Fidelis Care FIDA Plan 2017 List of Covered Drugs (Formulary)

Transcription

1 (Updated 11/2017) H1916_FC FIDA Fidelis Care FIDA Plan 2017 List of Covered s (Formulary) This is a list of drugs that Participants can get in Fidelis Care FIDA Plan. Fidelis Care is a managed care plan that contracts with both Medicare and the New York State Department of Health (Medicaid) to provide benefits of both programs to Participants through the Fully Integrated Duals Advantage (FIDA) Demonstration. The List of Covered s and/or pharmacy and provider networks may change throughout the year. We will send you a notice before we make a change that affects you. Benefits may change on January 1 of each year. You can always check Fidelis Care FIDA Plan s up-to-date List of Covered s online at fideliscare.org or by calling Fidelis Care FIDA Plan Participant Services at (TTY: ). Limitations and restrictions may apply. For more information, call Fidelis Care FIDA Plan Participant Services or read the Fidelis Care FIDA Plan Participant Handbook. This means that you need to follow certain rules to have Fidelis Care FIDA Plan pay for your services. There are no copays for any covered drugs. You can get this information for free in other languages. Call or (TTY) between 8 AM and 8 PM Monday through Friday. The call is free. Usted puede obtener esta información de forma gratuita en otros idiomas. Llame al o al (TTY) entre las 8 a.m. y las 8 p.m., de lunes a viernes. La llamada es gratuita. È possibile ottenere queste informazioni gratuitamente in altre lingue. Telefonare al numero oppure (TTY) tra le 8 e le 20 da lunedì a venerdì. La telefonata è gratuita. Вы можете получить данную информацию бесплатно на других языках. Звоните или (Телетайп) с 8:00 до 20:00 с понедельника по пятницу. Звонок бесплатный. 您可以通過其他語言免費獲取該信息 週一至週五上午 8 點至晚 8 點, 撥打 或 該電話免費? If you have questions, please call Fidelis Care FIDA Plan at (TTY: ) Monday through Friday, 8 AM to 8 PM. The call is free. For more information, visit fideliscare.org. 1

2 (Updated 11/2017) H1916_FC FIDA 다른언어로된정보를무료로받을수있습니다. 월 ~ 금요일오전 8시에서오후8시까지 또는 (TTY) 로전화해주십시오. 통화는무료입니다. Ou kapab jwenn enfòmasyon sa gratis nan lòt lang yo. Rele oswa (TTY) ant 8 AM ak 8 PM Lendi jiska Vandredi. Apèl la gratis. You can get this information for free in other formats, such as large print, braille, or audio. Call or (TTY) between 8 AM and 8 PM Monday through Friday. The call is free. If you would like to request for all of your materials to be sent to you in a language other than English, or in an alternative format, call Participant Services to make this request at or (TTY) between 8 AM and 8 PM Monday through Friday. The call is free. The State of New York has created a participant ombudsman program called the Independent Consumer Advocacy Network (ICAN) to provide Participants free, confidential assistance on any services offered by Fidelis Care FIDA Plan. ICAN may be reached at or online at (TTY users should call 711, then follow the prompts to dial ).? If you have questions, please call Fidelis Care FIDA Plan at (TTY: ) Monday through Friday, 8 AM to 8 PM. The call is free. For more information, visit fideliscare.org. 2

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 Fidelis Care FIDA Plan. 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. Fidelis Care FIDA Plan will cover all drugs on the List if: your doctor or other prescriber says you need them to get better or stay healthy, the drug is medically necessary for your condition, and you fill the prescription at a Fidelis Care FIDA Plan network pharmacy. Fidelis Care FIDA Plan may have additional steps to access certain drugs (see question #5 below). In some cases, you may have to do something before you can get a drug, like try other drugs first. You can also see an up-to-date list of drugs that we cover on our website at fideliscare.org or call Participant Services at (TTY: ). 2. Does the List ever change? Yes. Fidelis Care FIDA Plan may add or remove drugs on the List during the year. Generally, the List will only change if: a new drug comes along that works as well as a drug on the List now, or we learn that a drug is not safe. We may also change our rules about drugs. For example, we could: Decide to require or not require prior approval for a drug. (Prior approval is permission from Fidelis Care FIDA Plan or your Interdisciplinary Team (IDT) before you can get a drug.) Add or change the amount of a drug you can get (called quantity limits ).? If you have questions, please call Fidelis Care FIDA Plan at (TTY: ) Monday through Friday, 8 AM to 8 PM. The call is free. For more information, visit fideliscare.org. 3

4 Add or change step therapy restrictions on a drug. (Step therapy means you must try one drug before we will cover another drug.) (For more information on these drug rules, see page 10.) 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. You can always check Fidelis Care FIDA Plan s up to date List online at fideliscare.org. You can also call Participant Services to check the current List at (TTY: ). 3. What happens when a cheaper drug comes along that works as well as a drug on the List now? If a cheaper drug becomes available that works as well as a drug on the List now: Your pharmacist may give you the cheaper drug the next time you fill your prescription. If you and your provider decide that the cheaper drug is not right for you, your provider can tell the pharmacist to continue to give you the drug you take now. Fidelis Care FIDA Plan may decide to take the more expensive drug off of the List. If you are taking a drug that we remove from the List because a cheaper drug that works just as well comes along, we will tell you by sending you a letter 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. 4. 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 and call you to tell you that the unsafe drug was taken off the List. If you receive this letter and have any questions, call Participant Services at (TTY: ) and ask about it. 5. Are there any restrictions or limits on drug coverage? Or are there any required actions to take in order to get certain drugs?? If you have questions, please call Fidelis Care FIDA Plan at (TTY: ) Monday through Friday, 8 AM to 8 PM. The call is free. For more information, visit fideliscare.org. 4

5 Yes, some drugs have coverage rules or have limits on the amount you can get. In some cases you or your doctor or other prescriber must do something before you can get the drug. For example: Prior approval (or prior authorization): For some drugs, you or your doctor or other prescriber must get approval from Fidelis Care FIDA Plan or your Interdisciplinary Team (IDT) before you fill your prescription. If you don t get approval, Fidelis Care FIDA Plan may not cover the drug. Quantity limits: Sometimes Fidelis Care FIDA Plan limits the amount of a drug you can get. Step therapy: Sometimes Fidelis Care FIDA Plan 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 beginning on 10. You can also get more information by visiting our web site at fideliscare.org. We have posted online documents that explain our prior authorization and step therapy 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. If you are in a nursing facility 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, whether or not you are a new Fidelis Care FIDA Plan Participant. 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 ask for 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 Fidelis Care FIDA Plan at (TTY: ) Monday through Friday, 8 AM to 8 PM. The call is free. For more information, visit fideliscare.org. 5

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: You can search alphabetically (if you know how to spell the drug), or You can search by medical condition. To search alphabetically, go to the Alphabetical Listing section on page 83. Then look for the name of your drug in the list. To search by medical condition, find the section labeled List of Covered s on page 10. The drugs in this section are grouped into categories depending on the type of medical conditions they are used to treat. For example, if you have a heart condition, you should look in the CARDIOVASCULAR - DRUGS TO TREAT HEART AND CIRCULATION CONDITIONS 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 Participant Services at (TTY: ) and ask about it. If you learn that Fidelis Care FIDA Plan will not cover the drug, you can do one of these things: Ask Participant 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 You can ask the plan or your Interdisciplinary Team (IDT) to make an exception to cover your drug. Please see question 11 for more information about exceptions.? If you have questions, please call Fidelis Care FIDA Plan at (TTY: ) Monday through Friday, 8 AM to 8 PM. The call is free. For more information, visit fideliscare.org. 6

