How To Get A Drug Plan To Pay For A Prescription From Acpa

Transcription

1 +B/LVW2I'UXJV5B$SSURYHG 2015 List of Covered s (Formulary) FOR MORE INFORMATION, contact Member Services at from 8 a.m. to 8 p.m., seven days a week. TTY users call 711. On weekends and Federal holidays, you may be asked to leave a message. Your call will be returned the next business day , Version Number 14 UpdatedϬ4 Ϭϭ ϮϬϭϱ

2 H1723_LISTOFDRUGS15R_Approved Absolute Total Care 2015 List of Covered s (Formulary) This List of s is current as of April 1, For more recent information or other questions, please call Absolute Total Care at from 8 a.m. to 8 p.m., seven days a week. On weekends and Federal holidays, you may be asked to leave a message. Your call will be returned within the next business day. TTY users call 711. The call is free. For more information, visit This is a list of drugs that members can get in Absolute Total Care (ATC). Absolute Total Care (ATC) is a health plan that contracts with both Medicare and South Carolina Healthy Connections Medicaid to provide benefits of both programs to enrollees. Benefits, List of Covered s, pharmacy and provider networks, and/or copayments may change from time to time throughout the year and on January 1 of each year. You can always check ATC s up-to-date List of Covered s online at Limitations and restrictions may apply. For more information, call ATC Member Services or read the ATC Member Handbook. You can ask for this information in other formats, such as Braille or large print. Call The call is free. You can get this information for free in other languages. Call The call is free. Hours are from 8 a.m. to 8 p.m., seven days a week. On weekends and Federal holidays, you may be asked to leave a message. Your call will be returned within the next business day. TTY users call 711. The call is free. Usted puede obtener esta información de forma gratuita en otros idiomas. Llamar La llamada es gratuita. Horario es de 8 am a 8 pm los siete días de la semana. Los fines de semana y días feriados federales, se le puede pedir que deje un mensaje. Su llamada será devuelta dentro del siguiente día hábil. Usuarios de TTY deben llamar al 711. La llamada es gratuita ,Version Number14 Updated4? If you have questions, please call Absolute Total Care at from 8 a.m. to 8 p.m., seven days a week. On weekends and Federal holidays, you may be asked to leave a message. Your call will be returned within the next business day. TTY users call 711. The call is free. For more information, visit 1

3 Frequently Asked Questions (FAQ) Find answers here to questions you have about this List of Covered s. You can read all of the FAQ to learn more, or look for a question and answer. 1. What prescription drugs are on the List of Covered s? (We call the List of Covered s the List for short.) The drugs on the List of Covered s that starts on page 10 are the drugs covered by ATC. These drugs are available at pharmacies within our network. A pharmacy is in our network if we have an agreement with them to work with us and provide you services. We refer to these pharmacies as network pharmacies. o ATC will cover all medically necessary drugs on the List if: x your doctor or other prescriber says you need them to get better or stay healthy, and x you fill the prescription at a ATC network pharmacy. o ATC may have additional steps to access certain drugs (see question #5 below). You can also see an up-to-date list of drugs that we cover on our website at or call Member Services at Does the List ever change? Yes. ATC may add or remove drugs on the List during the year. Generally, the List will only change if: x a cheaper drug comes along that works as well as a drug on the List now, or x we learn that a drug is not safe. We may also change our rules about drugs. For example, we could: x Decide to require or not require prior approval for a drug. (Prior approval is permission from ATC before you can get a drug.) x Add or change the amount of a drug you can get (called quantity limits ). x Add or change step therapy restrictions on a drug. (Step therapy means you must try one drug before we will cover another drug.)? If you have questions, please call Absolute Total Care at from 8 a.m. to 8 p.m., seven days a week. On weekends and Federal holidays, you may be asked to leave a message. Your call will be returned within the next business day. TTY users call 711. The call is free. For more information, visit 2

4 (For more information on these drug rules, see page 4.) We will tell you when a drug you are taking is removed from the List. We will also tell you when we change our rules for covering a drug. Questions 3, 4, and 7 below have more information on what happens when the List changes. o You can always check ATC s up to date List online at You can also call Member Services to check the current List at What happens when a cheaper drug comes along that works as well as a drug on the List now? If you are taking a drug that is removed because a cheaper drug that works just as well comes along, we will tell you. We will tell you at least 60 days before we remove it from the List or when you ask for a refill. Then you can get a 60-day supply of the drug before the change to the List is made. We will mail you a notice if you are taking a drug, and we change our rules for covering it. You will receive the notice by mail at least 60 days before we change the drug rules or remove the drug from our List of Covered s. For example, if you are taking a drug, and we add prior authorization (approval), quantity limits, and/or step therapy, the notice you receive will explain the new rules. We must tell you of this change at least 60 days before it becomes effective. Or, we have to tell you when you request a refill of the drug. If we tell you when you refill your drug, you will receive a 60-day supply of the drug. For more information on these drug rules, see page 3. If you have questions about the notice you receive from ATC, call Member Services at from 8 a.m. to 8 p.m., seven days a week. On weekends and Federal holidays, you may be asked to leave a message. Your call will be returned within the next business day. TTY users call What happens when we find out a drug is not safe? If the Food and Administration (FDA) says a drug you are taking is not safe, we will take it off the List right away. We will also send you a letter telling you that. If you have any questions after being notified of the change, you should contact the doctor who prescribed the drug for you.? If you have questions, please call Absolute Total Care at from 8 a.m. to 8 p.m., seven days a week. On weekends and Federal holidays, you may be asked to leave a message. Your call will be returned within the next business day. TTY users call 711. The call is free. For more information, visit 3

5 5. Are there any restrictions or limits on drug coverage? Or are there any required actions to take in order to get certain drugs? Yes, some drugs have coverage rules or have limits on the amount you can get. In some cases you must do something before you can get the drug. For example: x Prior approval (or prior authorization): For some drugs, you or your doctor or other prescriber must get approval from ATC before you fill your prescription. If you don t get approval, ATC may not cover the drug. x Quantity limits: Sometimes ATC limits the amount of a drug you can get. x Step therapy: Sometimes ATC requires you to do step therapy. This means you will have to try drugs in a certain order for your medical condition. You might have to try one drug before we will cover another drug. If your doctor thinks the first drug doesn t work for you, then we will cover the second. You can find out if your drug has any additional requirements or limits by looking in the tables on pages 9. You can also get more information by visiting our web site at We have posted online a document that explains our prior authorization restrictions. You may also ask us to send you a copy. You can ask for an exception from these limits. Please see question 11 for more information on exceptions. o If you are in a nursing home or other long-term care facility and need a drug that is not on the List, or if you cannot easily get the drug you need, we can help. We will cover a 31-day emergency supply of the drug you need (unless you have a prescription for fewer days), whether or not you are a new ATC member. This will give you time to talk to your doctor or other prescriber. He or she can help you decide if there is a similar drug on the List you can take instead or whether to request an exception. Please see question 11 for more information about exceptions. 6. How will you know if the drug you want has limitations or if there are required actions to take to get the drug? The List of Covered s on page 10 has a column labeled Necessary actions, restrictions, or limits on use.? If you have questions, please call Absolute Total Care at from 8 a.m. to 8 p.m., seven days a week. On weekends and Federal holidays, you may be asked to leave a message. Your call will be returned within the next business day. TTY users call 711. The call is free. For more information, visit 4

