EXCHANGES_CVSC_NY3 eff 10/01/2015

Transcription

1 EXCHANGES_CVSC_NY3 eff 10/01/2015 Drug Name ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS Amphetamines amphetamine-dextroamphetamine cap sr 1 QL (90 caps / 25 days) 24hr 5 amphetamine-dextroamphetamine cap sr 1 QL (90 caps / 25 days) 24hr 10 amphetamine-dextroamphetamine cap sr 1 QL (30 caps / 25 days) 24hr 15 amphetamine-dextroamphetamine cap sr 1 QL (30 caps / 25 days) 24hr 20 amphetamine-dextroamphetamine cap sr 1 QL (30 caps / 25 days) 24hr 25 amphetamine-dextroamphetamine cap sr 1 QL (30 caps / 25 days) 24hr 30 amphetamine-dextroamphetamine tab 5 1 QL (90 tabs / 25 days) amphetamine-dextroamphetamine tab QL (90 tabs / 25 days) amphetamine-dextroamphetamine tab 10 1 QL (90 tabs / 25 days) amphetamine-dextroamphetamine tab QL (90 tabs / 25 days) amphetamine-dextroamphetamine tab 15 1 QL (60 tabs / 25 days) amphetamine-dextroamphetamine tab 20 1 QL (60 tabs / 25 days) amphetamine-dextroamphetamine tab 30 1 QL (30 tabs / 25 days) dextroamphetamine sulfate cap sr 24hr 5 1 QL (120 caps / 25 days) dextroamphetamine sulfate cap sr 24hr 10 1 QL (120 caps / 25 days) dextroamphetamine sulfate cap sr 24hr 15 1 QL (60 caps / 25 days) dextroamphetamine sulfate oral solution 5 1 QL (1,200 ml / 25 days) /5ml dextroamphetamine sulfate tab 5 1 QL (120 tabs / 25 days) dextroamphetamine sulfate tab 10 1 QL (120 tabs / 25 days) methamphetamine hcl tab 5 1 QL (150 tabs / 25 days) VYVANSE CAP 10MG 3 QL (60 caps / 25 days), PA; PA applies for members age 19 and 1

2 VYVANSE CAP 20MG 3 QL (60 caps / 25 days), PA; PA applies for members age 19 and VYVANSE CAP 30MG 3 QL (60 caps / 25 days), PA; PA applies for members age 19 and VYVANSE CAP 40MG 3 QL (30 caps / 25 days), PA; PA applies for members age 19 and VYVANSE CAP 50MG 3 QL (30 caps / 25 days), PA; PA applies for members age 19 and VYVANSE CAP 60MG 3 QL (30 caps / 25 days), PA; PA applies for members age 19 and VYVANSE CAP 70MG 3 QL (30 caps / 25 days), PA; PA applies for members age 19 and zenzedi tab QL (120 tabs / 25 days) zenzedi tab QL (120 tabs / 25 days) zenzedi tab 15 1 QL (60 tabs / 25 days) zenzedi tab 20 1 QL (60 tabs / 25 days) zenzedi tab 30 1 QL (30 tabs / 25 days) Attention-Deficit/Hyperactivity Disorder (ADHD) Agents guanfacine hcl tab sr 24hr 1 (base 1 ST; PA** equiv) guanfacine hcl tab sr 24hr 2 (base 1 ST; PA** equiv) guanfacine hcl tab sr 24hr 3 (base 1 ST; PA** equiv) guanfacine hcl tab sr 24hr 4 (base 1 ST; PA** equiv) STRATTERA CAP 10MG 2 QL (120 caps / 25 days) STRATTERA CAP 18MG 2 QL (120 caps / 25 days) STRATTERA CAP 25MG 2 QL (120 caps / 25 days) STRATTERA CAP 40MG 2 QL (60 caps / 25 days) STRATTERA CAP 60MG 2 QL (30 caps / 25 days) STRATTERA CAP 80MG 2 QL (30 caps / 25 days) STRATTERA CAP 100MG 2 QL (30 caps / 25 days) Stimulants - Misc. dexmethylphenidate hcl cap sr 24 hr 5 1 dexmethylphenidate hcl cap sr 24 hr 10 1 QL (60 caps / 25 days) QL (60 caps / 25 days) 2

3 dexmethylphenidate hcl cap sr 24 hr 15 1 QL (60 caps / 25 days) dexmethylphenidate hcl cap sr 24 hr 30 1 QL (30 caps / 25 days) dexmethylphenidate hcl cap sr 24 hr 40 1 QL (30 caps / 25 days) dexmethylphenidate hcl tab QL (120 tabs / 25 days) dexmethylphenidate hcl tab 5 1 QL (120 tabs / 25 days) dexmethylphenidate hcl tab 10 1 QL (60 tabs / 25 days) metadate tab 20 er 1 QL (90 tabs / 25 days) methylphenidate hcl cap cr 10 1 QL (60 caps / 25 days) methylphenidate hcl cap cr 20 1 QL (60 caps / 25 days) methylphenidate hcl cap cr 30 1 QL (60 caps / 25 days) methylphenidate hcl cap cr 40 1 QL (30 caps / 25 days) methylphenidate hcl cap cr 50 1 QL (30 caps / 25 days) methylphenidate hcl cap cr 60 1 QL (30 caps / 25 days) methylphenidate hcl cap sr 24hr 20 (la) 1 QL (60 caps / 25 days) methylphenidate hcl cap sr 24hr 30 (la) 1 QL (60 caps / 25 days) methylphenidate hcl cap sr 24hr 40 (la) 1 QL (30 caps / 25 days) methylphenidate hcl soln 5 /5ml 1 QL (1800 ml / 25 days) methylphenidate hcl soln 10 /5ml 1 QL (900 ml / 25 days) methylphenidate hcl tab 5 1 QL (180 tabs / 25 days) methylphenidate hcl tab 10 1 QL (180 tabs / 25 days) methylphenidate hcl tab 20 1 QL (90 tabs / 25 days) methylphenidate hcl tab cr 10 1 QL (90 tabs / 25 days) methylphenidate hcl tab cr 20 1 QL (90 tabs / 25 days) methylphenidate hcl tab sa osm 18 1 QL (60 tabs / 25 days) methylphenidate hcl tab sa osm 27 1 QL (60 tabs / 25 days) methylphenidate hcl tab sa osm 36 1 QL (60 tabs / 25 days) methylphenidate hcl tab sa osm 54 1 QL (30 tabs / 25 days) modafinil tab PA modafinil tab PA NUVIGIL TAB 50MG 2 PA NUVIGIL TAB 150MG 2 PA NUVIGIL TAB 200MG 2 PA NUVIGIL TAB 250MG 2 PA RITALIN LA CAP 10MG 2 QL (60 caps / 25 days) RITALIN LA CAP 60MG 2 QL (30 caps / 25 days) AMINOGLYCOSIDES Aminoglycosides streptomycin sulfate for inj 1 gm 1 tobramycin nebu soln 300 /5ml 1 PA ANALGESICS - ANTI-INFLAMMATORY Anti-TNF-alpha - Monoclonal Antibodies HUMIRA INJ 10MG/0.2 3 PA HUMIRA INJ 40MG/0.8 3 PA HUMIRA KIT 20MG/0.4 3 PA HUMIRA PEN INJ CROHNS 3 PA 3

4 Interleukin-1 Receptor Antagonist (IL-1Ra) KINERET INJ 3 PA, ST Interleukin-6 Receptor Inhibitors ACTEMRA INJ 80MG/4ML 3 PA, ST ACTEMRA INJ 162/0.9 3 PA, ST ACTEMRA INJ 200/10ML 3 PA, ST ACTEMRA INJ 400/20ML 3 PA, ST Nonsteroidal Anti-inflammatory Agents (NSAIDs) celecoxib cap 50 1 celecoxib cap celecoxib cap celecoxib cap diclofenac potassium tab 50 1 diclofenac sodium tab delayed release 25 1 diclofenac sodium tab delayed release 50 1 diclofenac sodium tab delayed release 75 1 diclofenac sodium tab sr 24hr diclofenac w/ misoprostol tab delayed 1 release diclofenac w/ misoprostol tab delayed 1 release etodolac cap etodolac cap etodolac tab etodolac tab fenoprofen calcium tab flurbiprofen tab 50 1 flurbiprofen tab ibuprofen susp 100 /5ml 1 ibuprofen tab ibuprofen tab ibuprofen tab INDOCIN SUS 25MG/5ML 3 indomethacin cap 25 1 indomethacin cap 50 1 indomethacin cap cr 75 1 ketoprofen cap 50 1 ketoprofen cap 75 1 ketoprofen cap sr 24hr ketorolac tromethamine im inj 60 /2ml 1 (30 /ml) ketorolac tromethamine inj 15 /ml 1 ketorolac tromethamine inj 30 /ml 1 4

