Health Net Medicare Part D Tier Employer Group Formulary (List of Covered Drugs)

Transcription

1 Health Net Medicare Part D Employer Group Formulary (List of Covered Drugs) Please read: This document contains information about the drugs we cover in this plan AS OF JULY 1, 01. Note to existing members: This formulary has changed since last year. Please review this document to make sure that it still contains the drugs you take. To get updated information about the drugs covered by Health Net, please visit our website at Beneficiaries must use network pharmacies to access their prescription drug benefit. Benefits, formulary, pharmacy network, premium and/or copayments/coinsurance may change on January 1, 013. This information is available for free in other languages. Please contact our Customer Service department at the toll free number listed at the beginning of this booklet. Esta información está disponible en forma gratuita en otros idiomas. Comuníquese con nuestro departamento de Servicio al Cliente al número de teléfono gratuito que aparece al comienzo de este folleto. A Medicare Advantage organization with a Medicare contract. A stand-alone prescription drug plan with a Medicare contract Material ID# Y0035_EG_01_0005_A (H0351, H056, H539, H550, H6815, S5678) Compliance Approved HPMS Approved Formulary File Submission ID 105, Version 15

2 i If you would like to contact Health Net Customer Service, please find the contact information for your state below: Arizona For medical plans: Health Net Attn: Arizona Medicare Program P.O. Box 100 Van Nuys, CA Fax For Health Net Orange, Part D prescription drug plans: Health Net P.O. Box 6501 Rensselaer, NY Fax Hours are: 8:00 a.m. 8:00 p.m., seven days a week. Current members: All medical plans , TTY Health Net Orange (PDP) prescription drug plans , TTY Prospective members: All medical plans , TTY Health Net Orange prescription drug plans , TTY California For medical plans: Health Net P.O. Box Van Nuys, CA Fax For Health Net Orange, Part D prescription drug plans: Health Net P.O. Box 6501 Rensselaer, NY Fax Hours are: 8:00 a.m. 8:00 p.m., seven days a week. Current members: Health Net Seniority Plus Ruby (H), Health Net Green (H), Salud con Health Net (H), Health Net Healthy Heart (H) , TTY Health Net Amber (H SNP) , TTY Health Net Violet (PPO) , TTY Health Net Orange (PDP) prescription drug plans , TTY Prospective members: All medical plans , TTY Health Net Orange prescription drug plans , TTY

3 All other states For Health Net Orange, Part D prescription drug plans: Health Net P.O. Box 6501 Rensselaer, NY Fax Hours are: 8:00 a.m. 8:00 p.m., seven days a week. Current members: Health Net Orange (PDP) prescription drug plans , TTY Prospective members: Health Net Orange prescription drug plans , TTY ii

4 Welcome to Health Net. We are glad you have chosen us to be your plan of choice for your prescription needs. This easy-toread formulary provides you with valuable information about the formulary (also known as a drug list ) that applies to your benefit, the prescription drugs we cover, copayment or coinsurance levels and details on how to use your benefit. To quickly find your drug, turn to the index at the end of this booklet. For detailed information on how to read the formulary, turn to page x. What is the Health Net Medicare Part D formulary? This formulary represents the entire list of Part D drugs covered by Health Net. A formulary is a list of covered drugs selected by Health Net in consultation with a team of health care providers, which represents the prescription therapies believed to be a necessary part of a quality treatment program. Health Net will generally cover the drugs listed on the formulary as long as the drug is medically necessary, the prescription is filled at a Health Net network pharmacy, and other plan rules are followed. For information on how to fill your prescriptions, please review your Evidence of Coverage (EOC). Can the formulary change? Generally, if you are taking a drug on the 01 formulary that was covered at the beginning of the year, we will not discontinue or reduce coverage of the drug during the 01 coverage year except when a new, less expensive generic drug becomes available and is offered at a lower tier or lower cost to you, or when new information about the safety or effectiveness of a drug is released. In most cases, formulary changes such as applying a new or revised restriction to a drug, moving a drug to a more expensive tier or removing a drug from the formulary, will not affect you if you are currently taking the drug. The drug will remain available at the same cost for the remainder of the contract year. We feel it is important that you have continued access for the remainder of the contract year to the formulary drugs that were available when you chose our plan. However, in some cases, these types of formulary changes may affect you. If a formulary change will affect you, we will notify you in advance of the change. You will receive notification at least 60 days before the change becomes effective, or you may receive a 60-day supply when you request a refill of the drug which will act as your notification. If we make any nonmaintenance formulary changes during the year, you will be notified via mail and the changes will be posted on our website. iii

5 If the United States Food and Drug Administration (FDA) deems a drug on the formulary to be unsafe or if the manufacturer of the drug removes the drug from the market, we will immediately remove the drug from the formulary and provide notice to you if you are currently receiving the drug. To get the most up-to-date information about the drugs covered by Health Net, please visit our website at where you may view and print a formulary. You may also call our Customer Service department at the toll-free number listed at the beginning of this booklet. You can ask Health Net to make an exception and cover your drug. See How do I request an exception to the Health Net Medicare Part D formulary? for information about how to request an exception. Are there any restrictions on my coverage? Some drugs may have additional restrictions or limits on coverage. You can find out if your drug has any restrictions or limits by looking in the column on the formulary. What if my drug is not on the formulary? If your drug is not included on the formulary, you should first contact Customer Service and ask if your drug is covered. If you learn that Health Net does not cover your drug, you have two options: You can ask Customer Service for a list of similar drugs that are covered by Health Net. When you receive the list, show it to your prescriber and ask him or her to prescribe a similar drug that is covered by Health Net. iv

6 The table below provides a description of abbreviations that may appear in the column on the formulary: Abbreviation Definition Description AL Age Limit Some drugs may require prior authorization if your age does not meet manufacturer, FDA, or clinical recommendations. B Medicare Part B Some drugs listed on the formulary are only covered under Medicare Part B. In some cases, these drugs may be obtained at a pharmacy if you have Part B coverage through Health Net. Please refer to your plan documents for the appropriate copayment or coinsurance. Medicare Part B vs. Part D Some drugs require prior authorization to determine coverage under the Medicare Part B or Part D benefit, according to Medicare guidelines. Your prescriber may need to supply additional information, which will allow Health Net to make the determination. If the drug qualifies for coverage under Medicare Part B and you do not have Medicare Part B coverage through Health Net, the drug will not be covered by Health Net. GL Gender Limit Some drugs are only covered for males or females based on manufacturer, FDA, or clinical recommendations. v

7 LA Limited Access Some drugs may be subject to limited access or restricted access. This means that a drug may only be available at one or a limited number of pharmacies. Limited access may be due to the following reasons: The FDA has restricted distribution of a drug to certain facilities, pharmacies or prescribers, or Certain drugs require special handling, coordination of care, or patient education that cannot be provided at a retail pharmacy. You should talk to your prescriber or pharmacist for details about acquiring limited access drugs. Mail Order These drugs are available at Health Net s network mail order pharmacy in addition to other network pharmacies. NT Non-TrOOP Health Net covers some drugs that the Centers for Medicare and Medicaid Services (CMS) excludes from coverage under Part D. The amount paid for these drugs will not count toward your true out-of-pocket costs (TrOOP) or Initial Coverage Limit. vi

8 PA Prior Authorization Some drugs require prior authorization for coverage, clinical effectiveness, or safety reasons. This means that you or your prescriber must request approval from Health Net before the drug will be covered. QL Quantity Limit For some drugs, Health Net limits the amount of the drug covered based on manufacturer, FDA, clinical dosing or treatment recommendations. This may replace your standard days supply limit. ST Step Therapy In some cases, Health Net requires you to first try certain drugs to treat your medical condition before covering another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, Health Net may not cover Drug B unless you try Drug A first. If Drug A is found in your recent Health Net prescription claims history, Drug B will be automatically approved. You can ask Health Net to make an exception to these restrictions or limits. See the next section. vii

