 days) escitalopram oxalate oral tablet Lexapro fluoxetine hcl oral capsule 10 mg PROzac fluoxetine hcl oral capsule 20 mg PROzac QLL (120 EA per 30 days) fluoxetine hcl oral capsule 40 mg PROzac QLL (60 EA per 30 days) fluoxetine hcl oral solution fluoxetine hcl oral tablet 10 mg fluvoxamine maleate oral tablet 100 mg fluvoxamine maleate oral tablet 25 mg, 50 mg QLL (600 ML per 30 days) QLL (90 EA per 30 days) paroxetine hcl oral tablet 10 mg, 20 mg Paxil paroxetine hcl oral tablet 30 mg Paxil QLL (60 EA per 30 days) paroxetine hcl oral tablet 40 mg Paxil QLL (45 EA per 30 days) 29

33 sertraline hcl oral concentrate Zoloft QLL (300 ML per 30 days) sertraline hcl oral tablet 100 mg Zoloft QLL (75 EA per 30 days) sertraline hcl oral tablet 25 mg, 50 mg Zoloft QLL (45 EA per 30 days) duloxetine hcl oral capsule delayed release particles venlafaxine hcl er oral capsule extended release 24 hour 150 mg venlafaxine hcl er oral capsule extended release 24 hour 37.5 mg, 75 mg venlafaxine hcl oral tablet amitriptyline hcl oral tablet amoxapine oral tablet desipramine hcl oral tablet doxepin hcl oral capsule doxepin hcl oral concentrate imipramine hcl oral tablet nortriptyline hcl oral capsule nortriptyline hcl oral solution protriptyline hcl oral tablet Irenka Effexor XR Effexor XR Norpramin Tofranil Pamelor Vivactil QLL (60 EA per 30 days) QLL (60 EA per 30 days) acarbose oral tablet Precose QLL (90 EA per 30 days) metformin hcl er oral tablet extended release 24 hour 500 mg metformin hcl er oral tablet extended release 24 hour 750 mg metformin hcl oral tablet Glucophage XR Glucophage XR Glucophage QLL (120 EA per 30 days) QLL (60 EA per 30 days) QLL (1 Unit Max Qty Per Fill Retail) QLL (1 Unit Max Qty Per Fill Retail) alogliptin benzoate oral tablet Nesina QLL (30 EA per 30 Days) 30

34 ST; alogliptin-metformin hcl oral tablet Kazano QLL (60 EA per 30 Days) ST; QLL (60 EA per 30 days) alogliptin-pioglitazone oral tablet Oseni QLL (30 EA per 30 Days) AL (Max 18 Years) AL (Max 18 Years) AL (Max 18 Years) OTC; AL (Max 18 Years) OTC; AL (Max 18 Years) AL (Max 18 Years) 31

35 AL (Max 18 Years) AL (Max 18 Years) ST; QLL (4 EA per 28 days) ST; QLL (4 ea per 28 days) nateglinide oral tablet Starlix QLL (90 EA per 30 days) repaglinide oral tablet 0.5 mg, 1 mg Prandin QLL (120 EA per 30 days) repaglinide oral tablet 2 mg Prandin QLL (240 EA per 30 days) repaglinide-metformin hcl oral tablet PrandiMet glipizide-metformin hcl oral tablet mg Metaglip glipizide-metformin hcl oral tablet mg glipizide-metformin hcl oral tablet mg glyburide-metformin oral tablet mg, mg Glucovance ST; QLL (60 EA per 30 days) QLL (60 EA per 30 days) QLL (120 EA per 30 days) QLL (60 EA per 30 days) glyburide-metformin oral tablet mg Glucovance QLL (120 EA per 30 days) chlorpropamide oral tablet glimepiride oral tablet 1 mg, 2 mg Amaryl glimepiride oral tablet 4 mg Amaryl QLL (60 EA per 30 days) glipizide er oral tablet extended release 24 hour 10 mg GlipiZIDE XL QLL (60 EA per 30 days) 32

36 glipizide er oral tablet extended release 24 hour 2.5 mg, 5 mg glipizide oral tablet glipizide xl oral tablet extended release 24 hour 10 mg glipizide xl oral tablet extended release 24 hour 2.5 mg, 5 mg GlipiZIDE XL Glucotrol GlipiZIDE XL GlipiZIDE XL QLL (60 EA per 30 days) glyburide micronized oral tablet 1.5 mg, 3 mg Glynase glyburide micronized oral tablet 6 mg Glynase QLL (60 EA per 30 days) glyburide oral tablet tolazamide oral tablet tolbutamide oral tablet Diabeta pioglitazone hcl-glimepiride oral tablet Duetact pioglitazone hcl-metformin hcl oral tablet Actoplus Met QLL (90 EA per 30 days) pioglitazone hcl oral tablet Actos diphenoxylate-atropine oral liquid diphenoxylate-atropine oral tablet lofene oral tablet loperamide hcl oral capsule naloxone hcl injection solution 0.4 mg/ml naltrexone hcl oral tablet Lonox Lonox Imodium A-D Depade ST; 33

