Recommended Drug List

Transcription

1 Health Net Medi-Cal Recommended List The Health Net Medi-Cal Recommended List (RDL) includes drugs covered by Health Net. The drug list is updated often and may change. To get the most up-to-date information, call Member Services at TTY users may call The latest drug list can be viewed on our website at.

2 Welcome to Health Net What is the Health Net Medi-Cal Recommended List? The drug list includes drugs used to treat common diseases or health problems. A team of doctors and pharmacists meets regularly to decide which drugs should be on the drug list. The team reviews new and existing drugs and chooses drugs that work best and are safe. How do I use the Health Net Medi-Cal Recommended List? Look for your drug in the index at the end of this booklet. The index lists all of the drugs on the drug list. Both brand name drugs and generic drugs are listed in the index. Next to your drug, you will see the page number where you can find your drug. The table below tells you what the abbreviations on the List mean. Abbreviation Term What it means Age Limit Some drugs are only covered for certain ages. Carve Out These drugs are carved out by the Department of Health Care Services. This means these drugs are covered by the Medi-Cal ee-for-service program and can be billed to the State by the pharmacy. ormulary These drugs are covered on the List. N Non-formulary These drugs are not covered on the List. If your doctor feels you need a drug that is not covered, he or she can ask us to make an exception. Prior Authorization Your doctor must ask for approval from Health Net before some drugs will be covered. QL Quantity Limit Some drugs are only covered for a certain amount. Prescription and OTC These drugs are made in both prescription form and Over-the-counter (OTC) form. ST Step Therapy In some cases, you must first try certain drugs before Health Net covers another drug for your medical condition. or example, if A and B both treat your medical condition, Health Net may not cover B unless you try A first. What if my drug is not on the Health Net Medi-Cal Recommended List? If your drug is not on the drug list, call Member Services at and ask if your drug is covered. If your drug is not covered, you can ask your doctor to prescribe a similar drug that is covered. If your doctor feels you need to have the drug that is not covered, your doctor can ask us to make an exception. ii

3 Can I go to any pharmacy? Members must use pharmacies that are in the network. These pharmacies have a contract with Health Net. To find a pharmacy, call Member Services at or visit our website at. Are there any limits on my drug coverage? Some drugs have limits on coverage. If a drug has limits, it will be noted in the column on the List. How can I get an exception to the rules for drug coverage? Your doctor can ask for an exception to our rules for drug coverage. Your doctor can ask us to cover your drug even if it is not on the drug list. Your doctor can ask us to make an exception for limits on your drug. or example, if your drug has a quantity limit of 1 tablet per day, your doctor can ask us to cover more. To request an exception, your doctor can fax a prior authorization form to us at After we receive your doctor s request, we usually make our decision within one business day. If we need more information, your doctor has five business days to give us that information before we make our decision. What if I m a new member? If you are a new member in our plan, you may be taking drugs that are not on our drug list. You may also be taking a drug that is on our drug list, but the drug may have some limits. In these cases, you should talk to your doctor to see if you should change to drugs that we cover. Your doctor may request an exception so that we could cover the drug you have been taking. See the section, How do I get an exception to the rules for the drug coverage? for more information. What are over-the-counter drugs? Over-the-counter (OTC) drugs are drugs you can buy without a prescription. The Health Net Medi- Cal List covers similar OTC drugs as those listed on the State Medi-Cal List of Contract s. However, if you want Health Net to cover an OTC drug on the drug list, your doctor must write a prescription for that drug. Are brand name drugs covered? Your pharmacy benefit does not cover brand name drugs when generic drugs are available. Brand name drugs may be covered when generic drugs are not available or if your doctor says the brand name drug is medically necessary. What is a generic drug? A generic drug contains the same active ingredient and works the same way as the brand name drug. Generic drugs must be safe and effective. iii

4 Will the pharmacist give me a generic drug if one is available? Yes. Pharmacies may give you a generic drug, unless your doctor says that you must take the brand name drug. Are there any excluded or carve-out drugs? Excluded drugs The Health Net Medi-Cal List is similar to the State Medi-Cal List of Contract s and does not include certain drugs. The following types of drugs are not included on the drug list because they are excluded from coverage: dental products multivitamins erectile dysfunction drugs drugs used for cosmetic reasons Carve-out drugs Some drugs are carved out by the Department of Health Care Services. This means that these drugs are covered by the Medi-Cal ee-for-service program and can be billed to the State by the pharmacy. The following types of drugs are carved out: certain psychotherapeutic drugs HIV-related drugs treatment drugs for alcohol and heroin detoxification and dependency certain drugs to treat hemophilia What is California Children s Services? California Children s Services (CCS) is a state program for children (up to 21 years old) with certain diseases or health problems. Some drugs for CCS-covered diseases or health problems are not covered by Health Net. Only doctors approved by CCS can write prescriptions for drugs used to treat CCS-covered conditions. Pharmacies must bill CCS, and not Health Net, for these drugs. If you are at the pharmacy and you are not yet in the CCS system, call Member Services at Member Services can help you register with CCS. They may also help you get an emergency supply of your drug. Need more information? or more information about your pharmacy benefits, please review your Member Handbook or call Member Services at iv