9 How do I request an exception to the Health Net Medicare Part D formulary? You can ask us to make an exception to our coverage rules. There are several types of exceptions that you can ask us to make. You can ask us to cover your drug even if it is not on the formulary. You can ask us to waive coverage restrictions or limits on your drug. For example, for certain drugs, Health Net may limit the amount of the drug that will be covered. If your drug has a quantity limit, you can ask us to waive the limit and cover more. You can ask us to make an exception and cover your drug at a lower tier. If your drug is on 3 (Non-preferred ) or on (Injectable ), you can ask us for an exception to cover it for the (Preferred ) copayment. Please note, if we grant your request to cover a drug that is not on the formulary, the drug will be available for the 3 (Non-preferred ) copayment. The drug is not eligible for an exception for payment at a lower tier. Also, drugs on (Preferred ) and 5 (Specialty ) are not eligible for an exception for payment at a lower tier. Generally, Health Net will only approve your request for an exception if preferred alternative drugs or utilization restrictions would not be as effective in treating your condition and/or would cause you to have adverse medical effects. You may contact us to request an exception. When requesting an exception, we require a statement from your prescriber supporting your request. Generally, we must make our decision within 7 hours of receiving your prescriber s supporting statement. You or your prescriber may request an expedited (fast) exception if you or your prescriber believe that your health could be seriously harmed by waiting up to 7 hours for a decision. If your request to expedite is granted, we must give you a decision no later than hours after we receive your prescriber s supporting statement. viii

10 Formulary tier descriptions To determine how much you will be required to pay for a drug, the abbreviations in the table below appear in the and columns on the formulary. The copayment or coinsurance level you will be required to pay is displayed in the Copayment/Coinsurance column. If you do not know your copayment or coinsurance for each tier, please refer to your Summary of Benefits or EOC. Abbreviation Copayment/ Coinsurance Description 1 1 copayment Preferred generic drugs. copayment Preferred brand drugs. 3 3 copayment Non-preferred brand drugs. (Injectable ) copayment or coinsurance Includes injectable drugs that do not meet the Centers for Medicare and Medicaid Services (CMS) minimum cost threshold required to be placed on the Specialty ( 5). These drugs may be limited to a maximum 30-day supply per fill. 5 (Specialty ) 5 copayment or coinsurance NF Non-formulary If Health Net approves an exception request for a nonformulary drug, the Nonpreferred ( 3) copayment will apply. High cost drugs. Some of these drugs may be limited to a maximum 30-day supply per fill. Specialty ( 5) drugs are not eligible for exceptions for payment at a lower tier. Drugs not covered on Health Net s Medicare Part D formulary. You may request an exception from Health Net to cover these drugs. See the section, How do I request an exception to the Health Net Medicare Part D formulary? for information about how to request an exception. ix

11 How do I use the formulary? The drugs in this formulary are grouped into Therapeutic Category and Therapeutic Class Name. If you know what your drug is used for, look for the category or class name which is listed alphabetically. For example, drugs used to treat depression are listed under the category, ANTIDEPRESSANTS. The index at the end of this booklet provides an alphabetical list of all of the drugs included in the formulary. Both brand name drugs and generic drugs are listed in the index. Next to the drug, you will see the page number where you can find coverage information. The name of each drug can be found in the first column. name drugs are in uppercase (example: ZOCOR) and generic drugs are in lowercase (example: simvastatin). When there is a brand name drug with a generic equivalent available, the drugs will be listed on the same line with the generic drug in parentheses, for example: ZOCOR (simvastatin). status The tier status is shown to the right of the drug name. Generally, when there is a brand name drug with a generic equivalent available, the brand name drug will be non-preferred or non-formulary. How do I read the formulary? If you have trouble finding a drug, turn to the index at the end of this booklet. and generic drugs Health Net covers both brand name drugs and generic drugs. A generic drug is approved by the FDA as having the same active ingredient as the brand name drug. Generally, generic drugs cost less than brand name drugs. x

12 The information in the column tells you if there are any limits or restrictions on a drug. For a complete description of abbreviations found in the column, please refer to the Abbreviations table beginning on page page v. drug only; generic not available Note: Example only drug (generic drug) Therapeutic Category Name Therapeutic Class Name - name (generic name) 1,, PA, QL name 3 LA, ST Sample of abbreviations; Turn to pages v - vii for a complete description of abbreviations Health Net s transition program The transition program is designed to ensure continuity of care for new members, existing members who may be subject to formulary changes, and members who experience a level of care change. The program also allows members in Long Term Care (LTC) facilities access to a temporary transition supply of drugs. Initial eligibility If you are a new member in our plan, you may be taking drugs that are not on the formulary, or you may be taking a drug that is on the formulary with restrictions or limits. For example, you may need a prior authorization from us before your prescription can be filled. You should talk to your prescriber to decide if you should change to a drug that we cover or request an exception so that we will cover the drug you take. While you talk to your prescriber to determine the right course of action for you, we may cover your drug in certain cases during the first 90 days you are a member of our plan. This may also apply if you are a renewing member and experience a change in the formulary at the beginning of the contract year. During this time, if your drug is not on the formulary or if your ability to get your drug is limited, we will cover a onetime temporary 30-day transition supply (unless you have a prescription written for fewer days) when you go to a network pharmacy. If your prescription is written for less than a 30-day transition supply, refills for up to a cumulative 30-day supply will be covered. If you are a resident of a LTC facility, we will cover a temporary 3-day transition supply (unless you have a prescription written for fewer days). We will allow you to refill your prescription until we have provided you with a 10-day transition supply, consistent with the dispensing increment, (unless you have a prescription written for fewer days). xi

13 Emergency supply If you are a resident of an LTC facility and need a drug that is not on the formulary or your ability to get your drug is limited, but you are past the first 90 days of membership in our plan, we will cover a 3-day emergency supply of that drug (unless you have a prescription written for fewer days) while you pursue an exception. Level of care changes If you experience a level of care change, we will cover a transition supply of your drugs. A level of care change occurs when you are discharged from a hospital or moved to or from a long-term care facility. If you move from a LTC facility or a hospital to home and need a transition supply right away, we will cover one 30-day supply, or less if your prescription is written for fewer days (in which case we will allow multiple fills to provide up to a total of a 30-day supply of medication). If you move from home or a hospital to a long-term care facility and need a transition supply right away, we will cover one 3-day supply, or less if your prescription is written for fewer days (in which case we will allow multiple fills to provide up to a total of a 3-day supply of medication). For more information For more detailed information about your Health Net prescription drug coverage, please review your EOC and other plan materials. If you have questions about Health Net, please call our Customer Service department at the toll-free number listed at the beginning of this booklet, or visit If you have general questions about Medicare prescription drug coverage, please call Medicare at MEDICARE ( ) hours a day/ 7 days a week. TTY/TDD users should call Or, visit xii

14 ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS Amphetamines ADDERALL (amphetaminedextroamphetamine) TABS OR 1.5 MG, MG,.5 MG, 3.15 MG, 3.75 MG, 5 MG, 7.5 MG ADDERALL XR (amphetaminedextroamphetamine) CP OR 1.5 MG,.5 MG, 3.75 MG, 5 MG, 6.5 MG, 7.5 MG DESOXYN (methamphetamine hcl) TABS OR 5 MG DEXEDRINE (dextroamphetamine sulfate) CP OR 10 MG, 15 MG, 5 MG DEXEDRINE (dextroamphetamine sulfate) TABS OR 5 MG DEXTROSTAT (dextroamphetamine sulfate) TABS OR 10 MG PROCENTRA (dextroamphetamine sulfate) SOLN OR 5 MG/5ML VYVANSE CAPS OR 0 MG, 30 MG, 0 MG, 50 MG, 60 MG, 70 MG Anti-Obesity Agents XENICAL CAPS OR 10 MG 3 3 PA; ; Attention-Deficit/Hyperactivity Disorder (ADHD) Agents INTUNIV TB OR 1 MG, MG, 3 MG, MG 3 KAPVAY TB1 OR 0.1 MG 3 STRATTERA CAPS OR 10 MG, 100 MG, 18 MG, 5 MG, 0 MG, 60 MG, 80 MG Stimulants - Misc. CONCERTA (methylphenidate hcl) TBCR OR 18 MG, 7 MG, 36 MG, 5 MG 1 DAYTRANA PTCH TD 10 MG/9HR, 15 MG/9HR, 0 MG/9HR, 30 MG/9HR 3 FOCALIN (dexmethylphenidate hcl) TABS OR 10 MG,.5 MG, 5 MG FOCALIN XR CP OR 10 MG, 15 MG, 0 MG, 5 MG, 30 MG, 35 MG, 0 MG, 5 MG 3 METADATE CD CPCR OR 10 MG, 0 MG, 3 30 MG, 0 MG, 50 MG, 60 MG LA=Limited Access =Available at Mail Order NT=Non-TrOOP 1