6 7. What happens if we change our rules on how we cover some drugs? For example, if we add prior authorization (approval), quantity limits, and/or step therapy restrictions on a drug. We will tell you if we add prior approval, quantity limits, and/or step therapy restrictions on a drug. We will tell you at least 60 days before the restriction is added or when you next ask for a refill. Then, you can get a 60-day supply of the drug before the change to the List is made. This gives you time to talk to your doctor or other prescriber about what to do next. 8. How can you find a drug on the List? There are two ways to find a drug: x You can search alphabetically (if you know how to spell the drug), or x You can search by medical condition. To search alphabetically, go to the Alphabetical Listing section. You can find it by reviewing the index of drugs beginning on page 87. To search by medical condition, find the section labeled List of drugs by medical condition on page 10. Then find your medical condition. For example, if you have a heart condition, you should look in that category. That is where you will find drugs that treat heart conditions. 9. What if the drug you want to take is not on the List? If you don t see your drug on the List, call Member Services at and ask about it. If you learn that ATC will not cover the drug, you can do one of these things: x Ask Member Services for a list of drugs like the one you want to take. Then show the list to your doctor or other prescriber. He or she can prescribe a drug on the List that is like the one you want to take. Or x You can ask the health plan to make an exception to cover your drug. Please see question 11 for more information about exceptions.? If you have questions, please call Absolute Total Care at from 8 a.m. to 8 p.m., seven days a week. On weekends and Federal holidays, you may be asked to leave a message. Your call will be returned within the next business day. TTY users call 711. The call is free. For more information, visit 5

7 10. What if you are a new ATC member and can t find your drug on the List or have a problem getting your drug? We can help. We will cover a temporary 30-day supply of your Part D drug and a 90-day supply of your Healthy Connections Medicaid drugs during the first 180 days you are a member of ATC. This will give you time to talk to your doctor or other prescriber. He or she will determine if there is a similar drug on the List you can take instead or whether to request an exception. We will cover a temporary supply of your drug if: x you are taking a drug that is not on our List, or x health plan rules do not let you get the amount ordered by your prescriber, or x the drug requires prior approval by ATC, or x you are taking a drug that is part of a step therapy restriction. If you live in a nursing home or other long-term care facility, you may refill your prescription for as long as 91 to 98 days for Part D drugs and 90 days for non-part D drugs. You may refill the drug multiple times during this time period. This gives your prescriber time to change your drugs to ones on the List or ask for an exception. Throughout the plan year, you may have a change in your treatment setting (the place where you get and take your medicine) because of the level of care you require. Such transitions may include, but are not limited to: Members who are discharged from a hospital or skilled-nursing facility to a home setting Members who are admitted to a hospital or skilled-nursing facility from a home setting Members who transfer from one skilled-nursing facility to another and are served by a different pharmacy Members who end their skilled-nursing facility Medicare Part A stay (where payments include all pharmacy charges) and who now need to use their Part D plan benefit Members who give up Hospice Status and go back to standard Medicare Part A and B coverage Members discharged from chronic psychiatric hospitals with highly individualized drug regimes For these changes in treatment settings, ATC will cover as much as a 31-day temporary supply of a Part D-covered drug when you fill your prescription at a network pharmacy. If you change treatment? If you have questions, please call Absolute Total Care at from 8 a.m. to 8 p.m., seven days a week. On weekends and Federal holidays, you may be asked to leave a message. Your call will be returned within the next business day. TTY users call 711. The call is free. For more information, visit 6

8 settings multiple times within the same month, you may have to request an exception or prior authorization and get approval for continued coverage of your drug. We will review these requests for continuation of therapy on a case-by-case basis when you are on a stabilized drug regimen that, if changed, is known to have risks. To ask for a temporary supply of a drug, call Member Services. 11. Can you ask for an exception to cover your drug? Yes. You can ask ATC to make an exception to cover a drug that is not on the List. You can also ask us to change the rules on your drug. x For example, ATC may limit the amount of a drug we will cover. If your drug has a limit, you can ask us to change the limit and cover more. x Other examples: You can ask us to drop step therapy restrictions or prior approval requirements. 12. How long does it take to get an exception? First, we must receive a statement from your prescriber supporting your request for an exception. After we receive the statement, we will give you a decision on your exception request within 72 hours. If you or your prescriber think your health may be harmed if you have to wait 72 hours for a decision, you can ask for an expedited exception. This is a faster decision. If your prescriber supports your request, we will give you a decision within 24 hours of receiving your prescriber s supporting statement. 13. How can you ask for an exception? To ask for an exception, call Member Services at from 8 a.m. to 8 p.m., seven days a week. On weekends and Federal holidays, you may be asked to leave a message. Your call will be returned within the next business day. TTY users call 711. A Member Services representative will work with you and your provider to help you ask for an exception.? If you have questions, please call Absolute Total Care at from 8 a.m. to 8 p.m., seven days a week. On weekends and Federal holidays, you may be asked to leave a message. Your call will be returned within the next business day. TTY users call 711. The call is free. For more information, visit 7

9 14. What are generic drugs? Generic drugs are made up of the same active ingredients as brand name drugs. They usually cost less than the brand name drug and usually don t have well-known names. Generic drugs are approved by the Food and Administration (FDA). ATC covers both brand name drugs and generic drugs. 15. What are OTC drugs? OTC stands for over-the-counter. ATC covers some OTC drugs when they are written as prescriptions by your provider. You can read the ATC List to see what OTC drugs are covered. 16. Does ATC cover OTC non-drug products? ATC covers some OTC non-drug products when they are written as prescriptions by your provider. You can read the ATC List to see what OTC non-drug products are covered. 17. What is your copay? You can read the ATC List to learn about the copay for each drug. ATC members living in nursing homes or other long-term care facilities will have no copays. Some members getting long-term care in the community will also have no copays. Copays are listed by tiers. Tiers are groups of drugs with the same copay. x Tier 1 drugs are generic drugs. The copay will be $0. x Tier 2 drugs are brand name drugs. The copay will be $0. x Tier 3 drugs are Healthy Connections Medicaid OTC. The copay will be $0.? If you have questions, please call Absolute Total Care at from 8 a.m. to 8 p.m., seven days a week. On weekends and Federal holidays, you may be asked to leave a message. Your call will be returned within the next business day. TTY users call 711. The call is free. For more information, visit 8

10 List of Covered s The list of covered drugs that begins on the next page gives you information about the drugs covered by ATC. If you have trouble finding your drug in the list, turn to the Index that begins on page 87. The first column of the chart lists the name of the drug. Brand name drugs are capitalized (e.g., HUMALOG) and generic drugs are listed in lower-case italics (e.g., amoxicillin). The information in the necessary actions, restrictions, or limits on use column tells you if ATC has any rules for covering your drug. Abbreviations B/D DP LA PA QL MO Descriptions This prescription drug has a Part B versus D administrative prior authorization requirement. This drug may be covered under Medicare Part B or D depending upon the circumstances. Information may need to be submitted describing the use and setting of the drug to make the determination. is not a Part D drug LA: Limited Availability. This prescription may be available only at certain pharmacies. For more information consult your Pharmacy Directory or call Member Services at , 8:00 am to 8:00 pm seven days a week. TTY/TDD users should call 711. This prescription requires you or your physician to get prior authorization. This means that you will need to get approval from ATC before you fill your prescriptions. If you don't get approval, ATC may not cover the drug. For certain drugs, ATC limits the amount of the drug that ATC will cover. For example, ATC provides 30 tablets per prescription for Januvia. This may be in addition to a standard one-month or three-month supply. This prescription drug is eligible for a 90-day supply through our mail order service as well as through our retail network pharmacies. Consider using mail order for your longterm (maintenance) medications (such as high blood pressure medications). Retail network pharmacies may be more appropriate for short-term prescriptions (such as antibiotics). Note: The DP next to a drug means the drug is not a Part D drug. The amount you pay when you fill a prescription for this drug does not count towards your total drug costs (that is, the amount you pay does not help you qualify for catastrophic coverage). In addition, if you are receiving Extra Help to pay for your prescriptions, you will not get any Extra Help to pay for these drugs. These drugs also have different rules for appeals. An appeal is a formal way of asking us to review a coverage decision and to change it if you think we made a mistake. For example, we might decide that a drug that you want is not covered or is no longer covered by Medicare or Healthy Connections Medicaid. If you or your doctor disagrees with our decision, you can appeal. To ask for instructions on how to appeal, call Member Services at You can also read the Member Handbook to learn how to appeal a decision.? If you have questions, please call Absolute Total Care at from 8 a.m. to 8 p.m., seven days a week. On weekends and Federal holidays, you may be asked to leave a message. Your call will be returned within the next business day. TTY users call 711. The call is free. For more information, visit 9

