Georgia Medicaid Comprehensive Preferred Drug List (List of Covered Drugs)

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1 2014 Georgia Medicaid Comprehensive referred Drug List (List of Covered Drugs) WellCare of Georgia, Inc lease read: This document contains information about the drugs we cover in this plan. ara solicitar este documento en español o para escuchar la traducción, llame al Servicio al Cliente al (TTY/TDD: ). lease note that the Georgia Medicaid referred Drug List is updated quarterly. roviders, please visit our website at to view updates to the preferred drug list. Members, please visit our website at to view updates to the preferred drug list. Last updated (01/01/2014)

2 Non-referred Drugs Georgia Medicaid Cough & Cold Drug List LEASE NOTE: The preferred cough & cold drugs on this list are covered only for members 20 years old or younger. ANTITUSSIVES,NON-NARCOTIC Benzonatate TESSALON 200 CASULE BENZONATATE 100 CASULE BENZONATATE 200 CASULE Dextromethorphan olistirex DELSYM 30 /5 ML EXTENDED-RELEASE SUSENSION Dextromethorphan HBr ROBITUSSIN EDIATRIC COUGH SY Dextromethorphan HBr/Menthol DELSYM COUGH RELIEF LUS LOZENGE NON-NARC ANTITUSS-1ST GEN. ANTIHISTAMINE-DECONGEST Brompheniramine/Dextromethorphan HBr/seudoephedrine HCl ALLANHIST DX DROS BROMHIST DX DROS BROTA DM LIQUID Q-TA DM ELIXIR BROMFED DM SYRU ENDACOF-D DROS Brophenaramine/Dextromethorphan HBr/henylephrine HCl COLD/COUGH CHILDRENS ELIXIR RYNEX DM DIMAHEN DM ELIXIR Chlorpheniramine/Dextromethorphan HBr/henylephrine HCl C-HEN DM RONDEX-DM SYRU DE-CHLOR DM LIQUID NOHIST-DM D-COF SYRU SILDEC E-DM SYRU CORFEN DM TRI-DEX E Chlorpheniramine/Dextromethorphan HBr/seudoephedrine HCl EDIATRIC COUGH-COLD LIQUID MESEHIST DM KIDKARE COUGH/COLD Dexchlorpheniramine/seudoephedrine HCl/Chlophedianol HCl VANACOF LIQUID Chlorpheniramine/Dextromethorphan HBr DIMETA LONG-ACTING COUGH LIQ ROBITUSSIN LONG ACTING LIQUID romethazine HCl/Dextromethorphan HBr ROMETHAZINE-DM SYRU DELSYM NIGHTTIME MULTI-SYMTOM EXECTORANTS DECONGESTANT-EXECTORANT COMBINATIONS Guaifenesin/henylephrine HCl DONATUSSIN DROS E-GUAI DROS DESEC LIQUID RESCON-GG LIQUID Guaifenesin/Dextromethorphan HBr/henylephreine ROBAFEN CF SYRU referred Drugs NON-NARC ANTITUSS-1ST GEN. ANTIHIST-ANALGESIC COMBINATION Dextromethorphan HBr/Acetaminophen/Doxylamine NON-NARCOTIC DECONGESTANT-EXECTORANT-ANTITUSSIVE Last updated 01/01/14 age 1 of 2

3 Georgia Medicaid Cough & Cold Drug List LEASE NOTE: The preferred cough & cold drugs on this list are covered only for members 20 years old or younger. Non-referred Drugs referred Drugs NON-NARCOTIC ANTITUSSIVE AND EXECTORANT COMB. Dextromethorphan HBr/Guaifenesin DURATUSS DM ELIXIR SU-TUSS DM ELIXIR MUCUS RELIEF COUGH LIQUID DIABETIC TUSSIN DM LIQUID SIMUC-DM ELIXIR GUAIFENESIN DM SYRU Q-TUSSIN-DM SYRU EXTRA ACTION COUGH SILTUSSIN DM COUGH SYRU REFENESEN DM SILTUSSIN DM DAS COUGH SYRU MUCOSA DM ROBITUSSIN COUGH CHEST CONGESTION DM LIQUID Chlorpheniramine/Hydrocodone olistirex TUSSIONEX ENNKINETIC SUS TUSSICAS (min. age 6 years old) HYDROCODONE-CHLORHENIRAMINE SUSENSION (min. age 6 years old) Codeine hosphate/romethazine HCl ROMETHAZINE-CODEINE SYRU (min. age 6 years old) Dexbrompheniramine/Hydrocodone Bit/henylephrine HCl Codeine/henylephrine HCl/romethazine CYTUSS-HC NR SYRU HC/E/DBROM SYRU ROMETH VC W/COD SYRU ROMETHAZINE VC/COD SYRU HC 2.5-E 5-DBROM 1 SYRU seudoephedrine HCl/Codeine/Chlorpheniramine HENYLHISTINE DH HYDROMET SYRU NARCOTIC ANTITUSSIVE-1ST GENERATION ANTIHISTAMINE NARCOTIC ANTITUSSIVE-1ST GEN. ANTIHISTAMINE-DECONGESTANT NARCOTIC ANTITUSSIVE-ANTICHOLINERGIC COMBINATION Hydrocodone Bit/Homatropine HYDROCODONE-HOMATROINE NARCOTIC ANTITUSSIVE-EXECTORANT COMBINATION Guaifenesin/Hydrocodone Bit Codeine hosphate/guaifenesin HYDROCODONE-GUAIFENESIN SYRU CHERATUSSIN AC SYRU NARCOF SYRU TUSSICLEAR DH SYRU GUAIFENESIN-CODEINE SYRU IOHEN C-NR NARCOTIC ANTITUSSIVE-DECONGESTANT-EXECTORANT COMBINATIONS Codeine hosphate/guaifenesin/seudoephedrine HCl CHERATUSSIN DAC SYRU Last updated 01/01/14 age 2 of 2

