LifeWorks Advantage (HMO SNP) 2018 Comprehensive Formulary. List of Covered Drugs

Transcription

1 LifeWorks Advantage (HMO SNP) 208 Comprehensive Formulary List of Covered Drugs PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN HPMS Approved Formulary File Submission ID, Version 0 This formulary was updated on 5/0/208. For more recent information or other questions, please contact LifeWorks Advantage Health Plan (HMO ISNP) Member Services at or, for TTY users, 7, Hours of operations: 8 a.m. to 8 p.m., seven days a week (except Thanksgiving and Christmas) from October through February 4, and Monday to Friday (except holidays) from February 5 through September 30, or visit LifeWorks Advantage is an HMO plan with a Medicare contract. Enrollment in LifeWorks Advantage depends on contract renewal. LifeWorks Advantage complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. LifeWorks Advantage cumple con las leyes federales de derechos civiles aplicables y no discrimina por motivos de raza, color, nacionalidad, edad, discapacidad o sexo. LifeWorks Advantage 은 ( 는 ) 관련연방공민권법을준수하며인종, 피부색, 출신국가, 연령, 장애또는 성별을이유로차별하지않습니다. This information is available for free in other languages. Esta información está disponible en otros idiomas de manera gratuita. Comuníquese con Servicios al Cliente al (TTY: 7). Horario de Atención al Cliente: Del de Octubre hasta el 4 de Febrero, de 8 a.m. a 8 p.m. los siete días de la semana (excepto Día de Acción de Gracias y Navidad), y del 5 de Febrero al 30 de Septiembre, de Lunes a Viernes (excepto feriados). H285_208_drug0 Accepted

2 Note to existing members: This formulary has changed since last year. Please review this document to make sure that it still contains the drugs you take. When this drug list (formulary) refers to we, us, or our, it means LifeWorks Advantage. When it refers to plan or our plan, it means LifeWorks Advantage. This document includes a list of the drugs (formulary) for our plan which is current as of 5/0/208. For an updated formulary, please contact us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages. You must generally use network pharmacies to use your prescription drug benefit. Benefits, formulary, pharmacy network, and/or copayments/coinsurance may change on January, 208, and from time to time during the year.

3 What is the LifeWorks Advantage (HMO ISNP) Formulary? A formulary is a list of covered drugs selected by LifeWorks Advantage 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. LifeWorks Advantage will generally cover the drugs listed in our formulary as long as the drug is medically necessary, the prescription is filled at an LifeWorks Advantage network pharmacy, and other plan rules are followed. For more information on how to fill your prescriptions, please review your Evidence of Coverage. Can the Formulary (drug list) change? Generally, if you are taking a drug on our 208 formulary that was covered at the beginning of the year, we will not discontinue or reduce coverage of the drug during the 208 coverage year except when a new, less expensive generic drug becomes available or when new adverse information about the safety or effectiveness of a drug is released. Other types of formulary changes, such as removing a drug from our formulary, will not affect members who are currently taking the drug. It will remain available at the same cost-sharing for those members taking it for the remainder of the coverage year. We feel it is important that you have continued access for the remainder of the coverage year to the formulary drugs that were available when you chose our plan, except for cases in which you can save additional money or we can ensure your safety. If we remove drugs from our formulary, or add prior authorization, quantity limits and/or step therapy restrictions on a drug, or move a drug to a higher cost-sharing tier, we must notify affected members of the change at least 60 days before the change becomes effective, or at the time the member requests a refill of the drug, at which time the member will receive a 60-day supply of the drug. If the Food and Drug Administration deems a drug on our formulary to be unsafe or the drug s manufacturer removes the drug from the market, we will immediately remove the drug from our formulary and provide notice to members who take the drug. The enclosed formulary is current as of 5/0/208. To get updated information about the drugs covered by LifeWorks Advantage, please contact us. Our contact information appears on the front and back cover pages. In the event that LifeWorks Advantage has CMS-approved non-maintenance changes to the formulary throughout the plan year (i.e. remove drugs from our formulary, add prior authorization, quantity limits and/or step therapy restrictions on a drug, or move a drug to a higher cost-sharing tier, LifeWorks Advantage will update our formulary and post in on our website. How do I use the Formulary? There are two ways to find your drug within the formulary: Medical Condition The formulary begins on page 7. The drugs in this formulary are grouped into categories depending on the type of medical conditions that they are used to treat. For example, drugs used to treat a heart condition are listed under the category, Cardiovascular Agents-Misc. If you know what your drug is used for, look for the category name in the list that begins on page 7. Then look under the category name for your drug. Alphabetical Listing If you are not sure what category to look under, you should look for your drug in the Index that begins on page 07. The Index provides an alphabetical list of all of the drugs included in this document. Both brand name drugs and generic drugs are listed in the Index. Look in the Index and find your drug. Next to your drug, you will see the page number where you can find coverage information. Turn to the page listed in the Index and find the name of your drug in the first column of the list. 2

4 What are generic drugs? LifeWorks Advantage 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. Are there any restrictions on my coverage? Some covered drugs may have additional requirements or limits on coverage. These requirements and limits may include: Prior Authorization (): LifeWorks Advantage requires you [or your physician] to get prior authorization for certain drugs. This means that you will need to get approval from LifeWorks Advantage before you fill your prescriptions. If you don t get approval, LifeWorks Advantage may not cover the drug. Prior Authorization Restriction for Part B vs Part D Determination (): This drug may be eligible for payment under Medicare Part B or Part D. You (or your physician) are required to get prior authorization from LifeWorks Advantage to determine that this drug is covered under Medicare Part D before you fill your prescription for this drug. Without prior approval, LifeWorks Advantage may not cover this drug. Prior Authorization Restriction for New Starts Only ( NSO): If you are a new member, you (or your physician) are required to get prior authorization from LifeWorks Advantage before you fill your prescription for this drug. Without prior approval, LifeWorks Advantage may not cover this drug. Quantity Limits (QL): For certain drugs, LifeWorks Advantage limits the amount of the drug that LifeWorks Advantage (HMO SNP) will cover. For example, LifeWorks Advantage provides 9 s per prescription for sumatriptan. This may be in addition to a standard one month or three-month supply. Step Therapy (ST): In some cases, LifeWorks Advantage requires you to first try certain drugs to treat your medical condition before we will cover another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, LifeWorks Advantage may not cover Drug B unless you try Drug A first. If Drug A does not work for you, LifeWorks Advantage will then cover Drug B. Non-Mail-Order Drug (NM): You may be able to receive greater than a -month supply of most of the drugs on your Formulary via mail order at a reduced cost share. Drugs not available via your mail-order benefit are noted with NM in the notes column of your Formulary. Limited Distribution (LD): The symbol (LD) next to a drug name indicates that the drug has been noted as being restricted to certain pharmacies by the Food and Drug Administration. These drugs can only be obtained at specialty designated pharmacies able to appropriately handle the drugs. 3