5 ketorolac tromethamine inj 60 /2ml (30 1 /ml) ketorolac tromethamine inj 300 /10ml 1 (30 /ml) ketorolac tromethamine tab 10 1 QL (20 tabs / 25 days) meclofenamate sodium cap 50 1 meclofenamate sodium cap mefenamic acid cap meloxicam susp 7.5 /5ml 1 meloxicam tab meloxicam tab 15 1 nabumetone tab nabumetone tab NALFON CAP 400MG 3 ST; PA** naproxen dr tab naproxen dr tab naproxen sodium tab naproxen sodium tab naproxen susp 125 /5ml 1 naproxen tab naproxen tab naproxen tab oxaprozin tab piroxicam cap 10 1 piroxicam cap 20 1 sulindac tab sulindac tab tolmetin sodium cap tolmetin sodium tab tolmetin sodium tab Pyrimidine Synthesis Inhibitors leflunomide tab 10 1 leflunomide tab 20 1 Selective Costimulation Modulators ORENCIA INJ 125MG/ML 3 PA, ST ORENCIA INJ 250MG 3 PA, ST Soluble Tumor Necrosis Factor Receptor Agents ENBREL INJ 25/0.5ML 3 PA ENBREL INJ 25MG 3 PA ENBREL INJ 50MG/ML 3 PA ENBREL SRCLK INJ 50MG/ML 3 PA ANALGESICS - NonNarcotic Analgesics-Sedatives butalbital-acetaminophen-caffeine cap QL (48 caps / 25 days) 5

6 butalbital-acetaminophen-caffeine cap 1 QL (48 caps / 25 days) butalbital-acetaminophen-caffeine tab 1 QL (48 tabs / 25 days) butalbital-aspirin-caffeine cap QL (48 caps / 25 days) butalbital-aspirin-caffeine tab QL (48 tabs / 25 days) margesic cap 1 QL (48 caps / 25 days) Salicylates aspirin chew tab 81 0 QL (100 tabs / 30 days); OTC; $0 copay for patients 12 and aspirin low tab 81 ec 0 QL (100 tabs / 30 days); OTC; $0 copay for patients 12 and ASPIRIN TAB 81 MG 0 QL (100 tabs / 30 days); OTC; $0 copay for patients 12 and aspirin tab QL (100 tabs / 30 days); OTC; $0 copay for patients 45 and aspirin tab delayed release QL (100 tabs / 30 days); OTC; $0 copay for patients 45 and diflunisal tab ANALGESICS - OPIOID Opioid Agonists CODEINE SULF SOL 30MG/5ML 2 codeine sulfate tab 15 1 QL (42 tabs / 25 days) codeine sulfate tab 30 1 QL (42 tabs / 25 days) codeine sulfate tab 60 1 QL (42 tabs / 25 days) EMBEDA CAP MG 3 QL (60 caps / 25 days) EMBEDA CAP MG 3 QL (60 caps / 25 days) EMBEDA CAP 50-2MG 3 QL (60 caps / 25 days) EMBEDA CAP MG 3 QL (30 caps / 25 days) EMBEDA CAP MG 3 QL (30 caps / 25 days) EMBEDA CAP 100-4MG 3 QL (30 caps / 25 days) fentanyl citrate lozenge on a handle 200 mcg 1 QL (120 lozenges / 25 days), PA fentanyl citrate lozenge on a handle 400 mcg 1 QL (120 lozenges / 25 days), PA fentanyl citrate lozenge on a handle 600 mcg 1 QL (120 lozenges / 25 days), PA fentanyl citrate lozenge on a handle 800 mcg 1 QL (120 lozenges / 25 days), PA 6

7 fentanyl citrate lozenge on a handle 1200 mcg 1 QL (120 lozenges / 25 days), PA fentanyl citrate lozenge on a handle 1600 mcg 1 QL (120 lozenges / 25 days), PA fentanyl td patch 72hr 12 mcg/hr 1 QL (10 patches / 25 days) fentanyl td patch 72hr 25 mcg/hr 1 QL (10 patches / 25 days) fentanyl td patch 72hr 50 mcg/hr 1 QL (10 patches / 25 days) fentanyl td patch 72hr 75 mcg/hr 1 QL (10 patches / 25 days) fentanyl td patch 72hr 100 mcg/hr 1 QL (10 patches / 25 days) HYDROMORPHON SUP 3MG 3 QL (120 units / 25 days) hydromorphone hcl liqd 1 /ml 1 QL (600 ml / 25 days) hydromorphone hcl tab 2 1 QL (180 tabs / 25 days) hydromorphone hcl tab 4 1 QL (180 tabs / 25 days) hydromorphone hcl tab 8 1 QL (180 tabs / 25 days) hydromorphone hcl tab er 24hr deter 8 1 QL (30 tablets per 25 days) hydromorphone hcl tab er 24hr deter 12 1 QL (30 tablets per 25 days) hydromorphone hcl tab er 24hr deter 16 1 QL (30 tablets per 25 days) hydromorphone hcl tab er 24hr deter 32 1 QL (30 tablets per 25 days) levorphanol tartrate tab 2 1 QL (120 tabs / 25 days) methadone hcl conc 10 /ml 1 QL (30mL / 25 days) methadone hcl soln 5 /5ml 1 QL (600 ml / 25 days) methadone hcl soln 10 /5ml 1 QL (300 ml / 25 days) methadone hcl tab 5 1 QL (120 tabs / 25 days) methadone hcl tab 10 1 QL (60 tabs / 25 days) methadone hcl tab for oral susp 40 1 QL (9 tabs / 25 days) MORPHINE SUL SUP 30MG 2 QL (180 supp / 25 days) morphine sulfate (concentrate) oral soln 201 QL (180 ml / 25 days) /ml morphine sulfate beads cap sr 24hr 30 1 QL (60 caps / 25 days) morphine sulfate beads cap sr 24hr 45 1 QL (60 caps / 25 days) morphine sulfate beads cap sr 24hr 60 1 QL (60 caps / 25 days) morphine sulfate beads cap sr 24hr 75 1 QL (30 caps / 25 days) morphine sulfate beads cap sr 24hr 90 1 QL (30 caps / 25 days) morphine sulfate beads cap sr 24hr QL (30 caps / 25 days) morphine sulfate oral soln 10 /5ml 1 QL (900 ml / 25 days) morphine sulfate oral soln 20 /5ml 1 QL (900 ml / 25 days) morphine sulfate suppos 5 1 QL (180 supp / 25 days) morphine sulfate suppos 10 1 QL (180 supp / 25 days) 7

8 morphine sulfate suppos 20 1 QL (180 supp / 25 days) morphine sulfate tab 15 1 QL (180 tabs / 25 days) morphine sulfate tab 30 1 QL (180 tabs / 25 days) morphine sulfate tab cr 15 1 QL (120 tabs / 25 days) morphine sulfate tab cr 30 1 QL (120 tabs / 25 days) morphine sulfate tab cr 60 1 QL (120 tabs / 25 days) morphine sulfate tab cr QL (60 tabs / 25 days) morphine sulfate tab cr QL (60 tabs / 25 days) NUCYNTA ER TAB 50MG 3 QL (120 tabs / 25 days) NUCYNTA ER TAB 100MG 3 QL (120 tabs / 25 days) NUCYNTA ER TAB 150MG 3 QL (60 tabs / 25 days) NUCYNTA ER TAB 200MG 3 QL (60 tabs / 25 days) NUCYNTA ER TAB 250MG 3 QL (60 tabs / 25 days) NUCYNTA TAB 50MG 3 QL (360 tabs / 25 days) NUCYNTA TAB 75MG 3 QL (240 tabs / 25 days) NUCYNTA TAB 100MG 3 QL (180 tabs / 25 days) OPANA ER TAB 5MG 3 QL (120 tabs / 25 days) OPANA ER TAB 7.5MG 3 QL (120 tabs / 25 days) OPANA ER TAB 10MG 3 QL (120 tabs / 25 days) OPANA ER TAB 15MG 3 QL (120 tabs / 25 days) OPANA ER TAB 20MG 3 QL (120 tabs / 25 days) OPANA ER TAB 30MG 3 QL (60 tabs / 25 days) OPANA ER TAB 40MG 3 QL (60 tabs / 25 days) oxycodone hcl cap 5 1 QL (180 caps / 25 days) oxycodone hcl conc 100 /5ml (20 /ml) 1 QL (180 ml / 25 days) oxycodone hcl soln 5 /5ml 1 QL (900 ml / 25 days) oxycodone hcl tab 5 1 QL (180 tabs / 25 days) oxycodone hcl tab 10 1 QL (180 tabs / 25 days) oxycodone hcl tab 15 1 QL (180 tabs / 25 days) oxycodone hcl tab 20 1 QL (180 tabs / 25 days) oxycodone hcl tab 30 1 QL (180 tabs / 25 days) oxycodone hcl tab er 12hr deter 10 1 QL (120 tabs / 25 days) oxycodone hcl tab er 12hr deter 20 1 QL (120 tabs / 25 days) oxycodone hcl tab er 12hr deter 40 1 QL (120 tabs / 25 days) oxycodone hcl tab er 12hr deter 80 1 QL (60 tabs / 25 days) OXYCONTIN TAB 10MG CR 2 QL (120 tabs / 25 days) OXYCONTIN TAB 15MG CR 2 QL (120 tabs / 25 days) OXYCONTIN TAB 20MG CR 2 QL (120 tabs / 25 days) OXYCONTIN TAB 30MG CR 2 QL (120 tabs / 25 days) OXYCONTIN TAB 40MG CR 2 QL (120 tabs / 25 days) OXYCONTIN TAB 60MG CR 2 QL (60 tabs / 25 days) OXYCONTIN TAB 80MG CR 2 QL (60 tabs / 25 days) oxymorphone hcl tab 5 1 QL (180 tabs / 25 days) oxymorphone hcl tab 10 1 QL (180 tabs / 25 days) oxymorphone hcl tab sr 12hr 5 1 QL (120 tabs / 25 days) oxymorphone hcl tab sr 12hr QL (120 tabs / 25 days) 8

