Pharmacy Program Preferred Drug List Pharmacy Benefit Manager Specialty Drugs Dispensing Limits

Transcription

1 referred List The Absolute Total Care Formulary includes a list of drugs covered by your prescription benefit. The formulary is updated often and may change. To get the most up-to-date information, you may view the latest formulary on our website or call us at referred List Medication Locator Instructions: 1. With the DF open, click on the Edit menu, then click Find 2. In the Find box type the name of the medication you want to locate 3. Click the Next button until you find the medication(s) you are looking for

2 harmacy rogram Absolute Total Care is committed to providing appropriate, high quality, and cost effective drug therapy to all Absolute Total Care members. Absolute Total Care works with providers and pharmacists to ensure that medications used to treat a variety of conditions and diseases are covered. Absolute Total Care covers prescription medications and certain over-the-counter (OTC) medications when ordered by a South Carolina Medicaid enrolled, Absolute Total Care practitioner. The pharmacy program does not cover all medications. Some medications require prior authorization (A) or have limitations on age, dosage, and maximum quantities. referred List The Absolute Total Care referred List (DL) is the list of covered drugs. The DL applies to drugs members can receive at retail pharmacies. The Absolute Total Care DL is continually evaluated by the Absolute Total Care harmacy and Therapeutics (&T) Committee to promote the appropriate and costeffective use of medications. The Committee is composed of the Absolute Total Care Medical Director, Absolute Total Care harmacy Director, and several South Carolina physicians, pharmacists, and other healthcare professionals. harmacy Benefit Manager Absolute Total Care works with Envolve harmacy Solutions to process pharmacy claims for prescribed drugs. Some drugs on the Absolute Total Care DL may require A, and Envolve harmacy Solutions is responsible for administering this process. Envolve harmacy Solutions is our harmacy Benefit Manager (BM). Specialty s The preferred specialty pharmacy provider of Absolute Total Care is AcariaHealth Specialty harmacy. All specialty drugs, such as biopharmaceuticals and injectables, require A to be approved for payment by Absolute Total Care. The Absolute Total Care Medical Director and Absolute Total Care harmacy Director oversee the clinical review of these A requests. AcariaHealth Specialty harmacy provides the following services: Delivers drugs to your home or provider s office rovide staff pharmacists who can help you 24 hours a day, seven days a week to answer your questions and offer help with your drugs Give you information, materials, and ongoing support to help you take the drugs to appropriately manage your health condition A list of Absolute Total Care preferred specialty products can be found on the last page of the DL and on the Total Care website ( ) under Specialty referred List. Dispensing s may be dispensed up to a maximum of thirty-one (31) days supply for each new prescription or refill. A total of 80% of the days supply or 25 days must have elapsed before the prescription can be

3 refilled for non-controlled-substance DL drugs. A total of 90% of the days supply must have elapsed before the prescription can be refilled for controlled substances and narcotic DL drugs. Appropriate Use and Safety Edits The health and safety of the member is a priority for Absolute Total Care. One of the ways we address member safety is through point-of sale (OS) edits at the time a prescription is processed at the pharmacy. These edits are based on FDA recommendations and promote safe and effective medication utilization. rior Authorizations Some medications listed on the Absolute Total Care DL may require A. The information should be submitted by the practitioner or pharmacist to Envolve harmacy Solutions on the Medication rior Authorization Form. This form should be faxed to Envolve harmacy Solutions at This document can be found on the Absolute Total Care website. All completed authorizations are reviewed within 24 hours from the time of receipt. Absolute Total Care will cover the medication if it is determined that: 1. There is a medical reason the member needs the specific medication. 2. Depending on the medication, other medications on the DL have not worked. Authorization requests are reviewed by a licensed clinical pharmacist using the criteria established by the Absolute Total Care &T Committee. If the request is approved, Envolve harmacy Solutions notifies the practitioner by fax. If the clinical information provided does not meet the coverage criteria for the requested medication, Absolute Total Care will notify the member and their practitioner of alternatives and provide information regarding the appeal process. Step Therapy Some medications listed on the Absolute Total Care DL may require specific medications to be used before the member can receive the step therapy medication. If Absolute Total Care has a record that the required medication was tried first the step therapy medications are automatically covered. If Absolute Total Care does not have a record that the required medication was tried, the member s practitioner may be required to provide additional information. If authorization is not granted, Absolute Total Care will notify the member and their practitioner and provide information regarding the appeal process. Quantity Absolute Total Care may limit how much of a certain medication a member can get at one time. If the practitioner feels the member has a medical reason for getting a greater amount, a A may be requested. If Absolute Total Care does not grant A we will notify the member and their practitioner and provide information regarding the appeal process. Age Some medications on the Absolute Total Care DL may have age limits. These are set for certain drugs based on FDA approved labeling and for safety concerns and quality standards of care. Age limits align

4 with current FDA alerts for the appropriate use of pharmaceuticals and also align with Healthy Connections Medicaid Guidelines. Medical Necessity Requests If the member requires a medication that does not appear on the DL, the member s practitioner can make a medical necessity (MN) request for the medication. It is anticipated that such exceptions will be rare as the DL medications are appropriate to treat the vast majority of medical conditions. For a MN request Absolute Total Care requires: Documentation of failure of at least two DL agents within the same therapeutic class (provided two agents exist in the therapeutic category with comparable labeled indications) for the same diagnosis (e.g. migraine, neuropathic pain, etc.); or Documented intolerance or contraindication to at least two DL agents within the same therapeutic class (provided two agents exist in the therapeutic category with comparable labeled indications); or Documented clinical history or presentation where the patient is not a candidate for any of the DL agents for the indication. These requests are reviewed by a licensed clinical pharmacist using the criteria established by the Absolute Total Care &T Committee. If the request is approved, Envolve harmacy Solutions notifies the practitioner by fax. If the clinical information provided does not meet the coverage criteria for the requested medication, Absolute Total Care will notify the member and their practitioner of alternatives and provide information regarding the appeal process. Emergency Supply olicy State and Federal law require that a pharmacy dispense a five (5) day supply of medication to any member awaiting A determination. The purpose is to avoid interruption of current therapy or delay in the initiation of therapy. All participating pharmacies are authorized to provide a five (5) day supply of medication and will be reimbursed for the ingredient cost and dispensing fee of the five (5) day supply of medication, whether or not the A request is ultimately approved or denied. If the pharmacy requires further assistance for any reason, they may call Envolve harmacy Solutions at Exclusions The following drug categories are not part of the Absolute Total Care DL and are not covered by the five (5) day emergency supply policy: Weight control products harmaceuticals used for cosmetic purposes or hair growth Investigational pharmaceuticals or products Immunizing agents Efficacy Study Implementation (DESI) and Identical, Related and Similar (IRS) drugs that are classified as ineffective

5 Fertility products Erectile dysfunction products prescribed to treat impotence Nutritional supplements Injectables (except those listed in the DL) Infusion supplies Hepatitis C Agents* *Effective July 1, 2015 all drugs used in the treatment of Hepatitis C will be provided by the Department of Health and Human Services (DHHS). Any member of Absolute Total Care who is presently treated with a Hepatitis C agent prior to July 1, 2015 will continue to get their medication from Acaria Health Specialty harmacy with no interruption. Any Absolute Total Care member requesting a Hepatitis C agent after July 1, 2015 will need to have their physician send the prior authorization (A) request to: o Magellan Clinical Call Center o hone: o Fax: Newly Approved roducts Absolute Total Care reviews new drugs for safety and effectiveness before adding them to the DL. During this period, access to these medications will be considered through the A review process. If Absolute Total Care does not grant A we will notify the member and their practitioner and provide information regarding the appeal process. Over-the-Counter Medications Absolute Total Care covers a variety of OTC medications. These medications can be found throughout the Absolute Total Care DL. Absolute Total Care covers OTC products listed on the DL if the member has a prescription from a licensed practitioner that meets all the legal requirements for a prescription. Generic s When generic drugs are available, the brand name drug will not be covered without Absolute Total Care authorization. Generic drugs have the same active ingredient and work the same as brand name drugs. Therefore treatment failure must be directly attributable to the member s use of a generic for the brand name drug. If the member or their practitioner feels a brand name drug is medically necessary, the practitioner must request the drug using the A process. Absolute Total Care will cover the brand-name drug according to our clinical guidelines if there is a medical reason the member needs the particular brand-name drug. If Absolute Total Care does not grant authorization, we will notify the member and their practitioner and provide information regarding the appeal process.

