Aetna Better Health Pennsylvania And Aetna Better Health ... · m/pennsylvania PA‐10‐03‐03A AETNA BETTER HEALTH® Formulary Guide – 2019 • Drugs and devices classified as

AETNA BETTER HEALTH® Formulary Guide – 2019

Aetna Better Health Pennsylvania And

Aetna Better Health KidsFormulary Guide December 2019

www.aetnabetterhealth.com/pennsylvania PA‐10‐03‐03A


What is the Aetna Better Health in Pennsylvania Formulary?

This is a drug list created by Aetna Better Health in Pennsylvania (“plan”). The plan will cover drugs on this list. Some drugs may have coverage rules. If the rules for that drug are met, the plan will cover the drug. Drugs must also be filled at a plan’s network pharmacy.

This list is for drugs covered under you prescription benefit. Drugs may not be listed here if they are covered under your medical benefit. Drugs covered under your medical benefit are usually those a health care professional gives to you, like an IV infusion or other injection, and not typically a medication you would take on your own.

Are there any exclusions from the formulary?

Yes, some drugs are excluded from coverage by direction of the department of Health Services (DHS). Examples include:

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• Drugs and devices classified as experimental by the FDA or whose use is classified as experimental by the FDA

• Drugs and devices not approved by the FDA or whose use is not approved by the FDA • Drugs and other items prescribed for obesity or appetite control • Drugs marketed by a drug company who does not participate in the Medicaid Drug Rebate

Program. • Drugs designated as a DESI (Drug Efficacy Study Implementation). A DESI drug is one that was

approved by the FDA solely on the basis of their safety prior to 1962. Subsequent to 1962, Congress required drugs to be shown to be effective as well. As a result, the FDA initiated a DESI to evaluate the effectiveness of medications previously approved based on safety alone. DESI drugs may continue to be marketed until proceedings evaluating efficacy have been concluded, at which point continued marketing would only be permitted if a New Drug Application is submitted for those drugs.

• Durable Medical Equipment (DME) items (with the exception of preferred diabetic supplies, syringes, lancets, alcohol wipes and condoms)

• Items prescribed or ordered by a physician who has been barred or suspended from participating in the Medical Assistance Program

• Pharmaceutical services provided to a hospitalized person • Placebos

Can the Plan’s Drug List change?

The plan may add or remove drugs on the list. All drug removals from the formulary will be sent to the state for review at least 30 days before the change is made. Utilizing members will be notified at least 30 days before a drug is removed from the formulary. All changes to the formulary will be posted on the plan’s website.

How do I use the Plan’s Formulary?

• Column #1: lists the covered drug. Brand drugs are in upper case letters (e.g., DRUG). Generics are in lower case letters (e.g., drug).

• Column #2: lists the brand name of the drug when a generic is covered • Column #3: shows coverage rules for the drug

Drugs are also grouped by the type of condition they treat. Drugs used to treat an earache are listed under the section, “Otic.” If you know what your drug is used for; please look for that section name on the drug list. Then look under that section for your drug.

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What are generic drugs?

Generic drugs are copies of brand‐name drugs. They are the same as those brand name drugs in dosage form, safety, strength, route of administration, quality, and intended use.

When a drug is available as a generic, you will be required to use the generic version for your prescription. If your provider feels it is medically necessary that you take only the brand, then your provider must request a prior authorization from the plan before the brand will be covered.

Are Over‐The‐Counter (OTC) drugs covered?

The plan will cover OTC drugs on the formulary. Some OTC drugs may have coverage rules. If the rules for that OTC drug are met, the plan will cover the OTC drug. Like other drugs, OTC drugs need a prescription from a doctor if they are to be covered by the plan. A list of covered OTC products can be found on our website: http://www.aetnabetterhealth.com/pennsylvania/members/pharmacy.

How much will I pay for covered drugs?

No Copays There are no copays for: • Pregnant women • Children under 21 years of age • Members in a nursing home or other facility (Intermediate Care Facility for Mental Retardation) • Family planning drugs • Emergency situation (condition in which emergency medical care is needed to prevent death or

serious injury of a member) • Certain drug groups listed below do not have copays. For those drug groups that will not

require a copay the drug group will be marked with a “no copay” on the formulary.

o Anti‐glaucoma drugs o Anti‐Parkinson drugs o Antipsychotic drugs (except for those anti‐anxiety drugs that are controlled

substances, like alprazolam or diazepam) o Cancer drugs o Diabetes drugs o Drugs used only to treat HIV/AIDS o Epilepsy drugs o Heart disease drugs o High blood pressure drugs o Naloxone injection/nasal spray for drug overdose o Preventative vaccines

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Copays Members 21 years of age and older: generic drugs on formulary are $1; brand drugs on formulary are $3 per prescription. Services cannot be denied if the member cannot afford the copay.

What are some types of coverage rules?

• Prior Approval (PA): This means your doctor will need to get approval from the plan first before the drug can be filled at the pharmacy. If it is not approved, the plan will not cover the drug.

• Quantity Level Limits (QLL): This means there is a limit on the amount of drug the plan will cover. For example, the plan provides 60 pills in 30 days for some drugs. Your doctor will need to get approval from the plan first before the drug can be filled for more than the plans limits.

• Step Therapy (ST): This means you may need to try certain drugs first to treat your condition. After the first drug is tried, the plan will then cover the other drug for that same condition. For example, Drug A and Drug B may treat your condition. The plan may not cover Drug B unless you try Drug A first. If Drug A does not work for you or you cannot take Drug A, then Drug B will be covered.

What if my drug is not on the plan’s Formulary?

First, please call your doctor and ask if your drug is on the formulary. If the drug is not listed on the formulary then:

• Ask your doctor for a similar drug that is on the formulary, or • Your doctor can ask the plan to cover your drug through the prior approval process.

Where can I fill my prescriptions?

You can fill your prescriptions at any network pharmacy. You can find the location of an in‐network pharmacy by visiting the CVS Caremark pharmacy locator. http://www.aetnabetterhealth.com/pennsylvania/providers/pharmacy This allows you to search for a pharmacy by zip c ode so you can find a location close to you.

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Definition of Symbols F Formulary

AL

Age Restriction: We require that the appropriate dose of medication based on age (e.g., pediatric and elderly populations) and indication AND Dosage requested must be based on national established/ recognized guidelines pertaining to the treatment and management of the diagnosis and age for which

the medication is being used to treat. OR FDA-approved age limitations. Click this symbol on the online search tool for more information.

Names in

Italics

Generic Drug - The plan covers both brand and generic drugs. Generic drugs have the same active ingredient formula as a brand name drug. Generic drugs usually cost less than brand name drugs and are rated by the Food and Drug Administration (FDA) to be as safe and effective as brand name drugs.

PA This means your doctor will need to get approval from the plan first before the drug can be filled at the pharmacy. If it is not approved, the plan will not cover the drug.

QLL This means there is a limit on the amount of drug the plan will cover. For example, the plan provides 60 pills in 30 days for some drugs.

ST

This means you may need to try certain drugs first to treat your condition. After the first drug is tried, the plan will then cover the other drug for that same condition. For example, Drug A and Drug B may treat your condition. The plan may not cover Drug B unless you try Drug A first. If Drug A does not work for you, then Drug B will be covered. For a complete list of all drugs requiring step therapy; click on the following -https://www.aetnabetterhealth.com/pennsylvania/assets/pdf/pharmacy/Pennsylvania_Step_Therapy.pdf

www.aetnabetterhealth.com/pennsylvania 6 PA‐10‐03‐03A


https://www.aetnabetterhealth.com/pennsylvania/assets/pdf/pharmacy/Pennsylvania_Step_Therapy.pdf

Aetna Better Health Pennsylvania

Table of Contents *ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS*....................................................................3

*ALTERNATIVE MEDICINES*............................................................................................................................. 4*AMINOGLYCOSIDES*......................................................................................................................................... 4*ANALGESICS - ANTI-INFLAMMATORY*........................................................................................................ 5*ANALGESICS - NONNARCOTIC*.......................................................................................................................7*ANALGESICS - OPIOID*...................................................................................................................................... 7*ANDROGENS-ANABOLIC*............................................................................................................................... 10*ANORECTAL AGENTS*.....................................................................................................................................10*ANTHELMINTICS*............................................................................................................................................. 11*ANTIANGINAL AGENTS*................................................................................................................................. 11*ANTIANXIETY AGENTS*..................................................................................................................................11*ANTIARRHYTHMICS*....................................................................................................................................... 12*ANTIASTHMATIC AND BRONCHODILATOR AGENTS*............................................................................ 13*ANTICOAGULANTS*......................................................................................................................................... 15*ANTICONVULSANTS*.......................................................................................................................................15*ANTIDEPRESSANTS*.........................................................................................................................................17*ANTIDIABETICS*............................................................................................................................................... 20*ANTIDIARRHEALS*...........................................................................................................................................22*ANTIDOTES*....................................................................................................................................................... 23*ANTIEMETICS*................................................................................................................................................... 23*ANTIFUNGALS*..................................................................................................................................................23*ANTIHISTAMINES*............................................................................................................................................ 24*ANTIHYPERLIPIDEMICS*.................................................................................................................................24*ANTIHYPERTENSIVES*.................................................................................................................................... 25*ANTI-INFECTIVE AGENTS - MISC.*............................................................................................................... 28*ANTIMALARIALS*.............................................................................................................................................29*ANTIMYASTHENIC AGENTS*......................................................................................................................... 29*ANTIMYCOBACTERIAL AGENTS*................................................................................................................. 29*ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES*................................................................................29*ANTIPARKINSON AGENTS*.............................................................................................................................32*ANTIPSYCHOTICS/ANTIMANIC AGENTS*................................................................................................... 33*ANTIRETROVIRALS ADJUVANTS***............................................................................................................ 36*ANTISEPTICS & DISINFECTANTS*.................................................................................................................36*ANTIVIRALS*......................................................................................................................................................36*ASSORTED CLASSES*....................................................................................................................................... 41*BETA BLOCKERS*............................................................................................................................................. 41*CALCIUM CHANNEL BLOCKERS*................................................................................................................. 42*CARDIOTONICS*................................................................................................................................................ 43*CARDIOVASCULAR AGENTS - MISC.*.......................................................................................................... 44*CEPHALOSPORINS*...........................................................................................................................................44*CONTRACEPTIVES*...........................................................................................................................................45*CORTICOSTEROIDS*......................................................................................................................................... 50*COUGH/COLD/ALLERGY*................................................................................................................................51*CYCLIN-DEPENDENT KINASES (CDK) INHIBITORS***............................................................................ 52*DERMATOLOGICALS*...................................................................................................................................... 52*DIAGNOSTIC PRODUCTS*................................................................................................................................58*DIGESTIVE AIDS*...............................................................................................................................................58

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*DIURETICS*.........................................................................................................................................................58

*ENDOCRINE AND METABOLIC AGENTS - MISC.*......................................................................................59*ESTROGENS*.......................................................................................................................................................60*FLUOROQUINOLONES*.................................................................................................................................... 61*GASTROINTESTINAL AGENTS - MISC.*........................................................................................................61*GENITOURINARY AGENTS - MISCELLANEOUS*....................................................................................... 62*GLYCOPEPTIDES***..........................................................................................................................................63*GOUT AGENTS*..................................................................................................................................................63*HEMATOLOGICAL AGENTS - MISC.*............................................................................................................ 63*HEMATOPOIETIC AGENTS*.............................................................................................................................64*HEPATITIS C AGENT - COMBINATIONS***................................................................................................. 65*HYPNOTICS*....................................................................................................................................................... 65*LAXATIVES*....................................................................................................................................................... 65*MACROLIDES*....................................................................................................................................................66*MEDICAL DEVICES*..........................................................................................................................................66*MIGRAINE PRODUCTS*....................................................................................................................................75*MINERALS & ELECTROLYTES*......................................................................................................................76*MOUTH/THROAT/DENTAL AGENTS*............................................................................................................77*MULTIVITAMINS*..............................................................................................................................................77*MUSCULOSKELETAL THERAPY AGENTS*..................................................................................................81*NASAL AGENTS - SYSTEMIC AND TOPICAL*............................................................................................. 82*NEPRILYSIN INHIB (ARNI)-ANGIOTENSIN II RECEPT ANTAG COMB***............................................. 83*NEUROMUSCULAR AGENTS*......................................................................................................................... 83*OPHTHALMIC AGENTS*...................................................................................................................................83*OTIC AGENTS*....................................................................................................................................................86*PASSIVE IMMUNIZING AGENTS*...................................................................................................................86*PENICILLINS*......................................................................................................................................................87*PHARMACEUTICAL ADJUVANTS*................................................................................................................ 88*POTASSIUM REMOVING AGENTS***............................................................................................................88*PROGESTINS*......................................................................................................................................................88*PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.*..........................................................89*RESPIRATORY AGENTS - MISC.*....................................................................................................................91*SEROTONIN MODULATORS***...................................................................................................................... 91*SINUS NODE INHIBITORS**.............................................................................................................................91*SODIUM-GLUCOSE CO-TRANSPORTER 2 INHIBITOR-BIGUANIDE COMB***..................................... 92*STEROIDS - MOUTH/THROAT/DENTAL***.................................................................................................. 92*SULFONAMIDES*...............................................................................................................................................92*TETRACYCLINES*............................................................................................................................................. 92*THYROID AGENTS*........................................................................................................................................... 92*TOXOIDS*............................................................................................................................................................ 93*ULCER DRUGS*.................................................................................................................................................. 93*URINARY ANTI-INFECTIVES*.........................................................................................................................95*URINARY ANTISPASMODICS*........................................................................................................................95*VACCINES*..........................................................................................................................................................96*VAGINAL PRODUCTS*......................................................................................................................................97*VASOPRESSORS*............................................................................................................................................... 97*VITAMINS*.......................................................................................................................................................... 97

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Aetna Better Health Pennsylvania

Drug Name Reference Restrictions *ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS* *Adhd Agent - Selective Alpha Adrenergic Agonists*** guanfacine hcl er oral tablet extended release 24 hour 1 mg, 2 mg, 3 mg, 4 mg Intuniv QLL (30 Tablets per 30 days);

AL (Min 6 Years)

*Amphetamine Mixtures*** amphetamine-dextroamphet er oral capsule extended release 24 hour 10 mg, 15 mg, 20 mg, 25 mg, 30 mg, 5 mg

Adderall XR QLL (1 EA per 1 day); AL (Min 6 Years and Max 17 Years)

amphetamine-dextroamphetamine oral tablet 10 mg, 12.5 mg, 15 mg, 20 mg, 5 mg, 7.5 mg Adderall QLL (3 EA per 1 day); AL (Min

6 Years and Max 17 Years) amphetamine-dextroamphetamine oral tablet 30 mg Adderall QLL (2 EA per 1 day); AL (Min

6 Years and Max 17 Years)

*Amphetamines*** dextroamphetamine sulfate er oral capsule extended release 24 hour 10 mg, 15 mg Dexedrine QLL (4 EA per 1 day); AL (Min

6 Years and Max 17 Years) dextroamphetamine sulfate er oral capsule extended release 24 hour 5 mg Dexedrine QLL (3 EA per 1 day); AL (Min

6 Years and Max 17 Years) dextroamphetamine sulfate oral tablet 10 mg, 5 mg Zenzedi QLL (6 EA per 1 day); AL (Min


ZENZEDI ORAL TABLET 10 MG, 5 MG Dextroamphetamine Sulfate QLL (6 EA per 1 day); AL (Min 6 Years and Max 17 Years)

*Analeptics*** caffeine citrate oral solution 20 mg/ml, 60 mg/3ml

*Stimulants - Misc.*** armodafinil oral tablet 150 mg, 200 mg, 250 mg Nuvigil PA; QLL (1 EA per 1 day)

armodafinil oral tablet 50 mg Nuvigil PA; QLL (2 EA per 1 day) dexmethylphenidate hcl er oral capsule extended release 24 hour 10 mg, 15 mg, 20 mg, 25 mg, 30 mg, 35 mg, 40 mg, 5 mg

Focalin XR QLL (1 EA per 1 day); AL (Min 6 Years and Max 17 Years)

dexmethylphenidate hcl oral tablet 10 mg, 2.5 mg, 5 mg Focalin QLL (2 EA per 1 day); AL (Min

6 Years and Max 17 Years) methylphenidate hcl er (cd) oral capsule extended release 10 mg, 20 mg, 30 mg, 40 mg, 50 mg, 60 mg

QLL (1 EA per 1 day); AL (Min 6 Years and Max 17 Years)

methylphenidate hcl er (la) oral capsule extended release 24 hour 20 mg, 40 mg Ritalin LA QLL (1 EA per 1 day); AL (Min

6 Years and Max 17 Years) 3

Drug Name Reference Restrictions methylphenidate hcl er (la) oral capsule extended release 24 hour 30 mg Ritalin LA QLL (2 EA per 1 day); AL (Min

6 Years and Max 17 Years) methylphenidate hcl er (la) oral capsule extended release 24 hour 60 mg


methylphenidate hcl er oral tablet extended release 10 mg


methylphenidate hcl er oral tablet extended release 18 mg, 27 mg, 54 mg Concerta QLL (1 EA per 1 day); AL (Min

6 Years and Max 17 Years) methylphenidate hcl er oral tablet extended release 20 mg Metadate ER QLL (3 EA per 1 day); AL (Min

6 Years and Max 17 Years) methylphenidate hcl er oral tablet extended release 24 hour 18 mg, 27 mg, 36 mg


methylphenidate hcl er oral tablet extended release 24 hour 54 mg


methylphenidate hcl er oral tablet extended release 36 mg Concerta QLL (2 EA per 1 day); AL (Min


methylphenidate hcl oral solution 10 mg/5ml, 5 mg/5ml Methylin

QLL (30 ML per 1 day); AL (Min 6 Years and Max 17 Years)

methylphenidate hcl oral tablet 10 mg, 20 mg, 5 mg Ritalin QLL (3 EA per 1 day); AL (Min

6 Years and Max 17 Years) methylphenidate hcl oral tablet chewable 10 mg


methylphenidate hcl oral tablet chewable 2.5 mg, 5 mg


METADATE ER ORAL TABLET EXTENDED RELEASE 20 MG Methylphenidate HCl ER QLL (3 EA per 1 day); AL (Min


*ALTERNATIVE MEDICINES* *Alternative Medicine - Me's*** melatonin maximum strength oral tablet 5 mg OTC melatonin oral tablet 1 mg, 3 mg, 5 mg OTC sm melatonin oral tablet 3 mg OTC

*AMINOGLYCOSIDES* *Aminoglycosides*** neomycin sulfate oral tablet 500 mg paromomycin sulfate oral capsule 250 mg tobramycin inhalation nebulization solution 300 mg/5ml Kitabis Pak

KITABIS PAK INHALATION NEBULIZATION SOLUTION 300 MG/5ML

Tobramycin PA

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Drug Name Reference Restrictions *ANALGESICS - ANTI-INFLAMMATORY* *Anti-Tnf-Alpha - Monoclonal Antibodies*** HUMIRA PEDIATRIC CROHNS START SUBCUTANEOUS PREFILLED SYRINGE KIT 40 MG/0.8ML

PA

HUMIRA PEDIATRIC CROHNS START SUBCUTANEOUS PREFILLED SYRINGE KIT 80 MG/0.8ML

PA; QLL (3 EA per 180 days)

HUMIRA PEDIATRIC CROHNS START SUBCUTANEOUS PREFILLED SYRINGE KIT 80 MG/0.8ML & 40MG/0.4ML


HUMIRA PEN SUBCUTANEOUS PEN-INJECTOR KIT 40 MG/0.4ML PA; QLL (2 EA per 25 days)

HUMIRA PEN SUBCUTANEOUS PEN-INJECTOR KIT 40 MG/0.8ML PA

HUMIRA PEN-CD/UC/HS STARTER SUBCUTANEOUS PEN-INJECTOR KIT 40 MG/0.8ML

PA

HUMIRA PEN-CD/UC/HS STARTER SUBCUTANEOUS PEN-INJECTOR KIT 80 MG/0.8ML


HUMIRA PEN-PS/UV/ADOL HS START SUBCUTANEOUS PEN-INJECTOR KIT 40 MG/0.8ML

PA

HUMIRA PEN-PS/UV/ADOL HS START SUBCUTANEOUS PEN-INJECTOR KIT 80 MG/0.8ML & 40MG/0.4ML


HUMIRA SUBCUTANEOUS PREFILLED SYRINGE KIT 10 MG/0.1ML PA; QLL (2 EA per 28 days)

HUMIRA SUBCUTANEOUS PREFILLED SYRINGE KIT 20 MG/0.2ML, 40 MG/0.4ML


*Cyclooxygenase 2 (Cox-2) Inhibitors*** celecoxib oral capsule 100 mg, 200 mg, 400 mg, 50 mg CeleBREX ST

*Gold Compounds*** RIDAURA ORAL CAPSULE 3 MG

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Drug Name Reference Restrictions *Nonsteroidal Anti-Inflammatory Agents (Nsaids)*** diclofenac potassium oral tablet 50 mg diclofenac sodium er oral tablet extended release 24 hour 100 mg diclofenac sodium oral tablet delayed release 25 mg, 50 mg, 75 mg etodolac er oral tablet extended release 24 hour 400 mg, 500 mg, 600 mg etodolac oral capsule 200 mg, 300 mg etodolac oral tablet 400 mg Lodine etodolac oral tablet 500 mg flurbiprofen oral tablet 100 mg, 50 mg ibuprofen oral tablet 400 mg, 600 mg, 800 mg IBU indomethacin er oral capsule extended release 75 mg indomethacin oral capsule 25 mg, 50 mg ketorolac tromethamine oral tablet 10 mg QLL (20 Tablets per 30 days) meloxicam oral tablet 15 mg, 7.5 mg Mobic nabumetone oral tablet 500 mg, 750 mg naproxen dr oral tablet delayed release 375 mg EC-Naprosyn

naproxen dr oral tablet delayed release 500 mg naproxen oral suspension 125 mg/5ml Naprosyn ST naproxen oral tablet 250 mg Naprosyn naproxen oral tablet 375 mg, 500 mg naproxen sodium oral tablet 275 mg piroxicam oral capsule 10 mg, 20 mg Feldene sulindac oral tablet 150 mg, 200 mg tolmetin sodium oral capsule 400 mg tolmetin sodium oral tablet 200 mg, 600 mg

*Pyrimidine Synthesis Inhibitors*** leflunomide oral tablet 10 mg, 20 mg Arava

*Soluble Tumor Necrosis Factor Receptor Agents*** ENBREL MINI SUBCUTANEOUS SOLUTION CARTRIDGE 50 MG/ML PA

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Drug Name Reference Restrictions ENBREL SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 25 MG/0.5ML, 50 MG/ML

PA

ENBREL SURECLICK SUBCUTANEOUS SOLUTION AUTO-INJECTOR 50 MG/ML

PA

*ANALGESICS - NONNARCOTIC* *Analgesics-Sedatives*** butalbital-acetaminophen oral tablet 50-325 mg Tencon QLL (60 EA per 30 days)

butalbital-apap-caffeine oral capsule 50-300-40 mg Fioricet QLL (60 EA per 30 days)

butalbital-apap-caffeine oral capsule 50-325-40 mg Esgic QLL (60 EA per 30 days)

butalbital-apap-caffeine oral tablet 50-325-40 mg Esgic QLL (60 EA per 30 days)

butalbital-asa-caffeine oral capsule 50-325-40 mg Fiorinal QLL (60 EA per 30 days)

*Salicylate Combinations*** choline-mag trisalicylate oral liquid 500 mg/5ml

*Salicylates*** diflunisal oral tablet 500 mg salsalate oral tablet 500 mg, 750 mg

*ANALGESICS - OPIOID* *Codeine Combinations*** acetaminophen-codeine #2 oral tablet 300-15 mg QLL (13 EA per 1 day)

acetaminophen-codeine #3 oral tablet 300-30 mg Tylenol with Codeine #3 QLL (11 EA per 1 day)

acetaminophen-codeine #4 oral tablet 300-60 mg Tylenol with Codeine #4 QLL (5 EA per 1 day)

acetaminophen-codeine oral solution 120-12 mg/5ml PA; QLL (137.5 ML per 1 day)

butalbital-apap-caff-cod oral capsule 50-300-40-30 mg Fioricet/Codeine QLL (6 EA per 1 day)

butalbital-apap-caff-cod oral capsule 50-325-40-30 mg QLL (6 EA per 1 day)

butalbital-asa-caff-codeine oral capsule 50-325-40-30 mg Ascomp-Codeine QLL (6 EA per 1 day)

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Drug Name Reference Restrictions *Hydrocodone Combinations*** hydrocodone-acetaminophen oral solution 7.5-325 mg/15ml QLL (100 ML per 1 day)

hydrocodone-acetaminophen oral tablet 10-325 mg Lorcet HD QLL (5 EA per 1 day)

hydrocodone-acetaminophen oral tablet 5-325 mg Lorcet QLL (8 EA per 1 day)

hydrocodone-acetaminophen oral tablet 7.5-325 mg Lorcet Plus QLL (6 EA per 1 day)

hydrocodone-ibuprofen oral tablet 10-200 mg PA hydrocodone-ibuprofen oral tablet 5-200 mg hydrocodone-ibuprofen oral tablet 7.5-200 mg QLL (5 EA per 1 day)

*Opioid Agonists*** codeine sulfate oral tablet 30 mg QLL (11 EA per 1 day) codeine sulfate oral tablet 60 mg QLL (5 EA per 1 day) fentanyl citrate buccal lozenge on a handle 1200 mcg, 1600 mcg, 200 mcg, 400 mcg, 600 mcg, 800 mcg

Actiq QLL (4 EA per 1 day)

fentanyl transdermal patch 72 hour 100 mcg/hr Duragesic-100 PA; QLL (10 EA per 30 days)

fentanyl transdermal patch 72 hour 12 mcg/hr Duragesic-12 PA; QLL (10 EA per 30 days) fentanyl transdermal patch 72 hour 25 mcg/hr Duragesic-25 PA; QLL (10 EA per 30 days) fentanyl transdermal patch 72 hour 50 mcg/hr Duragesic-50 PA; QLL (10 EA per 30 days) fentanyl transdermal patch 72 hour 75 mcg/hr Duragesic-75 PA; QLL (10 EA per 30 days) hydromorphone hcl injection solution 2 mg/ml Dilaudid hydromorphone hcl oral tablet 2 mg Dilaudid QLL (6 EA per 1 day) hydromorphone hcl oral tablet 4 mg Dilaudid QLL (3 EA per 1 day) hydromorphone hcl oral tablet 8 mg Dilaudid QLL (1 EA per 1 day) hydromorphone hcl pf injection solution 10 mg/ml, 50 mg/5ml, 500 mg/50ml hydromorphone hcl rectal suppository 3 mg QLL (4 EA per 1 day) methadone hcl oral concentrate 10 mg/ml Methadone HCl Intensol PA; QLL (1.25 ML per 1 day) methadone hcl oral solution 10 mg/5ml PA; QLL (6.25 ML per 1 day) methadone hcl oral solution 5 mg/5ml PA; QLL (12.5 ML per 1 day) methadone hcl oral tablet 10 mg Dolophine PA; QLL (1 EA per 1 day) methadone hcl oral tablet 5 mg Dolophine PA; QLL (2 EA per 1 day) methadone hcl oral tablet soluble 40 mg Methadose PA; QLL (1 EA per 1 day) morphine sulfate (concentrate) oral solution 10 mg/0.5ml QLL (2.5 ML per 1 day)

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Drug Name Reference Restrictions morphine sulfate er oral tablet extended release 100 mg, 200 mg, 30 mg MS Contin PA; QLL (1 EA per 1 day)

morphine sulfate er oral tablet extended release 15 mg MS Contin PA; QLL (3 EA per 1 day)

morphine sulfate er oral tablet extended release 60 mg MS Contin PA; QLL (2 EA per 1 day)

morphine sulfate oral solution 10 mg/5ml QLL (15 ML per 1 day) morphine sulfate oral solution 20 mg/5ml QLL (12.5 ML per 1 day) morphine sulfate oral tablet 15 mg QLL (3 EA per 1 day) morphine sulfate oral tablet 30 mg QLL (1 EA per 1 day) morphine sulfate rectal suppository 10 mg QLL (4 EA per 1 day) morphine sulfate rectal suppository 20 mg QLL (2 EA per 1 day) morphine sulfate rectal suppository 30 mg QLL (1 EA per 1 day) morphine sulfate rectal suppository 5 mg QLL (5 EA per 1 day) oxycodone hcl oral solution 5 mg/5ml QLL (30 ML per 1 day) oxycodone hcl oral tablet 10 mg QLL (3 EA per 1 day) oxycodone hcl oral tablet 15 mg Roxicodone QLL (4 EA per 1 day) oxycodone hcl oral tablet 20 mg QLL (1 EA per 1 day) oxycodone hcl oral tablet 30 mg Roxicodone QLL (1 EA per 1 day) oxycodone hcl oral tablet 5 mg Roxicodone QLL (6 EA per 1 day) oxymorphone hcl er oral tablet extended release 12 hour 10 mg, 15 mg, 20 mg, 30 mg, 40 mg

PA; ST; QLL (1 EA per 1 day)

oxymorphone hcl er oral tablet extended release 12 hour 5 mg PA; ST; QLL (3 EA per 1 day)

oxymorphone hcl er oral tablet extended release 12 hour 7.5 mg PA; ST; QLL (2 EA per 1 day)

tramadol hcl oral tablet 50 mg Ultram QLL (8 EA per 1 day)

*Opioid Combinations*** oxycodone-acetaminophen oral tablet 10-325 mg Endocet QLL (3 EA per 1 day)

oxycodone-acetaminophen oral tablet 2.5-325 mg Endocet QLL (12 EA per 1 day)

oxycodone-acetaminophen oral tablet 5-325 mg Endocet QLL (6 EA per 1 day)

oxycodone-acetaminophen oral tablet 7.5-325 mg Endocet QLL (4 EA per 1 day)

oxycodone-aspirin oral tablet 4.8355-325 mg QLL (6 EA per 1 day)

*Opioid Partial Agonists*** buprenorphine hcl sublingual tablet sublingual 2 mg, 8 mg

PA; QLL (60 EA per 30 days); AL (Min 18 Years)

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Drug Name Reference Restrictions buprenorphine hcl-naloxone hcl sublingual tablet sublingual 2-0.5 mg, 8-2 mg QLL (3 EA per 1 day)

pentazocine-naloxone hcl oral tablet 50-0.5 mg QLL (2 EA per 1 day)

*Tramadol Combinations*** tramadol-acetaminophen oral tablet 37.5-325 mg Ultracet QLL (8 EA per 1 day)

*ANDROGENS-ANABOLIC* *Androgens*** danazol oral capsule 100 mg, 200 mg, 50 mg testosterone cypionate intramuscular solution 100 mg/ml, 200 mg/ml Depo-Testosterone PA; QLL (1 ML per 28 days)

testosterone enanthate intramuscular solution 200 mg/ml QLL (5 ML per 30 days)

testosterone transdermal gel 10 mg/act (2%) Fortesta PA; QLL (2 canisters per 30 Days)

testosterone transdermal gel 12.5 mg/act (1%) Vogelxo Pump PA; QLL (4 canisters per 30 days)

testosterone transdermal gel 25 mg/2.5gm (1%) AndroGel PA

testosterone transdermal gel 50 mg/5gm (1%) AndroGel PA; QLL (60 PACKETS per 30 days)

*ANORECTAL AGENTS* *Intrarectal Steroids*** hydrocortisone rectal enema 100 mg/60ml Colocort

*Nitrate Vasodilating Agents*** RECTIV RECTAL OINTMENT 0.4 % PA; QLL (30 gm per 30 days)

*Rectal Anesthetic/Steroids*** lidocaine-hydrocortisone ace rectal cream 3-0.5 % PROCTOFOAM HC RECTAL FOAM 1-1 %

*Rectal Steroids*** PROCTO-PAK RECTAL CREAM 1 % Hydrocortisone PROCTOSOL HC RECTAL CREAM 2.5 % Hydrocortisone

