Buckeye Community Health Plan Preferred Drug List

Transcription

1 Buckeye Community Health Plan Preferred Drug List Approved August 8, 2014 Effective October 1, 2014 Preferred Drug List Medication Locator Instructions: 1. With the PDF open, click on the Edit menu, then click Find 2. In the Find box type the name of the medication you want to locate 3. Click the Next button until you find the medication(s) you are looking for BCHP-MM

2 Buckeye Community Health Plan Pharmacy Program Buckeye Community Health Plan, Inc. (Buckeye) is committed to providing appropriate, high quality, and cost effective drug therapy to all Buckeye members. Buckeye works with providers and pharmacists to ensure that medications used to treat a variety of conditions and diseases are covered. Buckeye covers prescription medications and certain over- the-counter (OTC) medications when ordered by a physician/clinician. The pharmacy program does not cover all medications. Some medications require prior authorization (PA) or have limitations on age, dosage, and maximum quantities. This section provides an overview of the Buckeye pharmacy program. For more detailed information, please visit our website at The following program covers both the Covered Families & Children (CFC) and Aged, Blind or Disabled (ABD) Ohio Medicaid consumers who are enrolled in Buckeye. Plan Preferred Drug List and Prior Authorization List The Buckeye Preferred Drug List (PDL) describes the circumstances under which contracted pharmacy providers will be reimbursed for medications dispensed to members covered under the program. All drugs covered under the Ohio Medicaid program are available for Buckeye members. The PDL includes all drugs available without PA and those agents that have the restrictions of (ST). The PA list includes those drugs that require PA for coverage. The PDL applies to drugs you receive at retail pharmacies. The PDL is continually evaluated by the Buckeye Pharmacy and Therapeutics (P&T) Committee to promote the appropriate and cost-effective use of medications. The Committee is composed of the Buckeye Medical Director, Buckeye Pharmacy Director, and several Ohio primary care physicians, pharmacists, and specialists. The PDL does not: Require or prohibit the prescribing or dispensing of any medication Substitute for the independent professional judgment of the physician/clinician or pharmacist, or Relieve the physician/clinician or pharmacist of any obligation to the patient or others US Script With the exceptions of biopharmaceuticals and specialty drugs, Buckeye works with US Script to process all pharmacy claims for prescribed drugs. Some drugs on the Buckeye PDL and PA list require a PA and US Script is responsible for administering this process. US Script is our Pharmacy Benefit Manager. Follow these guidelines for efficient processing of your authorization requests: 1. Complete the Buckeye Community Health Plan/US Script form: Medication Prior Authorization Request Form. 2. Fax to US Script at Once approved, US Script notifies the prescriber by fax. 4. If the clinical information provided does not explain the medical necessity for the requested PA medication, US Script will deny the request and offer PDL alternatives to the prescriber by fax. 5. For urgent or after-hours requests, a pharmacy can provide up to a 72-hour emergency supply of medication by calling

3 Prior Authorization Process The Buckeye PDL includes a broad spectrum of brand name and generic drugs. Clinicians are encouraged to prescribe from the Buckeye PDL for their patients who are members of Buckeye. Some drugs will require PA and are listed on the PA list. In addition, all name brand drugs not listed on either the PDL or PA list will require prior authorization. If a request for authorization is needed the information should be submitted by your physician/clinician to US Script on the Buckeye Community Health Plan/US Script form: Medication Prior Authorization Request Form. This form should be faxed to US Script at This document is located on the Buckeye website at Buckeye will cover the medication if it is determined that: 1. There is a medical reason you need the specific medication. 2. Depending on the medication, other medications on the PDL have not worked. All reviews are performed by a licensed clinical pharmacist using the criteria established by the Buckeye P&T Committee. Once approved, US Script notifies the physician/clinician by fax. If the clinical information provided does not meet the coverage criteria for the requested medication Buckeye we will notify you and your physician/clinician of alternatives and provide information regarding the appeal process. The P&T committee has reviewed and approved, with input from its members and in consideration of medical evidence, the list of drugs requiring prior authorization. This PDL attempts to provide appropriate and cost-effective drug therapy to all members covered under the Buckeye pharmacy program. If a patient requires a brand name medication that does not appear on the PDL, the physician/clinician can make a PA request for the brand name medication. It is anticipated that such exceptions will be rare and that PDL medications will be appropriate to treat the vast majority of medical conditions. A phone or fax-in process is available for PA requests. US Script Contact : Prior Authorization Fax Prior Authorization Phone Mailing Address: 2425 W Shaw Ave, Fresno, CA When calling, please have patient information, including Medicaid number, complete diagnosis, medication history and current medications readily available. US Script will provide a decision to the request by fax or phone within 24 hours. When incomplete information is received to support medical necessity of a drug requiring PA, the request will be denied. If the request is approved, information in the on-line pharmacy claims processing system will be changed to allow the specific member to receive this specific drug. If the request is denied, information about the denial will be provided to the clinician. Clinicians are requested to utilize the PDL when prescribing medication for those patients covered by the Buckeye pharmacy program. If a pharmacist receives a prescription for a drug that requires a PA, the pharmacist should attempt to contact the clinician to request a change to a product included in the PDL. Phone Numbers for Buckeye Community Health Plan Member Services The phone and fax lines listed in the Prior Authorization Process section are dedicated to clinicians requesting PA medication items only. Members can not be assisted if they call the PA toll-free number. Buckeye Member Services may be reached at (TTY ).

4 Transition Period Buckeye members new to managed care will be able to receive their prescription drugs with no new PA requirements than traditional Fee-for-Service (FFS) Medicaid for 30 days they are enrolled in our plan if the prescription drug does not require PA by traditional FFS Medicaid. This means that if you needed a PA under traditional FFS Medicaid to get your prescriptions you will most likely still need a PA to get the same medication. If you have not needed PA under traditional FFS Medicaid to get your prescription you will not need PA from Buckeye to get the same medication for the first 30 days you are enrolled. This will allow you and your doctor time to consider other medications that do not require PA and to learn the steps to getting PA. Buckeye s PDL and PA List identify the drugs that will require PA once you have been a managed care member for 30 days. If you are not sure when you will need to have your medications prior authorized or you have other questions about continuing to get your medications, call member services at (TTY ). 72-Hour Emergency Supply Policy State and federal law require that a pharmacy dispense a 72-hour (3-day) supply of medication to any patient awaiting a PA determination. The purpose is to avoid interruption of current therapy or delay in the initiation of therapy. All participating pharmacies are authorized to provide a 72-hour supply of medication and will be reimbursed for the ingredient cost and dispensing fee of the 72-hour supply of medication, whether or not the PA request is ultimately approved or denied. The pharmacy must call the US Script Pharmacy Help Desk at for a prescription override to submit the 72-hour medication supply for payment. Some medications listed on the Buckeye PDL may require specific medications to be used before you can receive the step therapy medication. If Buckeye has a record that the required medication was tried first the ST medications are automatically covered. If Buckeye does not have a record that the required medication was tried, you or your physician/clinician may be required to provide additional information. If Buckeye does not grant PA we will notify you and your physician/clinician and provide information regarding the appeal process. Dispensing Limits, Quantity Limits, and Age Limits Drugs may be dispensed up to a maximum 31 day supply for each new or refill non-controlled substance. A total of 80 percent (80%) of the days supplied must have elapsed before the prescription can be refilled. A prescription can be filled after 26 days. Dispensing outside the quantity limit (QL) or age limits (AL) requires PA. Buckeye may limit how much of a medication you can get at one time. If the physician/clinician feels you have a medical reason for getting a larger amount, he or she can ask for PA. If Buckeye does not grant PA we will notify you and your physician/clinician and provide information regarding the appeal process. Some medications on the Buckeye PDL may have AL. These are set for certain drugs based on Food and Drug Administration (FDA) approved labeling and for safety concerns and quality standards of care. The AL aligns with current FDA alerts for the appropriate use of pharmaceuticals.