9 oxymorphone hcl tab sr 12hr 10 1 QL (120 tabs / 25 days) oxymorphone hcl tab sr 12hr 15 1 QL (120 tabs / 25 days) oxymorphone hcl tab sr 12hr 20 1 QL (120 tabs / 25 days) oxymorphone hcl tab sr 12hr 30 1 QL (120 tabs / 25 days) oxymorphone hcl tab sr 12hr 40 1 QL (120 tabs / 25 days) tramadol hcl tab 50 1 QL (240 tabs / 25 days) tramadol hcl tab sr 24hr QL (30 tabs / 25 days) tramadol hcl tab sr 24hr QL (30 tabs / 25 days) tramadol hcl tab sr 24hr QL (30 tabs / 25 days) Opioid Combinations acetaminophen w/ codeine soln QL (5000 ml / 25 days) /5ml acetaminophen w/ codeine tab QL (400 tabs / 25 days) acetaminophen w/ codeine tab QL (400 tabs / 25 days) acetaminophen w/ codeine tab QL (400 tabs / 25 days) CAPITAL/COD SUS /5 3 QL (5000 ml / 25 days) endocet tab QL (375 tabs / 25 days) endocet tab QL (375 tabs / 25 days) endocet tab QL (375 tabs / 25 days) hydrocodone-acetaminophen soln QL (5540 ml / 25 days) /15ml HYDROCODONE-ACETAMINOPHEN SOLN 1 QL (5540 ml / 25 days) MG/15ML hydrocodone-acetaminophen tab QL (375 tabs / 25 days) hydrocodone-acetaminophen tab QL (400 tabs / 25 days) hydrocodone-acetaminophen tab QL (375 tabs / 25 days) hydrocodone-acetaminophen tab QL (400 tabs / 25 days) hydrocodone-acetaminophen tab QL (375 tabs / 25 days) hydrocodone-acetaminophen tab QL (400 tabs / 25 days) hydrocodone-acetaminophen tab QL (375 tabs / 25 days) oxycodone w/ acetaminophen tab QL (375 tabs / 25 days) oxycodone w/ acetaminophen tab QL (375 tabs / 25 days) oxycodone w/ acetaminophen tab QL (375 tabs / 25 days) oxycodone w/ acetaminophen tab QL (375 tabs / 25 days) oxycodone-aspirin tab QL (375 tabs / 25 days) oxycodone-ibuprofen tab QL (28 tabs / 25 days) PRIMLEV TAB 5-300MG 3 QL (400 tabs / 25 days) PRIMLEV TAB QL (400 tabs / 25 days) PRIMLEV TAB MG 3 QL (400 tabs / 25 days) 9

10 ROXICET SOL 5-325/5 3 QL (1850 ml / 25 days) roxicet tab QL (375 tabs / 25 days) vicodin es tab QL (400 tabs / 25 days) vicodin hp tab QL (400 tabs / 25 days) vicodin tab QL (400 tabs / 25 days) Opioid Partial Agonists buprenorphine hcl sl tab 2 (base equiv) 1 QL (120 tablets per 25 days), PA buprenorphine hcl sl tab 8 (base equiv) 1 QL (120 tablets per 25 days), PA buprenorphine hcl-naloxone hcl sl tab QL (120 tablets per 25 (base equiv) days), PA buprenorphine hcl-naloxone hcl sl tab 8-2 (base equiv) 1 QL (120 tablets per 25 days), PA butorphanol tartrate nasal soln 10 /ml 1 QL (2 bottles / 25 days) nalbuphine hcl inj 10 /ml 1 nalbuphine hcl inj 20 /ml 1 SUBOXONE MIS 2-0.5MG 2 QL (120 units per 25 days), PA SUBOXONE MIS 4-1MG 2 QL (120 units per 25 days), PA SUBOXONE MIS 8-2MG 2 QL (120 units per 25 days), PA SUBOXONE MIS 12-3MG 2 QL (60 films per 25 days), PA ANDROGENS-ANABOLIC Anabolic Steroids ANADROL-50 TAB 50MG 3 PA oxandrolone tab PA oxandrolone tab 10 1 PA Androgens ANDRODERM DIS 2MG/24HR 2 PA ANDRODERM DIS 4MG/24HR 2 PA android cap 10 1 PA AXIRON SOL 30MG/ACT 2 PA danazol cap 50 1 danazol cap danazol cap testosterone cypionate im inj in oil PA /ml testosterone cypionate im inj in oil PA /ml testosterone enanthate im inj in oil PA /ml ANORECTAL AGENTS Intrarectal Steroids 10

11 colocort ene Rectal Steroids proctosol hc cre 2.5% 1 Vasodilating Agents RECTIV OIN 0.4% 3 ANTHELMINTICS Anthelmintics ALBENZA TAB 200MG 2 BILTRICIDE TAB 600MG 3 ivermectin tab 3 1 ANTI-INFECTIVE AGENTS - MISC. Anti-infective Agents - Misc. aztreonam for inj 1 gm 1 aztreonam for inj 2 gm 1 metronidazole cap metronidazole tab metronidazole tab NEBUPENT INH 300MG 3 PENTAM 300 INJ 300MG 3 PRIMSOL SOL 50MG/5ML 2 tinidazole tab tinidazole tab trimethoprim tab vancomycin hcl cap ST; PA** vancomycin hcl cap ST; PA** VIBATIV INJ 250MG 3 VIBATIV INJ 750MG 3 XIFAXAN TAB 200MG 2 XIFAXAN TAB 550MG 2 PA Anti-infective Misc. - Combinations e.s.p. sus sulfamethoxazole-trimethoprim susp /5ml sulfamethoxazole-trimethoprim tab sulfamethoxazole-trimethoprim tab Antiprotozoal Agents ALINIA SUS 100/5ML 2 ALINIA TAB 500MG 2 Carbapenems DORIBAX INJ 250MG 3 DORIBAX INJ 500MG 3 Cyclic Lipopeptides CUBICIN SOL 500MG 3 11

12 Ketolides KETEK TAB 300MG 3 KETEK TAB 400MG 3 Leprostatics dapsone tab 25 1 dapsone tab Lincosamides clindamycin hcl cap 75 1 clindamycin hcl cap clindamycin hcl cap Oxazolidinones SIVEXTRO INJ 200MG 3 PA ZYVOX SUS 100MG/5M 2 ZYVOX TAB 600MG 2 ANTIANGINAL AGENTS Antianginals-Other RANEXA TAB 500MG 2 ST; PA** RANEXA TAB 1000MG 2 ST; PA** Nitrates isoditrate tab 40 er 1 ISORDIL TAB 40MG 2 isosorbide dinitrate sl tab isosorbide dinitrate tab 5 1 isosorbide dinitrate tab 10 1 isosorbide dinitrate tab 20 1 isosorbide dinitrate tab 30 1 isosorbide dinitrate tab cr 40 1 isosorbide mononitrate tab 10 1 isosorbide mononitrate tab 20 1 isosorbide mononitrate tab sr 24hr 30 1 isosorbide mononitrate tab sr 24hr 60 1 isosorbide mononitrate tab sr 24hr minitran dis 0.1/hr 1 minitran dis 0.2/hr 1 minitran dis 0.4/hr 1 minitran dis 0.6/hr 1 NITRO-DUR DIS 0.3MG/HR 2 NITRO-DUR DIS 0.8MG/HR 2 nitroglycerin cap cr nitroglycerin cap cr nitroglycerin cap cr 9 1 nitroglycerin lingual aerosol 400 mcg/spray 1 nitroglycerin td patch 24hr 0.1 /hr 1 nitroglycerin td patch 24hr 0.2 /hr 1 nitroglycerin td patch 24hr 0.4 /hr 1 12