PROCTOZONE-HC RECTAL CREAM 2.5 % Hydrocortisone

10

Drug Name Reference Restrictions *ANTHELMINTICS* *Anthelmintics*** albendazole oral tablet 200 mg Albenza ST ivermectin oral tablet 3 mg Stromectol praziquantel oral tablet 600 mg Biltricide PA reeses pinworm medicine oral suspension 144 (50 base) mg/ml OTC

reeses pinworm medicine oral tablet 180 mg OTC

*ANTIANGINAL AGENTS* *Nitrates*** isosorbide dinitrate er oral tablet extended release 40 mg No Copay

isosorbide dinitrate oral tablet 10 mg, 20 mg, 30 mg No Copay

isosorbide dinitrate oral tablet 5 mg Isordil Titradose No Copay isosorbide mononitrate er oral tablet extended release 24 hour 120 mg, 30 mg, 60 mg No Copay

isosorbide mononitrate oral tablet 10 mg, 20 mg No Copay

nitroglycerin er oral capsule extended release 6.5 mg, 9 mg Nitro-Time No Copay

nitroglycerin sublingual tablet sublingual 0.3 mg, 0.4 mg, 0.6 mg Nitrostat No Copay

nitroglycerin transdermal patch 24 hour 0.1 mg/hr, 0.2 mg/hr, 0.4 mg/hr, 0.6 mg/hr Minitran No Copay

NITRO-BID TRANSDERMAL OINTMENT 2 % No Copay

*ANTIANXIETY AGENTS* *Antianxiety Agents - Misc.*** buspirone hcl oral tablet 10 mg, 15 mg, 5 mg, 7.5 mg QLL (2 EA per 1 day)

hydroxyzine hcl oral syrup 10 mg/5ml hydroxyzine hcl oral tablet 10 mg, 25 mg, 50 mg QLL (4 EA per 1 day)

hydroxyzine pamoate oral capsule 100 mg hydroxyzine pamoate oral capsule 25 mg, 50 mg Vistaril

*Benzodiazepines*** alprazolam er oral tablet extended release 24 hour 0.5 mg, 1 mg, 2 mg, 3 mg Xanax XR AL (Min 18 Years)

11

Drug Name Reference Restrictions alprazolam oral tablet 0.25 mg, 0.5 mg Xanax QLL (4 EA per 1 day) alprazolam oral tablet 1 mg Xanax QLL (6 EA per 1 day) alprazolam oral tablet 2 mg Xanax QLL (5 EA per 1 day) alprazolam xr oral tablet extended release 24 hour 0.5 mg, 1 mg, 2 mg, 3 mg Xanax XR AL (Min 18 Years)

chlordiazepoxide hcl oral capsule 10 mg, 5 mg QLL (4 EA per 1 day) chlordiazepoxide hcl oral capsule 25 mg QLL (12 EA per 1 day) diazepam oral concentrate 5 mg/ml Diazepam Intensol diazepam oral solution 5 mg/5ml diazepam oral tablet 10 mg, 2 mg, 5 mg Valium lorazepam oral tablet 0.5 mg Ativan QLL (4 EA per 1 day) lorazepam oral tablet 1 mg Ativan QLL (6 EA per 1 day) lorazepam oral tablet 2 mg Ativan QLL (5 EA per 1 day) oxazepam oral capsule 10 mg, 15 mg, 30 mg QLL (4 EA per 1 day) DIAZEPAM INTENSOL ORAL CONCENTRATE 5 MG/ML Diazepam

LORAZEPAM INTENSOL ORAL CONCENTRATE 2 MG/ML LORazepam

*ANTIARRHYTHMICS* *Antiarrhythmics Type I-A*** disopyramide phosphate oral capsule 100 mg, 150 mg Norpace No Copay

procainamide hcl injection solution 100 mg/ml No Copay quinidine sulfate oral tablet 200 mg, 300 mg No Copay

*Antiarrhythmics Type I-B*** mexiletine hcl oral capsule 150 mg, 200 mg, 250 mg No Copay

*Antiarrhythmics Type I-C*** flecainide acetate oral tablet 100 mg, 150 mg, 50 mg No Copay

propafenone hcl er oral capsule extended release 12 hour 225 mg, 325 mg, 425 mg Rythmol SR No Copay

propafenone hcl oral tablet 150 mg, 225 mg, 300 mg No Copay

*Antiarrhythmics Type Iii*** amiodarone hcl oral tablet 100 mg, 200 mg, 400 mg Pacerone No Copay

MULTAQ ORAL TABLET 400 MG PA; No Copay

12

Drug Name Reference Restrictions *ANTIASTHMATIC AND BRONCHODILATOR AGENTS* *Adrenergic Combinations*** fluticasone-salmeterol inhalation aerosol powder breath activated 113-14 mcg/act AirDuo RespiClick 113/14 QLL (1 Inhaler per 30 days)

fluticasone-salmeterol inhalation aerosol powder breath activated 232-14 mcg/act AirDuo RespiClick 232/14 QLL (1 Inhaler per 30 days)

fluticasone-salmeterol inhalation aerosol powder breath activated 55-14 mcg/act AirDuo RespiClick 55/14 QLL (1 Inhaler per 30 days)

ipratropium-albuterol inhalation solution 0.5-2.5 (3) mg/3ml ANORO ELLIPTA INHALATION AEROSOL POWDER BREATH ACTIVATED 62.5-25 MCG/INH

QLL (1 inhaler per 30 Days)

BREO ELLIPTA INHALATION AEROSOL POWDER BREATH ACTIVATED 100-25 MCG/INH, 200-25 MCG/INH

QLL (1 EA per 30 days); AL (Min 18 Years)

COMBIVENT RESPIMAT INHALATION AEROSOL SOLUTION 20-100 MCG/ACT STIOLTO RESPIMAT INHALATION AEROSOL SOLUTION 2.5-2.5 MCG/ACT ST; QLL (1 inhaler per 30 days)

*Anti-Inflammatory Agents*** cromolyn sodium inhalation nebulization solution 20 mg/2ml

*Beta Adrenergics*** albuterol sulfate hfa inhalation aerosol solution 108 (90 base) mcg/act Ventolin HFA QLL (36 GM per 30 days)

albuterol sulfate inhalation nebulization solution (2.5 mg/3ml) 0.083% QLL (15 ML per 1 day)

albuterol sulfate inhalation nebulization solution (5 mg/ml) 0.5% QLL (15 EA per 1 day)

albuterol sulfate inhalation nebulization solution 0.63 mg/3ml, 1.25 mg/3ml ST; AL (Max 17 Years)

albuterol sulfate oral syrup 2 mg/5ml levalbuterol tartrate inhalation aerosol 45 mcg/act Xopenex HFA ST; QLL (2 INH per 30 days)

metaproterenol sulfate oral syrup 10 mg/5ml ARCAPTA NEOHALER INHALATION CAPSULE 75 MCG QLL (1 Inhaler per 30 days)

STRIVERDI RESPIMAT INHALATION AEROSOL SOLUTION 2.5 MCG/ACT QLL (1 Respimat per 30 days)

13

Drug Name Reference Restrictions VENTOLIN HFA INHALATION AEROSOL SOLUTION 108 (90 BASE) MCG/ACT

Albuterol Sulfate HFA QLL (36 GM per 30 days)

*Bronchodilators -Anticholinergics*** ipratropium bromide inhalation solution 0.02 % ATROVENT HFA INHALATION AEROSOL SOLUTION 17 MCG/ACT INCRUSE ELLIPTA INHALATION AEROSOL POWDER BREATH ACTIVATED 62.5 MCG/INH

QLL (1 Inhaler per 30 days)

*Leukotriene Receptor Antagonists*** montelukast sodium oral packet 4 mg Singulair AL (Max 1 Years) montelukast sodium oral tablet 10 mg Singulair montelukast sodium oral tablet chewable 4 mg, 5 mg Singulair

zafirlukast oral tablet 10 mg, 20 mg Accolate ST

*Steroid Inhalants*** budesonide inhalation suspension 0.25 mg/2ml, 0.5 mg/2ml Pulmicort QLL (120 ML per 30 days)

budesonide inhalation suspension 1 mg/2ml Pulmicort ARNUITY ELLIPTA INHALATION AEROSOL POWDER BREATH ACTIVATED 100 MCG/ACT, 200 MCG/ACT, 50 MCG/ACT FLOVENT HFA INHALATION AEROSOL 110 MCG/ACT, 220 MCG/ACT

QLL (0.4 GM per 1 day); AL (Max 12 Years)

FLOVENT HFA INHALATION AEROSOL 44 MCG/ACT

QLL (0.35 GM per 1 day); AL (Max 12 Years)

QVAR REDIHALER INHALATION AEROSOL BREATH ACTIVATED 40 MCG/ACT

QLL (10.6 GM per 30 days)

QVAR REDIHALER INHALATION AEROSOL BREATH ACTIVATED 80 MCG/ACT

QLL (21.2 GM per 30 days)

*Xanthines*** theophylline er oral tablet extended release 12 hour 300 mg Theochron

theophylline er oral tablet extended release 12 hour 450 mg

14

Drug Name Reference Restrictions theophylline er oral tablet extended release 24 hour 400 mg, 600 mg theophylline oral solution 80 mg/15ml

*ANTICOAGULANTS* *Coumarin Anticoagulants*** warfarin sodium oral tablet 1 mg, 10 mg, 2 mg, 2.5 mg, 3 mg, 4 mg, 5 mg, 6 mg, 7.5 mg Jantoven

JANTOVEN ORAL TABLET 1 MG, 10 MG, 2 MG, 2.5 MG, 3 MG, 4 MG, 5 MG, 6 MG, 7.5 MG

Warfarin Sodium

*Direct Factor Xa Inhibitors*** ELIQUIS ORAL TABLET 2.5 MG, 5 MG PA; QLL (60 EA per 30 days) XARELTO ORAL TABLET 10 MG, 15 MG, 20 MG PA; QLL (1 EA per 1 day)

XARELTO ORAL TABLET 2.5 MG PA; QLL (2 EA per 1 day) XARELTO STARTER PACK ORAL TABLET THERAPY PACK 15 & 20 MG PA; QLL (1 FILL per 90 days)

*Heparins And Heparinoid-Like Agents*** heparin sodium (porcine) injection solution 1000 unit/ml, 10000 unit/ml, 20000 unit/ml, 5000 unit/ml heparin sodium (porcine) pf injection solution 5000 unit/0.5ml

*Low Molecular Weight Heparins*** enoxaparin sodium injection solution 300 mg/3ml Lovenox QLL (21 days per 180 days)

enoxaparin sodium subcutaneous solution 100 mg/ml, 120 mg/0.8ml, 150 mg/ml, 30 mg/0.3ml, 40 mg/0.4ml, 60 mg/0.6ml, 80 mg/0.8ml

Lovenox QLL (21 days per 180 days)

*ANTICONVULSANTS* *Anticonvulsants -Benzodiazepines*** clonazepam oral tablet 0.5 mg, 1 mg, 2 mg KlonoPIN No Copay clonazepam oral tablet dispersible 0.125 mg, 0.25 mg, 0.5 mg, 1 mg, 2 mg No Copay

diazepam rectal gel 10 mg, 20 mg Diastat AcuDial No Copay; QLL (2 EA per 1 Fill)

diazepam rectal gel 2.5 mg Diastat Pediatric No Copay; QLL (2 EA per 1 Fill)

15

Drug Name Reference Restrictions *Anticonvulsants - Misc.*** carbamazepine er oral capsule extended release 12 hour 100 mg, 200 mg, 300 mg Carbatrol No Copay

carbamazepine er oral tablet extended release 12 hour 100 mg TEGretol-XR No Copay

carbamazepine er oral tablet extended release 12 hour 200 mg, 400 mg TEGretol-XR No Copay; QLL (120 EA per 30

days) carbamazepine oral suspension 100 mg/5ml TEGretol No Copay carbamazepine oral tablet 200 mg Epitol No Copay carbamazepine oral tablet chewable 100 mg No Copay gabapentin oral capsule 100 mg, 300 mg, 400 mg Neurontin No Copay; QLL (3600 MG

(cumulative) per 1 day)

gabapentin oral solution 250 mg/5ml Neurontin No Copay; QLL (3600 MG (cumulative) per 1 day)

gabapentin oral tablet 600 mg, 800 mg Neurontin No Copay; QLL (3600 MG (cumulative) per 1 day)

lamotrigine oral tablet 100 mg, 150 mg, 200 mg, 25 mg LaMICtal No Copay

lamotrigine oral tablet chewable 25 mg, 5 mg LaMICtal No Copay levetiracetam er oral tablet extended release 24 hour 500 mg, 750 mg Keppra XR No Copay

levetiracetam oral solution 100 mg/ml Keppra No Copay levetiracetam oral tablet 1000 mg, 250 mg, 500 mg, 750 mg Keppra No Copay

oxcarbazepine oral suspension 300 mg/5ml Trileptal No Copay oxcarbazepine oral tablet 150 mg, 300 mg, 600 mg Trileptal No Copay

primidone oral tablet 250 mg, 50 mg Mysoline No Copay

topiramate oral capsule sprinkle 15 mg, 25 mg Topamax Sprinkle No Copay; QLL (120 EA per 30 days)

topiramate oral tablet 100 mg, 200 mg, 25 mg, 50 mg Topamax No Copay; QLL (120 EA per 30

days) zonisamide oral capsule 100 mg, 25 mg Zonegran No Copay

zonisamide oral capsule 50 mg No Copay; QLL (6 EA per 1 day)

*Carbamates*** felbamate oral suspension 600 mg/5ml Felbatol No Copay felbamate oral tablet 400 mg, 600 mg Felbatol No Copay

*Gaba Modulators*** tiagabine hcl oral tablet 2 mg Gabitril No Copay

16

Drug Name Reference Restrictions

tiagabine hcl oral tablet 4 mg Gabitril No Copay; QLL (60 EA per 30 days)

GABITRIL ORAL TABLET 12 MG, 16 MG TiaGABine HCl No Copay

*Hydantoins*** phenytoin oral suspension 125 mg/5ml Dilantin No Copay phenytoin oral tablet chewable 50 mg Dilantin Infatabs No Copay phenytoin sodium extended oral capsule 100 mg Dilantin No Copay

phenytoin sodium extended oral capsule 200 mg, 300 mg Phenytek No Copay

DILANTIN ORAL CAPSULE 100 MG Phenytoin Sodium Extended No Copay

*Succinimides*** ethosuximide oral capsule 250 mg Zarontin No Copay ethosuximide oral solution 250 mg/5ml Zarontin No Copay

*Valproic Acid*** divalproex sodium er oral tablet extended release 24 hour 250 mg, 500 mg Depakote ER No Copay

divalproex sodium oral capsule delayed release sprinkle 125 mg Depakote Sprinkles No Copay

divalproex sodium oral tablet delayed release 125 mg, 250 mg, 500 mg Depakote No Copay

valproic acid oral capsule 250 mg No Copay valproic acid oral solution 250 mg/5ml No Copay

*ANTIDEPRESSANTS* *Alpha-2 Receptor Antagonists (Tetracyclics)*** mirtazapine oral tablet 15 mg Remeron QLL (30 EA per 30 days) mirtazapine oral tablet 30 mg Remeron QLL (60 EA per 30 days) mirtazapine oral tablet 45 mg QLL (45 EA per 30 days) mirtazapine oral tablet 7.5 mg QLL (30 EA per 30 days) mirtazapine oral tablet dispersible 15 mg, 45 mg Remeron SolTab QLL (30 EA per 30 days)

mirtazapine oral tablet dispersible 30 mg Remeron SolTab QLL (60 EA per 30 days)

*Antidepressants - Misc.*** bupropion hcl er (sr) oral tablet extended release 12 hour 100 mg Wellbutrin SR QLL (120 EA per 30 days)

bupropion hcl er (sr) oral tablet extended release 12 hour 150 mg Wellbutrin SR QLL (2 EA per 1 day)

17

Drug Name Reference Restrictions bupropion hcl er (sr) oral tablet extended release 12 hour 200 mg Wellbutrin SR QLL (30 EA per 30 days)

bupropion hcl er (xl) oral tablet extended release 24 hour 150 mg Wellbutrin XL QLL (90 EA per 30 days)

bupropion hcl er (xl) oral tablet extended release 24 hour 300 mg Wellbutrin XL QLL (30 EA per 30 days)

bupropion hcl oral tablet 100 mg QLL (135 EA per 30 days) bupropion hcl oral tablet 75 mg QLL (180 EA per 30 days) maprotiline hcl oral tablet 25 mg QLL (9 EA per 1 day) maprotiline hcl oral tablet 50 mg QLL (5 EA per 1 day) maprotiline hcl oral tablet 75 mg QLL (3 EA per 1 day)

*Modified Cyclics*** trazodone hcl oral tablet 100 mg, 50 mg QLL (6 EA per 1 day) trazodone hcl oral tablet 150 mg QLL (4 EA per 1 day)

*Monoamine Oxidase Inhibitors (Maois)*** phenelzine sulfate oral tablet 15 mg Nardil QLL (6 EA per 1 day)

*Selective Serotonin Reuptake Inhibitors (Ssris)*** citalopram hydrobromide oral solution 10 mg/5ml

QLL (600 ML per 30 days); AL (Max 10 Years)

citalopram hydrobromide oral tablet 10 mg, 20 mg, 40 mg CeleXA QLL (30 EA per 30 days)

escitalopram oxalate oral solution 5 mg/5ml QLL (600 ML per 30 days); AL (Max 10 Years)

escitalopram oxalate oral tablet 10 mg, 20 mg, 5 mg Lexapro QLL (30 EA per 30 days)

fluoxetine hcl oral capsule 10 mg PROzac QLL (30 EA per 30 days) 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 20 mg/5ml QLL (600 ML per 30 days) fluvoxamine maleate oral tablet 100 mg QLL (3 EA per 1 day) fluvoxamine maleate oral tablet 25 mg QLL (1 EA per 1 day) fluvoxamine maleate oral tablet 50 mg QLL (2 EA per 1 day) paroxetine hcl oral tablet 10 mg, 20 mg, 30 mg, 40 mg Paxil QLL (1 EA per 1 day)

sertraline hcl oral concentrate 20 mg/ml QLL (300 ML per 30 days); AL (Max 12 Years)

sertraline hcl oral tablet 100 mg Zoloft QLL (75 EA per 30 days) sertraline hcl oral tablet 25 mg Zoloft QLL (30 Tablet per 30 days)

18

Drug Name Reference Restrictions sertraline hcl oral tablet 50 mg Zoloft QLL (60 Tablet per 30 days)

*Serotonin-Norepinephrine Reuptake Inhibitors (Snris)*** duloxetine hcl oral capsule delayed release particles 20 mg, 30 mg, 60 mg Cymbalta QLL (30 EA per 30 days)

duloxetine hcl oral capsule delayed release particles 40 mg QLL (30 EA per 30 days)

venlafaxine hcl er oral capsule extended release 24 hour 150 mg Effexor XR QLL (60 EA per 30 days)

venlafaxine hcl er oral capsule extended release 24 hour 37.5 mg, 75 mg Effexor XR QLL (1 EA per 1 day)

venlafaxine hcl oral tablet 100 mg QLL (3 EA per 1 day) venlafaxine hcl oral tablet 25 mg QLL (9 EA per 1 day) venlafaxine hcl oral tablet 37.5 mg QLL (10 EA per 1 day) venlafaxine hcl oral tablet 50 mg QLL (7 EA per 1 day) venlafaxine hcl oral tablet 75 mg QLL (5 EA per 1 day)

*Tricyclic Agents*** amitriptyline hcl oral tablet 10 mg QLL (30 Tablets per 1 day) amitriptyline hcl oral tablet 100 mg QLL (3 Tablets per 1 day) amitriptyline hcl oral tablet 150 mg, 75 mg QLL (2 Tablets per 1 day) amitriptyline hcl oral tablet 25 mg QLL (12 Tablets per 1 day) amitriptyline hcl oral tablet 50 mg QLL (6 Tablets per 1 day) amoxapine oral tablet 100 mg QLL (6 EA per 1 day) amoxapine oral tablet 150 mg QLL (4 EA per 1 day) amoxapine oral tablet 25 mg QLL (24 EA per 1 day) amoxapine oral tablet 50 mg QLL (12 EA per 1 day) doxepin hcl oral capsule 10 mg QLL (30 EA per 1 day) doxepin hcl oral capsule 100 mg QLL (3 EA per 1 day) doxepin hcl oral capsule 150 mg QLL (2 EA per 1 day) doxepin hcl oral capsule 25 mg QLL (12 EA per 1 day) doxepin hcl oral capsule 50 mg QLL (6 EA per 1 day) doxepin hcl oral capsule 75 mg QLL (4 EA per 1 day) doxepin hcl oral concentrate 10 mg/ml imipramine hcl oral tablet 10 mg, 25 mg Tofranil imipramine hcl oral tablet 50 mg Tofranil QLL (180 EA per 30 days) nortriptyline hcl oral capsule 10 mg Pamelor nortriptyline hcl oral capsule 25 mg Pamelor QLL (180 EA per 30 days) nortriptyline hcl oral capsule 50 mg Pamelor QLL (90 EA per 30 days) nortriptyline hcl oral capsule 75 mg Pamelor QLL (60 EA per 30 days)

19

Drug Name Reference Restrictions nortriptyline hcl oral solution 10 mg/5ml AL (Max 10 Years)

*ANTIDIABETICS* *Alpha-Glucosidase Inhibitors*** acarbose oral tablet 100 mg, 25 mg, 50 mg Precose No Copay

*Biguanides*** metformin hcl er oral tablet extended release 24 hour 500 mg, 750 mg Glucophage XR No Copay

metformin hcl oral tablet 1000 mg, 500 mg, 850 mg Glucophage No Copay

*Diabetic Other*** GLUCAGEN HYPOKIT INJECTION SOLUTION RECONSTITUTED 1 MG No Copay

*Dipeptidyl Peptidase-4 (Dpp-4) Inhibitors*** alogliptin benzoate oral tablet 12.5 mg, 25 mg, 6.25 mg Nesina No Copay

JANUVIA ORAL TABLET 100 MG, 25 MG, 50 MG

ST; No Copay; QLL (30 EA per 30 days)

*Dipeptidyl Peptidase-4 Inhibitor-Biguanide Combinations*** alogliptin-metformin hcl oral tablet 12.5-1000 mg, 12.5-500 mg Kazano No Copay

JANUMET ORAL TABLET 50-1000 MG, 50-500 MG


JANUMET XR ORAL TABLET EXTENDED RELEASE 24 HOUR 100-1000 MG, 50-1000 MG, 50-500 MG


*Dpp-4 Inhibitor-Thiazolidinedione Combinations*** alogliptin-pioglitazone oral tablet 12.5-15 mg, 12.5-30 mg, 12.5-45 mg, 25-15 mg, 25-30 mg, 25-45 mg

Oseni No Copay

*Human Insulin*** ADMELOG SOLOSTAR SUBCUTANEOUS SOLUTION PEN-INJECTOR 100 UNIT/ML

Insulin Lispro (1 Unit Dial) No Copay

ADMELOG SUBCUTANEOUS SOLUTION 100 UNIT/ML Insulin Lispro

BASAGLAR KWIKPEN SUBCUTANEOUS SOLUTION PEN-INJECTOR 100 UNIT/ML

No Copay

20

Drug Name Reference Restrictions HUMALOG MIX 50/50 KWIKPEN SUBCUTANEOUS SUSPENSION PEN-INJECTOR (50-50) 100 UNIT/ML

No Copay

HUMALOG MIX 50/50 SUBCUTANEOUS SUSPENSION (50-50) 100 UNIT/ML No Copay

HUMALOG MIX 75/25 KWIKPEN SUBCUTANEOUS SUSPENSION PEN-INJECTOR (75-25) 100 UNIT/ML

No Copay

HUMALOG MIX 75/25 SUBCUTANEOUS SUSPENSION (75-25) 100 UNIT/ML No Copay

HUMULIN 70/30 SUBCUTANEOUS SUSPENSION (70-30) 100 UNIT/ML No Copay; OTC

HUMULIN R INJECTION SOLUTION 100 UNIT/ML No Copay; OTC

HUMULIN R U-500 (CONCENTRATED) SUBCUTANEOUS SOLUTION 500 UNIT/ML

No Copay

NOVOLIN 70/30 RELION SUBCUTANEOUS SUSPENSION (70-30) 100 UNIT/ML

No Copay; OTC

NOVOLIN 70/30 SUBCUTANEOUS SUSPENSION (70-30) 100 UNIT/ML No Copay; OTC

NOVOLIN N RELION SUBCUTANEOUS SUSPENSION 100 UNIT/ML No Copay; OTC

NOVOLIN N SUBCUTANEOUS SUSPENSION 100 UNIT/ML No Copay; OTC

NOVOLIN R INJECTION SOLUTION 100 UNIT/ML No Copay; OTC

NOVOLIN R RELION INJECTION SOLUTION 100 UNIT/ML No Copay; OTC

NOVOLOG MIX 70/30 FLEXPEN SUBCUTANEOUS SUSPENSION PEN-INJECTOR (70-30) 100 UNIT/ML

No Copay

NOVOLOG MIX 70/30 SUBCUTANEOUS SUSPENSION (70-30) 100 UNIT/ML No Copay

*Incretin Mimetic Agents (Glp-1 Receptor Agonists)*** OZEMPIC (0.25 OR 0.5 MG/DOSE) SUBCUTANEOUS SOLUTION PEN-INJECTOR 2 MG/1.5ML

ST; No Copay; QLL (0.05 ML per 1 day)

OZEMPIC (1 MG/DOSE) SUBCUTANEOUS SOLUTION PEN-INJECTOR 2 MG/1.5ML


21

Drug Name Reference Restrictions VICTOZA SUBCUTANEOUS SOLUTION PEN-INJECTOR 18 MG/3ML


*Meglitinide Analogues*** nateglinide oral tablet 120 mg, 60 mg Starlix No Copay repaglinide oral tablet 0.5 mg, 1 mg, 2 mg No Copay

*Meglitinide-Biguanide Combinations*** repaglinide-metformin hcl oral tablet 1-500 mg, 2-500 mg No Copay

*Sodium-Glucose Co-Transporter 2 (Sglt2) Inhibitors*** JARDIANCE ORAL TABLET 10 MG, 25 MG

PA; No Copay; QLL (1 EA per 1 day)

STEGLATRO ORAL TABLET 15 MG, 5 MG

ST; No Copay; QLL (1 EA per 1 day)

*Sulfonylurea-Biguanide Combinations*** glipizide-metformin hcl oral tablet 2.5-250 mg, 2.5-500 mg, 5-500 mg No Copay

glyburide-metformin oral tablet 1.25-250 mg, 2.5-500 mg, 5-500 mg No Copay

*Sulfonylureas*** glimepiride oral tablet 1 mg, 2 mg, 4 mg Amaryl No Copay glipizide er oral tablet extended release 24 hour 10 mg, 2.5 mg, 5 mg Glucotrol XL No Copay

glipizide oral tablet 10 mg, 5 mg Glucotrol No Copay glyburide micronized oral tablet 1.5 mg, 3 mg, 6 mg Glynase No Copay

glyburide oral tablet 1.25 mg, 2.5 mg, 5 mg No Copay

*Thiazolidinediones*** pioglitazone hcl oral tablet 15 mg, 30 mg, 45 mg Actos No Copay

AVANDIA ORAL TABLET 2 MG, 4 MG ST; No Copay

*ANTIDIARRHEALS* *Antiperistaltic Agents*** diphenoxylate-atropine oral liquid 2.5-0.025 mg/5ml diphenoxylate-atropine oral tablet 2.5-0.025 mg Lomotil

loperamide hcl oral capsule 2 mg Imodium A-D

22

Drug Name Reference Restrictions *ANTIDOTES* *Antidotes - Chelating Agents*** CHEMET ORAL CAPSULE 100 MG

*Opioid Antagonists***

naloxone hcl injection solution 0.4 mg/ml No Copay; QLL (2 ML Max Qty Per Fill Retail)

naltrexone hcl oral tablet 50 mg NARCAN NASAL LIQUID 4 MG/0.1ML No Copay VIVITROL INTRAMUSCULAR SUSPENSION RECONSTITUTED 380 MG

*ANTIEMETICS* *5-Ht3 Receptor Antagonists*** granisetron hcl oral tablet 1 mg ondansetron hcl oral tablet 24 mg ondansetron hcl oral tablet 4 mg, 8 mg Zofran QLL (3 EA per 1 day) ondansetron oral tablet dispersible 4 mg, 8 mg

*Substance P/Neurokinin 1 (Nk1) Receptor Antagonists*** EMEND ORAL CAPSULE 125 MG, 40 MG, 80 MG Aprepitant

*ANTIFUNGALS* *Antifungals*** griseofulvin microsize oral suspension 125 mg/5ml ST

griseofulvin microsize oral tablet 500 mg ST griseofulvin ultramicrosize oral tablet 125 mg, 250 mg ST

nystatin oral tablet 500000 unit terbinafine hcl oral tablet 250 mg LamISIL QLL (84 EA per 365 days)

*Imidazoles*** ketoconazole oral tablet 200 mg

*Triazoles*** fluconazole oral suspension reconstituted 10 mg/ml, 40 mg/ml Diflucan

fluconazole oral tablet 100 mg, 150 mg, 200 mg, 50 mg Diflucan

itraconazole oral capsule 100 mg Sporanox itraconazole oral solution 10 mg/ml Sporanox

23

Drug Name Reference Restrictions *ANTIHISTAMINES* *Antihistamines - Alkylamines*** brompheniramine tannate oral tablet chewable 12 mg

*Antihistamines - Ethanolamines*** carbinoxamine maleate oral tablet 4 mg clemastine fumarate oral tablet 2.68 mg diphenhydramine hcl oral liquid 6.25 mg/ml PediaClear Cough Childrens OTC

*Antihistamines - Non-Sedating*** allergy relief oral tablet dispersible 10 mg Alavert OTC; QLL (1 EA per 1 day) cetirizine hcl oral solution 1 mg/ml KLS Aller-Tec Childrens QLL (10 ML per 1 day) cetirizine hcl oral tablet 10 mg KLS Aller-Tec OTC; QLL (2 EA per 1 day) cetirizine hcl oral tablet 5 mg OTC loradamed oral tablet 10 mg Claritin OTC; QLL (1 EA per 1 day) loratadine childrens oral tablet chewable 5 mg Claritin OTC; QLL (2 EA per 1 day)

*Antihistamines - Phenothiazines*** promethazine hcl oral solution 6.25 mg/5ml promethazine hcl oral syrup 6.25 mg/5ml promethazine hcl oral tablet 12.5 mg, 25 mg, 50 mg promethazine hcl rectal suppository 12.5 mg, 25 mg Phenadoz

*Antihistamines - Piperidines*** cyproheptadine hcl oral syrup 2 mg/5ml cyproheptadine hcl oral tablet 4 mg

*ANTIHYPERLIPIDEMICS* *Antihyperlipidemics - Misc.*** omega-3-acid ethyl esters oral capsule 1 gm Lovaza ST; QLL (4 EA per 1 day)

*Bile Acid Sequestrants*** cholestyramine light oral packet 4 gm Prevalite No Copay cholestyramine oral packet 4 gm Questran No Copay colesevelam hcl oral packet 3.75 gm Welchol colestipol hcl oral tablet 1 gm Colestid No Copay

*Fibric Acid Derivatives*** fenofibrate micronized oral capsule 134 mg, 200 mg, 67 mg No Copay

fenofibrate oral tablet 160 mg, 54 mg No Copay

24


gemfibrozil oral tablet 600 mg Lopid No Copay; QLL (60 EA per 30 days)