5 Name ADHD/ANTI-NARLEPSY/ANTI- OBESITY/ANOREXIANTS - s to Treat ADHD, Sleep and Eating Disorders Amphetamines ADDERL (Use Amphetamine- Dextroamphetamine) ADDERL XR (Use Amphetamine- Dextroamphetamine) amphetaminedextroamphetamine cp mg-1.25mg-1.25mg- 1.25mg, 2.5mg-2.5mg- 2.5mg-2.5mg, 3.75mg- 3.75mg-3.75mg-3.75mg, 5mg-5mg-5mg-5mg, 6.25mg-6.25mg-6.25mg- 6.25mg, 7.5mg-7.5mg- 7.5mg-7.5mg amphetaminedextroamphetamine tabs 1.25mg-1.25mg-1.25mg- 1.25mg, 1.875mg mg-1.875mg mg, 2.5mg-2.5mg- 2.5mg-2.5mg, 3.125mg mg-3.125mg mg, 3.75mg-3.75mg- 3.75mg-3.75mg, 5mg-5mg- 5mg-5mg, 7.5mg-7.5mg- 7.5mg-7.5mg DEXEDRINE 10 MG,15 MG,5 MG (Use Dextroamphetamine Sulfate) dextroamphetamine sulfate cp24 10 mg, 15 mg, 5 mg dextroamphetamine sulfate tabs 10 mg dextroamphetamine sulfate tabs 5 mg N N N Anorexiants Non-Amphetamine ADIPEX-P (Use Phentermine HCl) N diethylpropion hcl tabs 25 mg ; ; QL(3 ea daily); Name DIETHYLPROPION HCL TABS 25 MG (Use Diethylpropion HCl) diethylpropion hcl tb24 75 mg phentermine hcl QSYMIA REGIMEX SUPRENZA Anti-Obesity Agents LI BELVIQ NTRAVE SAXENDA XENIC N Attention-Deficit/Hyperactivity Disorder (ADHD) guanfacine hcl (adhd) INTUNIV (Use Guanfacine HCl (ADHD)) STRATTERA Stimulants - Misc. METHYLPHENIDATE HCL ER 10 MG METHYLPHENIDATE HCL ER 18 MG, 27 MG, 54 MG METHYLPHENIDATE HCL ER 36 MG methylphenidate hcl tabs 10 mg, 20 mg, 5 mg methylphenidate hcl tbcr 20 mg modafinil NUVIGIL N QL(2 ea daily); ; QL(2 ea daily); ; QL(1 ea daily) 1

6 Name PROVIGIL (Use Modafinil) N RITIN (Use Methylphenidate HCl) RITIN SR (Use Methylphenidate HCl) N N ; QL(1 ea daily) AMINOGLYSIDES - s to Treat Bacterial Infections Aminoglycosides BETHKIS KITABIS K neomycin sulfate paromomycin sulfate TOBI (Use Tobramycin) N TOBI PODHER tobramycin ANGESICS - ANTI-INLAMMATORY - s to Treat Pain, Swelling, Muscle and Joint Conditions Anti-TN-alpha - Monoclonal Antibodies HUMIRA HUMIRA PEDIATRIC CROHNS DISEASE STARTER CK HUMIRA PEN HUMIRA PEN-CROHNS DISEASESTARTER HUMIRA PEN-PSORIASIS STARTER SIMPONI ARIA Antirheumatic Antimetabolites RHEUMATREX Gold Compounds RIDAURA Name Interleukin-1beta Blockers ILARIS Interleukin-6 Receptor Inhibitors ACTEMRA SOLN IV 200 MG/10ML, 400 MG/20ML, 80 MG/4ML Nonsteroidal Anti-inflammatory Agents (NSAIDs) ADVIL (Use Ibuprofen) ADVIL MIGRAINE (Use Ibuprofen) EVE CAPS (Use Naproxen Sodium) ANAPROX (Use Naproxen Sodium) ANAPROX DS (Use Naproxen Sodium) CATAM (Use Diclofenac Potassium) CELEBREX (Use Celecoxib) celecoxib CHILDRENS ADVIL (Use Ibuprofen) CHILDRENS MOTRIN CHEW 50 MG CHILDRENS MOTRIN JUNIOR STRENGTH (Use Ibuprofen) CHILDRENS MOTRIN SUSP 100 MG/5ML (Use Ibuprofen) CHILDRENS MOTRIN SUSP 40 MG/ML (Use Ibuprofen) DAYPRO (Use Oxaprozin) diclofenac potassium diclofenac sodium EC-NAPROSYN (Use Naproxen) N N N N N N N N N N N N N 2