13 nitroglycerin td patch 24hr 0.6 /hr 1 NITROSTAT SUB 0.3MG 2 NITROSTAT SUB 0.4MG 2 NITROSTAT SUB 0.6MG 2 ANTIANXIETY AGENTS Antianxiety Agents - Misc. buspirone hcl tab 5 1 buspirone hcl tab buspirone hcl tab 10 1 buspirone hcl tab 15 1 buspirone hcl tab 30 1 hydroxyzine hcl syrup 10 /5ml 1 PA; High Risk Medications require PA for members age 65 and hydroxyzine hcl tab 10 1 PA; High Risk Medications require PA for members age 65 and hydroxyzine hcl tab 25 1 PA; High Risk Medications require PA for members age 65 and hydroxyzine hcl tab 50 1 PA; High Risk Medications require PA for members age 65 and meprobamate tab meprobamate tab Benzodiazepines ALPRAZOLAM CON 1 MG/ML 2 QL (120 ml / 25 days) alprazolam orally disintegrating tab QL (90 tabs / 25 days) alprazolam orally disintegrating tab QL (90 tabs / 25 days) alprazolam orally disintegrating tab 1 1 QL (90 tabs / 25 days) alprazolam orally disintegrating tab 2 1 QL (60 tabs / 25 days) alprazolam tab QL (90 tabs / 25 days) alprazolam tab QL (90 tabs / 25 days) alprazolam tab 1 1 QL (90 tabs / 25 days) alprazolam tab 2 1 QL (60 tabs / 25 days) clorazepate dipotassium tab QL (120 tabs / 25 days) clorazepate dipotassium tab QL (120 tabs / 25 days) clorazepate dipotassium tab 15 1 QL (120 tabs / 25 days) DIAZEPAM CON 5MG/ML 1 QL (240 ml / 25 days) diazepam soln 1 /ml 1 QL (1200 ml / 25 days) diazepam tab 2 1 QL (120 tabs / 25 days) diazepam tab 5 1 QL (120 tabs / 25 days) diazepam tab 10 1 QL (120 tabs / 25 days) 13

14 lorazepam conc 2 /ml 1 QL (150 ml / 25 days) lorazepam tab QL (150 tabs / 25 days) lorazepam tab 1 1 QL (150 tabs / 25 days) lorazepam tab 2 1 QL (150 tabs / 25 days) oxazepam cap 10 1 QL (120 caps / 25 days) oxazepam cap 15 1 QL (120 caps / 25 days) oxazepam cap 30 1 QL (120 caps / 25 days) ANTIARRHYTHMICS Antiarrhythmics Type I-A disopyramide phosphate cap disopyramide phosphate cap NORPACE CAP 100MG CR 2 NORPACE CAP 150MG CR 2 procainamide hcl inj 100 /ml 1 PROCAINAMIDE INJ 500MG/ML 3 Antiarrhythmics Type I-B mexiletine hcl cap mexiletine hcl cap mexiletine hcl cap Antiarrhythmics Type I-C flecainide acetate tab 50 1 flecainide acetate tab flecainide acetate tab propafenone hcl cap sr 12hr propafenone hcl cap sr 12hr propafenone hcl cap sr 12hr propafenone hcl tab propafenone hcl tab propafenone hcl tab Antiarrhythmics Type III amiodarone hcl tab amiodarone hcl tab MULTAQ TAB 400MG 3 PA pacerone tab pacerone tab TIKOSYN CAP 125MCG 3 PA TIKOSYN CAP 250MCG 3 PA TIKOSYN CAP 500MCG 3 PA ANTIASTHMATIC AND BRONCHODILATOR AGENTS Anti-Inflammatory Agents cromolyn sodium soln nebu 20 /2ml 1 QL (2 boxes / 25 days) Bronchodilators - Anticholinergics ATROVENT HFA AER 17MCG 2 QL (2 inhalers / 25 days) ipratropium bromide inhal soln 0.02% 1 QL (5 boxes / 25 days) SPIRIVA CAP HANDIHLR 2 QL (30 caps / 25 days) 14

15 SPIRIVA SPR RESPIMAT 2 QL (1 inhaler / 25 days) Leukotriene Modulators montelukast sodium chew tab 4 (base 1 equiv) montelukast sodium chew tab 5 (base 1 equiv) montelukast sodium oral granules packet 4 1 (base equiv) montelukast sodium tab 10 (base equiv) 1 zafirlukast tab 10 1 zafirlukast tab 20 1 ZYFLO CR TAB 600MG 3 Selective Phosphodiesterase 4 (PDE4) Inhibitors DALIRESP TAB 500MCG 3 PA Steroid Inhalants ALVESCO AER 80MCG 3 QL (3 inhalers / 25 days), ST ALVESCO AER 160MCG 3 QL (2 inhalers / 25 days), ST ASMANEX 30 AER 110MCG 2 QL (2 inhalers / 25 days) ASMANEX 60 AER 220MCG 2 QL (2 inhalers per 25 days) ASMANEX 120 AER 220MCG 2 QL (1 inhaler per 25 days) ASMANEX HFA AER 100 MCG 2 QL (1 inhaler per 25 days) ASMANEX HFA AER 200 MCG 2 QL (1 inhaler per 25 days) budesonide inhalation susp 0.5 /2ml 1 QL (2 boxes / 25 days) budesonide inhalation susp 0.25 /2ml 1 QL (3 boxes / 25 days) PULMICORT INH 90MCG 3 QL (3 inhalers / 25 days), ST PULMICORT INH 180MCG 3 QL (2 inhalers / 25 days), ST PULMICORT SUS 1MG/2ML 3 QL (1 box / 25 days), ST QVAR AER 40MCG 2 QL (2 inhalers / 25 days) QVAR AER 80MCG 2 QL (2 inhalers / 25 days) Sympathomimetics ADVAIR DISKU AER 100/50 2 QL (1 inhaler / 25 days), ST; PA**; Covered for ages 4-11 albuterol sulfate soln nebu 0.5% (5 /ml) 1 QL (3 boxes / 25 days) albuterol sulfate soln nebu 0.5% (5 /ml) 1 QL (4 boxes / 25 days) albuterol sulfate soln nebu 0.63 /3ml (base equiv) 1 QL (5 boxes / 25 days) 15

16 albuterol sulfate soln nebu 0.083% (2.5 1 QL (5 boxes / 25 days) /3ml) albuterol sulfate soln nebu 1.25 /3ml 1 QL (5 boxes / 25 days) (base equiv) albuterol sulfate syrup 2 /5ml 1 albuterol sulfate tab 2 1 albuterol sulfate tab 4 1 albuterol sulfate tab sr 12hr 8 1 BREO ELLIPTA INH QL (1 Package / 25 days), PA BROVANA NEB 15MCG 3 QL (2 boxes / 25 days) COMBIVENT AER RESPIMAT 2 QL (2 inhalers / 25 days) DULERA AER 100-5MCG 2 QL (1 inhaler / 25 days), ST; PA** DULERA AER 200-5MCG 2 QL (1 inhaler / 25 days), ST; PA** epinephrine hcl inj 1 /ml 1 epinephrine hcl soln prefilled syringe /ml FORADIL CAP AEROLIZE 2 QL (60 caps / 25 days) ipratropium-albuterol nebu soln (3) 1 QL (6 boxes / 25 days) /3ml levalbuterol hcl soln nebu 0.31 /3ml 1 QL (4 boxes / 25 days) (base equiv) levalbuterol hcl soln nebu 0.63 /3ml 1 QL (4 boxes / 25 days) (base equiv) levalbuterol hcl soln nebu 1.25 /3ml 1 QL (4 boxes / 25 days) (base equiv) levalbuterol hcl soln nebu conc QL (3 boxes / 25 days) /0.5ml (base equiv) metaproterenol sulfate syrup 10 /5ml 1 metaproterenol sulfate tab 10 1 metaproterenol sulfate tab 20 1 PERFOROMIST NEB 20MCG 2 QL (2 boxes / 25 days) PROAIR HFA AER 2 QL (2 inhalers / 25 days) SEREVENT DIS AER 50MCG 3 QL (1 inhaler / 25 days) SYMBICORT AER QL (1 inhaler / 25 days), ST; PA** SYMBICORT AER QL (1 inhaler / 25 days), ST; PA** terbutaline sulfate tab terbutaline sulfate tab 5 1 Xanthines theochron tab 100 cr 1 theochron tab 200 cr 1 theochron tab 300 cr 1 theophylline tab sr 12hr

