2016 Prescription Drug List Effective May, 2016

Transcription

1 2016 Prescription Drug List Effective May, 2016 AmbetterofArkansas.com

2 Formulary Introduction FORMULARY The Ambetter of Arkansas Formulary, or Preferred Drug List, is a guide to available brand and generic drugs that are approved by the Food and Drug Administration (FDA) and covered through your prescription drug benefit. Generic drugs have the same active ingredients as their brand name counterparts and should be considered the first line of treatment. The FDA requires generics to be safe and work the same as brand name drugs. If there is no generic available, there may be more than one brand name drug to treat a condition. Preferred brand name drugs are listed on Tier 2 to help identify brand drugs that are clinically appropriate, safe, and cost-effective treatment options, if a generic medication on the formulary is not suitable for your condition. Please note, the Formulary is not meant to be a complete list of the drugs covered under your prescription benefit. Not all dosage forms or strengths of a drug may be covered. This list is periodically reviewed and updated and may be subject to change. Drugs may be added or removed, or additional requirements may be added in order to approve continued usage of a specific drug. pecific prescription benefit plan designs may not cover certain products or categories, regardless of their appearance in this document. Please check your benefits for coverage limitations and your share of cost for your drugs. Drug List Key: Brand name drugs are listed in CAP and generic drugs are lower case. Drugs are covered under different copay tiers depending on your benefit: Tier 0 - No copayment for those drugs that are used for prevention and are mandated by Affordable Care Act. elect oral contraceptives, vitamin D, folic acid for women of child bearing age, over-the-counter (OTC) aspirin, and smoking cessation products may be covered under this tier. Certain age or gender limits apply. Tier 1 - Lowest copayment for those drugs that offer the greatest value compared to other drugs used to treat similar conditions. elect over-the-counter (OTC), generic or brand name drugs may be covered under this tier. Tier 2 - Medium copayment covers brand name drugs that are generally more affordable, or may be preferred compared to other drugs to treat the same conditions. Tier 3 - Highest copayment covers higher cost brand name drugs. This tier may also cover non-specialty drugs that are not on the Preferred Drug List but approval has been granted for coverage. Tier 4 - Coverage for this tier is for specialty drugs used to treat complex, chronic conditions that may require special handling, storage or clinical management. For members who do not have a four Tier plan, these drugs may be covered under Tier 3. Prior Authorization for Non-Formulary Drugs To obtain prior authorization for a non-formulary drug, your provider must fill out the Prior Authorization form. U cript will respond via fax or phone within 48 hours of receipt of all necessary information, except during weekends and holidays. If the request is disapproved, the notice of disapproval will contain a clear explanation of the specific reasons for disapproving the prior authorization request, or if the request was incomplete, the explanation will identify the missing material information that is necessary to complete the request.

3 LEGEND TIER DECRIPTION 0 Preventative 1 Generics 2 Preferred Brands 3 Non-Preferred Brands 4 pecialty TYPE DECRIPTION Prior Authorization Prior Authorization required before prescription can be filled. T tep Therapy Requires trial and failure of one or more preferred products prior to coverage. GL Gender Limit Drug is limited to specific gender. AL Age Limit Drug is limited to specific age. Max Daily Dose A limit on the number of times the drug can be taken per day. MPL Max Package Limit A limit on the amount of drug covered per prescription. MFL Max Fill Limit There is a limit on the number of times this drug can be refilled. MD1 Max Days upply There is a limit on the amount of this drug that is covered. C Custom This drug has unique restrictions. FAL MAL pecialty Drug Female Age Limit Male Age Limit pecialty drugs are high-cost drugs used to treat complex or rare conditions, such as multiple sclerosis, rheumatoid arthritis, hepatitis C, and hemophilia. This prescription drug may only be covered if you are a female and meet the minimum or maximum age limit. This prescription drug may only be covered if you are a male and meet the minimum or maximum age limit. GE 2 LAT UPDATED 05/2016

4 LIT OF COVERED OVER-THE-COUNTER MEDICATION PRODUCT DECRIPTION BRAND/GEN TIER LIMIT & RETRICTION ANALGEIC NONTEROIDAL ANTI-INFLAMMATORY DRUG aspirin tab delayed release 81 mg generic 0 ibuprofen susp 100 mg/5ml ANTI-ADDICTION/UBTANCE ABUE TREATMENT AGENT MOKING CEATION AGENT COMMIT BRAND 0 FAL MAL Female - 55 to 79 yrs old Male - 45 to 79 yrs old NICODERM CQ BRAND 0 1 per day NICORETTE BRAND 0 NICORETTE MINI BRAND 0 NICORETTE REFILL BRAND 0 NICORETTE TARTER KIT BRAND 0 nicotine (patch 24hr 7 mg/24hr, patch 24hr 21 mg/24hr, patch 24hr 14 mg/24hr) generic 0 1 per day NICOTINE KIT MG/24HR BRAND 0 NICOTINE MINI BRAND 0 nicotine polacrilex generic 0 ANTIEMETIC ANTIEMETIC, OTHER meclizine hcl (tab 12.5 mg, tab 25 mg) ANTIFUNGAL clotrimazole (topical) (cream, soln) clotrimazole vaginal cream 1% GYNE-LOTRIMIN BRAND 1 LOTRIMIN ULTRA BRAND 2 MPL 1 / 30 days GE 3 LAT UPDATED 05/2016

5 PRODUCT DECRIPTION BRAND/GEN TIER LIMIT & RETRICTION CARDIOVACULAR AGENT DYLIPIDEMIC, OTHER niacin tab cr 750 mg DENTAL AND ORAL AGENT stannous fluoride conc 0.63% generic 0 DERMATOLOGICAL AGENT benzoyl peroxide (foam 5.3%, gel 5%, gel 10%, liq 4%, liq 10%, lotion 6%) AL At least 12 yrs old hydrocortisone (topical) (cream, oint) lactic acid (ammonium lactate) (cream, lotion) lidocaine hcl gel 2% NOXYL-4 CREAMY WAH BRAND 3 AL At least 12 yrs old GATROINTETINAL AGENT GATROINTETINAL AGENT, OTHER loperamide hcl cap 2 mg HITAMINE2 (H2) RECEPTOR ANTAGONIT cimetidine famotidine tab 20 mg ranitidine hcl tab 150 mg LAXATIVE bisacodyl tab delayed release 5 mg calcium polycarbophil docusate calcium docusate sodium (cap 100 mg, cap 250 mg) PROTON PUMP INHIBITOR CV OMEPRAZOLE BRAND 1 2 per day EQ OMEPRAZOLE BRAND 1 2 per day EQL OMEPRAZOLE BRAND 1 2 per day GNP OMEPRAZOLE BRAND 1 2 per day GE 4 LAT UPDATED 05/2016

6 PRODUCT DECRIPTION BRAND/GEN TIER LIMIT & RETRICTION HM OMEPRAZOLE BRAND 1 2 per day KL OMEPRAZOLE BRAND 1 2 per day lansoprazole 1 per day NEXIUM 24HR CAP DR 20 MG BRAND 1 2 per day omeprazole delayed release tab 20 mg 2 per day omeprazole magnesium 4 per day OMEPRAZOLE TAB DR 20 MG BRAND 1 2 per day omeprazole-sodium bicarbonate 1 per day PREVACID 24HR BRAND 1 1 per day PRILOEC OTC BRAND 1 4 per day PX OMEPRAZOLE BRAND 1 2 per day RA OMEPRAZOLE BRAND 1 2 per day B OMEPRAZOLE BRAND 1 2 per day M OMEPRAZOLE BRAND 1 2 per day W OMEPRAZOLE BRAND 1 2 per day TGT OMEPRAZOLE BRAND 1 2 per day ZEGERID OTC BRAND 1 1 per day GENITOURINARY AGENT GENITOURINARY AGENT, OTHER GYNOL II BRAND 0 TODAY PONGE BRAND 0 HORMONAL AGENT, TIMULANT/REPLACEMENT/MODIFYING (EX HORMONE/MODIFIER) ETROGEN levonorgestrel (emergency oc) generic 0 GL Female PLAN B ONE-TEP BRAND 0 GL Female GE 5 LAT UPDATED 05/2016

7 PRODUCT DECRIPTION BRAND/GEN TIER LIMIT & RETRICTION MICELLANEOU THERAPEUTIC AGENT AIMCO LUBRICATED BRAND 0 ELEXA NATURAL FEEL BRAND 0 ELEXA TIMULATING BRAND 0 ELEXA ULTRA ENITIVE BRAND 0 FANTAY LUBRICATED BRAND 0 FANTAY LUBRICATED/PERMICIDE BRAND 0 FC FEMALE CONDOM BRAND 0 FC2 FEMALE CONDOM BRAND 0 KAMELEON LUBRICATED BRAND 0 KIMONO BRAND 0 KIMONO MICRO THIN PLU BRAND 0 KIMONO PLU BRAND 0 KIMONO P BRAND 0 KIMONO P PLU BRAND 0 KIMONO ENATION BRAND 0 KIMONO ENATION PLU BRAND 0 MAXX BRAND 0 MAXX PLU BRAND 0 NOVA MAX PLU KETONE TET BRAND 1 PRECIION XTRA KETONE BRAND 1 PREMIUM CONDOM LUBRICATED BRAND 0 PT NEL KETONE TET BRAND 1 REALITY LATEX/ULTRA TEXTURED BRAND 0 REALITY LATEX/ULTRA THIN BRAND 0 TROJAN MAGNUM WARM ENATION BRAND 0 TROJAN UPRA PERMICIDAL BRAND 0 TROJAN TWITED PLEAURE BRAND 0 TRUTEX COLOR CONDOM + LUBE BRAND 0 TRUTEX LUB/RIBBED/TUDDED BRAND 0 TRUTEX LUB/PERMICIDE EX T BRAND 0 GE 6 LAT UPDATED 05/2016