*Hmg Coa Reductase Inhibitors*** atorvastatin calcium oral tablet 10 mg, 20 mg, 40 mg, 80 mg Lipitor No Copay; QLL (30 EA per 30

days) fluvastatin sodium er oral tablet extended release 24 hour 80 mg Lescol XL No Copay; QLL (30 EA per 30

days)

fluvastatin sodium oral capsule 20 mg, 40 mg No Copay; QLL (2 EA per 1 day)

lovastatin oral tablet 10 mg, 20 mg No Copay; QLL (1 EA per 1 day)

lovastatin oral tablet 40 mg No Copay; QLL (2 EA per 1 day)

pravastatin sodium oral tablet 10 mg No Copay; QLL (60 EA per 30 days)

pravastatin sodium oral tablet 20 mg, 40 mg Pravachol No Copay; QLL (1 EA per 1 day)

pravastatin sodium oral tablet 80 mg No Copay; QLL (1 EA per 1 day)

rosuvastatin calcium oral tablet 10 mg, 20 mg, 40 mg, 5 mg Crestor ST; No Copay; QLL (1 EA per

1 day) simvastatin oral tablet 10 mg, 20 mg, 40 mg, 5 mg Zocor No Copay; QLL (1 EA per 1

day)

simvastatin oral tablet 80 mg Zocor No Copay; QLL (30 EA per 30 days)

*Intestinal Cholesterol Absorption Inhibitors*** ezetimibe oral tablet 10 mg Zetia ST; No Copay

*ANTIHYPERTENSIVES* *Ace Inhibitor & Calcium Channel Blocker Combinations*** amlodipine besy-benazepril hcl oral capsule 10-20 mg, 10-40 mg, 5-10 mg, 5-20 mg Lotrel No Copay

amlodipine besy-benazepril hcl oral capsule 2.5-10 mg, 5-40 mg No Copay

*Ace Inhibitors & Thiazide/Thiazide-Like*** benazepril-hydrochlorothiazide oral tablet 10-12.5 mg, 20-12.5 mg, 20-25 mg Lotensin HCT No Copay

benazepril-hydrochlorothiazide oral tablet 5-6.25 mg No Copay

25

Drug Name Reference Restrictions enalapril-hydrochlorothiazide oral tablet 10-25 mg Vaseretic No Copay

enalapril-hydrochlorothiazide oral tablet 5-12.5 mg No Copay

fosinopril sodium-hctz oral tablet 10-12.5 mg, 20-12.5 mg No Copay

lisinopril-hydrochlorothiazide oral tablet 10-12.5 mg, 20-12.5 mg, 20-25 mg Zestoretic No Copay

quinapril-hydrochlorothiazide oral tablet 10-12.5 mg, 20-12.5 mg, 20-25 mg Accuretic No Copay

*Ace Inhibitors***

benazepril hcl oral tablet 10 mg, 20 mg Lotensin No Copay; QLL (2 EA per 1 day)

benazepril hcl oral tablet 40 mg Lotensin No Copay

benazepril hcl oral tablet 5 mg No Copay; QLL (2 EA per 1 day)

enalapril maleate oral tablet 10 mg, 2.5 mg, 5 mg Vasotec No Copay; QLL (2 EA per 1

day) enalapril maleate oral tablet 20 mg Vasotec No Copay

fosinopril sodium oral tablet 10 mg, 20 mg No Copay; QLL (2 EA per 1 day)

fosinopril sodium oral tablet 40 mg No Copay

lisinopril oral tablet 10 mg, 20 mg, 5 mg Prinivil No Copay; QLL (2 EA per 1 day)

lisinopril oral tablet 2.5 mg, 30 mg Zestril No Copay; QLL (2 EA per 1 day)

lisinopril oral tablet 40 mg Zestril No Copay; QLL (60 EA per 30 days)

perindopril erbumine oral tablet 2 mg, 4 mg, 8 mg No Copay

quinapril hcl oral tablet 10 mg, 20 mg, 5 mg Accupril No Copay; QLL (2 EA per 1 day)

quinapril hcl oral tablet 40 mg Accupril No Copay

ramipril oral capsule 1.25 mg, 2.5 mg, 5 mg Altace No Copay; QLL (2 EA per 1 day)

ramipril oral capsule 10 mg Altace No Copay trandolapril oral tablet 1 mg, 2 mg No Copay trandolapril oral tablet 4 mg Mavik No Copay

*Adrenolytics-Central & Thiazide/Thiazide-Like Comb*** methyldopa-hydrochlorothiazide oral tablet 250-15 mg, 250-25 mg No Copay

26

Drug Name Reference Restrictions *Angiotensin Ii Receptor Antag & Ca Channel Blocker Comb*** amlodipine besylate-valsartan oral tablet 10-160 mg, 10-320 mg, 5-160 mg, 5-320 mg Exforge No Copay; QLL (30 EA per 30

Days)

*Angiotensin Ii Receptor Antag & Thiazide/Thiazide-Like*** candesartan cilexetil-hctz oral tablet 16-12.5 mg, 32-12.5 mg, 32-25 mg Atacand HCT No Copay

irbesartan-hydrochlorothiazide oral tablet 150-12.5 mg, 300-12.5 mg Avalide No Copay

losartan potassium-hctz oral tablet 100-12.5 mg, 100-25 mg, 50-12.5 mg Hyzaar No Copay

valsartan-hydrochlorothiazide oral tablet 160-12.5 mg, 160-25 mg, 320-12.5 mg, 320-25 mg, 80-12.5 mg

Diovan HCT No Copay; QLL (1 EA per 1 day)

*Angiotensin Ii Receptor Antagonists*** candesartan cilexetil oral tablet 16 mg, 32 mg, 4 mg, 8 mg Atacand No Copay

irbesartan oral tablet 150 mg, 300 mg, 75 mg Avapro No Copay losartan potassium oral tablet 100 mg Cozaar No Copay

losartan potassium oral tablet 25 mg, 50 mg Cozaar No Copay; QLL (2 EA per 1 day)

telmisartan oral tablet 20 mg, 40 mg, 80 mg Micardis No Copay; QLL (1 EA per 1 day)

valsartan oral tablet 160 mg, 320 mg, 40 mg, 80 mg Diovan No Copay; QLL (60 EA per 30

days)

*Antiadrenergics - Centrally Acting*** clonidine hcl oral tablet 0.1 mg, 0.2 mg, 0.3 mg Catapres No Copay

clonidine transdermal patch weekly 0.1 mg/24hr Catapres-TTS-1 ST; No Copay



guanfacine hcl oral tablet 1 mg No Copay; QLL (240 EA per 30 days)

guanfacine hcl oral tablet 2 mg No Copay; QLL (120 EA per 30 days)

methyldopa oral tablet 250 mg, 500 mg No Copay

27

Drug Name Reference Restrictions *Antiadrenergics - Peripherally Acting*** doxazosin mesylate oral tablet 1 mg, 2 mg, 4 mg, 8 mg Cardura No Copay; QLL (1 EA per 1

day) prazosin hcl oral capsule 1 mg, 2 mg, 5 mg Minipress No Copay

terazosin hcl oral capsule 1 mg, 2 mg, 5 mg No Copay; QLL (1 EA per 1 day)

terazosin hcl oral capsule 10 mg No Copay; QLL (2 EA per 1 day)

*Beta Blocker & Diuretic Combinations*** atenolol-chlorthalidone oral tablet 100-25 mg Tenoretic 100 No Copay atenolol-chlorthalidone oral tablet 50-25 mg Tenoretic 50 No Copay bisoprolol-hydrochlorothiazide oral tablet 10-6.25 mg, 2.5-6.25 mg, 5-6.25 mg Ziac No Copay

metoprolol-hydrochlorothiazide oral tablet 100-25 mg, 100-50 mg No Copay

metoprolol-hydrochlorothiazide oral tablet 50-25 mg Lopressor HCT No Copay

propranolol-hctz oral tablet 40-25 mg, 80-25 mg No Copay

*Vasodilators*** hydralazine hcl oral tablet 10 mg, 100 mg, 25 mg, 50 mg No Copay

minoxidil oral tablet 10 mg, 2.5 mg No Copay

*ANTI-INFECTIVE AGENTS -MISC.* *Anti-Infective Agents - Misc.*** metronidazole oral capsule 375 mg Flagyl metronidazole oral tablet 250 mg, 500 mg Flagyl trimethoprim oral tablet 100 mg

*Anti-Infective Misc. -Combinations*** sulfamethoxazole-trimethoprim oral suspension 200-40 mg/5ml Sulfatrim Pediatric

sulfamethoxazole-trimethoprim oral tablet 400-80 mg Bactrim

*Leprostatics*** dapsone oral tablet 100 mg, 25 mg

28

Drug Name Reference Restrictions *Lincosamides*** clindamycin hcl oral capsule 150 mg, 300 mg, 75 mg Cleocin

clindamycin palmitate hcl oral solution reconstituted 75 mg/5ml Cleocin

*ANTIMALARIALS* *Antimalarials*** chloroquine phosphate oral tablet 250 mg, 500 mg hydroxychloroquine sulfate oral tablet 200 mg Plaquenil mefloquine hcl oral tablet 250 mg primaquine phosphate oral tablet 26.3 mg DARAPRIM ORAL TABLET 25 MG PA

*ANTIMYASTHENIC AGENTS* *Antimyasthenic Agents*** pyridostigmine bromide oral tablet 60 mg Mestinon

*ANTIMYCOBACTERIAL AGENTS* *Antimycobacterial Agents*** ethambutol hcl oral tablet 100 mg, 400 mg Myambutol isoniazid injection solution 100 mg/ml isoniazid oral syrup 50 mg/5ml isoniazid oral tablet 100 mg, 300 mg pyrazinamide oral tablet 500 mg rifabutin oral capsule 150 mg Mycobutin rifampin oral capsule 150 mg, 300 mg Rifadin PRIFTIN ORAL TABLET 150 MG

*ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES* *Alkylating Agents*** MYLERAN ORAL TABLET 2 MG No Copay

*Antiandrogens*** bicalutamide oral tablet 50 mg Casodex No Copay flutamide oral capsule 125 mg No Copay

nilutamide oral tablet 150 mg Nilandron No Copay; QLL (60 EA per 30 days)

*Antiestrogens*** tamoxifen citrate oral tablet 10 mg, 20 mg No Copay

29

Drug Name Reference Restrictions toremifene citrate oral tablet 60 mg Fareston SOLTAMOX ORAL SOLUTION 10 MG/5ML No Copay

*Antimetabolites*** capecitabine oral tablet 150 mg Xeloda PA; No Copay

capecitabine oral tablet 500 mg Xeloda PA; No Copay; QLL (154 EA per 21 days)

floxuridine injection solution reconstituted 0.5 gm No Copay

mercaptopurine oral tablet 50 mg No Copay methotrexate oral tablet 2.5 mg No Copay TABLOID ORAL TABLET 40 MG No Copay

*Antineoplastic - Multikinase Inhibitors*** SUTENT ORAL CAPSULE 12.5 MG, 25 MG, 37.5 MG


SUTENT ORAL CAPSULE 50 MG PA; No Copay; QLL (42 EA per 28 days)

*Antineoplastic - Tyrosine Kinase Inhibitors*** erlotinib hcl oral tablet 150 mg Tarceva PA; No Copay imatinib mesylate oral tablet 100 mg, 400 mg Gleevec PA; No Copay CABOMETYX ORAL TABLET 20 MG, 40 MG, 60 MG

PA; No Copay; QLL (30 EA per 30 Days)

IMBRUVICA ORAL CAPSULE 70 MG PA; No Copay; QLL (1 EA per 1 day)

IMBRUVICA ORAL TABLET 140 MG PA; No Copay; QLL (120 EA per 30 days)

SPRYCEL ORAL TABLET 100 MG, 140 MG, 20 MG, 50 MG, 70 MG, 80 MG

PA; No Copay; QLL (30 EA per 30 days)

TASIGNA ORAL CAPSULE 150 MG, 200 MG


TASIGNA ORAL CAPSULE 50 MG PA; No Copay; QLL (4 EA per 1 day)

TYKERB ORAL TABLET 250 MG PA; No Copay; QLL (180 EA per 30 days)

VOTRIENT ORAL TABLET 200 MG PA; No Copay; QLL (120 EA per 30 Days)

*Antineoplastics Misc.*** hydroxyurea oral capsule 500 mg Hydrea No Copay MATULANE ORAL CAPSULE 50 MG No Copay

30

Drug Name Reference Restrictions *Aromatase Inhibitors*** anastrozole oral tablet 1 mg Arimidex No Copay exemestane oral tablet 25 mg Aromasin No Copay letrozole oral tablet 2.5 mg Femara No Copay

*Folic Acid Antagonists Rescue Agents*** leucovorin calcium oral tablet 10 mg, 15 mg, 25 mg, 5 mg No Copay

*Gonadotropin Releasing Hormone (Gnrh) Antagonists*** FIRMAGON SUBCUTANEOUS SOLUTION RECONSTITUTED 120 MG, 80 MG

No Copay

*Imidazotetrazines*** temozolomide oral capsule 100 mg, 140 mg, 180 mg, 20 mg, 250 mg, 5 mg Temodar No Copay

*Lhrh Analogs*** leuprolide acetate injection kit 1 mg/0.2ml PA; No Copay ELIGARD SUBCUTANEOUS KIT 22.5 MG, 30 MG, 45 MG, 7.5 MG PA; No Copay

TRELSTAR MIXJECT INTRAMUSCULAR SUSPENSION RECONSTITUTED 22.5 MG

PA; No Copay

VANTAS SUBCUTANEOUS KIT 50 MG PA; No Copay ZOLADEX SUBCUTANEOUS IMPLANT 10.8 MG, 3.6 MG PA; No Copay

*Mitotic Inhibitors*** etoposide oral capsule 50 mg No Copay

*Nitrogen Mustards*** melphalan oral tablet 2 mg Alkeran No Copay LEUKERAN ORAL TABLET 2 MG No Copay

*Progestins-Antineoplastic*** hydroxyprogesterone caproate intramuscular solution 1.25 gm/5ml No Copay

megestrol acetate oral suspension 40 mg/ml, 400 mg/10ml No Copay

megestrol acetate oral tablet 20 mg, 40 mg No Copay

*Retinoids*** tretinoin oral capsule 10 mg No Copay

31

Drug Name Reference Restrictions *Selective Retinoid X Receptor Agonists*** bexarotene oral capsule 75 mg Targretin PA; No Copay

*Urinary Tract Protective Agents*** MESNEX ORAL TABLET 400 MG No Copay

*ANTIPARKINSON AGENTS* *Antiparkinson Anticholinergics*** benztropine mesylate oral tablet 0.5 mg, 1 mg, 2 mg No Copay

trihexyphenidyl hcl oral tablet 2 mg, 5 mg No Copay

*Antiparkinson Dopaminergics*** amantadine hcl oral capsule 100 mg No Copay amantadine hcl oral syrup 50 mg/5ml No Copay amantadine hcl oral tablet 100 mg No Copay bromocriptine mesylate oral capsule 5 mg Parlodel No Copay bromocriptine mesylate oral tablet 2.5 mg Parlodel No Copay

*Antiparkinson Monoamine Oxidase Inhibitors*** selegiline hcl oral capsule 5 mg No Copay selegiline hcl oral tablet 5 mg No Copay

*Levodopa Combinations*** carbidopa-levodopa er oral tablet extended release 25-100 mg, 50-200 mg Sinemet CR No Copay

carbidopa-levodopa oral tablet 10-100 mg, 25-100 mg, 25-250 mg Sinemet No Copay

carbidopa-levodopa oral tablet dispersible 10-100 mg, 25-100 mg, 25-250 mg No Copay

carbidopa-levodopa-entacapone oral tablet 12.5-50-200 mg Stalevo 50 No Copay; QL

carbidopa-levodopa-entacapone oral tablet 18.75-75-200 mg Stalevo 75 No Copay

carbidopa-levodopa-entacapone oral tablet 25-100-200 mg Stalevo 100 No Copay



carbidopa-levodopa-entacapone oral tablet 50-200-200 mg Stalevo 200 No Copay

32

Drug Name Reference Restrictions *Nonergoline Dopamine Receptor Agonists*** pramipexole dihydrochloride oral tablet 0.125 mg, 0.25 mg, 0.5 mg, 0.75 mg, 1 mg, 1.5 mg Mirapex No Copay

ropinirole hcl er oral tablet extended release 24 hour 12 mg, 4 mg, 6 mg, 8 mg Requip XL No Copay

ropinirole hcl er oral tablet extended release 24 hour 2 mg No Copay

ropinirole hcl oral tablet 0.25 mg, 0.5 mg, 1 mg, 2 mg, 3 mg, 4 mg, 5 mg

No Copay; QLL (3 EA per 1 day)

*Peripheral Comt Inhibitors***

entacapone oral tablet 200 mg Comtan No Copay; QLL (4 EA per 1 day)

*ANTIPSYCHOTICS/ANTIMANIC AGENTS* *Antimanic Agents*** lithium carbonate er oral tablet extended release 300 mg Lithobid No Copay; QLL (8 EA per 1

day) lithium carbonate er oral tablet extended release 450 mg


lithium carbonate oral capsule 150 mg No Copay; QLL (16 EA per 1 day)



lithium carbonate oral tablet 300 mg No Copay; QLL (8 EA per 1 day)

lithium oral solution 8 meq/5ml No Copay; QLL (40 ML per 1 day)

*Antipsychotics - Misc.*** ziprasidone hcl oral capsule 20 mg, 40 mg, 60 mg, 80 mg Geodon No Copay; QLL (2 EA per 1

day); AL (Min 18 Years)

*Benzisoxazoles***

risperidone oral solution 1 mg/ml RisperDAL No Copay; QLL (16 ML per 1 day); AL (Min 5 Years)

risperidone oral tablet 0.25 mg No Copay; QLL (2 EA per 1 day); AL (Min 5 Years)

risperidone oral tablet 0.5 mg, 1 mg, 2 mg RisperDAL No Copay; QLL (2 EA per 1 day); AL (Min 5 Years)

risperidone oral tablet 3 mg RisperDAL No Copay; QLL (3 EA per 1 day); AL (Min 5 Years)

33


risperidone oral tablet 4 mg RisperDAL No Copay; QLL (4 EA per 1 day); AL (Min 5 Years)

risperidone oral tablet dispersible 0.25 mg, 0.5 mg, 1 mg, 2 mg

No Copay; QLL (2 EA per 1 day); AL (Min 5 Years)

risperidone oral tablet dispersible 3 mg No Copay; QLL (3 EA per 1 day); AL (Min 5 Years)

risperidone oral tablet dispersible 4 mg No Copay; QLL (4 EA per 1 day); AL (Min 5 Years)

*Butyrophenones*** haloperidol decanoate intramuscular solution 100 mg/ml Haldol Decanoate No Copay; QLL (5 ML per 28

days); AL (Min 18 Years) haloperidol decanoate intramuscular solution 50 mg/ml Haldol Decanoate No Copay; QLL (9 ML per 28

days); AL (Min 18 Years)

haloperidol lactate injection solution 5 mg/ml Haldol No Copay; QLL (4 ML per 1 day); AL (Min 18 Years)

haloperidol lactate oral concentrate 2 mg/ml No Copay; QLL (50 ML per 1 day); AL (Min 18 Years)

haloperidol oral tablet 0.5 mg, 20 mg, 5 mg No Copay; QLL (5 EA per 1 day); AL (Min 18 Years)

haloperidol oral tablet 1 mg, 10 mg, 2 mg No Copay; QLL (10 EA per 1 day); AL (Min 18 Years)

*Dibenzodiazepines***

clozapine oral tablet 100 mg Clozaril No Copay; QLL (9 EA per 1 day); AL (Min 18 Years)

clozapine oral tablet 200 mg, 50 mg No Copay; QLL (4 EA per 1 day); AL (Min 18 Years)

clozapine oral tablet 25 mg Clozaril No Copay; QLL (3 EA per 1 day); AL (Min 18 Years)

*Dibenzothiazepines*** quetiapine fumarate oral tablet 100 mg, 200 mg, 25 mg, 50 mg SEROquel No Copay; QLL (3 EA per 1

day); AL (Min 10 Years) quetiapine fumarate oral tablet 300 mg, 400 mg SEROquel No Copay; QLL (2 EA per 1


*Dibenzoxazepines*** loxapine succinate oral capsule 10 mg, 5 mg, 50 mg


loxapine succinate oral capsule 25 mg No Copay; QLL (10 EA per 1 day); AL (Min 18 Years)

*Phenothiazines*** fluphenazine decanoate injection solution 25 mg/ml

No Copay; QLL (8 ML per 28 days); AL (Min 18 Years)

34


fluphenazine hcl oral concentrate 5 mg/ml No Copay; QLL (8 ML per 1 day); AL (Min 18 Years)

perphenazine oral tablet 16 mg No Copay; QLL (4 EA per 1 day); AL (Min 18 Years)

perphenazine oral tablet 2 mg, 4 mg No Copay; QLL (6 EA per 1 day); AL (Min 18 Years)

perphenazine oral tablet 8 mg No Copay; QLL (5 EA per 1 day); AL (Min 18 Years)

prochlorperazine maleate oral tablet 10 mg No Copay; QLL (4 EA per 1 day); AL (Min 18 Years)

prochlorperazine maleate oral tablet 5 mg No Copay; QLL (8 EA per 1 day); AL (Min 18 Years)

prochlorperazine rectal suppository 25 mg Compro No Copay; QLL (2 EA per 1 day); AL (Min 18 Years)

thioridazine hcl oral tablet 10 mg No Copay; QLL (6 EA per 1 day); AL (Min 18 Years)

thioridazine hcl oral tablet 100 mg No Copay; QLL (8 EA per 1 day); AL (Min 18 Years)

thioridazine hcl oral tablet 25 mg, 50 mg No Copay; QLL (3 EA per 1 day); AL (Min 18 Years)

trifluoperazine hcl oral tablet 1 mg, 10 mg, 2 mg


trifluoperazine hcl oral tablet 5 mg No Copay; QLL (3 EA per 1 day); AL (Min 18 Years)

COMPRO RECTAL SUPPOSITORY 25 MG Prochlorperazine No Copay; QLL (2 EA per 1


*Quinolinone Derivatives*** ABILIFY MAINTENA INTRAMUSCULAR PREFILLED SYRINGE 300 MG, 400 MG


ABILIFY MAINTENA INTRAMUSCULAR SUSPENSION RECONSTITUTED ER 300 MG, 400 MG


ARISTADA INTRAMUSCULAR PREFILLED SYRINGE 1064 MG/3.9ML

PA; No Copay; QLL (3.9 ML per 56 days)







35

Drug Name Reference Restrictions *Thienbenzodiazepines*** olanzapine oral tablet 10 mg, 15 mg, 2.5 mg, 20 mg, 5 mg, 7.5 mg ZyPREXA No Copay; QLL (1 EA per 1

day); AL (Min 13 Years) olanzapine oral tablet dispersible 10 mg, 15 mg, 20 mg ZyPREXA Zydis No Copay; QLL (1 EA per 1


olanzapine oral tablet dispersible 5 mg ZyPREXA Zydis No Copay; QLL (1 EA per 1 day); AL (Min 18 Years)

*Thioxanthenes*** thiothixene oral capsule 1 mg, 10 mg, 2 mg, 5 mg


*ANTIRETROVIRALS ADJUVANTS*** *Antiretrovirals Adjuvants***

TYBOST ORAL TABLET 150 MG No Copay; DIAGNOSIS REQUIRED

*ANTISEPTICS & DISINFECTANTS* *Chlorine Antiseptics*** chlorhexidine gluconate solution 20 %

*ANTIVIRALS* *Antiretroviral Combinations*** abacavir sulfate-lamivudine oral tablet 600-300 mg Epzicom No Copay; DIAGNOSIS

REQUIRED abacavir-lamivudine-zidovudine oral tablet 300-150-300 mg Trizivir No Copay; DIAGNOSIS

REQUIRED

lamivudine-zidovudine oral tablet 150-300 mg Combivir No Copay; DIAGNOSIS REQUIRED

lopinavir-ritonavir oral solution 400-100 mg/5ml Kaletra No Copay; DIAGNOSIS

REQUIRED ATRIPLA ORAL TABLET 600-200-300 MG

No Copay; DIAGNOSIS REQUIRED

BIKTARVY ORAL TABLET 50-200-25 MG

No Copay; DIAGNOSIS REQUIRED; QLL (1 EA per 1 day)

CIMDUO ORAL TABLET 300-300 MG No Copay; DIAGNOSIS REQUIRED; QLL (1 EA per 1 day)

COMPLERA ORAL TABLET 200-25-300 MG


DESCOVY ORAL TABLET 200-25 MG No Copay; DIAGNOSIS REQUIRED; QLL (1 EA per 1 day)

36


EVOTAZ ORAL TABLET 300-150 MG No Copay; DIAGNOSIS REQUIRED; QLL (1 EA per 1 day)

GENVOYA ORAL TABLET 150-150-200-10 MG


JULUCA ORAL TABLET 50-25 MG No Copay; DIAGNOSIS REQUIRED; QLL (1 EA per 1 day)

KALETRA ORAL TABLET 100-25 MG, 200-50 MG


STRIBILD ORAL TABLET 150-150-200-300 MG


SYMFI LO ORAL TABLET 400-300-300 MG


SYMFI ORAL TABLET 600-300-300 MG No Copay; DIAGNOSIS REQUIRED; QLL (1 EA per 1 day)

SYMTUZA ORAL TABLET 800-150-200-10 MG


TRIUMEQ ORAL TABLET 600-50-300 MG


TRUVADA ORAL TABLET 100-150 MG, 133-200 MG, 167-250 MG, 200-300 MG


*Antiretrovirals - Ccr5 Antagonists (Entry Inhibitor)*** SELZENTRY ORAL TABLET 150 MG, 25 MG, 300 MG, 75 MG


*Antiretrovirals - Fusion Inhibitors*** FUZEON SUBCUTANEOUS SOLUTION RECONSTITUTED 90 MG


*Antiretrovirals - Integrase Inhibitors***

ISENTRESS HD ORAL TABLET 600 MG No Copay; DIAGNOSIS REQUIRED; QLL (2 EA per 1 day)

ISENTRESS ORAL PACKET 100 MG No Copay; DIAGNOSIS REQUIRED

ISENTRESS ORAL TABLET 400 MG No Copay; DIAGNOSIS REQUIRED

37

Drug Name Reference Restrictions ISENTRESS ORAL TABLET CHEWABLE 100 MG, 25 MG


TIVICAY ORAL TABLET 10 MG, 25 MG, 50 MG


*Antiretrovirals - Protease Inhibitors*** atazanavir sulfate oral capsule 150 mg, 200 mg, 300 mg Reyataz No Copay; DIAGNOSIS

REQUIRED

fosamprenavir calcium oral tablet 700 mg Lexiva No Copay; DIAGNOSIS REQUIRED

ritonavir oral tablet 100 mg Norvir No Copay; DIAGNOSIS REQUIRED

APTIVUS ORAL CAPSULE 250 MG No Copay; DIAGNOSIS REQUIRED

APTIVUS ORAL SOLUTION 100 MG/ML No Copay; DIAGNOSIS REQUIRED

CRIXIVAN ORAL CAPSULE 200 MG, 400 MG


INVIRASE ORAL TABLET 500 MG No Copay; DIAGNOSIS REQUIRED

LEXIVA ORAL SUSPENSION 50 MG/ML No Copay; DIAGNOSIS REQUIRED

NORVIR ORAL PACKET 100 MG No Copay; DIAGNOSIS REQUIRED

NORVIR ORAL SOLUTION 80 MG/ML No Copay; DIAGNOSIS REQUIRED

PREZISTA ORAL SUSPENSION 100 MG/ML


PREZISTA ORAL TABLET 150 MG, 600 MG, 75 MG, 800 MG


REYATAZ ORAL PACKET 50 MG No Copay; DIAGNOSIS REQUIRED

VIRACEPT ORAL TABLET 250 MG, 625 MG


*Antiretrovirals - Rti-Non-Nucleoside Analogues***

efavirenz oral capsule 200 mg, 50 mg Sustiva No Copay; DIAGNOSIS REQUIRED

efavirenz oral tablet 600 mg Sustiva No Copay; DIAGNOSIS REQUIRED

nevirapine er oral tablet extended release 24 hour 100 mg


38

Drug Name Reference Restrictions nevirapine er oral tablet extended release 24 hour 400 mg Viramune XR No Copay; DIAGNOSIS

REQUIRED

nevirapine oral tablet 200 mg Viramune No Copay; DIAGNOSIS REQUIRED

EDURANT ORAL TABLET 25 MG No Copay; DIAGNOSIS REQUIRED

INTELENCE ORAL TABLET 100 MG, 200 MG, 25 MG


RESCRIPTOR ORAL TABLET 200 MG No Copay; DIAGNOSIS REQUIRED

*Antiretrovirals - Rti-Nucleoside Analogues-Purines***

abacavir sulfate oral solution 20 mg/ml Ziagen No Copay; DIAGNOSIS REQUIRED

abacavir sulfate oral tablet 300 mg Ziagen No Copay; DIAGNOSIS REQUIRED

didanosine oral capsule delayed release 200 mg, 250 mg Videx EC No Copay; DIAGNOSIS

REQUIRED didanosine oral capsule delayed release 400 mg


VIDEX ORAL SOLUTION RECONSTITUTED 2 GM


*Antiretrovirals - Rti-Nucleoside Analogues-Pyrimidines***

lamivudine oral solution 10 mg/ml Epivir No Copay; DIAGNOSIS REQUIRED

lamivudine oral tablet 150 mg, 300 mg Epivir No Copay; DIAGNOSIS REQUIRED

EMTRIVA ORAL CAPSULE 200 MG No Copay; DIAGNOSIS REQUIRED

EMTRIVA ORAL SOLUTION 10 MG/ML No Copay; DIAGNOSIS REQUIRED

*Antiretrovirals - Rti-Nucleoside Analogues-Thymidines***

stavudine oral capsule 15 mg, 20 mg No Copay; DIAGNOSIS REQUIRED

stavudine oral capsule 30 mg, 40 mg Zerit No Copay; DIAGNOSIS REQUIRED

zidovudine oral capsule 100 mg Retrovir No Copay; DIAGNOSIS REQUIRED

zidovudine oral syrup 50 mg/5ml Retrovir No Copay; DIAGNOSIS REQUIRED

39


zidovudine oral tablet 300 mg No Copay; DIAGNOSIS REQUIRED

*Antiretrovirals - Rti-Nucleotide Analogues***

tenofovir disoproxil fumarate oral tablet 300 mg Viread


VIREAD ORAL TABLET 150 MG, 200 MG, 250 MG No Copay

*Cmv Agents*** valganciclovir hcl oral tablet 450 mg Valcyte QLL (2 EA per 1 day)

*Hepatitis B Agents*** entecavir oral tablet 0.5 mg, 1 mg Baraclude QLL (1 EA per 1 day) lamivudine oral tablet 100 mg Epivir HBV BARACLUDE ORAL SOLUTION 0.05 MG/ML QLL (20 ML per 1 day)

EPIVIR HBV ORAL SOLUTION 5 MG/ML VEMLIDY ORAL TABLET 25 MG QLL (1 EA per 1 day)

*Hepatitis C Agents*** ribavirin oral capsule 200 mg ST ribavirin oral tablet 200 mg ST PEGASYS PROCLICK SUBCUTANEOUS SOLUTION 180 MCG/0.5ML PA

PEGASYS SUBCUTANEOUS SOLUTION 180 MCG/0.5ML, 180 MCG/ML PA

*Herpes Agents - Purine Analogues*** acyclovir oral capsule 200 mg Zovirax QLL (2 EA per 1 day) acyclovir oral suspension 200 mg/5ml Zovirax AL (Max 10 Years) acyclovir oral tablet 400 mg, 800 mg Zovirax QLL (2 EA per 1 day) valacyclovir hcl oral tablet 1 gm Valtrex QLL (30 EA per 30 days) valacyclovir hcl oral tablet 500 mg Valtrex QLL (60 EA per 30 days)

*Herpes Agents - Thymidine Analogues*** famciclovir oral tablet 125 mg, 250 mg, 500 mg

*Influenza Agents***

rimantadine hcl oral tablet 100 mg Flumadine QLL (14 EA Max Qty Per Fill Retail)

40

Drug Name Reference Restrictions *Neuraminidase Inhibitors*** oseltamivir phosphate oral capsule 30 mg, 45 mg, 75 mg Tamiflu QLL (10 EA Max Qty Per Fill