15 METHYLIN CHEW OR 10 MG,.5 MG, 5 MG METHYLIN (methylphenidate hcl) SOLN OR 10 MG/5ML, 5 MG/5ML 1 methylin er tbcr or 10 mg 1 methylphenidate hcl er tbcr or 10 mg 1 DAFINIL TABS OR 100 MG, 00 MG 3 NUVIGIL TABS OR 150 MG, 50 MG, 50 MG PROVIGIL TABS OR 100 MG, 00 MG 3 RITALIN (methylphenidate hcl) TABS OR 10 MG, 0 MG, 5 MG RITALIN LA (methylphenidate hcl) CP OR 0 MG, 30 MG, 0 MG RITALIN LA CP OR 10 MG 3 RITALIN SR (methylphenidate hcl) TBCR OR 0 MG AMINOGLYCOSIDES Aminoglycosides AMIKACIN SULFATE (amikacin sulfate) SOLN IJ 50 MG/ML amikacin sulfate soln ij 50 mg/ml amikacin sulfate soln ij 500 mg/ml AMIKIN (amikacin sulfate) SOLN IJ 50 MG/ML AMIKIN (amikacin sulfate) SOLN IJ 1 GM/ML GARAMYCIN (gentamicin sulfate) SOLN IJ 0 MG/ML gentamicin sulfate soln ij 10 mg/ml PA; ; PA; ; PA; ; gentamicin sulfate soln iv 10 mg/ml gentamicin sulfate/0.9% sodium chloride soln iv 0.9 %, mg/ml, %, mg/ml, %, mg/ml, %, mg/ml, %, mg/ml LA=Limited Access =Available at Mail Order NT=Non-TrOOP 15

16 gentamicin sulfate/0.9% sodium chloride soln iv %, mg/ml gentamicin sulfate/sodium chloride soln iv %, mg/ml, %, mg/ml, %, mg/ml, %, mg/ml gentamicin sulfate/sodium chloride soln iv %, mg/ml HUMATIN (paromomycin sulfate) CAPS OR 50 MG ISOTONIC GENTAMICIN SOLN IV 0.9- %, MG/ML isotonic gentamicin soln iv %, mg/ml, %, mg/ml, %, mg/ml, %, mg/ml isotonic gentamicin soln iv %, mg/ml KANAMYCIN SULFATE SOLN IJ 333 MG/ML NEO-FRADIN SOLN OR 5 MG/ML neomycin sulfate tabs or 500 mg 1 STREPTOMYCIN SULFATE SOLR IM 1 GM TOBI NEBU IN 300 MG/5ML 5 tobramycin sulfate soln ij 10 mg/ml, 0 mg/ml tobramycin sulfate soln ij 1. gm/30ml, 0 mg/ml, 80 mg/ml tobramycin sulfate solr ij 1. gm TOBRAMYCIN SULFATE ADD-VANTAGE SOLN IV 10 MG/ML tobramycin sulfate/sodium chloride soln iv %, mg/ml, %, mg/ml ANALGESICS - ANTI-INFLAMMATORY Anti-TNF-alpha - Monoclonoal Antibodies HUMIRA KIT SC 0 MG/0.ML, 0 MG/0.8ML HUMIRA PEN KIT SC 0 MG/0.8ML 5 LA=Limited Access =Available at Mail Order NT=Non-TrOOP 5 PA PA 16

17 HUMIRA PEN-CROHNS DISEASESTARTER KIT SC 0 MG/0.8ML HUMIRA PEN-PSORIASIS STARTER KIT SC 0 MG/0.8ML SIMPONI SOLN SC 50 MG/0.5ML 5 Antirheumatic Antimetabolites RHEUMATREX TABS OR.5 MG Gold Compounds RIDAURA CAPS OR 3 MG Interleukin-1 Blockers ARCALYST SOLR SC 0 MG 5 Interleukin-1 Receptor Antagonist (IL-1Ra) KINERET SOLN SC 100 MG/0.67ML 5 Interleukin-1beta Blockers ILARIS SOLR SC 180 MG PA PA PA LA PA LA Interleukin-6 Receptor Inhibitors ACTEMRA SOLN IV 00 MG/10ML, 00 MG/0ML, 80 MG/ML Nonsteroidal Anti-inflammatory Agents (NSAIDs) ANAPROX (naproxen sodium) TABS OR 75 MG ANAPROX DS (naproxen sodium) TABS OR 550 MG ARTHROTEC 50 TABS OR MCG, MG 3 ARTHROTEC 75 TABS OR MCG, MG 3 CATAFLAM (diclofenac potassium) TABS OR 50 MG CELEBREX CAPS OR 100 MG, 00 MG, 00 MG, 50 MG CLINORIL (sulindac) TABS OR 00 MG DAYPRO (oxaprozin) TABS OR 600 MG LA=Limited Access =Available at Mail Order NT=Non-TrOOP 5 PA 17

18 DUEXIS TABS OR MG 3 EC-NAPROSYN (naproxen) TBEC OR 375 MG, 500 MG etodolac caps or 00 mg 1 etodolac tabs or 00 mg, 500 mg 1 etodolac cr tb or 00 mg 1 etodolac er tb or 00 mg, 500 mg, 600 mg 1 FELDENE (piroxicam) CAPS OR 10 MG, 0 MG fenoprofen calcium tabs or 600 mg 1 fenoprofen calcium tabs or 600 mg 1 flurbiprofen tabs or 100 mg, 50 mg 1 ibuprofen susp or 100 mg/5ml 1 INDOCIN SUSP OR 5 MG/5ML indomethacin caps or 5 mg, 50 mg 1 indomethacin cr cpcr or 75 mg 1 indomethacin er cpcr or 75 mg 1 ketoprofen caps or 50 mg, 75 mg 1 ketoprofen er cp or 00 mg 1 KETOROLAC TROMETHAMINE SOLN IJ 300 MG/10ML ketorolac tromethamine soln ij 15 mg/ml, 30 mg/ml, 60 mg/ml KETOROLAC TROMETHAMINE (ketorolac tromethamine) SOLN IM 30 MG/ML ketorolac tromethamine soln im 30 mg/ml, 60 mg/ml LODINE (etodolac) CAPS OR 300 MG LA=Limited Access =Available at Mail Order NT=Non-TrOOP 18

19 meclofenamate sodium caps or 100 mg, 50 mg MEFENAMIC ACID (mefenamic acid) CAPS OR 50 MG 1 BIC (meloxicam) SUSP OR 7.5 MG/5ML BIC (meloxicam) TABS OR 15 MG, 7.5 MG TRIN (ibuprofen) TABS OR 00 MG, 600 MG, 800 MG NALFON CAPS OR 00 MG 3 NAPRELAN (naproxen sodium) TB OR 500 MG NAPRELAN TB OR 375 MG NAPRELAN TB OR 3 NAPRELAN TB OR 750 MG 3 NAPROSYN (naproxen) SUSP OR 15 MG/5ML NAPROSYN (naproxen) TABS OR 50 MG, 375 MG, 500 MG PONSTEL (mefenamic acid) CAPS OR 50 MG RELAFEN (nabumetone) TABS OR 500 MG, 750 MG SPRIX SOLN NA MG/SPRAY 3 1 sulindac tabs or 150 mg 1 tolmetin sodium caps or 00 mg 1 tolmetin sodium tabs or 00 mg, 600 mg 1 TORADOL ORAL (ketorolac tromethamine) TABS OR 10 MG VIVO TBEC OR MG, MG 500 MG & 750 MG Pack VOLTAREN (diclofenac sodium) TBEC OR 5 MG, 50 MG, 75 MG VOLTAREN-XR (diclofenac sodium) TB OR 100 MG LA=Limited Access =Available at Mail Order NT=Non-TrOOP 19

