Your Blue MedicareRx (PDP) and Senior Rx Plus Plan Formulary (List of Covered Drugs)

Transcription

1 Your Blue MedicareRx (PDP) and Senior Rx Plus Plan 04 Formulary (List of Covered s) PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN Your Medicare Prescription benefits and Senior Rx Plus benefits cover the same drug list (formulary). This formulary was updated on August, 0. For more recent information or other questions, please contact us, Anthem Blue Cross and Blue Shield at or, for TTY users, 7, Monday through Friday, except holidays from 8 a.m. to 9 p.m. ET, or visit Note to existing members: This formulary has changed since last year. Please review this document to make sure that it still contains the drugs you take. When this drug list (formulary) refers to we, us, or our, it means Anthem Blue Cross and Blue Shield. When it refers to plan or your plan, it means your 04 group retiree drug plan. This document includes a list of the drugs (formulary) for our plan which is current as of January, 04. For an updated formulary, please contact us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages. You must generally use network pharmacies to use your prescription drug benefit. Your formulary and pharmacy network may change on January, 05. Depending on your former group, employer or union's renewal date, your benefits, premium or copayments/coinsurance may also change on January, 05. Please refer to your Evidence of Coverage for information specific to your plan. Anthem Blue Cross and Blue Shield is a PDP plan with a Medicare contract. Enrollment in Anthem Blue Cross and Blue Shield depends on contract renewal. Our plan has free language interpreter services available to answer questions from non-english speaking members. Please call the Customer Service number listed above to request interpreter services. This document may be available in an alternate format, such as large print. Please call the Customer Service listed above for additional information. 8687MUSENMUB_047 August, 0_Comprehensive_ETNRC_6P

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3 Table of Contents What is the Blue MedicareRx (PDP) formulary?... Can the formulary ( List) change?... How do I use the formulary?... What are generic drugs?... Are there any restrictions on my coverage?... What if my drug is not on the formulary?... How do I request an exception to the Blue MedicareRx (PDP) formulary?... What do I do before I can talk to my doctor about changing my drugs or requesting an exception?...4 For more information...4 Your plan s formulary...4 Select Generics...6 Covered Medications by Therapeutic Category...8 Index of s...5 b+

4 Part D Formulary What is the Blue MedicareRx (PDP) formulary? A formulary is a list of covered drugs selected by us in consultation with a team of health care providers, which represents the prescription therapies believed to be a necessary part of a quality treatment program. Your plan will generally cover the drugs listed in the formulary as long as the drug is medically necessary, the prescription is filled at a network pharmacy and other plan rules are followed. For more information on how to fill your prescriptions, please review your Evidence of Coverage. If your plan uses a Closed Formulary (Closed List), you have coverage for most, but not all, Medicare Part D eligible drugs. The drugs on this list are all approved by the FDA and are selected by the plan with the help of a team of doctors and pharmacists. Not all drugs are on the Closed Formulary. The drugs covered under your retiree drug coverage are listed in your plan s List. If your plan uses an Open Formulary (Open List), you have coverage for all Medicare Part D eligible drugs. You also have coverage for certain additional drugs not typically covered by Medicare Part D plans. The additional drugs beyond those typically covered by Medicare are all approved by the FDA and are selected by the plan with the help of a team of doctors and pharmacists. These drugs are covered by your Senior Rx Plus supplemental benefits. The drugs covered under your retiree drug coverage are listed in your plan s List or your benefit chart. For both types of formularies, some drugs may sometimes be covered under the medical benefits of your plan rather than under the drug benefit of your plan. The drugs that are sometimes covered under your medical benefits are marked with a B/D in drug list. To find out whether you have a Closed or Open Formulary benefit, please check the benefit chart in the front of your Evidence of Coverage. For more information on how to fill your prescriptions, please review your Evidence of Coverage. Can the formulary ( List) change? Generally, if you are taking a drug on our 04 formulary that was covered at the beginning of the year, we will not discontinue or reduce coverage of the drug during the 04 coverage year except when a new, less expensive generic drug becomes available or when new adverse information about the safety or effectiveness of a drug is released. If we remove drugs from our formulary, or add prior authorization, quantity limits and/or step therapy restrictions on a drug, or move a drug to a higher cost sharing tier we must notify affected members of the change at least 60 days before the change becomes effective, or at the time the member requests a refill of the drug, at which time the member will receive a 60-day supply of the drug. If the Food and Administration deems a drug on our formulary to be unsafe or the drug s manufacturer removes the drug from the market, we will immediately remove the drug from our formulary and provide notice to members who take the drug. We evaluate new drugs as they come onto the market. Once we have completed a full evaluation based upon clinical effectiveness and cost relative to other drug therapies, the drug will be assigned to a drug plan tier or non-formulary designation. If your plan uses an Open Formulary you will have coverage for a new Part D eligible drug designated non-formulary following our review. During the period between the time the drug is first available and our review, the drug will not be automatically covered. If your physician feels you should use the new drug, you or your physician may request a coverage exception. The enclosed formulary is current as of January, 04. If any other type of approved formulary change is made during the year, we will notify you by sending you a list of these changes, or by sending you an updated formulary. To get updated information about the drugs covered by your plan, please contact us. Our contact information appears on the front and back cover pages.

5 How do I use the formulary? There are two ways to find your drug within the formulary: Medical Condition: The formulary begins on page 8. The drugs in this formulary are grouped into categories depending on the type of medical conditions that they are used to treat. For example, drugs used to treat a heart condition are listed under the category, Cardiovascular Medication. If you know what your drug is used for, look for the category name in the list that begins on page 8. Then look under the category name for your drug. Alphabetical Listing: If you are not sure what category to look under, you should look for your drug in the Index that begins on page 5. The Index provides an alphabetical list of all of the drugs included in this document. Both brand name drugs and generic drugs are listed in the Index. Look in the Index and find your drug. Next to your drug, you will see the page number where you can find coverage information. Turn to the page listed in the Index and find the name of your drug in the first column of the list. What are generic drugs? Your plan covers both brand name drugs and generic drugs. A generic drug is approved by the FDA as having the same active ingredient as the brand name drug. Generally, generic drugs cost less than brand name drugs. Many plans also cover a small group of $0 copay Select Generic drugs. These are drugs which have proven over time to be especially cost effective options for treating some conditions. Your plan offers these drugs at no cost to you when you purchase them at a network pharmacy. You can find the list of $0 copay Select Generic drugs on page 6. To find out whether your plan includes this benefit, please check the benefit chart in the front of your Evidence of Coverage. Are there any restrictions on my coverage? Some covered drugs may have additional requirements or limits on coverage. These requirements and limits may include: Prior Authorization: Your plan requires you or your provider to get prior authorization for certain drugs. This means that you will need to get approval from us before you fill your prescriptions. If you don't get approval, your plan may not cover the drug. Quantity : For certain drugs, we limit the amount of the drug that we will cover. For example, we provide 00 units per ml per prescription for HUMALOG. This may be in addition to a standard one month or three month supply. Step Therapy: In some cases, we require you to first try certain drugs to treat your medical condition before we will cover another drug for that condition. For example, if A and B both treat your medical condition, we may not cover B unless you try A first. If A does not work for you, we will then cover B. You can find out if your drug has any additional requirements or limits by looking in the formulary that begins on page 8. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages. You can ask us to make an exception to these restrictions or limits or for a list of other, similar drugs that may treat your health condition. See the section, How do I request an exception to the plan s formulary? for information about how to request an exception. What if my drug is not on the formulary? If you learn that access to your drug is limited, for any reason, you have two options: You can ask Customer Service for a list of similar drugs that are covered by your plan. When you receive the list, show it to your doctor and ask him or her to prescribe a similar drug that is covered by your plan. You can ask your plan to make an exception and cover your drug. See below for information about how to request an exception. How do I request an exception to the Blue MedicareRx (PDP) formulary? You can ask us to make an exception to our coverage rules. There are several types of exceptions that you can ask us to make.