11 Analgesics Analgesics butalbital/acetaminophen/caffeine/codeine capsule 325mg; 1 50mg; 40mg; 30mg butalbital/acetaminophen/caffeine capsule 325mg; 50mg; 1 40mg butalbital/acetaminophen/caffeine tablet 325mg; 50mg; 40mg 1 butalbital/acetaminophen tablet 325mg; 50mg 1 butalbital/aspirin/caffeine capsule 325mg; 50mg; 40mg 1 butalbital/aspirin/caffeine tablet 325mg; 50mg; 40mg 1 GRALISE STARTER MISCELLANEOUS 0 2 GRALISE TABLET 300MG 2 GRALISE TABLET 600MG 2 Nonsteroidal Anti-inflammatory s diclofenac potassium tablet 50mg 1 MO diclofenac sodium dr tablet delayed release 25mg 1 diclofenac sodium dr tablet delayed release 50mg 1 diclofenac sodium dr tablet delayed release 75mg 1 diclofenac sodium er tablet extended release 24 hour 100mg 1 diflunisal tablet 500mg 1 etodolac er tablet extended release 24 hour 400mg 1 etodolac er tablet extended release 24 hour 500mg 1 etodolac er tablet extended release 24 hour 600mg 1 etodolac capsule 200mg 1 etodolac capsule 300mg 1 etodolac tablet 400mg 1 etodolac tablet 500mg 1 fenoprofen calcium tablet 600mg 1 flurbiprofen tablet 100mg 1 flurbiprofen tablet 50mg 1 ibuprofen suspension 100mg/5ml 1 ibuprofen tablet 400mg 1 ibuprofen tablet 600mg 1 ibuprofen tablet 800mg 1 indomethacin er capsule extended release 75mg 1 PA (Anti-inflammatory Agents) indomethacin capsule 25mg 1 PA (Anti-inflammatory Agents) indomethacin capsule 50mg 1 PA (Anti-inflammatory Agents) ketoprofen er capsule extended release 24 hour 200mg 1 QL (30 EA per 30 days) ketoprofen capsule 50mg 1 ketoprofen capsule 75mg 1 ketorolac tromethamine injection 15mg/ml 1 ketorolac tromethamine injection 30mg/ml 1 meclofenamate sodium capsule 100mg 1 meclofenamate sodium capsule 50mg 1 meloxicam suspension 7.5mg/5ml 1 meloxicam tablet 15mg 1 QL (30 EA per 30 days) meloxicam tablet 7.5mg 1 QL (30 EA per 30 days) nabumetone tablet 500mg 1 nabumetone tablet 750mg 1 Page 1 of 103

12 naproxen dr tablet delayed release 375mg 1 naproxen dr tablet delayed release 500mg 1 naproxen sodium tablet 275mg 1 naproxen sodium tablet 550mg 1 naproxen suspension 125mg/5ml 1 naproxen tablet 250mg 1 naproxen tablet 375mg 1 naproxen tablet 500mg 1 oxaprozin tablet 600mg 1 piroxicam capsule 10mg 1 piroxicam capsule 20mg 1 sulindac tablet 150mg 1 sulindac tablet 200mg 1 tolmetin sodium capsule 400mg 1 tolmetin sodium tablet 200mg 1 MO tolmetin sodium tablet 600mg 1 Opioid Analgesics, Long-acting fentanyl patch 72 hour 100mcg/hr 1 QL (10 EA per 30 days) fentanyl patch 72 hour 12mcg/hr 1 QL (10 EA per 30 days) fentanyl patch 72 hour 25mcg/hr 1 QL (10 EA per 30 days) fentanyl patch 72 hour 50mcg/hr 1 QL (10 EA per 30 days) fentanyl patch 72 hour 75mcg/hr 1 QL (10 EA per 30 days) levorphanol tartrate tablet 2mg 1 QL (240 EA per 30 days) METHADONE HCL INJECTION 10MG/ML 2 methadone hcl solution 10mg/5ml 1 methadone hcl solution 5mg/5ml 1 methadone hcl tablet 10mg 1 methadone hcl tablet 5mg 1 methadose tablet 10mg 1 morphine sulfate er tablet extended release 100mg 1 QL (180 EA per 30 days) morphine sulfate er tablet extended release 15mg 1 QL (120 EA per 30 days) morphine sulfate er tablet extended release 200mg 1 QL (120 EA per 30 days) morphine sulfate er tablet extended release 30mg 1 QL (120 EA per 30 days) morphine sulfate er tablet extended release 60mg 1 QL (120 EA per 30 days) Opioid Analgesics, Short-acting acetaminophen/codeine #3 tablet 300mg; 30mg 1 QL (390 EA per 30 days) acetaminophen/codeine tablet 300mg; 15mg 1 QL (390 EA per 30 days) acetaminophen/codeine tablet 300mg; 60mg 1 QL (390 EA per 30 days) ascomp/codeine capsule 325mg; 50mg; 40mg; 30mg 1 butorphanol tartrate injection 1mg/ml 1 butorphanol tartrate injection 2mg/ml 1 butorphanol tartrate solution 10mg/ml 1 DEMEROL INJECTION 50MG/ML 2 duramorph injection 0.5mg/ml 1 duramorph injection 1mg/ml 1 endocet tablet 325mg; 10mg 1 QL (360 EA per 30 days) endocet tablet 325mg; 5mg 1 QL (360 EA per 30 days) endocet tablet 325mg; 7.5mg 1 QL (360 EA per 30 days) Page 2 of 103