4 Vaccines: Vaccines are covered under the Vaccines for Children program for members through 18 years of age. Coverage beyond the age of 18 is evaluated through the A process. UERCASE = Brand name drugs italics = Generic drugs reference Details = referred Dagger ( ) = N/A Asterisk (*) = N/A Asterisk (**) = N/A Asterisk (***) = N/A XX = N/A Coverage Details A = rior Authorization ST = Step Therapy QL = Quantity Limit AL = Age Limit = -Covered w/rx Drug Name reference Details Coverage Details *Adhd/Anti-Narcolepsy/Anti-Obesity/Anorexia nts* *Amphetamines** *Amphetamine Mixtures*** ADDERALL XR ORAL CASULE EXTENDED RELEASE 24 HOUR 10, 15, 20, 25, 30, 5 Amphetamine-Dextroamphetamine ORAL TABLET 10, 12.5, 15, 5, 7.5 Amphetamine-Dextroamphetamine ORAL TABLET 20 Amphetamine-Dextroamphetamine ORAL TABLET 30 *Amphetamines*** Dextroamphetamine Sulfate ORAL TABLET 10, 5 Dextroamphetamine Sulfate ER ORAL CASULE EXTENDED RELEASE 24 HOUR 10, 15, 5 VYVANSE ORAL CASULE 20, 30, 40, 50, 60, 70 *Anti-Obesity Agents** QL (62 EA per 31 day(s)); AL (Min 6 Years and Max 20 Years) QL (93 EA per 31 day(s)) QL (62 EA per 31 day(s)) ST; QL (31 EA per 31 Day(s)); AL (Min 5 Years and Max 20 Years) QL (31 EA per 31 day(s)); AL (Min 6 Years and Max 20 Years) 1

5 Drug Name reference Details Coverage Details *Lipase Inhibitors*** XENICAL ORAL CASULE 120 *Stimulants - Misc.** *Stimulants - Misc.*** Dexmethylphenidate HCl ORAL TABLET 10, 2.5, 5 METHYLIN ORAL TABLET CHEWABLE 10, 2.5, 5 Methylphenidate HCl ORAL TABLET 10, 5 Methylphenidate HCl ORAL TABLET 20 Methylphenidate HCl ER ORAL TABLET EXTENDEDRELEASE* 10 Methylphenidate HCl ER ORAL TABLET EXTENDEDRELEASE* 18, 27, 36 Methylphenidate HCl ER ORAL TABLET EXTENDEDRELEASE* 20 Methylphenidate HCl ER ORAL TABLET EXTENDEDRELEASE* 54 *Alternative Medicines* *Alternative Medicine - M's** *Alternative Medicine - Me's*** Melatonin Maximum Strength ORAL TABLET 5 *Aminoglycosides* *Aminoglycosides** *Aminoglycosides*** TOBI INHALATION NEBULIZATION SOLUTION 300 /5ML *Analgesics - Anti-Inflammatory* *Anti-Tnf-Alpha - Monoclonal Antibodies** *Anti-Tnf-Alpha - Monoclonal Antibodies*** HUMIRA SUBCUTANEOUS* KIT 20 /0.4ML, 40 /0.8ML HUMIRA EN SUBCUTANEOUS* KIT 40 /0.8ML A; AL (Min 12 Years and Max 21 Years) QL (62 EA per 31 day(s)); AL (Min 6 Years) AL (Min 6 Years) AL (Min 6 Years) QL (93 EA per 31 day(s)); AL (Min 6 Years) AL (Min 6 Years and Max 20 Years) QL (62 EA per 31 day(s)); AL (Min 6 Years and Max 20 Years) QL (93 EA per 31 day(s)); AL (Min 6 Years and Max 20 Years) QL (31 EA per 31 day(s)); AL (Min 6 Years and Max 20 Years) A A A 2

6 Drug Name reference Details Coverage Details HUMIRA EN-CROHNS STARTER SUBCUTANEOUS* KIT 40 /0.8ML SIMONI SUBCUTANEOUS* SOLUTION 100 /ML, 50 /0.5ML *Gold Compounds** *Gold Compounds*** RIDAURA ORAL CASULE 3 *Nonsteroidal Anti-Inflammatory Agents (Nsaids)** *Cyclooxygenase 2 (Cox-2) Inhibitors*** CELEBREX ORAL CASULE 100, 200, 400, 50 *Nonsteroidal Anti-Inflammatory Agents (Nsaids)*** Childrens Ibuprofen ORAL SUSENSION 40 /ML Diclofenac otassium ORAL TABLET 50 Diclofenac Sodium ORAL TABLET DELAYED RELEASE 25, 50, 75 Etodolac ORAL CASULE 200, 300 Etodolac ORAL TABLET 400, 500 Flurbiprofen ORAL TABLET 100, 50 Ibuprofen ORAL SUSENSION 100 /5ML A A ST; QL (31 EA per 31 day(s)) Ibuprofen ORAL TABLET 200 Ibuprofen ORAL TABLET 400, 600, 800 Indomethacin ORAL CASULE 25, 50 Ketorolac Tromethamine ORAL TABLET 10 Meloxicam ORAL TABLET 15, 7.5 Nabumetone ORAL TABLET 500, 750 Naproxen ORAL SUSENSION 125 /5ML Naproxen ORAL TABLET 250, 375, 500 QL (20 EA per 31 day(s)) QL (2000 ML per 31 day(s)) 3