7 10. What if you are a new Fidelis Care FIDA Plan Participant and can t find your drug on the List or have a problem getting your drug? We can help. We must cover up to 90 days of temporary supplies of your drug, as needed, during the first 90 days you are a Participant of Fidelis Care FIDA Plan. 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 ask for an exception. We will cover up to 90 days of temporary supplies of your drug if: you are taking a drug that is not on our List, or health plan rules do not let you get the amount ordered by your prescriber, or the drug requires prior approval by Fidelis Care FIDA Plan or your Interdisciplinary Team (IDT), or you are taking a drug that is part of a step therapy restriction. If you live in a nursing facility or other long-term care facility, you may refill your prescription for as long as 98 days. You may refill the drug multiple times during your first 90 days in the plan. This gives your prescriber time to change your drugs to ones on the List or ask for an exception. Current participants who do not reside in a long-term care facility and experience a level of care change are allowed at least a 30 day transition fill. Multiple fills up to a cumulative 90 days supply are allowed to accommodate fills for amounts less than prescribed. Current participants who reside in a long-term care facility and experience a level of care change are allowed up to a 31 days transition fill except for oral brand solids which are limited to 14 day fills (certain exceptions apply). Additional details on transition fills for current participants can be obtained by calling Participant Services at (TTY: ). 11. Can you ask for an exception to cover your drug? Yes. You can ask Fidelis Care FIDA Plan or your Interdisciplinary Team (IDT) to make an exception to cover a drug that is not on the List. You can also ask Fidelis Care FIDA Plan or your IDT to change the rules on your drug.? If you have questions, please call Fidelis Care FIDA Plan at (TTY: ) Monday through Friday, 8 AM to 8 PM. The call is free. For more information, visit fideliscare.org. 7

8 For example, Fidelis Care FIDA Plan may limit the amount of a drug we will cover. If your drug has a limit, you can ask us or your IDT to change the limit and cover more. Other examples: You can ask us or your IDT to drop step therapy restrictions or prior approval requirements. 12. How long does it take to get an exception? First, Fidelis Care FIDA Plan or your Interdisciplinary Team (IDT) must receive a statement from your prescriber supporting your request for an exception. After we get the statement, you will get 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, you will get a decision within 24 hours of getting your prescriber s supporting statement. 13. How can you ask for an exception? To ask for an exception, call your Care Manager. Your Care Manager will work with you and your provider to help you ask for an exception. 14. What are generic drugs? Generic drugs are made up of the same 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). Fidelis Care FIDA Plan covers both brand name drugs and generic drugs. 15. What are OTC drugs? OTC stands for over-the-counter. Fidelis Care FIDA Plan covers some OTC drugs when they are written as prescriptions by your provider. You can read the Fidelis Care FIDA Plan List to see what OTC drugs are covered.? If you have questions, please call Fidelis Care FIDA Plan at (TTY: ) Monday through Friday, 8 AM to 8 PM. The call is free. For more information, visit fideliscare.org. 8

9 16. Does Fidelis Care FIDA Plan cover OTC non-drug products? Fidelis Care FIDA Plan covers some OTC non-drug products when they are written as prescriptions by your provider (e.g. alcohol swabs, gauze pads). You can read the Fidelis Care FIDA Plan List to see what OTC non-drug products are covered. 17. What is your copay? You will not be charged a copay for drugs on the List. 18. What are drug tiers? s are groups of drugs on our List. Every drug on the Plan s List, including over-the-counter (OTC) drugs, is in one of two tiers. There is no cost to you for drugs in any of the tiers. 1 drugs are generic Part D drugs, generic non-medicare covered drugs, and/or generic non-medicare covered OTC drugs. 2 drugs are brand name Part D drugs, brand name non-medicare covered drugs, and/or brand name non-medicare covered OTC drugs.? If you have questions, please call Fidelis Care FIDA Plan at (TTY: ) Monday through Friday, 8 AM to 8 PM. The call is free. For more information, visit fideliscare.org. 9

10 List of Covered s The list of covered drugs gives you information about the drugs covered by Fidelis Care FIDA Plan. If you have trouble finding your drug in the list, turn to the Index that begins on page 83. The first column of the chart lists the name of the drug. Brand name drugs are capitalized (e.g., ROBITUSSIN PEAK COLD NIGH LIQD) and generic drugs are listed in lower-case italics (e.g., phenylephrine w/ acetaminophen). The information in the necessary actions, restrictions, or limits on use column tells you if Fidelis Care FIDA Plan has any rules for covering your drug. Note: The * next to a drug means the drug is not a Part D drug. These drugs have different rules for appeals. An appeal is a formal way of asking for a review of and change to a coverage decision if you think there was a mistake. For example, Fidelis Care FIDA Plan or your Interdisciplinary Team (IDT) might decide that a drug that you want is not covered or is no longer covered by Medicare or Medicaid. If you or your doctor or other prescriber disagrees with the decision, you can appeal. To ask for instructions on how to appeal, call Participant Services at (TTY: ) or the Independent Consumer Advocacy Network (ICAN) at (TTY users call 711, then follow the prompts to dial ). The call and the help are free. Free interpreter service is also available. You can also read the Participant Handbook to learn how to appeal a decision.? If you have questions, please call Fidelis Care FIDA Plan at (TTY: ) Monday through Friday, 8 AM to 8 PM. The call is free. For more information, visit fideliscare.org. 10

11 List of s by Medical Condition The drugs in this section are grouped into categories depending on the type of medical conditions they are used to treat. For example, if you have a heart condition, you should look in the CARDIOVASCULAR - DRUGS TO TREAT HEART AND CIRCULATION CONDITIONS category. That is where you will find drugs that treat heart conditions. The following abbreviations are used in the list of covered drugs: mailorder B/D - Covered under Medicare B or D LA - Limited Access * - Non-Part D s, or OTC Items that are covered by Medicaid Name ANALGESICS - DRUGS TO TREAT PAIN AND INFLAMMATION GOUT - DRUGS TO TREAT GOUT allopurinol tab 1 $0 colchicine w/ probenecid 1 $0 COLCRYS 2 $0 QL (120 tabs / 30 probenecid 1 $0 ULORIC 2 $0 ST MISCELLANEOUS acetaminophen CAPS 1 $0 NM; * acetaminophen CHEW 1 $0 NM; * acetaminophen LIQD 1 $0 NM; * acetaminophen SOLN 1 $0 NM; * 11

12 Name acetaminophen SUPP 120mg, 325mg, 650mg ACETAMINOPHEN SUPP 120mg, 325mg, 650mg 1 $0 NM; * 1 $0 NM; * acetaminophen SUSP 1 $0 NM; * acetaminophen TABS 1 $0 NM; * acetaminophen TBCR 1 $0 NM; * acetaminophen TBDP 1 $0 NM; * aspirin CHEW 1 $0 NM; * aspirin SUPP 300mg, 600mg 1 $0 NM; * aspirin TABS 1 $0 NM; * aspirin TBEC 1 $0 NM; * aspirin buffered (cal carb-mag carb-mag oxide) 1 $0 NM; * FEVERALL INFANTS 2 $0 NM; * NSAIDS - DRUGS TO TREAT PAIN AND INFLAMMATION celecoxib CAPS 50mg 1 $0 QL (240 caps / 30 celecoxib CAPS 100mg 1 $0 QL (120 caps / 30 celecoxib CAPS 200mg 1 $0 QL (60 caps / 30 celecoxib CAPS 400mg 1 $0 QL (30 caps / 30 diclofenac potassium 1 $0 QL (120 tabs / 30 12

13 Name diclofenac sodium TB24 1 $0 diclofenac sodium TBEC 1 $0 diflunisal 1 $0 etodolac 1 $0 etodolac er 1 $0 flurbiprofen TABS 1 $0 ibuprofen CAPS 1 $0 NM; * ibuprofen SUSP 100mg/5ml 1 $0 ibuprofen SUSP 100mg/5ml 1 $0 NM; * ibuprofen TABS 200mg 1 $0 NM; * ibuprofen TABS 400mg, 600mg, 800mg 1 $0 ketoprofen CAPS 1 $0 MELOXICAM SUSP 1 $0 meloxicam TABS 1 $0 nabumetone TABS 1 $0 naproxen SUSP; TABS; TBEC 1 $0 naproxen sodium TABS 275mg, 550mg 1 $0 piroxicam CAPS 1 $0 sulindac TABS 1 $0 OPIOID ANALGESICS - DRUGS TO TREAT PAIN 13