6 If your drug plan uses a closed formulary, you can ask us to cover your drug even if it is not on our formulary. If approved, this drug will be covered at a pre-determined cost-sharing level, and you would not be able to ask us to provide the drug at a lower cost-sharing level. You can ask us to cover a formulary drug at a lower cost-sharing level if this drug is not on the specialty tier. If approved this would lower the amount you must pay for your drug. You can ask us to waive coverage restrictions or limits on your drug. For example, for certain drugs, we limit the amount of the drug that we will cover. If your drug has a quantity limit, you can ask us to waive the limit and cover a greater amount. Generally, your plan will only approve your request for an exception if the alternative drugs included on the plan s formulary, the lower cost-sharing drug or additional utilization restrictions would not be as effective in treating your condition and/or would cause you to have adverse medical effects. You should contact us to ask us for an initial coverage decision for a formulary, tiering or utlization restriction exception. When you request a formulary, tiering or utilization restriction exception you should submit a statement from your prescribing provider supporting your request. Generally, we must make our decision within 7 hours of getting your provider s supporting statement. You can request an expedited (fast) exception if you or your doctor believe that your health could be seriously harmed by waiting up to 7 hours for a decision. If your request to expedite is granted, we must give you a decision no later than 4 hours after we get a supporting statement from your prescribing provider. What do I do before I can talk to my doctor about changing my drugs or requesting an exception? As a new or continuing member in our plan, you may be taking drugs that are not on our formulary. Or, you may be taking a drug that is on our formulary but your ability to get it is limited. For example, you may need a prior authorization from us before you can fill your prescription. You should talk to your doctor to decide if you should switch to an appropriate drug that we cover or request a formulary exception so that we will cover the drug you take. While you talk to your doctor to determine the right course of action for you, we may cover your drug in certain cases during the first 90 days you are a member of our plan. For each of your drugs that is not on our formulary or if your ability to get your drugs is limited, we will cover a temporary 0-day supply (unless you have a prescription written for fewer days) when you go to a network pharmacy. After your first 0-day supply, we will not pay for these drugs, even if you have been a member of the plan less than 90 days. If you are a resident of a long-term care facility, we will cover a temporary 98-day transition supply consistent with dispensing increment (unless you have a prescription written for fewer days). We will cover more than one refill of these drugs for the first 90 days you are a member of our plan. If you need a drug that is not on our formulary or if your ability to get your drugs is limited, but you are past the first 90 days of membership in our plan, we will cover a: -day emergency supply of that drug (unless you have a prescription for fewer days) while you pursue a formulary exception. For more information For more detailed information about your plan's prescription drug coverage, please review your Evidence of Coverage and other plan materials. If you have questions about your plan, please contact us. Our contact information, along with the date we last updated this formulary, appears on the front and back cover pages. If you have general questions about Medicare prescription drug coverage, please call Medicare at -800-MEDICARE ( ), 4 hours a day/7 days a week. TTY/ TDD users should call Or, visit 4

7 Your plan s formulary The formulary that begins on page 8 provides coverage information about the drugs covered by your plan. If you have trouble finding your drug in the list, turn to the Index that begins on page 5. The first column of the chart lists the drug name. Brand name drugs are capitalized (e.g., HUMALOG) and generic drugs are listed in lower-case italics (e.g., enalapril). The second column of the chart identifies the tier placement of each medication covered in your formulary. Many drug plans group drugs based upon cost with the lowest cost drugs in. These are typically generic drugs. To find out what your copayment is for each drug tier, please check the benefit chart in the front of your Evidence of Coverage. The benefit chart in your Evidence of Coverage will also tell you if the amount that you pay for covered drugs changes after the total drug cost paid by you and the plan reaches the initial coverage amount of $,850. Please check your benefit chart and Evidence of Coverage for complete details on the cost you must pay for drugs covered by your drug plan. The third column tells you if your plan has any special requirements for coverage of your drug. The formulary chart legend, located on page 8, contains the list of special requirements which can be applied to drugs in your plan. The legend also gives you a description of the restriction and the code used in the drug chart to tell you that the restriction applies to a specific drug. 5

8 Select Generics (Please check the Benefit Chart in the front of your Evidence of Coverage to find out if your plan offers $0 copay for Select Generic drugs.) Name Cardiovascular atenolol 5 mg tablet atenolol 50 mg tablet atenolol 00 mg tablet atenolol-chlorthalidone 50-5 tablet atenolol-chlorthalidone 00-5 tablet benazepril hcl 5 mg tablet benazepril hcl 0 mg tablet benazepril hcl 0 mg tablet benazepril hcl 40 mg tablet benazepril-hydrochlorothiazide mg tablet benazepril-hydrochlorothiazide 0-.5 mg tablet benazepril-hydrochlorothiazide 0-.5 mg tablet benazepril-hydrochlorothiazide 0-5 mg tablet bisoprolol-hydrochlorothiazide mg tablet bisoprolol-hydrochlorothiazide mg tablet bisoprolol-hydrochlorothiazide mg tablet captopril.5 mg tablet captopril 5 mg tablet captopril 50 mg tablet captopril 00 mg tablet captopril-hydrochlorothiazide 5-5 mg tablet captopril-hydrochlorothiazide 5-5 mg tablet captopril-hydrochlorothiazide 50-5 mg tablet captopril-hydrochlorothiazide 50-5 mg tablet chlorthalidone 5 mg tablet chlorthalidone 50 mg tablet enalapril maleate.5 mg tablet enalapril maleate 5 mg tablet enalapril maleate 0 mg tablet enalapril maleate 0 mg tablet enalapril-hydrochlorothiazide 5-.5 mg tablet enalapril-hydrochlorothiazide 0-5 mg tablet hydrochlorothiazide.5 mg capsule hydrochlorothiazide.5 mg tablet hydrochlorothiazide 5 mg tablet hydrochlorothiazide 50 mg tablet lisinopril.5 mg tablet lisinopril 5 mg tablet lisinopril 0 mg tablet lisinopril 0 mg tablet lisinopril 0 mg tablet Name lisinopril 40 mg tablet lisinopril-hydrochlorothiazide 0-.5 mg tablet lisinopril-hydrochlorothiazide 0-.5 mg tablet lisinopril-hydrochlorothiazide 0-5 mg tablet metoprolol 50 mg tablet metoprolol 00 mg tablet metoprolol tartrate 5 mg tablet metoprolol tartrate 50 mg tablet metoprolol tartrate 00 mg tablet Cholesterol lovastatin 0 mg tablet lovastatin 0 mg tablet lovastatin 40 mg tablet pravastatin sodium 0 mg tablet pravastatin sodium 0 mg tablet pravastatin sodium 40 mg tablet pravastatin sodium 80 mg tablet simvastatin 5 mg tablet simvastatin 0 mg tablet simvastatin 0 mg tablet simvastatin 40 mg tablet simvastatin 80 mg tablet Depression budeprion sr 00 mg tablet budeprion sr 50 mg tablet bupropion hcl 75 mg tablet bupropion hcl 00 mg tablet bupropion hcl sr 00 mg tablet bupropion sr 50 mg tablet bupropion hcl sr 00 mg tablet citalopram hbr 0 mg tablet citalopram hbr 0 mg tablet citalopram hbr 40 mg tablet fluoxetine hcl 0 mg capsule fluoxetine hcl 0 mg tablet fluoxetine hcl 0 mg capsule fluoxetine hcl 0 mg tablet fluoxetine hcl 40 mg capsule mirtazapine 7.5 mg tablet mirtazapine 5 mg orally disintegrating tablet mirtazapine 5 mg tablet 6