Retail) oseltamivir phosphate oral suspension reconstituted 6 mg/ml Tamiflu QLL (180 ML Max Qty Per Fill

Retail)

*ASSORTED CLASSES* *Cyclosporine Analogs*** cyclosporine modified oral capsule 100 mg, 25 mg Gengraf

cyclosporine modified oral capsule 50 mg cyclosporine modified oral solution 100 mg/ml Gengraf cyclosporine oral capsule 100 mg, 25 mg SandIMMUNE

*Inosine Monophosphate Dehydrogenase Inhibitors*** mycophenolate mofetil oral capsule 250 mg CellCept mycophenolate mofetil oral tablet 500 mg CellCept

*Macrolide Immunosuppressants*** sirolimus oral solution 1 mg/ml Rapamune sirolimus oral tablet 0.5 mg Rapamune tacrolimus oral capsule 0.5 mg, 1 mg, 5 mg Prograf

*Potassium Removing Resins*** sodium polystyrene sulfonate oral suspension 15 gm/60ml Kionex

sodium polystyrene sulfonate rectal suspension 30 gm/120ml

*Purine Analogs*** azathioprine oral tablet 50 mg Imuran

*BETA BLOCKERS* *Alpha-Beta Blockers*** carvedilol oral tablet 12.5 mg, 25 mg, 3.125 mg, 6.25 mg Coreg No Copay

labetalol hcl oral tablet 100 mg, 200 mg, 300 mg No Copay

*Beta Blockers Cardio-Selective*** acebutolol hcl oral capsule 200 mg, 400 mg No Copay atenolol oral tablet 100 mg, 25 mg, 50 mg Tenormin No Copay bisoprolol fumarate oral tablet 10 mg, 5 mg No Copay

41

Drug Name Reference Restrictions metoprolol succinate er oral tablet extended release 24 hour 100 mg, 200 mg, 25 mg, 50 mg

Toprol XL No Copay

metoprolol tartrate oral tablet 100 mg, 50 mg Lopressor No Copay metoprolol tartrate oral tablet 25 mg No Copay

*Beta Blockers Non-Selective*** propranolol hcl er oral capsule extended release 24 hour 120 mg, 160 mg, 60 mg Inderal LA No Copay

propranolol hcl er oral capsule extended release 24 hour 80 mg Inderal LA No Copay; QLL (1 EA per 1

day) propranolol hcl oral solution 20 mg/5ml, 40 mg/5ml No Copay

propranolol hcl oral tablet 10 mg, 20 mg, 40 mg, 60 mg, 80 mg No Copay

sotalol hcl (af) oral tablet 120 mg, 160 mg, 80 mg Betapace AF No Copay

sotalol hcl oral tablet 120 mg, 160 mg, 80 mg Betapace No Copay sotalol hcl oral tablet 240 mg Sorine No Copay timolol maleate oral tablet 10 mg, 20 mg, 5 mg No Copay

*CALCIUM CHANNEL BLOCKERS* *Calcium Channel Blockers***

amlodipine besylate oral tablet 10 mg Norvasc No Copay; QLL (1 EA per 1 day)

amlodipine besylate oral tablet 2.5 mg, 5 mg Norvasc No Copay; QLL (2 EA per 1 day)

diltiazem hcl er beads oral capsule extended release 24 hour 120 mg, 240 mg Taztia XT No Copay

diltiazem hcl er beads oral capsule extended release 24 hour 180 mg Taztia XT No Copay; QLL (3 EA per 1

day) diltiazem hcl er beads oral capsule extended release 24 hour 300 mg, 360 mg Taztia XT No Copay; QLL (1 EA per 1

day) diltiazem hcl er beads oral capsule extended release 24 hour 420 mg Tiazac No Copay; QLL (1 EA per 1

day) diltiazem hcl er coated beads oral capsule extended release 24 hour 120 mg, 240 mg Cardizem CD No Copay

diltiazem hcl er coated beads oral capsule extended release 24 hour 180 mg Cardizem CD No Copay; QLL (3 EA per 1

day) diltiazem hcl er coated beads oral capsule extended release 24 hour 300 mg Cardizem CD No Copay; QLL (1 EA per 1

day)

42

Drug Name Reference Restrictions diltiazem hcl er oral capsule extended release 12 hour 120 mg, 60 mg, 90 mg


diltiazem hcl er oral capsule extended release 24 hour 120 mg No Copay

diltiazem hcl oral tablet 120 mg, 30 mg, 60 mg Cardizem No Copay; QLL (4 EA per 1 day)

diltiazem hcl oral tablet 90 mg No Copay dilt-xr oral capsule extended release 24 hour 120 mg, 240 mg


dilt-xr oral capsule extended release 24 hour 180 mg


felodipine er oral tablet extended release 24 hour 10 mg, 2.5 mg, 5 mg No Copay

isradipine oral capsule 2.5 mg, 5 mg No Copay nicardipine hcl oral capsule 20 mg, 30 mg No Copay nifedipine er oral tablet extended release 24 hour 30 mg, 60 mg, 90 mg Adalat CC No Copay

nifedipine er osmotic release oral tablet extended release 24 hour 30 mg, 90 mg Procardia XL No Copay; QLL (90 EA per 30

days) nifedipine er osmotic release oral tablet extended release 24 hour 60 mg Nifedical XL No Copay; QLL (90 EA per 30

days) nifedipine oral capsule 10 mg Procardia No Copay nifedipine oral capsule 20 mg No Copay nimodipine oral capsule 30 mg No Copay verapamil hcl er oral capsule extended release 24 hour 120 mg, 180 mg, 240 mg Verelan No Copay; QLL (2 EA per 1

day) verapamil hcl er oral capsule extended release 24 hour 360 mg Verelan No Copay; QLL (1 EA per 1

day) verapamil hcl er oral tablet extended release 120 mg, 180 mg, 240 mg Calan SR No Copay; QLL (2 EA per 1

day)

verapamil hcl oral tablet 120 mg Calan No Copay; QLL (4 EA per 1 day)

verapamil hcl oral tablet 40 mg, 80 mg No Copay; QLL (4 EA per 1 day)

*CARDIOTONICS* *Cardiac Glycosides*** digoxin injection solution 0.25 mg/ml Lanoxin No Copay digoxin oral solution 0.05 mg/ml No Copay digoxin oral tablet 125 mcg, 250 mcg Digox No Copay DIGOX ORAL TABLET 125 MCG, 250 MCG Digoxin No Copay

43

Drug Name Reference Restrictions LANOXIN ORAL TABLET 125 MCG, 250 MCG Digoxin No Copay

LANOXIN ORAL TABLET 62.5 MCG No Copay

*CARDIOVASCULAR AGENTS -MISC.* *Calcium Channel Blocker & Hmg Coa Reductase Inhibit Comb*** amlodipine-atorvastatin oral tablet 10-10 mg, 10-20 mg, 10-40 mg, 10-80 mg, 5-10 mg, 5-20 mg, 5-40 mg, 5-80 mg

Caduet No Copay

amlodipine-atorvastatin oral tablet 2.5-10 mg, 2.5-20 mg, 2.5-40 mg No Copay

*Prostaglandin Vasodilators*** epoprostenol sodium intravenous solution reconstituted 0.5 mg, 1.5 mg Flolan PA

*Pulmonary Hypertension -Endothelin Receptor Antagonists*** ambrisentan oral tablet 10 mg, 5 mg Letairis PA; QLL (1 EA per 1 day) bosentan oral tablet 125 mg, 62.5 mg Tracleer PA; QLL (2 EA per 1 day) OPSUMIT ORAL TABLET 10 MG PA; QLL (30 EA per 30 days) TRACLEER ORAL TABLET SOLUBLE 32 MG PA; QLL (2 EA per 1 day)

*Pulmonary Hypertension -Phosphodiesterase Inhibitors*** sildenafil citrate oral tablet 20 mg Revatio PA; QLL (3 EA per 1 day) tadalafil (pah) oral tablet 20 mg Adcirca ST; QLL (2 EA per 1 day)

*CEPHALOSPORINS* *Cephalosporins - 1St Generation*** cefadroxil oral capsule 500 mg cefadroxil oral suspension reconstituted 250 mg/5ml, 500 mg/5ml cefadroxil oral tablet 1 gm cephalexin oral capsule 250 mg, 500 mg Keflex cephalexin oral suspension reconstituted 125 mg/5ml, 250 mg/5ml

*Cephalosporins - 2Nd Generation*** cefaclor oral capsule 250 mg, 500 mg cefaclor oral suspension reconstituted 125 mg/5ml, 250 mg/5ml, 375 mg/5ml

44

Drug Name Reference Restrictions cefprozil oral suspension reconstituted 125 mg/5ml, 250 mg/5ml cefprozil oral tablet 250 mg, 500 mg cefuroxime axetil oral tablet 250 mg, 500 mg

*Cephalosporins - 3Rd Generation*** cefdinir oral capsule 300 mg cefdinir oral suspension reconstituted 125 mg/5ml, 250 mg/5ml cefixime oral capsule 400 mg Suprax QLL (1 EA per 1 Fill) cefpodoxime proxetil oral suspension reconstituted 100 mg/5ml, 50 mg/5ml cefpodoxime proxetil oral tablet 100 mg, 200 mg ceftriaxone sodium injection solution reconstituted 1 gm, 2 gm, 250 mg, 500 mg QLL (2 EA per 30 days)

*CONTRACEPTIVES* *Biphasic Contraceptives - Oral***

viorele oral tablet 0.15-0.02/0.01 mg (21/5) Azurette No Copay; QLL (28 EA per 28 days)

AZURETTE ORAL TABLET 0.15-0.02/0.01 MG (21/5) Desogestrel-Ethinyl Estradiol No Copay; QLL (28 EA per 28

days) KARIVA ORAL TABLET 0.15-0.02/0.01 MG (21/5) Desogestrel-Ethinyl Estradiol No Copay; QLL (28 EA per 28

days) PIMTREA ORAL TABLET 0.15-0.02/0.01 MG (21/5) Desogestrel-Ethinyl Estradiol No Copay; QLL (28 EA per 28

days)

*Combination Contraceptives -Oral***

alyacen 1/35 oral tablet 1-35 mg-mcg Cyclafem 1/35 No Copay; QLL (28 EA per 28 days)

briellyn oral tablet 0.4-35 mg-mcg Balziva No Copay; QLL (28 EA per 28 days)

drospirenone-ethinyl estradiol oral tablet 3-0.03 mg Ocella No Copay; QLL (28 EA per 28

days) levonorgestrel-ethinyl estrad oral tablet 0.1-20 mg-mcg Aubra No Copay; QLL (28 EA per 28

days) levonorgestrel-ethinyl estrad oral tablet 0.15-30 mg-mcg Altavera No Copay; QLL (28 EA per 28

days)

marlissa oral tablet 0.15-30 mg-mcg Altavera No Copay; QLL (28 EA per 28 days)

norgestimate-eth estradiol oral tablet 0.25-35 mg-mcg Estarylla No Copay; QLL (28 EA per 28

days)

45

Drug Name Reference Restrictions ALTAVERA ORAL TABLET 0.15-30 MG-MCG Levonorgestrel-Ethinyl Estrad No Copay; QLL (28 EA per 28

days)

APRI ORAL TABLET 0.15-30 MG-MCG Desogestrel-Ethinyl Estradiol No Copay; QLL (28 EA per 28 days)

AUBRA ORAL TABLET 0.1-20 MG-MCG Levonorgestrel-Ethinyl Estrad No Copay; QLL (28 EA per 28 days)

AVIANE ORAL TABLET 0.1-20 MG-MCG Levonorgestrel-Ethinyl Estrad No Copay; QLL (28 EA per 28

days) BALZIVA ORAL TABLET 0.4-35 MG-MCG Briellyn No Copay; QLL (28 EA per 28

days) CHATEAL ORAL TABLET 0.15-30 MG-MCG Levonorgestrel-Ethinyl Estrad No Copay; QLL (28 EA per 28

days) CRYSELLE-28 ORAL TABLET 0.3-30 MG-MCG

No Copay; QLL (28 EA per 28 days)

CYCLAFEM 1/35 ORAL TABLET 1-35 MG-MCG Alyacen 1/35 No Copay; QLL (28 EA per 28

days) DASETTA 1/35 ORAL TABLET 1-35 MG-MCG Alyacen 1/35 No Copay; QLL (28 EA per 28

days) ELINEST ORAL TABLET 0.3-30 MG-MCG


EMOQUETTE ORAL TABLET 0.15-30 MG-MCG Desogestrel-Ethinyl Estradiol No Copay; QLL (28 EA per 28

days) ENSKYCE ORAL TABLET 0.15-30 MG-MCG Desogestrel-Ethinyl Estradiol No Copay; QLL (28 EA per 28

days) ESTARYLLA ORAL TABLET 0.25-35 MG-MCG Norgestimate-Eth Estradiol No Copay; QLL (28 EA per 28

days) FALMINA ORAL TABLET 0.1-20 MG-MCG Levonorgestrel-Ethinyl Estrad No Copay; QLL (28 EA per 28

days)

GIANVI ORAL TABLET 3-0.02 MG Drospirenone-Ethinyl Estradiol No Copay; QLL (28 EA per 28 days)

JUNEL 1.5/30 ORAL TABLET 1.5-30 MG-MCG

Norethindrone Acet-Ethinyl Est


JUNEL 1/20 ORAL TABLET 1-20 MG-MCG



JUNEL FE 1.5/30 ORAL TABLET 1.5-30 MG-MCG


JUNEL FE 1/20 ORAL TABLET 1-20 MG-MCG Norethin Ace-Eth Estrad-FE No Copay; QLL (28 EA per 28

days) KELNOR 1/35 ORAL TABLET 1-35 MG-MCG Ethynodiol Diac-Eth Estradiol No Copay; QLL (28 EA per 28

days) KURVELO ORAL TABLET 0.15-30 MG-MCG Levonorgestrel-Ethinyl Estrad No Copay; QLL (28 EA per 28

days) LARIN 1.5/30 ORAL TABLET 1.5-30 MG-MCG



46

Drug Name Reference Restrictions LARIN 1/20 ORAL TABLET 1-20 MG-MCG



LARIN FE 1.5/30 ORAL TABLET 1.5-30 MG-MCG


LARIN FE 1/20 ORAL TABLET 1-20 MG-MCG Norethin Ace-Eth Estrad-FE No Copay; QLL (28 EA per 28

days) LESSINA ORAL TABLET 0.1-20 MG-MCG Levonorgestrel-Ethinyl Estrad No Copay; QLL (28 EA per 28

days) LEVORA 0.15/30 (28) ORAL TABLET 0.15-30 MG-MCG Levonorgestrel-Ethinyl Estrad No Copay; QLL (28 EA per 28

days)

LORYNA ORAL TABLET 3-0.02 MG Drospirenone-Ethinyl Estradiol No Copay; QLL (28 EA per 28 days)

LOW-OGESTREL ORAL TABLET 0.3-30 MG-MCG


LUTERA ORAL TABLET 0.1-20 MG-MCG Levonorgestrel-Ethinyl Estrad No Copay; QLL (28 EA per 28

days) MICROGESTIN 1.5/30 ORAL TABLET 1.5-30 MG-MCG



MICROGESTIN 1/20 ORAL TABLET 1-20 MG-MCG



MICROGESTIN FE 1.5/30 ORAL TABLET 1.5-30 MG-MCG


MICROGESTIN FE 1/20 ORAL TABLET 1-20 MG-MCG Norethin Ace-Eth Estrad-FE No Copay; QLL (28 EA per 28

days) MONO-LINYAH ORAL TABLET 0.25-35 MG-MCG Norgestimate-Eth Estradiol No Copay; QLL (28 EA per 28

days) MONONESSA ORAL TABLET 0.25-35 MG-MCG Norgestimate-Eth Estradiol No Copay; QLL (28 EA per 28

days) NECON 1/35 (28) ORAL TABLET 1-35 MG-MCG Alyacen 1/35 No Copay; QLL (28 EA per 28

days) NORTREL 1/35 (21) ORAL TABLET 1-35 MG-MCG Alyacen 1/35 No Copay; QLL (21 EA per 28

days)

OCELLA ORAL TABLET 3-0.03 MG Drospirenone-Ethinyl Estradiol No Copay; QLL (28 EA per 28 days)

OGESTREL ORAL TABLET 0.5-50 MG-MCG


ORSYTHIA ORAL TABLET 0.1-20 MG-MCG Levonorgestrel-Ethinyl Estrad No Copay; QLL (28 EA per 28

days) PHILITH ORAL TABLET 0.4-35 MG-MCG Briellyn No Copay; QLL (28 EA per 28

days) PIRMELLA 1/35 ORAL TABLET 1-35 MG-MCG Alyacen 1/35 No Copay; QLL (28 EA per 28

days) PORTIA-28 ORAL TABLET 0.15-30 MG-MCG Levonorgestrel-Ethinyl Estrad No Copay; QLL (28 EA per 28

days) 47

Drug Name Reference Restrictions PREVIFEM ORAL TABLET 0.25-35 MG-MCG Norgestimate-Eth Estradiol No Copay; QLL (28 EA per 28

days) RECLIPSEN ORAL TABLET 0.15-30 MG-MCG Desogestrel-Ethinyl Estradiol No Copay; QLL (28 EA per 28

days) SPRINTEC 28 ORAL TABLET 0.25-35 MG-MCG Norgestimate-Eth Estradiol No Copay; QLL (28 EA per 28

days) SRONYX ORAL TABLET 0.1-20 MG-MCG Levonorgestrel-Ethinyl Estrad No Copay; QLL (28 EA per 28

days)

SYEDA ORAL TABLET 3-0.03 MG Drospirenone-Ethinyl Estradiol No Copay; QLL (28 EA per 28 days)

VYFEMLA ORAL TABLET 0.4-35 MG-MCG Briellyn No Copay; QLL (28 EA per 28

days)

ZARAH ORAL TABLET 3-0.03 MG Drospirenone-Ethinyl Estradiol No Copay; QLL (28 EA per 28 days)

ZOVIA 1/35E (28) ORAL TABLET 1-35 MG-MCG Ethynodiol Diac-Eth Estradiol No Copay; QLL (28 EA per 28

days)

*Combination Contraceptives -Transdermal*** XULANE TRANSDERMAL PATCH WEEKLY 150-35 MCG/24HR

No Copay; QLL (3 Patches per 28 days)

*Combination Contraceptives -Vaginal*** NUVARING VAGINAL RING 0.12-0.015 MG/24HR


*Copper Contraceptives - Iud*** PARAGARD INTRAUTERINE COPPER INTRAUTERINE INTRAUTERINE DEVICE

No Copay; QLL (1 EA per 10 Years)

*Copper Contraceptives - Iud*** (New) PARAGARD INTRAUTERINE COPPER INTRAUTERINE INTRAUTERINE DEVICE

No Copay; QLL (1 EA per 10 Years)

*Emergency Contraceptives*** levonorgestrel oral tablet 1.5 mg Aftera No Copay; OTC AFTERA ORAL TABLET 1.5 MG Levonorgestrel No Copay; OTC ECONTRA EZ ORAL TABLET 1.5 MG Levonorgestrel No Copay; OTC ELLA ORAL TABLET 30 MG No Copay MY CHOICE ORAL TABLET 1.5 MG Levonorgestrel No Copay; OTC MY WAY ORAL TABLET 1.5 MG Levonorgestrel No Copay; OTC NEW DAY ORAL TABLET 1.5 MG Levonorgestrel No Copay; OTC

48

Drug Name Reference Restrictions OPCICON ONE-STEP ORAL TABLET 1.5 MG Levonorgestrel No Copay; OTC

OPTION 2 ORAL TABLET 1.5 MG Levonorgestrel No Copay; OTC REACT ORAL TABLET 1.5 MG Levonorgestrel No Copay; OTC TAKE ACTION ORAL TABLET 1.5 MG Levonorgestrel No Copay; OTC

*Extended-Cycle Contraceptives -Oral*** levonorgest-eth estrad 91-day oral tablet 0.1-0.02 & 0.01 mg Amethia Lo No Copay; QLL (91 EA per 91

days) levonorgest-eth estrad 91-day oral tablet 0.15-0.03 mg Introvale No Copay; QLL (91 EA per 91

days) AMETHIA LO ORAL TABLET 0.1-0.02 & 0.01 MG

Levonorgest-Eth Estrad 91-Day


INTROVALE ORAL TABLET 0.15-0.03 MG

Levonorgest-Eth Estrad 91-Day


JOLESSA ORAL TABLET 0.15-0.03 MG Levonorgest-Eth Estrad 91-Day


*Progestin Contraceptives -Injectable*** medroxyprogesterone acetate intramuscular suspension 150 mg/ml Depo-Provera No Copay; QLL (1 ML per 84

days)

*Progestin Contraceptives - Iud*** KYLEENA INTRAUTERINE INTRAUTERINE DEVICE 19.5 MG QLL (1 EA per 5 Years)

MIRENA (52 MG) INTRAUTERINE INTRAUTERINE DEVICE 20 MCG/24HR QLL (1 EA per 5 Years)

SKYLA INTRAUTERINE INTRAUTERINE DEVICE 13.5 MG QLL (1 EA per 3 Years)

*Progestin Contraceptives - Oral***

norethindrone oral tablet 0.35 mg Camila No Copay; QLL (28 EA per 28 days)

*Triphasic Contraceptives - Oral*** alyacen 7/7/7 oral tablet 0.5/0.75/1-35 mg-mcg Cyclafem 7/7/7 No Copay; QLL (28 EA per 28

days) norgestim-eth estrad triphasic oral tablet 0.18/0.215/0.25 mg-25 mcg Ortho Tri-Cyclen Lo No Copay; QLL (28 EA per 28

Days) norgestim-eth estrad triphasic oral tablet 0.18/0.215/0.25 mg-35 mcg Tri-Estarylla No Copay; QLL (28 EA per 28

days) ARANELLE ORAL TABLET 0.5/1/0.5-35 MG-MCG


CAZIANT ORAL TABLET 0.1/0.125/0.15 -0.025 MG


49

Drug Name Reference Restrictions CYCLAFEM 7/7/7 ORAL TABLET 0.5/0.75/1-35 MG-MCG Alyacen 7/7/7 No Copay; QLL (28 EA per 28

days) DASETTA 7/7/7 ORAL TABLET 0.5/0.75/1-35 MG-MCG Alyacen 7/7/7 No Copay; QLL (28 EA per 28

days) ENPRESSE-28 ORAL TABLET 50-30/75-40/ 125-30 MCG Levonorg-Eth Estrad Triphasic No Copay; QLL (28 EA per 28

days) LEENA ORAL TABLET 0.5/1/0.5-35 MG-MCG


LEVONEST ORAL TABLET 50-30/75-40/ 125-30 MCG Levonorg-Eth Estrad Triphasic No Copay; QLL (28 EA per 28

days) NORTREL 7/7/7 ORAL TABLET 0.5/0.75/1-35 MG-MCG Alyacen 7/7/7 No Copay; QLL (28 EA per 28

days) PIRMELLA 7/7/7 ORAL TABLET 0.5/0.75/1-35 MG-MCG Alyacen 7/7/7 No Copay; QLL (28 EA per 28

days) TILIA FE ORAL TABLET 1-20/1-30/1-35 MG-MCG


TRI-ESTARYLLA ORAL TABLET 0.18/0.215/0.25 MG-35 MCG

Norgestim-Eth Estrad Triphasic


TRI-LEGEST FE ORAL TABLET 1-20/1-30/1-35 MG-MCG


TRI-LINYAH ORAL TABLET 0.18/0.215/0.25 MG-35 MCG



TRINESSA (28) ORAL TABLET 0.18/0.215/0.25 MG-35 MCG



TRI-PREVIFEM ORAL TABLET 0.18/0.215/0.25 MG-35 MCG



TRI-SPRINTEC ORAL TABLET 0.18/0.215/0.25 MG-35 MCG



TRIVORA (28) ORAL TABLET 50-30/75-40/ 125-30 MCG Levonorg-Eth Estrad Triphasic No Copay; QLL (28 EA per 28

days) VELIVET ORAL TABLET 0.1/0.125/0.15 -0.025 MG


*CORTICOSTEROIDS* *Glucocorticosteroids*** cortisone acetate oral tablet 25 mg dexamethasone oral elixir 0.5 mg/5ml dexamethasone oral solution 0.5 mg/5ml dexamethasone oral tablet 0.5 mg, 0.75 mg, 4 mg, 6 mg Decadron

dexamethasone oral tablet 1 mg, 1.5 mg, 2 mg hydrocortisone oral tablet 10 mg, 20 mg, 5 mg Cortef

50

Drug Name Reference Restrictions methylprednisolone oral tablet 16 mg, 32 mg, 4 mg, 8 mg Medrol

prednisolone oral solution 15 mg/5ml prednisolone oral syrup 15 mg/5ml prednisolone sodium phosphate oral solution 15 mg/5ml, 25 mg/5ml prednisolone sodium phosphate oral solution 6.7 (5 base) mg/5ml Pediapred

prednisolone sodium phosphate oral tablet dispersible 10 mg, 15 mg, 30 mg Orapred ODT

prednisone oral solution 5 mg/5ml AL (Max 10 Years) prednisone oral tablet 1 mg, 10 mg, 2.5 mg, 20 mg, 5 mg, 50 mg

*Mineralocorticoids*** fludrocortisone acetate oral tablet 0.1 mg

*COUGH/COLD/ALLERGY* *Antitussive - Nonnarcotic***

benzonatate oral capsule 100 mg Tessalon Perles QLL (6 EA per 1 day); AL (Min 10 Years)

benzonatate oral capsule 200 mg QLL (3 EA per 1 day); AL (Min 10 Years)

*Antitussive - Opioid*** hydrocodone-homatropine oral syrup 5-1.5 mg/5ml

QLL (30 ML per 1 day); AL (Min 18 Years)

hydrocodone-homatropine oral tablet 5-1.5 mg

QLL (6 EA per 1 day); AL (Min 18 Years)

hydromet oral syrup 5-1.5 mg/5ml QLL (30 ML per 1 day); AL (Min 18 Years)

*Misc. Respiratory Inhalants*** sodium chloride inhalation nebulization solution 0.9 %, 10 % sodium chloride inhalation nebulization solution 7 % HyperSal

NEBUSAL INHALATION NEBULIZATION SOLUTION 3 % Sodium Chloride

NEBUSAL INHALATION NEBULIZATION SOLUTION 6 %

*Mucolytics*** acetylcysteine inhalation solution 10 %, 20 %

51

Drug Name Reference Restrictions *Non-Narc Antitussive-Antihistamine*** promethazine-dm oral syrup 6.25-15 mg/5ml

*Opioid Antitussive-Antihistamine*** promethazine-codeine oral syrup 6.25-10 mg/5ml QLL (30 ML per 1 day)

*Opioid Antitussive-Decongestant-Antihistamine*** promethazine vc/codeine oral syrup 6.25-5-10 mg/5ml QLL (30 ML per 1 day)

RYDEX ORAL LIQUID 10-1.33-6.33 MG/5ML OTC; QLL (90 ML per 1 day)

*CYCLIN-DEPENDENT KINASES (CDK) INHIBITORS*** *Cyclin-Dependent Kinases (Cdk) Inhibitors*** VERZENIO ORAL TABLET 100 MG, 150 MG, 200 MG, 50 MG


*DERMATOLOGICALS* *Acne Antibiotics*** clindamycin phosphate external gel 1 % Cleocin-T clindamycin phosphate external lotion 1 % Cleocin-T clindamycin phosphate external solution 1 % clindamycin phosphate external swab 1 % Clindacin-P ery external pad 2 % erythromycin external gel 2 % Erygel erythromycin external solution 2 % sulfacetamide sodium (acne) external lotion 10 % Klaron

CLINDACIN-P EXTERNAL SWAB 1 % Clindamycin Phosphate

*Acne Products***

adapalene external cream 0.1 % Differin ST; QLL (45 GM per 30 days); AL (Max 35 Years)

adapalene external gel 0.1 % Differin ST; QLL (45 GM per 30 days); AL (Max 35 Years)

bp wash external liquid 2.5 % PanOxyl

tretinoin external cream 0.025 % Avita ST; QLL (45 GM per 30 days); AL (Max 35 Years)

52


tretinoin external cream 0.05 %, 0.1 % Retin-A ST; QLL (45 GM per 30 days); AL (Max 35 Years)

tretinoin external gel 0.01 % Retin-A ST; QLL (45 GM per 30 days); AL (Max 35 Years)

tretinoin external gel 0.025 % Avita ST; QLL (45 GM per 30 days); AL (Max 35 Years)

DIFFERIN EXTERNAL GEL 0.1 % Adapalene QLL (45 GM per 30 days); AL (Max 35 Years)

MYORISAN ORAL CAPSULE 10 MG, 20 MG, 30 MG ISOtretinoin

ST; Limited to 10 months per lifetime; QLL (60 EA per 30 days)

MYORISAN ORAL CAPSULE 40 MG ISOtretinoin ST; QLL (10 MONTHS per 1 LIFETIME)

ZENATANE ORAL CAPSULE 10 MG, 20 MG, 30 MG ISOtretinoin

ST; Limited to 10 months per lifetime; QLL (60 EA per 30 days)

ZENATANE ORAL CAPSULE 40 MG ISOtretinoin ST; QLL (10 MONTHS per 1 LIFETIME)

*Antibiotics - Topical*** gentamicin sulfate external cream 0.1 % gentamicin sulfate external ointment 0.1 % mupirocin external ointment 2 % Centany QLL (110 GM per 30 days)

*Antifungals - Topical Combinations*** clotrimazole-betamethasone external cream 1-0.05 % Lotrisone

hydrocortisone-iodoquinol external cream 1-1 % Dermazene

*Antifungals - Topical*** butenafine hcl external cream 1 % Lotrimin Ultra OTC ciclopirox external shampoo 1 % Loprox ST ciclopirox external solution 8 % Ciclodan ciclopirox olamine external cream 0.77 % Loprox ST ciclopirox olamine external suspension 0.77 % Loprox ST nystatin external cream 100000 unit/gm nystatin external ointment 100000 unit/gm

*Anti-Inflammatory Agents -Topical*** diclofenac sodium transdermal gel 1 % Voltaren QLL (6.67 GM per 1 day)

53

Drug Name Reference Restrictions *Antineoplastic Antimetabolites -Topical*** fluorouracil external cream 5 % Efudex fluorouracil external solution 2 %, 5 %

*Antipsoriatics - Systemic*** methoxsalen rapid oral capsule 10 mg Oxsoralen Ultra

*Antipsoriatics*** calcipotriene external cream 0.005 % Dovonex QLL (6.67 GM per 1 day) calcipotriene external ointment 0.005 % Calcitrene QLL (6.67 GM per 1 day) calcipotriene external solution 0.005 % QLL (6.67 ML per 1 day) tazarotene external cream 0.1 % Tazorac QLL (3 GM per 1 day)

*Antiseborrheic Products*** selenium sulfide external lotion 2.5 % sulfacetamide sodium external liquid 10 % Ovace Plus Wash

*Antivirals - Topical*** acyclovir external ointment 5 % Zovirax ST; QLL (15 GM per 30 days) docosanol external cream 10 % Abreva OTC; QLL (1 Tube per 30 days)

