MICHILD CHILDREN S SPECIAL HEALTH CARE SERVICES (CSHCS) FORMULARY Effective October 2015

Transcription

1 MICHILD CHILDREN S SPECIAL HEALTH CARE SERVICES (CSHCS) FORMULARY Effective October 2015 Provided by EnvisionRxOptions Introduction The Total Health Care (THC) MIChild Children s Special Health Care Services (CSHCS) Formulary was developed to serve as a guide for physicians, pharmacists, health care professionals and members in the selection of cost-effective drug therapy. Total Health Care recognizes that drug therapy is an integral part of effective health management. Total Health Care continually reviews new and existing medications to ensure the Formulary remains responsive to the needs of our members and health professionals. Criteria used to evaluate drug selection for the formulary includes, but is not limited to: safety, efficacy and cost-effectiveness data, as well as comparison of relevant benefits of similar prescription or over-the counter (OTC) agents while minimizing potential duplications. Notice The information contained in this formulary is provided by THC, solely for the convenience of medical providers and members. THC does not warrant or assure accuracy of this information, nor is it intended to be comprehensive in nature. This formulary is not intended to be a substitute for the knowledge, expertise, skill or judgment of the medical provider in their choice of prescription drugs. Total Health Care assumes no responsibility for the actions or omissions of any medical provider based upon reliance, in whole or in part, on the information contained herein. The medical provider should consult the drug manufacturer s product literature or standard references for more detailed information. How to Read the Formulary Drug Name All formulary drugs are listed either by their generic names (in lowercase) or by their brand names (in uppercase). Drugs are grouped together by their therapeutic drug category. Specific drug listings may be accessed by using the index, using the covered generic name or the covered brand name of the drug. The brand names listed are for reference use only, and do not denote coverage, unless specifically noted. Any drug not found in this Formulary listing shall be considered a non-formulary drug. i

2 Requirements/Limits This field includes potential limitations to the formulary drug. It also may contain additional information about the coverage of the drug such as applicable quantity limits (). For certain agents within the MIChild-CSHCS Formulary, a recommended prescribing guideline may apply. Prescribing Guidelines Prescribing guidelines may apply to select drugs on the THC formulary. Prescribing guidelines may vary by benefit design but may include: Prior Authorization Required () Over the Counter Drugs (OTC) Specialty Drugs (SP) Quantity Limit () Age Limit (AL) Drug requires prior authorization through a specific physician request process. Drug coverage is available for drugs that are available OTC with an authorized prescription from your provider. Drug requires processing through THC s contracted specialty pharmacy, Diplomat Specialty Pharmacy. Drug coverage may be limited to specific quantities per prescription and/or time period. Drug coverage may depend on patient age. Gender Restriction (GR) Drug coverage may depend on patient gender. Step Therapy Required (ST) Custom (C) Drug coverage requires that an alternative or trial of another drug be used before the medication is covered. Drug coverage has unique restrictions. Benefit Coverage and Limitations This formulary does not define benefit coverage and limitations. Members should contact Total Health Care at if they have questions regarding their coverage. Please note that the formulary process is evolutionary and changes can occur throughout the year. Prior Authorization () Drugs indicated with a require Prior Authorization for coverage. A prescriber may complete a Prior Authorization form that can be found on the Total Health Care website at You may also request a form by calling Total Health Care at Completed prior authorization forms should be faxed to Prior Authorization review of prescribing guidelines will be evaluated utilizing the established drug review criteria approved by Total Health Care. If the request does not meet the approved criteria, the request will not be approved and alternative therapy may be recommended along with the proper course of alternative action. The requesting provider will be provided written notification of Total Health ii

3 Care review decisions. THC s website has a contact link where members can contact THC s Pharmacy Department to ask for an exception request. Non-Formulary Agents Drugs not found on the Total Health Care MIChild - CSHCS Formulary, or any updates published by Total Health Care, shall be considered a non-formulary drug. Requests for coverage of non-formulary agents may be requested by the health professional depending on specific coverage parameters. Review for nonformulary drug requests will require a Prior Authorization request with documentation of medical necessity. Generally, the following basic medical necessity guidelines are used in conducting a review: The patient has failed an appropriate trial of formulary or preferred agents. The use of preferred or formulary agent is contraindicated in the patient. The formulary drug or preferred agents are not suited for the present patient care need, and the drug selected is required for patient safety. If the request does not meet the established guidelines request, it will not be approved and alternative therapy may be recommended along with the proper course of alternative action. Common Drug Exclusions The member s plan design may exclude certain drug classes. Prior authorization is generally not available for drugs that are specifically excluded by benefit design. Common excluded coverage may include, but are not limited to: Drug products used for cosmetic purposes. Drug products for erectile dysfunction. Drug products for infertility treatment. Experimental drug products or any drug product used in an experimental manner. Foreign drugs or drugs not approved by the United States Food & Drug Administration (FDA). MICHILD - CSHCS Fee-For-Service Carve Out List The State of Michigan has a carve-out list for the CSHCS formulary. The carve-out drugs include HIV/AIDS, Oncology, Hemophilia and other miscellaneous drugs that have been added to the State's 100% carve-out list. These drugs must be billed directly by the pharmacies at point-of-sale to the Michigan Department of Community Health's contracted Pharmacy Benefits Manager (PBM). A list of the carve-out drugs can be found at Mandated Generic Substitution Total Health Care advocates the use of cost-effective generic drugs where FDA- approved generic equivalent drugs are available. Generic products are listed in the Formulary and noted as generic wherever an FDAapproved generic drug product is available. The brand names listed in the formulary are for reference only. Total Health Care Pharmacy and Therapeutics (P&T) Committee Total Health Care s Pharmacy & Therapeutic Committee meets quarterly to review and recommend medications for formulary consideration. The Committee considers clinical information on drugs that are new to the market and drugs that are typically included in an outpatient pharmacy benefit. This assures that the formulary remains responsive to patient and physician needs. The Committee is composed of physicians, iii

4 pharmacists, and health care professionals. The Committee also uses reference materials from our Pharmacy Benefits Manager's Pharmacy and Therapeutics Advisory Panel. Product Selection Criteria The primary goal of the THC Pharmacy & Therapeutic Committee is to maintain and update the formulary based upon an objective analysis of the safety, efficacy, approved indications, adverse effects, contraindications, patient administration/compliance considerations and cost effectiveness of available drugs. When a drug is considered for formulary inclusion, it will be reviewed relative to similar drugs including those currently in the THC Formulary. Physicians may request a copy of THC s drug criteria by calling the Pharmacy Department at Diabetic Testing Supplies Total Health Care works with J&B Medical Supply to provide diabetic testing supplies to our members. Covered diabetic testing supplies include Glucocard Vital glucometer, Glucocard Expression glucometer, and SD Biosensor GlucoNavii glucometer, Glucocard Vital test strips, Glucocard Expression test strips, SD Biosensor GlucoNavii test strips, lancets, insulin syringes, alcohol swabs and ketone strips. These supplies are to be filled through J&B Medical Supply. If you have any questions about our diabetic supply program, please contact J&B Medical Supply at Specialty Bio-Pharmaceutical Pharmacy Program Total Health Care works with Diplomat Specialty Pharmacy to provide Specialty Bio-Pharmaceutical Pharmacy products to our members. These medications are to be filled exclusively through Diplomat Specialty Pharmacy. A Specialty Drug Prior Authorization Request form must be completed and faxed to EnvisionRxOptions at with supporting documentation and the prescription. A prescriber may obtain a Specialty Drug Prior Authorization Request form found on the Total Health Care website at Once the order is received, EnvisionRxOptions obtains authorization from Total Health Care. If the specialty prior authorization is approved, Total Health Care notifies Diplomat Specialty Pharmacy. Then, the Diplomat Specialty Pharmacy staff ships the medication directly to the physician's office or the patient s home. All packages are individually marked for each patient and refrigerated items are shipped in insulated containers. Where appropriate, each shipment includes needles, syringes and alcohol swabs. If you have any questions about our Specialty Bio-Pharmaceutical Pharmacy program, please contact EnvisionRxOptions at or Diplomat Specialty Pharmacy at Contact Information The Total Health Care MIChild-CSHCS formulary is designed to assist physicians, members and other health care professionals in the selection of cost-effective agents. Total Health Care encourages your input and feedback on how we can assist in improving this document and the formulary management process. You may contact THC at iv