37 granisetron hcl oral tablet QLL (8 EA per 30 days) ondansetron hcl oral solution Zofran QLL (1 ea per 30 days) ondansetron hcl oral tablet 24 mg QLL (1 EA per 30 days) ondansetron hcl oral tablet 4 mg, 8 mg Zofran ondansetron oral tablet dispersible Zofran ODT meclizine hcl oral tablet trimethobenzamide hcl oral capsule Antivert Tigan Aprepitant QLL (3 EA per 30 days) bio-statin oral powder griseofulvin microsize oral suspension griseofulvin microsize oral tablet griseofulvin ultramicrosize oral tablet nystatin oral powder nystatin oral tablet Grifulvin V Gris-PEG terbinafine hcl oral tablet LamISIL ketoconazole oral tablet fluconazole oral suspension reconstituted Diflucan fluconazole oral tablet Diflucan QLL (60 EA per 30 days) itraconazole oral capsule Sporanox Pulsepak QLL (120 EA per 30 days) brompheniramine tannate oral tablet chewable carbinoxamine maleate oral tablet clemastine fumarate oral tablet 2.68 mg Arbinoxa diphenhydramine hcl oral elixir Medi-Phedryl QLL (120 ml per 30 days) Carbinoxamine Maleate 34

38 cetirizine hcl oral solution Wal-Zyr Childrens QLL (150 ML per 30 days) cetirizine hcl oral syrup 1 mg/ml Wal-Zyr Childrens QLL (150 ML per 30 days) promethazine hcl oral solution promethazine hcl oral syrup promethazine hcl oral tablet promethazine hcl rectal suppository cyproheptadine hcl oral syrup cyproheptadine hcl oral tablet cholestyramine light oral packet cholestyramine light oral powder cholestyramine oral packet cholestyramine oral powder colestipol hcl oral granules colestipol hcl oral packet colestipol hcl oral tablet fenofibrate micronized oral capsule 134 mg, 200 mg, 67 mg Promethegan Promethazine HCl Promethazine HCl Promethazine HCl Questran Light Questran Light Questran Questran Colestid Flavored Colestid Colestid Cholestyramine Light Cholestyramine Light Lofibra QLL (180 ml per 30 days) QLL (180 ml per 30 days) fenofibrate oral tablet 145 mg, 48 mg Tricor fenofibrate oral tablet 160 mg, 54 mg Lofibra fenofibric acid oral capsule delayed release Trilipix gemfibrozil oral tablet Lopid QLL (60 EA per 30 days) atorvastatin calcium oral tablet Lipitor fluvastatin sodium er oral tablet extended release 24 hour Lescol XL fluvastatin sodium oral capsule Lescol 35

39 lovastatin oral tablet 10 mg lovastatin oral tablet 20 mg Mevacor lovastatin oral tablet 40 mg Mevacor QLL (60 EA per 30 days) pravastatin sodium oral tablet rosuvastatin calcium oral tablet Crestor PA simvastatin oral tablet 10 mg, 20 mg, 40 mg, 5 mg Zocor simvastatin oral tablet 80 mg Zocor ST; Ezetimibe PA; niacin er (antihyperlipidemic) oral tablet extended release Niaspan amlodipine besy-benazepril hcl oral capsule Lotrel benazepril-hydrochlorothiazide oral tablet Lotensin HCT captopril-hydrochlorothiazide oral tablet enalapril-hydrochlorothiazide oral tablet mg enalapril-hydrochlorothiazide oral tablet mg fosinopril sodium-hctz oral tablet lisinopril-hydrochlorothiazide oral tablet mg, mg lisinopril-hydrochlorothiazide oral tablet mg Vaseretic Zestoretic Zestoretic QLL (60 EA per 30 days) QLL (60 EA per 30 days) moexipril-hydrochlorothiazide oral tablet Uniretic quinapril-hydrochlorothiazide oral tablet Accuretic benazepril hcl oral tablet 10 mg, 20 mg Lotensin benazepril hcl oral tablet 40 mg Lotensin QLL (60 EA per 30 days) benazepril hcl oral tablet 5 mg captopril oral tablet 100 mg captopril oral tablet 12.5 mg, 25 mg, 50 mg QLL (90 EA per 30 days) 36