14 Name acetaminophen w/ codeine SOLN 1 $0 QL (5000 ml / 30 acetaminophen w/ codeine TABS 1 $0 QL (400 tabs / 30 butorphanol tartrate SOLN 1mg/ml, 2mg/ml 1 $0 BUTRANS 5mcg/hr 2 $0 QL (16 patches / 28 BUTRANS 10mcg/hr 2 $0 QL (8 patches / 28 BUTRANS 15mcg/hr, 20mcg/hr 2 $0 QL (4 patches / 28 BUTRANS 7.5MCG/HR 2 $0 QL (8 patches / 28 nalbuphine hcl SOLN 1 $0 tramadol hcl TABS 1 $0 QL (240 tabs / 30 tramadol-acetaminophen 1 $0 QL (240 tabs / 30 OPIOID ANALGESICS, CII - DRUGS TO TREAT PAIN DURAMORPH 1 $0 B/D endocet 1 $0 QL (360 tabs / 30 fentanyl citrate LPOP 2 $0 QL (120 lozenges / 30, PA 14

15 Name fentanyl patch 12 mcg/hr 1 $0 QL (10 patches / 30 fentanyl patch 25 mcg/hr 1 $0 QL (10 patches / 30 fentanyl patch 50 mcg/hr 1 $0 QL (10 patches / 30, PA fentanyl patch 75 mcg/hr 1 $0 QL (10 patches / 30, PA fentanyl patch 100 mcg/hr 1 $0 QL (10 patches / 30, PA FENTORA 2 $0 QL (120 tabs / 30, PA hydroco/apap tab 5-325mg 1 $0 QL (360 tabs / 30 hydroco/apap tab $0 QL (360 tabs / 30 hydroco/apap tab mg 1 $0 QL (360 tabs / 30 hydrocodone-acetaminophen mg/15ml hydrocodone-ibuprofen tab mg 1 $0 QL (5400 ml / 30 1 $0 QL (150 tabs / 30 hydromorphone hcl LIQD 1 $0 hydromorphone hcl SOLN 1 $0 B/D 10mg/ml, 50mg/5ml, 500mg/50ml hydromorphone hcl TABS 1 $0 QL (270 tabs / 30 15

16 Name HYSINGLA ER 20mg, 30mg, 40mg, 60mg HYSINGLA ER 80mg, 100mg, 120mg 2 $0 QL (60 tabs / 30 2 $0 QL (30 tabs / 30 lorcet hd tab mg 1 $0 QL (360 tabs / 30 lorcet plus tab $0 QL (360 tabs / 30 lorcet tab 5-325mg 1 $0 QL (360 tabs / 30 methadone hcl CONC 1 $0 QL (120 ml / 30 methadone hcl SOLN 5mg/5ml, 10mg/5ml 1 $0 QL (600 ml / 30 methadone hcl 5mg 1 $0 QL (240 tabs / 30 methadone hcl 10mg 1 $0 QL (240 tabs / 30 morphine ext-rel tab 15mg, 30mg, 1 $0 QL (90 tabs / 30 60mg, 100mg morphine ext-rel tab 200mg 1 $0 QL (60 tabs / 30 MORPHINE SUL INJ 1MG/ML 1 $0 B/D MORPHINE SUL INJ 4MG/ML 1 $0 B/D MORPHINE SUL INJ 10MG/ML 1 $0 B/D MORPHINE SUL INJ 15MG/ML 1 $0 B/D 16

17 Name MORPHINE SULFATE SOLN 2mg/ml, 8mg/ml, 150mg/30ml morphine sulfate SOLN.5mg/ml, 1mg/ml, 4mg/ml, 8mg/ml 1 $0 B/D 1 $0 B/D MORPHINE SULFATE TABS 1 $0 QL (180 tabs / 30 MORPHINE SULFATE ORAL SOL 1 $0 oxycodone hcl CAPS 1 $0 QL (180 caps / 30 oxycodone hcl CONC 1 $0 OXYCODONE HCL SOLN 1 $0 oxycodone hcl TABS 1 $0 QL (180 tabs / 30 oxycodone w/ acetaminophen mg oxycodone w/ acetaminophen 5-325mg oxycodone w/ acetaminophen mg oxycodone w/ acetaminophen mg 1 $0 QL (360 tabs / 30 1 $0 QL (360 tabs / 30 1 $0 QL (360 tabs / 30 1 $0 QL (360 tabs / 30 oxycodone w/ acetaminophen soln 1 $0 QL (1800 ml / 30 OXYCONTIN 2 $0 QL (120 tabs / 30 ANESTHETICS - DRUGS FOR NUMBING 17

18 Name LOCAL ANESTHETICS lidocaine hcl (local anesth.) 1 $0 B/D lidocaine inj 0.5% 1 $0 B/D lidocaine inj 1% 1 $0 B/D lidocaine inj 1.5% 1 $0 B/D lidocaine inj 2% 1 $0 B/D ANTI-INFECTIVES - DRUGS TO TREAT INFECTIONS ANTI-BACTERIALS - MISCELLANEOUS amikacin sulfate SOLN 1 $0 gentamicin in saline 1 $0 gentamicin sulfate SOLN 1 $0 neomycin sulfate TABS 1 $0 paromomycin sulfate CAPS 1 $0 streptomycin sulfate SOLR 1 $0 sulfadiazine TABS 2 $0 tobramycin NEBU 2 $0 NM, PA tobramycin inj 1.2 gm/30ml 1 $0 tobramycin inj 1.2gm 2 $0 tobramycin inj 10mg/ml 1 $0 tobramycin inj 40mg/ml 1 $0 tobramycin inj 80mg/2ml 1 $0 18

19 Name ANTI-INFECTIVES - MISCELLANEOUS ALBENZA 2 $0 ALINIA 2 $0 atovaquone SUSP 2 $0 AZACTAM IN ISO-OSMOTIC DE 2 $0 AZACTAM/DEX INJ 2GM 2 $0 aztreonam 1 $0 BILTRICIDE 2 $0 CAYSTON 2 $0 NM, LA, PA clindamycin cap 75mg 1 $0 clindamycin cap 300mg 1 $0 clindamycin hcl cap 150 mg 1 $0 clindamycin phosphate SOLN 1 $0 clindamycin phosphate in d5w 1 $0 CLINDAMYCIN PHOSPHATE IN NACL 2 $0 clindamycin phosphate inj 1 $0 clindamycin sol 75mg/5ml 1 $0 colistimethate sodium SOLR 1 $0 CUBICIN 2 $0 dapsone TABS 1 $0 daptomycin 2 $0 19

20 Name emverm 2 $0 imipenem-cilastatin 1 $0 INVANZ 2 $0 ivermectin TABS 1 $0 linezolid SOLN 2 $0 LINEZOLID SUSR; TABS 2 $0 LINEZOLID IN SODIUM CHLORIDE 2 $0 meropenem 1 $0 methenamine hippurate 1 $0 metronidazole TABS 1 $0 metronidazole in nacl 1 $0 NEBUPENT 2 $0 B/D nitrofurantoin macrocrystal 50mg, 100mg 2 $0 PA; PA applies if 65 years and older after a 90 day supply in a calendar year nitrofurantoin monohyd macro 2 $0 PA; PA applies if 65 years and older after a 90 day supply in a calendar year PENTAM $0 SIVEXTRO 2 $0 sulfamethoxazole-trimethop ds 1 $0 sulfamethoxazole-trimethoprim 1 $0 20

21 Name sulfamethoxazole-trimethoprim inj 1 $0 SYNERCID 2 $0 TIGECYCLINE 2 $0 trimethoprim TABS 1 $0 TYGACIL 2 $0 vancomycin hcl CAPS 2 $0 vancomycin hcl SOLR 1 $0 VANCOMYCIN IN NACL 2 $0 ANTIFUNGALS - DRUGS TO TREAT FUNGAL INFECTIONS ABELCET 2 $0 B/D AMBISOME 2 $0 B/D amphotericin b SOLR 1 $0 B/D CANCIDAS 2 $0 CASPOFUNGIN ACETATE 2 $0 fluconazole SUSR; TABS 1 $0 fluconazole in dextrose 1 $0 fluconazole inj nacl $0 fluconazole inj nacl $0 fluconazole inj nacl $0 flucytosine CAPS 2 $0 griseofulvin microsize 1 $0 21