5 Medication Limitations Quantity Limitations Quantity Limitations are on medications throughout the formulary and are indicated with a "" notation. These are medications that have a daily dose restriction, quantity/days supply limitation, and/or a limitation on the duration of therapy. Age Limitations Age Limitations are on medications throughout the formulary and are indicated with an "AL" notation. Coverage for a medication is indicated by the age limitation. This could be a minimum age, maximum age, and/or the combination of a minimum and maximum age edit. Gender Restrictions Gender restrictions are indicated with a GR on the formulary and require the member to be a specific gender for coverage. Step Therapy Criteria Step Therapy medications are indicated with a ST on the formulary and require that an alternative, first line medication be tried and failed before the requested medication can be covered. The online claims adjudication system will automatically allow for the requested medication to be filled based on electronic claims history indicating that the first line medication was filled. Step-Therapy Criteria Therapy Class First Line Second Line Step Therapy Criteria Antibiotics Amoxicillin, Ampicillin, Amoxicillin & Clavulanate, Cefpodoxime, Cefdinir, Cefuroxime, Cephalexin, Ciprofloxacin, Clindamycin, Dicloxacillin, Doxycycline, Erythromycin, Penicillin, Sulfamethoxazole- Trimethoprim, Tetracycline Cefadroxil, Cefaclor, Cefprozil Antidiabetic Agents Metformin Januvia, Janumet Attention Amphetamine Immediate- Deficit/Hyperactivity Release Amphetamine Extended-Release Antipsychotic Agents Risperidone Quetiapine Immediate-Release Benign Prostatic Doxazosin Immediate- Alfuzosin Hypertrophy agents Release, Prior use of Amoxicillin, Ampicillin, Amoxicillin & Clavulanate, Cefpodoxime, Cefdinir, Cefuroxime, Cephalexin, Ciprofloxacin, Clindamycin, Dicloxacillin, Doxycycline, Erythromycin, Penicillin, Sulfamethoxazole- Trimethoprim or Tetracycline in the last 30 days Prior use of Metformin in the last 90 days Prior use of Amphetamine Immediate-Release for 60 days within the last 90 days Prior use of Quetiapine within the last 90 days. Prior use of Doxazosin Immediate-Release, v

6 Finasteride, Tamsulosin, Terazosin Glucocorticoid Inhaler Dulera Breo Ellipta, Pediculicides Urinary Antispasmodics Lice-B-Gone Kit, Lice-B-Gone Shampoo, Pyrethrins-Piperonyl Butoxide Liquid, Permethrin Spray & Pyrethins-Piperonyl Butoxide Shampoo Kit Oxybutynin, Oxybutynin Syrup, Oxytrol OTC Symbicort Malathion Lotion Oxybutynin Extended-Release, Tolterodine, Tolterodine Extended-Release Finasteride, Tamsulosin or Terazosin in the last 90 days Prior use of Dulera within the last 90 days. Prior use of Lice-B-Gone Kit, Lice-B-Gone Shampoo, Pyrethrins-Piperonyl Butoxide Liquid, Permethrin Spray & Pyrethins- Piperonyl Butoxide Shampoo Kit in the last 30 days Prior use of Oxytrol OTC or Oxybutynin/Oxybutynin Syrup in the last 90 days. *Formulary Disclaimer: Coverage for some drugs may be limited to specific dosage forms and/or strengths. The benefit design determines what is covered. The medications listed on this formulary are subject to change pursuant to the formulary management activities of EnvisionRxOptions. The presence of a medication on this formulary list does not guarantee coverage. vi

7 ANALGESICS (IN, INFLAMMATION, MUSCLE, JOINT CONDITIONS DRUGS) Nonsteroidal Anti-inflammatory Drugs (IN, ANTI-INFLAMMATORY DRUGS) diclofenac potassium tab 50 mg diclofenac sodium tab delayed release 25 mg diclofenac sodium tab delayed release 50 mg diclofenac sodium tab delayed release 75 mg diclofenac sodium tab sr 24hr 100 mg diflunisal tab 500 mg etodolac cap 200 mg etodolac cap 300 mg etodolac tab 400 mg etodolac tab 500 mg etodolac tab sr 24hr 400 mg etodolac tab sr 24hr 500 mg etodolac tab sr 24hr 600 mg FENOPROFEN CALCIUM TAB 600 MG fenoprofen calcium flurbiprofen tab 100 mg flurbiprofen tab 50 mg ibuprofen susp 100 mg/5ml ibuprofen tab 200 mg ibuprofen tab 400 mg ibuprofen tab 600 mg ibuprofen tab 800 mg indomethacin cap 25 mg indomethacin cap 50 mg ketoprofen cap 50 mg ketoprofen cap 75 mg 120 / 30 days ketorolac tromethamine tab 10 mg 20 / 5 days GE 7 LAST UPDATED 09/2015

8 MECLOFENAMATE SODIUM CAP 50 MG meclofenamate sodium meloxicam tab 15 mg meloxicam tab 7.5 mg nabumetone tab 500 mg 120 / 30 days nabumetone tab 750 mg 60 / 30 days naproxen sodium tab 220 mg naproxen sodium tab 275 mg naproxen sodium tab 550 mg naproxen susp 125 mg/5ml NAPROXEN SUSPENSION 125 MG/5ML naproxen naproxen tab 250 mg naproxen tab 375 mg naproxen tab 500 mg naproxen tab ec 375 mg oxaprozin tab 600 mg piroxicam cap 10 mg piroxicam cap 20 mg sulindac tab 150 mg sulindac tab 200 mg Opioid Analgesics, Long-acting (NARCOTIC IN RELIEVERS) fentanyl td patch 72hr 100 mcg/hr fentanyl td patch 72hr 12 mcg/hr fentanyl td patch 72hr 25 mcg/hr fentanyl td patch 72hr 50 mcg/hr fentanyl td patch 72hr 75 mcg/hr 10 / 30 days 10 / 30 days 10 / 30 days 10 / 30 days 10 / 30 days GE 8 LAST UPDATED 09/2015

9 methadone hcl soln 10 mg/5ml methadone hcl soln 5 mg/5ml METHADONE HCL SOLUTION 10 MG/5ML methadone hcl METHADONE HCL SOLUTION 5 MG/5ML methadone hcl methadone hcl tab 10 mg 240 / 30 days methadone hcl tab 5 mg MORPHINE SULFATE TAB 15 MG morphine sulfate MORPHINE SULFATE TAB 30 MG morphine sulfate 180 / 30 days 180 / 30 days morphine sulfate tab cr 100 mg 90 / 30 days morphine sulfate tab cr 15 mg 90 / 30 days morphine sulfate tab cr 30 mg 90 / 30 days morphine sulfate tab cr 60 mg 90 / 30 days Opioid Analgesics, Short-Acting ( NARCOTIC IN RELIEVERS) acetaminophen w/ codeine soln mg/5ml acetaminophen w/ codeine tab mg 390 / 30 days acetaminophen w/ codeine tab mg 390 / 30 days acetaminophen w/ codeine tab mg 390 / 30 days butalbital-aspirin-caff w/ codeine cap mg codeine sulfate tab 30 mg CODEINE SULFATE TAB 30 MG codeine sulfate codeine sulfate tab 60 mg CODEINE SULFATE TAB 60 MG codeine sulfate hydrocodone-acetaminophen soln mg/15ml 900 / 90 days hydrocodone-acetaminophen soln mg/15ml 900 / 90 days HYDROCODONE-ACETAMINOPHEN SOLUTION MG/15ML hydrocodone-acetaminophen 900 / 90 days GE 9 LAST UPDATED 09/2015