9 mirtazapine 0 mg orally disintegrating tablet mirtazapine 0 mg tablet mirtazapine 45 mg orally disintegrating tablet mirtazapine 45 mg tablet paroxetine hcl 0 mg tablet paroxetine hcl 0 mg tablet paroxetine hcl 0 mg tablet paroxetine hcl 40 mg tablet Diabetes glimepiride mg tablet glimepiride mg tablet glimepiride 4 mg tablet glipizide 5 mg tablet glipizide 0 mg tablet glipizide er.5 mg tablet glipizide er 5 mg tablet glipizide er 0 mg tablet glipizide-metformin.5-50 mg glipizide-metformin mg glipizide-metformin mg metformin hcl 500 mg tablet metformin hcl 850 mg tablet metformin hcl,000 mg tablet metformin hcl er 500 mg tablet Osteoperosis alendronate sodium 5 mg tablet alendronate sodium 0 mg tablet alendronate sodium 5 mg tablet alendronate sodium 40 mg tablet alendronate sodium 70 mg tablet Smoking Cessation buproban 50 mg tablet bupropion hcl sr 50 mg tablet 7

10 Covered Medications by Therapeutic Category Legend Generic drugs are shown in lowercase italics (e.g. enalapril) Brand name drugs are shown in capital letters (e.g. LEXAPRO) QLL - Quantity : Restricts the frequency, amount or dosage of medication for which you can obtain benefits each time you get a prescription filled (most often set on a monthly basis). PAR - Prior Authorization: The process of obtaining approval for certain prescriptions before benefits will be approved. You, your doctor or other network provider will need to request prior authorization before you fill the prescription. ST - Step Therapy: The process of first trying a certain drug or drugs to determine if that drug or drugs will treat your medical condition before your plan will cover another drug for that condition. B/D - Part B vs Part D: This drug may be covered under either your Part D prescription drug benefits or as a Part B drug under your medical benefits, as determined by Medicare. LA - Limited Access: This prescription may be available only at certain pharmacies. For more information, consult your Pharmacy Directory or call Customer Service. The phone numbers are listed on the front and back covers of this booklet. INJ - Injectable: The drug is available in injectable form. - Mail Order: Prescription drugs available through Mail Order. [+] Preferred: The symbol [+] in the Name column denotes preferred products. Part D Eligible Name Adjunctive Agents amifostine calcium folinate dexrazoxane inj 50mg dexrazoxane inj 500mg ELITEK FUSILEV leucovorin calcium inj 00mg, 0mg/ml, 00mg, 50mg, 50mg leucovorin calcium inj 500mg leucovorin calcium tabs mesna MESNEX INJ MESNEX TABS XGEVA Adrenal Hormones a-hydrocort a-methapred ACTHAR HP CELESTONE cortisone acetate dexamethasone PAR B/D PAR B/D PAR B/D PAR PAR QLL(.7 per 8 days) PAR Name dexamethasone intensol dexamethasone sodium phosphate DEXPAK 0 DAY DEXPAK DAY DEXPAK 6 DAY fludrocortisone acetate hydrocortisone tabs methylprednisolone methylprednisolone acetate methylprednisolone dose pack methylprednisolone sodiumsuccinate inj 000mg, 5mg, gm, 40mg methylprednisolone sodiumsuccinate inj 500mg millipred dp millipred tabs ORAPRED ORAPRED ODT prednisolone prednisolone sodium phosphate oral soln 5mg/5ml, 5mg/5ml prednisone Effective January, 04 8 Comprehensive_ETNRC_6P

11 Name prednisone intensol veripred 0 Antiarrhythmic Agents amiodarone hcl inj amiodarone hcl tabs 00mg, 400mg disopyramide phosphate flecainide acetate lidocaine hcl inj 0mg/ml mexiletine hcl pacerone procainamide hcl inj 00mg/ ml procainamide hcl inj 500mg/ ml propafenone hcl propafenone hcl er quinidine gluconate cr quinidine gluconate er quinidine sulfate quinidine sulfate er sorine sotalol hcl sotalol hcl (af) TIKOSYN Antibiotics ak-poly-bac AZASITE bacitracin bacitracin/polymyxin b BESIVANCE CILOXAN ciprofloxacin hcl erythromycin gentak gentamicin sulfate levofloxacin ophthalmic soln XEZA [+] NATACYN neo-polycin neomycin/bacitracin/polymyxin neomycin/polymyxin/bacitracin zinc neomycin/polymyxin/ gramicidin NEOSPORIN B/D PAR Name ofloxacin polycin polymyxin b sulfate/ trimethoprim sulfate tobramycin sulfate ophthalmic soln TOBREX OINT trimethoprim sulfate/polymyxin b sulfate VIGAX [+] Anticholinergics & Antispasmodics ENABLEX QLL(0 per 0 days) ST flavoxate hcl GELNIQUE GEL 0% [+] QLL(0 per 0 days) ST GELNIQUE GEL % [+] QLL(00 per 0 days) ST MYRBETRIQ QLL(0 per 0 days) ST oxybutynin chloride er tb4 0mg, 5mg QLL(60 per 0 days) oxybutynin chloride er tb4 5mg QLL(0 per 0 days) oxybutynin chloride syrp QLL(600 per 0 days) oxybutynin chloride tabs QLL(0 per 0 days) OXYTROL QLL(8 per 8 days) ST tolterodine tartrate tabs mg QLL(0 per 0 days) tolterodine tartrate tabs mg QLL(60 per 0 days) TOVIAZ [+] QLL(0 per 0 days) trospium chloride QLL(60 per 0 days) trospium chloride er QLL(0 per 0 days) ST VESICARE QLL(0 per 0 days) ST Comprehensive_ETNRC_6P 9 Effective January, 04

12 Name Anticonvulsants BANZEL SUSP BANZEL TABS 00MG BANZEL TABS 400MG carbamazepine carbamazepine er CELONTIN clonazepam odt tbdp 0.5mg clonazepam odt tbdp 0.5mg clonazepam odt tbdp 0.5mg clonazepam odt tbdp mg clonazepam odt tbdp mg clonazepam tabs 0.5mg clonazepam tabs mg clonazepam tabs mg DEPACON DEPAKENE CAPS diazepam gel DILANTIN CAPS 00MG DILANTIN CAPS 0MG DILANTIN INFATABS DILANTIN SUSP divalproex sodium divalproex sodium dr divalproex sodium er epitol EQUETRO CP 00MG EQUETRO CP 00MG EQUETRO CP 00MG ethosuximide felbamate QLL(400 per 0 days) QLL(480 per 0 days) QLL(40 per 0 days) QLL(4800 per 0 days) QLL(400 per 0 days) QLL(00 per 0 days) QLL(600 per 0 days) QLL(00 per 0 days) QLL(00 per 0 days) QLL(600 per 0 days) QLL(00 per 0 days) QLL( per days) QLL(480 per 0 days) QLL(40 per 0 days) QLL(80 per 0 days) Name fosphenytoin sodium gabapentin caps 00mg gabapentin caps 00mg gabapentin caps 400mg gabapentin oral soln gabapentin tabs 600mg gabapentin tabs 800mg GABITRIL KLONOPIN TABS 0.5MG KLONOPIN TABS MG KLONOPIN TABS MG LAMICTAL ODT TBDP LAMICTAL STARTER/ NOT TAKING CARBAMAZEPINE LAMICTAL STARTER/ TAKING CARBAMAZEPINE/NOT TAKING VALPROATE LAMICTAL STARTER/ TAKING VALPROATE LAMICTAL XR lamotrigine lamotrigine er levetiracetam er tb4 500mg levetiracetam er tb4 750mg levetiracetam inj 500mg/5ml levetiracetam oral soln levetiracetam tabs LYRICA CAPS 00MG LYRICA CAPS 50MG LYRICA CAPS 00MG QLL(080 per 0 days) QLL(60 per 0 days) QLL(70 per 0 days) QLL(60 per 0 days) QLL(80 per 0 days) QLL(5 per 0 days) QLL(00 per 0 days) QLL(600 per 0 days) QLL(00 per 0 days) QLL(80 per 0 days) QLL(0 per 0 days) PAR QLL(80 per 0 days) PAR QLL(0 per 0 days) PAR QLL(90 per 0 days) Effective January, 04 0 Comprehensive_ETNRC_6P