22 Name griseofulvin ultramicrosize 1 $0 itraconazole CAPS 1 $0 PA ketoconazole TABS 1 $0 PA MYCAMINE 2 $0 NOXAFIL SUSP; TBEC 2 $0 nystatin TABS 1 $0 terbinafine hcl TABS 1 $0 QL (90 tabs / 365 voriconazole SOLR 1 $0 voriconazole SUSR; TABS 2 $0 ANTIMALARIALS - DRUGS TO TREAT MALARIA atovaquone-proguanil hcl 1 $0 chloroquine phosphate TABS 1 $0 COARTEM 2 $0 mefloquine hcl 1 $0 PRIMAQUINE PHOSPHATE 2 $0 quinine sulfate CAPS 1 $0 PA ANTIRETROVIRAL AGENTS - DRUGS TO SUPPRESS HIV/AIDS INFECTION abacavir sulfate 1 $0 APTIVUS 2 $0 CRIXIVAN 2 $0 didanosine 1 $0 22

23 Name EDURANT 2 $0 EMTRIVA 2 $0 FUZEON 2 $0 NM INTELENCE 2 $0 INVIRASE 2 $0 ISENTRESS 2 $0 ISENTRESS HD 2 $0 lamivudine 1 $0 LEXIVA 2 $0 NEVIRAPINE SUSP 1 $0 nevirapine TABS; TB24 1 $0 NORVIR 2 $0 PREZISTA 2 $0 RESCRIPTOR 2 $0 RETROVIR IV INFUSION 2 $0 REYATAZ 2 $0 SELZENTRY 2 $0 stavudine 1 $0 SUSTIVA 2 $0 TIVICAY 2 $0 TYBOST 2 $0 23

24 Name VIDEX PEDIATRIC 2 $0 VIRACEPT 2 $0 VIRAMUNE SUSP 2 $0 VIREAD 2 $0 ZERIT SOLR 2 $0 ZIAGEN SOLN 2 $0 zidovudine 1 $0 ANTIRETROVIRAL COMBINATION AGENTS - DRUGS TO SUPPRESS HIV/AIDS INFECTION ABACAVIR SULFATE-LAMIVUDINE 2 $0 abacavir sulfate-lamivudinezidovudine 2 $0 ATRIPLA 2 $0 COMPLERA 2 $0 DESCOVY 2 $0 EVOTAZ 2 $0 GENVOYA 2 $0 KALETRA SOL 2 $0 KALETRA TAB MG 2 $0 KALETRA TAB MG 2 $0 lamivudine-zidovudine 1 $0 lopinavir-ritonavir 2 $0 24

25 Name ODEFSEY 2 $0 PREZCOBIX 2 $0 STRIBILD 2 $0 TRIUMEQ 2 $0 TRUVADA TAB $0 QL (60 tabs / 30 TRUVADA TAB $0 QL (30 tabs / 30 TRUVADA TAB $0 QL (30 tabs / 30 TRUVADA TAB $0 QL (30 tabs / 30 ANTITUBERCULAR AGENTS - DRUGS TO TREAT TUBERCULOSIS CAPASTAT SULFATE 2 $0 cycloserine CAPS 2 $0 ethambutol hcl TABS 1 $0 isoniazid TABS 1 $0 isoniazid inj 100 mg/ml 1 $0 isoniazid syp 50mg/5ml 1 $0 paser d/r 2 $0 PRIFTIN 2 $0 pyrazinamide TABS 1 $0 rifabutin 1 $0 rifampin CAPS; SOLR 1 $0 RIFATER 2 $0 25

26 Name SIRTURO 2 $0 LA, PA TRECATOR 2 $0 ANTIVIRALS - DRUGS TO TREAT VIRAL INFECTIONS acyclovir CAPS 1 $0 acyclovir SUSP 1 $0 acyclovir TABS 1 $0 acyclovir sodium 1 $0 B/D adefovir dipivoxil 2 $0 BARACLUDE SOLN 2 $0 DAKLINZA 2 $0 NM, PA entecavir 2 $0 EPCLUSA 2 $0 NM, PA EPIVIR HBV SOLN 2 $0 famciclovir TABS 1 $0 ganciclovir inj 500mg 1 $0 B/D HARVONI 2 $0 NM, PA lamivudine (hbv) 1 $0 MAVYRET 2 $0 NM, PA moderiba tab 200mg 1 $0 NM oseltamivir phosphate 1 $0 PEGASYS 2 $0 NM, PA 26

27 Name PEGASYS PROCLICK 2 $0 NM, PA REBETOL SOLN 2 $0 NM RELENZA DISKHALER 2 $0 ribasphere CAPS 1 $0 NM ribasphere TABS 200mg 1 $0 NM ribasphere TABS 400mg, 600mg 2 $0 NM ribavirin 200mg 1 $0 NM rimantadine hydrochloride 1 $0 SOVALDI 2 $0 NM, PA TAMIFLU SUSR 2 $0 TYZEKA 2 $0 valacyclovir hcl TABS 1 $0 VALCYTE SOLR 2 $0 valganciclovir hcl 2 $0 VEMLIDY 2 $0 VOSEVI 2 $0 NM, PA ZEPATIER 2 $0 NM, PA CEPHALOSPORINS - DRUGS TO TREAT INFECTIONS cefaclor 1 $0 cefaclor monohydrate er 2 $0 cefadroxil 1 $0 27

28 Name CEFAZOLIN IN DEXTROSE 2GM/100ML-4% 2 $0 cefazolin inj 1 $0 cefazolin sodium SOLR 1gm, 20gm 1 $0 cefazolin sodium 1 gm/50ml 2 $0 cefdinir 1 $0 cefepime hcl 1 $0 cefixime 1 $0 cefotaxime sodium 1gm, 2gm, 500mg 1 $0 cefoxitin sodium 1 $0 cefpodoxime proxetil 1 $0 cefprozil 1 $0 ceftazidime SOLR 1 $0 CEFTAZIDIME/DEXTROSE 2 $0 ceftriaxone sodium SOLR 1gm, 2gm, 10gm, 250mg, 500mg 1 $0 cefuroxime axetil 1 $0 cefuroxime sodium 1 $0 cephalexin CAPS 250mg, 500mg 1 $0 cephalexin SUSR 1 $0 SUPRAX CAPS 2 $0 28

29 Name suprax CHEW 2 $0 SUPRAX SUSR 500mg/5ml 2 $0 tazicef SOLR 1 $0 tazicef vial 1 $0 TEFLARO 2 $0 ERYTHROMYCINS/MACROLIDES - DRUGS TO TREAT INFECTIONS AZITHROMYCIN PACK 1 $0 azithromycin SOLR; SUSR; TABS 1 $0 clarithromycin TABS 1 $0 clarithromycin er 1 $0 clarithromycin for susp 1 $0 DIFICID 2 $0 e.e.s. 1 $0 ery-tab 1 $0 erythrocin lactobionate 2 $0 erythrocin stearate 1 $0 erythromycin base 1 $0 erythromycin cap 250mg ec 1 $0 erythromycin ethylsuccinate TABS 1 $0 FLUOROQUINOLONES - DRUGS TO TREAT INFECTIONS ciprofloxacin SUSR 1 $0 29

30 Name ciprofloxacin er 1 $0 ciprofloxacin hcl tab 1 $0 ciprofloxacin in d5w 1 $0 ciprofloxacin inj 1 $0 levofloxacin TABS 1 $0 levofloxacin in d5w 1 $0 levofloxacin inj 25mg/ml 1 $0 levofloxacin oral soln 25 mg/ml 1 $0 moxifloxacin hcl TABS 1 $0 PENICILLINS - DRUGS TO TREAT INFECTIONS amoxicillin 1 $0 amoxicillin & pot clavulanate 1 $0 ampicillin & sulbactam sodium 1 $0 ampicillin cap 250 mg 1 $0 ampicillin cap 500 mg 1 $0 ampicillin inj 1 $0 ampicillin sodium 1 $0 ampicillin susp 1 $0 BICILLIN L-A 2 $0 dicloxacillin sodium 1 $0 nafcillin sodium 1 $0 30