8 PRODUCT DECRIPTION BRAND/GEN TIER LIMIT & RETRICTION TRUTEX LUB/PERMICIDE XL BRAND 0 TRUTEX LUBRICATED BRAND 0 TRUTEX LUBRICATED EX LARGE BRAND 0 TRUTEX LUBRICATED EXTRA T BRAND 0 TRUTEX LUBRICATED/PERMICIDE BRAND 0 TRUTEX NATURAL CONDOM + LUBE BRAND 0 TRUTEX RIA LUB/PERMICIDE BRAND 0 TRUTEX RIA LUBRICATED BRAND 0 TRUTEX-NONOXYNOL-9/RIB/TUD BRAND 0 OPHTHALMIC AGENT OPHTHALMIC AGENT, OTHER ketotifen fumarate (ophth) ZADITOR BRAND 1 REPIRATORY TRACT/PULMONARY AGENT ANTI-INFLAMMATORIE, INHALED CORTICOTEROID fluticasone propionate (nasal) MPL 1 / 30 days ANTIHITAMINE ALLEGRA ALLERGY CHILDREN (TAB 30 MG, TAB DIP 30 MG) ALLEGRA ALLERGY CHILDREN UPENION 30 MG/5ML BRAND 1 2 per day BRAND 1 MD1 900 ML / 30 DAY ALLEGRA ALLERGY TAB 180 MG BRAND 1 1 per day ALLEGRA ALLERGY TAB 60 MG BRAND 1 2 per day cetirizine hcl (cap 10 mg, chew tab 5 mg, chew tab 10 mg, tab 5 mg, tab 10 mg) 1 per day cetirizine hcl oral soln 1 mg/ml (5 mg/5ml) MD1 300 ML / 30 DAY CLARITIN (CAP 10 MG, CHEW TAB 5 MG, YRUP 5 MG/5ML, TAB 10 MG) BRAND 1 CLARITIN REDITAB BRAND 1 diphenhydramine hcl (cap 50 mg, elixir 12.5 mg/5ml) GE 7 LAT UPDATED 05/2016

9 PRODUCT DECRIPTION BRAND/GEN TIER LIMIT & RETRICTION fexofenadine hcl susp 30 mg/5ml (6 mg/ml) MD1 900 ML / 30 DAY fexofenadine hcl tab 180 mg 1 per day fexofenadine hcl tab 60 mg 2 per day loratadine (rapidly-disintegrating tab 10 mg, syrup 5 mg/5ml, tab 10 mg) ZYRTEC ALLERGY (CAP 10 MG, TAB 10 MG) BRAND 1 1 per day ZYRTEC CHILDREN ALLERGY (CHEW TAB 5 MG, CHEW TAB 10 MG) ZYRTEC CHILDREN ALLERGY (YRUP 1 MG/ML, YRUP 5 MG/5ML) BRAND 1 1 per day BRAND 1 MD1 300 / 30 DAY ZYRTEC CHILDREN HIVE RELIEF BRAND 1 MD1 300 ML / 30 DAY ZYRTEC HIVE RELIEF BRAND 1 1 per day REPIRATORY TRACT AGENT, OTHER cetirizine-pseudoephedrine 2 per day CLARITIN-D 12 HOUR BRAND 1 2 per day CLARITIN-D 24 HOUR BRAND 1 1 per day fexofenadine-pseudoephedrine tab sr 12hr mg fexofenadine-pseudoephedrine tab sr 24hr mg loratadine & pseudoephedrine tab sr 12hr mg loratadine & pseudoephedrine tab sr 24hr mg 2 per day 1 per day 2 per day 1 per day ZYRTEC-D ALLERGY & CONGETION BRAND 1 2 per day THERAPEUTIC NUTRIENT/MINERAL/ELECTROLYTE ELECTROLYTE/MINERAL REPLACEMENT FER-IN-OL BRAND 0 AL Up to 1 yrs old ferrous sulfate (tab 325 mg mg elemental fe), tab ec 325 mg mg fe equivalent)) ferrous sulfate soln 75 mg/ml (15 mg/ml elemental fe) generic 0 generic 0 AL Up to 1 yrs old GE 8 LAT UPDATED 05/2016

10 PRODUCT DECRIPTION BRAND/GEN TIER LIMIT & RETRICTION cholecalciferol tab 400 unit generic 0 DRIDOL BRAND 0 ergocalciferol soln 8000 unit/ml generic 0 ergocalciferol tab 400 unit generic 0 AL At least 65 yrs old folic acid (tab 1 mg, tab 400 mcg) generic 0 FAL niacin (tab 50 mg, tab 100 mg, tab 250 mg, tab 500 mg) Female - 12 to 55 yrs old GE 9 LAT UPDATED 05/2016

11 LIT OF COVERED PRECRIPTION MEDICATION PRODUCT DECRIPTION BRAND/GEN TIER LIMIT & RETRICTION ANALGEIC NONTEROIDAL ANTI-INFLAMMATORY DRUG celecoxib (cap 50 mg, cap 100 mg, cap 200 mg) 2 per day celecoxib cap 400 mg choline & magnesium salicylates tab 1000 mg diclofenac potassium 1 per day diclofenac sodium (tab delayed release 25 mg, tab delayed release 50 mg, tab delayed release 75 mg, tab sr 24hr 100 mg) diclofenac w/ misoprostol diflunisal tab 500 mg etodolac (cap 200 mg, cap 300 mg, tab 400 mg, tab 500 mg) fenoprofen calcium tab 600 mg 1 per day FLECTOR BRAND 3 flurbiprofen (tab 50 mg, tab 100 mg) 2 per day ibuprofen (susp 100 mg/5ml, tab 400 mg, tab 600 mg, tab 800 mg) indomethacin (cap 25 mg, cap 50 mg, cap cr 75 mg) ketoprofen (cap 50 mg, cap 75 mg) ketorolac tromethamine tab 10 mg MD1 20 / 30 DAY meclofenamate sodium (cap 50 mg, cap 100 mg) mefenamic acid cap 250 mg meloxicam (tab 7.5 mg, tab 15 mg) 1 per day meloxicam susp 7.5 mg/5ml GE 10 LAT UPDATED 05/2016

12 PRODUCT DECRIPTION BRAND/GEN TIER LIMIT & RETRICTION MOBIC UPENION 7.5 MG/5ML BRAND 1 nabumetone naproxen (susp 125 mg/5ml, tab 250 mg, tab 375 mg, tab 500 mg, tab ec 500 mg) naproxen sodium tab 550 mg oxaprozin piroxicam (cap 10 mg, cap 20 mg) salsalate sulindac (tab 150 mg, tab 200 mg) tolmetin sodium OPIOID ANALGEIC, LONG-ACTING BUTRAN BRAND 3 MD1 4 / 28 DAY EMBEDA BRAND 3 2 per day EXALGO (TB24 DETER 12 MG, TB24 DETER 16 MG, TB24 DETER 8 MG) BRAND 2 2 per day EXALGO TB24 DETER 32 MG BRAND 2 1 per day fentanyl (patch 72hr 25, patch 72hr 100, patch 72hr 12, patch 72hr 75, patch 72hr 50) MD1 10 / 30 DAY hydromorphone hcl (tab er 24hr deter 12 mg, tab er 24hr deter 8 mg, tab er 24hr deter 16 mg) 2 per day hydromorphone hcl tab er 24hr deter 32 mg generic 2 levorphanol tartrate 1 per day methadone hcl conc 10 mg/ml MD1 300 ML / 30 DAY methadone hcl soln 10 mg/5ml MD ML / 30 DAY methadone hcl soln 5 mg/5ml MD ML / 30 DAY METHADONE HCL OLUTION 10 MG/ML BRAND 1 GE 11 LAT UPDATED 05/2016

13 PRODUCT DECRIPTION BRAND/GEN TIER LIMIT & RETRICTION methadone hcl tab 10 mg 10 per day methadone hcl tab 5 mg 4 per day methadone hcl tab for oral susp 40 mg 2 per day METHADOE BRAND 1 MD1 300 ML / 30 DAY METHADOE UGAR-FREE BRAND 1 MD1 300 ML / 30 DAY morphine sulfate (cap sr 24hr 80 mg, cap sr 24hr 20 mg, cap sr 24hr 50 mg, cap sr 24hr 30 mg, cap sr 24hr 100 mg, cap sr 24hr 60 mg) 2 per day morphine sulfate (tab 15 mg, tab 30 mg, tab 60 mg, tab 100 mg, tab 200 mg) 2 per day NUCYNTA ER BRAND 2 2 per day oxycodone hcl (tab er deter 10 mg, tab er deter 20 mg, tab er deter 40 mg, tab er deter 80 mg) 2 per day OXYCONTIN (TB12 DETER 40 MG, TB12 DETER 80 MG, TB12 DETER 20 MG, TB12 DETER 10 MG) BRAND 3 2 per day OXYCONTIN (TB12 DETER 60 MG, TB12 DETER 30 MG, TB12 DETER 15 MG) BRAND 3 oxymorphone hcl (tab sr 5 mg, tab sr 7.5 mg, tab sr 15 mg, tab sr 30 mg) generic 3 2 per day tramadol hcl (tab sr 24hr biphasic release 300 mg, tab sr 24hr 300 mg, tab sr 24hr 200 mg, tab sr 24hr 100 mg) 1 per day ZOHYDRO ER BRAND 3 2 per day OPIOID ANALGEIC, HORT-ACTING acetaminophen w/ codeine soln mg/5ml MD ML / 30 DAY acetaminophen w/ codeine tab mg 13 per day acetaminophen w/ codeine tab mg 12 per day acetaminophen w/ codeine tab mg 6 per day butalbital-acetaminophen-caff w/ cod cap mg 6 per day GE 12 LAT UPDATED 05/2016