5 Gender Limits Some medications on the Buckeye PDL may be limited to one gender. These medications have a GL after them on the PDL. These limits are set for certain drugs based on FDA approved labeling and for safety concerns and quality standards of care. Gender limits align with current FDA alerts for the appropriate use of pharmaceuticals. Medical Necessity Requests If you require a medication that does not appear on the PDL, you or your physician/clinician can make a medical necessity request for the medication. It is anticipated that such exceptions will be rare and that PDL medications will be appropriate to treat the vast majority of medical conditions. Buckeye requires: Documentation of failure of at least two PDL agents within the same therapeutic class (provided two agents exist in the therapeutic category with comparable labeled indications) for the same diagnosis (e.g. migraine, neuropathic pain, etc.); or Documented intolerance or contraindication to at least two PDL agents within the same therapeutic class (provided two agents exist in the therapeutic category with comparable labeled indications); or Documented clinical history or presentation where the patient is not a candidate for any of the PDL agents for the indication. All reviews are performed by a licensed clinical pharmacist using the criteria established by the Buckeye P&T Committee. If the clinical information provided does not meet the coverage criteria for the requested medication Buckeye will notify you and your physician/clinician of alternatives and provide information regarding the appeal process. Appropriate Use and Safety Edits Your health and safety is a priority for Buckeye. One of the ways we address your safety is through Pointof-Sale (POS) edits at the time a prescription is processed at the pharmacy. These edits are based on FDA recommendations and promote safe and effective medication utilization. information about the drugs that are part of the Appropriate Use and Safety Edits can be found in the Appropriate Use and Safety Edits document located on the Buckeye website at DUR (Drug Utilization Review) Programs Buckeye will monitor ongoing prescribing of medications for clinical appropriateness. Buckeye reviews prescribing retrospectively to review for both safety and efficacy. Buckeye will work with US Script to review for such things as disease management, fraud and abuse (i.e. Coordinated Services Program), and prescriber profiling. Prescriber or member outreach may occur based on prescribing/dispensing patterns. Buckeye will continue to monitor for issues going forward and take action as needed. Mandatory Generic Substitution When generic drugs are available, the brand name drug will not be covered without Buckeye PA. Generic drugs have the same active ingredient and work the same as brand name drugs. If you or your physician/clinician feels a brand name drug is medically necessary, the physician/clinician can ask for PA.

6 We will cover the brand name drug according to our clinical guidelines if there is a medical reason you need the particular brand name drug. If Buckeye does not grant PA we will notify you and your physician/clinician and provide information regarding the appeal process. The provision is waived for the following products due to their narrow therapeutic index (NTI) as recognized by current medical and pharmaceutical literature: Aminophylline, Amiodarone, Carbamazepine, Clozapine, Cyclosporine, Digoxin, Disopyramide, Ethosuximide, Flecainide, L-thyroxine, Lithium, Phenytoin, Procainamide, Propafenone, Theophylline, Thyroid, Valproate Sodium, Valproic Acid, and Warfarin. Over-The-Counter Medications The pharmacy program covers a large selection of OTC medications. All covered OTC medications appear in the PDL. All OTC medications must be written on a valid prescription by a licensed physician/clinician in order to be reimbursed. Filling a Prescription You can have prescriptions filled at a Buckeye network pharmacy. If you decide to have a prescription filled at a network pharmacy you can locate a pharmacy near you by contacting a Buckeye Member Services Representative. At the pharmacy you will need to provide the pharmacist with your prescription and your Buckeye ID card. Please visit the Buckeye website at to access the Buckeye PDL, Buckeye PA lists, important forms, and provider/member information 24 hours a day, seven days a week. Mail Order Program Buckeye Community Health Plan offers a 90 day supply (3 month supply) of maintenance medications by mail. These drugs are used to treat long-term conditions or illnesses. You can find a list of covered maintenance medications in the Maintenance Drug Pharmacy Program document located on the Buckeye website at Please contact a Buckeye Member Service Representative if you have any questions. To transfer a current prescription or to have you doctor phone a prescription directly to our mail order pharmacy they may call RxDirect at

7 Buckeye Community Health Plan Pharmacy Program - Working with Our Pharmacy Benefit Managers Buckeye works with two Pharmacy Benefit Managers (PBMs). Health is the preferred provider of biopharmaceuticals and injectables for Buckeye. US Script administers all other prescribed drugs. Certain drugs require PA to be approved for payment by Buckeye. These include: Some Buckeye drugs listed on the PA list Most injectables including Procrit, Neulasta and Neupogen. Health Biopharmaceuticals and Injectables Health is the provider of biopharmaceuticals and injectables for Buckeye. Most injectables require PA to be approved for payment. Our Medical Director oversees the clinical review. Buckeye provides a number of biopharmaceutical products through the Biopharmaceutical Program. Most biopharmaceuticals and injectables require a PA to be approved for payment by Buckeye; however, PA requirements are programmed specific to the drug as indicated in the list provided in the Biopharmaceutical Program document located on the Buckeye website at Follow these guidelines for the most efficient processing of your authorization requests. Providers can request that Health deliver the specialty drug to the office/member. If you want Health to deliver the specialty drug to the office/member: 1. Fax the Health PA form to for PA. 2. If approved, Health will contact the provider or member for delivery confirmation. Pharmacy and Therapeutics Committee The Buckeye Pharmacy and Therapeutics (P&T) Committee continually evaluates the therapeutic classes included in the PDL. The Committee is composed of the Buckeye Medical Director, Buckeye Pharmacist, and several community based primary care physicians and specialists. The primary purpose of the Committee is to assist in developing and monitoring the Buckeye PDL and to establish programs and procedures that promote the appropriate and cost-effective use of medications. The P&T Committee schedules meetings at least twice yearly, and coordinates reviews with a national P&T Committee which meets at least 4 times a year. Changes to the Buckeye PDL are done in conjunction with the approval of the State of Ohio. Buckeye will meet with the State quarterly to review any proposed changes and update the PDL and PA lists accordingly based on the results of both the Buckeye P&T Committee and the requirements from the State of Ohio. Buckeye will follow all State policies regarding member notification when changes are made to the PA list. Unapproved Use of Preferred Medication Medication coverage under this program is limited to non-experimental indications as approved by the FDA. Other indications may also be covered if they are accepted as safe and effective using current medical and pharmaceutical reference texts and evidence-based medicine. Reimbursement decisions for