31 Name oxacillin sodium 1gm, 2gm 1 $0 oxacillin sodium 10gm 2 $0 PENICILLIN G POT IN DEXTROSE 2 $0 penicillin g procaine 2 $0 penicillin g sodium 1 $0 penicillin v potassium 1 $0 penicilln gk inj 5mu 1 $0 penicilln gk inj 20mu 1 $0 pfizerpen-g 1 $0 piperacillin sodium-tazobactam sodium 1 $0 piperacillin/tazobactam 1 $0 TETRACYCLINES - DRUGS TO TREAT INFECTIONS doxy 1 $0 doxycycline (monohydrate) CAPS 50mg, 100mg 1 $0 doxycycline (monohydrate) TABS 1 $0 doxycycline hyclate CAPS 1 $0 doxycycline hyclate SOLR 1 $0 doxycycline hyclate TABS 20mg, 100mg 1 $0 minocycline hcl CAPS 1 $0 morgidox cap 1x50mg 1 $0 31

32 Name ANTINEOPLASTIC AGENTS - DRUGS TO TREAT CANCER ALKYLATING AGENTS BENDEKA 2 $0 B/D, NM BICNU 2 $0 B/D busulfan 2 $0 B/D BUSULFEX 2 $0 B/D CYCLOPHOSPHAMIDE CAPS 2 $0 B/D cyclophosphamide SOLR 2 $0 B/D dacarbazine 1 $0 B/D EMCYT 2 $0 GLEOSTINE 2 $0 HEXALEN 2 $0 IFEX INJ 3GM 2 $0 B/D ifosfamide inj 1gm 1 $0 B/D ifosfamide inj 1gm/20ml 1 $0 B/D IFOSFAMIDE INJ 3GM 2 $0 B/D ifosfamide inj 3gm/60ml 1 $0 B/D LEUKERAN 2 $0 melphalan hcl 2 $0 B/D MUSTARGEN 2 $0 B/D TREANDA 2 $0 B/D, NM 32

33 Name ANTHRACYCLINES adriamycin 1 $0 B/D daunorubicin hcl 1 $0 B/D doxorubicin hcl 1 $0 B/D doxorubicin hcl liposomal inj 2mg/ml 2 $0 B/D doxorubicin inj 50mg 1 $0 B/D epirubicin hcl 1 $0 B/D idarubicin hcl 2 $0 B/D ANTIBIOTICS bleomycin sulfate 1 $0 B/D mitomycin SOLR 2 $0 B/D ANTIMETABOLITES adrucil 1 $0 B/D ALIMTA 2 $0 B/D azacitidine 2 $0 B/D, NM cladribine 2 $0 B/D cytarabine 20mg/ml 1 $0 B/D fludarabine phosphate 1 $0 B/D fluorouracil SOLN 1 $0 B/D GEMCITABINE HCL SOLN 2 $0 B/D gemcitabine hcl SOLR 2 $0 B/D 33

34 Name mercaptopurine TABS 1 $0 METHOTREXATE SODIUM 50mg/2ml methotrexate sodium 50mg/2ml, 100mg/4ml, 200mg/8ml, 250mg/10ml 1 $0 B/D 1 $0 B/D methotrexate sodium inj 1 $0 B/D NIPENT 2 $0 B/D PURIXAN 2 $0 NM TABLOID 2 $0 ANTIMITOTIC, TAXOIDS ABRAXANE 2 $0 B/D DOCEFREZ 2 $0 B/D DOCETAXEL 20mg/ml, 80mg/4ml, 160mg/8ml 2 $0 B/D docetaxel 80mg/4ml, 200mg/10ml 2 $0 B/D DOCETAXEL 20MG/2ML 2 $0 B/D DOCETAXEL 160MG/16ML 2 $0 B/D DOCETAXEL SOLN 80MG/8ML 2 $0 B/D paclitaxel 1 $0 B/D TAXOTERE 80mg/4ml 2 $0 B/D ANTIMITOTIC, VINCA ALKALOIDS vinblastine sulfate 2 $0 B/D 34

35 Name vincasar 1 $0 B/D vincristine sulfate 1 $0 B/D vinorelbine tartrate 1 $0 B/D BIOLOGIC RESPONSE MODIFIERS AVASTIN 2 $0 NM, LA, PA BELEODAQ 2 $0 NM, PA ERIVEDGE 2 $0 NM, LA, PA FARYDAK 2 $0 NM, LA, PA HERCEPTIN 2 $0 NM, PA IBRANCE 2 $0 NM, LA, PA IDHIFA 2 $0 NM, LA, PA ISTODAX (OVERFILL) 2 $0 B/D, NM KADCYLA 2 $0 B/D, NM KEYTRUDA 2 $0 NM, PA KISQALI 2 $0 NM, PA KISQALI FEMARA 200 DOSE 2 $0 NM, PA KISQALI FEMARA 400 DOSE 2 $0 NM, PA KISQALI FEMARA 600 DOSE 2 $0 NM, PA LYNPARZA CAPS 2 $0 NM, LA, PA NINLARO 2 $0 NM, PA PROLEUKIN 2 $0 B/D, NM 35

36 Name RITUXAN 2 $0 NM, LA, PA RITUXAN HYCELA 2 $0 NM, LA, PA RUBRACA 2 $0 NM, LA, PA TECENTRIQ 2 $0 NM, LA, PA VELCADE 2 $0 NM, PA VENCLEXTA 2 $0 NM, LA, PA VENCLEXTA STARTING PACK 2 $0 NM, LA, PA YERVOY 2 $0 NM, PA ZEJULA 2 $0 NM, LA, PA ZOLINZA 2 $0 NM, PA HORMONAL ANTINEOPLASTIC AGENTS anastrozole TABS 1 $0 bicalutamide 1 $0 DEPO-PROVERA INJ 400/ML 2 $0 B/D exemestane 1 $0 FARESTON 2 $0 FASLODEX 2 $0 B/D flutamide 1 $0 hydroxyprogesterone caproate (antineoplastic) 2 $0 B/D letrozole TABS 1 $0 leuprolide acetate KIT 1 $0 NM, PA 36

37 Name LUPRON DEPOT (1-MONTH) 3.75mg LUPRON DEPOT INJ 11.25MG (3- MONTH) 2 $0 NM, PA 2 $0 NM, PA LYSODREN 2 $0 megestrol ac sus 40mg/ml 2 $0 PA; PA if 65 years and older megestrol ac tab 20mg 2 $0 PA; PA if 65 years and older megestrol ac tab 40mg 2 $0 PA; PA if 65 years and older MEGESTROL SUS 625MG/5ML 2 $0 PA nilutamide 2 $0 SOLTAMOX 2 $0 tamoxifen citrate TABS 1 $0 TRELSTAR DEP INJ 3.75MG 2 $0 NM, PA TRELSTAR LA INJ 11.25MG 2 $0 NM, PA XTANDI 2 $0 NM, LA, PA ZYTIGA 2 $0 NM, LA, PA KINASE INHIBITORS AFINITOR 2 $0 NM, PA AFINITOR DISPERZ 2 $0 NM, PA ALECENSA 2 $0 NM, LA, PA 37

38 Name ALUNBRIG 2 $0 NM, LA, PA BOSULIF 2 $0 NM, PA CABOMETYX 2 $0 NM, LA, PA CAPRELSA 2 $0 NM, LA, PA COMETRIQ 2 $0 NM, LA, PA COTELLIC 2 $0 NM, LA, PA GILOTRIF TAB 20MG 2 $0 NM, LA, PA GILOTRIF TAB 30MG 2 $0 NM, LA, PA GILOTRIF TAB 40MG 2 $0 NM, LA, PA ICLUSIG 2 $0 NM, LA, PA imatinib mesylate 100mg 2 $0 QL (90 tabs / 30, NM, PA imatinib mesylate 400mg 2 $0 QL (60 tabs / 30, NM, PA IMBRUVICA CAP 140MG 2 $0 NM, LA, PA INLYTA 2 $0 NM, LA, PA IRESSA 2 $0 NM, LA, PA JAKAFI 2 $0 NM, LA, PA LENVIMA 8 MG DAILY DOSE 2 $0 NM, LA, PA LENVIMA 10 MG DAILY DOSE 2 $0 NM, LA, PA LENVIMA 14 MG DAILY DOSE 2 $0 NM, LA, PA LENVIMA 18 MG DAILY DOSE 2 $0 NM, LA, PA 38