13 Name LYRICA CAPS 5MG, 00MG LYRICA CAPS 5MG LYRICA CAPS 50MG LYRICA CAPS 75MG LYRICA ORAL SOLN ONFI TABS 0MG ONFI TABS 0MG ONFI TABS 5MG oxcarbazepine OXTELLAR XR TB4 50MG OXTELLAR XR TB4 00MG OXTELLAR XR TB4 600MG PEGANONE phenobarbital elix phenobarbital sodium phenobarbital tabs 00mg phenobarbital tabs 5mg phenobarbital tabs 6.mg phenobarbital tabs 0mg phenobarbital tabs.4mg phenobarbital tabs 60mg phenobarbital tabs 64.8mg phenobarbital tabs 97.mg phenytoin phenytoin infatabs phenytoin sodium phenytoin sodium extended PAR QLL(60 per 0 days) PAR QLL(70 per 0 days) PAR QLL(60 per 0 days) PAR QLL(40 per 0 days) PAR QLL(900 per 0 days) QLL(0 per 0 days) QLL(60 per 0 days) QLL(40 per 0 days) QLL(480 per 0 days) QLL(40 per 0 days) QLL(0 per 0 days) QLL(000 per 0 days) QLL(0 per 0 days) QLL(800 per 0 days) QLL(74 per 0 days) QLL(400 per 0 days) QLL(70 per 0 days) QLL(00 per 0 days) QLL(85 per 0 days) QLL( per 0 days) Name POTIGA TABS 00MG, 00MG, 400MG QLL(90 per 0 days) POTIGA TABS 50MG QLL(70 per 0 days) primidone SABRIL LA QLL(80 per 0 days) STAVZOR TEGRETOL-XR tiagabine hydrochloride topiramate cpsp PAR topiramate tabs 00mg PAR QLL(480 per 0 days) topiramate tabs 00mg PAR QLL(40 per 0 days) topiramate tabs 5mg PAR QLL(90 per 0 days) topiramate tabs 50mg PAR QLL(960 per 0 days) valproate sodium valproic acid VIMPAT INJ QLL(00 per 0 days) VIMPAT ORAL SOLN QLL(00 per 0 days) VIMPAT TABS 00MG QLL(0 per 0 days) VIMPAT TABS 50MG QLL(80 per 0 days) VIMPAT TABS 00MG QLL(60 per 0 days) VIMPAT TABS 50MG QLL(40 per 0 days) zonisamide Antidiarrheals & Antispasmodics atropine sulfate inj 0.05mg/ml, 0.mg/ml, 0.8mg/ml atropine sulfate inj 0.4mg/ml, mg/ml CANTIL dicyclomine hcl glycopyrrolate loperamide hcl caps methscopolamine bromide TOFEN opium Comprehensive_ETNRC_6P Effective January, 04

14 Name opium tincture PAMINE PAMINE FORTE paregoric propantheline bromide Antidotes acetylcysteine inj Antifungal Agents ABELCET B/D PAR AMBISOME B/D PAR amphotericin b B/D PAR CANCIDAS B/D PAR clotrimazole troc fluconazole fluconazole in dextrose fluconazole in nacl flucytosine griseofulvin microsize griseofulvin ultramicrosize itraconazole PAR ketoconazole tabs LAMISIL PACK MYCAMINE NOXAFIL nystatin terbinafine hcl tabs VFEND SUSR PAR voriconazole inj voriconazole tabs PAR Antihistamine & Antiallergenic Agents ADRENACLICK QLL( per days) cetirizine hcl syrp QLL(00 per 0 days) cyproheptadine hcl tabs desloratadine QLL(0 per 0 days) diphenhydramine hcl inj epinephrine QLL( per days) epinephrine hcl EPIPEN -PAK QLL( per days) EPIPEN-JR -PAK QLL( per days) Name levocetirizine dihydrochloride tabs Antihypertensive Therapy acebutolol hcl afeditab cr ALDACTAZIDE amiloride hcl amiloride/hydrochlorothiazide amlodipine besylate tabs 0mg,.5mg amlodipine besylate tabs 5mg amlodipine besylate/benazepril hcl amlodipine besylate/benazepril hydrochloride ATACAND HCT TABS 6MG;.5MG ATACAND HCT TABS MG;.5MG, MG; 5MG ATACAND TABS 6MG, 4MG, 8MG ATACAND TABS MG atenolol atenolol/chlorthalidone AZOR benazepril hcl benazepril hcl/ hydrochlorothiazide betaxolol hcl BIDIL [+] bisoprolol fumarate bisoprolol fumarate/ hydrochlorothiazide bumetanide BYSTOLIC [+] CALAN candesartan cilexetil tabs 6mg, 4mg, 8mg candesartan cilexetil tabs mg QLL(0 per 0 days) QLL(0 per 0 days) QLL(45 per 0 days) QLL(60 per 0 days) QLL(0 per 0 days) QLL(60 per 0 days) QLL(0 per 0 days) QLL(0 per 0 days) QLL(60 per 0 days) QLL(0 per 0 days) Effective January, 04 Comprehensive_ETNRC_6P

15 Name candesartan cilexetil/ hydrochlorothiazide tabs 6mg;.5mg candesartan cilexetil/ hydrochlorothiazide tabs mg;.5mg, mg; 5mg captopril captopril/hydrochlorothiazide CARDIZEM LA TB4 0MG CARDURA XL cartia xt carvedilol chlorothiazide chlorothiazide sodium chlorthalidone tabs 5mg, 50mg clonidine hcl ptwk clonidine hcl tabs clorpres tabs 5mg; 0.mg, 5mg; 0.mg CLORPRES TABS 5MG; 0.MG COREG CR DEMSER DIBENZYLINE dilt-cd dilt-xr diltiazem cd diltiazem hcl cd diltiazem hcl cp4 diltiazem hcl er diltiazem hcl inj diltiazem hcl tabs diltzac DIOVAN TABS 60MG DIOVAN TABS 0MG DIOVAN TABS 40MG, 80MG doxazosin mesylate DYAZIDE DYRENIUM enalapril maleate QLL(60 per 0 days) QLL(0 per 0 days) QLL(4 per 8 days) ST QLL(60 per 0 days) QLL(0 per 0 days) QLL(90 per 0 days) Name enalapril maleate/ hydrochlorothiazide eplerenone eprosartan mesylate EXFORGE EXFORGE HCT felodipine er fosinopril sodium fosinopril sodium/ hydrochlorothiazide furosemide hydralazine hcl hydrochlorothiazide indapamide INNOPRAN XL irbesartan irbesartan/hydrochlorothiazide isradipine labetalol hcl LEVATOL lisinopril lisinopril/hydrochlorothiazide LOPRESSOR HCT LOPRESSOR INJ losartan potassium tabs 00mg losartan potassium tabs 5mg, 50mg losartan potassium/ hydrochlorothiazide matzim la MAXZIDE MAXZIDE-5 methyclothiazide methyldopa metolazone metoprolol succinate er metoprolol tartrate inj metoprolol tartrate tabs metoprolol/hydrochlorothiazide QLL(0 per 0 days) QLL(0 per 0 days) QLL(0 per 0 days) QLL(0 per 0 days) QLL(0 per 0 days) QLL(0 per 0 days) QLL(60 per 0 days) QLL(0 per 0 days) Comprehensive_ETNRC_6P Effective January, 04