10 hydrocodone-acetaminophen tab mg 180 / 30 days hydrocodone-acetaminophen tab mg hydrocodone-acetaminophen tab mg hydrocodone-acetaminophen tab mg hydrocodone-acetaminophen tab mg hydrocodone-acetaminophen tab mg 360 / 30 days hydrocodone-acetaminophen tab mg hydrocodone-acetaminophen tab mg 180 / 30 days hydrocodone-acetaminophen tab mg HYDROCODONE-ACETAMINOPHEN TAB MG hydrocodone-acetaminophen hydrocodone-acetaminophen tab mg HYDROCODONE-ACETAMINOPHEN TAB MG hydrocodone-acetaminophen hydrocodone-acetaminophen tab mg HYDROCODONE-ACETAMINOPHEN TAB MG hydrocodone-acetaminophen hydromorphone hcl tab 2 mg 240 / 30 days hydromorphone hcl tab 4 mg 240 / 30 days hydromorphone hcl tab 8 mg 240 / 30 days LORTAB ELIXIR MG/15ML hydrocodone-acetaminophen morphine sulfate (concentrate) oral soln 20 mg/ml morphine sulfate oral soln 10 mg/5ml morphine sulfate oral soln 20 mg/5ml oxycodone hcl soln 5 mg/5ml OXYCODONE HCL SOLUTION 5 MG/5ML oxycodone hcl 900 / 90 days oxycodone hcl tab 15 mg 180 / 30 days oxycodone hcl tab 30 mg 180 / 30 days oxycodone hcl tab 5 mg 180 / 30 days GE 10 LAST UPDATED 09/2015

11 oxycodone w/ acetaminophen tab mg 180 / 30 days oxycodone w/ acetaminophen tab mg oxycodone w/ acetaminophen tab mg 360 / 30 days oxycodone w/ acetaminophen tab mg 180 / 30 days oxycodone w/ acetaminophen tab mg oxycodone-aspirin tab mg tramadol hcl tab 50 mg 240 / 30 days ZAMICET SOLUTION MG/15ML hydrocodone-acetaminophen Anesthetics LOCAL ANESTHETICS (LOCAL NUMBING DRUGS) 900 / 90 days lidocaine hcl cream 3% 85 / 30 days lidocaine hcl gel 2% lidocaine hcl laryngotracheal soln 4% lidocaine hcl local inj 4% lidocaine hcl soln 4% lidocaine hcl viscous soln 2% lidocaine-prilocaine cream % 30 / 30 days Anti-Addiction/Substance Abuse Treatment Agents (NERVE CONDITIONS DRUGS) Opioid Reversal Agents (MISCELLANEOUS MENTAL HEALTH DRUGS) naloxone hcl inj 0.4 mg/ml 2 / 90 days naloxone hcl inj 1 mg/ml 2 / 90 days NALOXONE HCL SOLUTION 0.4 MG/ML naloxone hcl NALOXONE HCL SOLUTION 1 MG/ML naloxone hcl Smoking Cessation Agents (DEPRESSION DRUGS) 2 / 90 days 2 / 90 days bupropion hcl (smoking deterrent) tab sr 12hr 150 mg 180 / 365 days CHANTIX CONTINUING MONTH K TAB 1 MG varenicline tartrate C 60 / 30 days 90 days of coverage per year GE 11 LAST UPDATED 09/2015

12 CHANTIX STARTING MONTH K TAB 0.5 MG X 11 & 1 MG X 42 varenicline tartrate CHANTIX TAB 0.5 MG varenicline tartrate CHANTIX TAB 1 MG varenicline tartrate NICOTROL NS SOLUTION 10 MG/ML nicotine Antibacterials (INFECTION FIGHTING DRUGS) Aminoglycosides (BACTERIAL INFECTION DRUGS (ANTIBIOTICS)) GENTAMICIN SULFATE CREAM 0.1 % gentamicin sulfate (topical) gentamicin sulfate cream 0.1% gentamicin sulfate oint 0.1% GENTAMICIN SULFATE OINTMENT 0.1 % gentamicin sulfate (topical) gentamicin sulfate ophth oint 0.3% gentamicin sulfate ophth soln 0.3% neomycin sulfate tab 500 mg tobramycin ophth soln 0.3% Antibacterials, Other (MISCELLANEOUS INFECTION FIGHTING DRUGS) BACITRACIN OINTMENT 500 UNIT/GM bacitracin (ophthalmic) bacitracin-polymyxin b ophth oint bacitracin-polymyxin-neomycin-hc ophth oint 1% CLEOCIN SUPPOS 100 MG clindamycin phosphate vaginal clindamycin hcl cap 150 mg clindamycin hcl cap 300 mg C C C C 60 / 30 days 90 days of coverage per year 60 / 30 days 90 days of coverage per year 60 / 30 days 90 days of coverage per year 90 days of coverage per year GE 12 LAST UPDATED 09/2015

13 clindamycin hcl cap 75 mg clindamycin palmitate hcl for soln 75 mg/5ml (base equiv) clindamycin phosphate vaginal cream 2% CURITY ALCOHOL PREPS D 70 % alcohol swabs MACRODANTIN CAP 25 MG nitrofurantoin macrocrystal methenamine hippurate tab 1 gm METHENAMINE MANDELATE TAB 0.5 GM methenamine mandelate methenamine mandelate tab 1 gm metronidazole cream 0.75% metronidazole gel 0.75% metronidazole lotion 0.75% metronidazole tab 250 mg metronidazole tab 500 mg metronidazole vaginal gel 0.75% mupirocin calcium cream 2% mupirocin oint 2% neomycin-bacitrac zn-polymyx 5(3.5)mg-400unt-10000unt op oin neomycin-polymy-gramicid op sol mg-unt-mg/ml NEOMYCIN-POLYMYXIN-HC SUSPENSION neomycin-polymyxin-hc (ophth) nitrofurantoin macrocrystalline cap 100 mg 60 / 30 days nitrofurantoin macrocrystalline cap 50 mg 60 / 30 days nitrofurantoin monohydrate macrocrystalline cap 100 mg 60 / 30 days polymyxin b-trimethoprim ophth soln unit/ml-0.1% silver sulfadiazine cream 1% trimethoprim tab 100 mg 60 / 30 days vancomycin hcl for inj 10 gm vancomycin hcl for inj 1000 mg vancomycin hcl for inj 500 mg GE 13 LAST UPDATED 09/2015

14 vancomycin hcl for inj 5000 mg VANCOMYCIN HCL RECON SOLN 750 MG vancomycin hcl Beta-lactam, Cephalosporins (BACTERIAL INFECTION DRUGS (ANTIBIOTICS)) cefaclor cap 250 mg cefaclor cap 500 mg CEFACLOR RECON SUSP 125 MG/5ML cefaclor CEFACLOR RECON SUSP 250 MG/5ML cefaclor CEFACLOR RECON SUSP 375 MG/5ML cefaclor cefadroxil cap 500 mg cefadroxil for susp 250 mg/5ml cefadroxil for susp 500 mg/5ml cefadroxil tab 1 gm cefdinir cap 300 mg ST ST ST ST ST ST ST ST ST 40 / 10 days 20 / 10 days cefdinir for susp 125 mg/5ml AL1 Up to 11 yrs old cefdinir for susp 250 mg/5ml AL1 Up to 11 yrs old cefpodoxime proxetil for susp 100 mg/5ml cefpodoxime proxetil for susp 50 mg/5ml cefpodoxime proxetil tab 100 mg 60 / 30 days cefpodoxime proxetil tab 200 mg 60 / 30 days cefprozil for susp 125 mg/5ml cefprozil for susp 250 mg/5ml cefprozil tab 250 mg cefprozil tab 500 mg ST ST ST ST 60 / 30 days 60 / 30 days GE 14 LAST UPDATED 09/2015