7 Name etodolac ELDENE (Use Piroxicam) ENOPROEN CCIUM TABS 600 MG ibuprofen caps 200 mg ibuprofen chew 100 mg ibuprofen susp 100 mg/5ml ibuprofen susp 40 mg/ml, 50 mg/1.25ml ibuprofen tabs 100 mg, 200 mg, 400 mg, 600 mg, 800 mg N Name NAPROSYN TABS 250 MG, 375 MG, 500 MG (Use Naproxen) NAPROXEN naproxen naproxen sodium caps 220 mg naproxen sodium tabs 275 mg, 550 mg oxaprozin piroxicam sulindac N INDOCIN tolmetin sodium indomethacin caps or 25 mg, 50 mg indomethacin cpcr or 75 mg INANTS ADVIL (Use Ibuprofen) ketoprofen MECLOENAMATE SODIUM meloxicam susp 7.5 mg/5ml meloxicam tabs 15 mg, 7.5 mg MOBIC SUSP 7.5 MG/5ML (Use Meloxicam) MOBIC TABS 15 MG, 7.5 MG (Use Meloxicam) MOTRIN INANTS (Use Ibuprofen) MOTRIN INANTS DROPS (Use Ibuprofen) MOTRIN JUNIOR STRENGTH (Use Ibuprofen) nabumetone N N N N N N TOLMETIN SODIUM VOLTAREN-XR (Use Diclofenac Sodium) N Phosphodiesterase 4 (PDE4) Inhibitors OTEZLA Selective Costimulation Modulators ORENCIA SOLR IV 250 MG Soluble Tumor Necrosis actor Receptor Agents ENBREL ENBREL SURECLICK ANGESICS - NonNarcotic - s to Treat Pain, Muscle and Joint Conditions Analgesic Combinations butalbital-acetaminophen butalbital-acetaminophencaffeine caps 325mg- 50mg-40mg, 500mg-50mg- 40mg butalbital-acetaminophencaffeine tabs 325mg-50mg- 40mg 3

8 Name Name butalbital-aspirin-caffeine ASPIRIN LOW DOSE BUTBIT/ASPIRIN/CA EINE ESGIC 325MG-50MG- 40MG (Use Butalbital- Acetaminophen-Caffeine) IORICET TABS 325MG- 50MG-40MG (Use Butalbital-Acetaminophen- Caffeine) IORIN (Use Butalbital- Aspirin-Caffeine) Analgesics Other acetaminophen chew or 160 mg, 80 mg acetaminophen elix or 160 mg/5ml, 80 mg/2.5ml acetaminophen liqd or 160 mg/5ml acetaminophen soln or 100 mg/ml, 160 mg/5ml, 80 mg/0.8ml acetaminophen supp re 120 mg acetaminophen susp or 160 mg/5ml, 80 mg/0.8ml, 80 mg/2.5ml acetaminophen tbdp or 160 mg, 80 mg EVERL INANTS TYLENOL CHILDRENS (Use Acetaminophen) TYLENOL CHILDRENS/LAVORCRE ATOR (Use Acetaminophen) TYLENOL INANTS (Use Acetaminophen) TYLENOL JR MELTAWAYS (Use Acetaminophen) Salicylates aspirin buffered (cal carbmag carb-mag oxide) N N N N N N N ASPIRIN SUPP RE 120 MG, 200 MG aspirin supp re 300 mg, 600 mg aspirin tabs or 325 mg, 81 mg aspirin tbec or 324 mg, 325 mg, 500 mg, 81 mg BUERIN (Use Aspirin Buffered (Cal Carb-Mag Carb-Mag Oxide)) BUERIN EXTRA STRENGTH BUERIN LOW DOSE choline & mag salicylate CHOLINE MAGNESIUM TRISICYLATE DISCID (Use Salsalate) ETRIN MAXIMUM STRENGTH (Use Aspirin) ETRIN REGULAR STRENGTH (Use Aspirin) salsalate N N N N ANGESICS - OPIOID - s to Treat Pain, Muscle and Joint Conditions Opioid Agonists DEINE SULATE TABS 15 MG codeine sulfate tabs 15 mg, 30 mg, 60 mg DEMEROL TABS OR 100 MG, 50 MG (Use Meperidine HCl) DILAUDID (Use Hydromorphone HCl) DOLOPHINE (Use Methadone HCl) N N N QL(240 ea per fill retail,720 ea per 75 days retail) 4

9 Name DOLOPHINE HCL (Use Methadone HCl) EXGO 12 MG, 16 MG, 8 MG (Use Hydromorphone HCl) hydromorphone hcl liqd or 1 mg/ml HYDROMORPHONE HCL SUPP RE 3 MG hydromorphone hcl t24a or 12 mg, 16 mg, 8 mg hydromorphone hcl tabs or 2 mg, 4 mg, 8 mg KADIAN 10 MG, 100 MG, 20 MG, 30 MG, 50 MG, 60 MG, 80 MG (Use Morphine Sulfate) KADIAN 200 MG LEVORPHANOL TARTRATE MEPERIDINE HCL SOLN OR 50 MG/5ML meperidine hcl tabs or 100 mg, 50 mg methadone hcl conc or 10 mg/ml methadone hcl soln or 10 mg/5ml, 5 mg/5ml methadone hcl tabs or 10 mg methadone hcl tabs or 5 mg methadone hcl tbso or 40 mg METHADOSE 10 MG/ML (Use Methadone HCl) METHADOSE SUGAR- REE (Use Methadone HCl) N N N N N QL(120 ea per fill retail,360 ea per 75 days retail) QL(2 ea daily) QL(2 ea daily) QL(240 ea per fill retail,720 ea per 75 days retail) QL(120 ea per fill retail,360 ea per 75 days retail) Name morphine sulfate cp24 or 10 mg, 100 mg, 20 mg, 30 mg, 50 mg, 60 mg, 80 mg MORPHINE SULATE ER morphine sulfate soln or 10 mg/5ml, 100 mg/5ml, 20 mg/5ml, 20 mg/ml MORPHINE SULATE SUPP RE 10 MG, 20 MG, 30 MG, 5 MG MORPHINE SULATE TABS OR 15 MG, 30 MG morphine sulfate tbcr or 100 mg, 15 mg, 200 mg, 30 mg, 60 mg MS NTIN (Use Morphine Sulfate) NUCYNTA ER oxycodone hcl caps 5 mg OXYDONE HCL ER oxycodone hcl soln 5 mg/5ml OXYDONE HCL SOLN 5 MG/5ML (Use Oxycodone HCl) oxycodone hcl tabs 10 mg, 15 mg, 20 mg, 30 mg, 5 mg OXYNTIN N N QL(2 ea daily) QL(120 ml per fill retail,360 ml per 75 days retail) QL(90 ea per fill retail,270 ea per 75 days retail) QL(90 ea per fill retail,270 ea per 75 days retail) QL(90 ea per fill retail,270 ea per 75 days retail) QL(90 ea per fill retail,270 ea per 75 days retail) QL(1000 ml per fill retail,3000 ml per 75 days retail) QL(1000 ml per fill retail,3000 ml per 75 days retail) QL(90 ea per fill retail,270 ea per 75 days retail) 5