*Burn Products*** silver sulfadiazine external cream 1 % Silvadene

*Corticosteroids - Topical*** alclometasone dipropionate external cream 0.05 % alclometasone dipropionate external ointment 0.05 % amcinonide external ointment 0.1 % betamethasone dipropionate aug external cream 0.05 % Diprolene AF

betamethasone dipropionate aug external gel 0.05 % QLL (60 GM per 30 days)

betamethasone dipropionate aug external lotion 0.05 % QLL (60 ML per 30 days)

betamethasone dipropionate aug external ointment 0.05 % Diprolene QLL (60 GM per 30 days)

betamethasone dipropionate external cream 0.05 % betamethasone dipropionate external lotion 0.05 % betamethasone dipropionate external ointment 0.05 % QLL (60 GM per 30 days)

betamethasone valerate external cream 0.1 % 54

Drug Name Reference Restrictions betamethasone valerate external lotion 0.1 % betamethasone valerate external ointment 0.1 % clobetasol prop emollient base external cream 0.05 % QLL (60 GM per 30 days)

clobetasol propionate external cream 0.05 % Temovate ST; QLL (60 GM per 30 days) clobetasol propionate external gel 0.05 % ST; QLL (60 GM per 30 days) clobetasol propionate external ointment 0.05 % Temovate ST; QLL (60 GM per 30 days)

clobetasol propionate external solution 0.05 % QLL (60 ML per 30 days) fluocinolone acetonide external cream 0.01 % fluocinolone acetonide external cream 0.025 % Synalar QLL (2 GM per 1 day)

fluocinolone acetonide external ointment 0.025 % Synalar QLL (2 GM per 1 day)

fluocinolone acetonide external solution 0.01 % Synalar

fluocinonide external cream 0.05 % fluocinonide external gel 0.05 % QLL (60 GM per 30 days) fluocinonide external ointment 0.05 % QLL (60 GM per 30 days) fluocinonide external solution 0.05 % fluticasone propionate external cream 0.05 % fluticasone propionate external ointment 0.005 % halobetasol propionate external cream 0.05 % QLL (50 GM per 30 days) halobetasol propionate external ointment 0.05 % QLL (50 GM per 30 days)

hydrocortisone external cream 2.5 % hydrocortisone external lotion 2.5 % hydrocortisone external ointment 2.5 % mometasone furoate external cream 0.1 % Elocon mometasone furoate external ointment 0.1 % mometasone furoate external solution 0.1 % prednicarbate external ointment 0.1 % triamcinolone acetonide external cream 0.025 % triamcinolone acetonide external cream 0.1 %, 0.5 % Triderm

triamcinolone acetonide external lotion 0.025 %, 0.1 %

55

Drug Name Reference Restrictions triamcinolone acetonide external ointment 0.025 %, 0.1 %, 0.5 %

*Emollients*** AQUAPHILIC EXTERNAL OINTMENT Hydrophor OTC

*Enzymes - Topical*** SANTYL EXTERNAL OINTMENT 250 UNIT/GM

*Imidazole-Related Antifungals -Topical*** clotrimazole anti-fungal external cream 1 % Clotrimazole GRx clotrimazole external cream 1 % Clotrimazole GRx ST

clotrimazole external solution 1 % FungiCure Intensive/NailGuard ST

clotrimazole solution 1 % external (otc) 1 % FungiCure Intensive/NailGuard

ketoconazole external cream 2 % ST; QLL (2 GM per 1 day) ketoconazole external shampoo 2 % Nizoral

*Immunomodulators Imidazoquinolinamines - Topical*** imiquimod external cream 5 % Aldara

*Insect Repellents*** OFF DEEP WOODS DRY EXTERNAL AEROSOL CVS Total Home Insect Repel OTC; QLL (1 bottle per 30

Days) OFF DEEP WOODS EXTERNAL AEROSOL CVS Total Home Insect Repel OTC; QLL (1 bottle per 30

Days) OFF DEEP WOODS SPORTSMEN EXTERNAL AEROSOL 30 % CVS Total Home Insect Repel OTC; QLL (1 bottle per 30

Days) OFF FAMILYCARE CLEAN FEEL EXTERNAL LIQUID 5 %

OTC; QLL (1 bottle per 30 Days)

OFF SMOOTH & DRY EXTERNAL AEROSOL 15 % CVS Total Home Insect Repel OTC; QLL (1 bottle per 30

Days) SAWYER INSECT REPELLENT EXTERNAL LIQUID 20 %

OTC; QLL (1 bottle per 30 Days)

ULTRATHON INSECT REPELLENT 8 EXTERNAL AEROSOL 25 % CVS Total Home Insect Repel OTC; QLL (1 bottle per 30

Days)

*Keratolytic/Antimitotic Agents*** podofilox external solution 0.5 % salicylic acid external cream 6 % salicylic acid external lotion 6 % salicylic acid external shampoo 6 % Salex

56

Drug Name Reference Restrictions *Local Anesthetics - Topical*** arthritis pain relieving external cream 0.075 % OTC

capsaicin external cream 0.025 % OTC capsaicin external cream 0.1 % Capzasin-HP OTC capsaicin hp external cream 0.1 % Capzasin-HP OTC gnp lidocaine pain relief external patch 4 % Aspercreme Lidocaine OTC; QLL (1 EA per 1 day) lidocaine external cream 4 % AneCream OTC; QLL (60 GM per 30 days) lidocaine external ointment 5 % PA; QLL (90 GM per 30 days) lidocaine external patch 5 % Lidoderm PA; QLL (90 EA per 30 days) lidocaine hcl external solution 4 % pain relieving external cream 4 % Aspercreme w/Lidocaine OTC qc lidocaine pain relief external patch 4 % Aspercreme Lidocaine OTC; QLL (1 EA per 1 day)

*Macrolide Immunosuppressants -Topical*** tacrolimus external ointment 0.03 %, 0.1 % Protopic ST; QLL (30 GM per 30 days)

*Rosacea Agents*** metronidazole external cream 0.75 % MetroCream metronidazole external gel 0.75 % Rosadan metronidazole external lotion 0.75 % MetroLotion

*Scabicides & Pediculicides***

lice treatment external lotion 1 % OTC; QLL (120 ML per 30 days)

malathion external lotion 0.5 % Ovide ST; QLL (1 pkg per 180 days) permethrin external cream 5 % Elimite QLL (2 pkg per 180 days)

ra lice treatment external lotion 1 % OTC; QLL (120 ML per 30 days)

sm lice treatment external lotion 1 % OTC; QLL (120 ML per 30 days)

spinosad external suspension 0.9 % Natroba

*Topical Anesthetic Combinations*** lidocaine-prilocaine external cream 2.5-2.5 % QLL (1 GM per 1 day) lidocaine-prilocaine external kit 2.5-2.5 % DermacinRx Empricaine

*Topical Selective Retinoid X Receptor Agonists*** TARGRETIN EXTERNAL GEL 1 %

57

Drug Name Reference Restrictions *DIAGNOSTIC PRODUCTS* *Diagnostic Tests*** ONETOUCH ULTRA BLUE IN VITRO STRIP Kroger Test OTC; QLL (150 EA per 30

days)

ONETOUCH VERIO IN VITRO STRIP Kroger Test OTC; QLL (150 EA per 30 days)

*DIGESTIVE AIDS* *Digestive Enzymes*** CREON ORAL CAPSULE DELAYED RELEASE PARTICLES 36000 UNIT VIOKACE ORAL TABLET 10440 UNIT, 20880 UNIT ZENPEP ORAL CAPSULE DELAYED RELEASE PARTICLES 10000-32000 UNIT, 15000-47000 UNIT, 20000-63000 UNIT, 25000-79000 UNIT, 3000-14000 UNIT, 5000-24000 UNIT

*DIURETICS* *Carbonic Anhydrase Inhibitors*** acetazolamide er oral capsule extended release 12 hour 500 mg No Copay

acetazolamide oral tablet 125 mg, 250 mg No Copay methazolamide oral tablet 25 mg, 50 mg No Copay

*Diuretic Combinations*** amiloride-hydrochlorothiazide oral tablet 5-50 mg No Copay

spironolactone-hctz oral tablet 25-25 mg Aldactazide No Copay triamterene-hctz oral capsule 37.5-25 mg Dyazide No Copay triamterene-hctz oral tablet 37.5-25 mg Maxzide-25 No Copay triamterene-hctz oral tablet 75-50 mg Maxzide No Copay

*Loop Diuretics*** bumetanide injection solution 0.25 mg/ml No Copay bumetanide oral tablet 0.5 mg, 1 mg, 2 mg Bumex No Copay furosemide injection solution 10 mg/ml No Copay furosemide oral solution 10 mg/ml, 8 mg/ml No Copay furosemide oral tablet 20 mg, 40 mg, 80 mg Lasix No Copay torsemide oral tablet 10 mg, 100 mg, 20 mg, 5 mg No Copay

*Potassium Sparing Diuretics*** amiloride hcl oral tablet 5 mg No Copay

58

Drug Name Reference Restrictions spironolactone oral tablet 100 mg, 25 mg, 50 mg Aldactone No Copay

*Thiazides And Thiazide-Like Diuretics*** chlorothiazide oral tablet 250 mg, 500 mg No Copay chlorthalidone oral tablet 25 mg, 50 mg No Copay hydrochlorothiazide oral capsule 12.5 mg No Copay hydrochlorothiazide oral tablet 12.5 mg, 25 mg, 50 mg No Copay

indapamide oral tablet 1.25 mg, 2.5 mg No Copay metolazone oral tablet 10 mg, 2.5 mg, 5 mg No Copay

*ENDOCRINE AND METABOLIC AGENTS - MISC.* *Bisphosphonates*** alendronate sodium oral solution 70 mg/75ml QLL (4 EA per 30 days) alendronate sodium oral tablet 10 mg, 40 mg, 5 mg QLL (4 EA per 30 days)

alendronate sodium oral tablet 35 mg QLL (4 EA per 28 days) alendronate sodium oral tablet 70 mg Fosamax QLL (4 EA per 30 days) etidronate disodium oral tablet 200 mg, 400 mg ibandronate sodium oral tablet 150 mg Boniva

*Calcitonins*** calcitonin (salmon) nasal solution 200 unit/act Miacalcin

*Carnitine Replenisher - Agents*** levocarnitine oral solution 1 gm/10ml Carnitor levocarnitine oral tablet 330 mg Carnitor

*Dopamine Receptor Agonists*** cabergoline oral tablet 0.5 mg

*Growth Hormones*** OMNITROPE SUBCUTANEOUS SOLUTION RECONSTITUTED 5.8 MG PA

*Hyperparathyroid Treatment -Vitamin D Analogs*** calcitriol oral capsule 0.25 mcg, 0.5 mcg Rocaltrol paricalcitol oral capsule 1 mcg, 2 mcg Zemplar ST paricalcitol oral capsule 4 mcg ST

59

Drug Name Reference Restrictions *Parathyroid Hormone And Derivatives*** TYMLOS SUBCUTANEOUS SOLUTION PEN-INJECTOR 3120 MCG/1.56ML PA; QLL (0.05 ML per 1 day)

*Selective Estrogen Receptor Modulators (Serms)*** raloxifene hcl oral tablet 60 mg Evista

*Somatostatic Agents*** octreotide acetate injection solution 100 mcg/ml, 50 mcg/ml, 500 mcg/ml SandoSTATIN PA

octreotide acetate injection solution 1000 mcg/ml, 200 mcg/ml PA

SANDOSTATIN LAR DEPOT INTRAMUSCULAR KIT 10 MG, 20 MG, 30 MG

PA

SOMATULINE DEPOT SUBCUTANEOUS SOLUTION 120 MG/0.5ML, 60 MG/0.2ML, 90 MG/0.3ML

PA

*Vasopressin*** desmopressin ace spray refrig nasal solution 0.01 % QLL (1 ML per 30 days)

desmopressin acetate injection solution 4 mcg/ml DDAVP

desmopressin acetate oral tablet 0.1 mg, 0.2 mg DDAVP QLL (3 EA per 1 day)

desmopressin acetate spray nasal solution 0.01 % DDAVP QLL (1 ML per 30 days)

*ESTROGENS* *Estrogen & Progestin*** estradiol-norethindrone acet oral tablet 0.5-0.1 mg Amabelz

estradiol-norethindrone acet oral tablet 1-0.5 mg Activella

COMBIPATCH TRANSDERMAL PATCH TWICE WEEKLY 0.05-0.14 MG/DAY, 0.05-0.25 MG/DAY FEMHRT LOW DOSE ORAL TABLET 0.5-2.5 MG-MCG Norethindrone-Eth Estradiol

JINTELI ORAL TABLET 1-5 MG-MCG Norethindrone-Eth Estradiol PREFEST ORAL TABLET 1/1-0.09 MG (15/15)

60

Drug Name Reference Restrictions *Estrogens*** estradiol oral tablet 0.5 mg, 1 mg, 2 mg Estrace estradiol transdermal patch twice weekly 0.025 mg/24hr, 0.05 mg/24hr, 0.075 mg/24hr, 0.1 mg/24hr

Alora QLL (8 EA per 30 days)

estradiol transdermal patch twice weekly 0.0375 mg/24hr Dotti QLL (8 EA per 30 days)

estradiol transdermal patch weekly 0.025 mg/24hr, 0.0375 mg/24hr, 0.05 mg/24hr, 0.06 mg/24hr, 0.075 mg/24hr, 0.1 mg/24hr

Climara QLL (4 Patches per 30 days)

MENEST ORAL TABLET 0.3 MG, 0.625 MG, 1.25 MG

*FLUOROQUINOLONES* *Fluoroquinolones*** ciprofloxacin hcl oral tablet 100 mg, 750 mg QLL (28 EA per 30 days) ciprofloxacin hcl oral tablet 250 mg, 500 mg Cipro QLL (28 EA per 30 days) levofloxacin oral solution 25 mg/ml levofloxacin oral tablet 250 mg, 500 mg, 750 mg Levaquin QLL (14 EA per 90 days)

*GASTROINTESTINAL AGENTS -MISC.* *Gallstone Solubilizing Agents*** ursodiol oral capsule 300 mg Actigall ursodiol oral tablet 250 mg Urso 250 ursodiol oral tablet 500 mg Urso Forte

*Gastrointestinal Stimulants*** metoclopramide hcl injection solution 5 mg/ml metoclopramide hcl oral solution 10 mg/10ml, 5 mg/5ml metoclopramide hcl oral tablet 10 mg, 5 mg Reglan

*Ibs Agent - Guanylate Cyclase-C (Gc-C) Agonists*** LINZESS ORAL CAPSULE 145 MCG, 290 MCG QLL (30 EA per 30 Days)

*Inflammatory Bowel Agents*** balsalazide disodium oral capsule 750 mg Colazal mesalamine oral capsule delayed release 400 mg Delzicol QLL (6 EA per 1 day)

mesalamine oral tablet delayed release 1.2 gm Lialda QLL (120 EA per 30 days)

61

Drug Name Reference Restrictions mesalamine oral tablet delayed release 800 mg Asacol HD

mesalamine rectal enema 4 gm mesalamine rectal suppository 1000 mg Canasa sulfasalazine oral tablet 500 mg Azulfidine sulfasalazine oral tablet delayed release 500 mg Azulfidine EN-tabs

APRISO ORAL CAPSULE EXTENDED RELEASE 24 HOUR 0.375 GM

*Intestinal Acidifiers*** enulose oral solution 10 gm/15ml generlac oral solution 10 gm/15ml lactulose encephalopathy oral solution 10 gm/15ml

*Peripheral Opioid Receptor Antagonists*** MOVANTIK ORAL TABLET 12.5 MG, 25 MG PA; QLL (30 EA per 30 Days)

*Phosphate Binder Agents*** calcium acetate (phos binder) oral tablet 667 mg Calphron

sevelamer carbonate oral tablet 800 mg Renvela ST AURYXIA ORAL TABLET 1 GM 210 MG(FE) ST

CALPHRON ORAL TABLET 667 MG Calcium Acetate (Phos Binder) OTC

*GENITOURINARY AGENTS -MISCELLANEOUS* *5-Alpha Reductase Inhibitors*** finasteride oral tablet 5 mg Proscar

*Alpha 1-Adrenoceptor Antagonists*** alfuzosin hcl er oral tablet extended release 24 hour 10 mg Uroxatral

tamsulosin hcl oral capsule 0.4 mg Flomax

*Citrates*** cytra k crystals oral packet 3300-1002 mg Taron-Crystals potassium citrate er oral tablet extended release 10 meq (1080 mg) Urocit-K 10

potassium citrate er oral tablet extended release 15 meq (1620 mg) Urocit-K 15

62

Drug Name Reference Restrictions potassium citrate er oral tablet extended release 5 meq (540 mg) Urocit-K 5

*Interstitial Cystitis Agents*** ELMIRON ORAL CAPSULE 100 MG PA

*Phosphates*** K-PHOS NO 2 ORAL TABLET 305-700 MG

*Urinary Analgesics*** phenazopyridine hcl oral tablet 100 mg Pyridium phenazopyridine hcl oral tablet 200 mg Phenazo

*GLYCOPEPTIDES*** *Glycopeptides*** FIRVANQ ORAL SOLUTION RECONSTITUTED 25 MG/ML FIRVANQ ORAL SOLUTION RECONSTITUTED 50 MG/ML Vancomycin HCl

*GOUT AGENTS* *Gout Agent Combinations*** colchicine-probenecid oral tablet 0.5-500 mg

*Gout Agents*** allopurinol oral tablet 100 mg, 300 mg Zyloprim colchicine oral capsule 0.6 mg Mitigare QLL (9 EA per 27 days) colchicine oral tablet 0.6 mg Colcrys QLL (9 EA per 27 days) febuxostat oral tablet 40 mg, 80 mg Uloric ST

*Uricosurics*** probenecid oral tablet 500 mg

*HEMATOLOGICAL AGENTS -MISC.* *Hematorheologic Agents*** pentoxifylline er oral tablet extended release 400 mg No Copay

*Phosphodiesterase Iii Inhibitors*** cilostazol oral tablet 100 mg, 50 mg No Copay

*Platelet Aggregation Inhibitors*** dipyridamole oral tablet 25 mg, 50 mg, 75 mg No Copay

*Quinazoline Agents*** anagrelide hcl oral capsule 0.5 mg Agrylin No Copay anagrelide hcl oral capsule 1 mg No Copay

63

Drug Name Reference Restrictions *Thienopyridine Derivatives***

clopidogrel bisulfate oral tablet 300 mg No Copay; QLL (30 EA per 30 days)

clopidogrel bisulfate oral tablet 75 mg Plavix No Copay; QLL (30 EA per 30 days)

prasugrel hcl oral tablet 10 mg, 5 mg Effient No Copay; QLL (1 EA per 1 day)

*HEMATOPOIETIC AGENTS* *Cobalamins*** cyanocobalamin injection solution 1000 mcg/ml QLL (1 ML per 30 days)

*Erythropoiesis-Stimulating Agents (Esas)*** EPOGEN INJECTION SOLUTION 10000 UNIT/ML, 2000 UNIT/ML, 20000 UNIT/ML, 3000 UNIT/ML, 4000 UNIT/ML

PA

RETACRIT INJECTION SOLUTION 10000 UNIT/ML, 2000 UNIT/ML, 3000 UNIT/ML, 4000 UNIT/ML, 40000 UNIT/ML

PA

*Erythropoietins*** EPOGEN INJECTION SOLUTION 10000 UNIT/ML, 2000 UNIT/ML, 20000 UNIT/ML, 3000 UNIT/ML, 4000 UNIT/ML

PA

RETACRIT INJECTION SOLUTION 10000 UNIT/ML, 2000 UNIT/ML, 3000 UNIT/ML, 4000 UNIT/ML, 40000 UNIT/ML

PA

*Granulocyte Colony-Stimulating Factors (G-Csf)*** FULPHILA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 6 MG/0.6ML

PA

NIVESTYM INJECTION SOLUTION 300 MCG/ML, 480 MCG/1.6ML PA

NIVESTYM INJECTION SOLUTION PREFILLED SYRINGE 300 MCG/0.5ML, 480 MCG/0.8ML

PA

UDENYCA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 6 MG/0.6ML

PA

64

Drug Name Reference Restrictions ZARXIO INJECTION SOLUTION PREFILLED SYRINGE 300 MCG/0.5ML, 480 MCG/0.8ML

PA

*Thrombopoietin (Tpo) Receptor Agonists*** PROMACTA ORAL TABLET 12.5 MG PA

*HEPATITIS C AGENT -COMBINATIONS*** *Hepatitis C Agent -Combinations*** MAVYRET ORAL TABLET 100-40 MG PA

*HYPNOTICS* *Antihistamine Hypnotics*** gnp sleep aid oral tablet 25 mg Unisom SleepTabs OTC

*Barbiturate Hypnotics*** phenobarbital oral elixir 20 mg/5ml No Copay phenobarbital oral solution 20 mg/5ml No Copay phenobarbital oral tablet 100 mg, 15 mg, 16.2 mg, 30 mg, 32.4 mg, 60 mg, 64.8 mg, 97.2 mg No Copay

*Benzodiazepine Hypnotics*** estazolam oral tablet 1 mg QLL (1 EA per 1 day) estazolam oral tablet 2 mg QLL (30 EA per 30 days) flurazepam hcl oral capsule 15 mg, 30 mg QLL (1 EA per 1 day) temazepam oral capsule 15 mg, 30 mg Restoril QLL (1 EA per 1 day)

*Non-Benzodiazepine - Gaba-Receptor Modulators*** zaleplon oral capsule 10 mg, 5 mg QLL (1 EA per 1 day)

zolpidem tartrate oral tablet 10 mg, 5 mg Ambien QLL (30 EA per 30 days); AL (Min 18 Years)

*Selective Melatonin Receptor Agonists*** ramelteon oral tablet 8 mg Rozerem ST; QLL (1 EA per 1 day)

*LAXATIVES* *Bowel Evacuant Combinations*** peg 3350/electrolytes oral solution reconstituted 240 gm Colyte with Flavor Packs

peg 3350-kcl-na bicarb-nacl oral solution reconstituted 420 gm GaviLyte-N with Flavor Pack

65

Drug Name Reference Restrictions peg-3350/electrolytes oral solution reconstituted 236 gm Golytely

*Laxatives - Miscellaneous*** constulose oral solution 10 gm/15ml lactulose oral solution 10 gm/15ml, 20 gm/30ml HEALTHYLAX ORAL PACKET RA Laxative OTC; QLL (17 GM per 1 day)

*Saline Laxative Mixtures*** FLEET ENEMA RECTAL ENEMA 7-19 GM/118ML QC Enema OTC

FLEET PEDIATRIC RECTAL ENEMA 3.5-9.5 GM/59ML Enema Pediatric OTC

*MACROLIDES* *Azithromycin*** azithromycin oral packet 1 gm Zithromax azithromycin oral suspension reconstituted 100 mg/5ml, 200 mg/5ml Zithromax

azithromycin oral tablet 250 mg Zithromax QLL (12 Tablets per 30 days) azithromycin oral tablet 500 mg Zithromax azithromycin oral tablet 600 mg Zithromax QLL (8 Tablets per 30 days)

*Clarithromycin*** clarithromycin er oral tablet extended release 24 hour 500 mg QLL (14 EA per 30 days)

clarithromycin oral suspension reconstituted 125 mg/5ml, 250 mg/5ml clarithromycin oral tablet 250 mg, 500 mg QLL (28 EA per 30 days)

*Erythromycins*** erythromycin ethylsuccinate oral suspension reconstituted 200 mg/5ml E.E.S. Granules

erythromycin ethylsuccinate oral suspension reconstituted 400 mg/5ml EryPed 400

*MEDICAL DEVICES* *Applicators,Cotton Balls,Etc***

alcohol prep pad BD Swabs Single Use Butterfly OTC

alcohol swabs pad 70 % BD Swabs Single Use Butterfly OTC

alcoh-wipe sheet

hm sterile alcohol prep pad BD Swabs Single Use Butterfly OTC

66


sure comfort alcohol prep pad 70 % BD Swabs Single Use Butterfly OTC

true comfort alcohol prep pads pad 70 % BD Swabs Single Use Butterfly OTC

BD SWABS SINGLE USE BUTTERFLY PAD QC Alcohol Swabs OTC

*Condoms - Female*** FC FEMALE CONDOM OTC FC2 FEMALE CONDOM OTC

*Condoms - Male*** condoms LifeStyles Assorted Colors OTC kimono Durex Extra Sensitive No Copay; OTC maxx Durex Extra Sensitive No Copay; OTC DUREX EXTRA SENSITIVE DEVICE Maxx No Copay; OTC LIFESTYLES ASSORTED COLORS Condoms OTC LIFESTYLES EXTRA STRENGTH Condoms OTC LIFESTYLES FORM FITTING Condoms OTC LIFESTYLES LUBRICATED Condoms OTC LIFESTYLES RIBBED Condoms OTC LIFESTYLES SKYN ORIGINAL Condoms OTC LIFESTYLES SPERMICIDAL LUBE Condoms OTC LIFESTYLES STUDDED Condoms OTC LIFESTYLES ULTRA SENSITIVE Condoms OTC LIFESTYLES VIBRA-RIBBED Condoms OTC LIFESTYLES XTRA PLEASURE Condoms OTC REALITY LATEX CONDOMS Maxx No Copay; OTC

*Diaphragms*** OMNIFLEX DIAPHRAGM VAGINAL DIAPHRAGM WIDE-SEAL DIAPHRAGM 60 VAGINAL DIAPHRAGM 2 % WIDE-SEAL DIAPHRAGM 65 VAGINAL DIAPHRAGM 2 % WIDE-SEAL DIAPHRAGM 70 VAGINAL DIAPHRAGM 2 % WIDE-SEAL DIAPHRAGM 75 VAGINAL DIAPHRAGM 2 % WIDE-SEAL DIAPHRAGM 80 VAGINAL DIAPHRAGM 2 %

67

Drug Name Reference Restrictions WIDE-SEAL DIAPHRAGM 85 VAGINAL DIAPHRAGM 2 % WIDE-SEAL DIAPHRAGM 90 VAGINAL DIAPHRAGM 2 % WIDE-SEAL DIAPHRAGM 95 VAGINAL DIAPHRAGM 2 %

*Glucose Monitoring Test Supplies*** control in vitro solution normal Advance Intuition Control OTC diatrue control level 1 in vitro solution low Advocate Control Solution OTC diatrue control level 2 in vitro solution normal Advance Intuition Control OTC diatrue control level 3 in vitro solution high Advocate Control Solution OTC easy plus ii control in vitro solution high , low Advocate Control Solution OTC easy talk control in vitro solution high , low Advocate Control Solution OTC easy talk control in vitro solution normal Advance Intuition Control OTC easy trak control in vitro solution high , low Advocate Control Solution OTC easy trak control in vitro solution normal Advance Intuition Control OTC element compact control 2 in vitro solution Accu-Chek Aviva OTC element compact control 3 in vitro solution Accu-Chek Aviva OTC ge100 control in vitro solution normal Advance Intuition Control OTC glucose control in vitro solution Accu-Chek Aviva OTC glucose control in vitro solution normal Advance Intuition Control OTC supreme ii high/low control in vitro liquid Accu-Chek Aviva OTC ACCU-CHEK AVIVA IN VITRO SOLUTION Glucose Control OTC

ACCU-CHEK COMPACT PLUS CONTROL IN VITRO SOLUTION Glucose Control OTC

ACCU-CHEK SMARTVIEW CONTROL IN VITRO LIQUID Glucose Control OTC

ACCUTREND GLUCOSE CONTROL IN VITRO SOLUTION Glucose Control OTC

ADVANCE INTUITION CONTROL IN VITRO LIQUID NORMAL Easy Talk Control OTC

ADVANCE MICRO-DRAW CONTROL IN VITRO LIQUID Glucose Control OTC

ADVANCE MICRO-DRAW NORMAL IN VITRO LIQUID Glucose Control OTC

ADVOCATE CONTROL SOLUTION IN VITRO LIQUID HIGH DiaTrue Control Level 3 OTC

ADVOCATE CONTROL SOLUTION IN VITRO LIQUID LOW Easy Talk Control OTC

68

Drug Name Reference Restrictions ADVOCATE REDI-CODE+ CONTROL IN VITRO SOLUTION HIGH DiaTrue Control Level 3 OTC

ADVOCATE REDI-CODE+ CONTROL IN VITRO SOLUTION LOW Easy Talk Control OTC

AGAMATRIX CONTROL IN VITRO SOLUTION Glucose Control OTC

AGAMATRIX CONTROL IN VITRO SOLUTION HIGH DiaTrue Control Level 3 OTC

AGAMATRIX CONTROL IN VITRO SOLUTION NORMAL Easy Talk Control OTC

ASSURE 3 CONTROL IN VITRO LIQUID Glucose Control OTC

ASSURE 4 CONTROL LEVEL 1 & 2 IN VITRO LIQUID Glucose Control OTC

ASSURE DOSE CONTROL IN VITRO SOLUTION NORMAL Easy Talk Control OTC

ASSURE DOSE NORM/HIGH CONTROL IN VITRO SOLUTION Glucose Control OTC

ASSURE II CONTROL IN VITRO LIQUID Glucose Control OTC

ASSURE II CONTROL LEVEL 1 & 2 IN VITRO LIQUID Glucose Control OTC

ASSURE PRO CONTROL LEVEL 1 & 2 IN VITRO LIQUID Glucose Control OTC

CARESENS CONTROL A IN VITRO SOLUTION Glucose Control OTC

CLEVER CHOICE GLUCOSE CONTROL IN VITRO LIQUID HIGH DiaTrue Control Level 3 OTC

CLEVER CHOICE GLUCOSE CONTROL IN VITRO LIQUID LOW Easy Talk Control OTC

DUO-CARE CONTROL SOLUTION IN VITRO LIQUID Glucose Control OTC

EASY STEP CONTROL IN VITRO SOLUTION HIGH DiaTrue Control Level 3 OTC

EASY STEP CONTROL IN VITRO SOLUTION LOW , NORMAL Easy Talk Control OTC

EASY TOUCH CONTROL HIGH & LOW IN VITRO SOLUTION Glucose Control OTC

EASY TOUCH HEALTHPRO CONTROL IN VITRO SOLUTION Glucose Control OTC

EASYGLUCO CONTROL IN VITRO SOLUTION HIGH DiaTrue Control Level 3 OTC

EASYGLUCO CONTROL IN VITRO SOLUTION LOW , NORMAL Easy Talk Control OTC

69

Drug Name Reference Restrictions EASYMAX 15 LEVEL 1 CONTROL IN VITRO SOLUTION Glucose Control OTC

EASYMAX 15 LEVEL 2 CONTROL IN VITRO SOLUTION Glucose Control OTC

EASYMAX CONTROL IN VITRO SOLUTION HIGH DiaTrue Control Level 3 OTC

EASYMAX CONTROL IN VITRO SOLUTION LOW , NORMAL Easy Talk Control OTC

ELEMENT CONTROL IN VITRO LIQUID HIGH DiaTrue Control Level 3 OTC

ELEMENT CONTROL IN VITRO LIQUID LOW , NORMAL Easy Talk Control OTC

EMBRACE CONTROL IN VITRO SOLUTION LOW Easy Talk Control OTC

EVENCARE CONTROL LOW/HIGH IN VITRO LIQUID Glucose Control OTC

EVENCARE G2 LOW/HIGH CONTROL IN VITRO SOLUTION Glucose Control OTC

EVENCARE G3 LOW/HIGH CONTROL IN VITRO SOLUTION Glucose Control OTC

EVOLUTION CONTROL IN VITRO SOLUTION NORMAL Easy Talk Control OTC

FORA CONTROL IN VITRO SOLUTION HIGH DiaTrue Control Level 3 OTC

FORA CONTROL IN VITRO SOLUTION LOW , NORMAL Easy Talk Control OTC

FORACARE GDH CONTROL IN VITRO SOLUTION HIGH DiaTrue Control Level 3 OTC

FORACARE GDH CONTROL IN VITRO SOLUTION LOW , NORMAL Easy Talk Control OTC

FREESTYLE CONTROL SOLUTION IN VITRO LIQUID Glucose Control OTC

GLUCOCARD 01 CONTROL IN VITRO LIQUID Glucose Control OTC

GLUCOCARD 01 CONTROL IN VITRO SOLUTION NORMAL Easy Talk Control OTC

GLUCOCARD EXPRESSION CONTROL IN VITRO SOLUTION Glucose Control OTC

GLUCOCARD X-SENSOR CONTROL IN VITRO SOLUTION NORMAL Easy Talk Control OTC

GLUCOCOM CONTROL IN VITRO LIQUID HIGH DiaTrue Control Level 3 OTC

GLUCOCOM CONTROL IN VITRO LIQUID NORMAL Easy Talk Control OTC

70

Drug Name Reference Restrictions INFINITY CONTROL IN VITRO SOLUTION HIGH DiaTrue Control Level 3 OTC