17 theophylline tab sr 24hr theophylline tab sr 24hr ANTICOAGULANTS Coumarin Anticoagulants jantoven tab 1 1 jantoven tab jantoven tab 2 1 jantoven tab 3 1 jantoven tab 4 1 jantoven tab 5 1 jantoven tab 6 1 jantoven tab jantoven tab 10 1 warfarin sodium tab 1 1 warfarin sodium tab 2 1 warfarin sodium tab warfarin sodium tab 3 1 warfarin sodium tab 4 1 warfarin sodium tab 5 1 warfarin sodium tab 6 1 warfarin sodium tab warfarin sodium tab 10 1 Direct Factor Xa Inhibitors ELIQUIS TAB 2.5MG 3 ELIQUIS TAB 5MG 3 XARELTO STAR TAB 15/20MG 2 XARELTO TAB 10MG 2 XARELTO TAB 15MG 2 XARELTO TAB 20MG 2 Heparins And Heparinoid-Like Agents enoxaparin sodium inj 30 /0.3ml 1 enoxaparin sodium inj 40 /0.4ml 1 enoxaparin sodium inj 60 /0.6ml 1 enoxaparin sodium inj 80 /0.8ml 1 enoxaparin sodium inj 100 /ml 1 enoxaparin sodium inj 120 /0.8ml 1 enoxaparin sodium inj 150 /ml 1 enoxaparin sodium inj 300 /3ml 1 fondaparinux sodium subcutaneous inj /0.5ml fondaparinux sodium subcutaneous inj 5 1 /0.4ml fondaparinux sodium subcutaneous inj /0.6ml fondaparinux sodium subcutaneous inj 10 1 /0.8ml 17

18 FRAGMIN INJ 2500/0.2 3 FRAGMIN INJ 5000/0.2 3 FRAGMIN INJ 7500/0.3 3 FRAGMIN INJ 10000/ML 3 FRAGMIN INJ 12500UNT 3 FRAGMIN INJ 15000UNT 3 FRAGMIN INJ 18000UNT 3 FRAGMIN INJ 25000/ML 3 FRAGMIN INJ 95000UNT 3 heparin sodium (porcine) inj 1000 unit/ml 1 heparin sodium (porcine) inj 5000 unit/ml 1 heparin sodium (porcine) inj unit/ml 1 heparin sodium (porcine) inj unit/ml 1 heparin sodium (porcine) pf inj unit/0.5ml Thrombin Inhibitors argatroban inj 100 /ml (concentrate for 1 iv infusion) ARGATROBAN INJ 125/125 3 ARGATROBAN INJ 250/250 3 PRADAXA CAP 75MG 2 PRADAXA CAP 150MG 2 ANTICONVULSANTS Anticonvulsants - Benzodiazepines clonazepam tab clonazepam tab 1 1 clonazepam tab 2 1 ONFI SUS 2.5MG/ML 3 PA ONFI TAB 5MG 3 PA ONFI TAB 10MG 3 PA ONFI TAB 20MG 3 PA Anticonvulsants - Misc. BANZEL SUS 40MG/ML 3 PA BANZEL TAB 200MG 3 PA BANZEL TAB 400MG 3 PA carbamazepine chew tab carbamazepine susp 100 /5ml 1 carbamazepine tab carbamazepine tab sr 12hr carbamazepine tab sr 12hr epitol tab gabapentin cap gabapentin cap gabapentin cap gabapentin tab gabapentin tab

19 LAMICTAL CHW 2MG 2 lamotrigine orally disintegrating tab 25 1 lamotrigine orally disintegrating tab 50 1 lamotrigine orally disintegrating tab lamotrigine orally disintegrating tab lamotrigine tab 25 1 lamotrigine tab lamotrigine tab lamotrigine tab lamotrigine tab chewable dispersible 5 1 lamotrigine tab chewable dispersible 25 1 lamotrigine tab sr 24hr 25 1 lamotrigine tab sr 24hr 50 1 lamotrigine tab sr 24hr lamotrigine tab sr 24hr lamotrigine tab sr 24hr lamotrigine tab sr 24hr levetiracetam oral soln 100 /ml 1 levetiracetam tab levetiracetam tab levetiracetam tab levetiracetam tab levetiracetam tab sr 24hr levetiracetam tab sr 24hr LYRICA CAP 25MG 3 ST; PA** LYRICA CAP 50MG 3 ST; PA** LYRICA CAP 75MG 3 ST; PA** LYRICA CAP 100MG 3 ST; PA** LYRICA CAP 150MG 3 ST; PA** LYRICA CAP 200MG 3 ST; PA** LYRICA CAP 225MG 3 ST; PA** LYRICA CAP 300MG 3 ST; PA** LYRICA SOL 20MG/ML 3 ST; PA** oxcarbazepine susp 300 /5ml (60 1 /ml) oxcarbazepine tab oxcarbazepine tab oxcarbazepine tab POTIGA TAB 50MG 3 PA POTIGA TAB 200MG 3 PA POTIGA TAB 300MG 3 PA POTIGA TAB 400MG 3 PA primidone tab 50 1 primidone tab TEGRETOL-XR TAB 100MG 2 topiramate sprinkle cap

20 topiramate sprinkle cap 25 1 topiramate tab 25 1 topiramate tab 50 1 topiramate tab topiramate tab VIMPAT SOL 10MG/ML 3 PA VIMPAT TAB 50MG 3 PA VIMPAT TAB 100MG 3 PA VIMPAT TAB 150MG 3 PA VIMPAT TAB 200MG 3 PA zonisamide cap 25 1 zonisamide cap 50 1 zonisamide cap Carbamates felbamate susp 600 /5ml 1 felbamate tab felbamate tab GABA Modulators GABITRIL TAB 12MG 2 GABITRIL TAB 16MG 2 SABRIL POW 500MG 3 PA SABRIL TAB 500MG 3 PA tiagabine hcl tab 2 1 tiagabine hcl tab 4 1 Hydantoins phenytoin chew tab 50 1 phenytoin sodium extended cap phenytoin sodium extended cap phenytoin sodium extended cap phenytoin susp 125 /5ml 1 Succinimides ethosuximide cap ethosuximide soln 250 /5ml 1 Valproic Acid divalproex sodium cap sprinkle divalproex sodium tab delayed release divalproex sodium tab delayed release divalproex sodium tab delayed release divalproex sodium tab sr 24 hr divalproex sodium tab sr 24 hr valproate sodium syrup 250 /5ml (base 1 equiv) valproic acid cap

21 ANTIDEPRESSANTS Alpha-2 Receptor Antagonists (Tetracyclics) mirtazapine orally disintegrating tab 15 1 mirtazapine orally disintegrating tab 30 1 mirtazapine orally disintegrating tab 45 1 mirtazapine tab mirtazapine tab 15 1 mirtazapine tab 30 1 mirtazapine tab 45 1 Antidepressants - Misc. bupropion hcl tab 75 1 bupropion hcl tab bupropion hcl tab sr 12hr bupropion hcl tab sr 12hr bupropion hcl tab sr 12hr bupropion hcl tab sr 24hr bupropion hcl tab sr 24hr maprotiline hcl tab 25 1 maprotiline hcl tab 50 1 maprotiline hcl tab 75 1 Modified Cyclics nefazodone hcl tab 50 1 nefazodone hcl tab nefazodone hcl tab nefazodone hcl tab nefazodone hcl tab trazodone hcl tab 50 1 trazodone hcl tab trazodone hcl tab trazodone hcl tab VIIBRYD KIT 3 ST; PA** VIIBRYD TAB 10MG 3 ST; PA** VIIBRYD TAB 20MG 3 ST; PA** VIIBRYD TAB 40MG 3 ST; PA** Monoamine Oxidase Inhibitors (MAOIs) EMSAM DIS 6MG/24HR 3 EMSAM DIS 9MG/24HR 3 EMSAM DIS 12MG/24H 3 MARPLAN TAB 10MG 3 phenelzine sulfate tab 15 1 tranylcypromine sulfate tab 10 1 Selective Serotonin Reuptake Inhibitors (SSRIs) citalopram hydrobromide oral soln 10 1 /5ml 21