10 Name ROXIDONE (Use Oxycodone HCl) tramadol hcl tabs 50 mg ULTRAM (Use Tramadol HCl) Opioid Combinations acetaminophen w/ codeine soln 120mg/5ml-12mg/5ml acetaminophen w/ codeine tabs 300mg-15mg, 300mg- 60mg acetaminophen w/ codeine tabs 300mg-30mg butalbital-acetaminophencaffeine w/ codeine butalbital-aspirin-caffeine w/cod CAPIT/DEINE IORICET/DEINE (Use Butalbital-Acetaminophen- Caffeine w/ Codeine) IORIN/DEINE #3 (Use Butalbital-Aspirin- Caffeine w/cod) hydrocodoneacetaminophen caps 5mg- 500mg hydrocodoneacetaminophen tabs 10mg- 300mg, 10mg-325mg, 5mg-300mg, 5mg-325mg, 7.5mg-300mg, 7.5mg- 325mg NOR (Use Hydrocodone- Acetaminophen) N N N N N QL(90 ea per fill retail,270 ea per 75 days retail) QL(60 ea per fill retail,180 ea per 75 days retail) QL(45 ea per fill retail,135 ea per 75 days retail) QL(45 ea per fill retail,135 ea per 75 days retail) QL(45 ea per fill retail,135 ea per 75 days retail) QL(45 ea per fill retail,135 ea per 75 days retail) Name oxycodone w/ acetaminophen caps 5mg- 500mg oxycodone w/ acetaminophen tabs 10mg- 325mg, 10mg-650mg, 7.5mg-325mg, 7.5mg- 500mg oxycodone w/ acetaminophen tabs 5mg- 325mg PERCET 10MG- 325MG, 10MG-650MG, 7.5MG-325MG, 7.5MG- 500MG (Use Oxycodone w/ Acetaminophen) PERCET 5MG-325MG (Use Oxycodone w/ Acetaminophen) ROXICET TYLENOL/DEINE #3 (Use Acetaminophen w/ Codeine) TYLENOL/DEINE #4 (Use Acetaminophen w/ Codeine) XODOL (Use Hydrocodone- Acetaminophen) Opioid Partial Agonists BUNAVAIL buprenorphine hcl subl sl 2 mg, 8 mg buprenorphine hclnaloxone hcl dihydrate BUTRANS N N N N N QL(120 ea per fill retail,360 ea per 75 days retail) QL(90 ea per fill retail,270 ea per 75 days retail) QL(120 ea per fill retail,360 ea per 75 days retail) QL(90 ea per fill retail,270 ea per 75 days retail) QL(120 ea per fill retail,360 ea per 75 days retail) QL(1000 ml per fill retail,3000 ml per 75 days retail) QL(45 ea per fill retail,135 ea per 75 days retail) QL(60 ea per fill retail,180 ea per 75 days retail) QL(45 ea per fill retail,135 ea per 75 days retail) 6