7 Drug Name reference Details Coverage Details Naproxen Sodium ORAL TABLET 275, 550 iroxicam ORAL CASULE 10, 20 Sulindac ORAL TABLET 150, 200 *yrimidine Synthesis Inhibitors** *yrimidine Synthesis Inhibitors*** Leflunomide ORAL TABLET 10, 20 *Analgesics - Nonnarcotic* *Analgesic Combinations** *Analgesics-Sedatives*** Butalbital-Acetaminophen ORAL TABLET Butalbital-AA-Caffeine ORAL CASULE Butalbital-AA-Caffeine ORAL TABLET , Butalbital-ASA-Caffeine ORAL CASULE QL (186 EA per 31 day(s)) QL (186 EA per 31 day(s)) QL (186 EA per 31 day(s)) TENCON ORAL TABLET QL (124 EA per 31 day(s)) ZEBUTAL ORAL CASULE QL (186 EA per 31 day(s)) *Analgesics Other** *Analgesics Other*** Acetaminophen ORAL SOLUTION 160 /5ML Acetaminophen ORAL TABLET 325 ; QL (279 EA per 31 day(s)) Acetaminophen ORAL TABLET 500 ; QL (186 EA per 31 day(s)) Mapap ORAL LIQUID 160 /5ML Mapap Infants ORAL SUSENSION 160 /5ML ain & Fever Childrens ORAL SOLUTION 160 /5ML *Salicylates** *Salicylate Combinations*** Choline & Mag Trisalicylate ORAL TABLET 1000 Choline-Mag Trisalicylate ORAL LIQUID 500 /5ML *Salicylates*** 4

8 Drug Name reference Details Coverage Details Aspirin ORAL TABLET 325, 81 Aspirin ORAL TABLET CHEWABLE 81 Aspirin RE SUOSITORY 300, 600 Aspirin Low Dose ORAL TABLET 81 Diflunisal ORAL TABLET 500 Salsalate ORAL TABLET 500, 750 *Analgesics - Opioid* *Opioid Agonists** *Opioid Agonists*** Codeine hosphate INJECTION SOLUTION 15 /ML, 30 /ML Codeine Sulfate ORAL TABLET 15, 30, 60 FentaNYL TRANSDERMAL ATCH 72 HR 100 MCG/HR, 12 MCG/HR, 25 MCG/HR, 50 MCG/HR, 75 MCG/HR HYDROmorphone HCl ORAL LIQUID 1 /ML HYDROmorphone HCl ORAL TABLET 2, 4, 8 HYDROmorphone HCl RE SUOSITORY 3 Methadone HCl ORAL SOLUTION 10 /5ML, 5 /5ML Methadone HCl ORAL TABLET 10, 5 QL (248 EA per 31 day(s)) A; QL (10 EA per 30 day(s)) QL (248 EA per 31 day(s)) QL (248 EA per 31 day(s)) METHADOSE ORAL TABLET 10 QL (248 EA per 31 day(s)) Morphine Sulfate INJECTION SOLUTION 10 /ML, 15 /ML, 5 /ML, 8 /ML Morphine Sulfate INTRAVENOUS* SOLUTION 1 /ML, 25 /ML, 50 /ML Morphine Sulfate ORAL SOLUTION 10 /5ML, 20 /5ML Morphine Sulfate ORAL TABLET 15, 30 Morphine Sulfate RE SUOSITORY 10, 20, 30, 5 QL (248 EA per 31 day(s)) 5

9 Drug Name reference Details Coverage Details Morphine Sulfate (Concentrate) ORAL SOLUTION 20 /ML Morphine Sulfate (F) INJECTION SOLUTION 0.5 /ML Morphine Sulfate (F) INTRAVENOUS* SOLUTION 8 /ML Morphine Sulfate ER ORAL TABLET EXTENDEDRELEASE* 100, 15, 200, 30, 60 QL (248 EA per 31 day(s)) OxyCODONE HCl ORAL CASULE 5 QL (248 EA per 31 day(s)) OxyCODONE HCl ORAL SOLUTION 5 /5ML OxyCODONE HCl ORAL TABLET 10, 15, 20, 5 OxyCODONE HCl ORAL TABLET 30 QL (248 EA per 31 day(s)) TraMADol HCl ORAL TABLET 50 QL (248 EA per 31 day(s)) *Opioid Combinations** *Codeine Combinations*** Acetaminophen-Codeine ORAL SOLUTION /5ML Acetaminophen-Codeine #2 ORAL TABLET Acetaminophen-Codeine #3 ORAL TABLET Acetaminophen-Codeine #4 ORAL TABLET ASCOM-CODEINE ORAL CASULE Butalbital-AA-Caff-Cod ORAL CASULE Butalbital-ASA-Caff-Codeine ORAL CASULE *Hydrocodone Combinations*** Hydrocodone-Acetaminophen ORAL SOLUTION /15ML, /15ML QL (248 EA per 31 day(s)) QL (248 EA per 31 day(s)) QL (248 EA per 31 day(s)) QL (186 EA per 31 day(s)) QL (3720 ML per 31 day(s)) 6

10 Drug Name reference Details Coverage Details Hydrocodone-Acetaminophen ORAL TABLET , , , , , , 5-325, 5-500, , , , Hydrocodone-Ibuprofen ORAL TABLET QL (248 EA per 31 day(s)) QL (155 EA per 31 day(s)) HYDROGESIC ORAL CASULE QL (248 EA per 31 day(s)) *Opioid Combinations*** ENDOCET ORAL TABLET , 5-325, , QL (248 EA per 31 day(s)) ENDOCET ORAL TABLET QL (186 EA per 31 day(s)) Oxycodone-Acetaminophen ORAL CASULE Oxycodone-Acetaminophen ORAL TABLET , 5-325, , Oxycodone-Acetaminophen ORAL TABLET Oxycodone-Aspirin ORAL TABLET QL (248 EA per 31 day(s)) QL (248 EA per 31 day(s)) QL (186 EA per 31 day(s)) QL (186 EA per 31 day(s)) ROXICET ORAL TABLET QL (248 EA per 31 day(s)) *Opioid artial Agonists** *Opioid artial Agonists*** Buprenorphine HCl SUBLINGUAL TABLET SUBLINGUAL 2, 8 Butorphanol Tartrate NASAL SOLUTION 10 /ML entazocine-naloxone HCl ORAL TABLET SUBOXONE SUBLINGUAL FILM 12-3, 2-0.5, 4-1, 8-2 *Androgens-Anabolic* *Anabolic Steroids** *Anabolic Steroids*** Oxandrolone ORAL TABLET 10, 2.5 A *Androgens** *Androgens*** A QL (3 ML per 31 day(s)) A 7