15 ceftriaxone sodium for inj 1 gm 10 / 30 days ceftriaxone sodium for inj 250 mg 10 / 30 days ceftriaxone sodium for inj 500 mg 10 / 30 days ceftriaxone sodium for iv soln 1 gm 10 / 30 days cefuroxime axetil tab 250 mg cefuroxime axetil tab 500 mg cephalexin cap 250 mg cephalexin cap 500 mg cephalexin for susp 125 mg/5ml cephalexin for susp 250 mg/5ml Beta-lactam, Other (BACTERIAL INFECTION DRUGS (ANTIBIOTICS)) DORIBAX RECON SOLN 250 MG doripenem DORIBAX RECON SOLN 500 MG doripenem Beta-lactam, Penicillins (BACTERIAL INFECTION DRUGS (ANTIBIOTICS)) amoxicillin & k clavulanate chew tab mg amoxicillin & k clavulanate chew tab mg amoxicillin & k clavulanate for susp mg/5ml amoxicillin & k clavulanate for susp mg/5ml amoxicillin & k clavulanate for susp mg/5ml amoxicillin & k clavulanate tab mg 42 / 14 days amoxicillin & k clavulanate tab mg 28 / 14 days amoxicillin & k clavulanate tab mg 28 / 14 days amoxicillin (trihydrate) cap 250 mg amoxicillin (trihydrate) cap 500 mg amoxicillin (trihydrate) chew tab 250 mg amoxicillin (trihydrate) for susp 125 mg/5ml amoxicillin (trihydrate) for susp 200 mg/5ml amoxicillin (trihydrate) for susp 250 mg/5ml GE 15 LAST UPDATED 09/2015

16 amoxicillin (trihydrate) for susp 400 mg/5ml amoxicillin (trihydrate) tab 500 mg amoxicillin (trihydrate) tab 875 mg AMOXICILLIN CHEW TAB 125 MG amoxicillin AMOXICILLIN CHEW TAB 250 MG amoxicillin ampicillin cap 250 mg ampicillin cap 500 mg BICILLIN C-R 900/300 SUSPENSION UNIT/2ML penicillin g benzathine & procaine BICILLIN C-R SUSPENSION UNIT/2ML penicillin g benzathine & procaine dicloxacillin sodium cap 250 mg dicloxacillin sodium cap 500 mg penicillin v potassium for soln 125 mg/5ml penicillin v potassium for soln 250 mg/5ml penicillin v potassium tab 250 mg penicillin v potassium tab 500 mg Macrolides (BACTERIAL INFECTION DRUGS (ANTIBIOTICS)) azithromycin for susp 100 mg/5ml azithromycin for susp 200 mg/5ml 4 / 28 days 4 / 28 days azithromycin tab 250 mg 12 / 30 days azithromycin tab 500 mg 6 / 30 days azithromycin tab 600 mg 60 / 30 days clarithromycin for susp 125 mg/5ml clarithromycin for susp 250 mg/5ml clarithromycin tab 250 mg clarithromycin tab 500 mg clarithromycin tab sr 24hr 500 mg erythromycin gel 2% erythromycin ophth oint 5 mg/gm GE 16 LAST UPDATED 09/2015

17 erythromycin soln 2% erythromycin-sulfisoxazole for susp mg/5ml Quinolones (BACTERIAL INFECTION DRUGS (ANTIBIOTICS)) ciprofloxacin hcl ophth soln 0.3% ciprofloxacin hcl tab 250 mg (base equiv) ciprofloxacin hcl tab 500 mg (base equiv) ciprofloxacin hcl tab 750 mg (base equiv) levofloxacin tab 250 mg 14 / 14 days levofloxacin tab 500 mg 14 / 14 days levofloxacin tab 750 mg 14 / 14 days ofloxacin ophth soln 0.3% ofloxacin otic soln 0.3% ofloxacin tab 200 mg 60 / 30 days ofloxacin tab 300 mg 60 / 30 days ofloxacin tab 400 mg 60 / 30 days OFLOXACIN TAB 400 MG ofloxacin Sulfonamides (BACTERIAL INFECTION DRUGS (ANTIBIOTICS)) BLEPHAMIDE S.O.P. OINTMENT % sulfacetamide sod-prednisolone BLEPHAMIDE SUSPENSION % sulfacetamide sod-prednisolone sulfacetamide sodium-prednisolone ophth soln (0.25)% SULFADIAZINE TAB 500 MG sulfadiazine sulfamethoxazole-trimethoprim susp mg/5ml sulfamethoxazole-trimethoprim tab mg sulfamethoxazole-trimethoprim tab mg Tetracyclines (BACTERIAL INFECTION DRUGS (ANTIBIOTICS)) doxycycline hyclate cap 100 mg doxycycline hyclate cap 50 mg 60 / 30 days GE 17 LAST UPDATED 09/2015

18 doxycycline hyclate tab 100 mg doxycycline monohydrate for susp 25 mg/5ml minocycline hcl cap 100 mg minocycline hcl cap 50 mg minocycline hcl cap 75 mg Anticonvulsants (NERVE CONDITIONS DRUGS) Anticonvulsants, Other (SEIZURE CONTROL DRUGS) levetiracetam oral soln 100 mg/ml levetiracetam tab 1000 mg 90 / 30 days levetiracetam tab 250 mg levetiracetam tab 500 mg 180 / 30 days levetiracetam tab 750 mg 120 / 30 days phenobarbital elixir 20 mg/5ml PHENOBARBITAL TAB 100 MG phenobarbital PHENOBARBITAL TAB 15 MG phenobarbital phenobarbital tab 16.2 mg PHENOBARBITAL TAB 30 MG phenobarbital phenobarbital tab 32.4 mg PHENOBARBITAL TAB 60 MG phenobarbital phenobarbital tab 64.8 mg phenobarbital tab 97.2 mg Calcium Channel Modifying Agents (SEIZURES CONTROL DRUGS) ethosuximide cap 250 mg ethosuximide soln 250 mg/5ml zonisamide cap 100 mg 180 / 30 days zonisamide cap 25 mg 30 / 30 days zonisamide cap 50 mg 30 / 30 days GE 18 LAST UPDATED 09/2015

19 Gamma-aminobutyric Acid (GABA) Augmenting Agents (SEIZURES CONTROL DRUGS) clonazepam tab 0.5 mg clonazepam tab 1 mg clonazepam tab 2 mg DIAZEM GEL 2.5 MG diazepam (anticonvulsant) divalproex sodium cap sprinkle 125 mg divalproex sodium tab delayed release 125 mg divalproex sodium tab delayed release 250 mg divalproex sodium tab delayed release 500 mg divalproex sodium tab sr 24 hr 250 mg divalproex sodium tab sr 24 hr 500 mg gabapentin cap 100 mg gabapentin cap 300 mg gabapentin cap 400 mg gabapentin oral soln 250 mg/5ml gabapentin tab 600 mg gabapentin tab 800 mg primidone tab 250 mg primidone tab 50 mg valproate sodium syrup 250 mg/5ml (base equiv) Glutamate Reducing Agents (SEIZURES CONTROL DRUGS) lamotrigine tab 100 mg lamotrigine tab 150 mg lamotrigine tab 200 mg lamotrigine tab 25 mg lamotrigine tab chewable dispersible 25 mg lamotrigine tab chewable dispersible 5 mg topiramate sprinkle cap 15 mg topiramate sprinkle cap 25 mg topiramate tab 100 mg 2 / 30 days GE 19 LAST UPDATED 09/2015