11 Name SUBOXONE ZUBSOLV ANDROGENS-ANABOLIC - s to Regulate Hormones Anabolic Steroids OXANDRIN (Use Oxandrolone) oxandrolone Androgens ANDROGEL ANDROGEL PUMP ANDROXY danazol METHITEST methyltestosterone TESTIM TESTOSTERONE 1 %, 25 MG/2.5GM, 50 MG/5GM TESTOSTERONE PUMP TESTRED (Use Methyltestosterone) VOGELXO VOGELXO PUMP N N ANORECT AGENTS - Rectal s to Treat Pain, Swelling and Itching Intrarectal Steroids RTENEMA (Use Hydrocortisone (Intrarectal)) RTIOAM hydrocortisone (intrarectal) N Name ANPRAM-HC CREA 1%-1%, 1%-2.5% (Use Hydrocortisone Acetate w/ Pramoxine) ANPRAM-HC LOTN 1%- 2.5% ANPRAM-HC SINGLES (Use Hydrocortisone Acetate w/ Pramoxine) hydrocortisone acetate w/ pramoxine crea 1%-1%, 1%-2.5% lidocaine-hydrocortisone acetate (rectal) crea 3%- 0.5% lidocaine-hydrocortisone acetate (rectal) kit 3%- 0.5%, 3%-1%, 3%-2.5% PROCTOOAM HC Rectal Steroids ANUSOL-HC (Use Hydrocortisone (Rectal)) ANUSOL-HC (Use Hydrocortisone Acetate (Rectal)) hydrocortisone (rectal) hydrocortisone acetate (rectal) 25 mg Vasodilating Agents RECTIV N N N N QL(2 ea per fill retail) ANTACIDS - Ulcer and Stomach Acid s Antacid Combinations MANE alum & mag hydroxsimethicone aluminum hydroxide-mag trisil GELUSIL 200MG-25MG- 200MG (Use Alum & Mag Hydrox-Simethicone) N Rectal Combinations 7

12 Name MYLANTA DOUBLE- STRENGTH (Use Alum & Mag Hydrox-Simethicone) MYLANTA SUSP 200MG/5ML-20MG/5ML- 200MG/5ML (Use Alum & Mag Hydrox-Simethicone) Antacids - Aluminum Salts UMINUM HYDROXIDE SUSP OR Antacids - Calcium Salts calcium carbonate (antacid) 500 mg, 600 mg, 750 mg CCIUM CARBONATE TABS 648 MG MAOX (Use Calcium Carbonate (Antacid)) TUMS (Use Calcium Carbonate (Antacid)) TUMS E-X 750 (Use Calcium Carbonate (Antacid)) TUMS KIDS (Use Calcium Carbonate (Antacid)) TUMS LASTING EECTS (Use Calcium Carbonate (Antacid)) TUMS SMOOTHIES (Use Calcium Carbonate (Antacid)) N N N N N N N N ANTHELMINTICS - s to Treat Worm Infections Anthelmintics BENZA BILTRICIDE pyrantel pamoate ANTI-INECTIVE AGENTS - MISC. - s to Treat Bacterial Infections Anti-infective Agents - Misc. CAYSTON Name LAGYL (Use Metronidazole) metronidazole trimethoprim N Anti-infective Misc. - Combinations BACTRIM (Use Sulfamethoxazole- N Trimethoprim) BACTRIM DS (Use Sulfamethoxazole- N Trimethoprim) erythromycin-sulfisoxazole sulfamethoxazoletrimethoprim Antiprotozoal Agents atovaquone MEPRON (Use Atovaquone) Leprostatics DAPSONE Lincosamides CLEOCIN CAPS OR 150 MG, 300 MG, 75 MG (Use Clindamycin HCl) CLEOCIN PEDIATRIC GRANULES (Use Clindamycin Palmitate Hydrochloride) clindamycin hcl clindamycin palmitate hydrochloride N N N ANTIANGIN AGENTS - s to Treat Chest Pain Nitrates DILATRATE SR IMDUR (Use Isosorbide Mononitrate) ISORDIL TITRADOSE 40 MG N 8

13 Name ISORDIL TITRADOSE 5 MG (Use Isosorbide Dinitrate) N Name ATIVAN TABS OR 0.5 MG, 1 MG, 2 MG (Use Lorazepam) N ISOSORBIDE DINITRATE chlordiazepoxide hcl isosorbide dinitrate isosorbide mononitrate NITRO-BID NITRO-DUR 0.1 MG/HR, 0.2 MG/HR, 0.4 MG/HR, 0.6 MG/HR (Use Nitroglycerin) NITRO-DUR 0.3 MG/HR, 0.8 MG/HR nitroglycerin cpcr or 2.5 mg, 6.5 mg, 9 mg nitroglycerin pt24 td 0.1 mg/hr, 0.2 mg/hr, 0.4 mg/hr, 0.6 mg/hr NITROSTAT N ANTIANXIETY AGENTS - s to Treat Anxiety Antianxiety Agents - Misc. buspirone hcl hydroxyzine hcl soln or 10 mg/5ml hydroxyzine hcl syrp or 10 mg/5ml hydroxyzine hcl tabs or 10 mg, 25 mg, 50 mg HYDROXYZINE MOATE hydroxyzine pamoate meprobamate VISTARIL (Use Hydroxyzine Pamoate) Benzodiazepines alprazolam tabs 0.25 mg, 0.5 mg, 1 mg, 2 mg N clorazepate dipotassium DIAZEM SOLN OR 1 MG/ML diazepam tabs or 10 mg, 2 mg, 5 mg lorazepam conc or 2 mg/ml lorazepam tabs or 0.5 mg, 1 mg, 2 mg oxazepam TRANXENE T (Use Clorazepate Dipotassium) VIUM (Use Diazepam) XANAX (Use Alprazolam) N N N ANTIARRHYTHMICS - s to treat abnormal heart rhythms Antiarrhythmics Type I-A disopyramide phosphate NORCE (Use Disopyramide Phosphate) NORCE CR quinidine gluconate tbcr or 324 mg QUINIDINE SULATE quinidine sulfate QUINIDINE SULATE ER Antiarrhythmics Type I-B mexiletine hcl Antiarrhythmics Type I-C flecainide acetate N 9