20 ZIPSOR CAPS OR 5 MG 3 Pyrimidine Synthesis Inhibitors ARAVA (leflunomide) TABS OR 10 MG, 0 MG Selective Costimulation Modulators ORENCIA SOLN SC 15 MG/1ML 5 ORENCIA SOLR IV 50 MG 5 Soluble Tumor Necrosis Factor Receptor Agents ENBREL KIT SC 5 MG 5 ENBREL SOLN SC 5 MG/0.5ML, 50 MG/ML 5 ENBREL SURECLICK SOLN SC 50 MG/ML 5 PA PA PA PA PA ANALGESICS - NonNarcotic Analgesic Combinations alagesic caps or mg 1 americet tabs or mg 1 anolor 300 caps or mg 1 butal/asa/caff tabs or mg 1 butalbital compound tabs or mg 1 butalbital/acetaminophen/caffeine caps or, mg butalbital/acetaminophen/caffeine tabs or mg, mg butalbital/acetaminophen/caffeine tabs or mg butalbital/apap/caffeine tabs or mg 1 butalbital/aspirin/caffeine tabs or mg capacet caps or mg 1 dolgic lq elix or %, mg/15ml ; NT ; NT ; NT ; NT ; NT ; NT ; NT NT ; NT ; NT ; NT LA=Limited Access =Available at Mail Order NT=Non-TrOOP NT 0

21 DOLGIC PLUS (butalbital-acetaminophencaffeine) TABS OR MG DOLGIC PLUS TABS OR MG 3 esgic caps or mg 1 esgic tabs or mg 1 esgic-plus caps or mg 1 esgic-plus tabs or mg 1 fioricet tabs or mg 1 FIORINAL (butalbital-aspirin-caffeine) CAPS OR MG fortabs tabs or mg 1 geone (g-1) caps or mg 1 margesic caps or mg 1 medigesic caps or mg 1 orbivan caps or mg 1 PHRENILIN (butalbital-acetaminophen) TABS OR MG PHRENILIN FORTE (butalbitalacetaminophen) CAPS OR MG repan tabs or mg 1 SEDAPAP (butalbital-acetaminophen) TABS OR MG tenake caps or mg 1 tencet caps or mg 1 TENCON (butalbital-acetaminophen) TABS OR MG triad caps or mg 1 zebutal caps or mg 1 ; NT NT ; NT ; NT ; NT ; NT ; NT ; NT ; NT ; NT ; NT ; NT ; NT ; NT ; NT ; NT ; NT ; NT ; NT ; NT ; NT ; NT LA=Limited Access =Available at Mail Order NT=Non-TrOOP 1

22 zebutal caps or mg 1 Analgesics Other DURACLON (clonidine hcl (analgesia)) SOLN EP 100 MCG/ML, 500 MCG/ML Analgesics-Peptide Channel Blockers PRIALT SOLN IT 100 MCG/ML, 500 MCG/0ML, 500 MCG/5ML Salicylates diflunisal tabs or 500 mg 1 ANALGESICS - OPIOID Opioid Agonists ABSTRAL SUBL SL 100 MCG, 00 MCG, 300 MCG, 00 MCG, 600 MCG, 800 MCG ACTIQ (fentanyl citrate) LPOP BU 00 MCG 5 1 ACTIQ (fentanyl citrate) LPOP BU 100 MCG, 1600 MCG, 00 MCG, 600 MCG, 800 MCG astramorph soln ij 0.5 mg/ml, 1 mg/ml AVINZA CP OR 10 MG, 30 MG, 5 MG, 60 MG, 75 MG, 90 MG codeine sulfate tabs or 30 mg, 60 mg 1 codeine sulfate tabs or 15 mg, 30 mg, 60 mg 1 NT PA; ; PA; ; DAZIDOX TABS OR 0 MG DEMEROL (meperidine hcl) SOLN IJ 5 MG/ML, 75 MG/ML DEMEROL (meperidine hcl) SOLN IJ 100 MG/ML, 50 MG/ML DEMEROL SOLN IJ 100 MG/ML, 5 MG/0.5ML, 75 MG/1.5ML DEMEROL SOLN IJ 75 MG/1.5ML DEMEROL SYRP OR 50 MG/5ML 3 DEMEROL (meperidine hcl) TABS OR 100 MG, 50 MG LA=Limited Access =Available at Mail Order NT=Non-TrOOP

23 DILAUDID (hydromorphone hcl) SOLN IJ MG/ML DILAUDID (hydromorphone hcl) SOLN IJ 1 MG/ML, MG/ML DILAUDID (hydromorphone hcl) TABS OR MG, MG, 8 MG DILAUDID-5 (hydromorphone hcl) LIQD OR 1 MG/ML DILAUDID-HP (hydromorphone hcl) SOLN IJ 10 MG/ML DILAUDID-HP SOLR IJ 50 MG DOLOPHINE (methadone hcl) TABS OR 10 MG DOLOPHINE HCL (methadone hcl) TABS OR 5 MG DURAGESIC (fentanyl) PT7 TD 100 MCG/HR, 1 MCG/HR, 5 MCG/HR, 50 MCG/HR, 75 MCG/HR 1 duramorph soln ij 0.5 mg/ml, 1 mg/ml EMBEDA CPCR OR MG, 100- MG, -50 MG EMBEDA CPCR OR MG,.-60 MG, MG EXALGO TB OR 1 MG, 16 MG, 8 MG 3 fentanyl citrate soln ij 0.5 mg/ml FENTORA TABS BU 300 MCG 5 FENTORA TABS BU 100 MCG, 00 MCG, 00 MCG, 600 MCG, 800 MCG hydromorphone hcl soln ij 50 mg/5ml, 500 mg/50ml INFURPH 00 SOLN IJ 10 MG/ML INFURPH 500 SOLN IJ 5 MG/ML KADIAN (morphine sulfate) CP OR 100 MG, 0 MG, 30 MG, 50 MG, 60 MG, 80 MG KADIAN CP OR 10 MG, 00 MG 5 1 PA PA; ; LA=Limited Access =Available at Mail Order NT=Non-TrOOP 3

24 LAZANDA SOLN NA 100 MCG/ACT, 00 MCG/ACT LEVO DRORAN SOLN IJ MG/ML LEVO-DRORAN (levorphanol tartrate) TABS OR MG 5 meperidine hcl soln ij 10 mg/ml meperidine hcl soln or 50 mg/5ml 1 PA meperidine hcl tabs or 50 mg 1 METHADONE HCL SOLN IJ 10 MG/ML methadone hcl soln or 10 mg/5ml, 5 mg/5ml 1 methadone hcl tbso or 0 mg 1 METHADONE HCL INTENSOL (methadone hcl) CONC OR 10 MG/ML methadose tbso or 0 mg 1 morphine sulfate soln ij 0.5 mg/ml, 1 mg/ml RPHINE SULFATE SOLN IV 1 MG/ML morphine sulfate soln iv 1 mg/ml RPHINE SULFATE (morphine sulfate) SOLN OR 10 MG/5ML RPHINE SULFATE SOLN OR 0 MG/10ML 1 morphine sulfate soln or 0 mg/5ml, 0 mg/ml 1 morphine sulfate tabs or 15 mg, 30 mg 1 morphine sulfate tabs or 15 mg, 30 mg 1 morphine sulfate stick-gard soln iv 1 mg/ml MS CONTIN (morphine sulfate) TB1 OR 100 MG, 15 MG, 00 MG, 30 MG, 60 MG NUCYNTA TABS OR 100 MG, 50 MG, 75 MG LA=Limited Access =Available at Mail Order NT=Non-TrOOP