5 You can find out if your drug has any additional requirements or limits by looking in the formulary that begins on page 7. You can also get more information about the restrictions applied to specific covered drugs by visiting our Web site. We have posted on line documents that explain our prior authorization restriction and step therapy restrictions. You may also ask us to send you a copy. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages. You can ask LifeWorks Advantage to make an exception to these restrictions or limits or for a list of other, similar drugs that may treat your health condition. See the section, How do I request an exception to the LifeWorks Advantage s formulary? on this page for information about how to request an exception. What if my drug is not on the Formulary? If your drug is not included in this formulary (list of covered drugs), you should first contact Member Services and ask if your drug is covered. If you learn that LifeWorks Advantage does not cover your drug, you have two options: You can ask Member Services for a list of similar drugs that are covered by LifeWorks Advantage. When you receive the list, show it to your doctor and ask him or her to prescribe a similar drug that is covered by LifeWorks Advantage. You can ask LifeWorks Advantage to make an exception and cover your drug. See below for information about how to request an exception. How do I request an exception to the LifeWorks Advantage Formulary? You can ask LifeWorks Advantage 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 a drug even if it is not on our formulary. If approved, this drug will be covered at a pre-determined cost-sharing level, and you would not be able to ask us to provide the drug at a lower cost-sharing level. You can ask us to cover a formulary drug at a lower cost-sharing level if this drug is not on the specialty tier. If approved this would lower the amount you must pay for your drug. You can ask us to waive coverage restrictions or limits on your drug. For example, for certain drugs, LifeWorks Advantage limits the amount of the drug that we will cover. If your drug has a quantity limit, you can ask us to waive the limit and cover a greater amount. Generally, LifeWorks Advantage will only approve your request for an exception if the alternative drugs included on the plan s formulary or additional utilization restrictions would not be as effective in treating your condition and/or would cause you to have adverse medical effects. You should contact us to ask us for an initial coverage decision for a formulary, or utilization restriction exception. When you request a formulary or utilization restriction exception you should submit a statement from your prescriber or physician supporting your request. Generally, we must make our decision within 72 hours of getting your prescriber s supporting statement. You can request an expedited (fast) exception if you or your doctor believe that your health could be seriously harmed by waiting up to 72 hours for a decision. If your request to expedite is granted, we must give you a decision no later than 24 hours after we get a supporting statement from your doctor or other prescriber. 4

6 What do I do before I can talk to my doctor about changing my drugs or requesting an exception? As a new or continuing member in our plan you may be taking drugs that are not on our formulary. Or, you may be taking a drug that is on our formulary but your ability to get it is limited. For example, you may need a prior authorization from us before you can fill your prescription. You should talk to your doctor to decide if you should switch to an appropriate drug that we cover or request a formulary exception so that we will cover the drug you take. While you talk to your doctor to determine the right course of action for you, we may cover your drug in certain cases during the first 90 days you are a member of our plan. For each of your drugs that is not on our formulary or if your ability to get your drugs is limited, we will cover a temporary 3-day supply (unless you have a prescription written for fewer days) when you go to a network pharmacy. After your first 3-day supply, we will not pay for these drugs, even if you have been a member of the plan less than 90 days. If you are a resident of a long-term care facility, we will allow you to refill your prescription until we have provided you with a 9-98-day transition supply, consistent with dispensing increment, (unless you have a prescription written for fewer days). We will cover more than one refill of these drugs for the first 90 days you are a member of our plan. If you need a drug that is not on our formulary or if your ability to get your drugs is limited, but you are past the first 90 days of membership in our plan, we will cover a 3-day emergency supply of that drug (unless you have a prescription for fewer days) while you pursue a formulary exception. We will provide a one-time 3-day transition supply per drug, which will cover a temporary supply if you have a change in your medications due to a level-of-care change. A level of care change may include: Entering or leaving a LTC facility Discharged from a hospital to a home End a Medicare Part A skilled nursing facility stay Give up Hospice status and revert back to standard Medicare benefits End an LTC facility stay and return to their home During the time when you are getting a temporary supply of a drug, you should talk with your provider to decide what to do when your temporary supply runs out. You can either switch to a different drug covered by the plan or ask the plan to make an exception for you and cover your current drug. For more information For more detailed information about your LifeWorks Advantage prescription drug coverage, please review your Evidence of Coverage and other plan materials. If you have questions about LifeWorks Advantage, please contact us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages. If you have general questions about Medicare prescription drug coverage, please call Medicare at MEDICARE ( ) 24 hours a day/7 days a week. TTY users should call Or, visit 5

7 LifeWorks Advantage s Formulary The formulary below provides coverage information about the drugs covered by LifeWorks Advantage. If you have trouble finding your drug in the list, turn to the Index that begins on page 07. The first column of the chart lists the drug name. Brand name drugs are capitalized (e.g., LIDODERM) and generic drugs are listed in lower-case italics (e.g., lidocaine). The second column of the chart lists the Drug Tier. The information in the Notes column tells you if LifeWorks Advantage (HMO SNP) has any special requirements for coverage of your drug. The symbol LD in the Notes column next to a drug name indicates that the drug has been noted as being restricted to certain pharmacies by the Food and Drug Administration. These drugs can only be obtained at specialty designated pharmacies able to appropriately handle the drugs. The symbol in the Notes column indicates that prior authorization may apply. The symbol in the Notes column indicates that prior authorization may apply for medications that could be eligible for payment under either Medicare Part B or Part D. The symbol NSO in the Notes column indicates that prior authorization may apply on certain medications for new members of the plan. The symbol QL in the Notes column indicates that quantities dispensed may be limited. The symbol ST in the Notes column indicates that step therapy may apply. The symbol NM in the Notes column indicates that the drug is not available via your mailorder benefit.

8 ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS AMPHETAMINES amphetamine 0mg er cap amphetamine 0mg amphetamine 2.5mg amphetamine 5mg er cap amphetamine 5mg amphetamine 20mg er cap amphetamine 20mg amphetamine 25mg er cap amphetamine 30mg er cap amphetamine 30mg amphetamine 5mg er cap amphetamine 5mg amphetamine 7.5mg dextroamphetamine sulfate 0mg er cap dextroamphetamine sulfate 0mg dextroamphetamine sulfate 5mg er cap dextroamphetamine sulfate 5mg er cap dextroamphetamine sulfate 5mg methamphetamine 5mg VYVANSE 0MG CAP VYVANSE 0MG CHEW VYVANSE 20MG CAP VYVANSE 20MG CHEW VYVANSE 30MG CAP VYVANSE 30MG CHEW VYVANSE 40MG CAP VYVANSE 40MG CHEW VYVANSE 50MG CAP VYVANSE 50MG CHEW VYVANSE 60MG CAP VYVANSE 60MG CHEW VYVANSE 70MG CAP ATTENTION-DEFICIT/HYPERACTIVITY DISORDER (ADHD) AGENTS atomoxetine 00mg cap atomoxetine 0mg cap atomoxetine 8mg cap atomoxetine 25mg cap atomoxetine 40mg cap atomoxetine 60mg cap atomoxetine 80mg cap guanfacine mg er guanfacine 2mg er guanfacine 3mg er guanfacine 4mg er You can find information on what the symbols and abbreviations on this le mean by going to the beginning of this le. 7

9 armodafinil 50mg STIMULANTS - MISC. QL=30 EA/30 Days armodafinil 200mg QL=30 EA/30 Days armodafinil 250mg QL=30 EA/30 Days armodafinil 50mg QL=30 EA/30 Days dexmethylphenidate 0mg er cap dexmethylphenidate 0mg dexmethylphenidate 5mg er cap dexmethylphenidate 2.5mg dexmethylphenidate 20mg er cap dexmethylphenidate 30mg er cap dexmethylphenidate 40mg er cap dexmethylphenidate 5mg er cap dexmethylphenidate 5mg metadate 20mg er methylphenidate 0mg cd cap methylphenidate 0mg chew methylphenidate 0mg er methylphenidate 0mg METHYLPHENIDATE 8MG SR methylphenidate mg/ml oral soln methylphenidate 2.5mg chew methylphenidate 20mg cd cap methylphenidate 20mg er methylphenidate 20mg la cap methylphenidate 20mg METHYLPHENIDATE 27MG SR methylphenidate 2mg/ml oral soln methylphenidate 30mg cd cap methylphenidate 30mg la cap METHYLPHENIDATE 36MG SR methylphenidate 40mg cd cap methylphenidate 40mg la cap methylphenidate 50mg cd cap METHYLPHENIDATE 54MG SR methylphenidate 5mg chew methylphenidate 5mg methylphenidate 60mg cd cap modafinil 00mg modafinil 200mg amikacin 250mg/ml inj AMINOGLYCOSIDES AMINOGLYCOSIDES gentamicin.2mg/ml inj gentamicin 40mg/ml inj gentamicin sulfate 0.8mg/ml inj You can find information on what the symbols and abbreviations on this le mean by going to the beginning of this le. 8