8 specific non-approved indications will be made by Buckeye. Experimental drugs and investigational drugs are not eligible for coverage. Benefit Exclusions The following drug categories are not part of the Buckeye PDL and are not covered by the 72-hour emergency supply policy: Fertility enhancing drugs Anorexia, weight loss, or weight gain drugs Immunizations and vaccines (except flu vaccine) Drug Efficacy Study Implementation (DESI) and Identical, Related and Similar (IRS) drugs that are classified as ineffective Infusion therapy and supplies Drugs and other agents used for cosmetic purposes or for hair growth Erectile dysfunction drugs prescribed to treat impotence DESI drugs products and known related drug products are defined as less than effective by the FDA because there is a lack of substantial evidence of effectiveness for all labeling indications and because a compelling justification for their medical need has not been established. State programs may allow coverage of certain DESI drugs. Any DESI drugs that are covered are listed in the PDL. Newly Approved Products We review new drugs for safety and effectiveness for the first 12 months before adding them to the Buckeye Community PDL. During this period, access to these medications will be considered through the PA review process. If Buckeye does not grant PA we will notify you and your physician/clinician and provide information regarding the appeal process. Medical Benefits The following drugs and medical services are a part of the Buckeye medical benefit and are not available at the retail pharmacy: 1. Members will receive vaccines as a medical benefit under physician reimbursement if listed the vaccine covered under the vaccine for children program. 2. Cosmetic-botox is a medical benefit that is covered for non-cosmetic purposes only- it requires a PA from Buckeye. 3. Blood and blood products. 4. Those specialty injectable drugs available as a medical benefit. Most injectables require PA from Buckeye. Prescribers who request medical prior authorizations at US Script will be redirected to contact Buckeye Community Health Plan as applicable.

9 DME/Home Health Benefits The following medical services are a part of the Buckeye medical benefit and are not available at the retail pharmacy: 1. Enteral products 2. Nebulizers 3. Medical supplies Injectable Drugs Injections that are self-administered by the member and/or a family member and appear on the PDL are covered by the Buckeye pharmacy program. Insulin vials, Glucagon Kit, Epi-pen, Ana-Kit, Imitrex, and Depo-Provera IM are covered by Buckeye and do not require a PA. Pre-filled insulin cartridges and syringes require PA. All other injectables require PA. Coordinated Services Program Consumers eligible for Ohio Medicaid may be selected for enrollment in the Coordinated Services Program, or CSP. CSP enrollees must get medications filled at one pharmacy and coordinate medical services through their primary care provider. After being enrolled in CSP, the member will still be able to get all medically necessary Medicaid- covered health care services. However, the member must select one pharmacy to fill their prescriptions. If they go to a different pharmacy without approval, their medication will not be covered. The member also has a primary care provider (PCP) to coordinate their health care services with other providers. Except in an emergency, the member should contact their PCP before seeing other providers. By knowing the complete medical history, the PCP and pharmacy can take better care of the patient. A care manager will also contact the member to discuss care management services. We help keep you informed The Buckeye Pharmacy Director, a registered pharmacist, compiles current pharmacological policy and information about important seasonal topics such as Respiratory Syncytial Virus (RSV) and influenza. The information is consistent with published guidelines and is mailed to network providers as a service. The most current Buckeye PDL and PA List can be downloaded from our website at Contacts for Pharmacy Appeals/Grievances Members: In the event that a member disagrees with the decision regarding coverage of a medication, the member may file an appeal with Buckeye by calling Buckeye Member Services at (TTY ). Physicians / Clinicians: In the event that a clinician disagrees with the decision regarding coverage of a medication, the clinician may request an appeal by submitting additional information to Buckeye in writing to the Appeals Department at the following address:

10 Buckeye Community Health Plan 4349 Easton Way, Suite 200 Columbus, Ohio A decision will be rendered and the clinician will be notified with a mailed response. An expedited appeal may be requested at any time the provider believes the adverse determination might seriously jeopardize the life or health of a member by calling Buckeye at ext (TTY ). A response will be rendered the same day as receipt of complete information. In circumstances that require research, a same day response may not be possible. Abbreviations The following notations and abbreviations may be found throughout the drug listing in the limitations and restrictions column. DS: DS/DU: Max Days: Max Fills: Max Qty: Min DS: PA: Pkg Size: QL: Days Supply Days Supply per Dosage Unit Maximum Days Supply Maximum Fills (per a designated time period) Maximum Quantity (per claim or designated time period) Minimum Days Supply Prior Authorization Package Size Quantity Limit

11 Over-the-Counter Pharmacy Program T he Buckeye Community Health Plan pharmacy program covers a variety of OTC products. The products listed below are covered when a valid prescription from a licensed clinician that meets all the legal requirements for a prescription is presented to be filled at a Buckeye network pharmacy. Covered products are available in quantities up to a 30-day supply. Refer to the Buckeye Community Health Plan PDL for a complete listing of available OTC items. Please note that generic products must be prescribed when available. ANALGESICS & ANTIPYRETICS Acetaminophen generic tablets, elixir, drops, suppositories Aspirin generic tablets ANTACIDS Maalox generic tablets, liquid Mylanta DS generic liquid ANTHELMINTICS Pin-X Pyrantel pamoate tablets/chewable/suspension ANTI-DIARRHEALS Imodium A-D generic (loperamide) capsules Kaopectate (attapulgite) suspension Pepto-Bismol generic (pink bismuth) chewable/liquid ANTI-EMETIC Antivert generic (meclizine) ANTI-FLATULENTS Gas-X chewables generic simethicone 80mg Mylicon drops** generic simethicone 40 mg/0.6ml ANTI-HISTAMINES Benadryl generic (diphenhydramine) capsules, liquid Chlor-Trimeton generic (chlorpheniramine) tablets, liquid Claritin generic (loratadine) tablets, syrup Claritin-D generic (loratadine/ pseudoephedrine) tablets Zyrtec generic (cetirizxine) tablets/chewables/liquid CONTRACEPTIVES Condoms lubricated COUGH/EXPECTORANT/DECONGESTANT Dallergy drops (chlorpheniramine & phenylephrine liquid) 1-2 mg/ml Decon A drops (brompheniramine & phenylephrine liquid) 2-5 mg/ml Delsym DM Polistirex Liquid CR Dimetapp generic (brompheniramine & phenylephrine elixir) mg/5ml Mucinex generic (guaifenesin) tablets Robitussin generic (guaifenesin) syrup Robitussin DM generic (guaifenesin DM) syrup Sudafed generic (pseudoephedrine) tablets, liquid Triaminic generic AM, Night, soft chewable tablets DILUENTS Sodium chloride generic aerosol solution DME PRODUCTS Diabetic testing supplies (TRUEtest preferred) Gauze pad 2 x2, 3 x3, 4 x4 Peak Flow Meters Spacers OTIC PREPARATIONS Debrox drops generic (carbamide peroxide 6.5%) ELECTROLYTES Electrolyte solutions generic H2-RECEPTOR ANTAGONISTS Pepcid generic (famotidine) 10mg tablets Tagamet generic (cimetidine) 200mg tablets Zantac generic (ranitidine) 75mg tablets IRON PREPERATIONS Ferrous fumarate generic tablets Ferrous gluconate generic tablets Ferrous sulfate generic tablets, elixir, drops Polysaccharide Iron Complex generic capsules 150mg LAXATIVES Citrate of magnesium generic Colace generic (docusate sodium) capsules Dulcolax generic (bisacodyl) tablets, suppositories Fleet enema generic Metamucil generic (psyllium) Milk Of Magnesium generic MOM Miralax OTC Pediatric glycerin suppositories generic Senokot generic (senna) tablets Sorbitol oral solution 70% MINERALS Citracal generic (calcium citrate) - tablets Citracal+D generic (calcium citrate+d) tablets Magnesium oxide generic Neutra-phos/K powder generic Oscal 500+Vit D generic (calcium carbonate+d) tablets Tums Chew Tabs generic (calcium carbonate) Zinc sulfate generic capsules 220mg