6 Efficacy Study and Implementation (DESI) s DESI products and known related drug products are defined as less than effective by the Food and Administration because there is a lack of substantial evidence of effectiveness for all labeling indications and because a compelling justification for their medical need has not been established. DESI products are not covered by Absolute Total Care. Filling a rescription A member can have prescriptions filled at an Absolute Total Care network pharmacy. If the member decides to have a prescription filled at a network pharmacy they can locate a pharmacy near them by contacting Absolute Total Care Member Services at A member can also log onto Absolute Total Care s website at and look under the For Members tab for a harmacy link that allows them to locate a pharmacy. The member can type in their address and/or zip code and see what pharmacies are close by. At the pharmacy the member will need to provide the pharmacist with the prescription and their Absolute Total Care ID card. While travelling a distance beyond 30 miles from the South Carolina border members are allowed a onetime fill of their medication. All necessary prescriptions are required to be filled on the same day for a maximum of 31 day supply. Copayments The copayment amount for all applicable prescriptions is $3.40 per prescription. roviders are responsible for collecting copayments. Service must be rendered despite a member s ability to pay. If a member is unable to pay at the time of service, the member is still responsible for the copayment amount. The following are categories of Medicaid Beneficiaries that are exempt from copayment: From birth to the date of their 19th birthday Living in long-term care facilities Receiving hospice care Family planning prescriptions During pregnancy Enrolled in South Carolina Department of Disabilities and Special Needs Mental Retardation or Related Disabilities or Head and Spinal Cord Injuries waiver program. Enrolled in DHHS VENT, HIV/AIDS, SC Choice, or elderly and disabled waiver program. *Effective May 1, 2015, Absolute Total Care will waive copays for all members on designated prescription drug list (DL) agents in the following categories: o Asthma o Chronic Obstructive ulmonary Disorder (COD) o Diabetes Therefore, any member who gets a prescription for an Asthma, COD or Diabetes medication that is on the prescription drug list (DL) will have a $0.00 copay for such medications.

7 *Effective July 1, 2017, Absolute Total Care will waive copays for all members who obtain a prescription for any tobacco cessation products on the DL. s The following notations define the preferred drug list status in the column. : referred drug product N: Non-referred drug product Abbreviations The following notations and abbreviations may be found throughout the drug listing in the requirements/limits column. AL: Age Lmit is limited to a specific age. QL: Quantity Limit There is a limit on the amount of drug covered per prescription, or within a specific time frame. Max Day(s) Supply: Day(s) Supply There is a limit on the amount of the drug that is covered per time. Max Fill: Fill Limit There is a limit on the number of times the drug can be filled. Opioid Smart A Unique for There may be limits on use such as a max 5-day supply for short- Opioid s acting opioids or rior Authorization required. Exceptions exist for specific diagnoses and/or history of use. A: rior rior Authorization is required before prescription can be filled. Authorization ack Lmt: ackage Limit There is a limit on the number of packages covered per prescription. Rtl: Retail The limit or restriction applies to coverage at a retail pharmacy : rescription/ The drug is available as both prescription and over-the-counter Over-the-Counter forms. S: Specialty s are high-cost drugs used to treat complex or rare conditions, such as multiple sclerosis, rheumatoid arthritis, hepatitis C and hemophilia. ST: Step Therapy Requires trial and failure of one or more preferred products prior to coverage.

8 Contact Information Absolute Total Care hone: Fax: Website: AcariaHealth Specialty harmacy hone: Fax: Website: Envolve harmacy Solutions A hone: Magellan Clinical Call Center (Hepatitis C A requests) A Fax: Help Desk: A hone: A Fax:

9 Name ADHD/ANTI-NARCOLESY/ANTI- OBESITY/ANOREXIANTS - s to Treat ADHD, Sleep and Eating Disorders Amphetamines ADDERALL TABS (Use Amphetamine- Dextroamphetamine) ADDERALL XR C24 (Use Amphetamine- Dextroamphetamine) amphetaminedextroamphetamine cp , , , , , amphetaminedextroamphetamine tabs , , , , , , DEXEDRINE C24 10 MG, 15 MG (Use Dextroamphetamine Sulfate) DEXEDRINE C24 5 MG (Use Dextroamphetamine Sulfate) dextroamphetamine sulfate cp24 10, 15 dextroamphetamine sulfate cp24 5 dextroamphetamine sulfate tabs 5, 10 N N N N ; AL; At least 3 ; AL; At least 6 ; AL; At least 6 ; AL; At least 3 ; AL; At least 6 ; AL; At least 6 ; AL; At least 6 ; AL; At least 6 ; AL; At least 3 Name VYVANSE CAS 10 MG, 20 MG, 30 MG, 40 MG, 50 MG, 60 MG, 70 MG Analeptics caffeine citrate soln or 20 /ml, 60 /3ml A; QL(1 ea Limit 2 fills per Lifetime;QL(45 ml per fill retail)2 rtl MAX fill,999 rtl day(s) supply, Attention-Deficit/Hyperactivity Disorder (ADHD) atomoxetine hcl caps ST; AL; At least 6 clonidine hcl (adhd) tb12 guanfacine hcl (adhd) tb24 INTUNIV TB24 (Use Guanfacine HCl (ADHD)) KAVAY TB12 (Use Clonidine HCl (ADHD)) STRATTERA CAS (Use Atomoxetine HCl) Stimulants - Misc. CONCERTA TBCR 18 MG, 27 MG, 54 MG (Use Methylphenidate HCl) CONCERTA TBCR 36 MG (Use Methylphenidate HCl) dexmethylphenidate hcl tabs 5, 10, 2.5 FOCALIN TABS (Use Dexmethylphenidate HCl) METADATE CD CCR (Use Methylphenidate HCl) methylphenidate hcl cpcr 10, 20, 30, 40, 50, 60 METHYLHENIDATE HCL ER TB24 18 MG, 27 MG, 54 MG N N N N N N N ; AL; At least 6 ; AL; At least 6 ST; AL; At least 6 ; AL; At least 6 ; AL; At least 6 ; AL; At least 6 ; AL; At least 6 ; AL; At least 6 ; AL; At least 6 1

10 Name METHYLHENIDATE HCL ER TB24 36 MG METHYLHENIDATE HCL ER TBCR 18 MG methylphenidate hcl tabs 10, 20 methylphenidate hcl tabs 5 methylphenidate hcl tbcr 10, 20, 36 methylphenidate hcl tbcr 18, 27, 54 RITALIN TABS 10 MG, 20 MG (Use Methylphenidate HCl) RITALIN TABS 5 MG (Use Methylphenidate HCl) N N ; AL; At least 6 QL(3 ea ; AL; At least 3 QL(6 ea ; AL; At least 3 ; AL; At least 6 ; AL; At least 6 QL(3 ea ; AL; At least 3 QL(6 ea ; AL; At least 3 ALLERGENIC EXTRACTS/BIOLOGICALS MISC Allergenic Extracts GRASTEK SUBL RAGWITEK SUBL ALTERNATIVE MEDICINES ; AL; At least 5 - Up to 65 ; AL; At least 18 - Up to 65 Alternative Medicine - G's ginger (zingiber officinalis) QL(4 ea caps 250 Alternative Medicine - M's melatonin tabs or 3, 5 AMINOGLYCOSIDES - s to Treat Bacterial Infections Aminoglycosides Name neomycin sulfate tabs TOBRAMYCIN SULFATE SOLN 10 MG/ML, 40 MG/ML A tobramycin sulfate soln 40 A /ml, 80 /2ml, 1.2 gm/30ml tobramycin sulfate solr 1.2 A gm ANALGESICS - ANTI-INFLAMMATORY - s to Treat ain, Swelling, Muscle and Joint Conditions Anti-TNF-alpha - Monoclonal Antibodies HUMIRA EDIATRIC CROHNS DISEASE A; S STARTER ACK SKT HUMIRA EN NKT A; S HUMIRA EN-CROHNS DISEASESTARTER NKT HUMIRA EN-SORIASIS STARTER NKT HUMIRA SKT Antirheumatic Antimetabolites RHEUMATREX TABS A; S A; S A; S Nonsteroidal Anti-inflammatory Agents (NSAIDs) ADVIL TABS (Use Ibuprofen) N ALEVE ARTHRITIS TABS (Use Naproxen Sodium) N ALEVE TABS (Use Naproxen Sodium) N ANAROX DS TABS (Use Naproxen Sodium) N CELEBREX CAS (Use Celecoxib) N A; QL(2 ea celecoxib caps A; QL(2 ea CHILDRENS ADVIL SUS (Use Ibuprofen) N CHILDRENS MOTRIN N SUS (Use Ibuprofen) 2