25 NUCYNTA ER TB1 OR 100 MG, 150 MG, 00 MG, 50 MG, 50 MG NURPHAN SOLN IJ 1 MG/ML ONSOLIS FILM BU 100 MCG, 00 MCG, 00 MCG, 600 MCG, 800 MCG OPANA SOLN IJ 1 MG/ML OPANA (oxymorphone hcl) TABS OR 10 MG, 5 MG OPANA ER TB1 OR 10 MG, 15 MG, 0 MG, 30 MG, 0 MG, 7.5 MG OPANA ER TB1 OR 5 MG OPANA ER (CRUSH RESISTANT) TB1 OR 5 MG OPANA ER (CRUSH RESISTANT) TB1 OR 10 MG, 0 MG, 30 MG, 0 MG ORARPH SR (morphine sulfate) TB1 OR 100 MG, 15 MG, 30 MG, 60 MG OXECTA TABS OR 5 MG 3 OXECTA TABS OR 7.5 MG 3 5 oxycodone hcl caps or 5 mg 1 oxycodone hcl conc or 0 mg/ml 1 oxycodone hcl tabs or 10 mg, 0 mg 1 OXYCODONE HCL CR (oxycodone hcl) TB1 OR 10 MG, 0 MG, 0 MG, 80 MG OXYCONTIN (oxycodone hcl) TB1 OR 10 MG, 0 MG, 0 MG, 80 MG OXYCONTIN TB1 OR 15 MG, 30 MG, 60 MG oxymorphone hydrochloride er tb1 or 15 mg, 7.5 mg ROXICODONE (oxycodone hcl) TABS OR 15 MG, 30 MG, 5 MG RYBIX ODT TBDP OR 50 MG PA; LA RYZOLT (tramadol hcl) TB OR 100 MG, 300 MG LA=Limited Access =Available at Mail Order NT=Non-TrOOP 5

26 RYZOLT TB OR 00 MG 3 SUBLIMAZE (fentanyl citrate) SOLN IJ 0.05 MG/ML tramadol hcl er tb or 00 mg 1 ULTRAM (tramadol hcl) TABS OR 50 MG ULTRAM ER (tramadol hcl) TB OR 100 MG, 00 MG, 300 MG Opioid Combinations acetaminophen/caffeine/dihydrocodeine bitartrate tabs or mg acetaminophen/codeine soln or %, mg/5ml, %, mg/5ml acetaminophen/codeine tabs or mg 1 acetaminophen/codeine # tabs or mg acetaminophen/codeine #3 tabs or mg acetaminophen/codeine phosphate tabs or mg ALCET (oxycodone w/ acetaminophen) TABS OR MG ANEXSIA (hydrocodone-acetaminophen) TABS OR MG anexsia tabs or 35-5 mg, mg, mg BANCAP-HC (hydrocodone-acetaminophen) CAPS OR MG NF 1 1 capital/codeine susp or 1-10 mg/5ml 1 co-gesic tabs or mg 1 cocet tabs or mg 1 cocet plus tabs or mg 1 COMBUNOX (oxycodone-ibuprofen) TABS OR 00-5 MG endocet tabs or mg, mg, 35-5 mg, mg, mg 1 LA=Limited Access =Available at Mail Order NT=Non-TrOOP 6

27 FIORICET/CODEINE (butalbitalacetaminophen-caffeine w/ codeine) CAPS OR MG FIORINAL/CODEINE #3 (butalbital-aspirincaffeine w/cod) CAPS OR MG hycet soln or %, mg/15ml 1 hydrocodone bitartrate/acetaminophen soln or, %, mg/15ml hydrocodone bitartrate/acetaminophen tabs or, mg, mg, mg, mg hydrocodone/acetaminophen soln or %, mg/15ml, mg/15ml hydrocodone/acetaminophen tabs or mg, 35-5 mg, mg hydrocodone/acetaminophen tabs or mg, mg, mg, 35-5 mg, mg, mg, mg, mg hydrocodone/ibuprofen tabs or 1 ibudone tabs or mg 1 LORCET 10/650 (hydrocodoneacetaminophen) TABS OR MG lortab elix or %, mg/15ml 1 LORTAB (hydrocodone-acetaminophen) TABS OR MG lortab tabs or mg, mg, mg LYNOX (oxycodone w/ acetaminophen) TABS OR MG MAGNACET (oxycodone w/ acetaminophen) TABS OR 00-5 MG, MG MAGNACET TABS OR.5-00 MG 3 1 NF 1 magnacet tabs or, mg 1 maxidone tabs or mg 1 norco tabs or mg, 35-5 mg, mg 1 LA=Limited Access =Available at Mail Order NT=Non-TrOOP 7

28 oxycodone/acetaminophen caps or mg 1 oxycodone/acetaminophen tabs or mg, mg,.5-35 mg, 35-5 mg, mg, mg oxycodone/aspirin tabs or mg 1 panlor dc caps or mg 1 panlor ss tabs or mg 1 pentazocine/acetaminophen tabs or mg pentazocine/acetaminophen tabs or mg percocet tabs or mg, mg,.5-35 mg, 35-5 mg, mg, mg PERCODAN (oxycodone-aspirin) TABS OR MG PERCODAN (oxycodone-aspirin) TABS OR MG PERLOXX (oxycodone w/ acetaminophen) TABS OR MG PERLOXX (oxycodone w/ acetaminophen) TABS OR MG, MG NF 1 NF 1 primalev tabs or mg 1 primlev tabs or 1 primlev tabs or 1 REPREXAIN (hydrocodone-ibuprofen) TABS OR 00-5 MG reprexain tabs or mg,.5-00 mg 1 roxicet soln or 35-5 mg/5ml 1 ROXICET (oxycodone w/ acetaminophen) TABS OR MG 1 roxicet tabs or 35-5 mg 1 SYNALGOS-DC CAPS OR MG 3 LA=Limited Access =Available at Mail Order NT=Non-TrOOP 8

29 tramadol hydrochloride/acetaminophen tabs or trezix caps or mg 1 tylenol/codeine #3 tabs or mg 1 TYLENOL/CODEINE # (acetaminophen w/ codeine) TABS OR MG 1 tylox caps or mg 1 ULTRACET (tramadol-acetaminophen) TABS OR MG vanacet tabs or mg 1 vicodin tabs or mg 1 vicodin es tabs or mg 1 vicodin hp tabs or mg 1 VICOPROFEN (hydrocodone-ibuprofen) TABS OR MG vopac tabs or mg 1 xodol tabs or, mg, mg, mg ZAMICET (hydrocodone-acetaminophen) SOLN OR %, MG/15ML 1 zerlor tabs or mg 1 zolvit soln or, mg/15ml 1 zydone tabs or mg, 00-5 mg, mg Opioid Partial Agonists BUPRENEX (buprenorphine hcl) SOLN IJ 0.3 MG/ML 1 butorphanol tartrate soln ij 1 mg/ml butorphanol tartrate soln na 10 mg/ml 1 BUTRANS PTWK TD 10 MCG/HR, 0 MCG/HR, 5 MCG/HR 3 LA=Limited Access =Available at Mail Order NT=Non-TrOOP 9

30 nalbuphine hcl soln ij 0 mg/ml NUBAIN (nalbuphine hcl) SOLN IJ 10 MG/ML, 0 MG/ML pentazocine/naloxone hcl tabs or mg 1 pentazocine/naloxone hcl tabs or mg 1 STADOL (butorphanol tartrate) SOLN IJ MG/ML SUBOXONE SUBL SL 0.5- MG, -8 MG 3 SUBUTEX (buprenorphine hcl) SUBL SL MG, 8 MG TALWIN SOLN IJ 30 MG/ML PA; ; PA; ; ANDROGENS-ANABOLIC Anabolic Steroids ANADROL-50 TABS OR 50 MG 5 OXANDRIN (oxandrolone) TABS OR 10 MG,.5 MG Androgens ANDRODERM PT TD MG/HR,.5 MG/HR, MG/HR, 5 MG/HR ANDROGEL GEL TD 5 MG/.5GM, 50 MG/5GM ANDROGEL PUMP GEL TD 1.5 GM/ACT, 1.6 % android caps or 10 mg 1 androxy tabs or 10 mg 1 AXIRON SOLN TD 30 MG/ACT 3 danazol caps or 100 mg, 00 mg, 50 mg 1 DELATESTRYL (testosterone enanthate) OIL IM 00 MG/ML depo-testosterone oil im 100 mg/ml, 00 mg/ml FORTESTA GEL TD 10 MG/ACT 3 GL; GL; GL; GL; GL; LA=Limited Access =Available at Mail Order NT=Non-TrOOP 30