11 Drug Name reference Details Coverage Details Danazol ORAL CASULE 100, 200, 50 Methitest ORAL TABLET 10 TESTIM TRANSDERMAL GEL 50 /5GM Testosterone Cypionate INTRAMUSCULAR* OIL 100 /ML, 200 /ML Testosterone Enanthate INTRAMUSCULAR* OIL 200 /ML *Anorectal Agents* *Intrarectal Steroids** *Intrarectal Steroids*** Hydrocortisone RE ENEMA 100 /60ML *Rectal Steroids** *Rectal Steroids*** ROCTOSOL HC RE CREAM 2.5 % ROCTOZONE-HC RE CREAM 2.5 % *Antacids* *Antacids - Aluminum Salts** *Antacids - Aluminum Salts*** Aluminum Hydroxide Gel ORAL SUSENSION 320 /5ML *Antacids - Calcium Salts** *Antacids - Calcium Salts*** Calcium Carbonate Antacid ORAL TABLET CHEWABLE 500 *Antacids - Magnesium Salts** *Antacids - Magnesium Salts*** Magnesium Oxide ORAL TABLET 250, 400, 420 *Anthelmintics* *Anthelmintics** *Anthelmintics*** ALBENZA ORAL TABLET 200 A BILTRICIDE ORAL TABLET 600 A Reeses inworm Medicine ORAL SUSENSION 144 /ML A 8

12 Drug Name reference Details Coverage Details STROMECTOL ORAL TABLET 3 QL (10 EA per 31 day(s)) *Antianginal Agents* *Nitrates** *Nitrates*** Isosorbide Dinitrate ORAL TABLET 10, 20, 30, 5 Isosorbide Dinitrate ER ORAL TABLET EXTENDEDRELEASE* 40 Isosorbide Mononitrate ORAL TABLET 10, 20 Isosorbide Mononitrate ER ORAL TABLET EXTENDED RELEASE 24 HR* 120, 30, 60 NITRO-BID TRANSDERMAL OINTMENT 2 % Nitroglycerin TRANSDERMAL ATCH 24 HR 0.1 /HR, 0.2 /HR, 0.4 /HR, 0.6 /HR NITROSTAT SUBLINGUAL TABLET SUBLINGUAL 0.3, 0.4, 0.6 *Antianxiety Agents* *Antianxiety Agents - Misc.** *Antianxiety Agents - Misc.*** BusIRone HCl ORAL TABLET 10, 15, 30, 5, 7.5 HydrOXYzine HCl ORAL SOLUTION 10 /5ML HydrOXYzine HCl ORAL SYRU 10 /5ML HydrOXYzine HCl ORAL TABLET 10, 25, 50 HydrOXYzine amoate ORAL CASULE 100, 25, 50 Meprobamate ORAL TABLET 200, 400 *Benzodiazepines** *Benzodiazepines*** ALRAZolam ORAL TABLET 0.25, 0.5, 1, 2 QL (450 ML per 31 day(s)) QL (450 ML per 31 day(s)) 9

13 Drug Name reference Details Coverage Details ChlordiazeOXIDE HCl ORAL CASULE 10, 25, 5 Clorazepate Dipotassium ORAL TABLET 15, 3.75, 7.5 Diazepam INJECTION SOLUTION 5 /ML AL (Min 9 Years) Diazepam ORAL SOLUTION 1 /ML QL (1240 ML per 31 day(s)) Diazepam ORAL TABLET 10, 2, 5 LORazepam INJECTION SOLUTION 2 /ML, 4 /ML LORazepam ORAL TABLET 0.5, 1, 2 Oxazepam ORAL CASULE 10, 15, 30 *Antiarrhythmics* *Antiarrhythmics Type I-A** *Antiarrhythmics Type I-A*** Disopyramide hosphate ORAL CASULE 100, 150 rocainamide HCl INJECTION SOLUTION 100 /ML, 500 /ML QuiNIDine Gluconate INJECTION SOLUTION 80 /ML QuiNIDine Gluconate ER ORAL TABLET EXTENDEDRELEASE* 324 QuiNIDine Sulfate ORAL TABLET 300 *Antiarrhythmics Type I-B** *Antiarrhythmics Type I-B*** Lidocaine HCl (Cardiac) INTRAVENOUS* SOLUTION 20 /ML Mexiletine HCl ORAL CASULE 150, 200, 250 *Antiarrhythmics Type I-C** *Antiarrhythmics Type I-C*** Flecainide Acetate ORAL TABLET 100, 150, 50 ropafenone HCl ORAL TABLET 150, 225,