14 Name propafenone hcl RYTHMOL (Use Propafenone HCl) RYTHMOL SR (Use Propafenone HCl) TAMBOR (Use lecainide Acetate) Antiarrhythmics Type III amiodarone hcl 200 mg, 400 mg RDARONE (Use Amiodarone HCl) MULTAQ TIKOSYN N N N N ANTIASTHMATIC AND BRONCHODILATOR AGENTS - s to Treat Lung Conditions Anti-Inflammatory Agents CROMOLYN SODIUM Antiasthmatic - Monoclonal Antibodies XOLAIR Asthma and Bronchodilator Agent Combinations dyphylline-guaifenesin Bronchodilators - Anticholinergics ATROVENT HA ipratropium bromide SPIRIVA HANDIHER SPIRIVA RESPIMAT TUDORZA PRESSAIR Leukotriene Modulators montelukast sodium SINGULAIR (Use Montelukast Sodium) Steroid Inhalants N QL(0.86 gm daily) QL(0.14 gm daily) QL(0.04 ea daily) Name AEROSN ARNUITY ELLIPTA ASMANEX HA ASMANEX TWISTHER 120 METERED DOSES ASMANEX TWISTHER 14 METERED DOSES ASMANEX TWISTHER 30 METERED DOSES ASMANEX TWISTHER 60 METERED DOSES ASMANEX TWISTHER 7 METERED DOSES budesonide (inhalation) 0.25 mg/2ml budesonide (inhalation) 0.5 mg/2ml LOVENT DISKUS 100 MCG/BLIST LOVENT DISKUS 250 MCG/BLIST LOVENT DISKUS 50 MCG/BLIST LOVENT HA 110 MCG/ACT, 220 MCG/ACT LOVENT HA 44 MCG/ACT PULMIRT 0.25 MG/2ML (Use Budesonide (Inhalation)) PULMIRT 0.5 MG/2ML (Use Budesonide (Inhalation)) PULMIRT 1 MG/2ML PULMIRT LEXHER 180 MCG/ACT PULMIRT LEXHER 90 MCG/ACT QVAR 40 MCG/ACT QVAR 80 MCG/ACT N N QL(0.6 gm daily) QL(0.44 gm daily) QL(1 ea per 30 days retail) QL(1 ea per 30 days retail) QL(1 ea per 30 days retail) QL(1 ea per 30 days retail) QL(1 ea per 30 days retail) QL(8 ml daily) QL(4 ml daily) QL(20 ea daily) QL(8 ea daily) QL(40 ea daily) QL(0.8 gm daily) QL(0.36 gm daily) QL(8 ml daily) QL(4 ml daily) QL(2 ml daily) QL(0.07 ea daily) QL(0.27 ea daily) QL(0.58 gm daily) QL(0.29 gm daily) 10

15 Name Sympathomimetics ACCUNEB (Use Albuterol Sulfate) ADVAIR DISKUS ADVAIR HA albuterol sulfate ANORO ELLIPTA N QL(2 ea daily) QL(0.4 gm daily) QL(2 ea daily) Name theophylline tb mg, 600 mg ANTIAGULANTS - Blood Thinners Coumarin Anticoagulants UMADIN TABS OR 1 MG, 10 MG, 2 MG, 2.5 MG, 3 MG, 4 MG, 5 MG, 6 MG, 7.5 MG warfarin sodium BREO ELLIPTA MBIVENT MBIVENT RESPIMAT DULERA EPHEDRINE HCL EPHEDRINE SULATE MAXAIR AUTOHER METAPROTERENOL SULATE SEREVENT DISKUS STRIVERDI RESPIMAT SYMBIRT terbutaline sulfate tabs or 2.5 mg, 5 mg VENTOLIN HA VOSPIRE ER (Use Albuterol Sulfate) Xanthines ELIXOPHYLLIN THEO MG, 200 MG, 300 MG theophylline tb mg, 200 mg, 300 mg, 450 mg N QL(2 ea daily) QL(0.2 gm daily) QL(0.45 gm daily) QL(2 ea daily) QL(0.14 gm daily) QL(0.34 gm daily) QL(1.2 gm daily) Direct actor Xa Inhibitors ELIQUIS XARELTO 10 MG XARELTO 15 MG, 20 MG XARELTO STARTER CK Heparins And Heparinoid-Like Agents enoxaparin sodium sc 100 mg/ml, 150 mg/ml QL(10 ml per 180 days retail) enoxaparin sodium sc 120 mg/0.8ml, 80 mg/0.8ml QL(8 ml per 180 days retail) enoxaparin sodium sc 30 mg/0.3ml QL(3 ml per 180 days retail) enoxaparin sodium sc 40 mg/0.4ml QL(4 ml per 180 days retail) enoxaparin sodium sc 60 mg/0.6ml QL(6 ml per 180 days retail) LOVENOX SC 100 MG/ML, QL(10 ml per 150 MG/ML (Use N 180 days retail) Enoxaparin Sodium) LOVENOX SC 120 QL(8 ml per MG/0.8ML, 80 MG/0.8ML N 180 days retail) (Use Enoxaparin Sodium) LOVENOX SC 30 MG/0.3ML (Use Enoxaparin Sodium) LOVENOX SC 40 MG/0.4ML (Use Enoxaparin Sodium) LOVENOX SC 60 MG/0.6ML (Use Enoxaparin Sodium) N N N QL(3 ml per 180 days retail) QL(4 ml per 180 days retail) QL(6 ml per 180 days retail) 11