13 fentanyl citrate oral transmucosal lozenge on a handle 1200mcg 1 QL (120 EA per 30 days) PA (Fentanyl Citrate Oral Transmucosal) fentanyl citrate oral transmucosal lozenge on a handle 1600mcg 1 QL (120 EA per 30 days) PA (Fentanyl Citrate Oral Transmucosal) fentanyl citrate oral transmucosal lozenge on a handle 200mcg 1 QL (120 EA per 30 days) PA (Fentanyl Citrate Oral Transmucosal) fentanyl citrate oral transmucosal lozenge on a handle 400mcg 1 QL (120 EA per 30 days) PA (Fentanyl Citrate Oral Transmucosal) fentanyl citrate oral transmucosal lozenge on a handle 600mcg 1 QL (120 EA per 30 days) PA (Fentanyl Citrate Oral Transmucosal) fentanyl citrate oral transmucosal lozenge on a handle 800mcg 1 QL (120 EA per 30 days) PA (Fentanyl Citrate Oral Transmucosal) hydrocodone bitartrate/acetaminophen tablet 325mg; 2.5mg 1 QL (360 EA per 30 days) hydrocodone bitartrate/acetaminophen tablet 750mg; 10mg 1 QL (150 EA per 30 days) hydrocodone/acetaminophen tablet 325mg; 10mg 1 QL (360 EA per 30 days) hydrocodone/acetaminophen tablet 325mg; 5mg 1 QL (360 EA per 30 days) hydrocodone/acetaminophen tablet 325mg; 7.5mg 1 QL (360 EA per 30 days) hydrocodone/acetaminophen tablet 500mg; 10mg 1 QL (240 EA per 30 days) hydrocodone/acetaminophen tablet 500mg; 5mg 1 QL (240 EA per 30 days) hydrocodone/acetaminophen tablet 500mg; 7.5mg 1 QL (240 EA per 30 days) hydrocodone/acetaminophen tablet 650mg; 10mg 1 hydrocodone/acetaminophen tablet 650mg; 7.5mg 1 QL (180 EA per 30 days) hydrocodone/acetaminophen tablet 660mg; 10mg 1 QL (180 EA per 30 days) hydrocodone/acetaminophen tablet 750mg; 7.5mg 1 QL (150 EA per 30 days) hydromorphone hcl injection 500mg/50ml 1 hydromorphone hcl tablet 2mg 1 hydromorphone hcl tablet 4mg 1 hydromorphone hcl tablet 8mg 1 LAZANDA SOLUTION 100MCG/ACT 2 QL (600 EA per 30 days) PA (Lazanda) LAZANDA SOLUTION 400MCG/ACT 2 QL (150 EA per 30 days) PA (Lazanda) meperidine hcl injection 100mg/ml 1 meperidine hcl injection 25mg/ml 1 meperidine hcl injection 50mg/ml 1 morphine sulfate solution 10mg/5ml 1 morphine sulfate solution 20mg/5ml 1 morphine sulfate solution 20mg/ml 1 morphine sulfate tablet 15mg 1 morphine sulfate tablet 30mg 1 nalbuphine hcl injection 10mg/ml 1 nalbuphine hcl injection 20mg/ml 1 oxycodone hcl tablet 10mg 1 Page 3 of 103

14 oxycodone hcl tablet 15mg 1 oxycodone hcl tablet 20mg 1 oxycodone hcl tablet 30mg 1 oxycodone hcl tablet 5mg 1 oxycodone/acetaminophen capsule 500mg; 5mg 1 oxycodone/acetaminophen tablet 325mg; 10mg 1 QL (360 EA per 30 days) oxycodone/acetaminophen tablet 325mg; 5mg 1 QL (360 EA per 30 days) oxycodone/acetaminophen tablet 325mg; 7.5mg 1 QL (360 EA per 30 days) oxycodone/acetaminophen tablet 500mg; 7.5mg 1 QL (240 EA per 30 days) oxycodone/acetaminophen tablet 650mg; 10mg 1 roxicet tablet 325mg; 5mg 1 QL (360 EA per 30 days) stagesic capsule 500mg; 5mg 1 QL (240 EA per 30 days) TALWIN INJECTION 30MG/ML 2 tramadol hcl tablet 50mg 1 QL (240 EA per 30 days) tramadol hydrochloride/acetaminophen tablet 325mg; 37.5mg 1 QL (240 EA per 30 days) Anesthetics Local Anesthetics lidocaine hcl jelly gel 2% 1 lidocaine hcl jelly gel 2% 1 lidocaine hcl injection 0.5% 1 lidocaine hcl injection 1% 1 lidocaine hcl solution 4% 1 lidocaine viscous solution 2% 1 lidocaine/prilocaine cream 2.5%; 2.5% 1 lidocaine ointment 5% 1 lidocaine patch 5% 1 QL (90 EA per 30 days) PA (Anesthetics) XYLOCAINE-MPF INJECTION 1% 2 Anti-Addiction/Substance Abuse Treatment Agents Alcohol Deterrents/Anti-craving acamprosate calcium dr tablet delayed release 333mg 1 disulfiram tablet 250mg 1 disulfiram tablet 500mg 1 Opioid Dependence Treatments buprenorphine hcl injection 0.3mg/ml 1 buprenorphine hcl tablet sublingual 2mg 1 buprenorphine hcl tablet sublingual 8mg 1 naltrexone hcl tablet 50mg 1 SUBOXONE FILM 12MG; 3MG 2 SUBOXONE FILM 2MG; 0.5MG 2 SUBOXONE FILM 4MG; 1MG 2 SUBOXONE FILM 8MG; 2MG 2 SUBOXONE TABLET SUBLINGUAL 2MG; 0.5MG 2 SUBOXONE TABLET SUBLINGUAL 8MG; 2MG 2 ZUBSOLV TABLET SUBLINGUAL 1.4MG; 0.36MG 2 ZUBSOLV TABLET SUBLINGUAL 5.7MG; 1.4MG 2 Opioid Reversal Agents naloxone hcl injection 1mg/ml 1 Smoking Cessation Agents Page 4 of 103

15 buproban tablet extended release 12 hour 150mg 1 CHANTIX STARTING MONTH PAK TABLET 0 2 CHANTIX TABLET 0.5MG 2 QL (56 EA per 28 days) CHANTIX TABLET 1MG 2 QL (56 EA per 28 days) NICOTROL NS SOLUTION 10MG/ML 2 Antibacterials Aminoglycosides amikacin sulfate injection 500mg/2ml 1 AMIKACIN SULFATE INJECTION 50MG/ML 2 gentak ointment 0.3% 1 GENTAMICIN SULFATE/0.9% SODIUM CHLORIDE 2 INJECTION 0.9MG/ML; 0.9% GENTAMICIN SULFATE/0.9% SODIUM CHLORIDE 2 INJECTION 1.4MG/ML; 0.9% gentamicin sulfate/0.9% sodium chloride injection 1.6mg/ml; 1 0.9% gentamicin sulfate/0.9% sodium chloride injection 1mg/ml; 1 0.9% gentamicin sulfate cream 0.1% 1 gentamicin sulfate injection 10mg/ml 1 gentamicin sulfate injection 40mg/ml 1 gentamicin sulfate ointment 0.1% 1 gentamicin sulfate ointment 0.3% 1 gentamicin sulfate solution 0.3% 1 isotonic gentamicin injection 0.8mg/ml; 0.9% 1 isotonic gentamicin injection 1.2mg/ml; 0.9% 1 neomycin sulfate tablet 500mg 1 neomycin/polymyxin b sulfates solution 40mg/ml; unit/ml paromomycin sulfate capsule 250mg 1 STREPTOMYCIN SULFATE INJECTION 1GM 2 TOBRAMYCIN SULFATE/SODIUM CHLORIDE 2 INJECTION 0.9%; 0.8MG/ML tobramycin sulfate injection 10mg/ml 1 tobramycin sulfate injection 80mg/2ml 1 tobramycin sulfate solution 0.3% 1 Antibacterials, Other alcohol preps pad 1 baciim injection 50000unit 1 BACITRACIN INJECTION 50000UNIT 2 CHLORAMPHENICOL SODIUM SUCCINATE 2 INJECTION 1GM CLEOCIN IN D5W INJECTION 300MG/50ML; 5% 2 CLEOCIN IN D5W INJECTION 600MG/50ML; 5% 2 CLEOCIN IN D5W INJECTION 900MG/50ML; 5% 2 CLEOCIN PEDIATRIC GRANULES SOLUTION 2 RECONSTITUTED 75MG/5ML clindamycin hcl capsule 150mg 1 clindamycin hcl capsule 300mg 1 Page 5 of 103