39 Name LENVIMA 20 MG DAILY DOSE 2 $0 NM, LA, PA LENVIMA 24 MG DAILY DOSE 2 $0 NM, LA, PA MEKINIST 2 $0 NM, LA, PA NERLYNX 2 $0 NM, LA, PA NEXAVAR 2 $0 NM, LA, PA RYDAPT 2 $0 NM, PA SPRYCEL 2 $0 NM, PA STIVARGA 2 $0 NM, LA, PA SUTENT 2 $0 NM, PA TAFINLAR 2 $0 NM, LA, PA TAGRISSO 2 $0 NM, LA, PA TARCEVA 2 $0 NM, LA, PA TASIGNA 2 $0 NM, PA TYKERB 2 $0 NM, LA, PA VOTRIENT 2 $0 NM, LA, PA XALKORI 2 $0 NM, LA, PA ZELBORAF 2 $0 NM, LA, PA ZYDELIG 2 $0 NM, LA, PA ZYKADIA 2 $0 NM, LA, PA MISCELLANEOUS bexarotene 2 $0 NM, PA 39

40 Name DROXIA 2 $0 hydroxyurea CAPS 1 $0 LONSURF 2 $0 NM, PA MATULANE 2 $0 LA mitoxantrone hcl 1 $0 B/D, NM ODOMZO 2 $0 NM, LA, PA SYLATRON KIT 200MCG 2 $0 NM, PA SYLATRON KIT 300MCG 2 $0 NM, PA SYLATRON KIT 600MCG 2 $0 NM, PA SYNRIBO 2 $0 NM, PA tretinoin (chemotherapy) 2 $0 TRISENOX 2 $0 B/D PLATINUM-BASED AGENTS carboplatin 1 $0 B/D cisplatin 1 $0 B/D oxaliplatin 1 $0 B/D PROTECTIVE AGENTS AMIFOSTINE 2 $0 B/D dexrazoxane 2 $0 B/D ELITEK 2 $0 B/D FUSILEV 2 $0 B/D, NM 40

41 Name leucovorin calcium SOLR 1 $0 B/D leucovorin calcium TABS 1 $0 leucovorin calcium for inj 500 mg 1 $0 B/D levoleucovorin calcium SOLN 2 $0 B/D, NM levoleucovorin calcium SOLR 50mg 2 $0 B/D, NM LEVOLEUCOVORIN CALCIUM SOLR 2 $0 B/D, NM 175mg mesna 1 $0 B/D MESNEX TABS 2 $0 TOPOISOMERASE INHIBITORS etoposide SOLN 1 $0 B/D irinotecan inj 40mg/2ml 1 $0 B/D irinotecan inj 100/5ml 1 $0 B/D irinotecan inj 500mg/25ml 1 $0 B/D toposar 1 $0 B/D TOPOTECAN HCL SOLN 2 $0 B/D topotecan hcl SOLR 2 $0 B/D CARDIOVASCULAR - DRUGS TO TREAT HEART AND CIRCULATION CONDITIONS ACE INHIBITOR COMBINATIONS - DRUGS TO TREAT HIGH BLOOD PRESSURE 41

42 Name amlodipine--benazepril hcl cap mg amlodipine-benazepril hcl cap mg 1 $0 1 $0 amlodipine-benazepril hcl cap 5-10 mg amlodipine-benazepril hcl cap 5-20 mg amlodipine-benazepril hcl cap 5-40 mg 1 $0 1 $0 1 $0 amlodipine-benazepril hcl cap 10-40mg 1 $0 benazepril & hydrochlorothiazide 1 $0 captopril & hydrochlorothiazide 1 $0 enalapril maleate & hydrochlorothiazide fosinopril sodium & hydrochlorothiazide 1 $0 1 $0 lisinopril & hydrochlorothiazide 1 $0 moexipril-hydrochlorothiazide 1 $0 quinapril-hydrochlorothiazide 1 $0 ACE INHIBITORS - DRUGS TO TREAT HIGH BLOOD PRESSURE benazepril hcl TABS 1 $0 captopril TABS 1 $0 enalapril maleate TABS 1 $0 42

43 Name fosinopril sodium 1 $0 lisinopril TABS 1 $0 moexipril hcl 1 $0 perindopril erbumine 1 $0 quinapril hcl 1 $0 ramipril 1 $0 trandolapril 1 $0 ALDOSTERONE RECEPTOR ANTAGONISTS - DRUGS TO TREAT HIGH BLOOD PRESSURE eplerenone 1 $0 spironolactone TABS 1 $0 ALPHA BLOCKERS - DRUGS TO TREAT HIGH BLOOD PRESSURE doxazosin mesylate 1mg, 2mg, 4mg 1 $0 QL (30 tabs / 30 doxazosin mesylate 8mg 1 $0 prazosin hcl 1 $0 terazosin hcl 1 $0 ANGIOTENSIN II RECEPTOR ANTAGONIST COMBINATIONS - DRUGS TO TREAT HIGH BLOOD PRESSURE amlodipine besylate-olmesartan medoxomil amlodipine besylate-valsartan tab mg 1 $0 1 $0 43

44 Name amlodipine besylate-valsartan tab mg amlodipine besylate-valsartan tab mg amlodipine besylate-valsartan tab mg 1 $0 1 $0 1 $0 amlodipine-valsartanhydrochlorothiazide mg 1 $0 amlodipine-valsartanhydrochlorothiazide mg amlodipine-valsartanhydrochlorothiazide mg amlodipine-valsartanhydrochlorothiazide mg amlodipine-valsartanhydrochlorothiazide mg candesartan cilexetilhydrochlorothiazide 1 $0 1 $0 1 $0 1 $0 1 $0 ENTRESTO 2 $0 irbesartan-hydrochlorothiazide 1 $0 losartan-hydrochlorothiazide 1 $0 olmesartan medoxomil-amlodipine-hydrochlorothiazide $0 olmesartan medoxomilhydrochlorothiazide 1 $0 44

45 Name telmisartan-hydrochlorothiazide 1 $0 valsartan & hctz tab mg 1 $0 valsartan & hctz tab mg 1 $0 valsartan & hctz tab mg 1 $0 valsartan & hctz tab mg 1 $0 valsartan & hctz tab mg 1 $0 ANGIOTENSIN II RECEPTOR ANTAGONISTS - DRUGS TO TREAT HIGH BLOOD PRESSURE candesartan cilexetil 1 $0 irbesartan 1 $0 losartan potassium 1 $0 olmesartan medoxomil TABS 1 $0 telmisartan 1 $0 valsartan 1 $0 ANTIARRHYTHMICS - DRUGS TO CONTROL HEART RHYTHM amiodarone hcl 1 $0 disopyramide phosphate 2 $0 PA; PA if 65 years and older DOFETILIDE 1 $0 NM flecainide acetate 1 $0 mexiletine hcl 1 $0 MULTAQ 2 $0 45

46 Name NORPACE CR 2 $0 PA; PA if 65 years and older pacerone 1 $0 propafenone hcl 1 $0 propafenone hcl 12hr 1 $0 quinidine gluconate TBCR 1 $0 quinidine sulfate TABS 1 $0 sorine 1 $0 sotalol hcl 1 $0 sotalol hcl (afib/afl) 1 $0 ANTILIPEMICS, HMG-CoA REDUCTASE INHIBITORS - DRUGS TO TREAT HIGH CHOLESTEROL atorvastatin calcium TABS 1 $0 lovastatin 1 $0 pravastatin sodium 1 $0 rosuvastatin calcium 1 $0 QL (30 tabs / 30 simvastatin TABS 5mg, 10mg, 20mg, 40mg 1 $0 simvastatin TABS 80mg 1 $0 QL (30 tabs / 30 ANTILIPEMICS, MISCELLANEOUS - DRUGS TO TREAT HIGH CHOLESTEROL cholestyramine 1 $0 cholestyramine light 1 $0 colestipol hcl 1 $0 46

47 Name ezetimibe 1 $0 fenofibrate TABS 48mg, 54mg, 145mg, 160mg fenofibrate micronized 67mg, 134mg, 200mg 1 $0 1 $0 gemfibrozil TABS 1 $0 JUXTAPID 2 $0 NM, LA, PA KYNAMRO 2 $0 NM, PA niacin er (antihyperlipidemic) 500mg niacin er (antihyperlipidemic) 750mg, 1000mg 1 $0 QL (90 tabs / 30 1 $0 niacor 1 $0 omega-3-acid ethyl esters 1 $0 PRALUENT 2 $0 NM, PA prevalite 1 $0 triklo 1 $0 VASCEPA 2 $0 WELCHOL 2 $0 BETA-BLOCKER/DIURETIC COMBINATIONS - DRUGS TO TREAT HIGH BLOOD PRESSURE AND HEART CONDITIONS atenolol & chlorthalidone 1 $0 bisoprolol & hydrochlorothiazide 1 $0 47