14 PRODUCT DECRIPTION BRAND/GEN TIER LIMIT & RETRICTION butalbital-aspirin-caffeine w/cod 6 per day butorphanol tartrate (inj 1 mg/ml, inj 2 mg/ml) butorphanol tartrate nasal soln 10 mg/ml MPL 1 / 30 days codeine sulfate (oral soln 30 mg/5ml, tab 15 mg) fentanyl citrate (fentnyl citrte lozenge hndle 200 mcg, fentnyl citrte lozenge hndle 400 mcg, fentnyl citrte lozenge hndle 600 mcg, fentnyl citrte lozenge hndle 800 mcg, fentnyl citrte lozenge hndle 1200 mcg, fentnyl citrte lozenge hndle 1600 mcg) 4 per day hydrocodone-acetaminophen (soln mg/15ml, soln mg/15ml, tab mg) hydrocodone-acetaminophen (tab mg, tab mg, tab mg, tab mg) hydrocodone-acetaminophen (tab mg, tab mg, tab mg) hydrocodone-acetaminophen (tab mg, tab mg, tab mg) hydrocodone-acetaminophen (tab mg, tab mg, tab mg) hydrocodone-acetaminophen (tab mg, tab mg) hydrocodone-acetaminophen soln mg/15ml hydrocodone-ibuprofen (tab mg, tab mg, tab mg) 8 per day 13 per day 12 per day 6 per day 5 per day MD ML / 30 DAY hydrocodone-ibuprofen tab mg 5 per day hydromorphone hcl (liqd 1 mg/ml, preservative free (pf) inj 10 mg/ml) hydromorphone hcl (tab 2 mg, tab 4 mg, tab 8 mg) meperidine hcl (inj 25 mg/ml, inj 50 mg/ml, inj 100 mg/ml) 8 per day meperidine hcl (tab 50 mg, tab 100 mg) 6 per day GE 13 LAT UPDATED 05/2016

15 PRODUCT DECRIPTION BRAND/GEN TIER LIMIT & RETRICTION meperidine hcl oral soln 50 mg/5ml MD1 500 ML / CLAIM morphine sulfate (inj 0.5 mg/ml, inj 1 mg/ml) morphine sulfate (tab 15 mg, tab 30 mg) 6 per day morphine sulfate oral soln 10 mg/5ml MD ML / 30 DAY morphine sulfate oral soln 20 mg/5ml MD ML / 30 DAY nalbuphine hcl 8 per day NUCYNTA BRAND 2 6 per day oxycodone hcl (tab 5 mg, tab 10 mg, tab 15 mg, tab 20 mg) 12 per day oxycodone hcl tab 30 mg 24 per day oxycodone w/ acetaminophen (tab mg, tab mg, tab mg) 12 per day oxycodone w/ acetaminophen tab mg 8 per day oxycodone-ibuprofen 1 per day oxymorphone hcl (tab 5 mg, tab 10 mg) 12 per day pentazocine w/ naloxone TALWIN BRAND 3 tramadol hcl tab 50 mg 8 per day tramadol-acetaminophen 8 per day ZOLVIT BRAND 2 ANETHETIC LOCAL ANETHETIC lidocaine hcl (local anesth.) (inj 0.5%, inj 1%, preservative free (pf) inj 0.5%, preservative free (pf) inj 1%, preservative free (pf) inj 2%, preservative free (pf) inj 4%) lidocaine hcl laryngotracheal soln 4% lidocaine hcl viscous soln 2% MD1 120 ML / 30 DAY XYLOCAINE OLUTION 1 % BRAND 3 GE 14 LAT UPDATED 05/2016

16 PRODUCT DECRIPTION BRAND/GEN TIER LIMIT & RETRICTION ANTI-ADDICTION/UBTANCE ABUE TREATMENT AGENT ALCOHOL DETERRENT/ANTI-CRAVING acamprosate calcium CAMPRAL BRAND 2 disulfiram naltrexone hcl tab 50 mg OPIOID DEPENDENCE TREATMENT buprenorphine hcl (sl tab 2 mg, sl tab 8 mg) buprenorphine hcl inj 0.3 mg/ml (base equiv) UBOXONE (FILM MG, FILM 4-1 MG) BRAND 3 UBOXONE (FILM 8-2 MG, FILM 12-3 MG) BRAND 3 3 per day 3 per day 2 per day OPIOID REVERAL AGENT naloxone hcl (inj 0.4 mg/ml, inj 1 mg/ml) MOKING CEATION AGENT bupropion hcl (smoking deterrent) generic 0 2 per day CHANTIX BRAND 0 2 per day CHANTIX CONTINUING MONTH K BRAND 0 2 per day CHANTIX TARTING MONTH K BRAND 0 NICOTROL BRAND 0 MPL 1 / claim NICOTROL N BRAND 0 MPL 1 / claim ZYBAN BRAND 0 2 per day ANTIBACTERIAL AMINOGLYCOIDE amikacin sulfate (inj 1 gm/4ml, inj 500 mg/2ml) GE 15 LAT UPDATED 05/2016

17 PRODUCT DECRIPTION BRAND/GEN TIER LIMIT & RETRICTION gentamicin in saline (gentamicsale j 0.8 mg/ml, gentamicsale j 1 mg/ml, gentamicsale j 1.2 mg/ml, gentamicsale j 1.6 mg/ml) GENTAMICIN IN ALINE (GENTAMICALE OLUTION , GENTAMICALE OLUTION ) gentamicin sulfate (inj 40 mg/ml, iv soln 10 mg/ml) BRAND 1 gentamicin sulfate (ophth) (oint, soln) kanamycin sulfate generic 3 neomycin sulfate paromomycin sulfate streptomycin sulfate for inj 1 gm generic 3 TOBRADEX OINTMENT % BRAND 3 tobramycin (ophth) tobramycin sulfate (inj 10 mg/ml, inj 80 mg/2ml (40 mg/ml)) TOBRAMYCIN ULFATE IN ALINE BRAND 1 ANTIBACTERIAL, OTHER acetic acid ALTABAX (1 %, OINTMENT 1 %) BRAND 2 bacitracin intramuscular for soln unit generic 3 chloramphenicol sodium succinate generic 4 pecialty Drug clindamycin hcl (cap 75 mg, cap 150 mg, cap 300 mg) clindamycin palmitate hydrochloride clindamycin phosphate (inj 9 gm/60ml, inj 300 mg/2ml, inj 600 mg/4ml, inj 900 mg/6ml, iv soln 300 mg/2ml, iv soln 600 mg/4ml, iv soln 900 mg/6ml) clindamycin phosphate (topical) (foam, gel, lotion, soln) AL At least 12 yrs old clindamycin phosphate vaginal CUBICIN BRAND 3 GE 16 LAT UPDATED 05/2016

18 PRODUCT DECRIPTION BRAND/GEN TIER LIMIT & RETRICTION LINCOCIN BRAND 3 LINEZOLID IN ODIUM CHLORIDE BRAND 1 linezolid iv soln 600 mg/300ml (2 mg/ml) linezolid tab 600 mg mafenide acetate generic 3 methenamine hippurate metronidazole (tab 250 mg, tab 500 mg) C 2 per day QL: 14 day supply/claim metronidazole (topical) (cream 0.75%, gel 0.75%, gel 1%, lotion 0.75%) metronidazole vaginal MONUROL BRAND 3 mupirocin calcium (topical) mupirocin oint 2% nitrofurantoin nitrofurantoin macrocrystal (cap 50 mg, cap 100 mg) nitrofurantoin monohyd macro polymyxin b sulfate for inj unit ULFAMYLON (CREAM 85 MG/GM, CKET 5 %) BRAND 3 trimethoprim tab 100 mg TYGACIL BRAND 3 vancomycin hcl (cap 125 mg, cap 250 mg) vancomycin hcl (inj 10 gm, inj 500 mg, inj 1000 mg) VIBATIV RECON OLN 750 MG BRAND 3 XIFAXAN BRAND 3 C AL 4 per day QL: 10 day supply/claim At least 12 yrs old GE 17 LAT UPDATED 05/2016