16 Name Thrombin Inhibitors PRADAXA ANTINVULSANTS - s to Treat Seizures AM Glutamate Receptor Antagonists YM Anticonvulsants - Benzodiazepines clonazepam DIASTAT ACUDI (Use Diazepam (Anticonvulsant)) DIASTAT PEDIATRIC (Use Diazepam (Anticonvulsant)) diazepam (anticonvulsant) KLONOPIN (Use Clonazepam) Anticonvulsants - Misc. BANZEL carbamazepine chew 100 mg carbamazepine susp 100 mg/5ml carbamazepine tabs 200 mg gabapentin caps 100 mg, 300 mg, 400 mg gabapentin tabs 600 mg, 800 mg KEPPRA SOLN OR 100 MG/ML (Use Levetiracetam) KEPPRA TABS OR 1000 MG, 250 MG, 500 MG, 750 MG (Use Levetiracetam) LAMICT CHEW 2 MG LAMICT CHEWABLE DISPERSIBLE (Use Lamotrigine) N N N N N N QL(4 ea per 30 days retail) QL(4 ea per 30 days retail) QL(4 ea per 30 days retail) Name LAMICT TABS 100 MG, 150 MG, 200 MG, 25 MG (Use Lamotrigine) lamotrigine chew 25 mg, 5 mg lamotrigine tabs 100 mg, 150 mg, 200 mg, 25 mg levetiracetam soln or 100 mg/ml, 500 mg/5ml levetiracetam tabs or 1000 mg, 250 mg, 500 mg, 750 mg MYSOLINE (Use Primidone) NEURONTIN CAPS 100 MG, 300 MG, 400 MG (Use Gabapentin) NEURONTIN TABS 600 MG, 800 MG (Use Gabapentin) oxcarbazepine POTIGA primidone TEGRETOL TOMAX (Use Topiramate) TOMAX SPRINKLE (Use Topiramate) topiramate TRILEPT (Use Oxcarbazepine) VIMT SOLN OR 10 MG/ML VIMT TABS OR 100 MG, 150 MG, 200 MG, 50 MG ZONEGRAN (Use Zonisamide) zonisamide Carbamates N N N N N N N N 12

17 Name felbamate ELBATOL (Use elbamate) GABA Modulators GABITRIL N Name valproate sodium syrp or 250 mg/5ml valproic acid ANTIDEPRESSANTS - s to Treat Depression Alpha-2 Receptor Antagonists (Tetracyclics) SABRIL mirtazapine tiagabine hcl Hydantoins DILANTIN DILANTIN INATABS (Use Phenytoin) DILANTIN-125 (Use Phenytoin) PHENYTEK (Use Phenytoin Sodium Extended) phenytoin phenytoin sodium extended Succinimides CELONTIN ethosuximide ZARONTIN (Use Ethosuximide) Valproic Acid DEKENE DEKOTE (Use Divalproex Sodium) DEKOTE ER (Use Divalproex Sodium) DEKOTE SPRINKLES (Use Divalproex Sodium) divalproex sodium valproate sodium soln or 250 mg/5ml N N N N N N N REMERON (Use Mirtazapine) REMERON SOLTAB (Use Mirtazapine) Antidepressants - Misc. APLENZIN bupropion hcl tabs 100 mg, 75 mg bupropion hcl tb mg, 150 mg bupropion hcl tb mg bupropion hcl tb mg, 300 mg WELLBUTRIN (Use Bupropion HCl) WELLBUTRIN SR 100 MG, 150 MG (Use Bupropion HCl) WELLBUTRIN SR 200 MG (Use Bupropion HCl) WELLBUTRIN XL (Use Bupropion HCl) N N N N N N ST Monoamine Oxidase Inhibitors (MAOIs) EMSAM MARPLAN NARDIL (Use Phenelzine Sulfate) RNATE (Use Tranylcypromine Sulfate) phenelzine sulfate tranylcypromine sulfate QL(2 ea daily) QL(2 ea daily) 13