20 topiramate tab 200 mg topiramate tab 25 mg topiramate tab 50 mg Sodium Channel Agents (SEIZURES CONTROL DRUGS) carbamazepine cap sr 12hr 300 mg carbamazepine chew tab 100 mg carbamazepine susp 100 mg/5ml carbamazepine tab 200 mg carbamazepine tab sr 12hr 200 mg carbamazepine tab sr 12hr 400 mg fosphenytoin sodium inj 100 mg/2ml (phenytoin equiv) fosphenytoin sodium inj 500 mg/10ml (phenytoin equiv) oxcarbazepine tab 150 mg oxcarbazepine tab 300 mg oxcarbazepine tab 600 mg phenytoin chew tab 50 mg phenytoin sodium extended cap 100 mg phenytoin susp 125 mg/5ml 750 / 30 days Antidepressants (NERVE CONDITIONS DRUGS) Antidepressants, Other (DEPRESSION DRUGS) bupropion hcl tab 100 mg bupropion hcl tab 75 mg bupropion hcl tab sr 12hr 100 mg bupropion hcl tab sr 12hr 150 mg bupropion hcl tab sr 12hr 200 mg bupropion hcl tab sr 24hr 150 mg bupropion hcl tab sr 24hr 300 mg mirtazapine tab 15 mg mirtazapine tab 30 mg mirtazapine tab 45 mg trazodone hcl tab 100 mg GE 20 LAST UPDATED 09/2015

21 trazodone hcl tab 150 mg trazodone hcl tab 300 mg trazodone hcl tab 50 mg Monoamine Oxidase Inhibitors (DEPRESSION DRUGS) phenelzine sulfate tab 15 mg tranylcypromine sulfate tab 10 mg SSRIs/SNRIs (Selective Serotonin Reuptake Inhibitors/Serotonin and Norepinephrine Reuptake Inhibitor (DEPRESSION) citalopram hydrobromide tab 10 mg (base equiv) 51 / 30 days citalopram hydrobromide tab 20 mg (base equiv) 51 / 30 days citalopram hydrobromide tab 40 mg (base equiv) duloxetine hcl enteric coated pellets cap 20 mg 30 / 30 days duloxetine hcl enteric coated pellets cap 30 mg 30 / 30 days duloxetine hcl enteric coated pellets cap 60 mg 30 / 30 days escitalopram oxalate tab 10 mg (base equiv) 45 / 30 days escitalopram oxalate tab 20 mg (base equiv) 30 / 30 days escitalopram oxalate tab 5 mg (base equiv) 45 / 30 days fluoxetine hcl cap 10 mg fluoxetine hcl cap 20 mg fluoxetine hcl cap 40 mg fluoxetine hcl solution 20 mg/5ml fluoxetine hcl tab 10 mg fluoxetine hcl tab 20 mg fluvoxamine maleate tab 100 mg fluvoxamine maleate tab 25 mg fluvoxamine maleate tab 50 mg paroxetine hcl tab 10 mg paroxetine hcl tab 20 mg paroxetine hcl tab 30 mg paroxetine hcl tab 40 mg GE 21 LAST UPDATED 09/2015

22 sertraline hcl tab 100 mg sertraline hcl tab 25 mg sertraline hcl tab 50 mg venlafaxine hcl cap sr 24hr 150 mg (base equivalent) venlafaxine hcl cap sr 24hr 37.5 mg (base equivalent) venlafaxine hcl cap sr 24hr 75 mg (base equivalent) venlafaxine hcl tab 100 mg venlafaxine hcl tab 25 mg venlafaxine hcl tab 37.5 mg venlafaxine hcl tab 50 mg venlafaxine hcl tab 75 mg Tricyclics (DEPRESSION DRUGS) amitriptyline hcl tab 10 mg amitriptyline hcl tab 100 mg amitriptyline hcl tab 150 mg amitriptyline hcl tab 25 mg amitriptyline hcl tab 50 mg amitriptyline hcl tab 75 mg AMOXAPINE TAB 100 MG amoxapine AMOXAPINE TAB 150 MG amoxapine AMOXAPINE TAB 25 MG amoxapine AMOXAPINE TAB 50 MG amoxapine clomipramine hcl cap 75 mg imipramine hcl tab 10 mg imipramine hcl tab 25 mg imipramine hcl tab 50 mg nortriptyline hcl cap 10 mg nortriptyline hcl cap 25 mg nortriptyline hcl cap 50 mg GE 22 LAST UPDATED 09/2015

23 nortriptyline hcl cap 75 mg nortriptyline hcl soln 10 mg/5ml NORTRIPTYLINE HCL SOLUTION 10 MG/5ML nortriptyline hcl trimipramine maleate cap 100 mg trimipramine maleate cap 25 mg trimipramine maleate cap 50 mg Antiemetics (BOWEL, INSTESTINE, AND STOMACH CONDITIONS DRUGS) ANTIEMETICS, Other (NAUSEA AND VOMITING DRUGS) meclizine hcl tab 12.5 mg meclizine hcl tab 25 mg promethazine hcl suppos 12.5 mg 28 / 14 days promethazine hcl suppos 25 mg 28 / 14 days promethazine hcl suppos 50 mg 28 / 14 days promethazine hcl syrup 6.25 mg/5ml promethazine hcl tab 12.5 mg promethazine hcl tab 25 mg promethazine hcl tab 50 mg trimethobenzamide hcl cap 300 mg Emetogenic Therapy Adjuncts (NAUSEA AND VOMITING DRUGS) dronabinol cap 10 mg dronabinol cap 2.5 mg dronabinol cap 5 mg ondansetron hcl oral soln 4 mg/5ml 50 / 30 days ondansetron hcl tab 4 mg ondansetron hcl tab 8 mg ondansetron orally disintegrating tab 4 mg ondansetron orally disintegrating tab 8 mg GE 23 LAST UPDATED 09/2015

24 ANTIFUNGALS (FUNGUS INFECTION DRUGS) *nystatin topical powder** ciclopirox solution 8% 6.6 / 30 days clotrimazole soln 1% clotrimazole troche 10 mg econazole nitrate cream 1% fluconazole for susp 10 mg/ml fluconazole for susp 40 mg/ml fluconazole tab 100 mg 30 / 30 days fluconazole tab 150 mg 4 / 30 days fluconazole tab 200 mg 30 / 30 days fluconazole tab 50 mg 30 / 30 days griseofulvin microsize susp 125 mg/5ml griseofulvin microsize tab 500 mg griseofulvin ultramicrosize tab 125 mg griseofulvin ultramicrosize tab 250 mg ketoconazole cream 2% ketoconazole shampoo 2% ketoconazole tab 200 mg MICONAZOLE 3 SUPPOS 200 MG miconazole nitrate vaginal miconazole nitrate vaginal suppos 100 mg nystatin cream unit/gm nystatin oint unit/gm NYSTATIN POWDER nystatin (topical) nystatin susp unit/ml nystatin tab unit nystatin-triamcinolone cream unit/gm-% nystatin-triamcinolone oint unit/gm-% terbinafine hcl tab 250 mg GE 24 LAST UPDATED 09/2015

25 terconazole vaginal cream 0.4% terconazole vaginal cream 0.8% terconazole vaginal suppos 80 mg Antigout Agents (GOUT DRUGS) allopurinol tab 100 mg allopurinol tab 300 mg COLCHICINE TAB 0.6 MG colchicine colchicine w/ probenecid tab mg probenecid tab 500 mg Antimigraine Agents (NERVE CONDITIONS DRUGS) Prophylactic (MIGRAINE DRUGS) TIMOLOL MALEATE TAB 10 MG timolol maleate TIMOLOL MALEATE TAB 20 MG timolol maleate TIMOLOL MALEATE TAB 5 MG timolol maleate valproic acid cap 250 mg Serotonin (5-HT) 1b/1d Receptor Agonists (MIGRAINE DRUGS) 20 / 30 days sumatriptan succinate tab 100 mg 9 / 30 days sumatriptan succinate tab 25 mg 9 / 30 days sumatriptan succinate tab 50 mg 9 / 30 days Antimycobacterials (INFECTION FIGHTING DRUGS) Antimycobacterials, Other (MISCELLANEOUS INFECTION FIGHTING DRUGS) DAPSONE TAB 100 MG dapsone DAPSONE TAB 25 MG dapsone Antituberculars ethambutol hcl tab 100 mg ethambutol hcl tab 400 mg GE 25 LAST UPDATED 09/2015