11 Name DAYRO TABS (Use Oxaprozin) diclofenac potassium tabs diclofenac sodium tb24 or 100 diclofenac sodium tbec or 25, 50, 75 EC-NAROSYN TBEC (Use Naproxen) etodolac caps etodolac tabs etodolac tb24 FELDENE CAS (Use iroxicam) flurbiprofen tabs ibuprofen chew 100 ibuprofen susp 100 /5ml ibuprofen susp 40 /ml, 50 /1.25ml ibuprofen tabs 200, 400, 600, 800 indomethacin caps indomethacin cpcr INFANTS ADVIL SUS (Use Ibuprofen) KETOROFEN CAS 50 MG, 75 MG ketoprofen caps 50, 75 KETOROFEN ER C24 ketorolac tromethamine tabs or 10 LODINE TABS (Use Etodolac) N N N N N QL(20 ea per ; AL; At least 17 Name MOBIC TABS 15 MG, 7.5 MG (Use Meloxicam) MOTRIN INFANTS DROS SUS (Use Ibuprofen) nabumetone tabs NAROSYN SUS (Use Naproxen) NAROSYN TABS (Use Naproxen) naproxen sodium tabs 220 naproxen sodium tabs 275, 550 naproxen susp 125 /5ml naproxen tabs 250, 375, 500 naproxen tbec 375, 500 oxaprozin tabs piroxicam caps sulindac tabs N N N N yrimidine Synthesis Inhibitors ARAVA TABS (Use N Leflunomide) leflunomide tabs Soluble Tumor Necrosis Factor Receptor Agents ENBREL SOLR A; S ENBREL SOSY A; S ENBREL SURECLICK A; S SOAJ ANALGESICS - NonNarcotic - s to Treat ain, Muscle and Joint Conditions Analgesic Combinations butalbital-acetaminophen tabs meloxicam tabs 3

12 Name butalbital-acetaminophencaffeine caps butalbital-acetaminophencaffeine tabs butalbital-aspirin-caffeine caps BUTALBITAL/ASIRIN/CA FFEINE TABS ESGIC TABS (Use Butalbital-Acetaminophen- Caffeine) FIORINAL CAS (Use Butalbital-Aspirin-Caffeine) TENCON TABS Analgesics Other acetaminophen chew or 80, 160 acetaminophen elix or 160 /5ml, 80 /2.5ml acetaminophen liqd or 160 /5ml acetaminophen soln or 160 /5ml, 650 /20.3ml, 325 /10.15ml acetaminophen supp re 120, 325, 650 acetaminophen susp or 160 /5ml, 80 /0.8ml, 80 /2.5ml acetaminophen tabs or 325, 500 NORTEM INFANTS SUS TYLENOL CHILDRENS CHEWABLES/AIN + FEVER CHEW (Use Acetaminophen) TYLENOL CHILDRENS SUS (Use Acetaminophen) TYLENOL EXTRA STRENGTH TABS (Use Acetaminophen) N N N N N QL(4 ea QL(4 ea QL(4 ea QL(4 ea QL(4 ea QL(4 ea QL(240 ml per QL(12 ea per Name TYLENOL INFANTS AIN+FEVER SUS (Use Acetaminophen) TYLENOL INFANTS SUS (Use Acetaminophen) TYLENOL TABS (Use Acetaminophen) Salicylates aspirin buffered (cal carbmag carb-mag oxide) tabs aspirin chew or 81 aspirin supp re 300, 600 ASIRIN SU RE 300 MG, 600 MG aspirin tabs or 325 aspirin tbec or 81, 324, 325, 500 BUFFERIN TABS (Use Aspirin Buffered (Cal Carb- Mag Carb-Mag Oxide)) diflunisal tabs DISALCID TABS (Use Salsalate) ECOTRIN MAXIMUM STRENGTH TBEC (Use Aspirin) ECOTRIN REGULAR STRENGTH TBEC (Use Aspirin) salsalate tabs N N N N N N N QL(12 ea per QL(12 ea per ANALGESICS - OIOID - s to Treat ain, Muscle and Joint Conditions Opioid Agonists codeine sulfate tabs 15, Opioid Smart 30, 60 CODEINE SULFATE TABS 15 MG, 30 MG, 60 MG (Use Codeine Sulfate) DEMEROL TABS OR 100 MG (Use Meperidine HCl) N N A Opioid Smart A Opioid Smart A;QL(6 ea 4

13 Name DILAUDID TABS OR 2 MG (Use Hydromorphone HCl) DILAUDID TABS OR 4 MG (Use Hydromorphone HCl) DILAUDID TABS OR 8 MG (Use Hydromorphone HCl) DOLOHINE TABS 10 MG (Use Methadone HCl) DOLOHINE TABS 5 MG (Use Methadone HCl) DURAGESIC T72 (Use Fentanyl) fentanyl pt72 12 mcg/hr, 25 mcg/hr, 50 mcg/hr, 75 mcg/hr, 100 mcg/hr HYDROMORHONE HCL SU RE 3 MG hydromorphone hcl tabs or 2 hydromorphone hcl tabs or 4 hydromorphone hcl tabs or 8 MEERIDINE HCL SOLN OR 50 MG/5ML meperidine hcl tabs or 50, 100 methadone hcl tabs or 10 methadone hcl tabs or 5 N N N N N N Opioid Smart A;QL(8 ea Opioid Smart A Opioid Smart A;QL(4 ea A; Opioid Smart A;QL(10 ea A; Opioid Smart A;QL(4 ea Opioid Smart A;QL(0.34 ea Opioid Smart A;QL(0.34 ea Opioid Smart A;QL(2 ea Opioid Smart A;QL(8 ea Opioid Smart A Opioid Smart A;QL(4 ea Opioid Smart A Opioid Smart A;QL(6 ea A; Opioid Smart A;QL(10 ea A; Opioid Smart A;QL(4 ea Name morphine sulfate soln or 10 /5ml, 20 /5ml morphine sulfate soln or 20 /ml, 100 /5ml MORHINE SULFATE SU RE 5 MG, 10 MG, 20 MG, 30 MG MORHINE SULFATE TABS OR 15 MG, 30 MG morphine sulfate tbcr or 15, 30, 60, 100, 200 MS CONTIN TBCR (Use Morphine Sulfate) oxycodone hcl caps 5 oxycodone hcl conc 100 /5ml oxycodone hcl soln 5 /5ml oxycodone hcl tabs 5, 10, 15, 20, 30 ROXICODONE TABS (Use Oxycodone HCl) tramadol hcl tabs 50 ULTRAM TABS (Use Tramadol HCl) Opioid Combinations acetaminophen w/ codeine tabs , , N N N Opioid Smart A;QL(16.67 ml daily,225 ml per 14 days retail) Opioid Smart A;112 rtl MAX day(s) supply,14 rtl lmt day(s), Opioid Smart A;QL(0.78 ea daily,11 ea per 14 days retail) Opioid Smart A;QL(6 ea Opioid Smart A;QL(3 ea Opioid Smart A;QL(3 ea Opioid Smart A;QL(6 ea Opioid Smart A;QL(4 ml daily,56 ml per 14 days retail) Opioid Smart A Opioid Smart A;QL(6 ea Opioid Smart A;QL(6 ea Opioid Smart A;QL(8 ea Opioid Smart A;QL(8 ea Opioid Smart A;QL(6 ea 5