14 Drug Name reference Details Coverage Details *Antiarrhythmics Type Iii** *Antiarrhythmics Type Iii*** Amiodarone HCl INTRAVENOUS* SOLUTION 150 /3ML Amiodarone HCl ORAL TABLET 200, 400 ACERONE ORAL TABLET 200, 400 *Antiasthmatic And Bronchodilator Agents* *Antiasthmatic - Monoclonal Antibodies** *Anti-Ige Monoclonal Antibodies*** XOLAIR SUBCUTANEOUS* SOLUTION RECONSTITUTED 150 *Anti-Inflammatory Agents** *Anti-Inflammatory Agents*** Cromolyn Sodium INHALATION NEBULIZATION SOLUTION 20 /2ML *Bronchodilators - Anticholinergics** *Bronchodilators - Anticholinergics*** ATROVENT HFA INHALATION AEROSOL, SOLUTION 17 MCG/ACT Ipratropium Bromide INHALATION SOLUTION 0.02 % TUDORZA RESSAIR INHALATION AEROSOL OWDER, BREATH ACTIVATED 400 MCG/ACT *Leukotriene Modulators** *Leukotriene Receptor Antagonists*** Montelukast Sodium ORAL ACKET 4 Montelukast Sodium ORAL TABLET 10 Montelukast Sodium ORAL TABLET CHEWABLE 4, 5 Zafirlukast ORAL TABLET 10, 20 *Steroid Inhalants** *Steroid Inhalants*** ASMANEX 120 METERED DOSES INHALATION AEROSOL OWDER, BREATH ACTIVATED 220 MCG/INH A QL (25.8 GM per 31 day(s)) QL (480 ML per 31 day(s)) QL (1 EA per 30 day(s)) QL (1 EA per 30 day(s)) 11

15 Drug Name reference Details Coverage Details ASMANEX 30 METERED DOSES INHALATION AEROSOL OWDER, BREATH ACTIVATED 110 MCG/INH, 220 MCG/INH ASMANEX 60 METERED DOSES INHALATION AEROSOL OWDER, BREATH ACTIVATED 220 MCG/INH Budesonide INHALATION SUSENSION 0.25 /2ML, 0.5 /2ML FLOVENT DISKUS INHALATION AEROSOL OWDER, BREATH ACTIVATED 100 MCG/BLIST, 250 MCG/BLIST, 50 MCG/BLIST FLOVENT HFA INHALATION AEROSOL 110 MCG/ACT, 220 MCG/ACT FLOVENT HFA INHALATION AEROSOL 44 MCG/ACT ULMICORT INHALATION SUSENSION 1 /2ML QVAR INHALATION AEROSOL, SOLUTION 40 MCG/ACT QVAR INHALATION AEROSOL, SOLUTION 80 MCG/ACT *Sympathomimetics** *Adrenergic Combinations*** ADVAIR DISKUS INHALATION AEROSOL OWDER, BREATH ACTIVATED MCG/DOSE, MCG/DOSE, MCG/DOSE ADVAIR HFA INHALATION AEROSOL MCG/ACT, MCG/ACT, MCG/ACT COMBIVENT INHALATION AEROSOL MCG/ACT COMBIVENT RESIMAT INHALATION AEROSOL, SOLUTION MCG/ACT DULERA INHALATION AEROSOL MCG/ACT, MCG/ACT Ipratropium-Albuterol INHALATION SOLUTION (3) /3ML QL (1 EA per 30 day(s)) QL (1 EA per 30 day(s)) QL (120 ML per 31 day(s)); AL (Max 8 Years) QL (60 EA per 30 day(s)) QL (12 GM per 30 day(s)) QL (10.6 GM per 30 day(s)) QL (120 ML per 31 day(s)); AL (Max 8 Years) QL (8.7 GM per 30 day(s)) QL (17.4 GM per 30 day(s)) QL (60 EA per 30 day(s)) QL (12 GM per 30 day(s)) QL (29.4 GM per 31 day(s)) QL (4 GM per 20 day(s)) QL (13 GM per 30 day(s)) QL (720 ML per 31 day(s)) 12

16 Drug Name reference Details Coverage Details SYMBICORT INHALATION AEROSOL MCG/ACT, MCG/ACT *Beta Adrenergics*** Albuterol Sulfate INHALATION NEBULIZATION SOLUTION (2.5 /3ML) 0.083% Albuterol Sulfate INHALATION NEBULIZATION SOLUTION (5 /ML) 0.5% Albuterol Sulfate INHALATION NEBULIZATION SOLUTION 0.63 /3ML, 1.25 /3ML QL (10.2 GM per 30 day(s)) QL (720 ML per 31 day(s)) QL (60 ML per 30 day(s)) QL (300 ML per 31 day(s)) Albuterol Sulfate ORAL SYRU 2 /5ML QL (2480 ML per 31 day(s)) Albuterol Sulfate ORAL TABLET 2, 4 FORADIL AEROLIZER INHALATION CASULE 12 MCG Metaproterenol Sulfate ORAL SYRU 10 /5ML SEREVENT DISKUS INHALATION AEROSOL OWDER, BREATH ACTIVATED 50 MCG/DOSE Terbutaline Sulfate INJECTION SOLUTION 1 /ML Terbutaline Sulfate ORAL TABLET 2.5, 5 VENTOLIN HFA INHALATION AEROSOL, SOLUTION 108 (90 BASE) MCG/ACT *Xanthines** *Xanthines*** Aminophylline INTRAVENOUS* SOLUTION 25 /ML ELIXOHYLLIN ORAL ELIXIR 80 /15ML Theophylline ORAL SOLUTION 80 /15ML Theophylline ER ORAL TABLET EXTENDED RELEASE 12 HR* 100, 200, 300, 450 QL (60 EA per 30 day(s)) QL (60 EA per 30 day(s)) QL (36 GM per 31 day(s)) 13