16 Name MICARDIS HCT TABS.5MG; 40MG, 5MG; 80MG [+] MICARDIS HCT TABS.5MG; 80MG [+] MICARDIS TABS 0MG, 40MG [+] MICARDIS TABS 80MG [+] MINIPRESS minoxidil tabs moexipril hcl moexipril/hydrochlorothiazide nadolol nadolol/bendroflumethiazide nicardipine hcl caps nicardipine hcl inj nifediac cc nifedical xl nifedipine er nimodipine perindopril erbumine pindolol prazosin hcl propranolol hcl er propranolol hcl inj propranolol hcl oral soln propranolol hcl tabs propranolol/ hydrochlorothiazide quinapril hcl quinapril/hydrochlorothiazide ramipril REDULIN reserpine tabs 0.mg spironolactone spironolactone/ hydrochlorothiazide TARKA taztia xt TEKTURNA TEKTURNA HCT terazosin hcl QLL(0 per 0 days) QLL(60 per 0 days) QLL(0 per 0 days) QLL(60 per 0 days) LA PAR QLL(0 per 0 days) QLL(0 per 0 days) Name TEVETEN HCT QLL(0 per 0 days) TEVETEN TABS 400MG QLL(60 per 0 days) timolol maleate torsemide inj 0mg/ml TORSEMIDE INJ 50MG/ 5ML torsemide tabs trandolapril triamterene/ hydrochlorothiazide TWYNSTA [+] QLL(0 per 0 days) valsartan/hydrochlorothiazide QLL(0 per 0 days) verapamil hcl er verapamil hcl inj verapamil hcl sr verapamil hcl tabs Antineoplastic & Immunosuppressant s ABRAXANE B/D PAR ADCETRIS PAR adriamycin inj 0mg, 0mg, B/D PAR 50mg adriamycin inj mg/ml B/D PAR adrucil B/D PAR AFINITOR PAR AFINITOR DISPERZ PAR ALIMTA PAR ALKERAN INJ B/D PAR ALKERAN TABS B/D PAR anastrozole ARRANON B/D PAR ARZERRA B/D PAR AVASTIN PAR AZASAN B/D PAR azathioprine B/D PAR azathioprine sodium B/D PAR bicalutamide BICNU B/D PAR bleomycin sulfate B/D PAR BOSULIF PAR BUSULFEX B/D PAR CAPRELSA LA PAR carboplatin B/D PAR Effective January, 04 4 Comprehensive_ETNRC_6P

17 Name CEENU CELLCEPT CAPS CELLCEPT INTRAVENOUS CELLCEPT SUSR CELLCEPT TABS cerubidine cisplatin cladribine CLOLAR COMETRIQ COSMEGEN cyclophosphamide tabs cyclosporine caps cyclosporine inj cyclosporine modified caps 00mg, 50mg cyclosporine modified caps 5mg cyclosporine modified oral soln cytarabine cytarabine aqueous dacarbazine inj 00mg dacarbazine inj 00mg DACOGEN daunorubicin hcl inj 0mg daunorubicin hcl inj 5mg/ml DOCEFREZ docetaxel inj 60mg/6ml, 60mg/8ml, 0mg/0.5ml, 0mg/ml, 80mg/ml, 80mg/ 8ml docetaxel inj 0mg/ml, 80mg/ 4ml DOXIL doxorubicin hcl DROXIA ELIGARD ELLENCE ELOXATIN INJ 00MG/ 0ML, 50MG/0ML ELOXATIN INJ 00MG/ 40ML ELSPAR EMCYT epirubicin hcl B/D PAR B/D PAR B/D PAR B/D PAR B/D PAR B/D PAR B/D PAR B/D PAR PAR B/D PAR B/D PAR B/D PAR B/D PAR B/D PAR B/D PAR B/D PAR B/D PAR B/D PAR B/D PAR B/D PAR B/D PAR B/D PAR B/D PAR B/D PAR B/D PAR B/D PAR B/D PAR PAR B/D PAR B/D PAR B/D PAR B/D PAR B/D PAR Name ERBITUX INJ 00MG/ 50ML ERBITUX INJ 00MG/ 00ML ERIVEDGE ETOPOPHOS etoposide inj exemestane FARESTON FASLODEX FIRMAGON fludarabine phosphate inj 50mg fludarabine phosphate inj 50mg/ml fluorouracil inj flutamide FOLOTYN gemcitabine gemcitabine hcl inj gm, 00mg gemcitabine hcl inj gm gengraf GLEEVEC HALAVEN hecoria HERCEPTIN HEXALEN hydroxyurea ICLUSIG IDAMYCIN PFS idarubicin hcl IFEX ifosfamide inj gm ifosfamide inj gm/0ml, gm, gm/60ml INLYTA irinotecan inj 00mg/5ml, 40mg/ml irinotecan inj 500mg/5ml ISTODAX IXEMPRA KIT JAKAFI JEVTANA KADCYLA KYPROLIS PAR PAR PAR B/D PAR B/D PAR PAR B/D PAR B/D PAR B/D PAR B/D PAR B/D PAR B/D PAR B/D PAR B/D PAR B/D PAR PAR PAR B/D PAR PAR PAR B/D PAR B/D PAR B/D PAR B/D PAR B/D PAR PAR B/D PAR B/D PAR PAR B/D PAR PAR B/D PAR PAR PAR Comprehensive_ETNRC_6P 5 Effective January, 04

18 Name letrozole LEUKERAN leuprolide acetate LUPRON DEPOT INJ.5MG,.5MG,.75MG, 7.5MG LUPRON DEPOT INJ 0MG, 45MG LUPRON DEPOT-PED INJ.5MG, 5MG, 0MG LUPRON DEPOT-PED INJ.5MG, 7.5MG LYSODREN MATULANE MEGACE ORAL megestrol acetate MEKINIST melphalan hydrochloride mercaptopurine methotrexate methotrexate sodium inj gm methotrexate sodium inj 5mg/ ml mitomycin mitoxantrone hcl MUSTARGEN mycophenolate mofetil MYFORTIC NEXAVAR NILANDRON NIPENT NULOJIX octreotide acetate ONTAK oxaliplatin inj 00mg, 50mg oxaliplatin inj 00mg/0ml, 50mg/0ml paclitaxel pentostatin PERJETA POMALYST PROGRAF INJ RAPAMUNE REVLIMID CAPS 0MG PAR PAR PAR PAR PAR PAR PAR PAR B/D PAR B/D PAR B/D PAR B/D PAR B/D PAR LA PAR B/D PAR B/D PAR PAR B/D PAR B/D PAR B/D PAR B/D PAR B/D PAR PAR PAR B/D PAR B/D PAR LA PAR QLL(60 per 0 days) Name REVLIMID CAPS 5MG, 0MG, 5MG REVLIMID CAPS.5MG REVLIMID CAPS 5MG RHEUMATREX RITUXAN SANDOSTATIN LAR DEPOT SIMULECT INJ 0MG SIMULECT INJ 0MG SOLTAX SPRYCEL STIVARGA SUTENT SYNRIBO TABLOID tacrolimus TAFINLAR tamoxifen citrate TARCEVA TARGRETIN CAPS TARGRETIN GEL TASIGNA TAXOTERE THALOMID thiotepa toposar topotecan hcl inj 4mg topotecan hcl inj 4mg/4ml TORISEL TREANDA INJ 00MG TREANDA INJ 5MG tretinoin caps TREXALL TRISENOX TYKERB VECTIBIX VELCADE VIDAZA vinblastine sulfate inj 0mg vinblastine sulfate inj mg/ml vincasar pfs vincristine sulfate vinorelbine tartrate VOTRIENT LA PAR QLL(0 per 0 days) LA PAR LA PAR QLL(50 per 0 days) PAR PAR B/D PAR B/D PAR PAR PAR PAR B/D PAR PAR PAR PAR PAR B/D PAR PAR B/D PAR B/D PAR B/D PAR B/D PAR B/D PAR B/D PAR B/D PAR B/D PAR LA PAR PAR PAR PAR B/D PAR B/D PAR B/D PAR B/D PAR B/D PAR PAR Effective January, 04 6 Comprehensive_ETNRC_6P