10 gentamicin sulfate.6mg/ml inj gentamicin sulfate mg/ml inj neomycin sulfate 500mg paromomycin 250mg cap STREPTOMYCIN 00MG TOBI PODHALER KIT 28MG CK TOBRAMYCIN 0MG/ML tobramycin 40mg/ml inj tobramycin 60mg/ml inh soln ANALGESICS - ANTI-INFLAMMATORY ANTI-TNF-ALPHA - MONOCLONAL ANTIBODIES HUMIRA 0MG/0.2ML HUMIRA 20MG/0.4ML HUMIRA 40MG/0.8ML AUTO-ECTOR HUMIRA 40MG/0.8ML HUMIRA PEDIATRIC CROHN'S STARTER CK (3) 40MG/0.8ML HUMIRA PEDIATRIC CROHN'S STARTER CK (6) 40MG/0.8ML HUMIRA PEN - CROHN'S STARTER CK 40MG/0.8ML HUMIRA PEN - PSORIASIS STARTER CK 40MG/0.8ML SIMPONI ARIA 50MG/4ML GOLD COMPOU RIDAURA 3MG CAP ARCALYST 220MG INTERLEUKIN- BLOCKERS ILARIS 80MG INTERLEUKIN-BETA BLOCKERS NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS) celecoxib 00mg cap celecoxib 200mg cap celecoxib 400mg cap celecoxib 50mg cap diclofenac potassium 50mg diclofenac sodium 00mg er diclofenac sodium 25mg dr diclofenac sodium 50mg dr diclofenac sodium 50mg/misoprostol 0.2mg diclofenac sodium 75mg dr diclofenac sodium 75mg/misoprostol 0.2mg etodolac 200mg cap etodolac 300mg cap etodolac 400mg er etodolac 400mg You can find information on what the symbols and abbreviations on this le mean by going to the beginning of this le. 9

11 etodolac 500mg er etodolac 500mg etodolac 600mg er FENOPROFEN 400MG CAP flurbiprofen 00mg flurbiprofen 50mg ibuprofen 20mg/ml oral susp ibuprofen 400mg ibuprofen 600mg ibuprofen 800mg INDOCIN 25MG/5ML ORAL SUSP indomethacin 25mg cap indomethacin 50mg cap indomethacin 75mg er cap ketoprofen 50mg cap ketoprofen 75mg cap ketorolac tromethamine 0mg QL=20 EA/5 Days ketorolac tromethamine 5mg/ml inj ketorolac tromethamine 30mg/ml cartridge ketorolac tromethamine 30mg/ml inj MECLOFENAMATE 00MG CAP MECLOFENAMATE 50MG CAP mefenamic acid 250mg cap meloxicam 5mg meloxicam 7.5mg nabumetone 500mg nabumetone 750mg naproxen 250mg naproxen 25mg/ml oral susp naproxen 375mg dr naproxen 375mg naproxen 500mg dr naproxen 500mg naproxen sodium 275mg naproxen sodium 550mg oxaprozin 600mg piroxicam 0mg cap piroxicam 20mg cap sulindac 50mg sulindac 200mg PYRIMIDINE SYNTHESIS INHIBITORS leflunomide 0mg leflunomide 20mg SELECTIVE COSTIMULATION MODULATORS ORENCIA 25MG/ML AUTO-ECTOR ORENCIA 25MG/ML You can find information on what the symbols and abbreviations on this le mean by going to the beginning of this le. 0

12 ORENCIA 250MG ORENCIA 50MG/0.4ML ORENCIA 87.5MG/0.7ML SOLUBLE TUMOR NECROSIS FACTOR RECEPTOR AGENTS ENBREL 25MG ENBREL 25MG/0.5ML ENBREL 50MG/ML SURECLICK ENBREL 50MG/ML ANALGESICS - NONNARCOTIC SALICYLATES diflunisal 500mg codeine sulfate 5mg ANALGESICS - OPIOID OPIOID AGONISTS QL=240 EA/30 Days codeine sulfate 30mg QL=240 EA/30 Days codeine sulfate 60mg QL=80 EA/30 Days duramorph 0.5mg/ml inj duramorph mg/ml inj EMBEDA 00-4MG ER CAP EMBEDA MG ER CAP EMBEDA 30-.2MG ER CAP EMBEDA 50-2MG ER CAP EMBEDA MG ER CAP EMBEDA MG ER CAP fentanyl 0.02mg/hr patch QL=0 EA/30 Days fentanyl 0.025mg/hr patch QL=0 EA/30 Days FENTANYL MG/HR TCH QL=0 EA/30 Days fentanyl 0.05mg/hr patch QL=0 EA/30 Days FENTANYL MG/HR TCH QL=0 EA/30 Days fentanyl 0.075mg/hr patch QL=0 EA/30 Days fentanyl 0.mg/hr patch QL=0 EA/30 Days fentanyl 0.2mg lozenge QL=20 EA/30 Days fentanyl 0.4mg lozenge QL=20 EA/30 Days fentanyl 0.6mg lozenge QL=20 EA/30 Days fentanyl 0.8mg lozenge QL=20 EA/30 Days fentanyl.2mg lozenge QL=20 EA/30 Days fentanyl.6mg lozenge QL=20 EA/30 Days FENTORA 00MCG BUCCAL QL=20 EA/30 Days FENTORA 200MCG BUCCAL QL=20 EA/30 Days FENTORA 400MCG BUCCAL QL=20 EA/30 Days FENTORA 600MCG BUCCAL QL=20 EA/30 Days FENTORA 800MCG BUCCAL QL=20 EA/30 Days hydromorphone 0mg/ml (ml) inj hydromorphone 0mg/ml (5ml) inj hydromorphone 2mg er hydromorphone 6mg er You can find information on what the symbols and abbreviations on this le mean by going to the beginning of this le.

13 hydromorphone mg/ml oral soln QL=2400 ML/30 Days hydromorphone 2mg QL=450 EA/30 Days hydromorphone 2mg/ml syringe hydromorphone 32mg er hydromorphone 4mg QL=240 EA/30 Days hydromorphone 8mg er hydromorphone 8mg QL=20 EA/30 Days HYSINGLA 00MG ER QL=30 EA/30 Days HYSINGLA 20MG ER QL=30 EA/30 Days HYSINGLA 20MG ER QL=30 EA/30 Days HYSINGLA 30MG ER QL=30 EA/30 Days HYSINGLA 40MG ER QL=30 EA/30 Days HYSINGLA 60MG ER QL=30 EA/30 Days HYSINGLA 80MG ER QL=30 EA/30 Days LEVORPHANOL 2MG QL=240 EA/30 Days meperidine 00mg QL=360 EA/30 Days meperidine 50mg QL=720 EA/30 Days methadone 0mg QL=360 EA/30 Days methadone mg/ml oral soln QL=3600 ML/30 Days methadone 2mg/ml oral soln QL=800 ML/30 Days methadone 5mg QL=360 EA/30 Days morphine sulfate 00mg er cap morphine sulfate 00mg er QL=20 EA/30 Days morphine sulfate 0mg er cap MORPHINE SULFATE 20MG ER (24HR) CAP morphine sulfate 5mg er QL=20 EA/30 Days morphine sulfate 5mg QL=80 EA/30 Days morphine sulfate 200mg er QL=20 EA/30 Days morphine sulfate 20mg er cap morphine sulfate 20mg/ml oral soln QL=80 ML/30 Days morphine sulfate 2mg/ml oral soln QL=800 ML/30 Days MORPHINE SULFATE 2MG/ML MORPHINE SULFATE 30MG ER (24 HR) CAP morphine sulfate 30mg er cap morphine sulfate 30mg er QL=20 EA/30 Days morphine sulfate 30mg QL=80 EA/30 Days MORPHINE SULFATE 45MG ER (24HR) CAP morphine sulfate 4mg/ml oral soln QL=900 ML/30 Days morphine sulfate 50mg er cap MORPHINE SULFATE 5MG/ML MORPHINE SULFATE 60MG (24HR) ER CAP morphine sulfate 60mg er cap morphine sulfate 60mg er QL=20 EA/30 Days MORPHINE SULFATE 75MG ER (24HR) CAP morphine sulfate 80mg er cap MORPHINE SULFATE 90MG ER (24HR) CAP You can find information on what the symbols and abbreviations on this le mean by going to the beginning of this le. 2