17 Drug Name reference Details Coverage Details Theophylline ER ORAL TABLET EXTENDED RELEASE 24 HR* 400, 600 *Anticoagulants* *Coumarin Anticoagulants** *Coumarin Anticoagulants*** JANTOVEN ORAL TABLET 1, 10, 2, 2.5, 3, 4, 5, 6, 7.5 Warfarin Sodium ORAL TABLET 1, 10, 2, 2.5, 3, 4, 5, 6, 7.5 *Direct Factor Xa Inhibitors** *Direct Factor Xa Inhibitors*** XARELTO ORAL TABLET 10 QL (35 EA per 365 day(s)) *Heparins And Heparinoid-Like Agents** *Low Molecular Weight Heparins*** Enoxaparin Sodium INJECTION SOLUTION 300 /3ML Enoxaparin Sodium SUBCUTANEOUS* SOLUTION 100 /ML, 150 /ML Enoxaparin Sodium SUBCUTANEOUS* SOLUTION 120 /0.8ML, 80 /0.8ML Enoxaparin Sodium SUBCUTANEOUS* SOLUTION 30 /0.3ML, 40 /0.4ML Enoxaparin Sodium SUBCUTANEOUS* SOLUTION 60 /0.6ML *Synthetic Heparinoid-Like Agents*** Fondaparinux Sodium SUBCUTANEOUS* SOLUTION 10 /0.8ML Fondaparinux Sodium SUBCUTANEOUS* SOLUTION 2.5 /0.5ML Fondaparinux Sodium SUBCUTANEOUS* SOLUTION 5 /0.4ML Fondaparinux Sodium SUBCUTANEOUS* SOLUTION 7.5 /0.6ML *Anticonvulsants* *Anticonvulsants - Benzodiazepines** *Anticonvulsants - Benzodiazepines*** QL (24 ML per 31 day(s)) QL (28 ML per 31 day(s)) QL (22.4 ML per 31 day(s)) QL (8.4 ML per 31 day(s)) QL (16.8 ML per 31 day(s)) QL (11.2 ML per 31 day(s)) QL (16 ML per 31 day(s)) QL (5.6 ML per 31 day(s)) QL (8.4 ML per 31 day(s)) 14

18 Drug Name reference Details Coverage Details ClonazeAM ORAL TABLET 0.5, 1, 2 Diazepam RE GEL 10, 2.5, 20 QL (3 EA per 31 day(s)) *Anticonvulsants - Misc.** *Anticonvulsants - Misc.*** CarBAMazepine ORAL SUSENSION 100 /5ML QL (2480 ML per 31 day(s)) CarBAMazepine ORAL TABLET 200 QL (248 EA per 31 day(s)) CarBAMazepine ORAL TABLET CHEWABLE 100 QL (310 EA per 31 day(s)) EITOL ORAL TABLET 200 QL (248 EA per 31 day(s)) Gabapentin ORAL CASULE 100 QL (310 EA per 31 day(s)) Gabapentin ORAL CASULE 300 QL (372 EA per 31 day(s)) Gabapentin ORAL CASULE 400 QL (279 EA per 31 day(s)) Gabapentin ORAL SOLUTION 250 /5ML QL (2230 ML per 31 day(s)) Gabapentin ORAL TABLET 600, 800 LamoTRIgine ORAL TABLET 100, 150, 200 LamoTRIgine ORAL TABLET 25 QL (310 EA per 31 day(s)) LamoTRIgine ORAL TABLET CHEWABLE 25, 5 LevETIRAcetam INTRAVENOUS* SOLUTION 500 /5ML LevETIRAcetam ORAL SOLUTION 100 /ML LevETIRAcetam ORAL TABLET 1000, 500, 750 QL (310 EA per 31 day(s)) QL (1000 ML per 31 day(s)) LevETIRAcetam ORAL TABLET 250 QL (372 EA per 31 day(s)) OXcarbazepine ORAL SUSENSION 300 /5ML QL (1240 ML per 31 day(s)) OXcarbazepine ORAL TABLET 150 QL (310 EA per 31 day(s)) OXcarbazepine ORAL TABLET 300 QL (248 EA per 31 day(s)) OXcarbazepine ORAL TABLET 600 rimidone ORAL TABLET 250 QL (248 EA per 31 day(s)) rimidone ORAL TABLET 50 QL (310 EA per 31 day(s)) Topiramate ORAL CASULE SRINKLE 15, 25 QL (310 EA per 31 day(s)) 15

19 Drug Name reference Details Coverage Details Topiramate ORAL TABLET 100, 25, 50 QL (310 EA per 31 day(s)) Topiramate ORAL TABLET 200 QL (248 EA per 31 day(s)) Zonisamide ORAL CASULE 100 QL (186 EA per 31 day(s)) Zonisamide ORAL CASULE 25 QL (310 EA per 31 day(s)) Zonisamide ORAL CASULE 50 QL (372 EA per 31 day(s)) *Gaba Modulators** *Gaba Modulators*** GABITRIL ORAL TABLET 12, 16 TiaGABine HCl ORAL TABLET 2, 4 *Hydantoins** *Hydantoins*** DILANTIN ORAL CASULE 30 QL (310 EA per 31 day(s)) Fosphenytoin Sodium INJECTION SOLUTION 100 E/2ML EGANONE ORAL TABLET 250 QL (372 EA per 31 day(s)) henytoin ORAL SUSENSION 125 /5ML henytoin ORAL TABLET CHEWABLE 50 henytoin Sodium INJECTION SOLUTION 50 /ML henytoin Sodium Extended ORAL CASULE 100, 200, 300 *Succinimides** *Succinimides*** Ethosuximide ORAL CASULE 250 Ethosuximide ORAL SOLUTION 250 /5ML *Valproic Acid** *Valproic Acid*** Divalproex Sodium ORAL CASULE SRINKLE 125 Divalproex Sodium ORAL TABLET DELAYED RELEASE 125, 250 Divalproex Sodium ORAL TABLET DELAYED RELEASE 500 QL (930 ML per 31 day(s)) QL (372 EA per 31 day(s)) QL (930 ML per 31 day(s)) QL (310 EA per 31 day(s)) QL (310 EA per 31 day(s)) QL (279 EA per 31 day(s)) 16