14 Name butalbital-acetaminophencaffeine w/ codeine caps butalbital-aspirin-caffeine w/cod caps CAITAL/CODEINE SUS FIORINAL/CODEINE #3 CAS (Use Butalbital- Aspirin-Caffeine w/cod) hydrocodoneacetaminophen soln 2.5/5ml-108/5ml, 5/10ml-217/10ml, 7.5/15ml-325/15ml hydrocodoneacetaminophen tabs 5-325, hydrocodoneacetaminophen tabs NORCO TABS 5MG- 325MG, 10MG-325MG (Use Hydrocodone- Acetaminophen) NORCO TABS 7.5MG- 325MG (Use Hydrocodone- Acetaminophen) oxycodone w/ acetaminophen tabs 5-325, , oxycodone-aspirin tabs OXYCODONE/ACETAMIN OHEN SOLN ERCOCET TABS 5MG- 325MG, 10MG-325MG, 7.5MG-325MG (Use Oxycodone w/ Acetaminophen) tramadol-acetaminophen tabs N N N N Opioid Smart A;QL(4 ea Opioid Smart A;QL(4 ea Opioid Smart A;QL(30 ml daily,14 day(s) limit) Opioid Smart A;QL(4 ea Opioid Smart A;QL(180 ml Opioid Smart A;QL(6 ea Opioid Smart A;QL(8 ea Opioid Smart A;QL(6 ea Opioid Smart A;QL(8 ea Opioid Smart A;QL(6 ea Opioid Smart A;QL(6 ea Opioid Smart A Opioid Smart A;QL(6 ea Opioid Smart A;QL(4 ea Name TYLENOL/CODEINE #3 TABS (Use Acetaminophen w/ Codeine) TYLENOL/CODEINE #4 TABS (Use Acetaminophen w/ Codeine) ULTRACET TABS (Use Tramadol-Acetaminophen) N N N Opioid Smart A;QL(6 ea Opioid Smart A;QL(6 ea Opioid Smart A;QL(4 ea Opioid artial Agonists SUBOXONE FILM 4MG- 1MG, 2MG-0.5MG SUBOXONE FILM 8MG- 2MG, 12MG-3MG ANDROGENS-ANABOLIC - s to Regulate Hormones Androgens ANDRODERM T24 ANDROXY TABS DEO-TESTOSTERONE SOLN 200 MG/ML (Use Testosterone Cypionate) METHITEST TABS testosterone cypionate soln 200 /ml N QL(4 ml per 31 days retail) QL(4 ml per 31 days retail) ANORECTAL AGENTS - Rectal s to Treat ain, Swelling and Itching Intrarectal Steroids CORTENEMA ENEM (Use Hydrocortisone N (Intrarectal)) hydrocortisone (intrarectal) enem Rectal Combinations ANALRAM-HC LOTN 1%- 2.5% QL(62 ml per phenylephrine-shark liver QL(12 ea per oil-cocoa butter supp phenylephrine-shark liver oil-mineral oil-petrolatum oint Rectal Steroids QL(31 gm per 6

15 Name ANUSOL-HC CREA (Use Hydrocortisone (Rectal)) hydrocortisone (rectal) crea 2.5 % ANTACIDS Antacid Combinations alum & mag hydroxsimethicone liqd 200/5ml-20/5ml- 200/5ml alum & mag hydroxsimethicone susp 200/5ml-20/5ml- 200/5ml, 200/5ml- 200/5ml-20/5ml- 20/5ml-200/5ml- 200/5ml Antacids - Aluminum Salts ALUMINUM HYDROXIDE SUS OR Antacids - Bicarbonate sodium bicarbonate (antacid) tabs Antacids - Calcium Salts calcium carbonate (antacid) chew 500 TUMS CHEW (Use Calcium Carbonate (Antacid)) TUMS LASTING EFFECTS CHEW (Use Calcium Carbonate (Antacid)) Antacids - Magnesium Salts magnesium oxide tabs 400 N N N QL(24 ml QL(24 ml QL(3.34 ea ANTHELMINTICS - s to Treat Worm Infections Anthelmintics EMVERM CHEW QL(1 ea per fill retail) pyrantel pamoate susp QL(60 ml per 1 rtl MAX fill,31 rtl day(s) supply, Name ANTI-INFECTIVE AGENTS - MISC. - s to Treat Bacterial Infections Anti-infective Agents - Misc. FLAGYL TABS 250 MG, 500 MG (Use N Metronidazole) metronidazole tabs 250, 500 trimethoprim tabs VANCOCIN HCL CAS QL(4 ea 125 MG (Use Vancomycin N HCl) VANCOCIN HCL CAS QL(8 ea 250 MG (Use Vancomycin N HCl) vancomycin hcl caps or QL(4 ea 125 vancomycin hcl caps or QL(8 ea 250 vancomycin hcl solr iv 1000 QL(14 ea per vancomycin hcl solr iv 500 QL(14 ea per Anti-infective Misc. - Combinations BACTRIM DS TABS (Use Sulfamethoxazole- N Trimethoprim) BACTRIM TABS (Use Sulfamethoxazole- N Trimethoprim) sulfamethoxazoletrimethoprim susp or 40/5ml-200/5ml sulfamethoxazoletrimethoprim tabs or , Leprostatics dapsone tabs Lincosamides CLEOCIN CAS OR 150 MG, 300 MG (Use Clindamycin HCl) N 7

16 Name CLEOCIN EDIATRIC GRANULES SOLR (Use Clindamycin almitate Hydrochloride) clindamycin hcl caps 150, 300 clindamycin palmitate hydrochloride solr Oxazolidinones SIVEXTRO TABS OR N QL(300 ml per QL(300 ml per A; QL(6 ea per ANTIANGINAL AGENTS - s to Treat Chest ain Nitrates ISORDIL TITRADOSE TABS 5 MG (Use N Isosorbide Dinitrate) ISOSORBIDE DINITRATE ER TBCR isosorbide dinitrate tabs isosorbide mononitrate tabs 10, 20 isosorbide mononitrate tb24 30, 60, 120 NITRO-BID OINT NITRO-DUR T MG/HR, 0.2 MG/HR, 0.4 MG/HR, 0.6 MG/HR (Use Nitroglycerin) nitroglycerin cpcr or 9, 2.5, 6.5 nitroglycerin pt24 td 0.1 /hr, 0.2 /hr, 0.4 /hr, 0.6 /hr nitroglycerin subl sl 0.3, 0.4, 0.6 NITROSTAT SUBL (Use Nitroglycerin) N N ANTIANXIETY AGENTS - s to Treat Anxiety Antianxiety Agents - Misc. buspirone hcl tabs 15 QL(4 ea Name buspirone hcl tabs 30, 7.5 buspirone hcl tabs 5, 10 hydroxyzine hcl syrp or 10 /5ml hydroxyzine hcl tabs or 10, 25, 50 HYDROXYZINE AMOATE CAS 100 MG hydroxyzine pamoate caps 25, 50 meprobamate tabs VISTARIL CAS (Use Hydroxyzine amoate) Benzodiazepines alprazolam tabs 0.25, 0.5, 1, 2 ATIVAN TABS OR 0.5 MG, 2 MG (Use Lorazepam) ATIVAN TABS OR 1 MG (Use Lorazepam) chlordiazepoxide hcl caps clorazepate dipotassium tabs DIAZEAM SOLN OR 1 MG/ML diazepam tabs or 2, 5, 10 lorazepam tabs or 0.5, 2 lorazepam tabs or 1 oxazepam caps 10, 15, 30 OXAZEAM CAS 30 MG TRANXENE T TABS (Use Clorazepate Dipotassium) VALIUM TABS (Use Diazepam) XANAX TABS (Use Alprazolam) N N N N N N QL(3 ea QL(6 ea QL(3 ea QL(3 ea QL(4 ea QL(4 ea QL(3 ea QL(4 ea QL(3 ea QL(4 ea QL(4 ea QL(4 ea QL(3 ea QL(4 ea QL(3 ea 8