19 Name XALKORI PAR XTANDI PAR YERVOY PAR ZALTRAP PAR ZANOSAR B/D PAR ZELBORAF PAR ZOLINZA PAR ZORTRESS B/D PAR ZYTIGA PAR Antiparkinsonism Agents APOKYN LA PAR AZILECT [+] benztropine mesylate inj benztropine mesylate tabs bromocriptine mesylate carbidopa/levodopa carbidopa/levodopa cr carbidopa/levodopa er carbidopa/levodopa odt carbidopa/levodopa sr carbidopa/levodopa/entacapone COGENTIN entacapone LODOSYN ST pramipexole dihydrochloride ropinirole er ropinirole hcl selegiline hcl TASMAR ZELAPAR Antipsoriatic / Antiseborrheic acitretin calcipotriene crea QLL(0 per 0 days) calcipotriene external soln QLL(60 per 0 days) calcipotriene oint QLL(0 per 0 days) calcitrene QLL(0 per 0 days) calcitriol oint QLL(800 per 8 days) dritho-creme hp selenium sulfide SORIATANE Name STELARA TACLONEX OINT Antithyroid Agents methimazole propylthiouracil Antivirals abacavir acyclovir caps acyclovir sodium inj 000mg, 50mg/ml acyclovir sodium inj 500mg acyclovir susp acyclovir tabs amantadine hcl caps amantadine hcl tabs APTIVUS CAPS APTIVUS ORAL SOLN ATRIPLA BARACLUDE cidofovir COMBIVIR COMPLERA CRIXIVAN didanosine EDURANT EMTRIVA EPIVIR HBV EPIVIR ORAL SOLN EPIVIR TABS EPZICOM famciclovir tabs 5mg, 50mg famciclovir tabs 500mg foscarnet sodium FUZEON ganciclovir HEPSERA INCIVEK INTELENCE TABS 00MG, 00MG INTELENCE TABS 5MG INVIRASE PAR QLL( per 8 days) B/D PAR B/D PAR PAR B/D PAR QLL(60 per 0 days) QLL( per 7 days) B/D PAR QLL(60 per 0 days) PAR Comprehensive_ETNRC_6P 7 Effective January, 04

20 Name ISENTRESS CHEW 00MG ISENTRESS CHEW 5MG ISENTRESS TABS KALETRA ORAL SOLN KALETRA TABS lamivudine lamivudine/zidovudine LEXIVA nevirapine NORVIR PREZISTA SUSP PREZISTA TABS 50MG, 75MG PREZISTA TABS 400MG, 600MG, 800MG REBETOL RELENZA DISKHALER RESCRIPTOR RETROVIR IV INFUSION RETROVIR SYRP REYATAZ CAPS 00MG REYATAZ CAPS 50MG, 00MG, 00MG ribapak ribasphere caps ribasphere tabs 00mg, 600mg ribasphere tabs 400mg RIBATAB ribavirin rimantadine hcl SELZENTRY stavudine STRIBILD SUSTIVA TAMIFLU CAPS 0MG TAMIFLU CAPS 45MG TAMIFLU CAPS 75MG TAMIFLU SUSR trifluridine TRIZIVIR QLL(60 per 80 days) QLL(84 per days) QLL(4 per days) QLL(56 per 65 days) QLL(60 per 80 days) Name TRUVADA TYZEKA PAR valacyclovir hcl QLL(0 per days) VALCYTE VICTRELIS PAR VIDEX EC VIDEX PEDIATRIC VIRACEPT VIRAMUNE SUSP VIRAMUNE XR TB4 00MG VIRAMUNE XR TB4 400MG VIRAZOLE PAR VIREAD VISTIDE B/D PAR ZERIT CAPS ZIAGEN ORAL SOLN zidovudine ZIRGAN [+] Benign Prostatic Hyperplasia (Bph) Therapy alfuzosin hcl er AVODART [+] finasteride tabs 5mg JALYN [+] RAPAFLO tamsulosin hcl Beta-Blockers BETAGAN betaxolol hcl BETIL BETOPTIC-S carteolol hcl ISTALOL levobunolol hcl metipranolol timolol maleate timolol maleate ophthalmic gel forming TIPTIC TIPTIC OCUDOSE TIPTIC-XE Effective January, 04 8 Comprehensive_ETNRC_6P

21 Name Biotechnology s ACTIMMUNE ARANESP ALBUMIN FREE [+] ARCALYST AVONEX [+] AVONEX PEN [+] BETASERON EPOGEN EXTAVIA GENOTROPIN GENOTROPIN MINIQUICK HUMATROPE HUMATROPE COMBO PACK ILARIS INFERGEN INTRON-A INTRON-A W/DILUENT LEUKINE NEULASTA NEUMEGA NEUPOGEN NORDITROPIN FLEXPRO NORDITROPIN NORDIFLEX PEN NUTROPIN NUTROPIN AQ NUTROPIN AQ NUSPIN 0 NUTROPIN AQ NUSPIN 0 NUTROPIN AQ NUSPIN 5 NUTROPIN AQ PEN OMNITROPE PEG-INTRON PEG-INTRON REDIPEN PEG-INTRON REDIPEN PAK 4 PEGASYS [+] PEGASYS PROCLICK [+] PROCRIT [+] PAR PAR PAR PAR PAR PAR PAR PAR PAR PAR PAR PAR LA PAR PAR PAR PAR PAR QLL( per 8 days) PAR QLL( per days) PAR PAR PAR PAR PAR PAR PAR PAR PAR PAR PAR PAR PAR PAR PAR PAR Name PROLEUKIN REBIF [+] REBIF REBIDOSE [+] REBIF REBIDOSE TITRATION PACK [+] REBIF TITRATION PACK [+] SAIZEN CLICK.EASY SAIZEN INJ 5MG SYLATRON TEV-TROPIN [+] ZORBTIVE Blood Derivatives albuminar-5 albutein inj 5% albutein inj 5% buminate inj 5% buminate inj 5% Burn Therapy silver sulfadiazine ssd Cardiac Glycosides digoxin oral soln digoxin tabs 0.5mg digoxin tabs 0.5mg LANOXIN TABS 0.5MG LANOXIN TABS 0.5MG Cephalosporins CEDAX CAPS cefaclor cefaclor er cefadroxil cefazolin sodium inj 00gm, 0gm, gm; 5%, 0gm, 00gm, 500mg cefazolin sodium inj gm cefazolin sodium/dextrose inj gm; 4% cefazolin sodium/dextrose inj gm; % cefdinir cefditoren pivoxil tabs 00mg cefditoren pivoxil tabs 400mg cefepime inj gm PAR PAR PAR PAR PAR PAR PAR PAR PAR QLL(0 per 0 days) QLL(0 per 0 days) Comprehensive_ETNRC_6P 9 Effective January, 04