12 NASAL Nasalcrom spray generic Saline nasal spray/gel/solution NSAIDS Ibuprofen generic tablets, chewable, liquid, drops Naproxen generic tablets NUTRITIONAL SUPPLEMENTS Omega-3 fatty acid capsules 1000mg, 1200mg OPHTHALMIC PREPARATIONS Alaway (ketotifen 0.025%) Artificial tears generic polyvinyl alcohol drops Lacri-lube generic (artificial tears) ointment Naphcon-A generic (naphazoline/pheniramine 0.025/0.3) Zaditor-OTC (ketotifen 0.025%) PEDICULICIDES NIX generic (permethrin) RID generic (pyrethrins/piperonyl butoxide) PROTON PUMP INHIBITORS (PPIS) Prevacid 24 HR capsules Prilosec OTC tablets SLEEPING AIDS Nytol generic (diphenhydramine sleep) tablets/capsules Unisom generic (doxylamine sleep) tablets SMOKING DETERRENTS Commit Lozenges NicoDerm CQ transdermal patch generic Nicorette DS gum generic Nicorette gum generic Nicotrol transdermal patch generic TOPICALS AmLactin generic Bacitracin ointment generic Benzoyl peroxide generic liquid/gel/lotion Calamine generic Capsaicin cream/gel/lotion generic Clotrimazole generic cream, vaginal cream/inserts Hibiclens generic (chlorhexidine gluconate liquid) 4% Hydrocortisone generic cream, lotion, ointment, solution Miconazole generic cream, vaginal cream/inserts Polysporin generic ointment Nupercainal generic (dibucaine rectal ointment) 1% Selsun Blue generic (selenium shampoo) 1% Tolnaftate generic cream Triple antibiotic ointment Vagistat generic (tioconazole vaginal ointment) 6.5% Xylocaine generic (lidocaine) gel 2% Zinc oxide ointment generic VITAMINS Folic acid generic Multi-vitamins with iron generic tablets, liquid, chewable Multi-vitamins generic tablets, liquid, chewable Niacin generic Prenatal vitamins generic tablets Pyridoxine generic tablets Slo-Niacin CR tablets Thiamine generic tablets

13 MEDICATION PRIOR AUTHORIZATION REQUEST FORM Buckeye Community Health Plan, Ohio Do Not Use This Form for Biopharmaceutical Products FAX this completed form to OR Mail requests to: US Script PA Dept / 2425 West Shaw Avenue / Fresno, CA Call to request a 72-hour supply of medication. I. Provider II. Member Prescriber name (print): Member name: Prescriber Specialty: Identification number: Fax: Phone: Date of Birth: Office Contact Name: Medication allergies: III. Drug (One drug request per form) Drug name and strength: Dosage form: Dosage interval (sig): Qty per Day: Diagnosis relevant to this request: Expected length of therapy: Medication History for this Diagnosis A. Is member currently treated on this medication? yes; How Long? [go to item B] no [skip items B & C; go to item D] B. Is this request for continuation of a previous approval? yes [go to item C] no [skip item C; go to item D] C. Has strength, dosage, or quantity required per day increased or decreased? yes [go to item D] D. Please indicate previous treatment and outcomes below. Drug Name Dates of Therapy (include strength and dosage) no [skip item D; indicate rationale for continuation in Section IV and submit form] Reason for Discontinuation NOTE: Confirmation of use will be made from member history on file; prior use of preferred drugs is a part of the exception criteria. The Buckeye Community Health Plan Preferred Drug List (PDL) is available on the Buckeye Community Health Plan website at IV. Rationale for Request / Pertinent Clinical (Required for all Prior Authorizations) Appropriate clinical information to support the request on Provider Signature: Date: the basis of medical necessity must be submitted. US Script will respond via fax or phone within 24 hours of receipt of all necessary information, except during weekends and holidays. Requests for prior authorization (PA) must include member name, ID#, and drug name. Incomplete forms will delay processing. Please include lab reports with requests when appropriate (e.g., Culture and Sensitivity; Hemoglobin A1C; Serum Creatinine; CD4; Hematocrit; WBC, etc.) *Contact Buckeye Community Health Plan at for Biopharmaceutical Products*

14 PENICILLINS Penicillin V Potassium Tab 250 Penicillin V Potassium Tab 500 Penicillin V Potassium For Soln 125 /5ML Penicillin V Potassium For Soln 250 /5ML Amoxicillin (Trihydrate) Cap 250 Amoxicillin (Trihydrate) Cap 500 Amoxicillin (Trihydrate) Tab 875 AMOXIL Amoxicillin (Trihydrate) Chew Tab 125 Amoxicillin (Trihydrate) Chew Tab 250 Amoxicillin (Trihydrate) Chew Tab 400 Amoxicillin (Trihydrate) For Susp 50 /ML Amoxicillin (Trihydrate) For Susp 125 /5ML Amoxicillin (Trihydrate) For Susp 125 /5ML Amoxicillin (Trihydrate) For Susp 250 /5ML Amoxicillin (Trihydrate) For Susp 400 /5ML Ampicillin Cap 250 Ampicillin Cap 500 Ampicillin For Susp 125 /5ML AUGMENTIN AUGMENTIN AUGMENTIN AUGMENTIN AUGMENTIN AUGMENTIN AUGMENTIN AUGMENTIN AUGMENTIN XR CEPHALOSPORINS Ampicillin For Susp 250 /5ML Dicloxacillin Sodium Cap 250 Dicloxacillin Sodium Cap 500 Amoxicillin & K Clavulanate Tab 250 Amoxicillin & K Clavulanate Tab 500 Amoxicillin & K Clavulanate Tab 875 Amoxicillin & K Clavulanate Chew Tab 200 Amoxicillin & K Clavulanate Chew Tab 250 Amoxicillin & K Clavulanate Chew Tab 400 Amoxicillin & K Clavulanate For Susp 125 /5ML Amoxicillin & K Clavulanate For Susp 200 /5ML Amoxicillin & K Clavulanate For Susp 250 /5ML Amoxicillin & K Clavulanate For Susp 400 /5ML Amoxicillin & K Clavulanate For Susp 600 /5ML Amoxicillin & K Clavulanate Tab SR 12HR Max Qty=30/claim Max Qty=30/claim Max Qty=20/claim Max Qty=20/claim Max Qty=30/claim Max Qty=20/claim Package Limit=2/claim Package Limit=2/claim Max Qty=40/30 days