14 NUCYNTA 00MG ER NUCYNTA 50MG ER NUCYNTA 200MG ER NUCYNTA 250MG ER NUCYNTA 50MG ER oxycodone 0mg QL=80 EA/30 Days oxycodone 5mg QL=80 EA/30 Days oxycodone mg/ml oral soln QL=5400 ML/30 Days oxycodone 20mg QL=80 EA/30 Days oxycodone 20mg/ml oral soln QL=270 ML/30 Days oxycodone 30mg QL=80 EA/30 Days oxycodone 5mg cap QL=360 EA/30 Days oxycodone 5mg QL=360 EA/30 Days OXYCONTIN 0MG ER OXYCONTIN 5MG ER OXYCONTIN 20MG ER OXYCONTIN 30MG ER OXYCONTIN 40MG ER OXYCONTIN 60MG ER OXYCONTIN 80MG ER QL=20 EA/30 Days oxymorphone 0mg QL=360 EA/30 Days oxymorphone 5mg QL=360 EA/30 Days tramadol 00mg er tramadol 00mg er (matrix delivery) tramadol 200mg er tramadol 200mg er (matrix delivery) tramadol 300mg er tramadol 300mg er (matrix delivery) tramadol 50mg QL=240 EA/30 Days XTAMPZA 3.5MG ER CAP QL=20 EA/30 Days XTAMPZA 8MG ER CAP QL=20 EA/30 Days XTAMPZA 27MG ER CAP QL=20 EA/30 Days XTAMPZA 36MG ER CAP QL=20 EA/30 Days XTAMPZA 9MG ER CAP QL=20 EA/30 Days OPIOID COMBINATIONS acetaminophen 2.7mg/ml/hydrocodone bitartrate QL=5400 ML/30 Days 0.5mg/ml oral soln acetaminophen 24mg/ml/codeine phosphate 2.4mg/ml QL=4980 ML/30 Days oral soln acetaminophen 300mg/codeine phosphate 5mg QL=390 EA/30 Days acetaminophen 300mg/codeine phosphate 30mg QL=390 EA/30 Days acetaminophen 300mg/codeine phosphate 60mg QL=390 EA/30 Days acetaminophen 300mg/hydrocodone bitartrate 0mg QL=390 EA/30 Days acetaminophen 300mg/hydrocodone bitartrate 5mg QL=390 EA/30 Days You can find information on what the symbols and abbreviations on this le mean by going to the beginning of this le. 3

15 acetaminophen 300mg/hydrocodone bitartrate 7.5mg QL=390 EA/30 Days ACETAMINOPHEN 325MG/5ML/OXYCODONE QL=800 ML/30 Days 5MG/5ML ORAL SOLN acetaminophen 325mg/hydrocodone bitartrate 0mg QL=360 EA/30 Days acetaminophen 325mg/hydrocodone bitartrate 2.5mg QL=360 EA/30 Days acetaminophen 325mg/hydrocodone bitartrate 5mg QL=360 EA/30 Days acetaminophen 325mg/hydrocodone bitartrate 7.5mg QL=360 EA/30 Days acetaminophen 325mg/oxycodone 0mg QL=360 EA/30 Days acetaminophen 325mg/oxycodone 2.5mg QL=360 EA/30 Days acetaminophen 325mg/oxycodone 5mg QL=360 EA/30 Days acetaminophen 325mg/oxycodone 7.5mg QL=360 EA/30 Days acetaminophen 325mg/tramadol 37.5mg QL=360 EA/30 Days aspirin 325mg/oxycodone 4.84mg QL=360 EA/30 Days endocet 0-325mg QL=360 EA/30 Days endocet 5-325mg QL=360 EA/30 Days endocet mg QL=360 EA/30 Days hydrocodone 0mg/ibuprofen 200mg QL=480 EA/30 Days hydrocodone 5mg/ibuprofen 200mg QL=480 EA/30 Days hydrocodone bitartrate 7.5mg/ibuprofen 200mg QL=480 EA/30 Days IBUPROFEN 400MG/OXYCODONE 5MG QL=240 EA/30 Days lorcet 0-325mg QL=360 EA/30 Days lorcet 5-325mg QL=360 EA/30 Days lorcet mg QL=360 EA/30 Days vicodin 0-300mg QL=390 EA/30 Days vicodin 5-300mg QL=390 EA/30 Days vicodin mg QL=390 EA/30 Days OPIOID RTIAL AGONISTS BUNAVAIL MG FILM BUNAVAIL MG FILM BUNAVAIL 6.3-MG FILM buprenorphine 0.3mg/ml cartridge buprenorphine 0.3mg/ml inj buprenorphine 2mg sl buprenorphine 8mg sl butorphanol tartrate 0mg/ml nasal spray QL=0 ML/30 Days BUTORPHANOL TARTRATE MG/ML butorphanol tartrate 2mg/ml inj naloxone 0.5mg/pentazocine 50mg QL=360 EA/30 Days SUBOXONE 2-3MG STRIP SUBOXONE 2-0.5MG STRIP SUBOXONE 4-MG STRIP You can find information on what the symbols and abbreviations on this le mean by going to the beginning of this le. 4

16 SUBOXONE 8-2MG STRIP ZUBSOLV.4-2.9MG SL ZUBSOLV MG SL QL=90 EA/30 Days ZUBSOLV MG SL QL=90 EA/30 Days ZUBSOLV MG SL QL=90 EA/30 Days ZUBSOLV MG SL ANADROL-50 50MG ANDROGENS-ANABOLIC ANABOLIC STEROIDS oxandrolone 0mg oxandrolone 2.5mg ANDRODERM 2MG/24HR TCH ANDROGENS ANDRODERM 4MG/24HR TCH QL=30 EA/30 Days ANDROGEL % (25MG) GEL QL=300 GM/30 Days ANDROGEL % (50MG) GEL QL=300 GM/30 Days ANDROGEL.62% (.25GM) GEL QL=37.50 GM/30 Days ANDROGEL.62% (2.5GM) GEL QL=50 GM/30 Days ANDROGEL.62% GEL QL=50 GM/30 Days danazol 00mg cap danazol 200mg cap danazol 50mg cap testosterone % (25mg) gel QL=300 GM/30 Days testosterone % (50mg) gel QL=300 GM/30 Days testosterone % gel pump QL=300 GM/30 Days testosterone cypionate 00mg/ml inj testosterone cypionate 200mg/ml inj testosterone enanthate 200mg/ml inj colocort 00mg/60ml enema ANORECTAL AGENTS INTRARECTAL STEROIDS hydrocortisone.67mg/ml enema UCERIS 2MG/ACT FOAM procto-med 2.5% cream RECTAL STEROIDS procto-pak % rectal cream proctosol 2.5% cream proctozone hc 2.5% cream ALBENZA 200MG ANTHELMINTICS ANTHELMINTICS ivermectin 3mg RANEXA 000MG ER ANTIANGINAL AGENTS ANTIANGINALS-OTHER RANEXA 500MG ER You can find information on what the symbols and abbreviations on this le mean by going to the beginning of this le. 5

