2019 Formulary (List of Covered Drugs)

Transcription

1 Allwell Dual Medicare (H SNP) and Allwell Dual Medicare Essentials (H SNP) 09 Formulary (List of Covered s) PLEASE READ: THIS DOCUMENT CONTAINS IORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN HPMS Approved Formulary File Submission ID 9, Version Number 9 This formulary was updated on 09/0/08. For more recent information or other questions, please contact Allwell Dual Medicare (H SNP) or Allwell Dual Medicare Essentials (H SNP) at: State Phone Number AZ FL GA IN KS State Phone Number MS OH SC TX WI or, for TTY users, 7, from October March, 7 days a week, 8 a.m. to 8 p.m. From April - September 0, Monday through Friday, 8 a.m. to 8 p.m. A messaging system is used after hours, weekends, and on federal holidays, or visit: State AZ FL GA IN KS Website Address allwell.azcompletehealth.com allwell.sunshinehealth.com allwell.pshpgeorgia.com allwell.mhsindiana.com allwell.sunflowerhealthplan.com allwell.homestatehealth.com State MS OH SC TX WI Website Address allwell.magnoliahealthplan.com allwell.buckeyehealthplan.com allwell.absolutetotalcare.com allwell.superiorhealthplan.com allwell.mhswi.com ALL_9_80FRMLY_C_90_08008

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 Bridgeway Health Solutions, Sunshine State Health Plan, Inc., Peach State Health Plan, Inc., Coordinated Care Corporation, Sunflower State Health Plan, Inc., Home State Health Plan, Inc., Magnolia Health Plan, Inc., Buckeye Community Health Plan, Inc., Absolute Total Care, Inc., Superior Health Plan, Inc., and Managed Health Services, Wisconsin. When it refers to plan or our plan, it means Allwell Dual Medicare (H SNP) and Allwell Dual Medicare Essentials (H SNP). This document includes a list of the drugs (formulary) for our plan which is current as of 09/0/08. 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, 00, and from time to time during the year. What is the Allwell Dual Medicare (H SNP) and Allwell Dual Medicare Essentials (H SNP) Formulary? A formulary is a list of covered drugs selected by our plan 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. We will generally cover the drugs listed in our formulary as long as the drug is medically necessary, the prescription is filled at a plan 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 09 formulary that was covered at the beginning of the year, we will not discontinue or reduce coverage of the drug during the 09 coverage year except when a new, less expensive generic drug becomes available, when new information about the safety or effectiveness of a drug is released, or the drug is removed from the market (see bullets below for more information on changes that affect members currently taking the drug). 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. Below are changes to the drug list that will also affect members currently taking a drug: New generic drugs. We may immediately remove a brand name drug on our List if we are replacing it with a new generic drug that will appear on the same or lower cost sharing tier and with the same or fewer restrictions. Also, when adding the new generic drug, we may decide to keep the brand name drug on our List, but immediately move it to a different cost-sharing tier or add new restrictions. If you are currently taking that brand name drug, we may not tell you in advance before we make that change, but we will later provide you with information about the specific change(s) we have made. ii

3 o If we make such a change, you or your prescriber can ask us to make an exception and continue to cover the brand name drug for you. The notice we provide you will also include information on the steps you may take to request an exception, and you can also find information in the section below entitled How do I request an exception to the Allwell Dual Medicare (H SNP) and Allwell Dual Medicare Essentials (H SNP) s Formulary? s removed from the market. If the Food and 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. Other changes. We may make other changes that affect members currently taking a drug. For instance, we may add a generic drug that is not new to market to replace a brand name drug currently on the formulary or add new restrictions to the brand name drug or move it to a different cost-sharing tier. Or we may make changes based on new clinical guidelines. If we 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, we must notify affected members of the change at least 0 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 0-day supply of the drug. The enclosed formulary is current as of 09/0/08. To get updated information about the drugs covered by Allwell Dual Medicare (H SNP) and Allwell Dual Medicare Essentials (H SNP), please contact us. Our contact information appears on the front and back cover pages. If we make any other negative changes to a drug you are taking, we will notify you via mail. We will also post the changes 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. 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. - s to Treat Heart and Circulation Conditions. If you know what your drug is used for, look for the category name in the list that begins on page. 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 Index. 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 iii