19 PRODUCT DECRIPTION BRAND/GEN TIER LIMIT & RETRICTION BETA-LACTAM, CEPHALOPORIN CEDAX (CAP 400 MG, RECON UP 90 MG/5ML, RECON UP 180 MG/5ML) cefaclor (cap 250 mg, cap 500 mg, for susp 125 mg/5ml, for susp 250 mg/5ml, for susp 375 mg/5ml) BRAND 3 cefaclor monohydrate cefadroxil (cap 500 mg, for susp 250 mg/5ml, for susp 500 mg/5ml, tab 1 gm) cefazolin sodium (inj 1 gm, inj 10 gm, inj 20 gm, inj 500 mg) cefdinir (cap 300 mg, for susp 125 mg/5ml, for susp 250 mg/5ml) AL At least 2 yrs old cefditoren pivoxil (tab 200 mg, tab 400 mg) generic 3 CEFDITOREN PIVOXIL TAB 200 MG BRAND 3 cefepime hcl (inj 1 gm, inj 2 gm) cefixime cefotaxime sodium (inj 1 gm, inj 2 gm, inj 10 gm) cefotetan disodium generic 3 cefoxitin sodium cefpodoxime proxetil (for susp 50 mg/5ml, for susp 100 mg/5ml, tab 100 mg, tab 200 mg) cefprozil (for susp 125 mg/5ml, for susp 250 mg/5ml, tab 250 mg, tab 500 mg) ceftazidime (inj 1 gm, inj 2 gm, inj 6 gm) CEFTIBUTEN CAP 400 MG BRAND 1 CEFTIBUTEN RECON UP 180 MG/5ML BRAND 3 CEFTIN RECON UP 125 MG/5ML BRAND 2 ceftriaxone sodium (inj 1 gm, inj 2 gm, inj 250 mg, inj 500 mg) cefuroxime axetil (for susp 125 mg/5ml, tab 250 mg, tab 500 mg) cefuroxime sodium (inj 1.5 gm, inj 7.5 gm, inj 750 mg) GE 18 LAT UPDATED 05/2016

20 PRODUCT DECRIPTION BRAND/GEN TIER LIMIT & RETRICTION cephalexin (cap 250 mg, cap 500 mg, cap 750 mg, for susp 125 mg/5ml, for susp 250 mg/5ml, tab 250 mg, tab 500 mg) PECTRACEF BRAND 3 UPRAX (RECON UP 100 MG/5ML, RECON UP 200 MG/5ML, TAB 400 MG) BRAND 2 TEFLARO BRAND 3 BETA-LACTAM, OTHER AZACTAM IN DEXTROE BRAND 3 aztreonam imipenem-cilastatin INVANZ BRAND 3 meropenem BETA-LACTAM, PENICILLIN amoxicillin & pot clavulanate (chew tab mg, chew tab mg, for susp mg/5ml, for susp mg/5ml, for susp mg/5ml, for susp mg/5ml, tab mg, tab mg, tab mg, tab sr 12hr mg) amoxicillin (cap 250 mg, cap 500 mg, chew tab 125 mg, chew tab 250 mg, for susp 125 mg/5ml, for susp 200 mg/5ml, for susp 250 mg/5ml, for susp 400 mg/5ml, tab 500 mg, tab 875 mg) ampicillin & sulbactam sodium (inj gm, inj 2-1 gm, iv soln 10-5 gm) ampicillin (cap 250 mg, cap 500 mg) AMPICILLIN (RECON UP 125, RECON UP 250) BRAND 1 ampicillin sodium (inj 1 gm, iv soln 10 gm) dicloxacillin sodium nafcillin sodium (inj 1 gm, inj 10 gm) oxacillin sodium (inj 1 gm, inj 10 gm) PENICILLIN G POT IN DEXTROE (PENICILLOLUTION 40000, PENICILLOLUTION 60000) BRAND 1 GE 19 LAT UPDATED 05/2016

21 PRODUCT DECRIPTION BRAND/GEN TIER LIMIT & RETRICTION penicillin g potassium for inj unit PENICILLIN G PROCAINE BRAND 3 penicillin g sodium generic 3 penicillin v potassium (for soln 125 mg/5ml, for soln 250 mg/5ml, tab 250 mg, tab 500 mg) piperacillin sodium-tazobactam sodium (sodtazobactam sod inj 2.25 gm ( gm), sodtazobactam sod inj 4.5 gm (4-0.5 gm), sodiumtazobactam sodium inj gm, sodiumtazobactam sodium inj gm, sodiumtazobactam sodium inj gm, sodiumtazobactam sodium inj gm) TIMENTIN RECON OLN 3.1 GM BRAND 3 MACROLIDE AZAITE BRAND 3 azithromycin (iv soln 500 mg, powd pack susp 1 gm, susp 100 mg/5ml) azithromycin for susp 200 mg/5ml MPL 1 / claim azithromycin tab 250 mg C Limited to 6 tablets per claim azithromycin tab 500 mg C Limited to 4 tablets per claim azithromycin tab 600 mg MD1 8 / 28 DAY clarithromycin (for susp 125 mg/5ml, for susp 250 mg/5ml, tab 250 mg, tab 500 mg, tab sr 24hr 500 mg) DIFICID BRAND 2 E.E BRAND 3 E.E.. GRANULE BRAND 3 ERY-TAB BRAND 3 ERYPED 200 BRAND 3 ERYPED 400 BRAND 3 erythromycin (acne aid) (pads, soln) AL At least 12 yrs old erythromycin (ophth) ERYTHROMYCIN BAE (TAB 250 MG, TAB 500 MG) BRAND 3 GE 20 LAT UPDATED 05/2016

22 PRODUCT DECRIPTION BRAND/GEN TIER LIMIT & RETRICTION ERYTHROMYCIN ETHYLUCCINATE TAB 400 MG BRAND 3 erythromycin w/ delayed release particles cap 250 mg generic 3 KETEK BRAND 3 ZITHROMAX CKET 1 GM BRAND 1 C 2 per day QL: 10 day supply/claim QUINOLONE AVELOX (OLUTION 400 MG/250ML, TAB 400 MG) BRAND 3 AVELOX ABC CK BRAND 3 BEIVANCE BRAND 3 CETRAXAL BRAND 1 CIPRO IN D5W OLUTION 200 MG/100ML BRAND 3 ciprofloxacin (for oral susp 250 mg/5ml (5%) (5 gm/100ml), for oral susp 500 mg/5ml (10%) (10 gm/100ml), iv soln 400 mg/40ml (1%)) ciprofloxacin 200 mg/100ml in d5w generic 3 ciprofloxacin hcl (ophth) ciprofloxacin hcl (otic) ciprofloxacin hcl (tab 100 mg, tab 250 mg, tab 500 mg, tab 750 mg) ciprofloxacin-ciprofloxacin hcl FACTIVE BRAND 3 gatifloxacin (ophth) levofloxacin (iv soln 25 mg/ml, oral soln 25 mg/ml, tab 250 mg, tab 500 mg, tab 750 mg) levofloxacin (ophth) levofloxacin in d5w iv soln 500 mg/100ml moxifloxacin hcl tab 400 mg (base equiv) NOROXIN BRAND 3 ofloxacin ofloxacin (ophth) GE 21 LAT UPDATED 05/2016

23 PRODUCT DECRIPTION BRAND/GEN TIER LIMIT & RETRICTION ofloxacin (otic) ZYMAXID BRAND 3 ULFONAMIDE silver sulfadiazine sulfacetamide sodium ophth soln 10% MPL 1 / Claim sulfadiazine tab 500 mg sulfamethoxazole-trimethoprim (iv soln mg/5ml, susp mg/5ml, tab mg, tab mg) TETRACYCLINE demeclocycline hcl (tab 150 mg, tab 300 mg) doxycycline (monohydrate) (cap 50 mg, cap 100 mg, tab 100 mg) doxycycline hyclate (cap 50 mg, cap 100 mg, tab 20 mg, tab 100 mg) 2 per day 2 per day doxycycline hyclate for inj 100 mg doxycycline monohydrate cap 75 mg minocycline hcl (cap 50 mg, cap 75 mg, cap 100 mg, tab 50 mg, tab 75 mg, tab 100 mg) 3 per day tetracycline hcl (cap 250 mg, cap 500 mg) 8 per day ANTICONVULANT ANTICONVULANT, OTHER levetiracetam (inj 500 mg/5ml (100 mg/ml), oral soln 100 mg/ml) levetiracetam (tab 250 mg, tab 500 mg, tab 750 mg, tab sr 24hr 750 mg, tab sr 24hr 500 mg) MD1 900 / 30 DAY 4 per day levetiracetam tab 1000 mg 3 per day POTIGA BRAND 3 3 per day CALCIUM CHANNEL MODIFYING AGENT CELONTIN BRAND 3 4 per day ethosuximide cap 250 mg 6 per day GE 22 LAT UPDATED 05/2016

24 PRODUCT DECRIPTION BRAND/GEN TIER LIMIT & RETRICTION ethosuximide soln 250 mg/5ml MD1 900 ML / 30 DAY zonisamide (cap 25 mg, cap 50 mg, cap 100 mg) 6 per day GAMMA-AMINOBUTYRIC ACID (GABA) AUGMENTING AGENT DIATAT ACUDIAL BRAND 3 MPL 1 / claim DIATAT PEDIATRIC BRAND 3 MPL 1 / claim diazepam (anticonvulsant) generic 3 MPL 1 / claim divalproex sodium (tab delayed release 125 mg, tab delayed release 250 mg, tab delayed release 500 mg, tab sr 24 hr 500 mg, tab sr 24 hr 250 mg) gabapentin (cap 100 mg, cap 300 mg, cap 400 mg, tab 600 mg, tab 800 mg) gabapentin oral soln 250 mg/5ml MD ML / 30 DAY ONFI (TAB 5 MG, TAB 10 MG, TAB 20 MG) BRAND 3 2 per day ONFI UPENION 2.5 MG/ML BRAND 3 MD1 480 ML / 30 DAY phenobarbital (elixir 20 mg/5ml, tab 16.2 mg, tab 30 mg, tab 32.4 mg, tab 64.8 mg, tab 97.2 mg, tab 100 mg) primidone ABRIL BRAND 4 tiagabine hcl valproate sodium valproic acid GLUTAMATE REDUCING AGENT 6 per day pecialty Drug felbamate susp 600 mg/5ml MD1 900 ML / 30 DAY felbamate tab 400 mg 9 per day felbamate tab 600 mg 6 per day GE 23 LAT UPDATED 05/2016