20 Drug Name reference Details Coverage Details Divalproex Sodium ER ORAL TABLET EXTENDED RELEASE 24 HR* 250 Divalproex Sodium ER ORAL TABLET EXTENDED RELEASE 24 HR* 500 QL (310 EA per 31 day(s)) QL (279 EA per 31 day(s)) Valproic Acid ORAL CASULE 250 QL (310 EA per 31 day(s)) Valproic Acid ORAL SOLUTION 250 /5ML QL (2790 ML per 31 day(s)) Valproic Acid ORAL SYRU 250 /5ML QL (2790 ML per 31 day(s)) *Antidepressants* *Alpha-2 Receptor Antagonists (Tetracyclics)** *Alpha-2 Receptor Antagonists (Tetracyclics)*** Mirtazapine ORAL TABLET 15, 30, 45, 7.5 Mirtazapine ORAL TABLET DISERSIBLE 15, 30, 45 *Antidepressants - Misc.** *Antidepressants - Misc.*** BUDERION SR ORAL TABLET EXTENDED RELEASE 12 HR* 150 BuROion HCl ORAL TABLET 100, 75 BuROion HCl ER (SR) ORAL TABLET EXTENDED RELEASE 12 HR* 100, 150, 200 BuROion HCl ER (XL) ORAL TABLET EXTENDED RELEASE 24 HR* 150, 300 Maprotiline HCl ORAL TABLET 25, 50, 75 *Modified Cyclics** *Modified Cyclics*** Nefazodone HCl ORAL TABLET 100, 150, 200, 250, 50 TraZODone HCl ORAL TABLET 100, 150, 50 *Monoamine Oxidase Inhibitors (Maois)** *Monoamine Oxidase Inhibitors (Maois)*** henelzine Sulfate ORAL TABLET 15 17

21 Drug Name reference Details Coverage Details Tranylcypromine Sulfate ORAL TABLET 10 *Selective Serotonin Reuptake Inhibitors (Ssris)** *Selective Serotonin Reuptake Inhibitors (Ssris)*** Citalopram Hydrobromide ORAL TABLET 10, 20, 40 Escitalopram Oxalate ORAL TABLET 10, 20, 5 FLUoxetine HCl ORAL CASULE 10, 20, 40 FLUoxetine HCl ORAL SOLUTION 20 /5ML FLUoxetine HCl ORAL TABLET 10, 20 FluvoxaMINE Maleate ORAL TABLET 100, 25, 50 ARoxetine HCl ORAL TABLET 10, 20, 30, 40 Sertraline HCl ORAL TABLET 100, 25, 50 *Serotonin-Norepinephrine Reuptake Inhibitors (Snris)** *Serotonin-Norepinephrine Reuptake Inhibitors (Snris)*** Venlafaxine HCl ORAL TABLET 100, 25, 37.5, 50, 75 Venlafaxine HCl ER ORAL CASULE EXTENDED RELEASE 24 HOUR 150, 37.5, 75 *Tricyclic Agents** *Tricyclic Agents*** Amitriptyline HCl ORAL TABLET 10, 100, 150, 25, 50, 75 Amoxapine ORAL TABLET 100, 150, 25, 50 ClomiRAMINE HCl ORAL CASULE 25, 50, 75 QL (31 EA per 31 day(s)) 18

22 Drug Name reference Details Coverage Details Desipramine HCl ORAL TABLET 10, 100, 150, 25, 50, 75 Doxepin HCl ORAL CASULE 10, 100, 25, 50, 75 Doxepin HCl ORAL CONCENTRATE 10 /ML Imipramine HCl ORAL TABLET 10, 25, 50 Nortriptyline HCl ORAL CASULE 10, 25, 50, 75 Nortriptyline HCl ORAL SOLUTION 10 /5ML rotriptyline HCl ORAL TABLET 10, 5 *Antidiabetics* *Alpha-Glucosidase Inhibitors** *Alpha-Glucosidase Inhibitors*** Acarbose ORAL TABLET 100, 25, 50 *Antidiabetic Combinations** *Dipeptidyl eptidase-4 Inhibitor-Biguanide Combinations*** JANUMET ORAL TABLET , JANUMET XR ORAL TABLET EXTENDED RELEASE 24 HR* , , JENTADUETO ORAL TABLET , , *Sulfonylurea-Biguanide Combinations*** GlipiZIDE-MetFORMIN HCl ORAL TABLET , , GlyBURIDE-MetFORMIN ORAL TABLET , , *Sulfonylurea-Thiazolidinedione Combinations*** AVANDARYL ORAL TABLET 4-1, 4-2, 4-4, 8-2, 8-4 *Thiazolidinedione-Biguanide Combinations*** QL (2325 ML per 31 day(s)) ST ST ST; QL (31 EA per 31 day(s)) ST 19

23 Drug Name reference Details Coverage Details AVANDAMET ORAL TABLET , 2-500, , ioglitazone HCl-Metformin HCl ORAL TABLET , *Biguanides** *Biguanides*** MetFORMIN HCl ORAL TABLET 1000, 500, 850 MetFORMIN HCl ER ORAL TABLET EXTENDED RELEASE 24 HR* 500, 750 MetFORMIN HCl ER (OSM) ORAL TABLET EXTENDED RELEASE 24 HR* 500 RIOMET ORAL SOLUTION 500 /5ML QL (900 ML per 31 day(s)) *Diabetic Other** *Diabetic Other*** GLUCAGEN INJECTION SOLUTION RECONSTITUTED 1 GLUCAGEN HYOKIT INJECTION SOLUTION RECONSTITUTED 1 GLUCAGON EMERGENCY INJECTION KIT 1 Glucose ORAL TABLET CHEWABLE 4 GM *Dipeptidyl eptidase-4 (Dpp-4) Inhibitors** *Dipeptidyl eptidase-4 (Dpp-4) Inhibitors*** JANUVIA ORAL TABLET 100, 25, 50 ST ST QL (2 EA per 31 day(s)) QL (2 EA per 31 day(s)) QL (2 EA per 31 day(s)) TRADJENTA ORAL TABLET 5 ST; QL (31 EA per 31 Day(s)) *Incretin Mimetic Agents (Glp-1 Receptor Agonists)** *Incretin Mimetic Agents (Glp-1 Receptor Agonists)*** BYDUREON SUBCUTANEOUS* SUSENSION RECONSTITUTED 2 *Insulin Sensitizing Agents** *Thiazolidinediones*** AVANDIA ORAL TABLET 2, 4, 8 ST ST; QL (4 EA per 28 day(s)) ST 20