INFINITY CONTROL IN VITRO SOLUTION LOW , NORMAL Easy Talk Control OTC

LIBERTY GLUCOSE CONTROL IN VITRO LIQUID NORMAL Easy Talk Control OTC

LIBERTY GLUCOSE CONTROL IN VITRO SOLUTION HIGH DiaTrue Control Level 3 OTC

LIBERTY GLUCOSE CONTROL IN VITRO SOLUTION NORMAL Easy Talk Control OTC

LIBERTY GLUCOSE CONTROL MID IN VITRO SOLUTION Glucose Control OTC

MEDISENSE GLUCOSE KETONE CONTR IN VITRO LIQUID Glucose Control OTC

MEDISENSE HI/MID/LOW CONTROL IN VITRO LIQUID Glucose Control OTC

MEDISENSE HIGH/LOW CONTROL IN VITRO LIQUID Glucose Control OTC

MEDISENSE MID CONTROL IN VITRO LIQUID Glucose Control OTC

MICRODOT CONTROL HIGH/LOW IN VITRO SOLUTION Glucose Control OTC

MYGLUCOHEALTH CONTROL IN VITRO SOLUTION Glucose Control OTC

NOVA MAX PLUS GLU/KET CONTROL IN VITRO LIQUID Glucose Control OTC

ON CALL EXPRESS GLUCOSE CONTR IN VITRO SOLUTION Glucose Control OTC

ON CALL PLUS GLUCOSE CONTROL IN VITRO SOLUTION Glucose Control OTC

ON CALL VIVID GLUCOSE CONTROL IN VITRO SOLUTION Glucose Control OTC

ONETOUCH ULTRA 2 KIT W/DEVICE Blood Glucose Monitor System OTC; QLL (1 Kit per 1 Year)

ONETOUCH ULTRA CONTROL IN VITRO SOLUTION Glucose Control OTC

ONETOUCH ULTRA MINI KIT W/DEVICE

Blood Glucose Monitor System OTC; QLL (1 Kit per 1 Year)

ONETOUCH ULTRALINK KIT W/DEVICE


ONETOUCH VERIO FLEX SYSTEM KIT W/DEVICE


ONETOUCH VERIO IQ SYSTEM KIT W/DEVICE


71


ONETOUCH VERIO KIT W/DEVICE Blood Glucose Monitor System OTC; QLL (1 Kit per 1 Year)

ONETOUCH VERIO SYNC SYSTEM KIT W/DEVICE


OPTUMRX GLUCOSE CONTROL IN VITRO SOLUTION Glucose Control OTC

POCKETCHEM EZ CONTROL IN VITRO SOLUTION Glucose Control OTC

PRECISION GLUCOSE CONTROL IN VITRO LIQUID Glucose Control OTC

PRECISION GLUCOSE CONTROL SOLN IN VITRO SOLUTION Glucose Control OTC

PRECISION GLUCOSE KETONE CONTR IN VITRO LIQUID Glucose Control OTC

PRECISION GLUCOSE/KETONE CONTR IN VITRO LIQUID Glucose Control OTC

PRODIGY CONTROL SOLUTION IN VITRO SOLUTION HIGH DiaTrue Control Level 3 OTC

PRODIGY CONTROL SOLUTION IN VITRO SOLUTION LOW Easy Talk Control OTC

QUICKTEK CONTROL SOLUTION IN VITRO LIQUID Glucose Control OTC

QUINTET CONTROL HIGH/NORMAL IN VITRO SOLUTION Glucose Control OTC

REFUAH PLUS GLUCOSE CONTROL IN VITRO SOLUTION Glucose Control OTC

RIGHTEST GC300 CONTROL IN VITRO LIQUID HIGH DiaTrue Control Level 3 OTC

RIGHTEST GC300 CONTROL IN VITRO LIQUID NORMAL Easy Talk Control OTC

SMARTEST CONTROL MEDIUM IN VITRO SOLUTION Glucose Control OTC

SOLARTEK GLUCOSE CONTROL IN VITRO LIQUID Glucose Control OTC

SOLUS V2 CONTROL IN VITRO SOLUTION HIGH DiaTrue Control Level 3 OTC

SOLUS V2 CONTROL IN VITRO SOLUTION LOW Easy Talk Control OTC

SURESTEP GLUCOSE CONTROL IN VITRO SOLUTION Glucose Control OTC

SURESTEP PRO HIGH GLUCOSE IN VITRO LIQUID DiaTrue Control Level 3 OTC

SURESTEP PRO LOW GLUCOSE IN VITRO LIQUID Easy Talk Control OTC

72

Drug Name Reference Restrictions SURESTEP PRO NORMAL GLUCOSE IN VITRO LIQUID Easy Talk Control OTC

TAI DOC CONTROL IN VITRO SOLUTION NORMAL Easy Talk Control OTC

TELCARE GLUCOSE CONTROL IN VITRO SOLUTION Glucose Control OTC

ULTRATRAK PRO CONTROL IN VITRO SOLUTION Glucose Control OTC

ULTRATRAK PRO CONTROL IN VITRO SOLUTION NORMAL Easy Talk Control OTC

ULTRATRAK ULTIMATE CONTROL IN VITRO SOLUTION Glucose Control OTC

UNISTRIP CONTROL IN VITRO SOLUTION HIGH DiaTrue Control Level 3 OTC

UNISTRIP CONTROL IN VITRO SOLUTION LOW Easy Talk Control OTC

VICTORY CONTROL LEVEL 1/2 IN VITRO SOLUTION Glucose Control OTC

*Needles & Syringes*** BD AUTOSHIELD 29G X 5MM , 29G X 8MM OTC

BD AUTOSHIELD DUO 30G X 5 MM Pen Needles OTC BD PEN NEEDLE MICRO U/F 32G X 6 MM Pen Needles OTC

BD PEN NEEDLE MINI U/F 31G X 5 MM Sure Comfort Pen Needles OTC BD PEN NEEDLE NANO U/F 32G X 4 MM Insupen Pen Needles

BD PEN NEEDLE ORIGINAL U/F 29G X 12.7MM Sure Comfort Pen Needles OTC

BD PEN NEEDLE SHORT U/F 31G X 8 MM Insupen Pen Needles OTC

*Respiratory Therapy Supplies*** BREATHERITE VALVED MDI CHAMBER DEVICE Nebulizer QLL (2 EA per 1 year)

PRIMEAIRE HOLDING CHAMBER DEVICE Nebulizer QLL (2 EA per 1 year)

VORTEX HOLDING CHAMBER/MASK DEVICE Nebulizer QLL (2 EA per 1 year)

*Spacer/Aerosol-Holding Chambers & Supplies*** valved holding chamber device AeroChamber Mini Chamber QLL (2 EA per 1 year)

73

Drug Name Reference Restrictions AEROCHAMBER MINI CHAMBER DEVICE Breathe Ease Medium QLL (2 EA per 1 year)

AEROCHAMBER MV Breathe Ease Medium QLL (2 EA per 1 year) AEROCHAMBER PLUS FLO-VU Breathe Ease Medium QLL (2 EA per 1 year) AEROCHAMBER PLUS FLO-VU LARGE Breathe Ease Medium QLL (2 EA per 1 year)

AEROCHAMBER PLUS FLO-VU MEDIUM Breathe Ease Medium QLL (2 EA per 1 year)

AEROCHAMBER PLUS FLO-VU SMALL Breathe Ease Medium QLL (2 EA per 1 year)

AEROCHAMBER PLUS FLO-VU W/MASK Breathe Ease Medium QLL (2 EA per 1 year)

AEROCHAMBER PLUS FLOW VU Breathe Ease Medium QLL (2 EA per 1 year) AEROCHAMBER W/FLOWSIGNAL Breathe Ease Medium QLL (2 EA per 1 year) AEROCHAMBER Z-STAT PLUS Breathe Ease Medium QLL (2 EA per 1 year) AEROCHAMBER Z-STAT PLUS CHAMBR Breathe Ease Medium QLL (2 EA per 1 year)

AEROCHAMBER Z-STAT PLUS/LARGE Breathe Ease Medium QLL (2 EA per 1 year)

AEROCHAMBER Z-STAT PLUS/MEDIUM Breathe Ease Medium QLL (2 EA per 1 year)

AEROCHAMBER Z-STAT PLUS/SMALL Breathe Ease Medium QLL (2 EA per 1 year)

ARIAL CHAMBER DEVICE Breathe Ease Medium OTC; QLL (2 EA per 1 year) BREATHERITE COLL SPACER ADULT Breathe Ease Medium QLL (2 EA per 1 year) BREATHERITE COLL SPACER CHILD Breathe Ease Medium QLL (2 EA per 1 year) BREATHERITE COLL SPACER INFANT Breathe Ease Medium QLL (2 EA per 1 year)

BREATHERITE RIGID SPACER/MASK Breathe Ease Medium QLL (2 EA per 1 year) BREATHERITE SPACER NEONATE Breathe Ease Medium QLL (2 EA per 1 year) BREATHERITE SPACER SMALL CHILD Breathe Ease Medium QLL (2 EA per 1 year)

COMPACT SPACE CHAMBER DEVICE Breathe Ease Medium QLL (2 EA per 1 year) COMPACT SPACE CHAMBER/LG MASK DEVICE Breathe Ease Medium QLL (2 EA per 1 year)

COMPACT SPACE CHAMBER/MED MASK DEVICE Breathe Ease Medium QLL (2 EA per 1 year)

COMPACT SPACE CHAMBER/SM MASK DEVICE Breathe Ease Medium QLL (2 EA per 1 year)

FLEXICHAMBER ADULT MASK/SMALL QLL (2 EA per 1 year)

74

Drug Name Reference Restrictions FLEXICHAMBER CHILD MASK/LARGE QLL (2 EA per 1 year)

FLEXICHAMBER CHILD MASK/SMALL QLL (2 EA per 1 year)

FLEXICHAMBER DEVICE Breathe Ease Medium QLL (2 EA per 1 year) INSPIRACHAMBER/LARGE DEVICE Breathe Ease Medium QLL (2 EA per 1 year) INSPIRACHAMBER/MEDIUM DEVICE Breathe Ease Medium QLL (2 EA per 1 year) INSPIRACHAMBER/MOUTHPIECE DEVICE Breathe Ease Medium QLL (2 EA per 1 year)

INSPIRACHAMBER/SMALL DEVICE Breathe Ease Medium QLL (2 EA per 1 year) MICROCHAMBER Breathe Ease Medium QLL (2 EA per 1 year) MICROSPACER Breathe Ease Medium QLL (2 EA per 1 year) OPTICHAMBER ADVANTAGE-LG MASK Breathe Ease Medium QLL (2 EA per 1 year)

OPTICHAMBER ADVANTAGE-MED MASK Breathe Ease Medium QLL (2 EA per 1 year)

OPTICHAMBER ADVANTAGE-SM MASK Breathe Ease Medium QLL (2 EA per 1 year)

OPTICHAMBER DIAMOND Breathe Ease Medium QLL (2 EA per 1 year) OPTICHAMBER DIAMOND-LG MASK DEVICE Breathe Ease Medium QLL (2 EA per 1 year)

OPTICHAMBER DIAMOND-MD MASK Breathe Ease Medium QLL (2 EA per 1 year) OPTICHAMBER DIAMOND-SM MASK Breathe Ease Medium QLL (2 EA per 1 year) OPTICHAMBER FACE MASK-LARGE Breathe Ease Medium OTC; QLL (2 EA per 1 year) OPTICHAMBER FACE MASK-MEDIUM Breathe Ease Medium OTC; QLL (2 EA per 1 year)

OPTICHAMBER FACE MASK-SMALL Breathe Ease Medium OTC; QLL (2 EA per 1 year) POCKET CHAMBER DEVICE Breathe Ease Medium QLL (2 EA per 1 year) POCKET SPACER DEVICE Breathe Ease Medium QLL (2 EA per 1 year) VORTEX VALVED HOLDING CHAMBER DEVICE Breathe Ease Medium QLL (2 EA per 1 year)

*MIGRAINE PRODUCTS* *Selective Serotonin Agonists 5-Ht(1)*** naratriptan hcl oral tablet 1 mg, 2.5 mg Amerge rizatriptan benzoate oral tablet 10 mg Maxalt rizatriptan benzoate oral tablet 5 mg rizatriptan benzoate oral tablet dispersible 10 mg Maxalt-MLT

rizatriptan benzoate oral tablet dispersible 5 mg

75

Drug Name Reference Restrictions sumatriptan nasal solution 20 mg/act, 5 mg/act Imitrex QLL (4 Vials per 30 days)

sumatriptan succinate oral tablet 100 mg, 25 mg, 50 mg Imitrex QLL (9 Tablets per 30 days)

sumatriptan succinate refill subcutaneous solution cartridge 4 mg/0.5ml, 6 mg/0.5ml Imitrex STATdose Refill QLL (4 Vials per 30 days)

sumatriptan succinate subcutaneous solution 6 mg/0.5ml Imitrex QLL (4 Vials per 30 days)

sumatriptan succinate subcutaneous solution auto-injector 4 mg/0.5ml Imitrex STATdose System QLL (4 Vials per 30 days)

sumatriptan succinate subcutaneous solution auto-injector 6 mg/0.5ml Imitrex STATdose System

*MINERALS & ELECTROLYTES* *Calcium Combinations*** qc calcium/minerals/vitamin d oral tablet 600-400 mg-unit OTC

*Electrolytes Oral***

pediatric electrolyte oral solution Advantage Care Electrolyte Ped OTC

*Fluoride*** fluoritab oral solution 0.275 (0.125 f) mg/drop NaFrinse Drops AL (Max 13 Years) fluoritab oral tablet chewable 0.55 (0.25 f) mg, 1.1 (0.5 f) mg, 2.2 (1 f) mg Ludent

sodium fluoride oral solution 1.1 (0.5 f) mg/ml AL (Max 13 Years) sodium fluoride oral tablet 1.1 (0.5 f) mg, 2.2 (1 f) mg sodium fluoride oral tablet chewable 0.55 (0.25 f) mg, 1.1 (0.5 f) mg, 2.2 (1 f) mg Ludent

FLUORABON ORAL SOLUTION 0.55 (0.25 F) MG/0.6ML AL (Max 13 Years)

*Phosphate*** K-PHOS ORAL TABLET 500 MG

*Potassium Combinations*** pot bicarb-pot chloride oral tablet effervescent 25 meq

*Potassium*** potassium bicarbonate oral tablet effervescent 25 meq Effer-K

potassium chloride crys er oral tablet extended release 10 meq Klor-Con M10

76

Drug Name Reference Restrictions potassium chloride crys er oral tablet extended release 20 meq Klor-Con M20

potassium chloride er oral capsule extended release 10 meq, 8 meq Klor-Con Sprinkle

potassium chloride er oral tablet extended release 10 meq, 20 meq, 8 meq K-Tab

KLOR-CON M15 ORAL TABLET EXTENDED RELEASE 15 MEQ

*MOUTH/THROAT/DENTAL AGENTS* *Anesthetics Topical Oral*** lidocaine hcl mouth/throat solution 4 %

*Anti-Infectives - Throat*** clotrimazole mouth/throat lozenge 10 mg nystatin mouth/throat suspension 100000 unit/ml

*Antiseptics - Mouth/Throat*** chlorhexidine gluconate mouth/throat solution 0.12 % Paroex

*Fluoride Dental Products*** neutral sodium fluoride mouth/throat solution 0.2 % PreviDent

*Saliva Stimulants*** pilocarpine hcl oral tablet 5 mg, 7.5 mg Salagen

*Steroids - Mouth/Throat*** triamcinolone acetonide mouth/throat paste 0.1 % Oralone

*MULTIVITAMINS* *Multiple Vitamins W/ Minerals*** ap-zel oral tablet Bacmin biocel oral tablet Bacmin b-plex plus oral tablet Bacmin v-c forte oral capsule Fortavit

BACMIN ORAL TABLET EQ Complete Multivit Adult 50+

CORVITE FREE ORAL TABLET EQ Complete Multivit Adult 50+

FORTAVIT ORAL CAPSULE EQ Vision Formula 50+

LYSIPLEX PLUS ORAL TABLET EQ Complete Multivit Adult 50+

77


NICAZEL FORTE ORAL TABLET EQ Complete Multivit Adult 50+

NICAZEL ORAL TABLET EQ Complete Multivit Adult 50+

NUTRICAP ORAL TABLET EQ Complete Multivit Adult 50+

NUTRIFAC ZX ORAL TABLET EQ Complete Multivit Adult 50+

REQ 49+ ORAL TABLET EQ Complete Multivit Adult 50+

SIDEROL ORAL TABLET EQ Complete Multivit Adult 50+

STROVITE FORTE ORAL TABLET EQ Complete Multivit Adult 50+

STROVITE ONE ORAL TABLET EQ Complete Multivit Adult 50+

VIC-FORTE ORAL CAPSULE EQ Vision Formula 50+

VITA S FORTE ORAL TABLET EQ Complete Multivit Adult 50+

VITACEL ORAL TABLET EQ Complete Multivit Adult 50+

VITAROCA PLUS ORAL TABLET EQ Complete Multivit Adult 50+

*Ped Multiple Vitamins W/ Minerals & C*** AQUADEKS ORAL LIQUID ABDEK Pediatric OTC

*Ped Mv W/ Fluoride*** multivitamin/fluoride oral tablet chewable 0.25 mg, 0.5 mg, 1 mg MVC-Fluoride

MVC-FLUORIDE ORAL TABLET CHEWABLE 0.25 MG, 1 MG Multivitamin/Fluoride

MVC-FLUORIDE ORAL TABLET CHEWABLE 0.5 MG Polyvitamin/Fluoride

*Ped Mv W/ Iron*** multivitamin drops/iron oral solution 11 mg/ml OTC

POLY-VI-SOL/IRON ORAL SOLUTION Poly-Vitamin/Iron OTC

*Ped Vitamins Acd W/ Fluoride*** tri-vitamin/fluoride oral solution 0.25 mg/ml, 0.5 mg/ml QL

vitamins acd-fluoride oral solution 0.25 mg/ml

78

Drug Name Reference Restrictions *Prenatal Mv & Min W/Fe-Fa***

classic prenatal oral tablet 28-0.8 mg OTC; QLL (100 EA per 90 days)

completenate oral tablet chewable 29-1 mg QLL (100 EA per 90 days)

eql prenatal formula oral tablet 28-0.8 mg OTC; QLL (100 EA per 90 days)

gnp prenatal oral tablet 28-0.8 mg OTC; QLL (100 EA per 90 days)

goodsense prenatal vitamins oral tablet 28-0.8 mg

OTC; QLL (100 EA per 90 days)

hm prenatal oral tablet 28-0.8 mg OTC; QLL (100 EA per 90 days)

kp prenatal multivitamins oral tablet 28-0.8 mg


m-natal plus oral tablet 27-1 mg M-Vit QLL (100 EA per 90 days)

multi prenatal oral tablet 27-0.8 mg NeoNatal Vitamin OTC; QLL (100 EA per 90 days)

pnv folic acid + iron oral tablet 27-1 mg M-Vit QLL (100 EA per 90 days) pnv prenatal plus multivitamin oral tablet 27-1 mg M-Vit QLL (100 EA per 90 days)

pnv tabs 29-1 oral tablet 29-1 mg Prenatabs Rx QLL (100 EA per 90 days) prenatal 19 oral tablet , 29-1 mg QLL (100 EA per 90 days) prenatal 19 oral tablet chewable , 29-1 mg QLL (100 EA per 90 days)

prenatal low iron oral tablet 27-0.8 mg NeoNatal Vitamin OTC; QLL (100 EA per 90 days)

prenatal low iron oral tablet 27-1 mg M-Vit QLL (100 EA per 90 days)

prenatal one daily oral tablet 27-0.8 mg NeoNatal Vitamin OTC; QLL (100 EA per 90 days)

prenatal oral tablet 27-0.8 mg NeoNatal Vitamin QLL (100 EA per 90 days) prenatal oral tablet 27-1 mg M-Vit QLL (100 EA per 90 days)

prenatal oral tablet 28-0.8 mg OTC; QLL (100 EA per 90 days)

prenatal plus iron oral tablet 29-1 mg Prenatabs Rx QLL (100 EA per 90 days) prenatal plus oral tablet 27-1 mg M-Vit QLL (100 EA per 90 days) prenatal plus/iron oral tablet 27-1 mg M-Vit QLL (100 EA per 90 days) prenatal vitamin and mineral oral tablet 28-0.8 mg


prenatal vitamin oral tablet 27-0.8 mg NeoNatal Vitamin OTC; QLL (100 EA per 90 days)

prenatal vitamin plus low iron oral tablet 27-1 mg M-Vit QLL (100 EA per 90 days)

79


prenatal vitamins oral tablet 28-0.8 mg OTC; QLL (100 EA per 90 days)

prenatal/iron oral tablet 28-0.8 mg OTC; QLL (100 EA per 90 days)

preplus oral tablet 27-1 mg M-Vit QLL (100 EA per 90 days) pretab oral tablet 29-1 mg Co-Natal FA QLL (100 EA per 90 days) px prenatal multivitamins oral tablet 28-0.8 mg


qc prenatal oral tablet 28-0.8 mg OTC; QLL (100 EA per 90 days)

ra prenatal formula oral tablet 28-0.8 mg OTC; QLL (100 EA per 90 days)

ra prenatal oral tablet 28-0.8 mg OTC; QLL (100 EA per 90 days)

se-natal 19 oral tablet 29-1 mg QLL (100 EA per 90 days) se-natal 19 oral tablet chewable 29-1 mg QLL (100 EA per 90 days)

sm prenatal vitamins oral tablet 28-0.8 mg OTC; QLL (100 EA per 90 days)

thrivite 19 oral tablet 29-1 mg QLL (100 EA per 90 days) thrivite rx oral tablet 29-1 mg Prenatabs Rx QLL (100 EA per 90 days) trinatal rx 1 oral tablet 60-1 mg Vinate One QLL (100 EA per 90 days) vol-nate oral tablet 28-1 mg Trinate QLL (100 EA per 90 days) vol-plus oral tablet 27-1 mg M-Vit QLL (100 EA per 90 days) vol-tab rx oral tablet 29-1 mg Prenatabs Rx QLL (100 EA per 90 days) CO-NATAL FA ORAL TABLET PreTAB QLL (100 EA per 90 days) CONCEPT OB ORAL CAPSULE 130-92.4-1 MG QLL (100 EA per 90 days)

FOLIVANE-OB ORAL CAPSULE 130-92.4-1 MG QLL (100 EA per 90 days)

INATAL GT ORAL TABLET QLL (100 EA per 90 days) M-VIT ORAL TABLET PrePLUS QLL (100 EA per 90 days) NEONATAL PLUS ORAL TABLET 27-1 MG PrePLUS QLL (100 EA per 90 days)

NEONATAL VITAMIN ORAL TABLET 27-0.8 MG Prenatal One Daily OTC; QLL (100 EA per 90

days) NIVA-PLUS ORAL TABLET 27-1 MG PrePLUS QLL (100 EA per 90 days) O-CAL FA ORAL TABLET 27-1 MG PrePLUS QLL (100 EA per 90 days) PRENATABS RX ORAL TABLET 29-1 MG PNV Tabs 29-1 QLL (100 EA per 90 days)

PRENATAL/FOLIC ACID ORAL TABLET PrePLUS QLL (100 EA per 90 days)

80

Drug Name Reference Restrictions PRENATAL-U ORAL CAPSULE 106.5-1 MG QLL (100 EA per 90 days)

PROVIDA OB ORAL CAPSULE 20-20-1.25 MG QLL (100 EA per 90 days)

RIGHT STEP PRENATAL ORAL TABLET 27-0.8 MG Prenatal One Daily OTC; QLL (100 EA per 90

days) TARON-C DHA ORAL CAPSULE 53.5-38-1 MG Virt-C DHA QLL (100 EA per 90 days)

THERANATAL CORE NUTRITION ORAL TABLET 27-1 MG PrePLUS OTC; QLL (100 EA per 90

days) TRICARE ORAL TABLET PrePLUS QLL (100 EA per 90 days) TRINATE ORAL TABLET Vol-Nate QLL (100 EA per 90 days) VINATE II ORAL TABLET 29-1 MG QLL (100 EA per 90 days) VINATE M ORAL TABLET 27-1 MG QLL (100 EA per 90 days) VINATE ONE ORAL TABLET 60-1 MG Trinatal Rx 1 QLL (100 EA per 90 days)

*Prenatal Mv & Min W/Fe-Fa-Dha*** ENFAMIL EXPECTA ORAL 28-0.8 & 200 MG


PRENATAL MULTIVITAMIN + DHA ORAL 28-0.8 & 200 MG


*Specialty Vitamins Products*** urosex oral tablet Allerwell Allergy Formula

*MUSCULOSKELETAL THERAPY AGENTS* *Central Muscle Relaxants*** baclofen oral tablet 10 mg, 20 mg baclofen oral tablet 5 mg QLL (4 EA per 1 day) carisoprodol oral tablet 350 mg Soma QLL (120 EA per 30 days) chlorzoxazone oral tablet 500 mg cyclobenzaprine hcl oral tablet 10 mg, 5 mg QLL (4 EA per 1 day) methocarbamol oral tablet 500 mg QLL (240 EA per 30 days) methocarbamol oral tablet 750 mg Robaxin-750 QLL (240 EA per 30 days) orphenadrine citrate er oral tablet extended release 12 hour 100 mg tizanidine hcl oral tablet 2 mg QLL (3 EA per 1 day) tizanidine hcl oral tablet 4 mg Zanaflex QLL (9 EA per 1 day)

*Direct Muscle Relaxants*** dantrolene sodium oral capsule 100 mg dantrolene sodium oral capsule 25 mg, 50 mg Dantrium

81

Drug Name Reference Restrictions *Muscle Relaxant Combinations*** carisoprodol-aspirin oral tablet 200-325 mg QLL (4 EA per 1 day) carisoprodol-aspirin-codeine oral tablet 200-325-16 mg QLL (8 EA per 1 day)

*Viscosupplements*** GEL-ONE INTRA-ARTICULAR PREFILLED SYRINGE 30 MG/3ML PA

HYALGAN INTRA-ARTICULAR SOLUTION 20 MG/2ML PA

HYALGAN INTRA-ARTICULAR SOLUTION PREFILLED SYRINGE 20 MG/2ML

Sodium Hyaluronate PA

*NASAL AGENTS - SYSTEMIC AND TOPICAL* *Nasal Anticholinergics*** ipratropium bromide nasal solution 0.03 %, 0.06 %

*Nasal Antihistamines*** azelastine hcl nasal solution 0.1 % QLL (30 ML per 30 days)

*Nasal Steroids*** budesonide nasal suspension 32 mcg/act Rhinocort Allergy QLL (1 bottle per 30 days) flunisolide nasal solution 25 mcg/act (0.025%) QLL (1.67 ML per 1 day) fluticasone propionate nasal suspension 50 mcg/act Flonase Allergy Relief QLL (1 bottle per 30 days)

gnp 24 hour nasal allergy nasal aerosol 55 mcg/act Nasacort Allergy 24HR OTC

gnp budesonide nasal spray nasal suspension 32 mcg/act Rhinocort Allergy OTC; QLL (1 bottle per 30

days) goodsense nasal allergy spray nasal aerosol 55 mcg/act Nasacort Allergy 24HR OTC

triamcinolone acetonide nasal aerosol 55 mcg/act Nasacort Allergy 24HR

FLONASE ALLERGY RELIEF NASAL SUSPENSION 50 MCG/ACT CVS Fluticasone Propionate OTC; QLL (1 bottle per 30

days)

*Systemic Decongestants*** SUDOGEST ORAL TABLET 60 MG KP Pseudoephedrine HCl OTC

82

Drug Name Reference Restrictions *NEPRILYSIN INHIB (ARNI)-ANGIOTENSIN II RECEPT ANTAG COMB*** *Neprilysin Inhib (Arni)-Angiotensin Ii Recept Antag Comb***

ENTRESTO ORAL TABLET 24-26 MG, 49-51 MG, 97-103 MG

PA; No Copay; This drug does not require a copay.; QLL (60 EA per 30 days)

*NEUROMUSCULAR AGENTS* *Benzathiazoles*** riluzole oral tablet 50 mg Rilutek

*OPHTHALMIC AGENTS* *Artificial Tears And Lubricants*** REFRESH LIQUIGEL OPHTHALMIC GEL 1 % CVS Lubricant Drops OTC

REFRESH TEARS OPHTHALMIC SOLUTION 0.5 % Lubricant Eye Drops OTC

*Beta-Blockers - Ophthalmic Combinations*** dorzolamide hcl-timolol mal ophthalmic solution 22.3-6.8 mg/ml Cosopt No Copay; QL

COMBIGAN OPHTHALMIC SOLUTION 0.2-0.5 % ST

*Beta-Blockers - Ophthalmic***

betaxolol hcl ophthalmic solution 0.5 % No Copay; QLL (10 ML per 30 days)

carteolol hcl ophthalmic solution 1 % No Copay; QLL (10 ML per 30 days)

levobunolol hcl ophthalmic solution 0.5 % No Copay; QLL (10 ML per 30 days)

timolol maleate ophthalmic gel forming solution 0.25 %, 0.5 % Timoptic-XE ST; No Copay

timolol maleate ophthalmic solution 0.25 %, 0.5 % Timoptic No Copay; QLL (10 ML per 30

days)

*Cycloplegic Mydriatics*** atropine sulfate ophthalmic ointment 1 % atropine sulfate ophthalmic solution 1 % Isopto Atropine cyclopentolate hcl ophthalmic solution 1 %, 2 % Cyclogyl

homatropine hbr ophthalmic solution 5 % Homatropaire

83

Drug Name Reference Restrictions phenylephrine hcl ophthalmic solution 10 %, 2.5 % Altafrin

tropicamide ophthalmic solution 0.5 % tropicamide ophthalmic solution 1 % Mydriacyl ALTAFRIN OPHTHALMIC SOLUTION 10 %, 2.5 % Phenylephrine HCl

HOMATROPAIRE OPHTHALMIC SOLUTION 5 % Homatropine HBr

*Miotics - Direct Acting*** pilocarpine hcl ophthalmic solution 1 %, 2 %, 4 % Isopto Carpine No Copay

*Ophthalmic Antiallergic*** azelastine hcl ophthalmic solution 0.05 % ST; QLL (6 ML per 30 days) cromolyn sodium ophthalmic solution 4 % ketotifen fumarate ophthalmic solution 0.025 % Alaway

olopatadine hcl ophthalmic solution 0.1 % Patanol ST; QLL (5 ML per 25 days) ALAWAY CHILDRENS ALLERGY OPHTHALMIC SOLUTION 0.025 % KP Ketotifen Fumarate OTC

ALAWAY OPHTHALMIC SOLUTION 0.025 % KP Ketotifen Fumarate OTC

*Ophthalmic Antibiotics*** bacitracin ophthalmic ointment 500 unit/gm ciprofloxacin hcl ophthalmic solution 0.3 % Ciloxan erythromycin ophthalmic ointment 5 mg/gm gentamicin sulfate ophthalmic solution 0.3 % levofloxacin ophthalmic solution 0.5 % ofloxacin ophthalmic solution 0.3 % Ocuflox tobramycin ophthalmic solution 0.3 % Tobrex GENTAK OPHTHALMIC OINTMENT 0.3 %

*Ophthalmic Anti-Infective Combinations*** bacitracin-polymyxin b ophthalmic ointment 500-10000 unit/gm Polycin

neomycin-bacitracin zn-polymyx ophthalmic ointment 5-400-10000 Neo-Polycin

neomycin-polymyxin-gramicidin ophthalmic solution 1.75-10000-.025 polymyxin b-trimethoprim ophthalmic solution 10000-0.1 unit/ml-% Polytrim

84

Drug Name Reference Restrictions NEO-POLYCIN OPHTHALMIC OINTMENT 3.5-400-10000

Neomycin-Bacitracin Zn-Polymyx

POLYCIN OPHTHALMIC OINTMENT 500-10000 UNIT/GM AK-Poly-Bac

*Ophthalmic Antivirals*** trifluridine ophthalmic solution 1 %

*Ophthalmic Carbonic Anhydrase Inhibitors*** dorzolamide hcl ophthalmic solution 2 % Trusopt No Copay AZOPT OPHTHALMIC SUSPENSION 1 %