17 Name ANTIARRHYTHMICS - s to treat abnormal heart rhythms Antiarrhythmics Type I-A disopyramide phosphate caps NORACE CAS (Use N Disopyramide hosphate) NORACE CR C MG quinidine gluconate tbcr or 324 QUINIDINE SULFATE TABS Antiarrhythmics Type I-B mexiletine hcl caps Antiarrhythmics Type I-C flecainide acetate tabs propafenone hcl cp12 propafenone hcl tabs RYTHMOL SR C12 (Use ropafenone HCl) RYTHMOL TABS (Use ropafenone HCl) Antiarrhythmics Type III amiodarone hcl tabs or 200 dofetilide caps N N TIKOSYN CAS (Use N Dofetilide) ANTIASTHMATIC AND BRONCHODILATOR AGENTS - s to Treat Lung Conditions Anti-Inflammatory Agents cromolyn sodium nebu QL(8 ml Bronchodilators - Anticholinergics ATROVENT HFA AERS Name INCRUSE ELLITA AEB ipratropium bromide soln TUDORZA RESSAIR AEB Leukotriene Modulators montelukast sodium chew montelukast sodium pack montelukast sodium tabs SINGULAIR CHEW (Use Montelukast Sodium) SINGULAIR ACK (Use Montelukast Sodium) SINGULAIR TABS (Use Montelukast Sodium) Steroid Inhalants AEROSAN AERS budesonide (inhalation) susp 0.25 /2ml, 0.5 /2ml budesonide (inhalation) susp 1 /2ml FLOVENT DISKUS AEB FLOVENT HFA AERO 110 MCG/ACT, 220 MCG/ACT FLOVENT HFA AERO 44 MCG/ACT ULMICORT FLEXHALER AEB ULMICORT SUS 0.25 MG/2ML, 0.5 MG/2ML (Use Budesonide (Inhalation)) N N N N QL(375 ml per 25 days retail) QL(9 gm per 31 days retail) QL(120 ml per ; AL; At least 1 - Up to 8 QL(60 ml per ; AL; At least 1 - Up to 8 QL(12 gm per 25 days retail) QL(11 gm per 25 days retail) QL(120 ml per ; AL; At least 1 - Up to 8 9

18 Name ULMICORT SUS 1 MG/2ML (Use Budesonide (Inhalation)) Sympathomimetics ADVAIR DISKUS AEB ALBUTEROL SULFATE ER TB12 albuterol sulfate nebu in % albuterol sulfate nebu in 0.5 % albuterol sulfate nebu in 0.63 /3ml, 1.25 /3ml albuterol sulfate syrp or 2 /5ml albuterol sulfate tabs or 2, 4 albuterol sulfate tb12 or 4, 8 COMBIVENT RESIMAT AERS DULERA AERO ipratropium-albuterol soln METAROTERENOL SULFATE SYR 10 MG/5ML METAROTERENOL SULFATE TABS 10 MG, 20 MG SEREVENT DISKUS AEB SYMBICORT AERO terbutaline sulfate tabs or 5, 2.5 VENTOLIN HFA AERS N QL(60 ml per ; AL; At least 1 - Up to 8 QL(60 ea per ; AL; At least 4 - Up to 5 QL(12.5 ml QL(375 ml per QL(4 gm per 31 days retail) QL(13 gm per QL(12 ml QL(30 ml QL(11 gm per Limit: 1 inhaler 2 per month Name VOSIRE ER TB12 (Use Albuterol Sulfate) Xanthines ELIXOHYLLIN ELIX THEO-24 C24 theophylline soln 80 /15ml theophylline tb12 100, 200, 300, 450 theophylline tb24 400, 600 N ANTICOAGULANTS - Blood Thinners Coumarin Anticoagulants COUMADIN TABS (Use Warfarin Sodium) warfarin sodium tabs Direct Factor Xa Inhibitors ELIQUIS STARTER ACK TABS ELIQUIS TABS XARELTO TABS 10 MG XARELTO TABS 15 MG XARELTO TABS 20 MG N Heparins And Heparinoid-Like Agents enoxaparin sodium soln ij 300 /3ml enoxaparin sodium soln sc 100 /ml QL(475 ml per QL(4 ea QL(4 ea QL(1 ea daily,35 ea per 180 days retail) Limit 3 fills per 180 days;ql(42 ml per 7 days retail) Limit 3 fills per 180 days;ql(14 ml per 7 days retail) 10

19 Name enoxaparin sodium soln sc 150 /ml enoxaparin sodium soln sc 30 /0.3ml enoxaparin sodium soln sc 40 /0.4ml enoxaparin sodium soln sc 60 /0.6ml enoxaparin sodium soln sc 80 /0.8ml, 120 /0.8ml heparin sodium (porcine) soln LOVENOX SOLN IJ 300 MG/3ML (Use Enoxaparin Sodium) LOVENOX SOLN SC 100 MG/ML (Use Enoxaparin Sodium) LOVENOX SOLN SC 150 MG/ML (Use Enoxaparin Sodium) LOVENOX SOLN SC 30 MG/0.3ML (Use Enoxaparin Sodium) LOVENOX SOLN SC 40 MG/0.4ML (Use Enoxaparin Sodium) N N N N N Limit 3 fills per 180 days;ql(150 ml per 7 days retail) Limit 3 fills per 180 days;ql(5 ml per 7 days retail) Limit 3 fills per 180 days;ql(6 ml per 7 days retail) Limit 3 fills per 180 days;ql(9 ml per 7 days retail) Limit 3 fills per 180 days;ql(12 ml per 7 days retail) Limit 3 fills per 180 days;ql(42 ml per 7 days retail) Limit 3 fills per 180 days;ql(14 ml per 7 days retail) Limit 3 fills per 180 days;ql(150 ml per 7 days retail) Limit 3 fills per 180 days;ql(5 ml per 7 days retail) Limit 3 fills per 180 days;ql(6 ml per 7 days retail) Name LOVENOX SOLN SC 60 MG/0.6ML (Use Enoxaparin Sodium) LOVENOX SOLN SC 80 MG/0.8ML, 120 MG/0.8ML (Use Enoxaparin Sodium) N N Limit 3 fills per 180 days;ql(9 ml per 7 days retail) Limit 3 fills per 180 days;ql(12 ml per 7 days retail) ANTICONVULSANTS - s to Treat Seizures Anticonvulsants - Benzodiazepines clonazepam tabs 0.5, 1 QL(4 ea, 2 KLONOIN TABS (Use Clonazepam) N QL(4 ea Anticonvulsants - Misc. carbamazepine chew 100 carbamazepine susp 100 /5ml carbamazepine tabs 200 carbamazepine tb12 100, 200, 400 gabapentin caps 100, QL(9 ea 300, 400 gabapentin soln 250 /5ml, 300 /6ml gabapentin tabs 600 QL(6 ea gabapentin tabs 800 QL(4 ea KERA SOLN OR 100 MG/ML (Use N QL(16 ml Levetiracetam) KERA TABS OR 1000 MG (Use Levetiracetam) N KERA TABS OR 250 MG, 750 MG (Use Levetiracetam) N QL(4 ea KERA TABS OR 500 N QL(6 ea MG (Use Levetiracetam) KERA XR TB24 (Use Levetiracetam) N ST 11