16 clindamycin hcl capsule 75mg 1 clindamycin palmitate hcl solution reconstituted 75mg/5ml 1 clindamycin phosphate add-vantage injection 150mg/ml 1 clindamycin phosphate in d5w injection 300mg/50ml; 5% 1 clindamycin phosphate in d5w injection 600mg/50ml; 5% 1 clindamycin phosphate in d5w injection 900mg/50ml; 5% 1 clindamycin phosphate cream 2% 1 clindamycin phosphate gel 1% 1 clindamycin phosphate lotion 1% 1 clindamycin phosphate solution 1% 1 clindamycin phosphate swab 1% 1 colistimethate sodium injection 150mg 1 B/D CUBICIN INJECTION 500MG 2 LINCOCIN INJECTION 300MG/ML 2 linezolid injection 2mg/ml 1 methenamine hippurate tablet 1gm 1 metronidazole in nacl 0.79% injection 500mg/100ml; 0.79% 1 metronidazole vaginal gel 0.75% 1 metronidazole cream 0.75% 1 metronidazole gel 0.75% 1 metronidazole lotion 0.75% 1 metronidazole tablet 250mg 1 metronidazole tablet 500mg 1 mupirocin ointment 2% 1 neomycin/polymyxin/bacitracin/hydrocortisone ointment 1 400unit/gm; 1%; 0.5%; 10000unit/gm neomycin/polymyxin/hydrocortisone suspension 1%; 1 3.5mg/ml; 10000unit/ml nitrofurantoin macrocrystals capsule 100mg 1 PA (Antibacterials) nitrofurantoin macrocrystals capsule 50mg 1 PA (Antibacterials) nitrofurantoin monohydrate capsule 100mg 1 PA (Antibacterials) polymyxin b sulfate injection unit 1 PRIMSOL SOLUTION 50MG/5ML 2 silver sulfadiazine cream 1% 1 ssd cream 1% 1 SYNERCID INJECTION 350MG; 150MG 2 trimethoprim tablet 100mg 1 TYGACIL INJECTION 50MG 2 vancomycin hcl capsule 125mg 1 vancomycin hcl capsule 250mg 1 vancomycin hcl injection 1000mg 1 vancomycin hcl injection 10gm 1 vancomycin hcl injection 500mg 1 vandazole gel 0.75% 1 XIFAXAN TABLET 200MG 2 ZYVOX INJECTION 2MG/ML 2 ZYVOX SUSPENSION RECONSTITUTED 100MG/5ML 2 QL (600 ML per 10 days) ZYVOX TABLET 600MG 2 QL (20 EA per 10 days) Beta-lactam, Cephalosporins Page 6 of 103

17 Name Tier cefaclor er tablet extended release 12 hour 500mg 1 cefaclor capsule 250mg 1 cefaclor capsule 500mg 1 cefadroxil capsule 500mg 1 cefadroxil suspension reconstituted 250mg/5ml 1 cefadroxil suspension reconstituted 500mg/5ml 1 cefadroxil tablet 1gm 1 cefazolin sodium injection 10gm 1 cefazolin sodium injection 1gm 1 CEFAZOLIN SODIUM INJECTION 1GM; 5% 2 cefazolin sodium injection 500mg 1 cefdinir capsule 300mg 1 cefdinir suspension reconstituted 125mg/5ml 1 cefdinir suspension reconstituted 250mg/5ml 1 cefepime injection 1gm 1 cefepime injection 2gm 1 cefotaxime sodium injection 10gm 1 cefotaxime sodium injection 1gm 1 cefotaxime sodium injection 2gm 1 cefotaxime sodium injection 500mg 1 cefoxitin sodium injection 10gm 1 cefoxitin sodium injection 1gm 1 cefoxitin sodium injection 2gm 1 cefpodoxime proxetil tablet 100mg 1 cefpodoxime proxetil tablet 200mg 1 cefprozil suspension reconstituted 125mg/5ml 1 cefprozil suspension reconstituted 250mg/5ml 1 cefprozil tablet 250mg 1 cefprozil tablet 500mg 1 ceftazidime injection 1gm 1 ceftazidime injection 2gm 1 ceftazidime injection 6gm 1 ceftriaxone sodium injection 10gm 1 ceftriaxone sodium injection 1gm 1 ceftriaxone sodium injection 1gm 1 ceftriaxone sodium injection 1gm 1 ceftriaxone sodium injection 1gm 1 ceftriaxone sodium injection 1gm 1 ceftriaxone sodium injection 1gm 1 ceftriaxone sodium injection 1gm 1 ceftriaxone sodium injection 1gm 1 ceftriaxone sodium injection 1gm 1 ceftriaxone sodium injection 1gm 1 ceftriaxone sodium injection 1gm 1 ceftriaxone sodium injection 1gm 1 ceftriaxone sodium injection 1gm 1 ceftriaxone sodium injection 1gm 1 ceftriaxone sodium injection 1gm 1 ceftriaxone sodium injection 1gm 1 Requirements/Limits Page 7 of 103

18 Name Tier ceftriaxone sodium injection 1gm 1 ceftriaxone sodium injection 1gm 1 ceftriaxone sodium injection 1gm 1 ceftriaxone sodium injection 1gm 1 ceftriaxone sodium injection 1gm 1 ceftriaxone sodium injection 1gm 1 ceftriaxone sodium injection 250mg 1 ceftriaxone sodium injection 2gm 1 ceftriaxone sodium injection 2gm 1 ceftriaxone sodium injection 2gm 1 ceftriaxone sodium injection 2gm 1 ceftriaxone sodium injection 2gm 1 ceftriaxone sodium injection 2gm 1 ceftriaxone sodium injection 2gm 1 ceftriaxone sodium injection 2gm 1 ceftriaxone sodium injection 2gm 1 ceftriaxone sodium injection 2gm 1 ceftriaxone sodium injection 2gm 1 ceftriaxone sodium injection 2gm 1 ceftriaxone sodium injection 2gm 1 ceftriaxone sodium injection 2gm 1 ceftriaxone sodium injection 2gm 1 ceftriaxone sodium injection 2gm 1 ceftriaxone sodium injection 2gm 1 ceftriaxone sodium injection 2gm 1 ceftriaxone sodium injection 2gm 1 ceftriaxone sodium injection 2gm 1 ceftriaxone sodium injection 2gm 1 ceftriaxone sodium injection 500mg 1 cefuroxime axetil tablet 250mg 1 cefuroxime axetil tablet 500mg 1 cefuroxime sodium injection 1.5gm 1 cefuroxime sodium injection 7.5gm 1 cefuroxime sodium injection 750mg 1 cephalexin capsule 250mg 1 cephalexin capsule 500mg 1 cephalexin suspension reconstituted 125mg/5ml 1 cephalexin suspension reconstituted 250mg/5ml 1 cephalexin tablet 250mg 1 cephalexin tablet 500mg 1 CLAFORAN INJECTION 10GM 2 CLAFORAN INJECTION 1GM 2 CLAFORAN INJECTION 2GM 2 CLAFORAN INJECTION 500MG 2 FORTAZ INJECTION 1GM 2 FORTAZ INJECTION 2GM 2 SUPRAX CAPSULE 400MG 2 SUPRAX SUSPENSION RECONSTITUTED 100MG/5ML 2 SUPRAX SUSPENSION RECONSTITUTED 200MG/5ML 2 Requirements/Limits Page 8 of 103