40 enalapril maleate oral tablet 10 mg, 2.5 mg, 5 mg Vasotec enalapril maleate oral tablet 20 mg Vasotec QLL (60 EA per 30 days) fosinopril sodium oral tablet 10 mg, 20 mg fosinopril sodium oral tablet 40 mg lisinopril oral tablet 10 mg, 2.5 mg, 20 mg, 30 mg, 5 mg Zestril QLL (60 EA per 30 days) lisinopril oral tablet 40 mg Zestril QLL (60 EA per 30 days) moexipril hcl oral tablet 15 mg Univasc QLL (60 EA per 30 days) moexipril hcl oral tablet 7.5 mg Univasc perindopril erbumine oral tablet 2 mg perindopril erbumine oral tablet 4 mg Aceon perindopril erbumine oral tablet 8 mg Aceon QLL (60 EA per 30 days) quinapril hcl oral tablet 10 mg, 20 mg, 5 mg Accupril quinapril hcl oral tablet 40 mg Accupril QLL (60 EA per 30 days) ramipril oral capsule 1.25 mg, 2.5 mg, 5 mg Altace ramipril oral capsule 10 mg Altace QLL (60 EA per 30 days) trandolapril oral tablet 1 mg, 2 mg Mavik trandolapril oral tablet 4 mg Mavik QLL (60 EA per 30 days) methyldopa-hydrochlorothiazide oral tablet amlodipine besylate-valsartan oral tablet Exforge candesartan cilexetil-hctz oral tablet Atacand HCT irbesartan-hydrochlorothiazide oral tablet Avalide losartan potassium-hctz oral tablet Hyzaar valsartan-hydrochlorothiazide oral tablet Diovan HCT candesartan cilexetil oral tablet Atacand irbesartan oral tablet Avapro losartan potassium oral tablet Cozaar valsartan oral tablet Diovan 37

41 amlodipine-valsartan-hctz oral tablet Exforge HCT clonidine hcl oral tablet Catapres clonidine hcl transdermal patch weekly Catapres-TTS-1 QLL (4 Patches per 30 days) guanfacine hcl oral tablet 1 mg Tenex QLL (240 EA per 30 days) guanfacine hcl oral tablet 2 mg Tenex QLL (120 EA per 30 days) methyldopa oral tablet doxazosin mesylate oral tablet 1 mg, 2 mg, 4 mg Cardura doxazosin mesylate oral tablet 8 mg Cardura QLL (60 EA per 30 days) prazosin hcl oral capsule Minipress QLL (120 EA per 30 days) terazosin hcl oral capsule 1 mg, 5 mg terazosin hcl oral capsule 10 mg, 2 mg atenolol-chlorthalidone oral tablet Tenoretic 100 bisoprolol-hydrochlorothiazide oral tablet metoprolol-hydrochlorothiazide oral tablet nadolol-bendroflumethiazide oral tablet propranolol-hctz oral tablet hydralazine hcl oral tablet minoxidil oral tablet metronidazole oral capsule metronidazole oral tablet trimethoprim oral tablet vancomycin hcl intravenous solution reconstituted 10 gm, 1000 mg, 500 mg, 5000 mg Ziac Lopressor HCT Corzide Flagyl Flagyl QLL (60 EA per 30 days) vancomycin hcl oral capsule 125 mg Vancocin HCl QLL (56 EA per 30 days) vancomycin hcl oral capsule 250 mg Vancocin HCl QLL (40 EA per 30 days) 38

42 sulfamethoxazole-trimethoprim oral suspension mg/5ml sulfamethoxazole-trimethoprim oral tablet dapsone oral tablet clindamycin hcl oral capsule clindamycin palmitate hcl oral solution reconstituted chloroquine phosphate oral tablet hydroxychloroquine sulfate oral tablet mefloquine hcl oral tablet pyridostigmine bromide oral tablet pyridostigmine bromide oral tablet pyridostigmine bromide oral tablet ethambutol hcl oral tablet isoniazid oral syrup isoniazid oral tablet Sulfatrim Pediatric Bactrim DS Sulfamethoxazole-Trimethopri m Cleocin Cleocin Aralen Plaquenil Mestinon Mestinon Mestinon Myambutol PA 39

43 pyrazinamide oral tablet rifabutin oral capsule rifampin oral capsule Mycobutin Rifadin bicalutamide oral tablet Casodex flutamide oral capsule nilutamide oral tablet Nilandron QLL (60 EA per 30 days) tamoxifen citrate oral tablet capecitabine oral tablet Xeloda PA mercaptopurine oral tablet methotrexate oral tablet methotrexate sodium (pf) injection solution 1 gm/40ml, 100 mg/4ml, 250 mg/10ml, 50 mg/2ml Purinethol PA; PA; QLL (120 EA per 30 days) PA; imatinib mesylate oral tablet 100 mg Gleevec PA; QLL (90 EA per 30 days) imatinib mesylate oral tablet 400 mg Gleevec PA; QLL (60 EA per 30 days) 40