20 Name LAMICTAL CHEWABLE DISERSIBLE CHEW (Use Lamotrigine) LAMICTAL TABS (Use Lamotrigine) LAMICTAL XR TB24 25 MG, 50 MG, 100 MG, 200 MG, 250 MG, 300 MG (Use Lamotrigine) lamotrigine chew 5, 25 lamotrigine tabs 25, 100, 150, 200 lamotrigine tb24 25, 50, 100, 200, 250, 300 levetiracetam soln or 100 /ml, 500 /5ml levetiracetam tabs or 1000 levetiracetam tabs or 250, 750 levetiracetam tabs or 500 levetiracetam tb24 or 500, 750 MYSOLINE TABS (Use rimidone) NEURONTIN CAS 100 MG, 300 MG, 400 MG (Use Gabapentin) NEURONTIN SOLN 250 MG/5ML (Use Gabapentin) NEURONTIN TABS 600 MG (Use Gabapentin) NEURONTIN TABS 800 MG (Use Gabapentin) oxcarbazepine susp oxcarbazepine tabs primidone tabs TEGRETOL SUS (Use Carbamazepine) TEGRETOL TABS (Use Carbamazepine) N N N N N N N N N N ST; QL(1 ea ST; QL(1 ea QL(16 ml QL(4 ea QL(6 ea ST QL(9 ea QL(6 ea QL(4 ea Name TEGRETOL-XR TB12 (Use Carbamazepine) TOAMAX SRINKLE CS 15 MG (Use Topiramate) TOAMAX SRINKLE CS 25 MG (Use Topiramate) TOAMAX TABS 100 MG (Use Topiramate) TOAMAX TABS 200 MG (Use Topiramate) TOAMAX TABS 25 MG, 50 MG (Use Topiramate) topiramate cpsp 15 topiramate cpsp 25 topiramate tabs 100 topiramate tabs 200 topiramate tabs 25, 50 TRILETAL SUS (Use Oxcarbazepine) TRILETAL TABS (Use Oxcarbazepine) ZONEGRAN CAS (Use Zonisamide) zonisamide caps Carbamates felbamate susp felbamate tabs FELBATOL SUS (Use Felbamate) FELBATOL TABS (Use Felbamate) GABA Modulators GABITRIL TABS (Use Tiagabine HCl) tiagabine hcl tabs N N N N N N N N N N N N QL(6 ea QL(8 ea QL(4 ea QL(6 ea QL(6 ea QL(8 ea QL(4 ea QL(6 ea 12

21 Name Hydantoins DILANTIN CAS 100 MG (Use henytoin Sodium Extended) DILANTIN CAS 30 MG DILANTIN INFATABS CHEW (Use henytoin) DILANTIN-125 SUS (Use henytoin) phenytoin chew phenytoin sodium extended caps 100 phenytoin susp Succinimides ethosuximide caps ethosuximide soln ZARONTIN CAS (Use Ethosuximide) ZARONTIN SOLN (Use Ethosuximide) Valproic Acid DEACON SOLN (Use Valproate Sodium) DEAKENE CAS 250 MG (Use Valproic Acid) DEAKOTE ER TB MG (Use Divalproex Sodium) DEAKOTE ER TB MG (Use Divalproex Sodium) DEAKOTE SRINKLES CSDR (Use Divalproex Sodium) DEAKOTE TBEC 125 MG (Use Divalproex Sodium) DEAKOTE TBEC 250 MG (Use Divalproex Sodium) DEAKOTE TBEC 500 MG (Use Divalproex Sodium) N N N N N N N N N N N N N A; QL(3 ea QL(7 ea QL(8 ea QL(3 ea QL(7 ea Name divalproex sodium csdr 125 divalproex sodium tb divalproex sodium tb divalproex sodium tbec 125 divalproex sodium tbec 250 divalproex sodium tbec 500 valproate sodium soln iv 100 /ml, 500 /5ml valproic acid caps QL(8 ea QL(3 ea QL(7 ea QL(3 ea QL(7 ea A; ANTIDERESSANTS - s to Treat Depression Alpha-2 Receptor Antagonists (Tetracyclics) mirtazapine tabs 15 QL(3 ea mirtazapine tabs 30 QL(1.5 ea mirtazapine tabs 45, 7.5 mirtazapine tbdp 15 mirtazapine tbdp 30 mirtazapine tbdp 45 REMERON SOLTAB TBD 15 MG (Use Mirtazapine) REMERON SOLTAB TBD 30 MG (Use Mirtazapine) REMERON SOLTAB TBD 45 MG (Use Mirtazapine) REMERON TABS 15 MG (Use Mirtazapine) REMERON TABS 30 MG (Use Mirtazapine) REMERON TABS 45 MG (Use Mirtazapine) Antidepressants - Misc. bupropion hcl tabs 75, 100 N N N N N N QL(3 ea QL(1.5 ea QL(3 ea QL(1.5 ea QL(3 ea QL(1.5 ea QL(3 ea 13

22 Name bupropion hcl tb bupropion hcl tb bupropion hcl tb bupropion hcl tb bupropion hcl tb MAROTILINE HCL TABS QL(4 ea QL(3 ea QL(3 ea WELLBUTRIN SR TB MG (Use Bupropion HCl) N QL(4 ea WELLBUTRIN SR TB12 QL(3 ea 150 MG (Use Bupropion N HCl) WELLBUTRIN SR TB MG (Use Bupropion N HCl) WELLBUTRIN XL TB24 QL(3 ea 150 MG (Use Bupropion N HCl) WELLBUTRIN XL TB MG (Use Bupropion N HCl) Monoamine Oxidase Inhibitors (MAOIs) NARDIL TABS (Use henelzine Sulfate) N ARNATE TABS (Use Tranylcypromine Sulfate) N phenelzine sulfate tabs tranylcypromine sulfate tabs Selective Serotonin Reuptake Inhibitors (SSRIs) CELEXA TABS 10 MG (Use Citalopram Hydrobromide) N QL(4 ea CELEXA TABS 20 MG (Use Citalopram N Hydrobromide) CELEXA TABS 40 MG (Use Citalopram N Hydrobromide) Name citalopram hydrobromide soln 10 /5ml citalopram hydrobromide tabs 10 citalopram hydrobromide tabs 20 citalopram hydrobromide tabs 40 escitalopram oxalate tabs 10 escitalopram oxalate tabs 20 escitalopram oxalate tabs 5 fluoxetine hcl caps 10, 20 fluoxetine hcl caps 40 fluoxetine hcl soln 20 /5ml fluoxetine hcl tabs 10 fluvoxamine maleate tabs 100 fluvoxamine maleate tabs 25, 50 LEXARO TABS 10 MG (Use Escitalopram Oxalate) LEXARO TABS 20 MG (Use Escitalopram Oxalate) LEXARO TABS 5 MG (Use Escitalopram Oxalate) paroxetine hcl tabs 10 paroxetine hcl tabs 20 paroxetine hcl tabs 30, 40 paroxetine hcl tb24 25, 12.5, 37.5 AXIL CR TB24 (Use aroxetine HCl) N N N N QL(4 ea QL(4 ea QL(4 ea ; AL; At least 7 QL(120 ml per fill retail,600 ml per 31 days retail); AL; Up to 6 ; AL; At least 7 QL(3 ea QL(4 ea QL(6 ea QL(3 ea 14

23 Name AXIL SUS 10 MG/5ML AXIL TABS 10 MG (Use aroxetine HCl) AXIL TABS 20 MG (Use aroxetine HCl) AXIL TABS 30 MG, 40 MG (Use aroxetine HCl) ROZAC CAS 10 MG, 20 MG (Use Fluoxetine HCl) ROZAC CAS 40 MG (Use Fluoxetine HCl) sertraline hcl conc 20 /ml sertraline hcl tabs 100 sertraline hcl tabs 25, 50 ZOLOFT CONC 20 MG/ML (Use Sertraline HCl) ZOLOFT TABS 100 MG (Use Sertraline HCl) ZOLOFT TABS 25 MG, 50 MG (Use Sertraline HCl) Serotonin Modulators NEFAZODONE HCL TABS 100 MG, 150 MG, 200 MG nefazodone hcl tabs 50, 250 trazodone hcl tabs 300 trazodone hcl tabs 50, 100, 150 TRINTELLIX TABS VIIBRYD TABS N N N N N N N N A; QL(40 ml QL(6 ea QL(3 ea QL(4 ea ; AL; At least 7 QL(186 ml per QL(4 ea QL(186 ml per QL(4 ea A; QL(1 ea ; AL; At least 18 A; QL(1 ea Serotonin-Norepinephrine Reuptake Inhibitors CYMBALTA CE (Use Duloxetine HCl) desvenlafaxine succinate tb N ; AL; At least 7 QL(4 ea Name desvenlafaxine succinate tb24 25, 50 duloxetine hcl cpep 20, 30, 60 EFFEXOR XR C MG (Use Venlafaxine HCl) EFFEXOR XR C MG (Use Venlafaxine HCl) EFFEXOR XR C24 75 MG (Use Venlafaxine HCl) RISTIQ TB MG (Use Desvenlafaxine Succinate) RISTIQ TB24 25 MG, 50 MG (Use Desvenlafaxine Succinate) venlafaxine hcl cp venlafaxine hcl cp venlafaxine hcl cp24 75 VENLAFAXINE HCL ER TB MG (Use Venlafaxine HCl) VENLAFAXINE HCL ER TB MG VENLAFAXINE HCL ER TB24 75 MG, 37.5 MG (Use Venlafaxine HCl) venlafaxine hcl tabs 25, 50, 75, 100, 37.5 venlafaxine hcl tb venlafaxine hcl tb24 75, 225, 37.5 Tricyclic Agents amitriptyline hcl tabs AMOXAINE TABS ANAFRANIL CAS 75 MG (Use Clomipramine HCl) clomipramine hcl caps 75 N N N N N N N N ; AL; At least 7 QL(4 ea QL(5 ea QL(4 ea QL(4 ea QL(5 ea 15