22 citalopram hydrobromide tab 10 (base 1 equiv) citalopram hydrobromide tab 20 (base 1 equiv) citalopram hydrobromide tab 40 (base 1 equiv) escitalopram oxalate soln 5 /5ml (base 1 equiv) escitalopram oxalate tab 5 (base equiv) 1 escitalopram oxalate tab 10 (base 1 equiv) escitalopram oxalate tab 20 (base 1 equiv) fluoxetine hcl cap 10 1 fluoxetine hcl cap 20 1 fluoxetine hcl cap 40 1 fluoxetine hcl solution 20 /5ml 1 fluoxetine hcl tab 10 1 fluoxetine hcl tab 20 1 fluvoxamine maleate cap sr 24hr fluvoxamine maleate cap sr 24hr fluvoxamine maleate tab 25 1 fluvoxamine maleate tab 50 1 fluvoxamine maleate tab paroxetine hcl tab 10 1 paroxetine hcl tab 20 1 paroxetine hcl tab 30 1 paroxetine hcl tab 40 1 paroxetine hcl tab sr 24hr paroxetine hcl tab sr 24hr 25 1 paroxetine hcl tab sr 24hr PAXIL SUS 10MG/5ML 2 PEXEVA TAB 10MG 3 ST; PA** PEXEVA TAB 20MG 3 ST; PA** PEXEVA TAB 30MG 3 ST; PA** PEXEVA TAB 40MG 3 ST; PA** sertraline hcl oral conc 20 /ml 1 sertraline hcl tab 25 1 sertraline hcl tab 50 1 sertraline hcl tab Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs) duloxetine hcl cap 20 1 duloxetine hcl cap 30 1 duloxetine hcl cap 60 1 PRISTIQ TAB 25MG 3 ST; PA** PRISTIQ TAB 50MG 3 ST; PA** 22

23 PRISTIQ TAB 100MG 3 ST; PA** venlafaxine hcl cap sr 24hr 37.5 (base 1 equivalent) venlafaxine hcl cap sr 24hr 75 (base 1 equivalent) venlafaxine hcl cap sr 24hr 150 (base 1 equivalent) venlafaxine hcl tab 25 1 venlafaxine hcl tab venlafaxine hcl tab 50 1 venlafaxine hcl tab 75 1 venlafaxine hcl tab venlafaxine hcl tab sr 24hr 37.5 (base 1 equivalent) venlafaxine hcl tab sr 24hr 75 (base 1 equivalent) venlafaxine hcl tab sr 24hr 150 (base 1 equivalent) venlafaxine hcl tab sr 24hr 225 (base 1 equivalent) Tricyclic Agents amitriptyline hcl tab 10 1 QL (150 tabs / 25 days); QL applies to members age 65 and amitriptyline hcl tab 25 1 QL (30 tabs / 25 days); QL applies to members age 65 and amitriptyline hcl tab 50 1 QL (30 tabs / 25 days); QL applies to members age 65 and amitriptyline hcl tab 75 1 Members 65 and subject to PA amitriptyline hcl tab Members 65 and subject to PA amitriptyline hcl tab Members 65 and subject to PA amoxapine tab 25 1 QL (90 tabs / 25 days); QL applies to members age 65 and amoxapine tab 50 1 QL (90 tabs / 25 days); QL applies to members age 65 and amoxapine tab QL (90 tabs / 25 days); QL applies to members age 65 and 23

24 amoxapine tab QL (60 tabs / 25 days); QL applies to members age 65 and regardles of QL clomipramine hcl cap 25 1 QL (150 caps / 25 days); QL applies to members age 65 and clomipramine hcl cap 50 1 QL (150 caps / 25 days); QL applies to members age 65 and clomipramine hcl cap 75 1 QL (90 caps / 25 days); QL applies to members age 65 and desipramine hcl tab 10 1 QL (90 tabs / 25 days); QL applies to members age 65 and desipramine hcl tab 25 1 QL (90 tabs / 25 days); QL applies to members age 65 and desipramine hcl tab 50 1 QL (90 tabs / 25 days); QL applies to members age 65 and desipramine hcl tab 75 1 QL (60 tabs / 25 days); QL applies to members age 65 and desipramine hcl tab QL (30 tabs / 25 days); QL applies to members age 65 and desipramine hcl tab QL (30 tabs / 25 days); QL applies to members age 65 and doxepin hcl cap 10 1 QL (90 caps / 25 days); QL applies to members age 65 and doxepin hcl cap 25 1 QL (90 caps / 25 days); QL applies to members age 65 and doxepin hcl cap 50 1 QL (90 caps / 25 days); QL applies to members age 65 and doxepin hcl cap 75 1 QL (60 caps / 25 days); QL applies to members age 65 and doxepin hcl cap QL (30 caps / 25 days); QL applies to members age 65 and doxepin hcl cap QL (30 caps / 25 days); QL applies to members age 65 and 24

25 doxepin hcl conc 10 /ml 1 QL (450 ml / 25 days); QL applies to members age 65 and imipramine hcl tab 10 1 QL (60 tabs / 25 days); QL applies to members age 65 and imipramine hcl tab 25 1 QL (60 tabs / 25 days); QL applies to members age 65 and imipramine hcl tab 50 1 QL (60 tabs / 25 days); QL applies to members age 65 and imipramine pamoate cap 75 1 QL (30 caps / 25 days); QL applies to members age 65 and imipramine pamoate cap QL (30 caps / 25 days); QL applies to members age 65 and imipramine pamoate cap Members 65 and subject to PA imipramine pamoate cap Members 65 and subject to PA nortriptyline hcl cap 10 1 QL (150 caps / 25 days); QL applies to members age 65 and nortriptyline hcl cap 25 1 QL (60 caps / 25 days); QL applies to members age 65 and nortriptyline hcl cap 50 1 QL (30 caps / 25 days); QL applies to members age 65 and nortriptyline hcl cap 75 1 Members 65 and subject to PA nortriptyline hcl soln 10 /5ml 1 QL (750 ml / 25 days); QL applies to members age 65 and protriptyline hcl tab 5 1 QL (90 tabs / 25 days); QL applies to members age 65 and protriptyline hcl tab 10 1 QL (60 tabs / 25 days); QL applies to members age 65 and SURMONTIL CAP 25MG 3 QL (60 caps / 25 days); QL applies to members age 65 and SURMONTIL CAP 50MG 3 QL (60 caps / 25 days); QL applies to members age 65 and 25

26 SURMONTIL CAP 100MG 3 QL (30 caps / 25 days); QL applies to members age 65 and ANTIDIABETICS Alpha-Glucosidase Inhibitors acarbose tab 25 1 acarbose tab 50 1 acarbose tab GLYSET TAB 25MG 3 GLYSET TAB 50MG 3 GLYSET TAB 100MG 3 Antidiabetic - Amylin Analogs SYMLINPEN 60 INJ 1000MCG 3 PA SYMLNPEN 120 INJ 1000MCG 3 PA Antidiabetic Combinations glipizide-metformin hcl tab glipizide-metformin hcl tab glipizide-metformin hcl tab glyburide-metformin tab PA; High Risk Medications require PA for members age 65 and glyburide-metformin tab PA; High Risk Medications require PA for members age 65 and glyburide-metformin tab PA; High Risk Medications require PA for members age 65 and JANUMET TAB MG 2 JANUMET TAB JANUMET XR TAB MG 2 JANUMET XR TAB JANUMET XR TAB JENTADUETO TAB JENTADUETO TAB JENTADUETO TAB pioglitazone hcl-glimepiride tab pioglitazone hcl-glimepiride tab pioglitazone hcl-metformin hcl tab pioglitazone hcl-metformin hcl tab Biguanides metformin hcl tab

27 metformin hcl tab metformin hcl tab metformin hcl tab sr 24hr metformin hcl tab sr 24hr metformin hcl tab sr 24hr osmotic metformin hcl tab sr 24hr osmotic Diabetic Other GLUCAGEN INJ HYPOKIT 2 GLUCAGON KIT 1MG 2 glucose gel/oral liquid/chew tab 2 PROGLYCEM SUS 50MG/ML 3 Dipeptidyl Peptidase-4 (DPP-4) Inhibitors JANUVIA TAB 25MG 2 JANUVIA TAB 50MG 2 JANUVIA TAB 100MG 2 ONGLYZA TAB 2.5MG 3 PA ONGLYZA TAB 5MG 3 PA TRADJENTA TAB 5MG 3 PA Dopamine Receptor Agonists - Antidiabetic CYCLOSET TAB 0.8MG 3 Incretin Mimetic Agents (GLP Receptor Agonists) BYDUREON INJ 2 BYETTA INJ 5MCG 3 QL (1 prefilled pen (60 doses) / 25 days), PA BYETTA INJ 10MCG 3 QL (1 prefilled pen (60 doses) / 25 days), PA VICTOZA INJ 18MG/3ML 3 PA Insulin APIDRA INJ SOLOSTAR 2 APIDRA INJ U HUMALOG INJ 100/ML 3 HUMALOG KWIK INJ 100/ML 3 HUMALOG MIX INJ 50/50 3 HUMALOG MIX INJ 50/50KWP 3 HUMALOG MIX INJ 75/25KWP 3 HUMALOG MIX SUS 75/25 3 HUMULIN INJ 70/30 3 OTC HUMULIN INJ 70/30KWP 3 OTC HUMULIN N INJ U OTC HUMULIN N INJ U-100KWP 3 OTC HUMULIN R INJ U OTC HUMULIN R INJ U LANTUS INJ 100/ML 2 LANTUS INJ SOLOSTAR 2 LEVEMIR INJ 2 27