25 PRODUCT DECRIPTION BRAND/GEN TIER LIMIT & RETRICTION lamotrigine (tab 25 mg, tab 100 mg, tab 150 mg, tab 200 mg, tab chewable dispersible 5 mg, tab chewable dispersible 25 mg) topiramate (tab 100 mg, tab 200 mg) 2 per day topiramate (tab 25 mg, tab 50 mg) 4 per day topiramate sprinkle cap 15 mg 6 per day topiramate sprinkle cap 25 mg 8 per day ODIUM CHANNEL AGENT BANZEL UPENION 40 MG/ML BRAND 2 MD ML / 30 DAY BANZEL TAB 200 MG BRAND 2 BANZEL TAB 400 MG BRAND 2 carbamazepine (cap sr 200 mg, tab sr 200 mg) carbamazepine (cap sr 300 mg, tab sr 400 mg) T T 2 per day 8 per day 6 per day 4 per day carbamazepine (chew tab 100 mg, susp 100 mg/5ml, tab 200 mg) carbamazepine cap sr 12hr 100 mg T DILANTIN (CAP 30 MG, CAP 100 MG, UPENION 125 MG/5ML) BRAND 2 DILANTIN INFATAB BRAND 2 EQUETRO CAP ER 12H 100 MG BRAND 3 EQUETRO CAP ER 12H 200 MG BRAND 3 EQUETRO CAP ER 12H 300 MG BRAND 3 T T T 2 per day 8 per day 4 per day GE 24 LAT UPDATED 05/2016

26 PRODUCT DECRIPTION BRAND/GEN TIER LIMIT & RETRICTION fosphenytoin sodium oxcarbazepine (tab 150 mg, tab 300 mg) 3 per day oxcarbazepine susp 300 mg/5ml (60 mg/ml) MD ML / 30 DAY oxcarbazepine tab 600 mg 4 per day PEGANONE BRAND 3 PHENYTEK CAP 200 MG BRAND 2 PHENYTEK CAP 300 MG BRAND 3 phenytoin (chew tab 50 mg, susp 125 mg/5ml) phenytoin sodium extended phenytoin sodium inj 50 mg/ml TEGRETOL (CHEW TAB 100 MG, UPENION 100 MG/5ML, TAB 200 MG) BRAND 2 VIMT (TAB 50 MG, TAB 100 MG, TAB 150 MG, TAB 200 MG) BRAND 3 2 per day VIMT OLUTION 10 MG/ML BRAND 3 MD ML / 30 DAY VIMT OLUTION 200 MG/20ML BRAND 3 MD ML / 30 DAY ANTIDEMENTIA AGENT CHOLINETERAE INHIBITOR donepezil hydrochloride (orally disintegrating tab 10 mg, tab 10 mg) donepezil hydrochloride (orally disintegrating tab 5 mg, tab 5 mg) galantamine hydrobromide (cap sr 24hr 8 mg, cap sr 24hr 24 mg, cap sr 24hr 16 mg) galantamine hydrobromide (tab 4 mg, tab 8 mg, tab 12 mg) 2 per day 1 per day 1 per day 2 per day galantamine hydrobromide oral soln 4 mg/ml 6 per day rivastigmine tartrate N-METHYL-D-ARTATE (NMDA) RECEPTOR ANTAGONIT memantine hcl tab 10 mg 2 per day GE 25 LAT UPDATED 05/2016

27 PRODUCT DECRIPTION BRAND/GEN TIER LIMIT & RETRICTION memantine hcl tab 5 mg 1 per day memantine hcl tab 5 mg (28) & 10 mg (21) titration pak NAMENDA TITRATION K BRAND 2 ANTIDEPREANT ANTIDEPREANT, OTHER bupropion hcl (tab 75 mg, tab 100 mg) 3 per day bupropion hcl (tab sr 100 mg, tab sr 150 mg, tab sr 200 mg) bupropion hcl (tab sr 24hr 150 mg, tab sr 24hr 300 mg) mirtazapine (orally disintegrating tab 15 mg, orally disintegrating tab 30 mg, orally disintegrating tab 45 mg, tab 7.5 mg, tab 15 mg, tab 30 mg, tab 45 mg) 2 per day 1 per day 1 per day perphenazine-amitriptyline 4 per day WELLBUTRIN R (R TAB ER 12H 150 MG, R TAB ER 12H 100 MG) BRAND 3 2 per day WELLBUTRIN TAB 75 MG BRAND 3 3 per day MONOAMINE OXIDAE INHIBITOR EMAM (9 MG/24HR, TCH 24HR 6 MG/24HR, TCH 24HR 9 MG/24HR, TCH 24HR 12 MG/24HR) BRAND 3 1 per day MARPLAN BRAND 2 6 per day phenelzine sulfate tranylcypromine sulfate RI/NRI (ELECTIVE EROTONIN REUPTAKE INHIBITOR/EROTONIN AND NOREPINEPHRINE REUPTAKE INHIBITOR BRINTELLIX BRAND 3 1 per day citalopram hydrobromide (tab 10 mg, tab 20 mg) 1.5 per day citalopram hydrobromide oral soln 10 mg/5ml MD1 600 ML / 30 DAY GE 26 LAT UPDATED 05/2016

28 PRODUCT DECRIPTION BRAND/GEN TIER LIMIT & RETRICTION citalopram hydrobromide tab 40 mg (base equiv) 1 per day escitalopram oxalate (tab 5 mg, tab 10 mg) 1.5 per day escitalopram oxalate soln 5 mg/5ml (base equiv) MD1 600 ML / 30 DAY escitalopram oxalate tab 20 mg (base equiv) 1 per day fluoxetine hcl (cap 10 mg, tab 10 mg, tab 60 mg) 1 per day fluoxetine hcl (cap 20 mg, tab 20 mg) 3 per day fluoxetine hcl (pmdd) cap 10 mg 1 per day fluoxetine hcl (pmdd) cap 20 mg 3 per day fluoxetine hcl cap 40 mg 2 per day fluoxetine hcl solution 20 mg/5ml MD1 600 ML / 30 DAY fluvoxamine maleate (tab 25 mg, tab 50 mg) 2 per day fluvoxamine maleate tab 100 mg 3 per day maprotiline hcl generic 3 nefazodone hcl generic 3 OLEPTRO BRAND 3 T 1 per day paroxetine hcl (tab 10 mg, tab 20 mg, tab 40 mg) 1 per day paroxetine hcl (tab sr 24hr 37.5 mg, tab sr 24hr 25 mg) 2 per day paroxetine hcl oral susp 10 mg/5ml (base equiv) generic 3 MD1 900 ML / 30 DAY paroxetine hcl tab 30 mg 2 per day paroxetine hcl tab sr 24hr 12.5 mg 1 per day XIL UPENION 10 MG/5ML BRAND 3 MD1 900 ML / 30 DAY GE 27 LAT UPDATED 05/2016

29 PRODUCT DECRIPTION BRAND/GEN TIER LIMIT & RETRICTION PRITIQ TAB ER 24H 100 MG BRAND 2 PRITIQ TAB ER 24H 25 MG BRAND 2 PRITIQ TAB ER 24H 50 MG BRAND 2 T T T 4 per day 1 per day 1 per day sertraline hcl (tab 25 mg, tab 50 mg) 1.5 per day sertraline hcl oral conc 20 mg/ml MD1 300 ML / 30 DAY sertraline hcl tab 100 mg 2 per day trazodone hcl (tab 50 mg, tab 100 mg, tab 150 mg, tab 300 mg) venlafaxine hcl (cap sr 24hr 150 mg, tab sr 24hr 150 mg) venlafaxine hcl (cap sr 24hr 37.5 mg, cap sr 24hr 75 mg, tab sr 24hr 75 mg, tab sr 24hr 37.5 mg) venlafaxine hcl (tab 25 mg, tab 37.5 mg, tab 50 mg, tab 75 mg, tab 100 mg) VENLAFAXINE HCL ER (ER TAB ER 24H 37.5 MG, ER TAB ER 24H 75 MG) 2 per day 1 per day 3 per day BRAND 3 1 per day VENLAFAXINE HCL ER TAB ER 24H 150 MG BRAND 1 2 per day VENLAFAXINE HCL ER TAB ER 24H 225 MG BRAND 1 1 per day VIIBRYD (TAB 10 MG, TAB 20 MG, TAB 40 MG) BRAND 2 1 per day VIIBRYD KIT 10 & 20 & 40 MG BRAND 2 MD1 1 / 365 DAY TRICYCLIC amitriptyline hcl (tab 10 mg, tab 25 mg, tab 50 mg, tab 75 mg, tab 100 mg, tab 150 mg) amoxapine generic 3 clomipramine hcl desipramine hcl (tab 10 mg, tab 25 mg, tab 50 mg, tab 75 mg, tab 100 mg, tab 150 mg) doxepin hcl (cap 10 mg, cap 25 mg, cap 50 mg, cap 75 mg, cap 100 mg, cap 150 mg, conc 10 mg/ml) GE 28 LAT UPDATED 05/2016