26 isoniazid tab 100 mg isoniazid tab 300 mg pyrazinamide tab 500 mg rifampin cap 150 mg rifampin cap 300 mg RIFATER TAB MG isoniazid-rifampin w/ pyrazinamide TRECATOR TAB 250 MG ethionamide ANTINEOPLASTICS (CANCER DRUGS) ALKYLATING AGENTS (CHEMOTHERAPY DRUGS) CYCLOPHOSPHAMIDE TAB 25 MG cyclophosphamide CYCLOPHOSPHAMIDE TAB 50 MG cyclophosphamide HEXALEN CAP 50 MG altretamine LEUKERAN TAB 2 MG chlorambucil LOMUSTINE CAP 10 MG lomustine LOMUSTINE CAP 100 MG lomustine LOMUSTINE CAP 40 MG lomustine MATULANE CAP 50 MG procarbazine hcl Antiandrogens (CANCER DRUGS) bicalutamide tab 50 mg flutamide cap 125 mg Antiestrogens/Modifiers (CANCER DRUGS) tamoxifen citrate tab 10 mg (base equivalent) GL AL1 Female At least 35 yrs old GE 26 LAST UPDATED 09/2015

27 tamoxifen citrate tab 20 mg (base equivalent) ANTIMETABOLITES (CHEMOTHERAPY DRUGS) hydroxyurea cap 500 mg mercaptopurine tab 50 mg TABLOID TAB 40 MG thioguanine Antineoplastics, Other (CANCER DRUGS) CYCLOPHOSPHAMIDE CAP 25 MG cyclophosphamide CYCLOPHOSPHAMIDE CAP 50 MG cyclophosphamide LEUCOVORIN CALCIUM TAB 15 MG leucovorin calcium leucovorin calcium tab 25 mg leucovorin calcium tab 5 mg MENEST TAB 0.3 MG esterified estrogens MENEST TAB MG esterified estrogens MENEST TAB 1.25 MG esterified estrogens MENEST TAB 2.5 MG esterified estrogens Aromatase Inhibitors, 3rd Generation (HORMONAL CHEMOTHERAPY DRUGS) GL AL1 GL GL GL GL Female At least 35 yrs old Female Female Female Female anastrozole tab 1 mg GL Female letrozole tab 2.5 mg Retinoids (CANCER DRUGS) tretinoin cap 10 mg AL1 30 / 30 days At least 18 yrs old GE 27 LAST UPDATED 09/2015

28 ANTIRASITICS (INFECTION FIGHTING DRUGS) Antiprotozoals (MALARIA DRUGS) atovaquone susp 750 mg/5ml 210 / 18 days chloroquine phosphate tab 250 mg DARAPRIM TAB 25 MG pyrimethamine hydroxychloroquine sulfate tab 200 mg 6 / 30 days mefloquine hcl tab 250 mg 5 / 30 days PRIMAQUINE PHOSPHATE TAB 26.3 MG primaquine phosphate quinine sulfate cap 324 mg Pediculicides/Scabicides (SCABIES DRUGS) EURAX CREAM 10 % crotamiton EURAX LOTION 10 % crotamiton lindane lotion 1% lindane shampoo 1% malathion lotion 0.5% OVIDE LOTION 0.5 % malathion ST ST 14 / 30 days 120 / 365 days 120 / 365 days permethrin cream 5% 120 / 30 days Antiparkinson Agents (NERVE CONDITIONS DRUGS) 'Dopamine Agonists (RKINSON'S DISEASE DRUGS)' pramipexole dihydrochloride tab mg Antipsychotics (NERVE CONDITIONS DRUGS) 1st Generation/Typical (MOOD DISORDER DRUGS) chlorpromazine hcl tab 10 mg chlorpromazine hcl tab 100 mg chlorpromazine hcl tab 200 mg chlorpromazine hcl tab 25 mg GE 28 LAST UPDATED 09/2015

29 chlorpromazine hcl tab 50 mg FLUPHENAZINE HCL CONC 5 MG/ML fluphenazine hcl FLUPHENAZINE HCL ELIXIR 2.5 MG/5ML fluphenazine hcl FLUPHENAZINE HCL SOLUTION 2.5 MG/ML fluphenazine hcl fluphenazine hcl tab 1 mg fluphenazine hcl tab 10 mg fluphenazine hcl tab 2.5 mg fluphenazine hcl tab 5 mg haloperidol decanoate im soln 100 mg/ml haloperidol tab 0.5 mg haloperidol tab 1 mg haloperidol tab 10 mg haloperidol tab 2 mg haloperidol tab 20 mg haloperidol tab 5 mg loxapine succinate cap 10 mg loxapine succinate cap 25 mg loxapine succinate cap 5 mg loxapine succinate cap 50 mg perphenazine tab 16 mg perphenazine tab 2 mg perphenazine tab 4 mg perphenazine tab 8 mg prochlorperazine maleate tab 10 mg (base equivalent) prochlorperazine maleate tab 5 mg (base equivalent) prochlorperazine suppos 25 mg 60 / 30 days thiothixene cap 1 mg thiothixene cap 10 mg thiothixene cap 2 mg GE 29 LAST UPDATED 09/2015

30 thiothixene cap 5 mg trifluoperazine hcl tab 1 mg trifluoperazine hcl tab 10 mg trifluoperazine hcl tab 2 mg trifluoperazine hcl tab 5 mg 2nd Generation/Atypical (MOOD DISORDER DRUGS) quetiapine fumarate tab 100 mg quetiapine fumarate tab 200 mg quetiapine fumarate tab 25 mg quetiapine fumarate tab 300 mg quetiapine fumarate tab 400 mg quetiapine fumarate tab 50 mg ST ST ST ST ST ST risperidone tab 0.25 mg risperidone tab 0.5 mg risperidone tab 1 mg risperidone tab 2 mg risperidone tab 3 mg risperidone tab 4 mg ziprasidone hcl cap 20 mg ziprasidone hcl cap 40 mg ziprasidone hcl cap 60 mg ziprasidone hcl cap 80 mg ST ST ST ST Treatment-Resistant (MOOD DISORDER DRUGS) clozapine tab 100 mg clozapine tab 200 mg clozapine tab 25 mg clozapine tab 50 mg GE 30 LAST UPDATED 09/2015

31 Antispasticity Agents (MUSCLE AND JOINT DRUGS) baclofen tab 10 mg baclofen tab 20 mg tizanidine hcl tab 2 mg 90 / 30 days tizanidine hcl tab 2 mg (base equivalent) 90 / 30 days tizanidine hcl tab 4 mg 90 / 30 days tizanidine hcl tab 4 mg (base equivalent) 90 / 30 days Antivirals (INFECTION FIGHTING DRUGS) Anti-hepatitis B (HBV) Agents (VIRUS INFECTION DRUGS) INTRON A RECON SOLN UNIT interferon alfa-2b INTRON A RECON SOLN UNIT interferon alfa-2b INTRON A RECON SOLN UNIT interferon alfa-2b INTRON A SOLUTION UNIT/ML interferon alfa-2b INTRON A SOLUTION UNIT/ML interferon alfa-2b Anti-hepatitis C (HCV) Agents (VIRUS INFECTION DRUGS) PEG-INTRON KIT 120 MCG/0.5ML peginterferon alfa-2b PEG-INTRON KIT 150 MCG/0.5ML peginterferon alfa-2b PEG-INTRON KIT 50 MCG/0.5ML peginterferon alfa-2b PEG-INTRON KIT 80 MCG/0.5ML peginterferon alfa-2b PEG-INTRON REDIPEN KIT 120 MCG/0.5ML peginterferon alfa-2b PEG-INTRON REDIPEN KIT 150 MCG/0.5ML peginterferon alfa-2b PEG-INTRON REDIPEN KIT 50 MCG/0.5ML peginterferon alfa-2b PEG-INTRON REDIPEN KIT 80 MCG/0.5ML peginterferon alfa-2b GE 31 LAST UPDATED 09/2015