48 Name metoprolol & hctz tab 50-25mg 1 $0 metoprolol & hctz tab mg 1 $0 metoprolol & hctz tab mg 1 $0 propranolol & hydrochlorothiazide 1 $0 BETA-BLOCKERS - DRUGS TO TREAT HIGH BLOOD PRESSURE AND HEART CONDITIONS acebutolol hcl CAPS 1 $0 atenolol TABS 1 $0 bisoprolol fumarate 1 $0 BYSTOLIC 2 $0 carvedilol 1 $0 labetalol hcl TABS 1 $0 metoprolol succinate 1 $0 metoprolol tartrate SOCT 1 $0 metoprolol tartrate SOLN 1 $0 metoprolol tartrate TABS 25mg, 50mg, 100mg 1 $0 nadolol TABS 1 $0 pindolol 1 $0 propranolol cap er 1 $0 propranolol hcl SOLN; TABS 1 $0 propranolol oral sol 1 $0 48

49 Name timolol maleate TABS 1 $0 CALCIUM CHANNEL BLOCKERS - DRUGS TO TREAT HIGH BLOOD PRESSURE AND HEART CONDITIONS afeditab cr 1 $0 amlodipine besylate TABS 1 $0 cartia xt cap 120/24hr 1 $0 cartia xt cap 180/24hr 1 $0 cartia xt cap 240/24hr 1 $0 cartia xt cap 300/24hr 1 $0 dilt-xr cap 1 $0 diltiazem cap 120mg cd 1 $0 diltiazem cap 180mg cd 1 $0 diltiazem cap 240mg cd 1 $0 diltiazem cap 300mg cd 1 $0 DILTIAZEM CAP 360MG CD 1 $0 diltiazem cap er/12hr 1 $0 diltiazem hcl SOLN; TABS 1 $0 diltiazem hcl cap sr 24hr 1 $0 diltiazem hcl coated beads cap sr 24hr diltiazem hcl extended release beads cap sr 1 $0 1 $0 felodipine 1 $0 49

50 Name isradipine 1 $0 nicardipine hcl CAPS 1 $0 nifedical xl 1 $0 nifedipine TB24 1 $0 nifedipine er 1 $0 nimodipine CAPS 2 $0 NYMALIZE 2 $0 taztia 1 $0 verapamil cap er 100mg, 120mg, 180mg, 200mg, 240mg, 300mg 1 $0 VERAPAMIL CAP ER 360mg 1 $0 verapamil hcl SOLN; TABS; TBCR 1 $0 verapamil tab er 1 $0 DIGITALIS GLYCOSIDES - DRUGS TO TREAT HEART CONDITIONS digitek.25mg 1 $0 PA; PA if 65 years and older digitek.125mg 1 $0 QL (30 tabs / 30 digox 125mcg 1 $0 QL (30 tabs / 30 digox 250mcg 1 $0 PA; PA if 65 years and older digoxin TABS 125mcg 1 $0 QL (30 tabs / 30 digoxin TABS 250mcg 1 $0 PA; PA if 65 years and older 50

51 Name digoxin inj 1 $0 DIGOXIN SOL 50MCG/ML 1 $0 PA; PA if 65 years and older DIURETICS - DRUGS TO TREAT HEART CONDITIONS acetazolamide CP12; TABS 1 $0 amiloride & hydrochlorothiazide 1 $0 amiloride hcl TABS 1 $0 bumetanide 1 $0 chlorothiazide tabs 1 $0 chlorthalidone 1 $0 furosemide SOLN; TABS 1 $0 furosemide inj 10mg/ml 1 $0 FUROSEMIDE INJ 10mg/ml 1 $0 hydrochlorothiazide CAPS; TABS 1 $0 indapamide 1 $0 methazolamide TABS 1 $0 methyclothiazide 1 $0 metolazone 1 $0 spironolactone & hydrochlorothiazide 1 $0 torsemide tabs 1 $0 triamterene & hydrochlorothiazide TABS 1 $0 51

52 Name triamterene & hydrochlorothiazide cap mg 1 $0 MISCELLANEOUS clonidine hcl PTWK; TABS 1 $0 DEMSER 2 $0 hydralazine hcl SOLN; TABS 1 $0 midodrine hcl 1 $0 minoxidil TABS 1 $0 NORTHERA 2 $0 NM, LA, PA RANEXA 2 $0 NITRATES - DRUGS TO TREAT HEART CONDITIONS isosorb mononitrate tab 1 $0 isosorbide dinitrate 1 $0 isosorbide dinitrate er 1 $0 isosorbide mononitrate er 1 $0 minitran 1 $0 nitro-bid 2 $0 NITRO-DUR DIS 0.3MG/HR 2 $0 NITRO-DUR DIS 0.8MG/HR 2 $0 nitroglycerin SUBL 1 $0 nitroglycerin td patch 1 $0 52

53 Name PULMONARY ARTERIAL HYPERTENSION - DRUGS TO TREAT PULMONARY HYPERTENSION ADCIRCA 2 $0 NM, PA ADEMPAS 2 $0 QL (90 tabs / 30, NM, LA, PA LETAIRIS 2 $0 QL (30 tabs / 30, NM, LA, PA OPSUMIT 2 $0 NM, LA, PA REMODULIN 2 $0 NM, LA, PA REVATIO SUSR 2 $0 QL (224 ml / 30, NM, PA sildenafil citrate (pulmonary hypertension) TABS 1 $0 QL (90 tabs / 30, NM, PA TRACLEER 62.5mg 2 $0 QL (120 tabs / 30, NM, LA, PA TRACLEER 125mg 2 $0 QL (60 tabs / 30, NM, LA, PA UPTRAVI TABS 200mcg 2 $0 QL (480 tabs / 30, NM, LA, PA UPTRAVI TABS 400mcg 2 $0 QL (240 tabs / 30, NM, LA, PA UPTRAVI TABS 600mcg 2 $0 QL (150 tabs / 30, NM, LA, PA UPTRAVI TABS 800mcg 2 $0 QL (120 tabs / 30, NM, LA, PA 53

54 Name UPTRAVI TABS 1000mcg 2 $0 QL (90 tabs / 30, NM, LA, PA UPTRAVI TABS 1200mcg, 1400mcg, 1600mcg 2 $0 QL (60 tabs / 30, NM, LA, PA UPTRAVI TBPK 2 $0 NM, LA, PA VENTAVIS 2 $0 NM, PA CENTRAL NERVOUS SYSTEM - DRUGS TO TREAT NERVOUS SYSTEM DISORDERS ANTIANXIETY - DRUGS TO TREAT ANXIETY alprazolam tab 0.5mg 1 $0 QL (240 tabs / 30 alprazolam tab 0.25mg 1 $0 QL (480 tabs / 30 alprazolam tab 1mg 1 $0 QL (120 tabs / 30 alprazolam tab 2mg 1 $0 QL (150 tabs / 30 buspirone hcl TABS 1 $0 fluvoxamine maleate TABS 25mg, 50mg 1 $0 QL (45 tabs / 30 fluvoxamine maleate TABS 100mg 1 $0 lorazepam CONC 1 $0 QL (150 ml / 30 lorazepam SOLN 1 $0 lorazepam TABS 1 $0 QL (150 tabs / 30 54

55 Name ANTICONVULSANTS - DRUGS TO TREAT SEIZURES APTIOM 200mg 2 $0 QL (180 tabs / 30 APTIOM 400mg 2 $0 QL (90 tabs / 30 APTIOM 600mg, 800mg 2 $0 QL (60 tabs / 30 BANZEL SUS 40MG/ML 2 $0 PA BANZEL TAB 200MG 2 $0 PA BANZEL TAB 400MG 2 $0 PA BRIVIACT 2 $0 PA carbamazepine CHEW; CP12; SUSP; TABS; TB12 1 $0 CELONTIN 2 $0 clonazepam TABS 1mg 1 $0 QL (120 tabs / 30 clonazepam TABS 2mg 1 $0 QL (300 tabs / 30 clonazepam TABS.5mg 1 $0 QL (240 tabs / 30 clonazepam TBDP 1mg 1 $0 QL (120 tabs / 30 clonazepam TBDP 2mg 1 $0 QL (300 tabs / 30 clonazepam TBDP.5mg 1 $0 QL (240 tabs / 30 55