28 LEVEMIR INJ FLEXTOUC 2 NOVOLIN INJ 70/30 2 OTC NOVOLIN N INJ U OTC NOVOLIN R INJ U OTC NOVOLOG INJ 100/ML 2 NOVOLOG INJ FLEXPEN 2 NOVOLOG INJ MIX FLEXPEN 2 NOVOLOG INJ PENFILL 2 NOVOLOG MIX INJ 70/30 2 Insulin Sensitizing Agents pioglitazone hcl tab 15 (base equiv) 1 pioglitazone hcl tab 30 (base equiv) 1 pioglitazone hcl tab 45 (base equiv) 1 Meglitinide Analogues nateglinide tab 60 1 nateglinide tab repaglinide tab repaglinide tab 1 1 repaglinide tab 2 1 Sulfonylureas chlorpropamide tab chlorpropamide tab glimepiride tab 1 1 glimepiride tab 2 1 glimepiride tab 4 1 glipizide tab 5 1 glipizide tab 10 1 glipizide tab sr 24hr glipizide tab sr 24hr 5 1 glipizide tab sr 24hr 10 1 glyburide micronized tab PA; High Risk Medications require PA for members age 65 and glyburide micronized tab 3 1 PA; High Risk Medications require PA for members age 65 and glyburide micronized tab 6 1 PA; High Risk Medications require PA for members age 65 and glyburide tab PA; High Risk Medications require PA for members age 65 and 28

29 glyburide tab PA; High Risk Medications require PA for members age 65 and glyburide tab 5 1 PA; High Risk Medications require PA for members age 65 and tolbutamide tab ANTIDIARRHEALS Antiperistaltic Agents anti-diarrhe tab 2 1 diphenoxylate w/ atropine liq /5ml diphenoxylate w/ atropine tab loperamide hcl cap 2 1 MOTOFEN TAB 3 ANTIDOTES Antidotes - Chelating Agents CHEMET CAP 100MG 3 EXJADE TAB 125MG 3 PA EXJADE TAB 250MG 3 PA EXJADE TAB 500MG 3 PA FERRIPROX TAB 500MG 3 PA Opioid Antagonists naltrexone hcl tab 50 1 ANTIEMETICS 5-HT3 Receptor Antagonists ALOXI INJ 0.25MG/5 3 QL (5 ml / 15 days) granisetron hcl tab 1 1 QL (6 tabs / 15 days) ondansetron hcl oral soln 4 /5ml 1 QL (2 bottles / 15 days) ondansetron hcl tab 4 1 QL (12 tabs / 15 days) ondansetron hcl tab 8 1 QL (12 tabs / 15 days) ondansetron hcl tab 24 1 QL (1 tab / 15 days) ondansetron orally disintegrating tab 4 1 QL (12 tabs / 15 days) ondansetron orally disintegrating tab 8 1 QL (12 tabs / 15 days) SANCUSO DIS 3.1MG 3 QL (1 patch / 15 days) Antiemetics - Anticholinergic ANTIVERT TAB 50MG 2 meclizine hcl tab meclizine hcl tab 25 1 TRANSDERM-SC DIS 1MG 3 trimethobenzamide hcl cap PA; High Risk Medications require PA for members age 65 and 29

30 univert tab 32 1 Antiemetics - Miscellaneous dronabinol cap QL (60 caps / 25 days) dronabinol cap 5 1 QL (60 caps / 25 days) dronabinol cap 10 1 QL (60 caps / 25 days) Substance P/Neurokinin 1 (NK1) Receptor Antagonists EMEND CAP 40MG 3 QL (3 caps / 180 days) EMEND CAP 80MG 3 QL (2 caps / 15 days) EMEND CAP 125MG 3 QL (1 cap / 15 days) EMEND PAK 80 & QL (1 pack / 15 days) ANTIFUNGALS Antifungal - Glucan Synthesis Inhibitors (Echinocandins) CANCIDAS INJ 50MG 3 CANCIDAS INJ 70MG 3 ERAXIS INJ 50MG 3 ERAXIS INJ 100MG 3 Antifungals ABELCET INJ 5MG/ML 3 AMPHOTEC INJ 50MG 3 AMPHOTEC INJ 100MG 3 amphotericin b for inj 50 1 BIO-STATIN CAP BIO-STATIN CAP griseofulvin microsize susp 125 /5ml 1 griseofulvin microsize tab griseofulvin ultramicrosize tab griseofulvin ultramicrosize tab nystatin oral powder 1 nystatin tab unit 1 terbinafine hcl tab PA Imidazole-Related Antifungals fluconazole for susp 10 /ml 1 fluconazole for susp 40 /ml 1 fluconazole tab 50 1 fluconazole tab fluconazole tab fluconazole tab itraconazole cap PA NOXAFIL SUS 40MG/ML 2 NOXAFIL TAB 100MG 2 SPORANOX SOL 10MG/ML 2 PA voriconazole for susp 40 /ml 1 PA voriconazole tab 50 1 PA voriconazole tab PA ANTIHISTAMINES 30

31 Antihistamines - Alkylamines brompheniramine tannate chew tab 12 1 dexchlorpheniramine maleate syrup 2 1 /5ml Antihistamines - Ethanolamines carbinoxamine maleate tab 4 1 clemastine fumarate syrup 0.67 /5ml (0.5 /5ml base eq) 1 PA; High Risk Medications require PA for members age 65 and clemastine fumarate tab PA; High Risk Medications require PA for members age 65 and diphenhydramine hcl cap 25 1 diphenhydramine hcl cap 50 1 diphenhydramine hcl elixir 12.5 /5ml 1 diphenhydramine hcl inj 50 /ml 1 Antihistamines - Non-Sedating all day allg cap 10 1 OTC all day allg chw 5 1 OTC all day allg chw 10 1 OTC allergy relf tab 10 1 OTC allergy tab 10 1 OTC cetirizine hcl tab 5 1 OTC cetirizine hcl tab 10 1 OTC cetirizine sol 1/ml 1 OTC CLARINEX SYP 0.5MG/ML 3 ST desloratadine tab 5 1 ST desloratadine tab orally disintegrating ST desloratadine tab orally disintegrating 5 1 ST fexofenadine hcl tab 60 1 OTC fexofenadine hcl tab OTC fexofenadine sus 30/5ml 1 OTC levocetirizine dihydrochloride soln /5ml (0.5 /ml) levocetirizine dihydrochloride tab 5 1 loratadine syp 5/5ml 1 OTC Antihistamines - Phenothiazines promethazine hcl syrup 6.25 /5ml 1 PA; High Risk Medications require PA for members age 65 and 31

32 promethazine hcl tab PA; High Risk Medications require PA for members age 65 and promethazine hcl tab 25 1 PA; High Risk Medications require PA for members age 65 and promethazine hcl tab 50 1 PA; High Risk Medications require PA for members age 65 and Antihistamines - Piperidines cyproheptadine hcl syrup 2 /5ml 1 cyproheptadine hcl tab 4 1 ANTIHYPERLIPIDEMICS Antihyperlipidemics - Combinations VYTORIN TAB 10-10MG 3 ST; PA** VYTORIN TAB 10-20MG 3 ST; PA** VYTORIN TAB 10-40MG 3 ST; PA** VYTORIN TAB 10-80MG 3 ST; PA** Antihyperlipidemics - Misc. omega-3-acid ethyl esters cap 1 gm 1 PA Bile Acid Sequestrants cholestyramine light powder 4 gm/dose 1 cholestyramine light powder packets 4 gm 1 cholestyramine powder 4 gm/dose 1 cholestyramine powder packets 4 gm 1 colestipol hcl granule packets 5 gm 1 colestipol hcl granules 5 gm 1 colestipol hcl tab 1 gm 1 prevalite pow 4gm 1 WELCHOL PAK 3.75GM 3 WELCHOL TAB 625MG 3 Fibric Acid Derivatives fenofibrate cap 50 1 fenofibrate cap fenofibrate micronized cap 43 1 fenofibrate micronized cap 67 1 fenofibrate micronized cap fenofibrate micronized cap fenofibrate micronized cap fenofibrate tab 48 1 fenofibrate tab 54 1 fenofibrate tab fenofibrate tab