17 isosorbide dinitrate 0mg NITRATES isosorbide dinitrate 20mg isosorbide dinitrate 30mg ISOSORBIDE DINITRATE 40MG ER isosorbide dinitrate 5mg isosorbide mononitrate 0mg isosorbide mononitrate 20mg er isosorbide mononitrate 20mg isosorbide mononitrate 30mg er isosorbide mononitrate 60mg er minitran 0.mg/hr patch minitran 0.2mg/hr patch minitran 0.4mg/hr patch minitran 0.6mg/hr patch NITRO-DUR 0.3MG/HR TCH NITRO-DUR 0.8MG/HR TCH nitroglycerin 0.mg/hr patch nitroglycerin 0.2mg/hr patch nitroglycerin 0.3mg sl nitroglycerin 0.4mg sl nitroglycerin 0.4mg/act pump spray nitroglycerin 0.4mg/hr patch nitroglycerin 0.6mg sl nitroglycerin 0.6mg/hr patch ANTIANXIETY AGENTS ANTIANXIETY AGENTS - MISC. buspirone 0mg buspirone 5mg buspirone 30mg buspirone 5mg buspirone 7.5mg hydroxyzine 0mg hydroxyzine 25mg HYDROXYZINE 25MG/ML hydroxyzine 2mg/ml oral soln hydroxyzine 50mg hydroxyzine 50mg/ml inj HYDROXYZINE MOATE 00MG CAP hydroxyzine pamoate 25mg cap hydroxyzine pamoate 50mg cap meprobamate 200mg meprobamate 400mg BENZODIAZEPINES alprazolam 0.25mg odt alprazolam 0.25mg You can find information on what the symbols and abbreviations on this le mean by going to the beginning of this le. 6

18 alprazolam 0.5mg er alprazolam 0.5mg odt alprazolam 0.5mg alprazolam mg er alprazolam mg odt alprazolam mg alprazolam 2mg er alprazolam 2mg odt alprazolam 2mg alprazolam 3mg er chlordiazepoxide 0mg cap chlordiazepoxide 25mg cap chlordiazepoxide 5mg cap clorazepate dipotassium 5mg clorazepate dipotassium 3.75mg clorazepate dipotassium 7.5mg diazepam 0mg DIAZEM MG/ML ORAL SOLN diazepam 2mg diazepam 5mg diazepam 5mg/ml oral soln lorazepam 0.5mg lorazepam mg lorazepam 2mg lorazepam 2mg/ml oral conc oxazepam 0mg cap oxazepam 5mg cap oxazepam 30mg cap disopyramide 00mg cap ANTIARRHYTHMICS ANTIARRHYTHMICS TYPE I-A disopyramide 50mg cap NORCE 00MG ER CAP NORCE 50MG ER CAP PROCAINAMIDE 00MG/ML PROCAINAMIDE 500MG/ML quinidine gluconate 324mg er QUINIDINE GLUCONATE 80MG/ML QUINIDINE SULFATE 200MG QUINIDINE SULFATE 300MG ANTIARRHYTHMICS TYPE I-B mexiletine 50mg cap mexiletine 200mg cap mexiletine 250mg cap ANTIARRHYTHMICS TYPE I-C flecainide acetate 00mg You can find information on what the symbols and abbreviations on this le mean by going to the beginning of this le. 7

19 flecainide acetate 50mg flecainide acetate 50mg propafenone 50mg propafenone 225mg er cap propafenone 225mg propafenone 300mg propafenone 325mg er cap propafenone 425mg er cap amiodarone 200mg ANTIARRHYTHMICS TYPE III amiodarone 400mg amiodarone 50mg/ml inj amiodarone hydrochloride 00mg dofetilide 25mcg cap dofetilide 250mcg cap dofetilide 500mcg cap MULTAQ 400MG NEXTERONE 50MG/00ML NEXTERONE 360MG/200ML pacerone 200mg pacerone 400mg ANTIASTHMATIC AND BRONCHODILATOR AGENTS ANTIASTHMATIC - MONOCLONAL ANTIBODIES NUCALA 00MG XOLAIR 50MG ANTI-INFLAMMATORY AGENTS CROMOLYN SODIUM 0MG/ML INH SOLN BRONCHODILATORS - ANTICHOLINERGICS ATROVENT 7MCG INH INCRUSE 62.5MCG INH ipratropium bromide 0.02% inh soln SPIRIVA.25MCG RESPIMAT INH ST QL=4 GM/30 Days SPIRIVA 8MCG HANDIHALER SPIRIVA 2.5MCG RESPIMAT INH LEUKOTRIENE MODULATORS montelukast 0mg montelukast 4mg chew montelukast 4mg granules montelukast 5mg chew zafirlukast 0mg zafirlukast 20mg zileuton 600mg er SELECTIVE PHOSPHODIESTERASE 4 (PDE4) INHIBITORS DALIRESP 500MCG ARNUITY 00MCG INH STEROID INHALANTS QL=30 EA/30 Days You can find information on what the symbols and abbreviations on this le mean by going to the beginning of this le. 8

20 ARNUITY 200MCG INH QL=30 EA/30 Days ASMANEX 00MCG (20ACT) HFA INH QL=3 GM/30 Days ASMANEX 0MCG (30ACT) INH QL= EA/30 Days ASMANEX 200MCG (20ACT) HFA INH QL=3 GM/30 Days ASMANEX 220MCG (20ACT) INH QL= EA/30 Days ASMANEX 220MCG (30ACT) INH QL= EA/30 Days ASMANEX 220MCG (60ACT) INH QL= EA/30 Days budesonide 0.25mg/ml inh soln QL=20 ML/30 Days budesonide 0.25mg/ml inh soln QL=20 ML/30 Days budesonide 0.5mg/ml inh soln QL=20 ML/30 Days FLOVENT 00MCG DISKUS FLOVENT 0MCG HFA INH QL=24 GM/30 Days FLOVENT 220MCG HFA INH QL=24 GM/30 Days FLOVENT 250MCG DISKUS FLOVENT 44MCG HFA INH QL=2.20 GM/30 Days FLOVENT 50MCG DISKUS ADVAIR 00-50MCG DISKUS SYMTHOMIMETICS ADVAIR 5-2MCG HFA INH QL=2 GM/30 Days ADVAIR 230-2MCG HFA INH QL=2 GM/30 Days ADVAIR MCG DISKUS ADVAIR 45-2MCG HFA INH QL=2 GM/30 Days ADVAIR MCG DISKUS albuterol 0.2mg/ml (0.63mg/3ml) inh soln albuterol 0.47mg/ml (.25mg/3ml) inh soln albuterol 0.4mg/ml (2mg/5ml) oral soln albuterol 0.83mg/ml (0.083%) inh soln albuterol mg/ml (0.5%) inh soln albuterol 2mg albuterol 4mg er albuterol 4mg albuterol 8mg er ANORO MCG ELLIPTA INH BREO 00-25MCG ELLIPTA INH BREO MCG ELLIPTA INH BROVANA 5MCG/2ML INH SOLN COMBIVENT RESPIMAT 20-00MCG INH DULERA 00-5MCG INH QL=3 GM/30 Days DULERA 200-5MCG INH QL=3 GM/30 Days FLUTICASONE PROPIONATE/SALMETEROL XINAFOATE 3-4MCG/ACT POWDER INH FLUTICASONE PROPIONATE/SALMETEROL XINAFOATE 232-4MCG/ACT POWDER INH FLUTICASONE PROPIONATE/SALMETEROL XINAFOATE 55-4MCG/ACT POWDER INH ipratropium/albuterol mg/3ml inh soln You can find information on what the symbols and abbreviations on this le mean by going to the beginning of this le. 9