32 PEG-INTRON REDIPEN K 4 KIT 120 MCG/0.5ML peginterferon alfa-2b PEG-INTRON REDIPEN K 4 KIT 150 MCG/0.5ML peginterferon alfa-2b PEG-INTRON REDIPEN K 4 KIT 50 MCG/0.5ML peginterferon alfa-2b PEG-INTRON REDIPEN K 4 KIT 80 MCG/0.5ML peginterferon alfa-2b PEGINTRON KIT 120 MCG/0.5ML peginterferon alfa-2b PEGINTRON KIT 150 MCG/0.5ML peginterferon alfa-2b PEGINTRON KIT 50 MCG/0.5ML peginterferon alfa-2b PEGINTRON KIT 80 MCG/0.5ML peginterferon alfa-2b ribavirin cap 200 mg Anti-HIV Agents, Nucleoside and Nucleotide Reverse Transcriptase Inhibitors (NRTI) (RETROVIRUS INFECTION DRUGS) EPIVIR HBV SOLUTION 5 MG/ML lamivudine (hbv) Anti-influenza Agents (VIRUS INFECTION DRUGS) amantadine hcl cap 100 mg amantadine hcl syrup 50 mg/5ml RELENZA DISKHALER AER POW BA 5 MG/BLISTER zanamivir rimantadine hydrochloride tab 100 mg TAMIFLU CAP 30 MG oseltamivir phosphate TAMIFLU CAP 45 MG oseltamivir phosphate TAMIFLU CAP 75 MG oseltamivir phosphate Antiherpetic Agents acyclovir cap 200 mg 1800 / 30 days 20 / 5 days 10 / 5 days 10 / 5 days 10 / 5 days acyclovir susp 200 mg/5ml AL1 Up to 12 yrs old GE 32 LAST UPDATED 09/2015

33 acyclovir tab 400 mg acyclovir tab 800 mg trifluridine ophth soln 1% Anxiolytics (NERVE CONDITIONS DRUGS) Anxiolytics, Other (ANXIETY DRUGS) buspirone hcl tab 10 mg buspirone hcl tab 15 mg buspirone hcl tab 30 mg buspirone hcl tab 5 mg buspirone hcl tab 7.5 mg doxepin hcl cap 10 mg doxepin hcl cap 100 mg doxepin hcl cap 150 mg doxepin hcl cap 25 mg doxepin hcl cap 50 mg DOXEPIN HCL CAP 75 MG doxepin hcl doxepin hcl conc 10 mg/ml Benzodiazepines (ANXIETY DRUGS) alprazolam tab 0.25 mg alprazolam tab 0.5 mg alprazolam tab 1 mg alprazolam tab 2 mg alprazolam tab sr 24hr 0.5 mg alprazolam tab sr 24hr 1 mg alprazolam tab sr 24hr 2 mg alprazolam tab sr 24hr 3 mg clorazepate dipotassium tab 15 mg clorazepate dipotassium tab 3.75 mg clorazepate dipotassium tab 7.5 mg GE 33 LAST UPDATED 09/2015

34 DIAZEM SOLUTION 1 MG/ML diazepam DIAZEM SOLUTION 5 MG/ML diazepam diazepam tab 10 mg diazepam tab 2 mg diazepam tab 5 mg lorazepam tab 0.5 mg lorazepam tab 1 mg lorazepam tab 2 mg oxazepam cap 10 mg oxazepam cap 15 mg oxazepam cap 30 mg temazepam cap 15 mg temazepam cap 30 mg Bipolar Agents (NERVE CONDITIONS DRUGS) Mood Stabilizers (MISCELLANEOUS NERVE CONDITIONS DRUGS) lithium carbonate cap 150 mg LITHIUM CARBONATE CAP 150 MG lithium carbonate lithium carbonate cap 300 mg lithium carbonate cap 600 mg LITHIUM CARBONATE CAP 600 MG lithium carbonate lithium carbonate tab 300 mg lithium carbonate tab cr 300 mg lithium carbonate tab cr 450 mg Blood Glucose Regulators (HORMONE AND DIABETIC DRUGS) ANTIDIABETIC AGENTS (BLOOD SUGAR PRODUCTS) acarbose tab 100 mg acarbose tab 25 mg acarbose tab 50 mg GE 34 LAST UPDATED 09/2015

35 glimepiride tab 1 mg glimepiride tab 2 mg glimepiride tab 4 mg glipizide tab 10 mg glipizide tab 5 mg glipizide tab sr 24hr 10 mg 60 / 30 days glipizide tab sr 24hr 2.5 mg 60 / 30 days glipizide tab sr 24hr 5 mg 60 / 30 days glyburide micronized tab 1.5 mg glyburide micronized tab 3 mg glyburide micronized tab 6 mg glyburide tab 1.25 mg GLYBURIDE TAB 1.25 MG glyburide glyburide tab 2.5 mg GLYBURIDE TAB 2.5 MG glyburide glyburide tab 5 mg GLYBURIDE TAB 5 MG glyburide glyburide-metformin tab mg glyburide-metformin tab mg glyburide-metformin tab mg JANUMET TAB MG sitagliptin-metformin hcl JANUMET TAB MG sitagliptin-metformin hcl JANUVIA TAB 100 MG sitagliptin phosphate JANUVIA TAB 25 MG sitagliptin phosphate ST ST ST ST 60 / 30 days 60 / 30 days 30 / 30 days 30 / 30 days GE 35 LAST UPDATED 09/2015

36 JANUVIA TAB 50 MG sitagliptin phosphate metformin hcl tab 1000 mg metformin hcl tab 500 mg metformin hcl tab 850 mg metformin hcl tab sr 24hr 500 mg metformin hcl tab sr 24hr 750 mg ST 30 / 30 days nateglinide tab 120 mg 90 / 30 days nateglinide tab 60 mg 90 / 30 days pioglitazone hcl tab 15 mg (base equiv) 30 / 30 days pioglitazone hcl tab 30 mg (base equiv) 30 / 30 days pioglitazone hcl tab 45 mg (base equiv) 30 / 30 days pioglitazone hcl-metformin hcl tab mg 60 / 30 days pioglitazone hcl-metformin hcl tab mg 60 / 30 days GLYCEMIC AGENTS (LOW BLOOD GLUCOSE DRUGS) GLUCAGON EMERGENCY KIT 1 MG glucagon (rdna) Insulins (INJECTABLE DIABETES, BLOOD SUGAR DRUGS) APIDRA SOLOSTAR SOLN PEN 100 UNIT/ML insulin glulisine APIDRA SOLUTION 100 UNIT/ML insulin glulisine LANTUS SOLOSTAR SOLN PEN 100 UNIT/ML insulin glargine LANTUS SOLUTION 100 UNIT/ML insulin glargine LEVEMIR SOLUTION 100 UNIT/ML insulin detemir NOVOLIN 70/30 RELION SUSPENSION (70-30) 100 UNIT/ML insulin isophane & reg (human) NOVOLIN 70/30 SUSPENSION (70-30) 100 UNIT/ML insulin isophane & reg (human) NOVOLIN N RELION SUSPENSION 100 UNIT/ML insulin isophane (human) GE 36 LAST UPDATED 09/2015

37 NOVOLIN N SUSPENSION 100 UNIT/ML insulin isophane (human) NOVOLIN R RELION SOLUTION 100 UNIT/ML insulin regular (human) NOVOLIN R SOLUTION 100 UNIT/ML insulin regular (human) NOVOLOG MIX 70/30 SUSPENSION (70-30) 100 UNIT/ML insulin aspart protamine & aspart (human) Blood Products/Modifiers/Volume Expanders (BLOOD DISORDER DRUGS) ANTICOAGULANTS (BLOOD THINNERS) enoxaparin sodium inj 100 mg/ml enoxaparin sodium inj 120 mg/0.8ml enoxaparin sodium inj 150 mg/ml enoxaparin sodium inj 30 mg/0.3ml enoxaparin sodium inj 300 mg/3ml enoxaparin sodium inj 40 mg/0.4ml enoxaparin sodium inj 60 mg/0.6ml enoxaparin sodium inj 80 mg/0.8ml heparin sodium (porcine) inj 1000 unit/ml heparin sodium (porcine) inj unit/ml heparin sodium (porcine) inj unit/ml heparin sodium (porcine) inj 5000 unit/ml heparin sodium (porcine) pf inj 5000 unit/0.5ml warfarin sodium tab 1 mg GL GL GL GL GL GL GL GL Female Female Female Female Female Female Female Female GE 37 LAST UPDATED 09/2015