22 Name cefepime inj gm/50ml, gm, gm/00ml cefotaxime sodium inj 0gm, gm cefotaxime sodium inj gm, 500mg cefotetan cefoxitin sodium inj 0gm, gm; 4%, gm, gm;.% cefoxitin sodium inj gm cefpodoxime proxetil cefprozil ceftazidime inj gm, 6gm ceftazidime inj gm CEFTAZIDIME/ DEXTROSE CEFTIN SUSR ceftriaxone in iso-osmotic dextrose ceftriaxone sodium ceftriaxone/dextrose cefuroxime axetil tabs cefuroxime sodium inj.5gm, 750mg cefuroxime sodium inj 7.5gm cephalexin CLAFORAN INJ 0GM, GM, GM CLAFORAN INJ 500MG SUPRAX SUSR 00MG/ 5ML, 00MG/5ML SUPRAX SUSR 500MG/ 5ML SUPRAX TABS Cholinergic Stimulants bethanechol chloride Cholinesterase Inhibitor Miotics PHOSPHOLINE IODIDE Coagulation Therapy AGGRENOX [+] QLL(60 per 0 days) aminocaproic acid syrp ARIXTRA INJ 0MG/ 0.8ML, 5MG/0.4ML, 7.5MG/0.6ML Name ARIXTRA INJ.5MG/ 0.5ML cilostazol clopidogrel tabs 00mg clopidogrel tabs 75mg COUMADIN CYKLOKAPRON EFFIENT enoxaparin sodium fondaparinux sodium FRAGMIN heparin lock flush inj 00unit/ ml heparin lock inj 00unit/ml heparin sodium dcu heparin sodium inj 0000unit/ ml, 000unit/ml, 0000unit/ ml, 000unit/ml, 5000unit/ 0.5ml, 5000unit/ml heparin sodium inj 500unit/ ml heparin sodium lock flush inj 00unit/ml heparin sodium/d5w heparin sodium/nacl 0.45% heparin sodium/nacl 0.9% heparin sodium/sodium chloride 0.9% heparin sodium/sodium chloride 0.9% premix jantoven LOVENOX INJ 00MG/ ML, 0MG/0.8ML, 50MG/ML, 60MG/0.6ML, 80MG/0.8ML LOVENOX INJ 00MG/ ML, 0MG/0.ML, 40MG/0.4ML pentoxifylline er PRADAXA PROMACTA tranexamic acid inj warfarin sodium QLL(0 per 0 days) QLL(0 per 0 days) ST B/D PAR B/D PAR B/D PAR B/D PAR B/D PAR B/D PAR B/D PAR B/D PAR B/D PAR B/D PAR B/D PAR PAR QLL(60 per 0 days) LA PAR Effective January, 04 0 Comprehensive_ETNRC_6P

23 Name XARELTO TABS 0MG, 0MG XARELTO TABS 5MG Cycloplegic Mydriatics atropine sulfate oint atropine sulfate ophthalmic soln atropine-care cyclopentolate hcl ophthalmic soln % homatropaire homatropine hbr tropicamide Diabetes Therapy acarbose tabs 00mg acarbose tabs 5mg acarbose tabs 50mg ACTOPLUS MET XR TB4 000MG; 5MG ACTOPLUS MET XR TB4 000MG; 0MG alcohol preps pads APIDRA APIDRA SOLOSTAR BYDUREON [+] BYETTA INJ 0MCG/ 0.04ML [+] BYETTA INJ 5MCG/ 0.0ML [+] CYCLOSET gauze pads "x" glimepiride tabs mg glimepiride tabs mg glimepiride tabs 4mg glipizide er tb4 0mg PAR QLL(0 per 0 days) PAR QLL(4 per 0 days) QLL(90 per 0 days) QLL(60 per 0 days) QLL(80 per 0 days) QLL(60 per 0 days) QLL(45 per 0 days) ST ST PAR QLL(4 per 8 days) PAR QLL(.4 per 0 days) PAR QLL(. per 0 days) QLL(80 per 0 days) QLL(00 per 0 days) QLL(40 per 0 days) QLL(0 per 0 days) QLL(60 per 0 days) QLL(60 per 0 days) Name glipizide er tb4.5mg glipizide er tb4 5mg glipizide tabs 0mg glipizide tabs 5mg glipizide xl tb4 0mg glipizide xl tb4.5mg glipizide xl tb4 5mg glipizide/metformin hcl tabs.5mg; 50mg glipizide/metformin hcl tabs.5mg; 500mg, 5mg; 500mg GLUCAGEN GLUCAGEN HYPOKIT [+] GLUCAGON EMERGENCY KIT GLUMETZA TB4 000MG GLUMETZA TB4 500MG GLYSET TABS 00MG GLYSET TABS 5MG GLYSET TABS 50MG HUMALOG [+] HUMALOG KWIKPEN [+] HUMALOG MIX 50/50 [+] HUMALOG MIX 50/50 KWIKPEN [+] HUMALOG MIX 75/5 [+] HUMALOG MIX 75/5 KWIKPEN [+] HUMAPEN LUXURA HD HUMAPEN MEIR HUMULIN 70/0 [+] HUMULIN 70/0 PEN [+] HUMULIN N [+] HUMULIN N U-00 PEN [+] QLL(40 per 0 days) QLL(0 per 0 days) QLL(0 per 0 days) QLL(40 per 0 days) QLL(60 per 0 days) QLL(40 per 0 days) QLL(0 per 0 days) QLL(40 per 0 days) QLL(0 per 0 days) QLL(60 per 0 days) QLL(0 per 0 days) QLL(90 per 0 days) QLL(60 per 0 days) QLL(80 per 0 days) Comprehensive_ETNRC_6P Effective January, 04

24 Name HUMULIN R [+] HUMULIN R U-500 (CONCENTRATED) [+] INSULIN PEN NEEDLE INSULIN SYRINGE (DISP) U ML INSULIN SYRINGE (DISP) U-00 ML INSULIN SYRINGE (DISP) U-00 / ML JANUMET [+] JANUMET XR TB4 000MG; 00MG [+] JANUMET XR TB4 000MG; 50MG, 500MG; 50MG [+] JANUVIA TABS 00MG [+] JANUVIA TABS 5MG [+] JANUVIA TABS 50MG [+] JUVISYNC [+] KAZANO [+] KOMBIGLYZE XR TB4 000MG;.5MG [+] KOMBIGLYZE XR TB4 000MG; 5MG, 500MG; 5MG [+] LANTUS [+] LANTUS SOLOSTAR [+] LEVEMIR [+] LEVEMIR FLEXPEN [+] metformin hcl er tb4 000mg metformin hcl er tb4 500mg metformin hcl er tb4 500mg metformin hcl er tb4 750mg metformin hcl tabs 000mg QLL(00 per 0 days) QLL(00 per 0 days) QLL(00 per 0 days) QLL(00 per 0 days) QLL(60 per 0 days) QLL(0 per 0 days) QLL(60 per 0 days) QLL(0 per 0 days) QLL(0 per 0 days) QLL(60 per 0 days) QLL(0 per 0 days) QLL(60 per 0 days) QLL(60 per 0 days) QLL(0 per 0 days) QLL(75 per 0 days) QLL(0 per 0 days) QLL(50 per 0 days) QLL(80 per 0 days) QLL(76 per 0 days) Name metformin hcl tabs 500mg metformin hcl tabs 850mg nateglinide tabs 0mg nateglinide tabs 60mg NEEDLES, INSULIN DISP., SAFETY NESINA TABS.5MG [+] NESINA TABS 5MG [+] NESINA TABS 6.5MG [+] NOVOLIN 70/0 [+] NOVOLIN 70/0 RELION NOVOLIN N [+] NOVOLIN N RELION NOVOLIN R [+] NOVOLIN R RELION NOVOLOG [+] NOVOLOG FLEXPEN [+] NOVOLOG MIX 70/0 [+] NOVOLOG MIX 70/0 PREFILLED FLEXPEN [+] NOVOLOG PENFILL [+] ONGLYZA TABS.5MG [+] ONGLYZA TABS 5MG [+] OSENI TABS.5MG; 5MG [+] OSENI TABS.5MG; 0MG,.5MG; 45MG, 5MG; 5MG, 5MG; 0MG, 5MG; 45MG [+] pioglitazone hcl tabs 5mg pioglitazone hcl tabs 0mg pioglitazone hcl tabs 45mg pioglitazone hcl-glimepiride QLL(5 per 0 days) QLL(90 per 0 days) QLL(90 per 0 days) QLL(80 per 0 days) QLL(00 per 0 days) QLL(60 per 0 days) QLL(0 per 0 days) QLL(0 per 0 days) QLL(60 per 0 days) QLL(0 per 0 days) QLL(60 per 0 days) QLL(0 per 0 days) QLL(90 per 0 days) QLL(45 per 0 days) QLL(0 per 0 days) QLL(0 per 0 days) Effective January, 04 Comprehensive_ETNRC_6P