31 methitest tabs or 10 mg 1 STRIANT MISC BU 30 MG 3 TESTIM GEL TD 1 % TESTOPEL (testosterone) PLLT IL 75 MG NF 1 testosterone cypionate oil im 100 mg/ml, 00 mg/ml testred caps or 10 mg 1 ANORECTAL AGENTS Intrarectal Steroids CORTENEMA (hydrocortisone (intrarectal)) ENEM RE 100 MG/60ML CORTIFOAM FOAM RE 90 MG 3 Rectal Combinations ANALPRAM-HC (hydrocortisone acetate w/ pramoxine) CREA RE 1 % ANALPRAM-HC SINGLES (hydrocortisone acetate w/ pramoxine) CREA RE 1 % PROCTOFOAM HC (hydrocortisone acetate w/ pramoxine) FOAM RE 1 % Rectal Steroids 3 NF 3 NF NF 1 anusol-hc crea re.5 % 1 procto-kit crea re.5 % 1 PROCTOCORT (hydrocortisone (rectal)) CREA RE 1 % proctocream hc crea re.5 % 1 proctocream-hc crea re.5 % 1 proctosol hc crea re.5 % 1 proctozone-hc crea re.5 % 1 GL; GL; GL ; NT ; NT Vasodilating Agents RECTIV OINT RE 0. % LA=Limited Access =Available at Mail Order NT=Non-TrOOP 31

32 ANTHELMINTICS Anthelmintics ALBENZA TABS OR 00 MG 3 BILTRICIDE TABS OR 600 MG mebendazole chew or 100 mg 1 STROMECTOL TABS OR 3 MG 3 ANTI-INFECTIVE AGENTS - MISC. Anti-infective Agents - Misc. AZACTAM (aztreonam) SOLR IJ GM AZACTAM (aztreonam) SOLR IJ 1 GM AZACTAM IN DEXTROSE SOLN IV 1 GM, GM AZACTAMIN ISO-OSTIC DEXTROSE SOLN IV 1 GM, GM baciim solr im unit bacitracin solr im unit CAYSTON SOLR IN 75 MG 5 COLY-MYCIN M (colistimethate sodium) SOLR IJ 150 MG COLY-MYCIN-M (colistimethate sodium) SOLR IJ 150 MG FLAGYL (metronidazole) CAPS OR 375 MG FLAGYL (metronidazole) TABS OR 50 MG, 500 MG FLAGYL ER TB OR 750 MG 3 LA METRO IV SOLN IV %, MG/100ML metronidazole in nacl 0.79% soln iv %, mg/ml, %, mg/100ml NEBUPENT SOLR IN 300 MG ; LA=Limited Access =Available at Mail Order NT=Non-TrOOP 3

33 PENTAM 300 (pentamidine isethionate) SOLR IJ 300 MG PRIMSOL SOLN OR 50 MG/5ML PROLOPRIM (trimethoprim) TABS OR 100 MG VANCOCIN HCL (vancomycin hcl) CAPS OR 15 MG, 50 MG vancomycin hcl solr iv 10 gm, 5000 mg, 750 mg 5 5 vancomycin hcl solr iv 1000 mg, 500 mg VANCOMYCIN HCL IN DEXTROSE SOLN IV 1 GM/00ML, 500 MG/100ML, 750 MG/150ML XIFAXAN TABS OR 00 MG 3 XIFAXAN TABS OR 550 MG 5 PA; ; ; Anti-infective Misc. - Combinations BACTRIM (sulfamethoxazole-trimethoprim) TABS OR MG BACTRIM DS (sulfamethoxazoletrimethoprim) TABS OR MG PEDIAZOLE (erythromycin-sulfisoxazole) SUSR OR MG/5ML SEPTRA (sulfamethoxazole-trimethoprim) SUSP OR 00-0 MG/5ML SEPTRA (sulfamethoxazole-trimethoprim) TABS OR MG SEPTRA DS (sulfamethoxazole-trimethoprim) TABS OR MG SULFAMETHOXAZOLE/TRIMETHOPRIM SOLN IV MG/5ML sulfamethoxazole/trimethoprim soln iv mg/5ml sulfamethoxazole/trimethoprim susp or %, mg/0ml, %, mg/5ml, %, mg/5ml, %, mg/5ml, %, mg/5ml Antiprotozoal Agents ALINIA SUSR OR 100 MG/5ML 3 LA=Limited Access =Available at Mail Order NT=Non-TrOOP

34 ALINIA TABS OR 500 MG 3 MEPRON SUSP OR 750 MG/5ML 5 NEUTREXIN SOLR IV 5 MG Carbapenems DORIBAX SOLR IV 500 MG DORIBAX SOLR IV 50 MG 5 imipenem/cilastatin solr iv, 50 mg, 500 mg 1 INVANZ SOLR IJ 1 GM INVANZ SOLR IV 1 GM MERREM (meropenem) SOLR IV 1 GM, 500 MG PRIMAXIN I.M. SOLR IM 500 MG PRIMAXIN IV (imipenem-cilastatin) SOLR IV 50 MG, 500 MG Chloramphenicols CHLORAMPHENICOL SODIUM SUCCINATE SOLR IV 1 GM CHLOROMYCETIN SOLR IV 1 GM Cyclic Lipopeptides CUBICIN SOLR IV 500 MG 5 1 ; Glycylcyclines TYGACIL SOLR IV 50 MG Ketolides KETEK TABS OR 300 MG 3 KETEK TABS OR 00 MG 3 KETEK PAK TABS OR 00 MG 3 Leprostatics LA=Limited Access =Available at Mail Order NT=Non-TrOOP 3

35 dapsone tabs or 100 mg, 5 mg 1 Lincosamides CLEOCIN (clindamycin hcl) CAPS OR 75 MG 1 CLEOCIN (clindamycin hcl) CAPS OR 150 MG, 300 MG CLEOCIN IN D5W SOLN IV, %, MG/50ML cleocin pediatric granules solr or 75 mg/5ml 1 CLEOCIN PHOSPHATE (clindamycin phosphate) SOLN IJ 150 MG/ML, 300 MG/ML CLEOCIN PHOSPHATE (clindamycin phosphate) SOLN IJ 600 MG/ML, 900 MG/6ML CLEOCIN PHOSPHATE (clindamycin phosphate) SOLN IV 150 MG/ML CLEOCIN PHOSPHATE SOLN IV 600 MG/ML CLEOCINGALAXY SOLN IV %, MG/50ML, %, MG/50ML clindamycin palmitate hcl solr or 75 mg/5ml 1 clindamycin phosphate soln ij 9000 mg/60ml CLINDAMYCIN PHOSPHATE SOLN IV 150 MG/ML clindamycin phosphateadd-vantage soln iv 150 mg/ml LINCOCIN SOLN IJ 300 MG/ML Oxazolidinones ZYVOX SOLN IV MG/ML 5 ZYVOX SUSR OR 100 MG/5ML 5 ZYVOX TABS OR 600 MG 5 PA PA; ; PA; ; Polymyxins polymyxin b sulfate solr ij unit LA=Limited Access =Available at Mail Order NT=Non-TrOOP 35