30 PRODUCT DECRIPTION BRAND/GEN TIER LIMIT & RETRICTION imipramine hcl (tab 10 mg, tab 25 mg, tab 50 mg) imipramine pamoate nortriptyline hcl (cap 10 mg, cap 25 mg, cap 50 mg, cap 75 mg) protriptyline hcl trimipramine maleate (cap 25 mg, cap 50 mg, cap 100 mg) ANTIEMETIC ANTIEMETIC, OTHER meclizine hcl (tab 12.5 mg, tab 25 mg) metoclopramide hcl (tab 5 mg, tab 10 mg) metoclopramide hcl inj 5 mg/ml C 6 per day LIMIT = 84 DAY UPPLY PER 365 DAY metoclopramide hcl soln 5 mg/5ml (10 mg/10ml) C 60 per day LIMIT = 84 DAY UPPLY PER 365 DAY perphenazine prochlorperazine prochlorperazine maleate (tab 5 mg, tab 10 mg) TRANDERM-COP BRAND 2 trimethobenzamide hcl cap 300 mg EMETOGENIC THERAPY ADJUNCT ALOXI BRAND 3 ANZEMET (TAB 50 MG, TAB 100 MG) BRAND 3 MD1 5 / 30 DAY ANZEMET OLUTION 20 MG/ML BRAND 3 CEAMET BRAND 3 dronabinol EMEND (CAP 40 MG, CAP 125 MG) BRAND 2 MD1 2 / 30 DAY GE 29 LAT UPDATED 05/2016

31 PRODUCT DECRIPTION BRAND/GEN TIER LIMIT & RETRICTION EMEND CAP 80 MG BRAND 2 MD1 4 / 30 DAY granisetron hcl (inj 0.1 mg/ml, inj 1 mg/ml) granisetron hcl tab 1 mg MD1 10 / 30 DAY ondansetron MD1 30 / 30 DAY ondansetron hcl (tab 4 mg, tab 8 mg) MD1 30 / 30 DAY ondansetron hcl inj 4 mg/2ml (2 mg/ml) ondansetron hcl oral soln 4 mg/5ml MD1 100 ML / 30 DAY ondansetron hcl tab 24 mg MD1 4 / 28 DAY ANTIFUNGAL ABELCET BRAND 3 AMBIOME BRAND 3 AMPHOTEC RECON UP 50 MG BRAND 3 amphotericin b for inj 50 mg generic 3 CANCIDA BRAND 3 ciclopirox & vitamin e ciclopirox (gel 0.77%, shampoo 1%, solution 8%) ciclopirox olamine (cream, susp) clotrimazole (topical) (cream, soln) clotrimazole troche 10 mg econazole nitrate ERAXI (50 MG, RECON OLN 50 MG, 100 MG, RECON OLN 100 MG) BRAND 3 ERTACZO BRAND 3 MPL 1 / 30 days EXELDERM (CREAM 1 %, OLUTION 1 %) BRAND 3 MPL 1 / 30 days fluconazole (for susp 10 mg/ml, for susp 40 mg/ml, tab 50 mg, tab 100 mg, tab 150 mg, tab 200 mg) flucytosine griseofulvin microsize susp 125 mg/5ml T AL At least 2 yrs old GE 30 LAT UPDATED 05/2016

32 PRODUCT DECRIPTION BRAND/GEN TIER LIMIT & RETRICTION griseofulvin microsize tab 500 mg griseofulvin ultramicrosize GYNAZOLE-1 BRAND 3 itraconazole cap 100 mg ketoconazole (topical) (cream, shampoo) ketoconazole tab 200 mg 4 per day MENTAX BRAND 2 MPL 1 / 30 days MICONAZOLE 3 BRAND 3 MYCAMINE BRAND 3 NAFTIFINE HCL CREAM 1 % BRAND 1 MPL 1 / 30 days NAFTIN (CREAM 1 %, CREAM 2 %, GEL 1 %) BRAND 3 MPL 1 / 30 days NATACYN BRAND 2 MPL 1 / 30 days NOXAFIL UPENION 40 MG/ML BRAND 3 MD1 600 ML / 30 DAY nystatin (mouth-throat) nystatin (topical) (*nystatin topical powder**, nystatin cream unit/gm, nystatin oint unit/gm) nystatin tab unit nystatin-triamcinolone OXITAT (CREAM 1 %, LOTION 1 %) BRAND 2 MPL 1 / 30 days PORANOX OLUTION 10 MG/ML BRAND 3 MD1 600 ML / 30 DAY terbinafine hcl tab 250 mg 1 per day terconazole vaginal (cream 0.4%, cream 0.8%, suppos 80 mg) MPL 1 / Claim voriconazole (tab 50 mg, tab 200 mg) 4 per day ANTIGOUT AGENT allopurinol COLCHICINE TAB 0.6 MG BRAND 2 C QL: 6 caps/claim GE 31 LAT UPDATED 05/2016

33 PRODUCT DECRIPTION BRAND/GEN TIER LIMIT & RETRICTION colchicine tab 0.6 mg generic 2 C QL: 6 caps/claim colchicine w/ probenecid COLCRY BRAND 2 C QL: 6 caps/claim probenecid ULORIC BRAND 3 1 per day ANTIMIGRAINE AGENT ERGOT ALKALOID CAFERGOT BRAND 2 D.H.E. 45 BRAND 2 dihydroergotamine mesylate inj 1 mg/ml dihydroergotamine mesylate nasal spray 4 mg/ml T MD1 8 ML / 30 DAY ERGOMAR BRAND 3 MD1 20 / 30 DAY MIGRANAL BRAND 2 T MD1 8 ML / 30 DAY EROTONIN (5-HT) 1B/1D RECEPTOR AGONIT T AXERT TAB 12.5 MG BRAND 3 AL At least 12 yrs old MD1 12 / 30 DAY T AXERT TAB 6.25 MG BRAND 3 AL At least 12 yrs old MD1 9 / 30 DAY T FROVA BRAND 3 IMITREX (OLUTION 5, OLUTION 20) BRAND 1 naratriptan hcl AL At least 18 yrs old MD1 12 / 30 DAY AL At least 18 yrs old MD1 6 / 30 DAY AL At least 18 yrs old MD1 9 / 30 DAY GE 32 LAT UPDATED 05/2016

34 PRODUCT DECRIPTION BRAND/GEN TIER LIMIT & RETRICTION T RELX BRAND 3 AL At least 18 yrs old MD1 6 / 30 DAY rizatriptan benzoate (orally disintegrating tab 10 mg, tab 10 mg) rizatriptan benzoate (orally disintegrating tab 5 mg, tab 5 mg) AL At least 6 yrs old MD1 18 / 30 DAY AL At least 6 yrs old MD1 12 / 30 DAY sumatriptan (5, 20) AL At least 18 yrs old MD1 6 / 30 DAY sumatriptan succinate (inj 6, solution autoinjector 4, solution auto-injector 6, solution cartridge 4, solution cartridge 6, solution prefilled syringe 4, solution prefilled syringe 6) sumatriptan succinate (tab 25 mg, tab 50 mg, tab 100 mg) AL At least 18 yrs old MD1 4 / 30 DAY AL At least 18 yrs old MD1 9 / 30 DAY sumatriptan succinate inj 4 mg/0.5ml AL MPL At least 18 yrs old 2 / 30 days zolmitriptan (orally disintegrating tab 2.5 mg, orally disintegrating tab 5 mg, tab 2.5 mg, tab 5 mg) T AL At least 12 yrs old MD1 9 / 30 DAY ZOMIG (OLUTION 2.5 MG, OLUTION 5 MG) BRAND 2 T AL At least 12 yrs old MD1 6 / 30 DAY T ZOMIG (TAB 2.5 MG, TAB 5 MG) BRAND 2 AL At least 12 yrs old MD1 9 / 30 DAY T ZOMIG ZMT BRAND 2 AL At least 12 yrs old MD1 9 / 30 DAY GE 33 LAT UPDATED 05/2016

35 PRODUCT DECRIPTION BRAND/GEN TIER LIMIT & RETRICTION ANTIMYATHENIC AGENT RAYMTHOMIMETIC guanidine hcl generic 2 METINON (YRUP 60 MG/5ML, TAB ER 180 MG) BRAND 2 MYTELAE BRAND 3 pyridostigmine bromide ANTIMYCOBACTERIAL ANTIMYCOBACTERIAL, OTHER MYCOBUTIN BRAND 3 rifabutin ANTITUBERCULAR CATAT ULFATE BRAND 3 CYCLOERINE BRAND 3 4 per day ethambutol hcl (tab 100 mg, tab 400 mg) isoniazid (inj 100 mg/ml, tab 100 mg, tab 300 mg) IONIAZID YRUP 50 MG/5ML BRAND 1 ER BRAND 3 3 per day PRIFTIN BRAND 3 pyrazinamide RIFAMATE BRAND 3 rifampin (cap 150 mg, cap 300 mg, for inj 600 mg) RIFATER BRAND 3 6 per day EROMYCIN BRAND 3 4 per day TRECATOR BRAND 3 4 per day GE 34 LAT UPDATED 05/2016

36 PRODUCT DECRIPTION BRAND/GEN TIER LIMIT & RETRICTION ANTINEOPLATIC ALKYLATING AGENT ALKERAN TAB 2 MG BRAND 2 BICNU BRAND 4 BUULFEX BRAND 4 CEENU BRAND 4 cyclophosphamide generic 4 dacarbazine for inj 200 mg generic 4 DAUNOXOME BRAND 4 HEXALEN BRAND 4 IFEX RECON OLN 1 GM BRAND 4 ifosfamide & mesna generic 4 pecialty Drug pecialty Drug pecialty Drug pecialty Drug pecialty Drug pecialty Drug pecialty Drug pecialty Drug pecialty Drug ifosfamide (for inj 1 gm, iv inj 1 gm/20ml (50 mg/ml)) generic 4 pecialty Drug LEUKERAN BRAND 4 lomustine generic 4 MATULANE BRAND 4 pecialty Drug pecialty Drug pecialty Drug GE 35 LAT UPDATED 05/2016