24 Drug Name reference Details Coverage Details ioglitazone HCl ORAL TABLET 15, 30, 45 *Insulin** *Human Insulin*** AIDRA INJECTION SOLUTION 100 UNIT/ML AIDRA SOLOSTAR SUBCUTANEOUS* SOLUTION 100 UNIT/ML HUMALOG SUBCUTANEOUS* SOLUTION 100 UNIT/ML HUMALOG KWIKEN SUBCUTANEOUS* SOLUTION 100 UNIT/ML HUMALOG MIX 50/50 SUBCUTANEOUS* SUSENSION (50-50) 100 UNIT/ML HUMALOG MIX 50/50 KWIKEN SUBCUTANEOUS* SUSENSION (50-50) 100 UNIT/ML HUMALOG MIX 75/25 SUBCUTANEOUS* SUSENSION (75-25) 100 UNIT/ML HUMALOG MIX 75/25 KWIKEN SUBCUTANEOUS* SUSENSION (75-25) 100 UNIT/ML HUMULIN 70/30 SUBCUTANEOUS* SUSENSION (70-30) 100 UNIT/ML HUMULIN 70/30 EN SUBCUTANEOUS* SUSENSION (70-30) 100 UNIT/ML HUMULIN N SUBCUTANEOUS* SUSENSION 100 UNIT/ML HUMULIN N EN SUBCUTANEOUS* SUSENSION 100 UNIT/ML HUMULIN R INJECTION SOLUTION 100 UNIT/ML HUMULIN R U-500 (CONCENTRATED) SUBCUTANEOUS* SOLUTION 500 UNIT/ML LANTUS SUBCUTANEOUS* SOLUTION 100 UNIT/ML LANTUS SOLOSTAR SUBCUTANEOUS* SOLUTION 100 UNIT/ML *Sulfonylureas** ST QL (60 ML per 31 day(s)) QL (60 ML per 31 day(s)) QL (60 ML per 31 day(s)) QL (60 ML per 31 day(s)) QL (60 ML per 31 day(s)) QL (60 ML per 31 day(s)) QL (60 ML per 31 day(s)) QL (60 ML per 31 day(s)) ; QL (60 ML per 31 day(s)) ; QL (60 ML per 31 day(s)) ; QL (60 ML per 31 day(s)) ; QL (60 ML per 31 day(s)) ; QL (60 ML per 31 day(s)) QL (60 ML per 31 day(s)) QL (60 ML per 31 day(s)) QL (60 ML per 31 day(s)) 21

25 Drug Name reference Details Coverage Details *Sulfonylureas*** ChlorproAMIDE ORAL TABLET 100, 250 Glimepiride ORAL TABLET 1, 2, 4 GlipiZIDE ORAL TABLET 10, 5 GlipiZIDE ER ORAL TABLET EXTENDED RELEASE 24 HR* 10, 2.5, 5 GLIIZIDE XL ORAL TABLET EXTENDED RELEASE 24 HR* 10, 2.5, 5 GlyBURIDE ORAL TABLET 1.25, 2.5, 5 GlyBURIDE Micronized ORAL TABLET 1.5, 3, 6 *Antidiarrheals* *Antiperistaltic Agents** *Antiperistaltic Agents*** Diphenoxylate-Atropine ORAL LIQUID /5ML Diphenoxylate-Atropine ORAL TABLET LONOX ORAL TABLET Loperamide HCl ORAL CASULE 2 *Antidotes* *Antidotes - Chelating Agents** *Antidotes - Chelating Agents*** EXJADE ORAL TABLET SOLUBLE 125, 250, 500 *Antidotes** *Antidotes*** Deferoxamine Mesylate INJECTION SOLUTION RECONSTITUTED 2 GM, 500 *Opioid Antagonists** *Opioid Antagonists*** Naltrexone HCl ORAL TABLET 50 *Antiemetics* A 22

26 Drug Name reference Details Coverage Details *5-Ht3 Receptor Antagonists** *5-Ht3 Receptor Antagonists*** Ondansetron ORAL TABLET DISERSIBLE 4, 8 Ondansetron HCl ORAL SOLUTION 4 /5ML Ondansetron HCl ORAL TABLET 4, 8 *Antiemetics - Anticholinergic** *Antiemetics - Anticholinergic*** Meclizine HCl ORAL TABLET 12.5, 25 Meclizine HCl ORAL TABLET CHEWABLE 25 Travel Sickness ORAL TABLET CHEWABLE 25 *Antifungals* *Antifungals** *Antifungals*** Griseofulvin Microsize ORAL SUSENSION 125 /5ML Griseofulvin Microsize ORAL TABLET 500 Griseofulvin Ultramicrosize ORAL TABLET 125, 250 Nystatin ORAL TABLET UNIT Terbinafine HCl ORAL TABLET 250 *Imidazole-Related Antifungals** *Imidazoles*** Ketoconazole ORAL TABLET 200 *Triazoles*** Fluconazole ORAL SUSENSION RECONSTITUTED 10 /ML, 40 /ML Fluconazole ORAL TABLET 100, 150, 200, 50 *Antihistamines* *Antihistamines - Alkylamines** *Antihistamines - Alkylamines*** QL (450 ML per 31 day(s)) 23

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