21 levalbuterol 0.3mg inh soln levalbuterol 0.63mg inh soln levalbuterol.25mg inh soln levalbuterol 2.5mg inh soln METAPROTERENOL SULFATE 0MG METAPROTERENOL SULFATE 20MG METAPROTERENOL SULFATE 2MG/ML ORAL SOLN SEREVENT 50MCG/DOSE INH STIOLTO MCG INH QL=4 GM/30 Days terbutaline sulfate mg/ml inj terbutaline sulfate 2.5mg terbutaline sulfate 5mg TRELEGY MCG ELLIPTA INH VENTOLIN 08MCG INH QL=36 GM/30 Days XANTHINES aminophylline 25mg/ml inj theophylline 00mg er theophylline 200mg er theophylline 300mg er theophylline 400mg er theophylline 5.33mg/ml oral soln theophylline 600mg er ANTICOAGULANTS COUMARIN ANTICOAGULANTS jantoven 0mg jantoven mg jantoven 2.5mg jantoven 2mg jantoven 3mg jantoven 4mg jantoven 5mg jantoven 6mg jantoven 7.5mg warfarin sodium 0mg warfarin sodium mg warfarin sodium 2.5mg warfarin sodium 2mg warfarin sodium 3mg warfarin sodium 4mg warfarin sodium 5mg warfarin sodium 6mg warfarin sodium 7.5mg DIRECT FACTOR XA INHIBITORS ELIQUIS 2.5MG ELIQUIS 30-DAY STARTER CK You can find information on what the symbols and abbreviations on this le mean by going to the beginning of this le. 20

22 ELIQUIS 5MG XARELTO 0MG XARELTO 5MG XARELTO 20MG XARELTO STARTER CK HERINS AND HERINOID-LIKE AGENTS enoxaparin sodium 00mg/ml syringe QL=34 ML/7 Days enoxaparin sodium 20mg/0.8ml syringe QL=27.20 ML/7 Days enoxaparin sodium 50mg/ml syringe QL=34 ML/7 Days enoxaparin sodium 300mg/3ml syringe QL=5 ML/7 Days enoxaparin sodium 30mg/0.3ml syringe QL=0.20 ML/7 Days enoxaparin sodium 40mg/0.4ml syringe QL=3.60 ML/7 Days enoxaparin sodium 60mg/0.6ml syringe QL=20.40 ML/7 Days enoxaparin sodium 80mg/0.8ml syringe QL=27.20 ML/7 Days fondaparinux sodium 2.5mg/ml (0.4ml) syringe fondaparinux sodium 2.5mg/ml (0.6ml) syringe fondaparinux sodium 2.5mg/ml (0.8ml) syringe fondaparinux sodium 5mg/ml syringe FRAGMIN 0000UNIT/ML FRAGMIN 2500UNIT/0.5ML FRAGMIN 5000UNIT/0.6ML FRAGMIN 8000UNIT/0.72ML FRAGMIN 2500UNIT/0.2ML FRAGMIN 5000UNIT/0.2ML FRAGMIN 7500UNIT/0.3ML FRAGMIN 95000UNIT/3.8ML heparin sodium, porcine 0000unit/ml inj heparin sodium, porcine 000unit/ml inj HERIN SODIUM, PORCINE 00UNIT/ML heparin sodium, porcine 20000unit/ml inj heparin sodium, porcine 40unit/ml inj heparin sodium, porcine 5000unit/ml inj heparin sodium, porcine 50unit/ml inj THROMBIN INHIBITORS argatroban 00mg/ml inj ARGATROBAN MG/ML PRADAXA 0MG CAP PRADAXA 50MG CAP PRADAXA 75MG CAP ANTICONVULSANTS AM GLUTAMATE RECEPTOR ANTAGONISTS FYCOM 0.5MG/ML ORAL SUSP NSO FYCOM 0MG NSO FYCOM 2MG NSO FYCOM 2MG NSO FYCOM 4MG NSO You can find information on what the symbols and abbreviations on this le mean by going to the beginning of this le. 2

23 FYCOM 6MG NSO FYCOM 8MG NSO ANTICONVULSANTS - BENZODIAZEPINES clonazepam 0.25mg odt clonazepam 0.25mg odt clonazepam 0.5mg odt clonazepam 0.5mg clonazepam mg odt clonazepam mg clonazepam 2mg odt clonazepam 2mg DIASTAT 0MG APPLICATOR DIASTAT 2.5MG APPLICATOR DIASTAT 20MG PF APPLICATOR ONFI 0MG NSO ONFI 2.5MG/ML ORAL SUSP NSO ONFI 20MG NSO APTIOM 200MG ANTICONVULSANTS - MISC. NSO APTIOM 400MG NSO APTIOM 600MG NSO APTIOM 800MG NSO BANZEL 200MG BANZEL 400MG BANZEL 40MG/ML ORAL SUSP BRIVIACT 00MG NSO BRIVIACT 0MG NSO BRIVIACT 0MG/ML NSO BRIVIACT 0MG/ML ORAL SOLN NSO BRIVIACT 25MG NSO BRIVIACT 50MG NSO BRIVIACT 75MG NSO carbamazepine 00mg chew carbamazepine 00mg er cap carbamazepine 00mg er carbamazepine 200mg er cap carbamazepine 200mg er carbamazepine 200mg carbamazepine 20mg/ml oral susp carbamazepine 300mg er cap carbamazepine 400mg er epitol 200mg gabapentin 00mg cap gabapentin 300mg cap gabapentin 400mg cap gabapentin 50mg/ml oral soln You can find information on what the symbols and abbreviations on this le mean by going to the beginning of this le. 22

24 gabapentin 600mg gabapentin 800mg LAMICTAL BLUE KIT LAMICTAL GREEN KIT LAMICTAL ORANGE KIT LAMICTAL XR BLUE KIT LAMICTAL XR GREEN KIT LAMICTAL XR ORANGE KIT lamotrigine 00mg er lamotrigine 00mg odt lamotrigine 00mg lamotrigine 50mg lamotrigine 200mg er lamotrigine 200mg odt lamotrigine 200mg lamotrigine 250mg er lamotrigine 25mg chew lamotrigine 25mg er lamotrigine 25mg odt lamotrigine 25mg lamotrigine 300mg er lamotrigine 50mg er lamotrigine 50mg odt lamotrigine 5mg chew levetiracetam 000mg levetiracetam 00mg/ml inj levetiracetam 00mg/ml oral soln levetiracetam 0mg/ml inj levetiracetam 5mg/ml inj levetiracetam 250mg levetiracetam 500mg er levetiracetam 500mg levetiracetam 5mg/ml inj levetiracetam 750mg er levetiracetam 750mg LYRICA 00MG CAP LYRICA 50MG CAP LYRICA 200MG CAP LYRICA 20MG/ML ORAL SOLN LYRICA 225MG CAP LYRICA 25MG CAP LYRICA 300MG CAP LYRICA 50MG CAP LYRICA 75MG CAP oxcarbazepine 50mg oxcarbazepine 300mg You can find information on what the symbols and abbreviations on this le mean by going to the beginning of this le. 23

25 oxcarbazepine 600mg oxcarbazepine 60mg/ml oral susp OXTELLAR 50MG XR OXTELLAR 300MG XR OXTELLAR 600MG XR primidone 250mg primidone 50mg QUDEXY 00MG XR CAP NSO QUDEXY 50MG XR CAP NSO QUDEXY 200MG XR CAP NSO QUDEXY 25MG XR CAP NSO QUDEXY 50MG XR CAP NSO roweepra 000mg roweepra 500mg er roweepra 500mg roweepra 750mg er roweepra 750mg SPRITAM 000MG ODT NSO SPRITAM 250MG ODT NSO SPRITAM 500MG ODT NSO SPRITAM 750MG ODT NSO TOPIRAMATE 00MG ER CAP NSO topiramate 00mg TOPIRAMATE 50MG ER CAP NSO topiramate 5mg cap TOPIRAMATE 200MG ER CAP NSO topiramate 200mg topiramate 25mg cap TOPIRAMATE 25MG ER CAP NSO topiramate 25mg TOPIRAMATE 50MG ER CAP NSO topiramate 50mg TROKENDI 00MG XR CAP NSO TROKENDI 200MG XR CAP NSO TROKENDI 25MG XR CAP NSO TROKENDI 50MG XR CAP NSO VIMT 00MG VIMT 0MG/ML ORAL SOLN VIMT 50MG VIMT 200MG VIMT 200MG/20ML VIMT 50MG zonisamide 00mg cap zonisamide 25mg cap zonisamide 50mg cap CARBAMATES You can find information on what the symbols and abbreviations on this le mean by going to the beginning of this le. 24