33 gemfibrozil tab HMG CoA Reductase Inhibitors atorvastatin calcium tab 10 (base 1 equivalent) atorvastatin calcium tab 20 (base 1 equivalent) atorvastatin calcium tab 40 (base 1 equivalent) atorvastatin calcium tab 80 (base 1 equivalent) CRESTOR TAB 5MG 3 ST; PA** CRESTOR TAB 10MG 3 ST; PA** CRESTOR TAB 20MG 3 ST; PA** CRESTOR TAB 40MG 3 PA** fluvastatin sodium cap 20 1 fluvastatin sodium cap 40 1 LIVALO TAB 1MG 3 ST; PA** LIVALO TAB 2MG 3 ST; PA** LIVALO TAB 4MG 3 ST; PA** lovastatin tab 10 1 lovastatin tab 20 1 lovastatin tab 40 1 pravastatin sodium tab 10 1 pravastatin sodium tab 20 1 pravastatin sodium tab 40 1 pravastatin sodium tab 80 1 simvastatin tab 5 1 simvastatin tab 10 1 simvastatin tab 20 1 simvastatin tab 40 1 simvastatin tab 80 1 ST Intestinal Cholesterol Absorption Inhibitors ZETIA TAB 10MG 3 ST; PA** Nicotinic Acid Derivatives niacin tab cr 500 (antihyperlipidemic) 1 niacin tab cr 750 (antihyperlipidemic) 1 niacin tab cr 1000 (antihyperlipidemic) 1 ANTIHYPERTENSIVES ACE Inhibitors benazepril hcl tab 5 1 benazepril hcl tab 10 1 benazepril hcl tab 20 1 benazepril hcl tab 40 1 captopril tab captopril tab 25 1 captopril tab

34 captopril tab enalapril maleate tab enalapril maleate tab 5 1 enalapril maleate tab 10 1 enalapril maleate tab 20 1 fosinopril sodium tab 10 1 fosinopril sodium tab 20 1 fosinopril sodium tab 40 1 lisinopril tab lisinopril tab 5 1 lisinopril tab 10 1 lisinopril tab 20 1 lisinopril tab 30 1 lisinopril tab 40 1 moexipril hcl tab moexipril hcl tab 15 1 perindopril erbumine tab 2 1 perindopril erbumine tab 4 1 perindopril erbumine tab 8 1 quinapril hcl tab 5 1 quinapril hcl tab 10 1 quinapril hcl tab 20 1 quinapril hcl tab 40 1 ramipril cap ramipril cap ramipril cap 5 1 ramipril cap 10 1 trandolapril tab 1 1 trandolapril tab 2 1 trandolapril tab 4 1 Agents for Pheochromocytoma DIBENZYLINE CAP 10MG 3 Angiotensin II Receptor Antagonists BENICAR TAB 5MG 3 ST; PA** BENICAR TAB 20MG 3 ST; PA** BENICAR TAB 40MG 3 ST; PA** candesartan cilexetil tab 4 1 candesartan cilexetil tab 8 1 candesartan cilexetil tab 16 1 candesartan cilexetil tab 32 1 EDARBI TAB 40MG 3 ST; PA** EDARBI TAB 80MG 3 ST; PA** eprosartan mesylate tab irbesartan tab 75 1 irbesartan tab irbesartan tab

35 losartan potassium tab 25 1 losartan potassium tab 50 1 losartan potassium tab telmisartan tab 20 1 telmisartan tab 40 1 telmisartan tab 80 1 valsartan tab 40 1 valsartan tab 80 1 valsartan tab valsartan tab Antiadrenergic Antihypertensives clonidine hcl tab clonidine hcl tab clonidine hcl tab clonidine hcl td patch weekly 0.1 /24hr 1 clonidine hcl td patch weekly 0.2 /24hr 1 clonidine hcl td patch weekly 0.3 /24hr 1 doxazosin mesylate tab 1 1 doxazosin mesylate tab 2 1 doxazosin mesylate tab 4 1 doxazosin mesylate tab 8 1 guanfacine hcl tab 1 1 guanfacine hcl tab 2 1 methyldopa tab methyldopa tab prazosin hcl cap 1 1 prazosin hcl cap 2 1 prazosin hcl cap 5 1 terazosin hcl cap 1 1 terazosin hcl cap 2 1 terazosin hcl cap 5 1 terazosin hcl cap 10 1 Antihypertensive Combinations amlodipine besylate-benazepril hcl cap amlodipine besylate-benazepril hcl cap amlodipine besylate-benazepril hcl cap amlodipine besylate-benazepril hcl cap amlodipine besylate-benazepril hcl cap amlodipine besylate-benazepril hcl cap

36 amlodipine besylate-valsartan tab amlodipine besylate-valsartan tab amlodipine besylate-valsartan tab amlodipine besylate-valsartan tab amlodipine-valsartan-hydrochlorothiazide 1 tab amlodipine-valsartan-hydrochlorothiazide 1 tab amlodipine-valsartan-hydrochlorothiazide 1 tab amlodipine-valsartan-hydrochlorothiazide 1 tab amlodipine-valsartan-hydrochlorothiazide 1 tab atenolol & chlorthalidone tab atenolol & chlorthalidone tab benazepril & hydrochlorothiazide tab benazepril & hydrochlorothiazide tab benazepril & hydrochlorothiazide tab benazepril & hydrochlorothiazide tab bisoprolol & hydrochlorothiazide tab bisoprolol & hydrochlorothiazide tab bisoprolol & hydrochlorothiazide tab candesartan cilexetil-hydrochlorothiazide 1 tab candesartan cilexetil-hydrochlorothiazide 1 tab candesartan cilexetil-hydrochlorothiazide 1 tab captopril & hydrochlorothiazide tab captopril & hydrochlorothiazide tab captopril & hydrochlorothiazide tab captopril & hydrochlorothiazide tab

37 enalapril maleate & hydrochlorothiazide tab enalapril maleate & hydrochlorothiazide tab fosinopril sodium & hydrochlorothiazide tab fosinopril sodium & hydrochlorothiazide tab irbesartan-hydrochlorothiazide tab irbesartan-hydrochlorothiazide tab lisinopril & hydrochlorothiazide tab lisinopril & hydrochlorothiazide tab lisinopril & hydrochlorothiazide tab losartan potassium & hydrochlorothiazide 1 tab losartan potassium & hydrochlorothiazide 1 tab losartan potassium & hydrochlorothiazide 1 tab metoprolol & hydrochlorothiazide tab metoprolol & hydrochlorothiazide tab metoprolol & hydrochlorothiazide tab moexipril-hydrochlorothiazide tab moexipril-hydrochlorothiazide tab moexipril-hydrochlorothiazide tab nadolol & bendroflumethiazide tab nadolol & bendroflumethiazide tab propranolol & hydrochlorothiazide tab propranolol & hydrochlorothiazide tab quinapril-hydrochlorothiazide tab quinapril-hydrochlorothiazide tab quinapril-hydrochlorothiazide tab telmisartan-amlodipine tab telmisartan-amlodipine tab

38 telmisartan-amlodipine tab telmisartan-amlodipine tab telmisartan-hydrochlorothiazide tab telmisartan-hydrochlorothiazide tab telmisartan-hydrochlorothiazide tab trandolapril-verapamil hcl tab cr trandolapril-verapamil hcl tab cr trandolapril-verapamil hcl tab cr trandolapril-verapamil hcl tab cr valsartan-hydrochlorothiazide tab valsartan-hydrochlorothiazide tab valsartan-hydrochlorothiazide tab valsartan-hydrochlorothiazide tab valsartan-hydrochlorothiazide tab Direct Renin Inhibitors TEKTURNA TAB 150MG 3 ST; PA** TEKTURNA TAB 300MG 3 ST; PA** Selective Aldosterone Receptor Antagonists (SARAs) eplerenone tab 25 1 eplerenone tab 50 1 Vasodilators hydralazine hcl tab 10 1 hydralazine hcl tab 25 1 hydralazine hcl tab 50 1 hydralazine hcl tab minoxidil tab minoxidil tab 10 1 ANTIMALARIALS Antimalarial Combinations atovaquone-proguanil hcl tab atovaquone-proguanil hcl tab COARTEM TAB MG 3 Antimalarials chloroquine phosphate tab chloroquine phosphate tab DARAPRIM TAB 25MG 3 hydroxychloroquine sulfate tab mefloquine hcl tab