37 PRODUCT DECRIPTION BRAND/GEN TIER LIMIT & RETRICTION melphalan hcl MUTARGEN BRAND 4 MYLERAN BRAND 4 TEMODAR BRAND 4 temozolomide generic 4 pecialty Drug pecialty Drug pecialty Drug pecialty Drug TREANDA (RECON OLN 25 MG, RECON OLN 100 MG) BRAND 4 pecialty Drug ZANOAR BRAND 4 pecialty Drug ANTIANDROGEN bicalutamide generic 4 CAODEX BRAND 4 flutamide generic 4 pecialty Drug pecialty Drug pecialty Drug NILANDRON BRAND 3 2 per day XTANDI BRAND 4 ZYTIGA BRAND 4 pecialty Drug pecialty Drug ANTIANGIOGENIC AGENT REVLIMID (CAP 2.5 MG, CAP 5 MG, CAP 10 MG, CAP 15 MG, CAP 25 MG) BRAND 4 pecialty Drug THALOMID BRAND 4 pecialty Drug GE 36 LAT UPDATED 05/2016

38 PRODUCT DECRIPTION BRAND/GEN TIER LIMIT & RETRICTION ANTIETROGEN/MODIFIER EMCYT BRAND 4 pecialty Drug FARETON BRAND 2 FALODEX (125 MG/2.5ML, OLUTION 250 MG/5ML) BRAND 4 pecialty Drug OLTAMOX BRAND 3 tamoxifen citrate (tab 10 mg, tab 20 mg) generic 0 ANTIMETABOLITE ALIMTA RECON OLN 500 MG BRAND 4 capecitabine generic 4 cladribine generic 4 CLOLAR BRAND 4 pecialty Drug pecialty Drug pecialty Drug cytarabine (for inj 100 mg, for inj 500 mg, inj pf 20 mg/ml, inj pf 100 mg/ml) generic 4 pecialty Drug DEPOCYT BRAND 4 DROXIA BRAND 3 floxuridine for inj 0.5 gm generic 4 fluorouracil inj 500 mg/10ml (50 mg/ml) generic 4 FOLOTYN OLUTION 20 MG/ML BRAND 4 gemcitabine hcl (inj 2 gm, inj 200 mg) generic 4 GEMZAR RECON OLN 200 MG BRAND 4 pecialty Drug pecialty Drug pecialty Drug pecialty Drug pecialty Drug pecialty Drug GE 37 LAT UPDATED 05/2016

39 PRODUCT DECRIPTION BRAND/GEN TIER LIMIT & RETRICTION HYDREA BRAND 3 hydroxyurea mercaptopurine NIPENT BRAND 4 pentostatin generic 4 PURINETHOL BRAND 3 TABLOID BRAND 4 XELODA BRAND 4 pecialty Drug pecialty Drug pecialty Drug pecialty Drug ANTINEOPLATIC, OTHER ABRAXANE BRAND 4 ARRANON BRAND 4 azacitidine generic 4 bleomycin sulfate for inj 15 unit generic 4 CAMTH BRAND 4 pecialty Drug pecialty Drug pecialty Drug pecialty Drug pecialty Drug CAMPTOAR (OLUTION 40 MG/2ML, OLUTION 100 MG/5ML) BRAND 4 pecialty Drug carboplatin iv soln 50 mg/5ml generic 4 CERUBIDINE BRAND 4 pecialty Drug pecialty Drug GE 38 LAT UPDATED 05/2016

40 PRODUCT DECRIPTION BRAND/GEN TIER LIMIT & RETRICTION cisplatin inj 100 mg/100ml (1 mg/ml) generic 4 COMEGEN BRAND 4 DACOGEN BRAND 4 dactinomycin generic 4 pecialty Drug pecialty Drug pecialty Drug pecialty Drug daunorubicin hcl (for inj 20 mg, inj 5 mg/ml (base equiv)) generic 4 pecialty Drug decitabine generic 4 DOCEFREZ BRAND 4 pecialty Drug pecialty Drug DOCETAXEL (CONC 20 MG/ML, CONC 20 MG/0.5ML, OLUTION 20 MG/2ML) BRAND 4 pecialty Drug docetaxel (inj conc 20 mg/ml, inj conc 20 mg/0.5ml (40 mg/ml), soln iv infusion 20 mg/2ml) generic 4 pecialty Drug DOXIL BRAND 4 pecialty Drug doxorubicin hcl (for inj 10 mg, for inj 50 mg, inj 2 mg/ml) generic 4 pecialty Drug DOXORUBICIN HCL (RECON OLN 10 MG, RECON OLN 50 MG) BRAND 4 pecialty Drug doxorubicin hcl liposomal generic 4 pecialty Drug ELOXATIN (OLUTION 50 MG/10ML, OLUTION 100 MG/20ML) BRAND 4 pecialty Drug ELR BRAND 4 pecialty Drug GE 39 LAT UPDATED 05/2016

41 PRODUCT DECRIPTION BRAND/GEN TIER LIMIT & RETRICTION epirubicin hcl (inj 50, iv soln 50) generic 4 ERWINAZE BRAND 4 FLUDARA BRAND 4 pecialty Drug pecialty Drug pecialty Drug fludarabine phosphate (for inj 50 mg, inj 25 mg/ml) generic 4 pecialty Drug HALAVEN BRAND 4 pecialty Drug IDAMYCIN PF (OLUTION 5 MG/5ML, OLUTION 10 MG/10ML) BRAND 4 pecialty Drug idarubicin hcl (inj 5 mg/5ml, inj 10 mg/10ml) generic 4 irinotecan hcl (inj 40 mg/2ml, inj 100 mg/5ml) generic 4 ITODAX BRAND 4 IXEMPRA KIT RECON OLN 15 MG BRAND 4 JEVTANA BRAND 4 pecialty Drug pecialty Drug pecialty Drug pecialty Drug pecialty Drug leucovorin calcium (for inj 50 mg, for inj 100 mg, for inj 200 mg, for inj 350 mg, for inj 500 mg, inj 10 mg/ml, tab 5 mg, tab 10 mg, tab 15 mg, tab 25 mg) LEUCOVORIN CALCIUM RECON OLN 50 MG BRAND 1 LYODREN BRAND 4 mitomycin for inj 20 mg generic 4 pecialty Drug pecialty Drug GE 40 LAT UPDATED 05/2016

42 PRODUCT DECRIPTION BRAND/GEN TIER LIMIT & RETRICTION mitoxantrone hcl inj conc 25 mg/12.5ml (2 mg/ml) generic 4 pecialty Drug NAVELBINE OLUTION 10 MG/ML BRAND 4 OFORTA BRAND 4 ONCAR BRAND 4 ONTAK BRAND 4 oxaliplatin (soln50mg/10ml, soln100mg/20ml) generic 4 pecialty Drug pecialty Drug pecialty Drug pecialty Drug pecialty Drug paclitaxel (conc 100 mg/16.7ml, conc 150 mg/25ml) generic 4 pecialty Drug PHOTOFRIN BRAND 4 PROLEUKIN BRAND 4 YLATRON BRAND 4 YNRIBO BRAND 4 pecialty Drug pecialty Drug pecialty Drug pecialty Drug TAXOTERE (CONC 20 MG/0.5ML, CONC 20 MG/ML) BRAND 4 pecialty Drug TENIPOIDE BRAND 4 thiotepa generic 4 TRIENOX BRAND 4 pecialty Drug pecialty Drug pecialty Drug GE 41 LAT UPDATED 05/2016

43 PRODUCT DECRIPTION BRAND/GEN TIER LIMIT & RETRICTION UVADEX BRAND 4 VALTAR BRAND 4 VELCADE BRAND 4 VIDAZA BRAND 4 vinblastine sulfate for inj 10 mg generic 4 vincristine sulfate generic 4 pecialty Drug pecialty Drug pecialty Drug pecialty Drug pecialty Drug pecialty Drug vinorelbine tartrate (inj 10 mg/ml, inj 10 mg/ml (base equiv)) generic 4 pecialty Drug VORAXAZE BRAND 4 VUMON BRAND 4 ZALTRAP OLUTION 100 MG/4ML BRAND 4 ZOLINZA BRAND 4 pecialty Drug pecialty Drug pecialty Drug pecialty Drug AROMATAE INHIBITOR, 3RD GENERATION anastrozole tab 1 mg ARIMIDEX BRAND 4 AROMAIN BRAND 4 pecialty Drug exemestane generic 4 pecialty Drug FEMARA BRAND 4 GE 42 LAT UPDATED 05/2016

44 PRODUCT DECRIPTION BRAND/GEN TIER LIMIT & RETRICTION letrozole tab 2.5 mg ENZYME INHIBITOR ETOPOPHO BRAND 4 pecialty Drug etoposide (cap 50 mg, inj 1 gm/50ml (20 mg/ml), inj 100mg/5ml (20 mg/ml), inj 500mg/25ml (20 mg/ml)) generic 4 pecialty Drug HYCAMTIN BRAND 4 topotecan hcl for inj 4 mg generic 4 pecialty Drug pecialty Drug MOLECULAR TARGET INHIBITOR AFINITOR BRAND 4 BOULIF BRAND 4 CAPRELA BRAND 4 COMETRIQ (100 MG DAILY DOE) BRAND 4 COMETRIQ (140 MG DAILY DOE) BRAND 4 COMETRIQ (60 MG DAILY DOE) BRAND 4 ERIVEDGE BRAND 4 GLEEVEC BRAND 4 imatinib mesylate generic 4 pecialty Drug pecialty Drug pecialty Drug pecialty Drug pecialty Drug pecialty Drug pecialty Drug pecialty Drug pecialty Drug GE 43 LAT UPDATED 05/2016