15 DURICEF Cefadroxil Cap 500 Max Qty=20/claim CEFADROXIL 1 GM TABLET Max Qty=10/claim CEFADROXIL 250 /5 ML SUSP CEFADROXIL 500 /5 ML SUSP KEFLEX Cephalexin Cap 250 KEFLEX Cephalexin Cap 500 Cephalexin For Susp 125 /5ML Cephalexin For Susp 250 /5ML Cefaclor Cap 250 Cefaclor Cap 500 Cefaclor For Susp 125 /5ML Cefaclor For Susp 250 /5ML Cefaclor For Susp 375 /5ML Cefprozil Tab 250 Max Qty=20/claim Cefprozil Tab 500 Max Qty=20/claim Limit=2/claim; Pkg Size Cefprozil For Susp 125 /5ML 100: Package Limit=2/claim Cefprozil For Susp 250 /5ML Pkg Size 50: Package Limit=1/claim CEFTIN Cefuroxime Axetil Tab 250 Max Qty=20/claim CEFTIN Cefuroxime Axetil Tab 500 Max Qty=20/claim CEFTIN Cefuroxime Axetil For Susp 125 /5ML CEFTIN Susp 250 /5ML OMNI-PAC, OMNICEF Cefdinir Cap 300 Max Qty=20/claim OMNICEF Cefdinir For Susp 125 /5ML OMNICEF Cefdinir For Susp 250 /5ML MACROLIDES ERYC Erythromycin Tab 250 Erythromycin Tab 500 Erythromycin Tab Delayed Release 250 Erythromycin Tab Delayed Release 333 Erythromycin Tab Delayed Release 500 Erythromycin w/ Enteric Coated Particles Cap 250 Erythromycin w/ Enteric Coated Particles Tab 333 Erythromycin w/ Enteric Coated Particles Tab 500 Erythromycin Stearate Tab 250 Erythromycin Stearate Tab 500 Erythromycin Ethylsuccinate Tab 400 Erythromycin Ethylsuccinate Susp 200 /5ML Erythromycin Ethylsuccinate Susp 400 /5ML Erythromycin Ethylsuccinate For Susp 100 /2.5ML ERYTHROMYCIN ERYTHROMYCIN E-MYCIN, ERY-TAB ERY-TAB, ERYTHROMYCIN ERY-TAB ERYTHROMYCIN PCE PCE ERYTHROCIN, ERYTHROM ST ERYTHROCIN, ERYTHROM ST ERYPED

16 E.E.S. GRAN, ERYPED 200 Erythromycin Ethylsuccinate For Susp 200 /5ML Erythromycin Ethylsuccinate For Susp 400 /5ML ERYPED 400 ZITHROMAX Azithromycin Tab 250 Max Qty=6/claim ZITHROMAX Azithromycin Tab 500 Max Qty=3/claim ZITHROMAX Azithromycin Tab 600 Max Qty=8/28 days ZITHROMAX ZITHROMAX Azithromycin For Susp 100 /5ML Azithromycin For Susp 200 /5ML Pkg Size 15: Package Limit=1/claim; Pkg Size 30: Package Limit=2/claim; Pkg Size 22.5: Package Limit=2/claim Azithromycin Powd Pack for Susp 1 GM Max Qty=2/claim BIAXIN Clarithromycin Tab 250 Max Qty=28/claim BIAXIN Clarithromycin Tab 500 Max Qty=28/claim BIAXIN Clarithromycin For Susp 125 /5ML BIAXIN Clarithromycin For Susp 250 /5ML BIAXIN XL Clarithromycin Tab SR 24HR 500 Max Qty=14/claim TETRACYCLINES Doxycycline Hyclate Cap 50 VIBRAMYCIN Doxycycline Hyclate Cap 100 PERIOSTAT DOXYCYCLINE HYCLATE 20 T VIBRATAB Doxycycline Hyclate Tab 100 MINOCIN Minocycline HCl Cap 50 Minocycline HCl Cap 75 MINOCIN Minocycline HCl Cap 100 Tetracycline HCl Cap 250 Tetracycline HCl Cap 500 FLUOROQUINOLONES Ciprofloxacin HCl Tab 100 (Base Equiv) Max Qty=6/claim CIPRO Ciprofloxacin HCl Tab 250 (Base Equiv) CIPRO Ciprofloxacin HCl Tab 500 (Base Equiv) CIPRO Ciprofloxacin HCl Tab 750 (Base Equiv) LEVAQUIN Levofloxacin Tab 250 Max Qty=14/claim; LEVAQUIN Levofloxacin Tab 500 Max Qty=14/claim; LEVAQUIN Levofloxacin Tab 750 Max Qty=14/claim; Ofloxacin Tab 200 Max Qty=56/claim Ofloxacin Tab 300 Max Qty=56/claim Ofloxacin Tab 400 Max Qty=56/claim AMINOGLYCOSIDES Neomycin Sulfate Tab 500 SULFONAMIDES Sulfisoxazole Acetyl Susp 500 /5ML GANTRIS PED ANTIMYCOBACTERIAL AGENTS MYAMBUTOL Ethambutol HCl Tab 100 MYAMBUTOL Ethambutol HCl Tab 400 TRECATOR Tab 250mg

17 Isoniazid Tab 100 Isoniazid Tab 300 Isoniazid Syrup 50 /5ML Pyrazinamide Tab 500 MYCOBUTIN 150 CAPSULE RIFADIN Rifampin Cap 150 RIFADIN Rifampin Cap 300 ANTIFUNGALS GRIFULVIN V Tab 500 GRIFULVIN V Griseofulvin Microsize Susp 125 /5ML GRIS-PEG Tab 125 GRIS-PEG, GRISEOFULVIN Tab 250 Nystatin Tab U Daily Dosage=6 LAMISIL Terbinafine HCl Tab 250 Max Qty=90/120 days; Ketoconazole Tab 200 DIFLUCAN Fluconazole Tab 50 Max Qty=3/14 days DIFLUCAN Fluconazole Tab 100 DIFLUCAN Fluconazole Tab 150 Max Qty=2/claim DIFLUCAN Fluconazole Tab 200 DIFLUCAN Fluconazole For Susp 10 /ML Max Qty=70/claim DIFLUCAN Fluconazole For Susp 40 /ML Max Qty=70/claim ANTIVIRALS SELZENTRY Tab 150 SELZENTRY Tab 300 TIVICAY 50 TABLET ISENTRESS Tab 400 (Base Equiv) ISENTRESS 100 TABLET CHE AGENERASE Cap 50 AGENERASE Soln 15 /ML REYATAZ Cap 100 (Base Equiv) REYATAZ Cap 150 (Base Equiv) REYATAZ Cap 200 (Base Equiv) REYATAZ Cap 300 (Base Equiv) PREZISTA Tab 75 (Base Equiv) PREZISTA Tab 150 (Base Equiv) PREZISTA Tab 300 (Base Equiv) PREZISTA Tab 400 (Base Equiv) PREZISTA Tab 600 (Base Equiv) PREZISTA 800 TABLET PREZISTA 100 /ML SUSPENSI LEXIVA Tab 700 (Base Equiv) LEXIVA Susp 50 /ML (Base Equiv) CRIXIVAN Cap 100 CRIXIVAN Cap 200 Daily Dosage=4 Daily Dosage=3 Daily Dosage=4 Daily Dosage=4 Daily Dosage=56 Daily Dosage=6 Daily Dosage=9 Biopharmacy benefit via Biopharmacy benefit via Biopharmacy benefit via Biopharmacy benefit via