38 warfarin sodium tab 10 mg warfarin sodium tab 2 mg warfarin sodium tab 2.5 mg warfarin sodium tab 3 mg warfarin sodium tab 4 mg warfarin sodium tab 5 mg warfarin sodium tab 6 mg warfarin sodium tab 7.5 mg XARELTO TAB 10 MG rivaroxaban Blood Formation Modifiers (BLOOD FORMATION DRUGS) anagrelide hcl cap 0.5 mg anagrelide hcl cap 1 mg EPOGEN SOLUTION UNIT/ML epoetin alfa EPOGEN SOLUTION 2000 UNIT/ML epoetin alfa EPOGEN SOLUTION 3000 UNIT/ML epoetin alfa EPOGEN SOLUTION 4000 UNIT/ML epoetin alfa NEUPOGEN SOLUTION 300 MCG/0.5ML filgrastim NEUPOGEN SOLUTION 300 MCG/ML filgrastim NEUPOGEN SOLUTION 480 MCG/0.8ML filgrastim NEUPOGEN SOLUTION 480 MCG/1.6ML filgrastim PROCRIT SOLUTION UNIT/ML epoetin alfa PROCRIT SOLUTION 2000 UNIT/ML epoetin alfa PROCRIT SOLUTION 3000 UNIT/ML epoetin alfa 35 / 35 days GE 38 LAST UPDATED 09/2015

39 PROCRIT SOLUTION 4000 UNIT/ML epoetin alfa PROCRIT SOLUTION UNIT/ML epoetin alfa DRUG DESCRIPTION (RX) Platelet Modifying Agents (BLOOD THINNERS) cilostazol tab 100 mg cilostazol tab 50 mg clopidogrel bisulfate tab 300 mg (base equiv) 5 / 90 days clopidogrel bisulfate tab 75 mg (base equiv) 30 / 30 days dipyridamole tab 25 mg dipyridamole tab 50 mg dipyridamole tab 75 mg EFFIENT TAB 10 MG prasugrel hcl EFFIENT TAB 5 MG prasugrel hcl ticlopidine hcl tab 250 mg TICLOPIDINE HCL TAB 250 MG ticlopidine hcl Cardiovascular Agents (HEART AND CIRCULATION CONDITIONS DRUGS) Alpha-adrenergic Agonists (HEART AND CIRCULATION CONDITIONS DRUGS) clonidine hcl tab 0.1 mg clonidine hcl tab 0.2 mg clonidine hcl tab 0.3 mg guanfacine hcl tab 1 mg guanfacine hcl tab 2 mg methyldopa tab 250 mg methyldopa tab 500 mg midodrine hcl tab 10 mg 120 / 30 days midodrine hcl tab 2.5 mg 30 / 30 days midodrine hcl tab 5 mg 240 / 30 days GE 39 LAST UPDATED 09/2015

40 Alpha-adrenergic Blocking Agents (BLOOD PRESSURE DRUGS) prazosin hcl cap 1 mg prazosin hcl cap 2 mg prazosin hcl cap 5 mg ANGIOTENSIN II RECEPTOR ANTAGONISTS (BLOOD PRESSURE DRUGS) irbesartan tab 150 mg 30 / 30 days irbesartan tab 300 mg 30 / 30 days irbesartan tab 75 mg 30 / 30 days irbesartan-hydrochlorothiazide tab mg 30 / 30 days irbesartan-hydrochlorothiazide tab mg 30 / 30 days losartan potassium & hydrochlorothiazide tab mg 30 / 30 days losartan potassium & hydrochlorothiazide tab mg 30 / 30 days losartan potassium & hydrochlorothiazide tab mg 30 / 30 days losartan potassium tab 100 mg 30 / 30 days losartan potassium tab 25 mg 30 / 30 days losartan potassium tab 50 mg 30 / 30 days Angiotensin-converting Enzyme (ACE) Inhibitors (BLOOD PRESSURE DRUGS) benazepril & hydrochlorothiazide tab mg 30 / 30 days benazepril & hydrochlorothiazide tab mg 30 / 30 days benazepril & hydrochlorothiazide tab mg 30 / 30 days benazepril & hydrochlorothiazide tab mg 30 / 30 days benazepril hcl tab 10 mg 30 / 30 days benazepril hcl tab 20 mg 30 / 30 days benazepril hcl tab 40 mg benazepril hcl tab 5 mg 30 / 30 days captopril & hydrochlorothiazide tab mg 30 / 30 days captopril & hydrochlorothiazide tab mg 30 / 30 days GE 40 LAST UPDATED 09/2015

41 captopril & hydrochlorothiazide tab mg 30 / 30 days captopril & hydrochlorothiazide tab mg 30 / 30 days captopril tab 100 mg captopril tab 12.5 mg 90 / 30 days captopril tab 25 mg 90 / 30 days captopril tab 50 mg 90 / 30 days CAPTOPRIL-HYDROCHLOROTHIAZIDE TAB MG captopril & hydrochlorothiazide CAPTOPRIL-HYDROCHLOROTHIAZIDE TAB MG captopril & hydrochlorothiazide CAPTOPRIL-HYDROCHLOROTHIAZIDE TAB MG captopril & hydrochlorothiazide CAPTOPRIL-HYDROCHLOROTHIAZIDE TAB MG captopril & hydrochlorothiazide 30 / 30 days 30 / 30 days 30 / 30 days 30 / 30 days enalapril maleate & hydrochlorothiazide tab mg 30 / 30 days enalapril maleate & hydrochlorothiazide tab mg 30 / 30 days enalapril maleate tab 10 mg 30 / 30 days enalapril maleate tab 2.5 mg 30 / 30 days enalapril maleate tab 20 mg enalapril maleate tab 5 mg 30 / 30 days fosinopril sodium tab 10 mg 30 / 30 days fosinopril sodium tab 20 mg 30 / 30 days fosinopril sodium tab 40 mg lisinopril & hydrochlorothiazide tab mg 30 / 30 days lisinopril & hydrochlorothiazide tab mg 30 / 30 days lisinopril & hydrochlorothiazide tab mg 30 / 30 days lisinopril tab 10 mg 30 / 30 days lisinopril tab 2.5 mg 30 / 30 days lisinopril tab 20 mg 30 / 30 days GE 41 LAST UPDATED 09/2015

42 lisinopril tab 30 mg 30 / 30 days lisinopril tab 40 mg lisinopril tab 5 mg 30 / 30 days moexipril hcl tab 15 mg moexipril hcl tab 7.5 mg 30 / 30 days quinapril hcl tab 10 mg 30 / 30 days quinapril hcl tab 20 mg 30 / 30 days quinapril hcl tab 40 mg quinapril hcl tab 5 mg 30 / 30 days quinapril-hydrochlorothiazide tab mg 30 / 30 days quinapril-hydrochlorothiazide tab mg 30 / 30 days quinapril-hydrochlorothiazide tab mg 30 / 30 days ramipril cap 1.25 mg 30 / 30 days ramipril cap 10 mg ramipril cap 2.5 mg 30 / 30 days ramipril cap 5 mg 30 / 30 days trandolapril tab 1 mg 30 / 30 days trandolapril tab 2 mg 30 / 30 days trandolapril tab 4 mg ANTIARRHYTHMICS (HEART REGULATION DRUGS) amiodarone hcl tab 200 mg disopyramide phosphate cap 100 mg disopyramide phosphate cap 150 mg flecainide acetate tab 100 mg flecainide acetate tab 150 mg flecainide acetate tab 50 mg NORCE CR CAP ER 12H 100 MG disopyramide phosphate NORCE CR CAP ER 12H 150 MG disopyramide phosphate 60 / 30 days 120 / 30 days GE 42 LAST UPDATED 09/2015