19 SUPRAX SUSPENSION RECONSTITUTED 500MG/5ML 2 SUPRAX TABLET CHEWABLE 100MG 2 SUPRAX TABLET CHEWABLE 200MG 2 SUPRAX TABLET 400MG 2 TEFLARO INJECTION 400MG 2 TEFLARO INJECTION 600MG 2 Beta-lactam, Other AZACTAM IN ISO-OSMOTIC DEXTROSE INJECTION 1GM; 0 AZACTAM IN ISO-OSMOTIC DEXTROSE INJECTION 2 2GM; 0 AZACTAM INJECTION 1GM 2 aztreonam injection 1gm 1 imipenem/cilastatin injection 250mg; 250mg 1 imipenem/cilastatin injection 500mg; 500mg 1 INVANZ INJECTION 1GM 2 meropenem injection 500mg 1 Beta-lactam, Penicillins amoxicillin/clavulanate potassium er tablet extended release 12 hour 1000mg; 62.5mg amoxicillin/clavulanate potassium suspension reconstituted 1 200mg/5ml; 28.5mg/5ml amoxicillin/clavulanate potassium suspension reconstituted 1 250mg/5ml; 62.5mg/5ml amoxicillin/clavulanate potassium suspension reconstituted 1 400mg/5ml; 57mg/5ml amoxicillin/clavulanate potassium suspension reconstituted 1 600mg/5ml; 42.9mg/5ml amoxicillin/clavulanate potassium tablet chewable 200mg; mg amoxicillin/clavulanate potassium tablet chewable 400mg; 1 57mg amoxicillin/clavulanate potassium tablet 250mg; 125mg 1 amoxicillin/clavulanate potassium tablet 500mg; 125mg 1 amoxicillin/clavulanate potassium tablet 875mg; 125mg 1 amoxicillin capsule 250mg 1 amoxicillin capsule 500mg 1 amoxicillin suspension reconstituted 125mg/5ml 1 amoxicillin suspension reconstituted 200mg/5ml 1 amoxicillin suspension reconstituted 250mg/5ml 1 amoxicillin suspension reconstituted 400mg/5ml 1 amoxicillin tablet chewable 125mg 1 amoxicillin tablet chewable 250mg 1 amoxicillin tablet 500mg 1 amoxicillin tablet 875mg 1 ampicillin sodium injection 10gm 1 AMPICILLIN SODIUM INJECTION 125MG 2 ampicillin sodium injection 1gm 1 ampicillin-sulbactam injection 10gm; 5gm 1 Tier 2 1 Requirements/Limits Page 9 of 103

20 ampicillin-sulbactam injection 2gm; 1gm 1 ampicillin capsule 250mg 1 ampicillin capsule 500mg 1 ampicillin suspension reconstituted 125mg/5ml 1 ampicillin suspension reconstituted 250mg/5ml 1 BACTOCILL IN DEXTROSE INJECTION 0; 1GM/50ML 2 BACTOCILL IN DEXTROSE INJECTION 0; 2GM/50ML 2 BICILLIN C-R INJECTION UNIT/ML; UNIT/ML BICILLIN C-R INJECTION UNIT/2ML; UNIT/2ML BICILLIN L-A INJECTION UNIT/2ML 2 BICILLIN L-A INJECTION UNIT/4ML 2 BICILLIN L-A INJECTION UNIT/ML 2 dicloxacillin sodium capsule 250mg 1 dicloxacillin sodium capsule 500mg 1 nafcillin sodium injection 10gm 1 nafcillin sodium injection 1gm 1 NALLPEN/DEXTROSE INJECTION 0; 1GM/50ML 2 oxacillin sodium injection 10gm 1 oxacillin sodium injection 2gm 1 PENICILLIN G POTASSIUM IN ISO-OSMOTIC 2 DEXTROSE INJECTION 0; 40000UNIT/ML PENICILLIN G POTASSIUM IN ISO-OSMOTIC 2 DEXTROSE INJECTION 0; 60000UNIT/ML penicillin g potassium injection unit 1 PENICILLIN G PROCAINE INJECTION UNIT/ML 2 PENICILLIN G SODIUM INJECTION UNIT 2 penicillin v potassium solution reconstituted 125mg/5ml 1 penicillin v potassium solution reconstituted 250mg/5ml 1 penicillin v potassium tablet 250mg 1 penicillin v potassium tablet 500mg 1 PFIZERPEN-G INJECTION UNIT 2 piperacillin sodium/tazobactam sodium injection 4gm; 0.5gm 1 TIMENTIN INJECTION 0.1GM; 3GM 2 ZOSYN INJECTION 3GM; 0.375GM 2 ZOSYN INJECTION 5%; 2GM/50ML; 0.25GM/50ML 2 ZOSYN INJECTION 5%; 3GM/50ML; 0.375GM/50ML 2 Macrolides azithromycin injection 500mg 1 azithromycin suspension reconstituted 100mg/5ml 1 QL (15 ML per 5 days) azithromycin suspension reconstituted 200mg/5ml 1 QL (22.5 ML per 5 days) azithromycin tablet 250mg 1 QL (6 EA per 5 days) azithromycin tablet 500mg 1 QL (3 EA per 3 days) azithromycin tablet 600mg 1 QL (8 EA per 28 days) clarithromycin er tablet extended release 24 hour 500mg 1 clarithromycin suspension reconstituted 125mg/5ml 1 clarithromycin suspension reconstituted 250mg/5ml 1 clarithromycin tablet 250mg 1 QL (28 EA per 14 days) Page 10 of 103

21 clarithromycin tablet 500mg 1 QL (42 EA per 21 days) e.e.s. 400 tablet 400mg 1 e.e.s. granules suspension reconstituted 200mg/5ml 1 ERY-TAB TABLET DELAYED RELEASE 250MG 2 ERY-TAB TABLET DELAYED RELEASE 333MG 2 ERY-TAB TABLET DELAYED RELEASE 500MG 2 ERYPED 400 SUSPENSION RECONSTITUTED 2 400MG/5ML ERYTHROCIN LACTOBIONATE INJECTION 500MG 2 erythrocin stearate tablet 250mg 1 erythromycin base tablet 250mg 1 erythromycin base tablet 500mg 1 erythromycin ointment 5mg/gm 1 erythromycin solution 2% 1 KETEK TABLET 300MG 2 KETEK TABLET 400MG 2 QL (20 EA per 10 days) ZMAX SUSPENSION RECONSTITUTED 2GM 2 Quinolones AVELOX INJECTION 400MG/250ML; 0.8% 2 ciprofloxacin hcl solution 0.3% 1 ciprofloxacin hcl tablet 100mg 1 ciprofloxacin hcl tablet 250mg 1 ciprofloxacin hcl tablet 500mg 1 ciprofloxacin hcl tablet 750mg 1 ciprofloxacin i.v.-in d5w injection 200mg/100ml; 5% 1 ciprofloxacin injection 400mg/40ml 1 LEVAQUIN INJECTION 5%; 750MG/150ML 2 levofloxacin in d5w injection 5%; 500mg/100ml 1 levofloxacin injection 25mg/ml 1 levofloxacin solution 25mg/ml 1 levofloxacin tablet 250mg 1 QL (10 EA per 10 days) levofloxacin tablet 500mg 1 QL (14 EA per 14 days) levofloxacin tablet 750mg 1 QL (14 EA per 14 days) ofloxacin solution 0.3% 1 ofloxacin solution 0.3% 1 ofloxacin tablet 200mg 1 ofloxacin tablet 300mg 1 ofloxacin tablet 400mg 1 Sulfonamides sodium sulfacetamide solution 10% 1 sulfacetamide sodium suspension 10% 1 sulfadiazine tablet 500mg 1 sulfamethoxazole/trimethoprim ds tablet 800mg; 160mg 1 SULFAMETHOXAZOLE/TRIMETHOPRIM INJECTION 2 400MG/5ML; 80MG/5ML sulfamethoxazole/trimethoprim suspension 200mg/5ml; 1 40mg/5ml sulfamethoxazole/trimethoprim tablet 400mg; 80mg 1 Tetracyclines Page 11 of 103