ST; No Copay; QLL (10 ML per 30 days)

*Ophthalmic Nonsteroidal Anti-Inflammatory Agents*** diclofenac sodium ophthalmic solution 0.1 % flurbiprofen sodium ophthalmic solution 0.03 % ketorolac tromethamine ophthalmic solution 0.4 % Acular LS QLL (1 bottle per 30 days)

ketorolac tromethamine ophthalmic solution 0.5 % Acular QLL (1 bottle per 30 days)

*Ophthalmic Selective Alpha Adrenergic Agonists*** brimonidine tartrate ophthalmic solution 0.2 %

No Copay; QLL (10 ML per 30 days)

*Ophthalmic Steroid Combinations*** neomycin-polymyxin-dexameth ophthalmic ointment 3.5-10000-0.1 Maxitrol

neomycin-polymyxin-dexameth ophthalmic suspension 3.5-10000-0.1 Maxitrol

sulfacetamide-prednisolone ophthalmic solution 10-0.23 %

*Ophthalmic Steroids*** dexamethasone sodium phosphate ophthalmic solution 0.1 % fluorometholone ophthalmic suspension 0.1 % FML Liquifilm prednisolone acetate ophthalmic suspension 1 % Pred Forte

prednisolone sodium phosphate ophthalmic solution 1 %

85

Drug Name Reference Restrictions *Ophthalmic Sulfonamides*** sulfacetamide sodium ophthalmic ointment 10 % sulfacetamide sodium ophthalmic solution 10 % Bleph-10

*Prostaglandins - Ophthalmic***

latanoprost ophthalmic solution 0.005 % Xalatan No Copay; QLL (2.5 ML per 30 days)

*OTIC AGENTS* *Otic Agents - Miscellaneous*** acetic acid otic solution 2 % ear drops earwax aid otic solution 6.5 % Clearcanal Earwax Softener OTC ear wax removal drops otic solution 6.5 % Clearcanal Earwax Softener OTC ear wax removal kit otic solution 6.5 % Clearcanal Earwax Softener OTC earwax removal kit otic solution 6.5 % Clearcanal Earwax Softener OTC earwax treatment drops otic solution 6.5 % Clearcanal Earwax Softener OTC gnp ear systems otic solution 6.5 % Clearcanal Earwax Softener OTC hm earwax removal aid otic solution 6.5 % Clearcanal Earwax Softener OTC hm earwax removal kit otic solution 6.5 % Clearcanal Earwax Softener OTC sm ear drops otic solution 6.5 % Clearcanal Earwax Softener OTC

*Otic Anti-Infectives*** ciprofloxacin hcl otic solution 0.2 % Cetraxal ofloxacin otic solution 0.3 % Floxin Otic

*Otic Steroid-Anti-Infective Combinations*** neomycin-polymyxin-hc otic solution 3.5-10000-1 neomycin-polymyxin-hc otic suspension 3.5-10000-1

*Otic Steroids*** hydrocortisone-acetic acid otic solution 1-2 % Acetasol HC ACETASOL HC OTIC SOLUTION 2-1 % Hydrocortisone-Acetic Acid

*PASSIVE IMMUNIZING AGENTS* *Immune Serums*** FLEBOGAMMA DIF INTRAVENOUS SOLUTION 10 GM/100ML, 20 GM/200ML, 5 GM/50ML

PA

86

Drug Name Reference Restrictions GAMMAGARD INJECTION SOLUTION 1 GM/10ML, 10 GM/100ML, 2.5 GM/25ML, 20 GM/200ML, 30 GM/300ML, 5 GM/50ML

PA

GAMMAKED INJECTION SOLUTION 10 GM/100ML, 20 GM/200ML, 5 GM/50ML

PA

GAMUNEX-C INJECTION SOLUTION 1 GM/10ML, 10 GM/100ML, 2.5 GM/25ML, 20 GM/200ML, 40 GM/400ML, 5 GM/50ML

PA

HEPAGAM B INJECTION SOLUTION HYPERHEP B S/D INTRAMUSCULAR SOLUTION HYPERRHO S/D INTRAMUSCULAR SOLUTION PREFILLED SYRINGE 1500 UNIT, 250 UNIT MICRHOGAM ULTRA-FILTERED PLUS INTRAMUSCULAR SOLUTION PREFILLED SYRINGE 250 UNIT NABI-HB INTRAMUSCULAR SOLUTION RHOGAM ULTRA-FILTERED PLUS INTRAMUSCULAR SOLUTION PREFILLED SYRINGE 1500 UNIT RHOPHYLAC INJECTION SOLUTION PREFILLED SYRINGE 1500 UNIT/2ML

*PENICILLINS* *Aminopenicillins*** amoxicillin oral capsule 250 mg, 500 mg amoxicillin oral suspension reconstituted 125 mg/5ml, 200 mg/5ml, 250 mg/5ml, 400 mg/5ml amoxicillin oral tablet 500 mg, 875 mg amoxicillin oral tablet chewable 125 mg, 250 mg ampicillin oral capsule 500 mg

*Natural Penicillins*** penicillin v potassium oral solution reconstituted 125 mg/5ml, 250 mg/5ml penicillin v potassium oral tablet 250 mg, 500 mg

87

Drug Name Reference Restrictions *Penicillin Combinations*** amoxicillin-pot clavulanate oral suspension reconstituted 200-28.5 mg/5ml, 400-57 mg/5ml amoxicillin-pot clavulanate oral suspension reconstituted 250-62.5 mg/5ml Augmentin

amoxicillin-pot clavulanate oral suspension reconstituted 600-42.9 mg/5ml Augmentin ES-600

amoxicillin-pot clavulanate oral tablet 250-125 mg, 875-125 mg QLL (28 EA per 30 days)

amoxicillin-pot clavulanate oral tablet 500-125 mg Augmentin QLL (28 EA per 30 days)

amoxicillin-pot clavulanate oral tablet chewable 200-28.5 mg, 400-57 mg QLL (28 EA per 30 days)

*Penicillinase-Resistant Penicillins*** dicloxacillin sodium oral capsule 250 mg, 500 mg

*PHARMACEUTICAL ADJUVANTS* *Oral Vehicles*** sorbitol solution syrpalta oral syrup 85 %

*POTASSIUM REMOVING AGENTS*** *Potassium Removing Agents*** sodium polystyrene sulfonate oral suspension 15 gm/60ml Kionex

sodium polystyrene sulfonate rectal suspension 30 gm/120ml

*PROGESTINS* *Progestins*** hydroxyprogesterone caproate intramuscular oil 250 mg/ml Makena PA

medroxyprogesterone acetate oral tablet 10 mg, 2.5 mg, 5 mg Provera

megestrol acetate oral suspension 625 mg/5ml Megace ES norethindrone acetate oral tablet 5 mg Aygestin ST progesterone micronized oral capsule 100 mg, 200 mg Prometrium

88

Drug Name Reference Restrictions MAKENA SUBCUTANEOUS SOLUTION AUTO-INJECTOR 275 MG/1.1ML PA

*PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS -MISC.* *Alcohol Deterrents*** disulfiram oral tablet 250 mg, 500 mg Antabuse

*Benzodiazepines & Tricyclic Agents*** chlordiazepoxide-amitriptyline oral tablet 10-25 mg, 5-12.5 mg

*Cholinomimetics - Ache Inhibitors***

donepezil hcl oral tablet 10 mg, 5 mg Aricept QLL (30 EA per 30 days); AL (Min 18 Years)

donepezil hcl oral tablet dispersible 10 mg, 5 mg


galantamine hydrobromide er oral capsule extended release 24 hour 16 mg, 24 mg, 8 mg Razadyne ER QLL (30 EA per 30 days); AL

(Min 18 Years) galantamine hydrobromide oral tablet 12 mg, 4 mg, 8 mg Razadyne QLL (60 EA per 30 days); AL

(Min 18 Years) rivastigmine tartrate oral capsule 1.5 mg, 3 mg, 4.5 mg, 6 mg


rivastigmine transdermal patch 24 hour 13.3 mg/24hr, 4.6 mg/24hr, 9.5 mg/24hr Exelon QLL (60 EA per 30 days); AL

(Min 18 Years)

*Fibromyalgia Agent - Snris*** SAVELLA ORAL TABLET 100 MG, 12.5 MG, 25 MG, 50 MG ST; QLL (60 EA per 30 days)

SAVELLA TITRATION PACK ORAL 12.5 & 25 & 50 MG ST; QLL (1 FILL per 90 days)

*Ms Agents - Pyrimidine Synthesis Inhibitors***

AUBAGIO ORAL TABLET 14 MG, 7 MG PA; QLL (30 EA per 30 days); AL (Min 18 Years)

*Multiple Sclerosis Agents -Interferons*** AVONEX PEN INTRAMUSCULAR AUTO-INJECTOR KIT 30 MCG/0.5ML PA; QLL (4 EA per 28 days)

AVONEX PREFILLED INTRAMUSCULAR PREFILLED SYRINGE KIT 30 MCG/0.5ML


89

Drug Name Reference Restrictions EXTAVIA SUBCUTANEOUS KIT 0.3 MG PA; AL (Min 18 Years) REBIF REBIDOSE SUBCUTANEOUS SOLUTION AUTO-INJECTOR 22 MCG/0.5ML, 44 MCG/0.5ML

PA

REBIF REBIDOSE TITRATION PACK SUBCUTANEOUS SOLUTION AUTO-INJECTOR 6X8.8 & 6X22 MCG

PA

REBIF SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 22 MCG/0.5ML, 44 MCG/0.5ML

PA

REBIF TITRATION PACK SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 6X8.8 & 6X22 MCG

PA

*Multiple Sclerosis Agents - Nrf2 Pathway Activators***

TECFIDERA ORAL 120 & 240 MG PA; QLL (1 STARTER PACK per 90 days)

TECFIDERA ORAL CAPSULE DELAYED RELEASE 120 MG, 240 MG PA; QLL (60 EA per 30 days)

*Multiple Sclerosis Agents*** glatiramer acetate subcutaneous solution prefilled syringe 40 mg/ml Copaxone PA

GLATOPA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 20 MG/ML

Glatiramer Acetate PA

*N-Methyl-D-Aspartate (Nmda) Receptor Antagonists*** memantine hcl oral solution 2 mg/ml AL (Min 18 Years) memantine hcl oral tablet 10 mg, 5 mg Namenda AL (Min 18 Years) memantine hcl oral tablet 28 x 5 mg & 21 x 10 mg Namenda Titration Pak AL (Min 18 Years)

*Phenothiazines & Tricyclic Agents*** perphenazine-amitriptyline oral tablet 2-10 mg, 2-25 mg, 4-10 mg, 4-25 mg, 4-50 mg No Copay; AL (Min 18 Years)

*Smoking Deterrents*** bupropion hcl er (smoking det) oral tablet extended release 12 hour 150 mg nicotine polacrilex mouth/throat gum 2 mg KLS Quit2 OTC nicotine polacrilex mouth/throat gum 4 mg KLS Quit4 OTC nicotine polacrilex mouth/throat lozenge 2 mg KLS Quit2 OTC

90

Drug Name Reference Restrictions nicotine polacrilex mouth/throat lozenge 4 mg KLS Quit4 OTC nicotine step 1 transdermal patch 24 hour 21 mg/24hr Nicoderm CQ OTC

nicotine step 2 transdermal patch 24 hour 14 mg/24hr Nicoderm CQ OTC

nicotine step 3 transdermal patch 24 hour 7 mg/24hr Nicoderm CQ OTC

nicotine transdermal kit 21-14-7 mg/24hr OTC CHANTIX ORAL TABLET 0.5 MG, 1 MG CHANTIX STARTING MONTH PAK ORAL TABLET 0.5 MG X 11 & 1 MG X 42 NICOTROL INHALATION INHALER 10 MG QLL (1 Inhaler per 30 days)

NICOTROL NS NASAL SOLUTION 10 MG/ML QLL (10 ML per 30 days)

*Sphingosine 1-Phosphate (S1p) Receptor Modulators*** GILENYA ORAL CAPSULE 0.5 MG PA; QLL (30 EA per 30 days)

*Thienbenzodiazepines & Ssris*** olanzapine-fluoxetine hcl oral capsule 12-25 mg No Copay; AL (Min 18 Years)

olanzapine-fluoxetine hcl oral capsule 12-50 mg, 3-25 mg, 6-25 mg, 6-50 mg Symbyax No Copay; AL (Min 18 Years)

*RESPIRATORY AGENTS -MISC.* *Hydrolytic Enzymes*** PULMOZYME INHALATION SOLUTION 1 MG/ML PA; QLL (5 ML per 1 day)

*SEROTONIN MODULATORS*** *Serotonin Modulators*** trazodone hcl oral tablet 100 mg, 50 mg QLL (6 EA per 1 day) trazodone hcl oral tablet 150 mg QLL (4 EA per 1 day)

*SINUS NODE INHIBITORS** *Sinus Node Inhibitors** CORLANOR ORAL TABLET 5 MG, 7.5 MG


91

Drug Name Reference Restrictions *SODIUM-GLUCOSE CO-TRANSPORTER 2 INHIBITOR-BIGUANIDE COMB*** *Sodium-Glucose Co-Transporter 2 Inhibitor-Biguanide Comb*** SEGLUROMET ORAL TABLET 2.5-1000 MG, 2.5-500 MG, 7.5-1000 MG, 7.5-500 MG

ST; No Copay; QLL (2 EA per 1 day)

*STEROIDS -MOUTH/THROAT/DENTAL*** *Steroids - Mouth/Throat/Dental*** triamcinolone acetonide mouth/throat paste 0.1 % Oralone

*SULFONAMIDES* *Sulfonamides*** sulfadiazine oral tablet 500 mg

*TETRACYCLINES* *Tetracyclines*** avidoxy oral tablet 100 mg demeclocycline hcl oral tablet 150 mg, 300 mg doxycycline hyclate oral tablet 20 mg doxycycline monohydrate oral capsule 50 mg doxycycline monohydrate oral suspension reconstituted 25 mg/5ml Vibramycin

doxycycline monohydrate oral tablet 100 mg, 150 mg, 50 mg, 75 mg minocycline hcl oral capsule 100 mg, 50 mg Minocin minocycline hcl oral capsule 75 mg

*THYROID AGENTS* *Antithyroid Agents*** methimazole oral tablet 10 mg, 5 mg Tapazole propylthiouracil oral tablet 50 mg

*Thyroid Hormones*** levothyroxine sodium oral tablet 100 mcg, 112 mcg, 125 mcg, 137 mcg, 150 mcg, 175 mcg, 200 mcg, 25 mcg, 50 mcg, 75 mcg, 88 mcg

Levoxyl

levothyroxine sodium oral tablet 300 mcg Unithroid liothyronine sodium oral tablet 25 mcg Cytomel liothyronine sodium oral tablet 5 mcg Cytomel QLL (4 EA per 1 day)

92

Drug Name Reference Restrictions liothyronine sodium oral tablet 50 mcg Cytomel QLL (2 EA per 1 day) np thyroid oral tablet 120 mg, 15 mg, 30 mg, 60 mg, 90 mg Armour Thyroid QLL (1 EA per 1 day)

ARMOUR THYROID ORAL TABLET 180 MG, 240 MG, 300 MG QLL (1 EA per 1 day)

LEVOXYL ORAL TABLET 100 MCG, 112 MCG, 125 MCG, 137 MCG, 150 MCG, 175 MCG, 200 MCG, 25 MCG, 50 MCG, 75 MCG, 88 MCG

Levothyroxine Sodium

UNITHROID ORAL TABLET 100 MCG, 112 MCG, 125 MCG, 150 MCG, 175 MCG, 200 MCG, 25 MCG, 300 MCG, 50 MCG, 75 MCG, 88 MCG

Levothyroxine Sodium

*TOXOIDS* *Toxoid Combinations*** ADACEL INTRAMUSCULAR SUSPENSION 5-2-15.5 LF-MCG/0.5 No Copay; AL (Min 19 Years)

TENIVAC INTRAMUSCULAR INJECTABLE 5-2 LFU No Copay; AL (Min 19 Years)

*ULCER DRUGS* *Antispasmodics*** dicyclomine hcl oral capsule 10 mg dicyclomine hcl oral solution 10 mg/5ml AL (Max 10 Years) dicyclomine hcl oral tablet 20 mg

*Belladonna Alkaloids*** ed-spaz oral tablet dispersible 0.125 mg NuLev hyoscyamine sulfate er oral tablet extended release 12 hour 0.375 mg Symax-SR

hyoscyamine sulfate oral elixir 0.125 mg/5ml hyoscyamine sulfate oral solution 0.125 mg/ml hyoscyamine sulfate oral tablet 0.125 mg Levsin hyoscyamine sulfate oral tablet dispersible 0.125 mg NuLev

hyoscyamine sulfate sublingual tablet sublingual 0.125 mg Symax-SL

hyosyne oral elixir 0.125 mg/5ml hyosyne oral solution 0.125 mg/ml oscimin oral tablet 0.125 mg Levsin oscimin oral tablet dispersible 0.125 mg NuLev oscimin sr oral tablet extended release 12 hour 0.375 mg Symax-SR

93

Drug Name Reference Restrictions oscimin sublingual tablet sublingual 0.125 mg Symax-SL NULEV ORAL TABLET DISPERSIBLE 0.125 MG Ed-Spaz

SYMAX-SL SUBLINGUAL TABLET SUBLINGUAL 0.125 MG Oscimin

SYMAX-SR ORAL TABLET EXTENDED RELEASE 12 HOUR 0.375 MG Hyoscyamine Sulfate ER

*H-2 Antagonists*** cimetidine hcl oral solution 300 mg/5ml cimetidine oral tablet 300 mg, 400 mg, 800 mg famotidine oral suspension reconstituted 40 mg/5ml AL (Max 10 Years)

famotidine oral tablet 20 mg, 40 mg Pepcid nizatidine oral capsule 150 mg, 300 mg nizatidine oral solution 15 mg/ml ranitidine hcl oral capsule 150 mg, 300 mg ranitidine hcl oral syrup 15 mg/ml, 150 mg/10ml, 75 mg/5ml ranitidine hcl oral tablet 300 mg

*Misc. Anti-Ulcer*** sucralfate oral suspension 1 gm/10ml Carafate AL (Max 10 Years) sucralfate oral tablet 1 gm Carafate CARAFATE ORAL SUSPENSION 1 GM/10ML Sucralfate AL (Max 10 Years)

*Proton Pump Inhibitors*** esomeprazole magnesium oral capsule delayed release 20 mg GoodSense Esomeprazole QLL (60 EA per 30 days)

kp omeprazole magnesium oral capsule delayed release 20.6 (20 base) mg OTC; QLL (2 EA per 1 day)

lansoprazole oral capsule delayed release 15 mg Prevacid QLL (60 EA per 30 days)

lansoprazole oral capsule delayed release 30 mg Prevacid QLL (30 EA per 30 days)

omeprazole oral capsule delayed release 20 mg QLL (60 EA per 30 Days)

omeprazole oral capsule delayed release 40 mg QLL (30 EA per 30 Days)

omeprazole oral tablet delayed release 20 mg OTC; QLL (60 EA per 30 days) pantoprazole sodium oral tablet delayed release 20 mg Protonix QLL (60 EA per 30 days)

94

Drug Name Reference Restrictions pantoprazole sodium oral tablet delayed release 40 mg Protonix QLL (30 EA per 30 days)

rabeprazole sodium oral tablet delayed release 20 mg Aciphex QLL (30 EA per 30 Days)

FIRST-LANSOPRAZOLE ORAL SUSPENSION 3 MG/ML AL (Max 10 Years)

FIRST-OMEPRAZOLE ORAL SUSPENSION 2 MG/ML AL (Max 10 Years)

OMEPRAZOLE+SYRSPEND SF ALKA ORAL SUSPENSION 2 MG/ML AL (Max 10 Years)

*Quaternary Anticholinergics*** glycopyrrolate injection solution 0.2 mg/ml, 0.4 mg/2ml, 1 mg/5ml, 4 mg/20ml glycopyrrolate oral tablet 1 mg, 2 mg propantheline bromide oral tablet 15 mg

*Ulcer Drugs - Prostaglandins*** misoprostol oral tablet 100 mcg, 200 mcg Cytotec

*URINARY ANTI-INFECTIVES* *Urinary Anti-Infectives*** methenamine hippurate oral tablet 1 gm Hiprex methenamine mandelate oral tablet 0.5 gm, 1 gm nitrofurantoin macrocrystal oral capsule 100 mg, 25 mg, 50 mg Macrodantin

nitrofurantoin monohyd macro oral capsule 100 mg Macrobid

nitrofurantoin oral suspension 25 mg/5ml AL (Max 10 Years)

*URINARY ANTISPASMODICS* *Urinary Antispasmodic -Antimuscarinics (Antichol)***(New) oxybutynin chloride er oral tablet extended release 24 hour 10 mg, 5 mg Ditropan XL

oxybutynin chloride er oral tablet extended release 24 hour 15 mg QLL (2 EA per 1 day)

oxybutynin chloride oral syrup 5 mg/5ml QLL (20 ML per 1 day) oxybutynin chloride oral tablet 5 mg QLL (4 EA per 1 day) tolterodine tartrate er oral capsule extended release 24 hour 2 mg, 4 mg Detrol LA ST; QLL (1 EA per 1 day)

tolterodine tartrate oral tablet 1 mg, 2 mg Detrol ST trospium chloride er oral capsule extended release 24 hour 60 mg ST; QLL (1 EA per 1 day)

95

Drug Name Reference Restrictions trospium chloride oral tablet 20 mg ST; QLL (2 EA per 1 day)

*Urinary Antispasmodics -Cholinergic Agonists*** (New) bethanechol chloride oral tablet 10 mg, 25 mg, 5 mg, 50 mg Urecholine

*Urinary Antispasmodics - Direct Muscle Relaxants*** (New) flavoxate hcl oral tablet 100 mg

*VACCINES* *Bacterial Vaccines*** MENACTRA INTRAMUSCULAR INJECTABLE No Copay; AL (Min 19 Years)

MENVEO INTRAMUSCULAR SOLUTION RECONSTITUTED No Copay; AL (Min 19 Years)

PNEUMOVAX 23 INJECTION INJECTABLE 25 MCG/0.5ML No Copay; AL (Min 19 Years)

*Viral Vaccines*** AFLURIA QUADRIVALENT INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE 0.5 ML

No Copay

ENGERIX-B INJECTION SUSPENSION 10 MCG/0.5ML, 20 MCG/ML No Copay; AL (Min 19 Years)

ENGERIX-B INTRAMUSCULAR INJECTABLE 10 MCG/0.5ML No Copay; AL (Min 19 Years)

FLUARIX QUADRIVALENT INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE 0.5 ML

No Copay

FLULAVAL QUADRIVALENT INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE 0.5 ML

No Copay

FLUZONE QUADRIVALENT INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE 0.5 ML

No Copay

GARDASIL 9 INTRAMUSCULAR SUSPENSION

No Copay; AL (Min 19 Years and Max 26 Years)

GARDASIL 9 INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE

No Copay; AL (Min 19 Years and Max 26 Years)

HAVRIX INTRAMUSCULAR SUSPENSION 1440 EL U/ML, 720 EL U/0.5ML

No Copay; AL (Min 19 Years)

HEPLISAV-B INTRAMUSCULAR SOLUTION PREFILLED SYRINGE 20 MCG/0.5ML


96

Drug Name Reference Restrictions RECOMBIVAX HB INJECTION SUSPENSION 10 MCG/ML, 40 MCG/ML, 5 MCG/0.5ML


VAQTA INTRAMUSCULAR SUSPENSION 25 UNIT/0.5ML, 50 UNIT/ML


VARIVAX SUBCUTANEOUS INJECTABLE 1350 PFU/0.5ML No Copay; AL (Min 19 Years)

ZOSTAVAX SUBCUTANEOUS SUSPENSION RECONSTITUTED 19400 UNT/0.65ML


*VAGINAL PRODUCTS* *Imidazole-Related Antifungals*** terconazole vaginal cream 0.4 % Terazol 7 terconazole vaginal cream 0.8 %

*Vaginal Anti-Infectives*** clindamycin phosphate vaginal cream 2 % Cleocin metronidazole vaginal gel 0.75 % Vandazole VANDAZOLE VAGINAL GEL 0.75 % MetroNIDAZOLE

*Vaginal Estrogens*** estradiol vaginal cream 0.1 mg/gm Estrace PA ESTRING VAGINAL RING 2 MG QLL (1 EA per 84 days) YUVAFEM VAGINAL TABLET 10 MCG Estradiol

*VASOPRESSORS* *Anaphylaxis Therapy Agents*** epinephrine injection solution auto-injector 0.15 mg/0.15ml Auvi-Q QLL (2 PENS per 30 days)

epinephrine injection solution auto-injector 0.15 mg/0.3ml EpiPen Jr 2-Pak QLL (2 PENS per 30 days)

epinephrine injection solution auto-injector 0.3 mg/0.3ml Auvi-Q QLL (2 PENS per 30 days)

*Vasopressors*** midodrine hcl oral tablet 10 mg, 2.5 mg, 5 mg No Copay

*VITAMINS* *Vitamin B-3*** niacin er oral tablet extended release 750 mg Endur-Acin OTC

*Vitamin B-6*** pyridoxine hcl injection solution 100 mg/ml

97

Drug Name Reference Restrictions *Vitamin D*** ergocal oral capsule 62.5 mcg (2500 ut) QLL (30 EA per 30 days) ergocalciferol oral capsule 1.25 mg (50000 ut) Drisdol vitamin d (ergocalciferol) oral capsule 1.25 mg (50000 ut) Drisdol

vitamin d3 oral tablet dispersible 125 mcg (5000 ut) OTC

*Vitamin K*** phytonadione oral tablet 5 mg Mephyton

98

Index Header

abacavir sulfate 39abacavir sulfate-lamivudine 36abacavir-lamivudine-zidovudine 36ABILIFY MAINTENA 35acarbose 20ACCU-CHEK AVIVA 68ACCU-CHEK COMPACT PLUS CONTROL 68ACCU-CHEK SMARTVIEW CONTROL 68ACCUTREND GLUCOSE CONTROL 68acebutolol hcl 41acetaminophen-codeine 7acetaminophen-codeine #2 7acetaminophen-codeine #3 7acetaminophen-codeine #4 7ACETASOL HC 86acetazolamide 58acetazolamide er 58acetic acid 86acetylcysteine 51acyclovir 40, 54ADACEL 93adapalene 52ADMELOG 20ADMELOG SOLOSTAR 20ADVANCE INTUITION CONTROL 68ADVANCE MICRO-DRAW CONTROL 68ADVANCE MICRO-DRAW NORMAL 68ADVOCATE CONTROL SOLUTION 68ADVOCATE REDI-CODE+ CONTROL 69AEROCHAMBER MINI CHAMBER 74AEROCHAMBER MV 74AEROCHAMBER PLUS FLO-VU 74AEROCHAMBER PLUS FLO-VU LARGE 74AEROCHAMBER PLUS FLO-VU MEDIUM 74AEROCHAMBER PLUS FLO-VU SMALL 74AEROCHAMBER PLUS FLO-VU W/MASK 74

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AEROCHAMBER PLUS FLOW VU 74AEROCHAMBER W/FLOWSIGNAL 74AEROCHAMBER Z-STAT PLUS 74AEROCHAMBER Z-STAT PLUS CHAMBR 74AEROCHAMBER Z-STAT PLUS/LARGE 74AEROCHAMBER Z-STAT PLUS/MEDIUM 74AEROCHAMBER Z-STAT PLUS/SMALL 74AFLURIA QUADRIVALENT 96AFTERA 48AGAMATRIX CONTROL 69ALAWAY 84ALAWAY CHILDRENS ALLERGY 84albendazole 11albuterol sulfate 13albuterol sulfate hfa 13alclometasone dipropionate 54alcohol prep 66alcohol swabs 66alcoh-wipe 66alendronate sodium 59alfuzosin hcl er 62allergy relief 24allopurinol 63alogliptin benzoate 20alogliptin-metformin hcl 20alogliptin-pioglitazone 20alprazolam 12alprazolam er 11alprazolam xr 12ALTAFRIN 84ALTAVERA 46alyacen 1/35 45alyacen 7/7/7 49amantadine hcl 32ambrisentan 44amcinonide 54AMETHIA LO 49amiloride hcl 58amiloride-hydrochlorothiazide 58amiodarone hcl 12amitriptyline hcl 19amlodipine besy-benazepril hcl 25amlodipine besylate 42

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amlodipine besylate-valsartan 27amlodipine-atorvastatin 44amoxapine 19amoxicillin 87amoxicillin-pot clavulanate 88amphetamine-dextroamphet er 3amphetamine- dextroamphetamine 3ampicillin 87anagrelide hcl 63anastrozole 31ANORO ELLIPTA 13APRI 46APRISO 62APTIVUS 38ap-zel 77AQUADEKS 78AQUAPHILIC 56ARANELLE 49ARCAPTA NEOHALER 13ARIAL CHAMBER 74ARISTADA 35armodafinil 3ARMOUR THYROID 93ARNUITY ELLIPTA 14arthritis pain relieving 57ASSURE 3 CONTROL 69ASSURE 4 CONTROL LEVEL 1 & 2 69ASSURE DOSE CONTROL 69ASSURE DOSE NORM/HIGH CONTROL 69ASSURE II CONTROL 69ASSURE II CONTROL LEVEL 1 & 2 69ASSURE PRO CONTROL LEVEL 1 & 2 69atazanavir sulfate 38atenolol 41atenolol-chlorthalidone 28atorvastatin calcium 25ATRIPLA 36atropine sulfate 83ATROVENT HFA 14AUBAGIO 89AUBRA 46AURYXIA 62AVANDIA 22AVIANE 46avidoxy 92AVONEX PEN 89

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99

AVONEX PREFILLED 89azathioprine 41azelastine hcl 82, 84azithromycin 66AZOPT 85AZURETTE 45bacitracin 84bacitracin-polymyxin b 84baclofen 81BACMIN 77balsalazide disodium 61BALZIVA 46BARACLUDE 40BASAGLAR KWIKPEN 20BD AUTOSHIELD 73BD AUTOSHIELD DUO 73BD PEN NEEDLE MICRO U/F 73BD PEN NEEDLE MINI U/F 73BD PEN NEEDLE NANO U/F 73BD PEN NEEDLE ORIGINAL U/F 73BD PEN NEEDLE SHORT U/F 73BD SWABS SINGLE USE BUTTERFLY 67benazepril hcl 26benazepril-hydrochlorothiazide 25benzonatate 51benztropine mesylate 32betamethasone dipropionate 54betamethasone dipropionate aug 54betamethasone valerate 54, 55betaxolol hcl 83bethanechol chloride 96bexarotene 32bicalutamide 29BIKTARVY 36biocel 77bisoprolol fumarate 41bisoprolol-hydrochlorothiazide 28bosentan 44bp wash 52b-plex plus 77BREATHERITE COLL SPACER ADULT 74BREATHERITE COLL SPACER CHILD 74BREATHERITE COLL SPACER INFANT 74

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BREATHERITE RIGID SPACER/MASK 74BREATHERITE SPACER NEONATE 74BREATHERITE SPACER SMALL CHILD 74BREATHERITE VALVED MDI CHAMBER 73BREO ELLIPTA 13briellyn 45brimonidine tartrate 85bromocriptine mesylate 32brompheniramine tannate 24budesonide 14, 82bumetanide 58buprenorphine hcl 9buprenorphine hcl-naloxone hcl 10bupropion hcl 18bupropion hcl er (smoking det) 90bupropion hcl er (sr) 17, 18bupropion hcl er (xl) 18buspirone hcl 11butalbital-acetaminophen 7butalbital-apap-caff-cod 7butalbital-apap-caffeine 7butalbital-asa-caff-codeine 7butalbital-asa-caffeine 7butenafine hcl 53cabergoline 59CABOMETYX 30caffeine citrate 3calcipotriene 54calcitonin (salmon) 59calcitriol 59calcium acetate (phos binder) 62CALPHRON 62candesartan cilexetil 27candesartan cilexetil-hctz 27capecitabine 30capsaicin 57capsaicin hp 57CARAFATE 94carbamazepine 16carbamazepine er 16carbidopa-levodopa 32carbidopa-levodopa er 32carbidopa-levodopa-entacapone 32carbinoxamine maleate 24CARESENS CONTROL A 69carisoprodol 81carisoprodol-aspirin 82carisoprodol-aspirin-codeine 82