36 Streptogramins SYNERCID SOLR IV MG ANTIANGINAL AGENTS Antianginals-Other RANEXA TB1 OR 1000 MG, 500 MG 3 PA; ; Nitrates DILATRATE SR CPCR OR 0 MG IMDUR (isosorbide mononitrate) TB OR 10 MG, 30 MG, 60 MG IS (isosorbide mononitrate) TABS OR 0 MG isochron tbcr or 0 mg 1 isoditrate er tbcr or 0 mg 1 ISORDIL TITRADOSE TABS OR 0 MG ISORDIL TITRADOSE (isosorbide dinitrate) TABS OR 5 MG isosorbide dinitrate subl sl 5 mg 1 isosorbide dinitrate subl sl.5 mg, 5 mg 1 isosorbide dinitrate tabs or 10 mg, 0 mg 1 isosorbide dinitrate tabs or 30 mg 1 isosorbide dinitrate er tbcr or 0 mg 1 isosorbide mononitrate er tb or 10 mg, 30 mg, 60 mg NOKET (isosorbide mononitrate) TABS OR 10 MG, 0 MG 1 nitro-bid oint td % 1 NITRO-DUR PT TD 0.3 MG/HR, 0.8 MG/HR NITRO-DUR (nitroglycerin) PT TD 0.1 MG/HR, 0. MG/HR, 0. MG/HR, 0.6 MG/HR LA=Limited Access =Available at Mail Order NT=Non-TrOOP 36

37 nitroglycerin soln iv 5 mg/ml NITROGLYCERIN IN DEXTROSE 5% (nitroglycerin in d5w) SOLN IV %, MCG/ML, 00-5 %, MCG/ML, 00-5 %, MCG/ML NITROLINGUAL PUMPSPRAY (nitroglycerin) SOLN TL 0. MG/SPRAY NITROLINGUAL PUMPSPRAY DUO PACK (nitroglycerin) SOLN TL 0. MG/SPRAY NITROMIST AERS TL 00 MCG/SPRAY NITROSTAT (nitroglycerin) SUBL SL 0.3 MG, 0. MG, 0.6 MG ANTIANXIETY AGENTS Antianxiety Agents - Misc. ATARAX (hydroxyzine hcl) SYRP OR 10 MG/5ML BUSPAR (buspirone hcl) TABS OR 10 MG, 15 MG, 30 MG, 5 MG 1 droperidol soln ij mg/ml hydroxyzine hcl soln im 5 mg/ml hydroxyzine hcl soln im 50 mg/ml hydroxyzine hcl soln or 10 mg/5ml 1 hydroxyzine hcl tabs or 10 mg, 5 mg, 50 mg 1 hydroxyzine pamoate caps or 100 mg 1 hyzine soln im 50 mg/ml INAPSINE (droperidol) SOLN IJ.5 MG/ML meprobamate tabs or 00 mg, 00 mg 1 VANSPAR (buspirone hcl) TABS OR 7.5 MG VISTARIL (hydroxyzine pamoate) CAPS OR 5 MG, 50 MG Benzodiazepines LA=Limited Access =Available at Mail Order NT=Non-TrOOP 37

38 alprazolam intensol conc or 1 mg/ml 1 ATIVAN (lorazepam) TABS OR 0.5 MG, 1 MG, MG diazepam soln or 1 mg/ml 1 diazepam intensol conc or 5 mg/ml 1 LIBRIUM (chlordiazepoxide hcl) CAPS OR 10 MG, 5 MG, 5 MG LORAZEPAM INTENSOL (lorazepam) CONC OR MG/ML NIRAVAM (alprazolam) TBDP OR 0.5 MG, 0.5 MG, 1 MG, MG SERAX (oxazepam) CAPS OR 10 MG, 15 MG, 30 MG TRANXENE T (clorazepate dipotassium) TABS OR 15 MG, 3.75 MG, 7.5 MG TRANXENE-SD TB OR 11.5 MG,.5 MG VALIUM (diazepam) TABS OR 10 MG, MG, 5 MG XANAX (alprazolam) TABS OR 0.5 MG, 0.5 MG, 1 MG, MG XANAX TABS OR 0.5 MG 3 XANAX XR (alprazolam) TB OR 0.5 MG, 1 MG, MG, 3 MG ANTIARRHYTHMICS Antiarrhythmics - Misc. ADENOCARD (adenosine) SOLN IV 6 MG/ML Antiarrhythmics Type I-A NORPACE (disopyramide phosphate) CAPS OR 100 MG, 150 MG NORPACE CR CP1 OR 100 MG 3 ; NT ; NT ; NT ; NT ; NT ; NT ; NT ; NT ; NT NT ; NT ; NT ; NT ; NT NORPACE CR (disopyramide phosphate) CP1 OR 150 MG PROCAINAMIDE HCL (procainamide hcl) SOLN IJ 100 MG/ML LA=Limited Access =Available at Mail Order NT=Non-TrOOP 38

39 procainamide hcl soln ij 500 mg/ml QUINIDINE GLUCONATE SOLN IJ 80 MG/ML quinidine gluconate cr tbcr or 3 mg 1 quinidine gluconate er tbcr or 3 mg 1 quinidine gluconate sa tbcr or 3 mg 1 quinidine sulfate tabs or 00 mg, 300 mg 1 quinidine sulfate er tbcr or 300 mg 1 Antiarrhythmics Type I-B LIDOCAINE HCL (lidocaine hcl (cardiac)) SOLN IV 10 MG/ML lidocaine hcl in d5w soln iv -5 %, mg/ml lidocaine hcl/dextrose soln iv -5 %, mg/ml mexiletine hcl caps or 150 mg, 00 mg, 50 mg XYLOCAINE (lidocaine hcl (cardiac)) SOLN IV 0 MG/ML Antiarrhythmics Type I-C 1 propafenone hcl tabs or 300 mg 1 RYTHL (propafenone hcl) TABS OR 150 MG, 5 MG RYTHL SR (propafenone hcl) CP1 OR 5 MG, 35 MG, 5 MG TAMBOCOR (flecainide acetate) TABS OR 100 MG, 150 MG, 50 MG Antiarrhythmics Type III AMIODARONE HCL (amiodarone hcl) SOLN IV 900 MG/18ML amiodarone hcl soln iv 150 mg/3ml, 50 mg/9ml, 50 mg/ml 1 amiodarone hcl tabs or 00 mg 1 CORDARONE (amiodarone hcl) TABS OR 00 MG LA=Limited Access =Available at Mail Order NT=Non-TrOOP 39

40 CORDARONE I.V. (amiodarone hcl) SOLN IV 50 MG/ML MULTAQ TABS OR 00 MG PACERONE TABS OR 300 MG pacerone tabs or 100 mg, 00 mg 1 TIKOSYN CAPS OR 15 MCG, 50 MCG, 500 MCG ANTIASTHMATIC AND BRONCHODILATOR AGENTS Anti-Inflammatory Agents INTAL (cromolyn sodium) NEBU IN 0 MG/ML Antiasthmatic - Monoclonal Antibodies XOLAIR SOLR SC 150 MG 5 Bronchodilators - Anticholinergics ATROVENT HFA AERS IN 17 MCG/ACT ipratropium bromide soln in 0.0 %, 0. % 1 SPIRIVA HANDIHALER CAPS IN 18 MCG Leukotriene Modulators ACCOLATE (zafirlukast) TABS OR 10 MG, 0 MG SINGULAIR CHEW OR MG, 5 MG SINGULAIR PACK OR MG SINGULAIR TABS OR 10 MG ZYFLO CR TB1 OR 600 MG 3 Selective Phosphodiesterase (PDE) Inhibitors DALIRESP TABS OR 500 MCG 3 1 ; LA ; PA; ; Steroid Inhalants ALVESCO AERS IN 160 MCG/ACT, 80 MCG/ACT 3 LA=Limited Access =Available at Mail Order NT=Non-TrOOP 0