18 Name Selective Serotonin Reuptake Inhibitors (SSRIs) CELEXA 10 MG (Use N QL(4 ea daily) Citalopram Hydrobromide) CELEXA 20 MG (Use N QL(2 ea daily) Citalopram Hydrobromide) CELEXA 40 MG (Use N Citalopram Hydrobromide) citalopram hydrobromide soln 10 mg/5ml QL(20 ml daily) citalopram hydrobromide tabs 10 mg QL(4 ea daily) citalopram hydrobromide tabs 20 mg QL(2 ea daily) citalopram hydrobromide tabs 40 mg escitalopram oxalate fluoxetine hcl caps 10 mg, 20 mg, 40 mg fluoxetine hcl soln 20 mg/5ml fluoxetine hcl tabs 10 mg, 20 mg fluvoxamine maleate LEXAPRO (Use Escitalopram Oxalate) LUVOX CR (Use luvoxamine Maleate) paroxetine hcl XIL CR (Use Paroxetine HCl) XIL SUSP 10 MG/5ML XIL TABS 10 MG, 20 MG, 30 MG, 40 MG (Use Paroxetine HCl) PROZAC (Use luoxetine HCl) sertraline hcl ZOLOT (Use Sertraline HCl) Serotonin Modulators N N N N N N Name NEAZODONE HCL nefazodone hcl trazodone hcl Serotonin-Norepinephrine Reuptake Inhibitors CYMBTA (Use N QL(2 ea daily) Duloxetine HCl) DESVENLAAXINE ER ST duloxetine hcl 20 mg, 30 mg, 60 mg EEXOR XR (Use Venlafaxine HCl) KHEDEZLA PRISTIQ venlafaxine hcl Tricyclic Agents amitriptyline hcl ANARANIL (Use Clomipramine HCl) clomipramine hcl desipramine hcl DOXEPIN HCL doxepin hcl imipramine hcl NORPRAMIN (Use Desipramine HCl) NORTRIPTYLINE HCL nortriptyline hcl MELOR (Use Nortriptyline HCl) protriptyline hcl TORANIL (Use Imipramine HCl) N N N N N QL(2 ea daily) ST ST 14

19 Name VIVACTIL (Use Protriptyline HCl) N ANTIDIABETICS - s to Regulate Blood Sugar Alpha-Glucosidase Inhibitors acarbose PRESE (Use Acarbose) Antidiabetic - Amylin Analogs SYMLINPEN 120 SYMLINPEN 60 Antidiabetic Combinations ACTOPLUS MET (Use Pioglitazone HCl-Metformin HCl) AVANDAMET AVANDARYL DUETACT (Use Pioglitazone HCl- Glimepiride) glipizide-metformin hcl GLUVANCE (Use Glyburide-Metformin) glyburide-metformin INVOKAMET JANUMET JANUMET XR JENTADUETO JUVISYNC 100MG-10MG, 100MG-20MG, 50MG- 10MG, 50MG-20MG JUVISYNC 40MG-100MG, 40MG-50MG KAZANO KOMBIGLYZE XR N N N N QL(2 ea daily) QL(2 ea daily) Name OSENI pioglitazone hcl-glimepiride pioglitazone hcl-metformin hcl Biguanides GLUPHAGE (Use Metformin HCl) GLUPHAGE XR (Use Metformin HCl) metformin hcl tabs 1000 mg, 500 mg, 850 mg metformin hcl tb mg, 750 mg Diabetic Other GLUCAGON EMERGENCY KIT KORLYM N N Dipeptidyl Peptidase-4 (DPP-4) Inhibitors JANUVIA NESINA ONGLYZA TRADJENTA Dopamine Receptor Agonists - Antidiabetic CYCLOSET Incretin Mimetic Agents (GLP-1 Receptor BYDUREON BYETTA TANZEUM TRULICITY VICTOZA Insulin Sensitizing Agents ACTOS (Use Pioglitazone HCl) N 15

20 Name AVANDIA pioglitazone hcl Insulin APIDRA APIDRA SOLOSTAR HUMOG HUMOG KWIKPEN HUMOG MIX 50/50 HUMOG MIX 50/50 KWIKPEN HUMOG MIX 75/25 HUMOG MIX 75/25 KWIKPEN HUMULIN 70/30 HUMULIN 70/30 KWIKPEN HUMULIN 70/30 PEN HUMULIN N HUMULIN N KWIKPEN HUMULIN N U-100 PEN HUMULIN R HUMULIN R U-500 (NCENTRATED) LANTUS LANTUS SOLOSTAR LEVEMIR ; QL(50 ml per 30 days retail) ; QL(50 ml per 30 days retail) QL(50 ml per 30 days retail) QL(50 ml per 30 days retail) QL(50 ml per 30 days retail) QL(50 ml per 30 days retail) QL(50 ml per 30 days retail) QL(50 ml per 30 days retail) QL(50 ml per 30 days retail) QL(50 ml per 30 days retail) QL(50 ml per 30 days retail) QL(50 ml per 30 days retail) QL(50 ml per 30 days retail) QL(50 ml per 30 days retail) QL(50 ml per 30 days retail) QL(20 ml per 30 days retail) QL(50 ml per 30 days retail) QL(50 ml per 30 days retail) QL(50 ml per 30 days retail) Name LEVEMIR LEXPEN LEVEMIR LEXTOUCH TOUJEO SOLOSTAR Meglitinide Analogues nateglinide STARLIX (Use Nateglinide) N QL(50 ml per 30 days retail) QL(50 ml per 30 days retail) Limited to 3 boxes per month.;ql(0.5 ml daily) Sodium-Glucose Co-Transporter 2 (SGLT2) INVOKANA JARDIANCE Sulfonylureas AMARYL (Use Glimepiride) DIABETA (Use Glyburide) glimepiride glipizide GLUTROL (Use Glipizide) GLUTROL XL (Use Glipizide) glyburide glyburide micronized GLYNASE (Use Glyburide Micronized) TOLAZAMIDE tolazamide TOLBUTAMIDE N N N N N ANTIDIARRHES - s to Treat Diarrhea Antidiarrheal Agents - Misc. 16