56 Name clonazepam TBDP.25mg 1 $0 QL (480 tabs / 30 clonazepam TBDP.125mg 1 $0 QL (960 tabs / 30 clorazepate dipotassium 3.75mg, 7.5mg 1 $0 QL (120 tabs / 30, PA; PA if 65 years and older clorazepate dipotassium 15mg 1 $0 QL (180 tabs / 30, PA; PA if 65 years and older DIASTAT ACUDIAL 2 $0 DIASTAT PEDIATRIC 2 $0 diazepam CONC 1 $0 QL (240 ml / 30, PA; PA if 65 years and older diazepam SOLN 1mg/ml 1 $0 QL (1200 ml / 30, PA; PA if 65 years and older diazepam SOLN 5mg/ml 1 $0 diazepam TABS 1 $0 QL (120 tabs / 30, PA; PA if 65 years and older DIAZEPAM GEL 1 $0 dilantin 2 $0 DILANTIN-125 SUS 125/5ML 2 $0 divalproex sodium CSDR; TB24; TBEC 1 $0 56

57 Name epitol 1 $0 ethosuximide CAPS; SOLN 1 $0 felbamate SUSP 2 $0 felbamate TABS 1 $0 FYCOMPA SUSP 2 $0 QL (720 ml / 30, PA FYCOMPA TABS 2mg 2 $0 QL (180 tabs / 30, PA FYCOMPA TABS 4mg 2 $0 QL (90 tabs / 30, PA FYCOMPA TABS 6mg 2 $0 QL (60 tabs / 30, PA FYCOMPA TABS 8mg, 10mg, 12mg 2 $0 QL (30 tabs / 30, PA gabapentin CAPS 100mg 1 $0 QL (1080 caps / 30 gabapentin CAPS 300mg 1 $0 QL (360 caps / 30 gabapentin CAPS 400mg 1 $0 QL (270 caps / 30 gabapentin SOLN 1 $0 QL (2160 ml / 30 gabapentin TABS 600mg 1 $0 QL (180 tabs / 30 gabapentin TABS 800mg 1 $0 QL (120 tabs / 30 57

58 Name GABITRIL 12mg, 16mg 2 $0 lamotrigine CHEW; TABS; TB24 1 $0 levetiracetam SOLN; TABS; TB24 1 $0 LEVETIRACETAM IN SODIUM CHLORIDE 2 $0 LEVETIRACETAM IV 1 $0 levetiracetam oral soln 100 mg/ml 1 $0 LYRICA CAPS 25mg, 50mg, 75mg, 2 $0 QL (120 caps / mg, 150mg LYRICA CAPS 200mg 2 $0 QL (90 caps / 30 LYRICA CAPS 225mg, 300mg 2 $0 QL (60 caps / 30 LYRICA SOLN 2 $0 QL (946 ml / 30 ONFI 2 $0 PA oxcarbazepine 1 $0 PEGANONE 2 $0 phenobarbital ELIX; TABS 2 $0 PA; PA if 65 years and older PHENOBARBITAL SODIUM SOLN 65mg/ml phenobarbital sodium SOLN 130mg/ml 2 $0 PA; PA if 65 years and older 2 $0 PA; PA if 65 years and older phenytek 2 $0 phenytoin CHEW; SUSP 1 $0 58

59 Name phenytoin sodium SOLN 1 $0 phenytoin sodium extended 1 $0 POTIGA 50mg 2 $0 POTIGA 200mg 2 $0 QL (180 tabs / 30 POTIGA 300mg, 400mg 2 $0 QL (90 tabs / 30 primidone TABS 1 $0 roweepra 1 $0 SABRIL PACK 2 $0 QL (180 packets / 30, NM, LA, PA SABRIL TABS 2 $0 QL (180 tabs / 30, NM, LA, PA SPRITAM 2 $0 TEGRETOL 2 $0 TEGRETOL-XR 2 $0 tiagabine hcl 1 $0 topiramate CPSP; TABS 1 $0 valproate sodium SOLN 1 $0 valproic acid 1 $0 vigabatrin powd pack 2 $0 QL (180 packets / 30, NM, LA, PA VIMPAT SOLN 10mg/ml 2 $0 QL (1200 ml / 30 59

60 Name VIMPAT SOLN 200mg/20ml 2 $0 VIMPAT TABS 50mg 2 $0 QL (180 tabs / 30 VIMPAT TABS 100mg, 150mg, 200mg 2 $0 QL (60 tabs / 30 zonisamide CAPS 1 $0 ANTIDEMENTIA - DRUGS TO TREAT DEMENTIA AND MEMORY LOSS donepezil hydrochloride TABS 5mg 1 $0 QL (60 tabs / 30 donepezil hydrochloride TABS 10mg, 23mg 1 $0 donepezil hydrochloride TBDP 5mg 1 $0 QL (60 tabs / 30 donepezil hydrochloride TBDP 10mg 1 $0 galantamine hydrobromide SOLN 1 $0 galantamine hydrobromide TABS 4mg galantamine hydrobromide TABS 8mg galantamine hydrobromide TABS 12mg galantamine hydrobromide er 8mg, 16mg galantamine hydrobromide er 24mg 1 $0 QL (180 tabs / 30 1 $0 QL (90 tabs / 30 1 $0 1 $0 QL (30 caps / 30 1 $0 memantine hcl SOLN 1 $0 PA; PA if < 30 yrs 60

61 Name memantine hcl TABS 5mg 1 $0 PA; PA if < 30 yrs MEMANTINE HCL TABS 10mg 1 $0 PA; PA if < 30 yrs NAMENDA XR 2 $0 PA; PA if < 30 yrs NAMENDA XR TITRATION PACK 2 $0 PA; PA if < 30 yrs NAMZARIC 2 $0 rivastigmine tartrate 1 $0 rivastigmine td patch 24hr 4.6 mg/24hr rivastigmine td patch 24hr 9.5 mg/24hr rivastigmine td patch 24hr 13.3 mg/24hr 1 $0 QL (30 patches / 30 1 $0 QL (30 patches / 30 1 $0 QL (30 patches / 30 ANTIDEPRESSANTS - DRUGS TO TREAT DEPRESSION amitriptyline hcl TABS 2 $0 PA; PA if 65 years and older amoxapine tab 25mg 1 $0 amoxapine tab 50mg 1 $0 amoxapine tab 100mg 1 $0 amoxapine tab 150mg 1 $0 bupropion hcl TABS 1 $0 bupropion hcl TB12 1 $0 bupropion hcl TB24 150mg 1 $0 QL (90 tabs / 30 bupropion hcl TB24 300mg 1 $0 QL (30 tabs / 30 61

62 Name citalopram hydrobromide SOLN 1 $0 citalopram hydrobromide TABS 10mg, 20mg citalopram hydrobromide TABS 40mg 1 $0 QL (45 tabs / 30 1 $0 QL (30 tabs / 30 clomipramine hcl CAPS 2 $0 PA; PA if 65 years and older desipramine hcl TABS 1 $0 desvenlafaxine succinate 1 $0 QL (30 tabs / 30 doxepin hcl CAPS; CONC 2 $0 PA; PA if 65 years and older duloxetine hcl CPEP 20mg 1 $0 QL (180 caps / 30 duloxetine hcl CPEP 30mg 1 $0 QL (120 caps / 30 duloxetine hcl CPEP 60mg 1 $0 QL (60 caps / 30 EMSAM 2 $0 QL (30 patches / 30, PA escitalopram oxalate SOLN 1 $0 QL (600 ml / 30 escitalopram oxalate TABS 5mg, 10mg 1 $0 QL (45 tabs / 30 escitalopram oxalate TABS 20mg 1 $0 QL (60 tabs / 30 FETZIMA 20mg 2 $0 QL (180 caps / 30 FETZIMA 40mg 2 $0 QL (90 caps / 30 62