41 ASMANEX 10 METERED DOSES AEPB IN 0 MCG/INH ASMANEX 1 METERED DOSES AEPB IN 0 MCG/INH ASMANEX 30 METERED DOSES AEPB IN 110 MCG/INH, 0 MCG/INH ASMANEX 60 METERED DOSES AEPB IN 0 MCG/INH ASMANEX 7 METERED DOSES AEPB IN 110 MCG/INH AZMACORT AERS IN 75 MCG/ACT 3 FLOVENT DISKUS AEPB IN 100 MCG/BLIST, 50 MCG/BLIST, 50 MCG/BLIST FLOVENT HFA AERO IN 110 MCG/ACT, 0 MCG/ACT, MCG/ACT PULMICORT SUSP IN 1 MG/ML PULMICORT (budesonide (inhalation)) SUSP IN 0.5 MG/ML, 0.5 MG/ML PULMICORT FLEXHALER AEPB IN 180 MCG/ACT, 90 MCG/ACT QVAR AERS IN 0 MCG/ACT, 80 MCG/ACT 3 ; ; Sympathomimetics ACCUNEB (albuterol sulfate) NEBU IN 0.63 MG/3ML, 1.5 MG/3ML ADVAIR DISKUS AEPB IN MCG/DOSE, MCG/DOSE, MCG/DOSE ADVAIR HFA AERO IN MCG/ACT, 1-30 MCG/ACT, 1-5 MCG/ACT airet nebu in 0.83 % 1 albuterol sulfate nebu in 0.5 %, 0.83 % 1 albuterol sulfate syrp or mg/5ml 1 albuterol sulfate tabs or mg, mg 1 ARCAPTA NEOHALER CAPS IN 75 MCG 3 ; ; ; LA=Limited Access =Available at Mail Order NT=Non-TrOOP 1

42 BRETHINE (terbutaline sulfate) TABS OR.5 MG, 5 MG BROVANA NEBU IN 15 MCG/ML 3 COMBIVENT AERO IN MCG/ACT DULERA AERO IN, MCG/ACT, 00-5 MCG/ACT DUONEB (ipratropium-albuterol) SOLN IN MG/3ML epinephrine hcl soln ij 0.1 mg/ml FORADIL AEROLIZER CAPS IN 1 MCG ISUPREL SOLN IJ 0. MG/ML metaproterenol sulfate nebu in 0. %, 0.6 % 1 metaproterenol sulfate syrp or 10 mg/5ml 1 metaproterenol sulfate tabs or 10 mg, 0 mg 1 PERFOROMIST NEBU IN 0 MCG/ML 3 PROAIR HFA AERS IN 108 MCG/ACT PROVENTIL (albuterol sulfate) NEBU IN % PROVENTIL HFA AERS IN 108 MCG/ACT SEREVENT DISKUS AEPB IN 50 MCG/DOSE SYMBICORT AERO IN MCG/ACT,.5-80 MCG/ACT terbutaline sulfate soln ij 1 mg/ml VENTOLIN HFA AERS IN 108 MCG/ACT 3 ; ; ; ; VOSPIRE ER (albuterol sulfate) TB1 OR MG, 8 MG XOPENEX NEBU IN 0.31 MG/3ML, 0.63 MG/3ML, 1.5 MG/3ML 3 ; XOPENEX CONCENTRATE (levalbuterol hcl) NEBU IN 1.5 MG/0.5ML ; LA=Limited Access =Available at Mail Order NT=Non-TrOOP

43 XOPENEX HFA AERO IN 5 MCG/ACT 3 Xanthines aminophylline soln iv 5 mg/ml aminophylline tabs or 100 mg, 00 mg 1 elixophyllin elix or 80 mg/15ml 1 LUFYLLIN TABS OR 00 MG, 00 MG 3 QUIBRON-T/SR (theophylline) TB1 OR 300 MG theo- cp or 100 mg, 00 mg, 300 mg, 00 mg theochron tb1 or 50 mg 1 theochron tb1 or 100 mg, 00 mg 1 theophylline cr tb1 or 100 mg, 00 mg 1 theophylline er tb1 or 50 mg 1 theophylline er tb1 or 100 mg, 00 mg, 50 mg theophylline er tb or 00 mg, 600 mg 1 theophylline td tb1 or 100 mg, 00 mg 1 THEOPHYLLINE/D5W (theophylline in dextrose) SOLN IV %, MG/ML, %, MG/ML, -5 %, MG/ML, 3.-5 %, MG/ML, -5 %, MG/ML 1 1 uniphyl tb or 00 mg, 600 mg 1 ANTICOAGULANTS Coumarin Anticoagulants COUMADIN SOLR IV 5 MG COUMADIN (warfarin sodium) TABS OR 1 MG, 10 MG, MG,.5 MG, 3 MG, MG, 5 MG, 6 MG, 7.5 MG Direct Factor Xa Inhibitors LA=Limited Access =Available at Mail Order NT=Non-TrOOP 3

44 XARELTO TABS OR 10 MG, 15 MG, 0 MG Heparins And Heparinoid-Like Agents ARIXTRA (fondaparinux sodium) SOLN SC 10 MG/0.8ML,.5 MG/0.5ML, 5 MG/0.ML, 7.5 MG/0.6ML FRAGMIN INJ SC UNIT/ML, 500 UNIT/0.ML, 5000 UNIT/ML, 5000 UNIT/0.ML, 7500 UNIT/0.3ML FRAGMIN SOLN SC UNIT/9.5ML FRAGMIN SOLN SC UNIT/ML, 1500 UNIT/0.5ML, UNIT/0.6ML, UNT/0.7ML, 500 UNIT/0.ML, 5000 UNIT/ML, 5000 UNIT/0.ML, 7500 UNIT/0.3ML HEPARIN SODIUM SOLN IJ 500 UNIT/ML heparin sodium soln ij 1000 unit/ml, unit/ml, 0000 unit/ml, 5000 unit/ml HEPARIN SODIUM SOLN IV 000 UNIT/ML heparin sodium dcu soln ij 0000 unit/ml HEPARIN SODIUM/D5W (heparin sod (porcine) in d5w) SOLN IV %, UNIT/ML, 5-50 %, UNIT/ML HEPARIN SODIUM/D5W SOLN IV %, MG/ML, UNIT/ML heparin sodium/d5w soln iv %, mg/ml, unit/ml, 0-5 %, unit/ml HEPARIN SODIUM/NACL 0.5% SOLN IJ %, UNIT/ML, %, UNIT/ML HEPARIN SODIUM/SODIUM CHLORIDE 0.9% (heparin (porcine) in sodium chloride) SOLN IJ 0.9- %, UNIT/ML INNOHEP SOLN SC 0000 UNIT/ML ; ; LOVENOX (enoxaparin sodium) SOLN IJ 300 MG/3ML LOVENOX (enoxaparin sodium) SOLN SC 100 MG/ML, 10 MG/0.8ML, 150 MG/ML, 30 MG/0.3ML, 0 MG/0.ML, 60 MG/0.6ML, 80 MG/0.8ML LA=Limited Access =Available at Mail Order NT=Non-TrOOP

45 Thrombin Inhibitors ARGATROBAN SOLN IV 100 MG/ML 5 IPRIVASK SOLR SC 15 MG 5 PRADAXA CAPS OR 150 MG, 75 MG REFLUDAN SOLR IV 50 MG 5 ANTICONVULSANTS Anticonvulsants - Benzodiazepines KLONOPIN (clonazepam) TABS OR 0.5 MG, 1 MG, MG KLONOPIN WAFERS (clonazepam) TBDP OR 0.15 MG, 0.5 MG, 0.5 MG, 1 MG, MG ONFI TABS OR 10 MG, 0 MG, 5 MG 3 ; NT ; NT ; NT Anticonvulsants - Misc. BANZEL SUSP OR 0 MG/ML BANZEL TABS OR 00 MG, 00 MG CARBATROL (carbamazepine) CP1 OR 100 MG, 00 MG, 300 MG GABARONE (gabapentin) TABS OR 100 MG, 300 MG, 00 MG KEPPRA (levetiracetam) SOLN IV 500 MG/5ML KEPPRA (levetiracetam) SOLN OR 100 MG/ML KEPPRA (levetiracetam) TABS OR 1000 MG, 50 MG, 500 MG, 750 MG KEPPRA XR (levetiracetam) TB OR 500 MG, 750 MG LAMICTAL CHEW OR MG 3 LAMICTAL (lamotrigine) TABS OR 100 MG, 150 MG, 00 MG, 5 MG LAMICTAL CHEWABLE DISPERSIBLE (lamotrigine) CHEW OR 5 MG, 5 MG LAMICTAL ODT KIT OR LA=Limited Access =Available at Mail Order NT=Non-TrOOP 5