18 CRIXIVAN Cap 333 CRIXIVAN Cap 400 VIRACEPT Tab 250 VIRACEPT Tab 625 VIRACEPT Oral Powder 50 /GM NORVIR Cap 100 NORVIR Tab 100 NORVIR Oral Soln 80 /ML INVIRASE Cap 200 INVIRASE Tab 500 APTIVUS Cap 250 APTIVUS Oral Soln 100 /ML Daily Dosage=6 Daily Dosage=9 Daily Dosage=4 Daily Dosage= Daily Dosage=4 Daily Dosage=4 0 ZIAGEN ZIAGEN Tab 300 (Base Equiv) ZIAGEN Soln 20 /ML (Base Equiv) Daily Dosage=30 VIDEX For Soln 2 GM 0 VIDEX For Soln 4 GM VIDEX EC Didanosine Delayed Release Capsule 125 VIDEX EC Didanosine Delayed Release Capsule 200 VIDEX EC Didanosine Delayed Release Capsule 250 VIDEX EC Didanosine Delayed Release Capsule 400 EMTRIVA Caps 200 EMTRIVA Soln 10 /ML EPIVIR EPIVIR Tab 150 EPIVIR EPIVIR Tab 300 EPIVIR Oral Soln 10 /ML Daily Dosage=30 ZERIT Stavudine Cap 15 ZERIT Stavudine Cap 20 ZERIT Stavudine Cap 30 ZERIT Stavudine Cap 40 ZERIT Stavudine For Oral Soln 1 /ML Daily Dosage=80 RETROVIR Zidovudine Cap 100 Daily Dosage=6 RETROVIR Zidovudine Tab 300 RETROVIR Zidovudine Syrup 10 /ML Daily Dosage=60 VIREAD Tab 150 VIREAD Tab 200 VIREAD Tab 250 VIREAD Tab 300 VIREAD POWDER Max dose= 240/30 days RESCRIPTOR Tab RESCRIPTOR Tab 200 Daily Dosage=6 SUSTIVA Cap 50 SUSTIVA Cap 100 SUSTIVA Cap 200 SUSTIVA Tab 600 INTELENCE Tab 25 Daily Dosage=4 INTELENCE Tab 100 Daily Dosage=4 INTELENCE 200 TABLET VIRAMUNE VIRAMUNE Tab 200 VIRAMUNE Susp 50 /5ML Daily Dosage=40 VIRAMUNE XR 100 TABLET EDURANT HCl Tab 25 EPZICOM Tab TRUVADA Tab COMBIVIR COMBIVIR Tab KALETRA Cap Daily Dosage=6

19 COMPLERA TABLET KALETRA Tab KALETRA Tab KALETRA Soln /5ML (80-20 /ML) TRIZIVIR Tab ATRIPLA Tab COMPLERA Daily Dosage=4 Daily Dosage=4 Max Qty=480/30 days Ganciclovir Cap 250 Daily Dosage=6 Ganciclovir Cap 500 Daily Dosage=6 VALCYTE Tab 450 ZOVIRAX Acyclovir Cap 200 Max Qty=50/30 days ZOVIRAX Acyclovir Tab 400 ZOVIRAX Acyclovir Tab 800 Max Qty=50/30 days ZOVIRAX Acyclovir Susp 200 /5ML Max Qty=400/30 days VALTREX Valacyclovir HCl Tab 500 Max Qty=42/31 days VALTREX Valacyclovir HCl Tab 1 GM Max Qty=21/31 days FLUMADINE Max DS/DU=Lesser Of Rimantadine Hydrochloride Tab 100 Max Days Sply=10/Max Qty=20 TAMIFLU Cap 30 (Base Equiv) Max Qty=20/30 days; Max fill=1/180 days TAMIFLU Cap 45 (Base Equiv) Max Qty=10/30 days; Max fill=1/180 days TAMIFLU Cap 75 (Base Equiv) Max Qty=10/30 days; Max fill=1/180 days TAMIFLU Susp 12 /ML (Base Equiv) Max Qty=75/30 days; Max fill=1/180 days Limited to Ages 5 and RELENZA 5 /BLISTER Older ; Package Limit=1/30 days ANTIMALARIALS Chloroquine Phosphate Tab 250 ARALEN Chloroquine Phosphate Tab 500 PLAQUENIL LARIAM ANTHELMINTICS VERMOX Hydroxychloroquine Sulfate Tab 200 Mefloquine HCl Tab 250 PRIMAQUINE Tab 26.3 QUALAQUIN 324 CAPSULE COARTEM Tab Mebendazole Chew Tab 100 Pyrantel Pamoate Susp 250 /5ML (50 /ML Base Equiv) Max Qty=24/claim Max Qty=120/claim ANTI-INFECTIVE AGENTS - MISCELLANEOUS FLAGYL Metronidazole Tab 250 FLAGYL Metronidazole Tab 500 TRIMPEX Trimethoprim Tab 100 Vancomycin HCl For Inj 500 CLEOCIN Clindamycin HCl Cap 150 CLEOCIN Clindamycin HCl Cap 300 Clindamycin Palmitate HCl For Soln CLEOCIN PED 75 /5ML (Base Equiv) Dapsone Tab 25 Dapsone Tab 100 MEPRON 750 /5 ML SUSPENSI Erythromycin & Sulfisoxazole For PEDIAZOLE Susp /5ML Max Qty=14/30 days Max Qty=300/claim