24 Name desipramine hcl tabs 10, 50, 75, 100, 150 desipramine hcl tabs 25 doxepin hcl caps doxepin hcl conc ELAVIL TABS (Use Amitriptyline HCl) imipramine hcl tabs N NORRAMIN TABS 10 MG (Use Desipramine HCl) N NORRAMIN TABS 25 MG (Use Desipramine HCl) N nortriptyline hcl caps 10, 25, 50, 75 nortriptyline hcl soln 10 QL(20 ml /5ml AMELOR CAS (Use Nortriptyline HCl) N TOFRANIL TABS (Use Imipramine HCl) N ANTIDIABETICS - s to Regulate Blood Sugar Antidiabetic - Amylin Analogs SYMLINEN 120 SON QL(11 ml per SYMLINEN 60 SON QL(6 ml per 31 days retail) Antidiabetic Combinations ACTOLUS MET TABS (Use ioglitazone HCl- N Metformin HCl) alogliptin-metformin hcl A; QL(2 ea tabs alogliptin-pioglitazone tabs A; QL(1 ea glipizide-metformin hcl tabs GLUCOVANCE TABS (Use Glyburide-Metformin) glyburide-metformin tabs N Name pioglitazone hcl-metformin hcl tabs Biguanides GLUCOHAGE TABS 500 MG (Use Metformin HCl) GLUCOHAGE TABS 850 MG, 1000 MG (Use Metformin HCl) GLUCOHAGE XR TB MG (Use Metformin HCl) GLUCOHAGE XR TB MG (Use Metformin HCl) metformin hcl tabs 500 metformin hcl tabs 850, 1000 metformin hcl tb metformin hcl tb Diabetic Other BD GLUCOSE CHEW CVS GLUCOSE CHEW 4 GM DEX4 QUICK DISSOLVE GLUCOSE CHEW GLUCAGEN HYOKIT SOLR GLUCAGON EMERGENCY KIT KIT GLUCOSE CHEW 4 GM GN GLUCOSE CHEW 4 GM GN QUICK DISSOLVE GLUCOSE CHEW LEADER QUICK DISSOLVE GLUCOSE CHEW SM GLUCOSE CHEW 4 GM N N N N QL(5 ea QL(4 ea QL(3 ea QL(5 ea QL(4 ea QL(3 ea QL(50 ea per QL(50 ea per QL(50 ea per 4 rtl MAX fill,365 rtl day(s) supply, QL(50 ea per QL(50 ea per QL(50 ea per QL(50 ea per QL(50 ea per 16

25 Name WALGREENS GLUCOSE CHEW 4 GM QL(50 ea per Dipeptidyl eptidase-4 (D-4) Inhibitors alogliptin benzoate tabs A; QL(1 ea Incretin Mimetic Agents (GL-1 Receptor A; QL(4 ea BYDUREON EN EN per 28 days retail); AL; At least 18 BYDUREON SRER A; QL(4 ea per 28 days retail); AL; At least 18 BYETTA SON 10 MCG/0.04ML A; QL(2 ml per 31 days retail); AL; At least 18 BYETTA SON 5 MCG/0.02ML VICTOZA SON Insulin Sensitizing Agents ACTOS TABS (Use ioglitazone HCl) pioglitazone hcl tabs Insulin ADMELOG SOLN ADMELOG SOLOSTAR SON AIDRA SOLN AIDRA SOLOSTAR SON BASAGLAR KWIKEN SON FIAS FLEXTOUCH SON FIAS SOLN HUMALOG JUNIOR KWIKEN SON N A; QL(1 ml per 31 days retail); AL; At least 18 A; QL(1.8 ml QL(30 ml per QL(30 ml per QL(40 ml per QL(30 ml per QL(1 ml QL(30 ml per QL(40 ml per QL(30 ml per Name HUMALOG KWIKEN SON HUMALOG MIX 50/50 KWIKEN SUN HUMALOG MIX 50/50 SUS HUMALOG MIX 75/25 KWIKEN SUN HUMALOG MIX 75/25 SUS HUMALOG SOCT HUMALOG SOLN HUMULIN 70/30 KWIKEN SUN HUMULIN 70/30 SUS HUMULIN N KWIKEN SUN HUMULIN N SUS HUMULIN R SOLN NOVOLIN 70/30 RELION SUS NOVOLIN 70/30 SUS NOVOLIN N RELION SUS NOVOLIN N SUS NOVOLIN R RELION SOLN NOVOLIN R SOLN NOVOLOG FLEXEN SON NOVOLOG MIX 70/30 REFILLED FLEXEN SUN NOVOLOG MIX 70/30 SUS NOVOLOG ENFILL SOCT QL(30 ml per QL(30 ml per QL(40 ml per QL(30 ml per QL(40 ml per QL(30 ml per QL(30 ml per QL(30 ml per QL(40 ml per QL(30 ml per QL(40 ml per QL(40 ml per QL(40 ml per QL(40 ml per QL(40 ml per QL(40 ml per QL(40 ml per QL(40 ml per QL(30 ml per QL(30 ml per QL(40 ml per QL(30 ml per 17

26 Name NOVOLOG SOLN Meglitinide Analogues nateglinide tabs QL(40 ml per QL(3 ea STARLIX TABS (Use Nateglinide) N QL(3 ea Sodium-Glucose Co-Transporter 2 (SGLT2) A; ST;QL(1 FARXIGA TABS ea ; AL; At least 18 yrs old JARDIANCE TABS A; QL(1 ea Sulfonylureas AMARYL TABS 1 MG, 2 N QL(4 ea MG (Use Glimepiride) AMARYL TABS 4 MG (Use Glimepiride) N glimepiride tabs 1, 2 QL(4 ea glimepiride tabs 4 glipizide tabs glipizide tb24 GLUCOTROL TABS (Use Glipizide) GLUCOTROL XL TB24 (Use Glipizide) glyburide micronized tabs N N glyburide tabs GLYNASE TABS (Use N Glyburide Micronized) ANTIDIARRHEAL/ROBIOTIC AGENTS - s to Treat Diarrhea Antidiarrheal/robiotic Agents - Misc. bismuth subsalicylate chew 262 bismuth subsalicylate susp 525 /15ml Name ETO-BISMOL CHEW 262 MG (Use Bismuth Subsalicylate) ETO-BISMOL INSTACOOL CHEW (Use Bismuth Subsalicylate) ETO-BISMOL MAX STRENGTH SUS (Use Bismuth Subsalicylate) ETO-BISMOL TO-GO CHEW (Use Bismuth Subsalicylate) Antiperistaltic Agents diphenoxylate w/ atropine tabs DIHENOXYLATE/ATRO INE LIQD IMODIUM A-D CAS 2 MG (Use Loperamide HCl) IMODIUM A-D TABS 2 MG (Use Loperamide HCl) LOMOTIL TABS (Use Diphenoxylate w/ Atropine) loperamide hcl caps 2 loperamide hcl liqd 1 /5ml loperamide hcl tabs 2 N N N N N N N ANTIDOTES AND SECIFIC ANTAGONISTS Antidotes - Chelating Agents CHEMET CAS JADENU TABS Antidotes and Specific Antagonists VISTOGARD ACK Opioid Antagonists NALOXONE HCL SOCT 0.4 MG/ML naloxone hcl soln 0.4 /ml, 4 /10ml NALOXONE HCL SOSY 2 MG/2ML A; S QL(2 ml per 90 days retail) QL(2 ml per 90 days retail) QL(4 ml per 90 days retail) 18