22 demeclocycline hcl tablet 150mg 1 demeclocycline hcl tablet 300mg 1 doxycycline hyclate capsule 100mg 1 doxycycline hyclate capsule 50mg 1 doxycycline hyclate tablet 100mg 1 doxycycline hyclate tablet 20mg 1 minocycline hcl capsule 100mg 1 minocycline hcl capsule 50mg 1 minocycline hcl capsule 75mg 1 Anticonvulsants Anticonvulsants, Other APTIOM TABLET 200MG 2 QL (30 EA per 30 days) MO APTIOM TABLET 400MG 2 QL (30 EA per 30 days) MO APTIOM TABLET 600MG 2 QL (60 EA per 30 days) MO APTIOM TABLET 800MG 2 QL (30 EA per 30 days) MO FYCOMPA TABLET 10MG 2 QL (30 EA per 30 days) MO FYCOMPA TABLET 12MG 2 QL (30 EA per 30 days) MO FYCOMPA TABLET 2MG 2 QL (30 EA per 30 days) MO FYCOMPA TABLET 4MG 2 QL (30 EA per 30 days) MO FYCOMPA TABLET 6MG 2 QL (30 EA per 30 days) MO FYCOMPA TABLET 8MG 2 QL (30 EA per 30 days) MO levetiracetam injection 500mg/5ml 1 levetiracetam solution 100mg/ml 1 levetiracetam tablet 1000mg 1 QL (90 EA per 30 days) levetiracetam tablet 250mg 1 QL (180 EA per 30 days) MO levetiracetam tablet 500mg 1 QL (180 EA per 30 days) levetiracetam tablet 750mg 1 QL (120 EA per 30 days) POTIGA TABLET 200MG 2 QL (90 EA per 30 days) POTIGA TABLET 300MG 2 QL (90 EA per 30 days) POTIGA TABLET 400MG 2 QL (90 EA per 30 days) POTIGA TABLET 50MG 2 QL (180 EA per 30 days) MO Calcium Channel Modifying Agents CELONTIN CAPSULE 300MG 2 ethosuximide capsule 250mg 1 ethosuximide solution 250mg/5ml 1 LYRICA CAPSULE 100MG 2 QL (90 EA per 30 days) LYRICA CAPSULE 150MG 2 QL (60 EA per 30 days) LYRICA CAPSULE 200MG 2 QL (60 EA per 30 days) LYRICA CAPSULE 225MG 2 QL (60 EA per 30 days) LYRICA CAPSULE 25MG 2 QL (90 EA per 30 days) LYRICA CAPSULE 300MG 2 QL (60 EA per 30 days) LYRICA CAPSULE 50MG 2 QL (90 EA per 30 days) LYRICA CAPSULE 75MG 2 QL (90 EA per 30 days) LYRICA SOLUTION 20MG/ML 2 zonisamide capsule 100mg 1 zonisamide capsule 25mg 1 zonisamide capsule 50mg 1 Gamma-aminobutyric Acid (GABA) Augmenting Agents clonazepam odt tablet dispersible 0.125mg 1 QL (150 EA per 30 days) Page 12 of 103

23 clonazepam odt tablet dispersible 0.25mg 1 QL (150 EA per 30 days) clonazepam odt tablet dispersible 0.5mg 1 QL (150 EA per 30 days) clonazepam odt tablet dispersible 1mg 1 QL (150 EA per 30 days) clonazepam odt tablet dispersible 2mg 1 QL (300 EA per 30 days) clonazepam tablet 0.5mg 1 QL (150 EA per 30 days) clonazepam tablet 1mg 1 QL (150 EA per 30 days) clonazepam tablet 2mg 1 QL (300 EA per 30 days) diazepam gel 10mg 1 QL (50 EA per 30 days) diazepam gel 2.5mg 1 QL (24.9 EA per 30 days) diazepam gel 20mg 1 QL (100 EA per 30 days) divalproex sodium dr tablet delayed release 125mg 1 divalproex sodium dr tablet delayed release 250mg 1 divalproex sodium dr tablet delayed release 500mg 1 divalproex sodium er tablet extended release 24 hour 250mg 1 divalproex sodium er tablet extended release 24 hour 500mg 1 divalproex sodium capsule sprinkle 125mg 1 gabapentin capsule 100mg 1 gabapentin capsule 300mg 1 gabapentin capsule 400mg 1 gabapentin solution 250mg/5ml 1 gabapentin tablet 600mg 1 gabapentin tablet 800mg 1 GABITRIL TABLET 12MG 2 QL (90 EA per 30 days) GABITRIL TABLET 16MG 2 QL (90 EA per 30 days) ONFI SUSPENSION 2.5MG/ML 2 MO ONFI TABLET 10MG 2 ONFI TABLET 20MG 2 ONFI TABLET 5MG 2 phenobarbital elixir 20mg/5ml 1 phenobarbital tablet 100mg 1 phenobarbital tablet 15mg 1 phenobarbital tablet 16.2mg 1 phenobarbital tablet 30mg 1 phenobarbital tablet 32.4mg 1 phenobarbital tablet 60mg 1 phenobarbital tablet 64.8mg 1 phenobarbital tablet 97.2mg 1 primidone tablet 250mg 1 primidone tablet 50mg 1 SABRIL PACKET 500MG 2 QL (360 EA per 30 days) SABRIL TABLET 500MG 2 QL (360 EA per 30 days) tiagabine hydrochloride tablet 2mg 1 QL (90 EA per 30 days) tiagabine hydrochloride tablet 4mg 1 valproate sodium injection 500mg/5ml 1 valproic acid capsule 250mg 1 valproic acid syrup 250mg/5ml 1 Glutamate Reducing Agents felbamate suspension 600mg/5ml 1 felbamate tablet 400mg 1 Page 13 of 103