20 Sulfamethoxazole-Trimethoprim Tab BACTRIM, SEPTRA BACTRIM DS, SEPTRA Sulfamethoxazole-Trimethoprim Tab DS Sulfamethoxazole-Trimethoprim Susp /5ML ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES MYLERAN Tab 2 LEUKERAN Tab 2 Cyclophosphamide Tab 25 Cyclophosphamide Tab 50 ALKERAN Tab 2 CEENU Cap 10 CEENU Cap 40 CEENU Cap 100 PURINETHOL Mercaptopurine Tab 50 Methotrexate Sodium Tab 2.5 (Base Equiv) Methotrexate Sodium Tab 5 (Base Equiv) TREXALL Tab 7.5 (Base Equiv) TREXALL Tab 10 (Base Equiv) TREXALL Tab 15 (Base Equiv) Methotrexate Sodium Inj 25 /ML CASODEX ARIMIDEX Methotrexate Sodium Inj PF 25 /ML TESLAC Tab 50 LYSODREN Tab 500 Bicalutamide Tab 50 Flutamide Cap 125 Tamoxifen Citrate Tab 10 (Base Equivalent) Tamoxifen Citrate Tab 20 (Base Equivalent) Anastrozole Tab 1 AROMASIN AROMASIN Tab 25 FEMARA Letrozole Tab 2.5 MEGACE ORAL HYDREA CORTICOSTEROIDS Megestrol Acetate Tab 20 Megestrol Acetate Tab 40 Megestrol Acetate Susp 40 /ML Etoposide Cap 50 Hydroxyurea Cap 500 Leucovorin Calcium Tab 5 Leucovorin Calcium Tab 10 Leucovorin Calcium Tab 15 Leucovorin Calcium Tab 25 Cortisone Acetate Tab 25 Dexamethasone Tab 0.5 Dexamethasone Tab 0.75 Dexamethasone Tab 1 Dexamethasone Tab 1.5 Dexamethasone Tab 2 Dexamethasone Tab 4 Dexamethasone Tab 6 Dexamethasone Elixir 0.5 /5ML Prior use of Anastrozole Prior use of Anastrozole

21 Dexamethasone Conc 1 /ML Dexamethasone Soln 0.5 /5ML CORTEF CORTEF CORTEF MEDROL MEDROL MEDROL MEDROL MEDROL PRELONE ORAPRED PEDIAPRED STERAPRED STERAPRED DS ANDROGENS-ANABOLIC DEPO-TESTOST ESTROGENS Dexamethasone sodium phosphate 4mg/mL Inj Hydrocortisone Tab 5 Hydrocortisone Tab 10 Hydrocortisone Tab 20 Methylprednisolone Tab 4 Methylprednisolone Tab 8 METHYLPREDNISOLONE 16 TA METHYLPREDNISOLONE 32 TA Methylprednisolone Tab 4 Dose Pack MILLIPRED Tab 5 Prednisolone Syrup 5 /5ML Prednisolone Syrup 15 /5ML Prednisolone Sod Phosphate Oral Soln 15 /5ML (Base Equiv) Prednisolone Sod Phosph Oral Soln 6.7 /5ML (5 /5ML Base) VERIPRED 20 Oral Soln 20 /5ML (Base Equiv) Prednisone Tab 1 Prednisone Tab 2.5 Prednisone Tab 5 Prednisone Tab 10 Prednisone Tab 20 Prednisone Tab 50 Prednisone Conc 5 /ML Prednisone Oral Soln 5 /5ML Prednisone Tab 5 Dose Pack Prednisone Tab 10 Dose Pack Fludrocortisone Acetate Tab 0.1 DANAZOL 50 CAPSULE DANAZOL 100 CAPSULE DANAZOL 200 CAPSULE ANDRODERM Patch 24HR 2 /24HR ANDRODERM Patch 24HR 2.5 /24HR ANDRODERM Patch 24HR 4 /24HR ANDRODERM Patch 24HR 5 /24HR Testosterone Cypionate IM in Oil 200 /ML PREMARIN Tab 0.3 PREMARIN Tab 0.45 PREMARIN Tab PREMARIN Tab 0.9 PREMARIN Tab 1.25 QL = 1 dispense/month Max Qty=150/claim Max Qty=4/30 days Limited to Female ; Limited to Female ; Limited to Female ; Limited to Female ; Limited to Female ;

22 ESTRACE Estradiol Tab 0.5 Limited to Female ESTRACE Estradiol Tab 1 Limited to Female ESTRACE Estradiol Tab 2 Limited to Female CLIMARA CLIMARA CLIMARA CLIMARA CLIMARA CLIMARA OGEN OGEN OGEN ESTRATEST HS ALORA Patch Biweekly /24HR ALORA Patch Biweekly 0.05 /24HR Estradiol TD Patch Biweekly 0.05 /24HR ALORA Patch Biweekly /24HR ALORA Patch Biweekly 0.1 /24HR Estradiol TD Patch Biweekly 0.1 /24HR Estradiol TD Patch Weekly /24HR Estradiol TD Patch Weekly /24HR (37.5 MCG/24HR) Estradiol TD Patch Weekly 0.05 /24HR Estradiol TD Patch Weekly 0.06 /24HR Estradiol TD Patch Weekly /24HR Estradiol TD Patch Weekly 0.1 /24HR Estropipate Tab 0.75 Estropipate Tab 1.5 Estropipate Tab 3 Esterified Estrogens & Methyltestosterone Tab Limited to Female; Max DS/DU=Lesser Of Max Days Sply=28/Max Qty=8 Limited to Female; Max DS/DU=Lesser Of Max Days Sply=28/Max Qty=8 Limited to Female; Max DS/DU=Lesser Of Max Days Sply=28/Max Qty=8 Limited to Female; Max DS/DU=Lesser Of Max Days Sply=28/Max Qty=8 Limited to Female; Max DS/DU=Lesser Of Max Days Sply=28/Max Qty=8 Limited to Female; Max DS/DU=Lesser Of Max Days Sply=28/Max Qty=8 Limited to Female; Max DS/DU=Lesser Of Max Days Sply=28/Max Qty=4 Limited to Female; Max DS/DU=Lesser Of Max Days Sply=28/Max Qty=4 Limited to Female; Max DS/DU=Lesser Of Max Days Sply=28/Max Qty=4 Limited to Female; Max DS/DU=Lesser Of Max Days Sply=28/Max Qty=4 Limited to Female; Max DS/DU=Lesser Of Max Days Sply=28/Max Qty=4 Limited to Female; Max DS/DU=Lesser Of Max Days Sply=28/Max Qty=4 Limited to Female; Daily Dosage=1 Limited to Female; Daily Dosage=1 Limited to Female; Daily Dosage=2 ESTRATEST Esterified Estrogens & Methyltestosterone Tab PREMPRO Tab Limited to Female