26 felbamate 20mg/ml oral susp felbamate 400mg felbamate 600mg GABITRIL 2MG GABA MODULATORS GABITRIL 6MG SABRIL 500MG ORAL SOLN NSO SABRIL 500MG NSO tiagabine 2mg tiagabine 4mg vigabatrin 50mg/ml oral soln NSO DILANTIN 30MG ER CAP HYDANTOINS fosphenytoin sodium 75mg/ml inj PEGANONE 250MG phenytoin 25mg/ml oral susp phenytoin 50mg chew phenytoin sodium 00mg er cap phenytoin sodium 200mg er cap phenytoin sodium 300mg er cap phenytoin sodium 50mg/ml inj CELONTIN 300MG CAP SUCCINIMIDES ethosuximide 250mg cap ethosuximide 50mg/ml oral soln divalproex sodium 25mg dr cap VALPROIC ACID divalproex sodium 25mg dr divalproex sodium 250mg dr divalproex sodium 250mg er divalproex sodium 500mg dr divalproex sodium 500mg er valproic acid 00mg/ml inj valproic acid 250mg cap valproic acid 50mg/ml oral soln ANTIDEPRESSANTS ALPHA-2 RECEPTOR ANTAGONISTS (TETRACYCLICS) mirtazapine 5mg odt mirtazapine 5mg mirtazapine 30mg odt mirtazapine 30mg mirtazapine 45mg odt mirtazapine 45mg mirtazapine 7.5mg APLENZIN 74MG ER ANTIDEPRESSANTS - MISC. ST You can find information on what the symbols and abbreviations on this le mean by going to the beginning of this le. 25

27 APLENZIN 348MG ER ST APLENZIN 522MG ER ST bupropion 00mg sr bupropion 00mg bupropion 50mg sr (2 hr) bupropion 50mg xl (24 hr) bupropion 200mg sr bupropion 300mg xl bupropion 75mg MAPROTILINE 25MG MAPROTILINE 50MG MAPROTILINE 75MG MONOAMINE OXIDASE INHIBITORS (MAOIS) EMSAM 2MG/24HR TCH EMSAM 6MG/24HR TCH EMSAM 9MG/24HR TCH MARPLAN 0MG phenelzine 5mg tranylcypromine 0mg SELECTIVE SEROTONIN REUPTAKE INHIBITORS (SSRIS) citalopram 0mg citalopram 20mg citalopram 2mg/ml oral soln citalopram 40mg escitalopram 0mg escitalopram mg/ml oral soln escitalopram 20mg escitalopram 5mg fluoxetine 0mg cap fluoxetine 0mg fluoxetine 20mg cap fluoxetine 20mg fluoxetine 40mg cap fluoxetine 4mg/ml oral soln fluvoxamine maleate 00mg er cap ST fluvoxamine maleate 00mg fluvoxamine maleate 50mg er cap ST fluvoxamine maleate 25mg fluvoxamine maleate 50mg paroxetine 0mg paroxetine 2.5mg er paroxetine 20mg paroxetine 25mg er paroxetine 30mg paroxetine 37.5mg er paroxetine 40mg You can find information on what the symbols and abbreviations on this le mean by going to the beginning of this le. 26

28 XIL 0MG/5ML ORAL SUSP PEXEVA 0MG ST PEXEVA 20MG ST PEXEVA 30MG ST PEXEVA 40MG ST sertraline 00mg sertraline 20mg/ml oral soln sertraline 25mg sertraline 50mg NEFAZODONE 00MG SEROTONIN MODULATORS NEFAZODONE 50MG NEFAZODONE 200MG nefazodone 250mg nefazodone 50mg trazodone 00mg trazodone 50mg trazodone 300mg trazodone 50mg TRINTELLIX 0MG ST QL=30 EA/30 Days TRINTELLIX 20MG ST QL=30 EA/30 Days TRINTELLIX 5MG ST QL=30 EA/30 Days VIIBRYD 0/20MG STARTER CK ST QL=30 EA/30 Days VIIBRYD 0MG ST QL=30 EA/30 Days VIIBRYD 20MG ST QL=30 EA/30 Days VIIBRYD 40MG ST QL=30 EA/30 Days SEROTONIN-NOREPINEPHRINE REUPTAKE INHIBITORS (SNRIS) DESVENLAFAXINE FUMARATE 00MG ER ST DESVENLAFAXINE FUMARATE 50MG ER ST desvenlafaxine succinate 00mg er desvenlafaxine succinate 25mg er desvenlafaxine succinate 50mg er duloxetine 20mg dr cap duloxetine 30mg dr cap DULOXETINE 40MG DR CAP ST QL=30 EA/30 Days duloxetine 60mg dr cap FETZIMA 20MG ER CAP ST QL=30 EA/30 Days FETZIMA 20MG ER CAP ST QL=30 EA/30 Days FETZIMA 40MG ER CAP ST QL=30 EA/30 Days FETZIMA 80MG ER CAP ST QL=30 EA/30 Days FETZIMA CK ST QL=30 EA/30 Days KHEDEZLA 00MG ER ST KHEDEZLA 50MG ER ST venlafaxine 00mg venlafaxine 50mg er cap venlafaxine 50mg er You can find information on what the symbols and abbreviations on this le mean by going to the beginning of this le. 27

29 VENLAFAXINE 225MG ER venlafaxine 25mg venlafaxine 37.5mg er cap venlafaxine 37.5mg er venlafaxine 37.5mg venlafaxine 50mg venlafaxine 75mg er cap venlafaxine 75mg er venlafaxine 75mg amitriptyline 00mg TRICYCLIC AGENTS amitriptyline 0mg amitriptyline 50mg amitriptyline 25mg amitriptyline 50mg amitriptyline 75mg AMOXAPINE 00MG AMOXAPINE 50MG AMOXAPINE 25MG AMOXAPINE 50MG clomipramine 25mg cap clomipramine 50mg cap clomipramine 75mg cap desipramine 00mg desipramine 0mg desipramine 50mg desipramine 25mg desipramine 50mg desipramine 75mg doxepin 00mg cap doxepin 0mg cap doxepin 0mg/ml oral soln doxepin 50mg cap doxepin 25mg cap doxepin 50mg cap DOXEPIN 75MG CAP imipramine 0mg imipramine 25mg imipramine 50mg imipramine pamoate 00mg cap imipramine pamoate 25mg cap imipramine pamoate 50mg cap imipramine pamoate 75mg cap nortriptyline 0mg cap nortriptyline 25mg cap NORTRIPTYLINE 2MG/ML ORAL SOLN You can find information on what the symbols and abbreviations on this le mean by going to the beginning of this le. 28

30 nortriptyline 50mg cap nortriptyline 75mg cap protriptyline 0mg protriptyline 5mg trimipramine 00mg cap trimipramine 25mg cap trimipramine 50mg cap ANTIDIABETICS ALPHA-GLUCOSIDASE INHIBITORS acarbose 00mg acarbose 25mg acarbose 50mg miglitol 00mg miglitol 25mg miglitol 50mg ANTIDIABETIC COMBINATIONS glimepiride 2mg/pioglitazone 30mg glimepiride 4mg/pioglitazone 30mg glipizide 2.5mg/metformin 250mg glipizide 2.5mg/metformin 500mg glipizide 5mg/metformin 500mg glyburide.25mg/metformin 250mg glyburide 2.5mg/metformin 500mg glyburide 5mg/metformin 500mg GLYXAMBI 0-5MG QL=30 EA/30 Days GLYXAMBI 25-5MG QL=30 EA/30 Days JANUMET MG XR QL=30 EA/30 Days JANUMET MG JANUMET MG XR JANUMET MG JANUMET MG XR JENTADUETO MG JENTADUETO MG XR QL=30 EA/30 Days JENTADUETO MG JENTADUETO MG JENTADUETO 5-000MG XR QL=30 EA/30 Days metformin 500mg/pioglitazone 5mg metformin 850mg/pioglitazone 5mg SYNJARDY MG SYNJARDY MG SYNJARDY 5-000MG SYNJARDY 5-500MG XIGDUO 0-000MG XR QL=30 EA/30 Days XIGDUO 0-500MG XR QL=30 EA/30 Days XIGDUO MG XR XIGDUO 5-000MG XR You can find information on what the symbols and abbreviations on this le mean by going to the beginning of this le. 29