45 PRODUCT DECRIPTION BRAND/GEN TIER LIMIT & RETRICTION INLYTA BRAND 4 JAKAFI BRAND 4 KYPROLI BRAND 4 NEXAVAR BRAND 4 pecialty Drug pecialty Drug pecialty Drug pecialty Drug NINLARO BRAND 4 MD1 4 / 28.0 DAY PRYCEL BRAND 4 TIVARGA BRAND 4 pecialty Drug pecialty Drug UTENT (CAP 12.5 MG, CAP 25 MG, CAP 50 MG) BRAND 4 pecialty Drug TARCEVA BRAND 4 TAIGNA BRAND 4 TORIEL BRAND 4 TYKERB BRAND 4 VANDETANIB BRAND 4 VOTRIENT BRAND 4 XALKORI BRAND 4 pecialty Drug pecialty Drug pecialty Drug pecialty Drug pecialty Drug pecialty Drug pecialty Drug GE 44 LAT UPDATED 05/2016

46 PRODUCT DECRIPTION BRAND/GEN TIER LIMIT & RETRICTION ZELBORAF BRAND 4 pecialty Drug MONOCLONAL ANTIBODIE ADCETRI BRAND 4 ARZERRA BRAND 4 AVATIN OLUTION 100 MG/4ML BRAND 4 BEXXAR BRAND 4 ERBITUX BRAND 4 HERCEPTIN BRAND 4 PERJETA BRAND 4 RITUXAN BRAND 4 VECTIBIX OLUTION 100 MG/5ML BRAND 4 YERVOY BRAND 4 pecialty Drug pecialty Drug pecialty Drug pecialty Drug pecialty Drug pecialty Drug pecialty Drug pecialty Drug pecialty Drug pecialty Drug RETINOID bexarotene generic 4 NRETIN BRAND 3 MPL 1 / 30 days pecialty Drug TARGRETIN CAP 75 MG BRAND 4 MPL 1 / 30 days pecialty Drug GE 45 LAT UPDATED 05/2016

47 PRODUCT DECRIPTION BRAND/GEN TIER LIMIT & RETRICTION TARGRETIN GEL 1 % BRAND 4 tretinoin (chemotherapy) ANTIRAITIC ANTIHELMINTHIC ALBENZA BRAND 3 BILTRICIDE BRAND 3 ivermectin mebendazole chew tab 100 mg KLICE BRAND 3 TROMECTOL BRAND 3 pecialty Drug ANTIPROTOZOAL ALINIA (RECON UP 100 MG/5ML, TAB 500 MG) BRAND 2 atovaquone susp 750 mg/5ml atovaquone-proguanil hcl chloroquine phosphate (tab 250 mg, tab 500 mg) COARTEM BRAND 2 MD1 12 / 3 DAY C Limit of 3 claims every 180 days MD1 24 / 3 DAY C Limit of 3 claims every 180 days DARAPRIM BRAND 3 3 per day hydroxychloroquine sulfate MALARONE BRAND 2 MD1 12 / 3 DAY C Limit of 3 claims every 180 days mefloquine hcl MEPRON BRAND 3 NEBUPENT BRAND 3 PENTAM BRAND 3 PRIMAQUINE PHOPHATE TAB 26.3 MG BRAND 3 GE 46 LAT UPDATED 05/2016

48 PRODUCT DECRIPTION BRAND/GEN TIER LIMIT & RETRICTION primaquine phosphate tab 26.3 mg (15 mg base) generic 3 quinine sulfate cap 324 mg MD1 84 / 365 DAY PEDICULICIDE/CABICIDE EURAX BRAND 3 lindane generic 3 malathion NATROBA BRAND 1 permethrin PINOAD BRAND 2 ULEFIA BRAND 3 ANTIRKINON AGENT ANTICHOLINERGIC benztropine mesylate (inj 1 mg/ml, tab 0.5 mg, tab 1 mg, tab 2 mg) trihexyphenidyl hcl (elixir 0.4 mg/ml, tab 2 mg, tab 5 mg) ANTIRKINON AGENT, OTHER amantadine hcl (cap 100 mg, syrup 50 mg/5ml, tab 100 mg) CARBIDO-LEVODO-ENTACAPONE (TAB MG, TAB MG, TAB MG, TAB MG, TAB MG, TAB MG) carbidopa-levodopa-entacapone (tabs mg, tabs mg, tabs mg, tabs mg, tabs mg, tabs mg) BRAND 1 entacapone 8 per day TALEVO 100 BRAND 1 TALEVO 125 BRAND 1 TALEVO 150 BRAND 1 TALEVO 200 BRAND 1 TALEVO 50 BRAND 1 GE 47 LAT UPDATED 05/2016

49 PRODUCT DECRIPTION BRAND/GEN TIER LIMIT & RETRICTION TALEVO 75 BRAND 1 TAMAR BRAND 3 DOMINE AGONIT APOKYN BRAND 4 bromocriptine mesylate (cap 5 mg, tab 2.5 mg) NEUPRO BRAND 2 pecialty Drug pramipexole dihydrochloride (tab 0.25 mg, tab 0.5 mg, tab 0.75 mg, tab 1 mg, tab 1.5 mg) pramipexole dihydrochloride tab mg 4 per day ropinirole hydrochloride (tab 0.25 mg, tab 0.5 mg, tab 1 mg, tab 2 mg, tab 3 mg, tab 4 mg, tab 5 mg) ropinirole hydrochloride (tab sr 24hr 12 mg, tab sr 24hr 8 mg) T 2 per day ropinirole hydrochloride (tab sr 24hr 2 mg, tab sr 24hr 4 mg, tab sr 24hr 6 mg) T 1 per day DOMINE PRECUROR/L-AMINO ACID DECARBOXYLAE INHIBITOR carbidopa carbidopa-levodopa LODOYN BRAND 1 MONOAMINE OXIDAE B (MAO-B) INHIBITOR AZILECT BRAND 2 selegiline hcl (cap 5 mg, tab 5 mg) ANTIPYCHOTIC 1 per day 1T GENERATION/TYPICAL chlorpromazine hcl (inj 25 mg/ml, inj 50 mg/2ml) chlorpromazine hcl (tab 10 mg, tab 25 mg, tab 50 mg, tab 100 mg, tab 200 mg) generic 3 GE 48 LAT UPDATED 05/2016

50 PRODUCT DECRIPTION BRAND/GEN TIER LIMIT & RETRICTION fluphenazine hcl (elixir 2.5 mg/5ml, inj 2.5 mg/ml, oral conc 5 mg/ml, tab 1 mg, tab 2.5 mg, tab 5 mg, tab 10 mg) haloperidol haloperidol decanoate MFL 1 / 28 days haloperidol lactate inj 5 mg/ml loxapine succinate ORAP BRAND 3 pimozide thioridazine hcl thiothixene trifluoperazine hcl (tab 1 mg, tab 2 mg, tab 5 mg, tab 10 mg) 2ND GENERATION/ATYPICAL aripiprazole oral solution 1 mg/ml generic 3 AL At least 6 yrs old MD1 900 ML / 30 DAY FANAPT BRAND 2 FANAPT TITRATION CK BRAND 2 MPL 2 per day 2 / 365 days INVEGA (TAB ER 24H 1.5 MG, TAB ER 24H 3 MG, TAB ER 24H 9 MG) BRAND 2 1 per day INVEGA TAB ER 24H 6 MG BRAND 2 LATUDA BRAND 3 2 per day 1 per day olanzapine (tab 15 mg, tab 20 mg) 2 per day olanzapine (tab 2.5 mg, tab 5 mg, tab 7.5 mg, tab 10 mg) 1 per day olanzapine for im inj 10 mg MD1 6 / 28 DAY GE 49 LAT UPDATED 05/2016

51 PRODUCT DECRIPTION BRAND/GEN TIER LIMIT & RETRICTION quetiapine fumarate RIPERDAL CONTA BRAND 2 AL MFL At least 10 yrs old 2 per day 2 / 28 days risperidone (tab 0.25 mg, tab 0.5 mg, tab 1 mg, tab 2 mg, tab 3 mg) 2 per day risperidone (tab 0.25 mg, tab 0.5 mg, tab 1 mg, tab 2 mg, tab 3 mg, tab 4 mg) 2 per day risperidone soln 1 mg/ml MD1 240 ML / 30 DAY risperidone tab 4 mg 4 per day APHRI (L TAB 5 MG, L TAB 10 MG) BRAND 2 2 per day EROQUEL XR (TAB ER 24H 400 MG, TAB ER 24H 300 MG) BRAND 2 AL At least 10 yrs old 2 per day EROQUEL XR (TAB ER 24H 50 MG, TAB ER 24H 200 MG, TAB ER 24H 150 MG) BRAND 2 AL At least 10 yrs old 1 per day ziprasidone hcl AL At least 18 yrs old 2 per day TREATMENT-REITANT clozapine (tab 25 mg, tab 50 mg, tab 100 mg, tab 200 mg) ANTIVIRAL ANTI-CYTOMEGALOVIRU (CMV) AGENT cidofovir iv inj 75 mg/ml generic 3 FOCAVIR BRAND 3 ganciclovir sodium VALCYTE RECON OLN 50 MG/ML BRAND 2 MD1 540 ML / 30 DAY GE 50 LAT UPDATED 05/2016