23 PREMPRO Tab PREMPRO Tab PREMPRO Tab ACTIVELLA TABLET CONTRACEPTIVES NOR-QD, ORTHO MICRON DEPO-PROVERA PLAN B PLAN B COMBIPATCH TD PTTW /DAY COMBIPATCH TD PTTW /DAY Norethindrone Tab 0.35 Medroxyprogesterone Acetate IM Susp 150 /ML DEPO-SQ PROV Subcutaneous Susp 104 /0.65ML Levonorgestrel Tab 0.75 PLAN B Tab 1.5 ELLA Tab 30 ORTHO EVRA TD PTWK MCG/24HR NUVARING VA Ring /24HR Limited to Female; Max Qty=1/claim; Min DS=84 Limited to Female; Max Qty=1/claim; Min DS=84 Limited to Female; Max Qty=4/365 days Max Qty=4/365 days; 1/21 days Max Qty=4/365 days Max Qty=3/claim; Min DS=28 Limited to Female; Max Qty=1/claim DESOGEN, DESOGEN- Desogestrel & Ethinyl Estradiol Tab 28, ORTHO-CEPT MCG Desogest-Eth Estrad & Eth Estrad Tab /.01 (21/5) Limited to Female Limited to Female YAZ YASMIN 28 Drospirenone-Ethinyl Estradiol Tab Drospirenone-Ethinyl Estradiol Tab Ethynodiol Diacetate & Ethinyl Estradiol Tab 1-35MCG Limited to Female Limited to Female Limited to Female ZOVIA 1/50E Tab 1-50MCG Limited to Female NORDETTE, NORDETTE-28 OVCON-35 BREVICON, MODICON NORINYL, ORTHO- NOVUM LOESTRIN LOESTRIN 21 LO/OVRAL, LO/OVRAL-28 Levonorgestrel & Ethinyl Estradiol Tab MCG Levonorgestrel & Ethinyl Estradiol Tab MCG Norethindrone & Ethinyl Estradiol Tab MCG Norethindrone & Ethinyl Estradiol Tab MCG Norethindrone & Ethinyl Estradiol Tab 1-35MCG OVCON TABLET Norethindrone Ace & Ethinyl Estradiol Tab 1-20MCG Norethindrone Ace & Ethinyl Estradiol Tab MCG Norethindrone & Mestranol Tab 1-50MCG Norgestrel & Ethinyl Estradiol Tab MCG NECON, NORINYL Limited to Female Limited to Female Limited to Female Limited to Female Limited to Female Limited to Female Limited to Female Limited to Female Limited to Female Limited to Female; Daily Dosage=2 OGESTREL Tab MCG Limited to Female ORTHO-CYCLEN Norgestimate & Ethinyl Estradiol Tab MCG Limited to Female

24 LOESTRIN FE Norethindrone Ace & Ethinyl Estradiol-FE Tab 1-20MCG LOESTRIN 24-FE Tab 1-20 MCG (24 Limited to Female LOESTRIN FE MIRCETTE 28 DAY TABLET CYCLESSA ORTHO-NOVUM TRI-NORINYL Norethindrone Ace & Ethinyl Estradiol-FE Tab MCG MIRCETTE 28 DAY TABLET NECON Tab /1-35 -MCG (10/11) Desogest-Ethinyl Estrad Tab / / Levonorgestrel-Eth Estrad Tab.05-30/ / MCG ORTHO-NOVUM Tab / /1-35 -MCG Norethindrone-Eth Estradiol Tab /1-35/ MCG Limited to Female Limited to Female Limited to Female Limited to Female Norgestimate-Eth Estrad Tab / / MCG ORTHO TRI-, ORTHO TRI-CY ORTHO TRI- Norgestimate-Eth Estrad Tab / / MCG PROGESTINS SEASONALE SEASONIQUE PROVERA PROVERA PROVERA AYGESTIN Levonorgestrel & Ethinyl Estradiol (91-Day) Tab SEASONIQUE Tab (84) & Eth Est Tab 0.01(7) Medroxyprogesterone Acetate Tab 2.5 Medroxyprogesterone Acetate Tab 5 Medroxyprogesterone Acetate Tab 10 Norethindrone Acetate Tab 5 Limited to Female; Max Qty=91/claim; Min DS=91 Limited to Female; Max Qty=91/claim; Min DS=91 PROMETRIUM PROMETRIUM 100 CAPSULE Max Qty=30/30 days PROMETRIUM PROMETRIUM 200 CAPSULE Max Qty=30/30 days ANTIDIABETICS Insulin Aspart Inj 100 U/ML NOVOLOG VIALS Max Qty=40/30 days Insulin Glargine Inj 100 U/ML LANTUS VIALS Max Qty=30/30 days APIDRA 100 UNITS/ML VIAL Max Qty=40/30 days Insulin Lispro (Human) Inj 100 U/ML HUMALOG VIALS Max Qty=40/30 days HUMULIN R, Insulin Regular (Human) Inj 100 HUMULIN R, U/ML NOVOLIN R, Max Qty=40/30 days RELION R VIALS Insulin Regular (Human) Inj 100 U/ML HUMULIN R 500 UNITS/ML VIAL HUMULIN R, HUMULIN R, NOVOLIN R, RELION R VIALS Max Qty=40/30 days

25 Insulin Isophane (Human) Inj 100 U/ML Insulin Isophane (Human) Inj 100 U/ML Insulin Aspart & Aspart Prot (Human) Inj 100 U/ML (30-70) HUMULIN N, HUMULIN N PN, HUMULIN N PN, NOVOLIN N, RELION N VIALS HUMULIN N, HUMULIN N PN, HUMULIN N PN, NOVOLIN N, RELION N VIALS NOVOLOG MIX VIALS Max Qty=40/30 days Max Qty=40/30 days Max Qty=40/30 days Insulin Lispro Prot & Lispro (Human) Inj 100 Unit/ML (75-25) HUMALOG MIX VIALS Max Qty=40/30 days Insulin Lispro Prot & Lispro (Human) Inj 100 Unit/ML (50-50) HUMALOG MIX VIALS Max Qty=40/30 days Insulin Isophane & Regular (Human) Inj 100 U/ML (70-30) HUMULIN, NOVOLIN, NOVOLIN 70/, RELION 70/30 VIALS Max Qty=40/30 days Insulin Isophane & Regular (Human) Inj 100 U/ML (70-30) HUMULIN, NOVOLIN, NOVOLIN 70/, RELION 70/30 VIALS Max Qty=40/30 days CHLORPROPAMIDE 100 TABLE DIABINESE CHLORPROPAMIDE 250 TABLE AMARYL Glimepiride Tab 1 AMARYL Glimepiride Tab 2 AMARYL Glimepiride Tab 4 GLUCOTROL Glipizide Tab 5 GLUCOTROL Glipizide Tab 10 GLUCOTROL XL Glipizide Tab SR 24HR 2.5 GLUCOTROL XL Glipizide Tab SR 24HR 5 GLUCOTROL XL Glipizide Tab SR 24HR 10 Glyburide Tab 1.25 MICRONASE Glyburide Tab 2.5 MICRONASE Glyburide Tab 5 GLYNASE GLYNASE GLYNASE Glyburide Micronized Tab 1.5 Glyburide Micronized Tab 3 Glyburide Micronized Tab 6 TOLAZAMIDE 250 TABLET TOLAZAMIDE 500 TABLET TOLBUTAMIDE 500 TABLET GLUCOPHAGE Metformin HCl Tab 500 Daily Dosage=4 GLUCOPHAGE Metformin HCl Tab 850 GLUCOPHAGE Metformin HCl Tab 1000 GLUCOPHAGE Metformin HCl Tab SR 24HR 500 Daily Dosage=4 GLUCOPHAGE Metformin HCl Tab SR 24HR 750 Daily Dosage=3 STARLIX NATEGLINIDE 60 TABLET STARLIX NATEGLINIDE 120 TABLET