31 XIGDUO 5-500MG XR QL=30 EA/30 Days XULTOPHY 00UNIT-3.6MG/ML PEN QL=5 ML/30 Days metformin 000mg BIGUANIDES metformin 500mg er metformin 500mg metformin 750mg er metformin 850mg GLUCAGEN MG HYPOKIT DIABETIC OTHER GLUCAGON MG KORLYM 300MG PROGLYCEM 50MG/ML ORAL SUSP DIPEPTIDYL PEPTIDASE-4 (DPP-4) INHIBITORS JANUVIA 00MG QL=30 EA/30 Days JANUVIA 25MG QL=30 EA/30 Days JANUVIA 50MG QL=30 EA/30 Days TRADJENTA 5MG QL=30 EA/30 Days INCRETIN MIMETIC AGENTS (GLP- RECEPTOR AGONISTS) BYDUREON 2.35MG/ML AUTO-ECTOR BYDUREON 2MG BYDUREON 2MG PEN VICTOZA 8MG/3ML PEN INSULIN HUMULIN R 500UNIT/ML HUMULIN R 500UNIT/ML PEN LANTUS 00UNIT/ML LANTUS 00UNIT/ML SOLOSTAR LEVEMIR 00UNIT/ML FLEXTOUCH LEVEMIR 00UNIT/ML NOVOLIN 00UNIT/ML NOVOLIN N 00UNIT/ML NOVOLIN R 00UNIT/ML NOVOLOG 00UNIT/ML FLEXPEN NOVOLOG 00UNIT/ML NOVOLOG 00UNIT/ML PENFILL NOVOLOG MIX 00UNIT/ML FLEXPEN NOVOLOG MIX 00UNIT/ML TOUJEO 300UNIT/ML PEN TRESIBA 00UNIT/ML PEN TRESIBA 200UNIT/ML PEN INSULIN SENSITIZING AGENTS AVANDIA 2MG AVANDIA 4MG pioglitazone 5mg pioglitazone 30mg You can find information on what the symbols and abbreviations on this le mean by going to the beginning of this le. 30

32 pioglitazone 45mg nateglinide 20mg MEGLITINIDE ANALOGUES nateglinide 60mg repaglinide 0.5mg repaglinide mg repaglinide 2mg SODIUM-GLUCOSE CO-TRANSPORTER 2 (SGLT2) INHIBITORS FARXIGA 0MG QL=30 EA/30 Days FARXIGA 5MG QL=30 EA/30 Days JARDIANCE 0MG QL=30 EA/30 Days JARDIANCE 25MG QL=30 EA/30 Days CHLORPROMIDE 00MG SULFONYLUREAS CHLORPROMIDE 250MG glimepiride mg glimepiride 2mg glimepiride 4mg glipizide 0mg er glipizide 0mg glipizide 2.5mg er glipizide 5mg er glipizide 5mg glyburide.25mg glyburide.5mg glyburide 2.5mg glyburide 3mg glyburide 5mg glyburide 6mg tolazamide 250mg tolazamide 500mg TOLBUTAMIDE 500MG ANTIDIARRHEALS ANTIPERISTALTIC AGENTS atropine sulfate 0.005mg/ml/diphenoxylate 0.5mg/ml oral soln atropine sulfate 0.025mg/diphenoxylate 2.5mg loperamide 2mg cap ANTIDOTES ANTIDOTES fomepizole 000mg/ml inj ANTIDOTES - CHELATING AGENTS CHEMET 00MG CAP FERRIPROX 00MG/ML ORAL SOLN FERRIPROX 500MG JADENU 80MG You can find information on what the symbols and abbreviations on this le mean by going to the beginning of this le. 3

33 JADENU 90MG ANTIDOTES AND SPECIFIC ANTAGONISTS ANTIDOTES - CHELATING AGENTS EXJADE 25MG ORAL SUSP EXJADE 250MG ORAL SUSP EXJADE 500MG ORAL SUSP JADENU 80MG GRANULE CKET JADENU 360MG GRANULE CKET JADENU 360MG JADENU 90MG GRANULE CKET NALOXONE 0.4MG/ML CARTRIDGE OPIOID ANTAGONISTS NALOXONE MG/ML QL=2 ML/2 Days naltrexone 50mg NARCAN 4MG/0.ML NASAL SPRAY QL=2 EA/2 Days ANTIEMETICS 5-HT3 RECEPTOR ANTAGONISTS granisetron 0.mg/ml inj granisetron mg granisetron mg/ml (ml) inj granisetron mg/ml inj ondansetron 0.8mg/ml oral soln ondansetron 24mg ondansetron 2mg/ml inj ondansetron 2mg/ml syringe ondansetron 4mg odt ondansetron 4mg ondansetron 8mg odt ondansetron 8mg ANTIEMETICS - ANTICHOLINERGIC meclizine 2.5mg meclizine 25mg scopolamine mg/3days patch TRANSDERM SCOP MG/3DAYS TCH trimethobenzamide 300mg cap CESAMET MG CAP ANTIEMETICS - MISCELLANEOUS dronabinol 0mg cap dronabinol 2.5mg cap dronabinol 5mg cap SUBSTANCE P/NEUROKININ (NK) RECEPTOR ANTAGONISTS aprepitant 25mg cap QL=3 EA/2 Days aprepitant 25mg/80mg pack QL=3 EA/2 Days aprepitant 40mg cap QL=3 EA/2 Days aprepitant 80mg cap QL=3 EA/2 Days VARUBI 90MG QL=2 EA/4 Days You can find information on what the symbols and abbreviations on this le mean by going to the beginning of this le. 32

34 ANTIFUNGALS ANTIFUNGAL - GLUCAN SYNTHESIS INHIBITORS (ECHINOCANDINS) CANCIDAS 50MG CANCIDAS 70MG CASPOFUNGIN ACETATE 50MG CASPOFUNGIN ACETATE 70MG ERAXIS 00MG ERAXIS 50MG MYCAMINE 00MG MYCAMINE 50MG ABELCET 5MG/ML ANTIFUNGALS AMBISOME 50MG AMPHOTERICIN B 50MG flucytosine 250mg cap flucytosine 500mg cap griseofulvin 25mg griseofulvin 250mg griseofulvin 25mg/ml oral susp griseofulvin 500mg nystatin unit terbinafine 250mg IMIDAZOLE-RELATED ANTIFUNGALS fluconazole 00mg fluconazole 0mg/ml oral susp fluconazole 50mg fluconazole 200mg fluconazole 2mg/ml (00ml) inj fluconazole 2mg/ml inj fluconazole 40mg/ml oral susp fluconazole 50mg itraconazole 00mg cap ketoconazole 200mg NOXAFIL 00MG DR NOXAFIL 40MG/ML ORAL SUSP voriconazole 200mg inj voriconazole 200mg voriconazole 40mg/ml oral susp voriconazole 50mg ANTIHISTAMINES ANTIHISTAMINES - ETHANOLAMINES carbinoxamine maleate 0.8mg/ml oral soln carbinoxamine maleate 4mg CLEMASTINE FUMARATE 2.68MG diphenhydramine 50mg/ml inj ANTIHISTAMINES - NON-SEDATING You can find information on what the symbols and abbreviations on this le mean by going to the beginning of this le. 33