25 Name pioglitazone hcl/metformin hcl PRANDIMET PRANDIN TABS 0.5MG PRANDIN TABS MG PRANDIN TABS MG PROGLYCEM repaglinide tabs mg repaglinide tabs mg SYMLINPEN 0 SYMLINPEN 60 tolazamide tabs 50mg tolazamide tabs 500mg tolbutamide VICTOZA [+] Direct Acting Miotics pilocarpine hcl PILOPINE HS Electrolytes calcium acetate caps calcium acetate tabs 667mg dextrose 5%/potassium chloride 0.5% effervescent pot chloride effervescent potassium effervescent potassium/chloride k-effervescent k-phos neutral k-vescent tbef kcl 0.075%/d5w/nacl 0.45% kcl 0.5%/d5w/ nacl 0.% kcl 0.5%/d5w/lr kcl 0.5%/d5w/nacl 0.% kcl 0.5%/d5w/nacl 0.5% kcl 0.5%/d5w/nacl 0.45% QLL(90 per 0 days) QLL(50 per 0 days) QLL(960 per 0 days) QLL(480 per 0 days) QLL(40 per 0 days) QLL(480 per 0 days) QLL(40 per 0 days) PAR PAR QLL(0 per 0 days) QLL(60 per 0 days) QLL(80 per 0 days) PAR QLL(9 per 0 days) QLL(60 per 0 days) Name kcl 0.5%/d5w/nacl 0.9% kcl 0.%/d5w/lr iv lac ring kcl 0.%/d5w/nacl 0.45% kcl 0.%/d5w/nacl 0.9% klor-con 0 klor-con 8 klor-con m0 klor-con m5 klor-con m0 klor-con/ef lactated ringers lactated ringers viaflex magnesium sulfate inj 40mg/ ml, 80mg/ml magnesium sulfate inj 50% NORSOL -R NORSOL-R IN D5W phospha 50 neutral potassium chloride 0.5% / nacl 0.45% viaflex potassium chloride 0.5% d5w/nacl 0.% potassium chloride 0.5% d5w/nacl 0.45% potassium chloride 0.5% d5w/nacl 0.45% viaflex potassium chloride 0.5% nacl 0.9% potassium chloride 0.5% w/ nacl 0.9% viaflex potassium chloride 0.5%/d5w potassium chloride 0.5%/nacl 0.9% potassium chloride 0.% d5w/nacl 0.45% potassium chloride 0.4%/ d5w/nacl 0.45% potassium chloride 0.4%d5w/nacl 0.45% viaflex potassium chloride 0.%/ nacl 0.9% potassium chloride 0.%/d5w potassium chloride 0.%/nacl 0.9%/viaflex potassium chloride cr Comprehensive_ETNRC_6P Effective January, 04

26 Name potassium chloride er potassium chloride inj 0.4meq/ ml, 0meq/00ml, 0meq/ 50ml, 0meq/00ml, 0meq/ 50ml, 0meq/00ml, 40meq/ 00ml potassium chloride inj meq/ml potassium chloride liqd potassium chloride oral soln potassium chloride sr ringers injection sodium bicarbonate inj 4.% sodium bicarbonate inj 7.5%, 8.4% sodium bicarbonate partial fill sodium chloride 0.45% sodium chloride 0.45% viaflex sodium chloride inj.5meq/ml, %, 4meq/ml sodium chloride inj 5% sodium lactate inj TPN ELECTROLYTES Erythromycins & Other Macrolides AZITHROMYCIN INJ.5GM azithromycin inj 500mg azithromycin pack azithromycin susr 00mg/5ml QLL(5 per days) azithromycin susr 00mg/5ml QLL(46 per days) azithromycin tabs 50mg QLL(6 per days) azithromycin tabs 500mg QLL( per days) azithromycin tabs 600mg QLL(8 per days) clarithromycin clarithromycin er QLL(8 per days) DIFICID [+] PAR E.E.S. GRANULES e.s.p. ery-tab tbec 50mg, mg ERY-TAB TBEC 500MG ERYPED 00 Name ERYPED 400 ERYTHROCIN LACTOBIONATE erythrocin stearate erythromycin erythromycin base erythromycin ethylsuccinate erythromycin/sulfisoxazole PCE ZMAX Estrogens & Progestins camila CLIMARA PRO CRINONE DEPO-ESTRADIOL DEPO-SUBQ PROVERA 04 errin ESTRACE CREA estradiol ptwk estradiol tabs estradiol valerate ESTRING FEMRING heather jolivette medroxyprogesterone acetate MENEST NOR-QD nora-be norethindrone norethindrone acetate PREMARIN CREA PREMARIN INJ PREMARIN TABS progesterone caps VAGIFEM Gout Therapy allopurinol allopurinol sodium aloprim COLCRYS PAR QLL(4 per 8 days) QLL(4 per 8 days) PAR QLL( per 90 days) QLL( per 90 days) PAR PAR PAR ST PAR Effective January, 04 4 Comprehensive_ETNRC_6P

27 Name probenecid probenecid/colchicine ULORIC [+] Irrigating Solutions ST lactated ringers irrigation B/D PAR neomycin/polymyxin b sulfates PHYSIOLYTE B/D PAR PHYSIOSOL IRRIGATION B/D PAR PHYSIOSOL IRRIGATION B/D PAR PH 7.4 ringers irrigation B/D PAR Lipid/Cholesterol Lowering Agents ADVICOR TB4 0MG; 000MG, 0MG; 750MG QLL(60 per 0 days) ADVICOR TB4 0MG; 500MG, 40MG; 000MG QLL(0 per 0 days) ALTOPREV PAR QLL(0 per 0 days) amlodipine besylate/ atorvastatin calcium QLL(0 per 0 days) atorvastatin calcium QLL(0 per 0 days) cholestyramine cholestyramine light colestipol hcl colestipol hcl for oral suspension CRESTOR [+] QLL(0 per 0 days) ST fenofibrate caps fenofibrate micronized caps 4mg, 00mg QLL(0 per 0 days) fenofibrate micronized caps 67mg QLL(90 per 0 days) fenofibrate tabs 45mg, 48mg fenofibrate tabs 60mg QLL(0 per 0 days) fenofibrate tabs 54mg QLL(90 per 0 days) fenofibric acid dr fluvastatin QLL(60 per 0 days) gemfibrozil LESCOL XL PAR QLL(0 per 0 days) LIPOFEN [+] Name LIVALO PAR QLL(0 per 0 days) LOFIBRA CAPS 67MG QLL(90 per 0 days) lovastatin tabs 0mg, 0mg QLL(0 per 0 days) lovastatin tabs 40mg QLL(60 per 0 days) LOVAZA [+] micronized colestipol hcl NIACOR NIASPAN [+] QLL(60 per 0 days) pravastatin sodium QLL(0 per 0 days) prevalite SIMCOR TB4 000MG; 0MG, 500MG; 0MG, 750MG; 0MG QLL(60 per 0 days) SIMCOR TB4 000MG; 40MG, 500MG; 40MG QLL(0 per 0 days) simvastatin QLL(0 per 0 days) TRILIPIX [+] VYTORIN PAR QLL(0 per 0 days) WELCHOL [+] ZETIA PAR QLL(0 per 0 days) Migraine & Cluster Headache Therapy AMERGE QLL(9 per 0 days) AXERT QLL(9 per 0 days) dihydroergotamine mesylate inj dihydroergotamine mesylate nasal soln QLL(8 per 8 days) ERGOMAR FROVA QLL( per 0 days) IMITREX NASAL SOLN 0MG/ACT QLL(8 per 0 days) IMITREX NASAL SOLN 5MG/ACT QLL(6 per 0 days) IMITREX TABS QLL(9 per 0 days) Comprehensive_ETNRC_6P 5 Effective January, 04