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carteolol hcl 83carvedilol 41CAZIANT 49cefaclor 44cefadroxil 44cefdinir 45cefixime 45cefpodoxime proxetil 45cefprozil 45ceftriaxone sodium 45cefuroxime axetil 45celecoxib 5cephalexin 44cetirizine hcl 24CHANTIX 91CHANTIX STARTING MONTH PAK 91CHATEAL 46CHEMET 23chlordiazepoxide hcl 12chlordiazepoxide-amitriptyline 89chlorhexidine gluconate 36, 77chloroquine phosphate 29chlorothiazide 59chlorthalidone 59chlorzoxazone 81cholestyramine 24cholestyramine light 24choline-mag trisalicylate 7ciclopirox 53ciclopirox olamine 53cilostazol 63CIMDUO 36cimetidine 94cimetidine hcl 94ciprofloxacin hcl 61, 84, 86citalopram hydrobromide 18clarithromycin 66clarithromycin er 66classic prenatal 79clemastine fumarate 24CLEVER CHOICE GLUCOSE CONTROL 69CLINDACIN-P 52clindamycin hcl 29clindamycin palmitate hcl 29clindamycin phosphate 52, 97clobetasol prop emollient base 55clobetasol propionate 55clonazepam 15clonidine 27clonidine hcl 27

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100

clopidogrel bisulfate 64clotrimazole 56, 77clotrimazole anti-fungal 56clotrimazole-betamethasone 53clozapine 34codeine sulfate 8colchicine 63colchicine-probenecid 63colesevelam hcl 24colestipol hcl 24COMBIGAN 83COMBIPATCH 60COMBIVENT RESPIMAT 13COMPACT SPACE CHAMBER 74COMPACT SPACE CHAMBER/LG MASK 74COMPACT SPACE CHAMBER/MED MASK 74COMPACT SPACE CHAMBER/SM MASK 74COMPLERA 36completenate 79COMPRO 35CO-NATAL FA 80CONCEPT OB 80condoms 67constulose 66control 68CORLANOR 91cortisone acetate 50CORVITE FREE 77CREON 58CRIXIVAN 38cromolyn sodium 13, 84CRYSELLE-28 46cyanocobalamin 64CYCLAFEM 1/35 46CYCLAFEM 7/7/7 50cyclobenzaprine hcl 81cyclopentolate hcl 83cyclosporine 41cyclosporine modified 41cyproheptadine hcl 24cytra k crystals 62danazol 10dantrolene sodium 81dapsone 28DARAPRIM 29DASETTA 1/35 46DASETTA 7/7/7 50demeclocycline hcl 92

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DESCOVY 36desmopressin ace spray refrig 60desmopressin acetate 60desmopressin acetate spray 60dexamethasone 50dexamethasone sodium phosphate 85dexmethylphenidate hcl 3dexmethylphenidate hcl er 3dextroamphetamine sulfate 3dextroamphetamine sulfate er 3diatrue control level 1 68diatrue control level 2 68diatrue control level 3 68diazepam 12, 15DIAZEPAM INTENSOL 12diclofenac potassium 6diclofenac sodium 6, 53, 85diclofenac sodium er 6dicloxacillin sodium 88dicyclomine hcl 93didanosine 39DIFFERIN 53diflunisal 7DIGOX 43digoxin 43DILANTIN 17diltiazem hcl 43diltiazem hcl er 43diltiazem hcl er beads 42diltiazem hcl er coated beads 42dilt-xr 43diphenhydramine hcl 24diphenoxylate-atropine 22dipyridamole 63disopyramide phosphate 12disulfiram 89divalproex sodium 17divalproex sodium er 17docosanol 54donepezil hcl 89dorzolamide hcl 85dorzolamide hcl-timolol mal 83doxazosin mesylate 28doxepin hcl 19doxycycline hyclate 92doxycycline monohydrate 92drospirenone-ethinyl estradiol 45duloxetine hcl 19DUO-CARE CONTROL SOLUTION 69DUREX EXTRA SENSITIVE 67

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ear drops earwax aid 86ear wax removal drops 86ear wax removal kit 86earwax removal kit 86earwax treatment drops 86easy plus ii control 68EASY STEP CONTROL 69easy talk control 68EASY TOUCH CONTROL HIGH & LOW 69EASY TOUCH HEALTHPRO CONTROL 69easy trak control 68EASYGLUCO CONTROL 69EASYMAX 15 LEVEL 1 CONTROL 70EASYMAX 15 LEVEL 2 CONTROL 70EASYMAX CONTROL 70ECONTRA EZ 48ed-spaz 93EDURANT 39efavirenz 38element compact control 2 68element compact control 3 68ELEMENT CONTROL 70ELIGARD 31ELINEST 46ELIQUIS 15ELLA 48ELMIRON 63EMBRACE CONTROL 70EMEND 23EMOQUETTE 46EMTRIVA 39enalapril maleate 26enalapril-hydrochlorothiazide 26ENBREL 7ENBREL MINI 6ENBREL SURECLICK 7ENFAMIL EXPECTA 81ENGERIX-B 96enoxaparin sodium 15ENPRESSE-28 50ENSKYCE 46entacapone 33entecavir 40ENTRESTO 83enulose 62epinephrine 97EPIVIR HBV 40EPOGEN 64

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101

epoprostenol sodium 44eql prenatal formula 79ergocal 98ergocalciferol 98erlotinib hcl 30ery 52erythromycin 52, 84erythromycin ethylsuccinate 66escitalopram oxalate 18esomeprazole magnesium 94ESTARYLLA 46estazolam 65estradiol 61, 97estradiol-norethindrone acet 60ESTRING 97ethambutol hcl 29ethosuximide 17etidronate disodium 59etodolac 6etodolac er 6etoposide 31EVENCARE CONTROL LOW/HIGH 70EVENCARE G2 LOW/HIGH CONTROL 70EVENCARE G3 LOW/HIGH CONTROL 70EVOLUTION CONTROL 70EVOTAZ 37exemestane 31EXTAVIA 90ezetimibe 25FALMINA 46famciclovir 40famotidine 94FC FEMALE CONDOM 67FC2 FEMALE CONDOM 67febuxostat 63felbamate 16felodipine er 43FEMHRT LOW DOSE 60fenofibrate 24fenofibrate micronized 24fentanyl 8fentanyl citrate 8finasteride 62FIRMAGON 31FIRST-LANSOPRAZOLE 95FIRST-OMEPRAZOLE 95FIRVANQ 63flavoxate hcl 96FLEBOGAMMA DIF 86

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flecainide acetate 12FLEET ENEMA 66FLEET PEDIATRIC 66FLEXICHAMBER 75FLEXICHAMBER ADULT MASK/SMALL 74FLEXICHAMBER CHILD MASK/LARGE 75FLEXICHAMBER CHILD MASK/SMALL 75FLONASE ALLERGY RELIEF 82FLOVENT HFA 14floxuridine 30FLUARIX QUADRIVALENT 96fluconazole 23fludrocortisone acetate 51FLULAVAL QUADRIVALENT 96flunisolide 82fluocinolone acetonide 55fluocinonide 55FLUORABON 76fluoritab 76fluorometholone 85fluorouracil 54fluoxetine hcl 18fluphenazine decanoate 34fluphenazine hcl 35flurazepam hcl 65flurbiprofen 6flurbiprofen sodium 85flutamide 29fluticasone propionate 55, 82fluticasone-salmeterol 13fluvastatin sodium 25fluvastatin sodium er 25fluvoxamine maleate 18FLUZONE QUADRIVALENT 96FOLIVANE-OB 80FORA CONTROL 70FORACARE GDH CONTROL 70FORTAVIT 77fosamprenavir calcium 38fosinopril sodium 26fosinopril sodium-hctz 26FREESTYLE CONTROL SOLUTION 70FULPHILA 64furosemide 58

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FUZEON 37gabapentin 16GABITRIL 17galantamine hydrobromide 89galantamine hydrobromide er 89GAMMAGARD 87GAMMAKED 87GAMUNEX-C 87GARDASIL 9 96ge100 control 68GEL-ONE 82gemfibrozil 25generlac 62GENTAK 84gentamicin sulfate 53, 84GENVOYA 37GIANVI 46GILENYA 91glatiramer acetate 90GLATOPA 90glimepiride 22glipizide 22glipizide er 22glipizide-metformin hcl 22GLUCAGEN HYPOKIT 20GLUCOCARD 01 CONTROL 70GLUCOCARD EXPRESSION CONTROL 70GLUCOCARD X-SENSOR CONTROL 70GLUCOCOM CONTROL 70glucose control 68glyburide 22glyburide micronized 22glyburide-metformin 22glycopyrrolate 95gnp 24 hour nasal allergy 82gnp budesonide nasal spray 82gnp ear systems 86gnp lidocaine pain relief 57gnp prenatal 79gnp sleep aid 65goodsense nasal allergy spray 82goodsense prenatal vitamins 79granisetron hcl 23griseofulvin microsize 23griseofulvin ultramicrosize 23guanfacine hcl 27guanfacine hcl er 3halobetasol propionate 55haloperidol 34

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102

haloperidol decanoate 34haloperidol lactate 34HAVRIX 96HEALTHYLAX 66HEPAGAM B 87heparin sodium (porcine) 15heparin sodium (porcine) pf 15HEPLISAV-B 96hm earwax removal aid 86hm earwax removal kit 86hm prenatal 79hm sterile alcohol prep 66HOMATROPAIRE 84homatropine hbr 83HUMALOG MIX 50/50 21HUMALOG MIX 50/50 KWIKPEN 21HUMALOG MIX 75/25 21HUMALOG MIX 75/25 KWIKPEN 21HUMIRA 5HUMIRA PEDIATRIC CROHNS START 5HUMIRA PEN 5HUMIRA PEN-CD/UC/HS STARTER 5HUMIRA PEN-PS/UV/ADOL HS START 5HUMULIN 70/30 21HUMULIN R 21HUMULIN R U-500 (CONCENTRATED) 21HYALGAN 82hydralazine hcl 28hydrochlorothiazide 59hydrocodone-acetaminophen 8hydrocodone-homatropine 51hydrocodone-ibuprofen 8hydrocortisone 10, 50, 55hydrocortisone-acetic acid 86hydrocortisone-iodoquinol 53hydromet 51hydromorphone hcl 8hydromorphone hcl pf 8hydroxychloroquine sulfate 29hydroxyprogesterone caproate

31, 88hydroxyurea 30hydroxyzine hcl 11hydroxyzine pamoate 11hyoscyamine sulfate 93hyoscyamine sulfate er 93

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hyosyne 93HYPERHEP B S/D 87HYPERRHO S/D 87ibandronate sodium 59ibuprofen 6imatinib mesylate 30IMBRUVICA 30imipramine hcl 19imiquimod 56INATAL GT 80INCRUSE ELLIPTA 14indapamide 59indomethacin 6indomethacin er 6INFINITY CONTROL 71INSPIRACHAMBER/LARG E 75INSPIRACHAMBER/MEDIU M 75INSPIRACHAMBER/MOUT HPIECE 75INSPIRACHAMBER/SMAL L 75INTELENCE 39INTROVALE 49INVIRASE 38ipratropium bromide 14, 82ipratropium-albuterol 13irbesartan 27irbesartan-hydrochlorothiazide 27ISENTRESS 37, 38ISENTRESS HD 37isoniazid 29isosorbide dinitrate 11isosorbide dinitrate er 11isosorbide mononitrate 11isosorbide mononitrate er 11isradipine 43itraconazole 23ivermectin 11JANTOVEN 15JANUMET 20JANUMET XR 20JANUVIA 20JARDIANCE 22JINTELI 60JOLESSA 49JULUCA 37JUNEL 1.5/30 46JUNEL 1/20 46JUNEL FE 1.5/30 46JUNEL FE 1/20 46

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KALETRA 37KARIVA 45KELNOR 1/35 46ketoconazole 23, 56ketorolac tromethamine 6, 85ketotifen fumarate 84kimono 67KITABIS PAK 4KLOR-CON M15 77kp omeprazole magnesium 94kp prenatal multivitamins 79K-PHOS 76K-PHOS NO 2 63KURVELO 46KYLEENA 49labetalol hcl 41lactulose 66lactulose encephalopathy 62lamivudine 39, 40lamivudine-zidovudine 36lamotrigine 16LANOXIN 44lansoprazole 94LARIN 1.5/30 46LARIN 1/20 47LARIN FE 1.5/30 47LARIN FE 1/20 47latanoprost 86LEENA 50leflunomide 6LESSINA 47letrozole 31leucovorin calcium 31LEUKERAN 31leuprolide acetate 31levalbuterol tartrate 13levetiracetam 16levetiracetam er 16levobunolol hcl 83levocarnitine 59levofloxacin 61, 84LEVONEST 50levonorgest-eth estrad 91-day 49levonorgestrel 48levonorgestrel-ethinyl estrad 45LEVORA 0.15/30 (28) 47levothyroxine sodium 92LEVOXYL 93LEXIVA 38LIBERTY GLUCOSE CONTROL 71

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103

LIBERTY GLUCOSE CONTROL MID 71lice treatment 57lidocaine 57lidocaine hcl 57, 77lidocaine-hydrocortisone ace 10lidocaine-prilocaine 57LIFESTYLES ASSORTED COLORS 67LIFESTYLES EXTRA STRENGTH 67LIFESTYLES FORM FITTING 67LIFESTYLES LUBRICATED 67LIFESTYLES RIBBED 67LIFESTYLES SKYN ORIGINAL 67LIFESTYLES SPERMICIDAL LUBE 67LIFESTYLES STUDDED 67LIFESTYLES ULTRA SENSITIVE 67LIFESTYLES VIBRA-RIBBED 67LIFESTYLES XTRA PLEASURE 67LINZESS 61liothyronine sodium 92, 93lisinopril 26lisinopril-hydrochlorothiazide 26lithium 33lithium carbonate 33lithium carbonate er 33loperamide hcl 22lopinavir-ritonavir 36loradamed 24loratadine childrens 24lorazepam 12LORAZEPAM INTENSOL 12LORYNA 47losartan potassium 27losartan potassium-hctz 27lovastatin 25LOW-OGESTREL 47loxapine succinate 34LUTERA 47LYSIPLEX PLUS 77MAKENA 89malathion 57maprotiline hcl 18marlissa 45

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MATULANE 30MAVYRET 65maxx 67MEDISENSE GLUCOSE KETONE CONTR 71MEDISENSE HI/MID/LOW CONTROL 71MEDISENSE HIGH/LOW CONTROL 71MEDISENSE MID CONTROL 71medroxyprogesterone acetate

49, 88mefloquine hcl 29megestrol acetate 31, 88melatonin 4melatonin maximum strength 4meloxicam 6melphalan 31memantine hcl 90MENACTRA 96MENEST 61MENVEO 96mercaptopurine 30mesalamine 61, 62MESNEX 32METADATE ER 4metaproterenol sulfate 13metformin hcl 20metformin hcl er 20methadone hcl 8methazolamide 58methenamine hippurate 95methenamine mandelate 95methimazole 92methocarbamol 81methotrexate 30methoxsalen rapid 54methyldopa 27methyldopa-hydrochlorothiazide 26methylphenidate hcl 4methylphenidate hcl er 4methylphenidate hcl er (cd) 3methylphenidate hcl er (la) 3, 4methylprednisolone 51metoclopramide hcl 61metolazone 59metoprolol succinate er 42metoprolol tartrate 42metoprolol-hydrochlorothiazide 28metronidazole 28, 57, 97

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mexiletine hcl 12MICRHOGAM ULTRA-FILTERED PLUS 87MICROCHAMBER 75MICRODOT CONTROL HIGH/LOW 71MICROGESTIN 1.5/30 47MICROGESTIN 1/20 47MICROGESTIN FE 1.5/30 47MICROGESTIN FE 1/20 47MICROSPACER 75midodrine hcl 97minocycline hcl 92minoxidil 28MIRENA (52 MG) 49mirtazapine 17misoprostol 95m-natal plus 79mometasone furoate 55MONO-LINYAH 47MONONESSA 47montelukast sodium 14morphine sulfate 9morphine sulfate (concentrate) 8morphine sulfate er 9MOVANTIK 62MULTAQ 12multi prenatal 79multivitamin drops/iron 78multivitamin/fluoride 78mupirocin 53MVC-FLUORIDE 78M-VIT 80MY CHOICE 48MY WAY 48mycophenolate mofetil 41MYGLUCOHEALTH CONTROL 71MYLERAN 29MYORISAN 53NABI-HB 87nabumetone 6naloxone hcl 23naltrexone hcl 23naproxen 6naproxen dr 6naproxen sodium 6naratriptan hcl 75NARCAN 23nateglinide 22NEBUSAL 51NECON 1/35 (28) 47

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104

neomycin sulfate 4neomycin-bacitracin zn-polymyx 84neomycin-polymyxin-dexameth 85neomycin-polymyxin-gramicidin 84neomycin-polymyxin-hc 86NEONATAL PLUS 80NEONATAL VITAMIN 80NEO-POLYCIN 85neutral sodium fluoride 77nevirapine 39nevirapine er 38, 39NEW DAY 48niacin er 97nicardipine hcl 43NICAZEL 78NICAZEL FORTE 78nicotine 91nicotine polacrilex 90, 91nicotine step 1 91nicotine step 2 91nicotine step 3 91NICOTROL 91NICOTROL NS 91nifedipine 43nifedipine er 43nifedipine er osmotic release 43nilutamide 29nimodipine 43NITRO-BID 11nitrofurantoin 95nitrofurantoin macrocrystal 95nitrofurantoin monohyd macro 95nitroglycerin 11nitroglycerin er 11NIVA-PLUS 80NIVESTYM 64nizatidine 94norethindrone 49norethindrone acetate 88norgestimate-eth estradiol 45norgestim-eth estrad triphasic 49NORTREL 1/35 (21) 47NORTREL 7/7/7 50nortriptyline hcl 19, 20NORVIR 38NOVA MAX PLUS GLU/KET CONTROL 71NOVOLIN 70/30 21NOVOLIN 70/30 RELION 21NOVOLIN N 21NOVOLIN N RELION 21

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NOVOLIN R 21NOVOLIN R RELION 21NOVOLOG MIX 70/30 21NOVOLOG MIX 70/30 FLEXPEN 21np thyroid 93NULEV 94NUTRICAP 78NUTRIFAC ZX 78NUVARING 48nystatin 23, 53, 77O-CAL FA 80OCELLA 47octreotide acetate 60OFF DEEP WOODS 56OFF DEEP WOODS DRY 56OFF DEEP WOODS SPORTSMEN 56OFF FAMILYCARE CLEAN FEEL 56OFF SMOOTH & DRY 56ofloxacin 84, 86OGESTREL 47olanzapine 36olanzapine-fluoxetine hcl 91olopatadine hcl 84omega-3-acid ethyl esters 24omeprazole 94OMEPRAZOLE+SYRSPEN D SF ALKA 95OMNIFLEX DIAPHRAGM 67OMNITROPE 59ON CALL EXPRESS GLUCOSE CONTR 71ON CALL PLUS GLUCOSE CONTROL 71ON CALL VIVID GLUCOSE CONTROL 71ondansetron 23ondansetron hcl 23ONETOUCH ULTRA 2 71ONETOUCH ULTRA BLUE 58ONETOUCH ULTRA CONTROL 71ONETOUCH ULTRA MINI 71ONETOUCH ULTRALINK 71ONETOUCH VERIO 58, 72ONETOUCH VERIO FLEX SYSTEM 71ONETOUCH VERIO IQ SYSTEM 71

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ONETOUCH VERIO SYNC SYSTEM 72OPCICON ONE-STEP 49OPSUMIT 44OPTICHAMBER ADVANTAGE-LG MASK 75OPTICHAMBER ADVANTAGE-MED MASK 75OPTICHAMBER ADVANTAGE-SM MASK 75OPTICHAMBER DIAMOND 75OPTICHAMBER DIAMOND-LG MASK 75OPTICHAMBER DIAMOND-MD MASK 75OPTICHAMBER DIAMOND-SM MASK 75OPTICHAMBER FACE MASK-LARGE 75OPTICHAMBER FACE MASK-MEDIUM 75OPTICHAMBER FACE MASK-SMALL 75OPTION 2 49OPTUMRX GLUCOSE CONTROL 72orphenadrine citrate er 81ORSYTHIA 47oscimin 93, 94oscimin sr 93oseltamivir phosphate 41oxazepam 12oxcarbazepine 16oxybutynin chloride 95oxybutynin chloride er 95oxycodone hcl 9oxycodone-acetaminophen 9oxycodone-aspirin 9oxymorphone hcl er 9OZEMPIC (0.25 OR 0.5 MG/DOSE) 21OZEMPIC (1 MG/DOSE) 21pain relieving 57pantoprazole sodium 94, 95PARAGARD INTRAUTERINE COPPER 48paricalcitol 59paromomycin sulfate 4paroxetine hcl 18pediatric electrolyte 76peg 3350/electrolytes 65peg 3350-kcl-na bicarb-nacl 65

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peg-3350/electrolytes 66PEGASYS 40PEGASYS PROCLICK 40penicillin v potassium 87pentazocine-naloxone hcl 10pentoxifylline er 63perindopril erbumine 26permethrin 57perphenazine 35perphenazine-amitriptyline 90phenazopyridine hcl 63phenelzine sulfate 18phenobarbital 65phenylephrine hcl 84phenytoin 17phenytoin sodium extended 17PHILITH 47phytonadione 98pilocarpine hcl 77, 84PIMTREA 45pioglitazone hcl 22PIRMELLA 1/35 47PIRMELLA 7/7/7 50piroxicam 6PNEUMOVAX 23 96pnv folic acid + iron 79pnv prenatal plus multivitamin 79pnv tabs 29-1 79POCKET CHAMBER 75POCKET SPACER 75POCKETCHEM EZ CONTROL 72podofilox 56POLYCIN 85polymyxin b-trimethoprim 84POLY-VI-SOL/IRON 78PORTIA-28 47pot bicarb-pot chloride 76potassium bicarbonate 76potassium chloride crys er 76, 77potassium chloride er 77potassium citrate er 62, 63pramipexole dihydrochloride 33prasugrel hcl 64pravastatin sodium 25praziquantel 11prazosin hcl 28PRECISION GLUCOSE CONTROL 72PRECISION GLUCOSE CONTROL SOLN 72

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PRECISION GLUCOSE KETONE CONTR 72PRECISION GLUCOSE/KETONE CONTR 72prednicarbate 55prednisolone 51prednisolone acetate 85prednisolone sodium phosphate

51, 85prednisone 51PREFEST 60PRENATABS RX 80prenatal 79prenatal 19 79prenatal low iron 79PRENATAL MULTIVITAMIN + DHA 81prenatal one daily 79prenatal plus 79prenatal plus iron 79prenatal plus/iron 79prenatal vitamin 79prenatal vitamin and mineral 79prenatal vitamin plus low iron 79prenatal vitamins 80PRENATAL/FOLIC ACID 80prenatal/iron 80PRENATAL-U 81preplus 80pretab 80PREVIFEM 48PREZISTA 38PRIFTIN 29primaquine phosphate 29PRIMEAIRE HOLDING CHAMBER 73primidone 16probenecid 63procainamide hcl 12prochlorperazine 35prochlorperazine maleate 35PROCTOFOAM HC 10PROCTO-PAK 10PROCTOSOL HC 10PROCTOZONE-HC 10PRODIGY CONTROL SOLUTION 72progesterone micronized 88PROMACTA 65promethazine hcl 24promethazine vc/codeine 52

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promethazine-codeine 52promethazine-dm 52propafenone hcl 12propafenone hcl er 12propantheline bromide 95propranolol hcl 42propranolol hcl er 42propranolol-hctz 28propylthiouracil 92PROVIDA OB 81PULMOZYME 91px prenatal multivitamins 80pyrazinamide 29pyridostigmine bromide 29pyridoxine hcl 97qc calcium/minerals/vitamin d 76qc lidocaine pain relief 57qc prenatal 80quetiapine fumarate 34QUICKTEK CONTROL SOLUTION 72quinapril hcl 26quinapril-hydrochlorothiazide 26quinidine sulfate 12QUINTET CONTROL HIGH/NORMAL 72QVAR REDIHALER 14ra lice treatment 57ra prenatal 80ra prenatal formula 80rabeprazole sodium 95raloxifene hcl 60ramelteon 65ramipril 26ranitidine hcl 94REACT 49REALITY LATEX CONDOMS 67REBIF 90REBIF REBIDOSE 90REBIF REBIDOSE TITRATION PACK 90REBIF TITRATION PACK 90RECLIPSEN 48RECOMBIVAX HB 97RECTIV 10reeses pinworm medicine 11REFRESH LIQUIGEL 83REFRESH TEARS 83REFUAH PLUS GLUCOSE CONTROL 72repaglinide 22

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repaglinide-metformin hcl 22REQ 49+ 78RESCRIPTOR 39RETACRIT 64REYATAZ 38RHOGAM ULTRA-FILTERED PLUS 87RHOPHYLAC 87ribavirin 40RIDAURA 5rifabutin 29rifampin 29RIGHT STEP PRENATAL 81RIGHTEST GC300 CONTROL 72riluzole 83rimantadine hcl 40risperidone 33, 34ritonavir 38rivastigmine 89rivastigmine tartrate 89rizatriptan benzoate 75ropinirole hcl 33ropinirole hcl er 33rosuvastatin calcium 25RYDEX 52salicylic acid 56salsalate 7SANDOSTATIN LAR DEPOT 60SANTYL 56SAVELLA 89SAVELLA TITRATION PACK 89SAWYER INSECT REPELLENT 56SEGLUROMET 92selegiline hcl 32selenium sulfide 54SELZENTRY 37se-natal 19 80sertraline hcl 18, 19sevelamer carbonate 62SIDEROL 78sildenafil citrate 44silver sulfadiazine 54simvastatin 25sirolimus 41SKYLA 49sm ear drops 86sm lice treatment 57sm melatonin 4

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sm prenatal vitamins 80SMARTEST CONTROL MEDIUM 72sodium chloride 51sodium fluoride 76sodium polystyrene sulfonate 41, 88SOLARTEK GLUCOSE CONTROL 72SOLTAMOX 30SOLUS V2 CONTROL 72SOMATULINE DEPOT 60sorbitol 88sotalol hcl 42sotalol hcl (af) 42spinosad 57spironolactone 59spironolactone-hctz 58SPRINTEC 28 48SPRYCEL 30SRONYX 48stavudine 39STEGLATRO 22STIOLTO RESPIMAT 13STRIBILD 37STRIVERDI RESPIMAT 13STROVITE FORTE 78STROVITE ONE 78sucralfate 94SUDOGEST 82sulfacetamide sodium 54, 86sulfacetamide sodium (acne) 52sulfacetamide-prednisolone 85sulfadiazine 92sulfamethoxazole-trimethoprim 28sulfasalazine 62sulindac 6sumatriptan 76sumatriptan succinate 76sumatriptan succinate refill 76supreme ii high/low control 68sure comfort alcohol prep 67SURESTEP GLUCOSE CONTROL 72SURESTEP PRO HIGH GLUCOSE 72SURESTEP PRO LOW GLUCOSE 72SURESTEP PRO NORMAL GLUCOSE 73SUTENT 30SYEDA 48SYMAX-SL 94

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SYMAX-SR 94SYMFI 37SYMFI LO 37SYMTUZA 37syrpalta 88TABLOID 30tacrolimus 41, 57tadalafil (pah) 44TAI DOC CONTROL 73TAKE ACTION 49tamoxifen citrate 29tamsulosin hcl 62TARGRETIN 57TARON-C DHA 81TASIGNA 30tazarotene 54TECFIDERA 90TELCARE GLUCOSE CONTROL 73telmisartan 27temazepam 65temozolomide 31TENIVAC 93tenofovir disoproxil fumarate 40terazosin hcl 28terbinafine hcl 23terconazole 97testosterone 10testosterone cypionate 10testosterone enanthate 10theophylline 15theophylline er 14, 15THERANATAL CORE NUTRITION 81thioridazine hcl 35thiothixene 36thrivite 19 80thrivite rx 80tiagabine hcl 16, 17TILIA FE 50timolol maleate 42, 83TIVICAY 38tizanidine hcl 81tobramycin 4, 84tolmetin sodium 6tolterodine tartrate 95tolterodine tartrate er 95topiramate 16toremifene citrate 30torsemide 58TRACLEER 44tramadol hcl 9

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tramadol-acetaminophen 10trandolapril 26trazodone hcl 18, 91TRELSTAR MIXJECT 31tretinoin 31, 52, 53triamcinolone acetonide

55, 56, 77, 82, 92triamterene-hctz 58TRICARE 81TRI-ESTARYLLA 50trifluoperazine hcl 35trifluridine 85trihexyphenidyl hcl 32TRI-LEGEST FE 50TRI-LINYAH 50trimethoprim 28trinatal rx 1 80TRINATE 81TRINESSA (28) 50TRI-PREVIFEM 50TRI-SPRINTEC 50TRIUMEQ 37tri-vitamin/fluoride 78TRIVORA (28) 50tropicamide 84trospium chloride 96trospium chloride er 95true comfort alcohol prep pads 67TRUVADA 37TYBOST 36TYKERB 30TYMLOS 60UDENYCA 64ULTRATHON INSECT REPELLENT 8 56ULTRATRAK PRO CONTROL 73ULTRATRAK ULTIMATE CONTROL 73UNISTRIP CONTROL 73UNITHROID 93urosex 81ursodiol 61valacyclovir hcl 40valganciclovir hcl 40valproic acid 17valsartan 27valsartan-hydrochlorothiazide 27valved holding chamber 73VANDAZOLE 97VANTAS 31VAQTA 97

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VARIVAX 97v-c forte 77VELIVET 50VEMLIDY 40venlafaxine hcl 19venlafaxine hcl er 19VENTOLIN HFA 14verapamil hcl 43verapamil hcl er 43VERZENIO 52VIC-FORTE 78VICTORY CONTROL LEVEL 1/2 73VICTOZA 22VIDEX 39VINATE II 81VINATE M 81VINATE ONE 81VIOKACE 58viorele 45VIRACEPT 38VIREAD 40VITA S FORTE 78VITACEL 78vitamin d (ergocalciferol) 98vitamin d3 98vitamins acd-fluoride 78VITAROCA PLUS 78VIVITROL 23vol-nate 80vol-plus 80vol-tab rx 80VORTEX HOLDING CHAMBER/MASK 73VORTEX VALVED HOLDING CHAMBER 75VOTRIENT 30VYFEMLA 48warfarin sodium 15WIDE-SEAL DIAPHRAGM 60 67WIDE-SEAL DIAPHRAGM 65 67WIDE-SEAL DIAPHRAGM 70 67WIDE-SEAL DIAPHRAGM 75 67WIDE-SEAL DIAPHRAGM 80 67WIDE-SEAL DIAPHRAGM 85 68

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WIDE-SEAL DIAPHRAGM 90 68WIDE-SEAL DIAPHRAGM 95 68XARELTO 15XARELTO STARTER PACK 15XULANE 48YUVAFEM 97zafirlukast 14zaleplon 65ZARAH 48ZARXIO 65ZENATANE 53ZENPEP 58ZENZEDI 3zidovudine 39, 40ziprasidone hcl 33ZOLADEX 31zolpidem tartrate 65zonisamide 16ZOSTAVAX 97ZOVIA 1/35E (28) 48

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Aetna Better Health Pennsylvania And Aetna Better Health ... · m/pennsylvania PA‐10‐03‐03A AETNA BETTER HEALTH® Formulary Guide – 2019 • Drugs and devices classified as