27 Name naltrexone hcl tabs NARCAN LIQD QL(4 ea per 90 days retail) ANTIEMETICS - s to Treat Nausea and Vomiting 5-HT3 Receptor Antagonists ondansetron hcl soln ij 4 /2ml, 40 /20ml ondansetron hcl soln or 4 QL(50 ml per /5ml ondansetron hcl tabs or 24 QL(1 ea per 14 ondansetron hcl tabs or 4, 8 ondansetron tbdp ZOFRAN ODT TBD (Use N Ondansetron) ZOFRAN SOLN 4 MG/5ML N (Use Ondansetron HCl) ZOFRAN TABS 4 MG, 8 MG (Use Ondansetron N HCl) Antiemetics - Anticholinergic dimenhydrinate tabs or 50 DRAMAMINE CHEW DRAMAMINE TABS (Use Dimenhydrinate) meclizine hcl chew 25 meclizine hcl tabs 25, 12.5 N days retail) QL(20 ea per QL(20 ea per QL(20 ea per QL(50 ml per QL(20 ea per QL(24 ea per QL(24 ea per QL(24 ea per ANTIFUNGALS - s to Treat Fungal Infections Antifungals GRIS-EG TABS (Use Griseofulvin Ultramicrosize) griseofulvin microsize susp griseofulvin microsize tabs N Name griseofulvin ultramicrosize tabs LAMISIL TABS 250 MG (Use Terbinafine HCl) nystatin tabs terbinafine hcl tabs N Imidazole-Related Antifungals DIFLUCAN SUSR 10 MG/ML, 40 MG/ML (Use N Fluconazole) DIFLUCAN TABS 100 MG, 200 MG (Use Fluconazole) N DIFLUCAN TABS 150 MG (Use Fluconazole) N DIFLUCAN TABS 50 MG (Use Fluconazole) N fluconazole susr 10 /ml, 40 /ml fluconazole tabs 100, 200 fluconazole tabs 150 fluconazole tabs 50 itraconazole caps SORANOX CAS 100 MG (Use Itraconazole) SORANOX ULSEAK CAS (Use Itraconazole) N N QL(1 ea daily,90 ea per 120 days retail) QL(6 ea QL(1 ea daily,90 ea per 120 days retail) QL(70 ml per QL(2 ea per fill retail) QL(3 ea per 14 days retail) QL(70 ml per QL(2 ea per fill retail) QL(3 ea per 14 days retail) A; QL(1 ea A; QL(1 ea A; QL(1 ea ANTIHISTAMINES - s to Treat Allergies Antihistamines - Alkylamines CHLOR-TRIMETON SYR 2 MG/5ML (Use Chlorpheniramine Maleate) CHLOR-TRIMETON TABS 4 MG (Use Chlorpheniramine Maleate) chlorpheniramine maleate syrp 2 /5ml N N QL(120 ea per 19

28 Name chlorpheniramine maleate tabs 4 Antihistamines - Ethanolamines ALER-DRYL TABS BENADRYL ALLERGY CAS (Use Diphenhydramine HCl) BENADRYL ALLERGY CHILDRENS LIQD 12.5 MG/5ML (Use Diphenhydramine HCl) BENADRYL ALLERGY TABS (Use Diphenhydramine HCl) clemastine fumarate tabs 1.34 diphenhydramine hcl caps or 25 diphenhydramine hcl caps or 50 diphenhydramine hcl elix or 12.5 /5ml diphenhydramine hcl liqd or 25 /10ml, 50 /20ml, 12.5 /5ml diphenhydramine hcl syrp or 12.5 /5ml diphenhydramine hcl tabs or 25 SILHEN COUGH SYR N N N TAVIST ALLERGY TABS (Use Clemastine N Fumarate) Antihistamines - Non-Sedating ALLEGRA ALLERGY TABS 180 MG (Use N Fexofenadine HCl) ALLEGRA ALLERGY TABS 60 MG (Use N Fexofenadine HCl) cetirizine hcl chew 5, 10 QL(120 ea per QL(4 ea QL(4 ea QL(240 ml per QL(4 ea QL(4 ea QL(4 ea ; QL(240 ml per ; QL(240 ml per QL(240 ml per QL(4 ea QL(240 ml per Name cetirizine hcl soln 1 /ml, 5 /5ml cetirizine hcl syrp 1 /ml, 5 /5ml cetirizine hcl tabs 5, 10 CLARITIN ALLERGY CHILDRENS SYR (Use Loratadine) CLARITIN REDITABS TBD 10 MG (Use Loratadine) CLARITIN SYR 5 MG/5ML (Use Loratadine) CLARITIN TABS 10 MG (Use Loratadine) fexofenadine hcl tabs 180 fexofenadine hcl tabs 60 levocetirizine dihydrochloride tabs 5 loratadine soln 5 /5ml loratadine syrp 5 /5ml loratadine tabs 10 loratadine tbdp 10 N N N N XYZAL ALLERGY 24HR TABS (Use Levocetirizine N Dihydrochloride) XYZAL TABS 5 MG (Use Levocetirizine N Dihydrochloride) ZYRTEC ALLERGY TABS N (Use Cetirizine HCl) ZYRTEC CHILDRENS ALLERGY SOLN (Use N Cetirizine HCl) Antihistamines - henothiazines promethazine hcl soln or 6.25 /5ml QL(240 ml per ; QL(240 ml per ; QL(240 ml per QL(240 ml per ; QL(240 ml per QL(240 ml per ; ; QL(240 ml per ; QL(240 ml per ; AL; At least 2 20

29 Name promethazine hcl supp re 25, 50, 12.5 promethazine hcl syrp or 6.25 /5ml promethazine hcl tabs or 25, 50, 12.5 Antihistamines - iperidines cyproheptadine hcl syrp cyproheptadine hcl tabs QL(12 ea per ; AL; At least 2 QL(240 ml per ; AL; At least 2 AL; At least 2 ANTIHYERLIIDEMICS - s to Treat High Cholesterol Antihyperlipidemics - Combinations ezetimibe-simvastatin tabs A; QL(1 ea VYTORIN TABS (Use Ezetimibe-Simvastatin) Bile Acid Sequestrants cholestyramine light pack cholestyramine light powd cholestyramine pack cholestyramine powd COLESTID FLAVORED GRAN 5 GM (Use Colestipol HCl) COLESTID GRAN 5 GM (Use Colestipol HCl) COLESTID TABS 1 GM (Use Colestipol HCl) colestipol hcl gran 5 gm colestipol hcl tabs 1 gm QUESTRAN LIGHT OWD (Use Cholestyramine Light) QUESTRAN ACK (Use Cholestyramine) QUESTRAN OWD (Use Cholestyramine) N N N N N N N A; QL(1 ea Name Fibric Acid Derivatives fenofibrate micronized caps 134, 200 fenofibrate micronized caps 67 fenofibrate tabs 54 gemfibrozil tabs LOFIBRA CAS 134 MG, 200 MG (Use Fenofibrate N Micronized) LOFIBRA CAS 67 MG (Use Fenofibrate N Micronized) LOFIBRA TABS 54 MG N (Use Fenofibrate) LOID TABS (Use N Gemfibrozil) HMG CoA Reductase Inhibitors atorvastatin calcium tabs CRESTOR TABS (Use Rosuvastatin Calcium) LIITOR TABS (Use Atorvastatin Calcium) lovastatin tabs 10, 20 lovastatin tabs 40 MEVACOR TABS (Use Lovastatin) RAVACHOL TABS (Use ravastatin Sodium) pravastatin sodium tabs rosuvastatin calcium tabs simvastatin tabs 5, 10, 20, 40 ZOCOR TABS 5 MG, 10 MG, 20 MG, 40 MG (Use Simvastatin) Nicotinic Acid Derivatives niacin (antihyperlipidemic) tbcr N N N N N QL(3 ea QL(3 ea ST ST 21