24 felbamate tablet 600mg 1 lamotrigine tablet chewable 25mg 1 lamotrigine tablet chewable 5mg 1 lamotrigine tablet 100mg 1 lamotrigine tablet 150mg 1 lamotrigine tablet 200mg 1 lamotrigine tablet 25mg 1 QUDEXY XR CAPSULE ER 24 HOUR SPRINKLE 100MG 2 QL (30 EA per 30 days) MO QUDEXY XR CAPSULE ER 24 HOUR SPRINKLE 150MG 2 QL (60 EA per 30 days) MO QUDEXY XR CAPSULE ER 24 HOUR SPRINKLE 200MG 2 QL (60 EA per 30 days) MO QUDEXY XR CAPSULE ER 24 HOUR SPRINKLE 25MG 2 QL (30 EA per 30 days) MO QUDEXY XR CAPSULE ER 24 HOUR SPRINKLE 50MG 2 QL (30 EA per 30 days) MO topiramate er capsule er 24 hour sprinkle 100mg 1 QL (30 EA per 30 days) MO topiramate er capsule er 24 hour sprinkle 150mg 1 QL (60 EA per 30 days) MO topiramate er capsule er 24 hour sprinkle 200mg 1 QL (60 EA per 30 days) MO topiramate er capsule er 24 hour sprinkle 25mg 1 QL (30 EA per 30 days) MO topiramate er capsule er 24 hour sprinkle 50mg 1 QL (30 EA per 30 days) MO topiramate capsule sprinkle 15mg 1 topiramate capsule sprinkle 25mg 1 topiramate tablet 100mg 1 topiramate tablet 200mg 1 topiramate tablet 25mg 1 topiramate tablet 50mg 1 TROKENDI XR CAPSULE EXTENDED RELEASE 24 2 QL (90 EA per 30 days) MO HOUR 100MG TROKENDI XR CAPSULE EXTENDED RELEASE 24 2 QL (60 EA per 30 days) MO HOUR 200MG TROKENDI XR CAPSULE EXTENDED RELEASE 24 2 QL (30 EA per 30 days) MO HOUR 25MG TROKENDI XR CAPSULE EXTENDED RELEASE 24 2 QL (30 EA per 30 days) MO HOUR 50MG Sodium Channel Agents BANZEL SUSPENSION 40MG/ML 2 BANZEL TABLET 200MG 2 QL (240 EA per 30 days) BANZEL TABLET 400MG 2 QL (240 EA per 30 days) carbamazepine er capsule extended release 12 hour 100mg 1 carbamazepine er capsule extended release 12 hour 200mg 1 carbamazepine er capsule extended release 12 hour 300mg 1 carbamazepine er tablet extended release 12 hour 200mg 1 carbamazepine er tablet extended release 12 hour 400mg 1 carbamazepine suspension 100mg/5ml 1 carbamazepine tablet chewable 100mg 1 carbamazepine tablet 200mg 1 CARBATROL CAPSULE EXTENDED RELEASE 12 2 HOUR 100MG CARBATROL CAPSULE EXTENDED RELEASE 12 2 HOUR 200MG CARBATROL CAPSULE EXTENDED RELEASE 12 HOUR 300MG 2 Page 14 of 103

25 CEREBYX INJECTION 500MG PE/10ML 2 DILANTIN INFATABS TABLET CHEWABLE 50MG 2 DILANTIN-125 SUSPENSION 125MG/5ML 2 DILANTIN CAPSULE 100MG 2 DILANTIN CAPSULE 30MG 2 epitol tablet 200mg 1 fosphenytoin sodium injection 100mg pe/2ml 1 oxcarbazepine suspension 300mg/5ml 1 oxcarbazepine tablet 150mg 1 oxcarbazepine tablet 300mg 1 oxcarbazepine tablet 600mg 1 OXTELLAR XR TABLET EXTENDED RELEASE 24 2 QL (60 EA per 30 days) MO HOUR 150MG OXTELLAR XR TABLET EXTENDED RELEASE 24 2 QL (90 EA per 30 days) MO HOUR 300MG OXTELLAR XR TABLET EXTENDED RELEASE 24 2 QL (120 EA per 30 days) MO HOUR 600MG PEGANONE TABLET 250MG 2 PHENYTEK CAPSULE 200MG 2 PHENYTEK CAPSULE 300MG 2 phenytoin infatabs tablet chewable 50mg 1 phenytoin sodium extended capsule 100mg 1 phenytoin sodium extended capsule 200mg 1 phenytoin sodium extended capsule 300mg 1 phenytoin sodium injection 50mg/ml 1 phenytoin suspension 125mg/5ml 1 phenytoin tablet chewable 50mg 1 TEGRETOL-XR TABLET EXTENDED RELEASE 12 2 HOUR 100MG TEGRETOL-XR TABLET EXTENDED RELEASE 12 2 HOUR 200MG TEGRETOL-XR TABLET EXTENDED RELEASE 12 2 HOUR 400MG TEGRETOL SUSPENSION 100MG/5ML 2 TEGRETOL TABLET 200MG 2 VIMPAT INJECTION 200MG/20ML 2 VIMPAT SOLUTION 10MG/ML 2 VIMPAT TABLET 100MG 2 VIMPAT TABLET 150MG 2 QL (60 EA per 30 days) VIMPAT TABLET 200MG 2 QL (60 EA per 30 days) VIMPAT TABLET 50MG 2 Antidementia Agents Antidementia Agents, Other ergoloid mesylates tablet 1mg 1 Cholinesterase Inhibitors donepezil hcl tablet dispersible 10mg 1 QL (30 EA per 30 days) donepezil hcl tablet dispersible 5mg 1 QL (30 EA per 30 days) donepezil hcl tablet 10mg 1 QL (30 EA per 30 days) donepezil hcl tablet 5mg 1 QL (30 EA per 30 days) Page 15 of 103

26 galantamine hydrobromide capsule extended release 24 hour 1 QL (30 EA per 30 days) 16mg galantamine hydrobromide capsule extended release 24 hour 1 QL (30 EA per 30 days) 24mg galantamine hydrobromide capsule extended release 24 hour 1 QL (30 EA per 30 days) 8mg galantamine hydrobromide solution 4mg/ml 1 galantamine hydrobromide tablet 12mg 1 QL (60 EA per 30 days) galantamine hydrobromide tablet 4mg 1 QL (180 EA per 30 days) galantamine hydrobromide tablet 8mg 1 QL (90 EA per 30 days) rivastigmine tartrate capsule 1.5mg 1 QL (60 EA per 30 days) rivastigmine tartrate capsule 3mg 1 QL (60 EA per 30 days) rivastigmine tartrate capsule 4.5mg 1 QL (60 EA per 30 days) rivastigmine tartrate capsule 6mg 1 QL (60 EA per 30 days) N-methyl-D-aspartate (NMDA) Receptor Antagonist NAMENDA TITRATION PAK TABLET 0 2 NAMENDA SOLUTION 10MG/5ML 2 QL (360 ML per 30 days) NAMENDA TABLET 10MG 2 QL (60 EA per 30 days) NAMENDA TABLET 5MG 2 QL (60 EA per 30 days) Antidepressants Antidepressants, Other BRINTELLIX TABLET 10MG 2 MO BRINTELLIX TABLET 20MG 2 MO BRINTELLIX TABLET 5MG 2 MO budeprion sr tablet extended release 12 hour 100mg 1 budeprion sr tablet extended release 12 hour 150mg 1 bupropion hcl sr tablet extended release 12 hour 100mg 1 bupropion hcl sr tablet extended release 12 hour 150mg 1 bupropion hcl sr tablet extended release 12 hour 200mg 1 bupropion hcl xl tablet extended release 24 hour 150mg 1 QL (30 EA per 30 days) bupropion hcl xl tablet extended release 24 hour 300mg 1 QL (30 EA per 30 days) bupropion hcl tablet 100mg 1 bupropion hcl tablet 75mg 1 maprotiline hcl tablet 25mg 1 maprotiline hcl tablet 50mg 1 maprotiline hcl tablet 75mg 1 mirtazapine odt tablet dispersible 30mg 1 mirtazapine odt tablet dispersible 45mg 1 mirtazapine tablet dispersible 15mg 1 mirtazapine tablet 15mg 1 mirtazapine tablet 30mg 1 mirtazapine tablet 45mg 1 mirtazapine tablet 7.5mg 1 nefazodone hcl tablet 100mg 1 nefazodone hcl tablet 150mg 1 nefazodone hcl tablet 200mg 1 nefazodone hcl tablet 250mg 1 nefazodone hcl tablet 50mg 1 trazodone hcl tablet 100mg 1 Page 16 of 103