4 information. Turn to the page listed in the Index and find the name of your drug in the first column of the list. What are generic drugs? Our plan 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: Our plan requires you or your physician to get prior authorization for certain drugs. This means that you will need to get approval from us before you fill your prescriptions. If you don t get approval, we may not cover the drug. Quantity : For certain drugs, our plan limits the amount of the drug that we will cover. For example, our plan provides one tablet per day per prescription for simvastatin 0. This may be in addition to a standard one-month or three-month supply. Step Therapy: In some cases, our plan requires you to first try certain drugs to treat your medical condition before we will cover another drug for that condition. For example, if A and B both treat your medical condition, we may not cover B unless you try A first. If A does not work for you, we will then cover B. You can find out if your drug has any additional requirements or limits by looking in the formulary that begins on page. You can also get more information about the restrictions applied to specific covered drugs by visiting our Web site. We have posted online documents that explain our prior authorization 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 us 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 Allwell Dual Medicare (H SNP) and Allwell Dual Medicare Essentials (H SNP) formulary? on page iv 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 our plan does not cover your drug, you have two options: iv

5 You can ask Member Services for a list of similar drugs that are covered by our plan. When you receive the list, show it to your doctor and ask him or her to prescribe a similar drug that is covered by us. You can ask us 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 Allwell Dual Medicare (H SNP) and Allwell Dual Medicare Essentials (H SNP) Formulary? You can ask us to make an exception to our coverage rules. There are several types of exceptions that you can ask us to make. You can ask us to cover 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, our plan 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, we will only approve your request for an exception if the alternative drugs included on the plan s formulary, the lower cost-sharing drug 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, tiering or utilization restriction exception. When you request a formulary, tiering or utilization restriction exception you should submit a statement from your prescriber or physician supporting your request. Generally, we must make our decision within 7 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 7 hours for a decision. If your request to expedite is granted, we must give you a decision no later than hours after we get a supporting statement from your doctor or other prescriber. 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 v

6 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 0-day supply. If your prescription is written for fewer days, we ll allow refills to provide up to a maximum 0-day supply of medication. After your first 0-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 and 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 -day emergency supply of that drug while you pursue a formulary exception. Level of care changes If you experience a change in your level of care, we will cover a transition supply of your drugs. A level of care change occurs when you are discharged from a hospital or moved to or from a long-term care facility. If you move home from a long-term care facility or hospital and need a transition supply, we will cover one 0-day supply. If your prescription is written for fewer days, we will allow multiple fills to provide up to a total of a 0-day supply. If you move from home or a hospital to a long-term care facility and need a transition supply, we will cover one -day supply. If your prescription is written for fewer days, we will allow multiple fills to provide up to a total of a -day supply. For more information For more detailed information about your plan s prescription drug coverage, please review your Evidence of Coverage and other plan materials. If you have questions about our plan, 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 ( ) hours a day/7 days a week. TTY users should call Or, visit Allwell Dual Medicare (H SNP) and Allwell Dual Medicare Essentials (H SNP) Formulary The formulary that begins on page provides coverage information about the drugs covered by our plan. If you have trouble finding your drug in the list, turn to the Index that begins on page Index. The first column of the chart lists the drug name. Brand name drugs are capitalized (e.g., ELIQUIS TABS) and generic drugs are listed in lower-case italics (e.g., warfarin sodium tabs). The information in the column tells you if our plan has any special requirements for coverage of your drug. vi

7 Abbreviations The abbreviations below may appear in the Requirement/ column on the formulary. Abbreviation Definition Description AL Age Limit This drug may require prior authorization if your age does not meet manufacturer, FDA, or clinical recommendations. B/D Medicare Part B vs. Part D This drug may be covered under Medicare Part B or Part D depending upon the circumstances. Information may need to be submitted describing the use and setting of the drug to make the determination. LA Limited Access This prescription may be available only at certain pharmacies. For more information consult your Pharmacy Directory or call Member Services from October March, 7 days a week, 8 a.m. to 8 p.m. From April - September 0, Monday through Friday, 8 a.m. to 8 p.m. Our contact information appears on the front and back covers. TTY users should call 7. Mail Order This drug is available at our mail order pharmacy in addition to other network pharmacies. PA Non-Extended Day Supply Prior Authorization This prescription drug may not be available for an extended day supply. Call Member Services to ask if the drug is available as an extended supply. This drug requires prior authorization. This means that you or your prescriber must get approval from us before you fill your prescription. If you don t get approval, we may not cover the drug. QL Quantity Limit This drug has a limit on the amount that we will cover. For example, we cover one tablet per day per prescription for simvastatin 0. This may be in addition to a standard onemonth or three-month supply limit. RX/OTC Prescription and Over-the- Counter (OTC) This drug is available both in a prescription form and in an OTC form. Other than some insulins and insulin supplies, only prescription drugs are covered by our Medicare Part D plans. SL Safety Limit This drug has a maximum daily dose limit for safety supported by the FDA. This means that we will not cover more than the maximum daily dose. For example, the FDA maximum daily dose of ibuprofen is 00. Therefore, we will only cover four tablets per day for ibuprofen 800. vii

8 Abbreviation Definition Description ST Step Therapy This drug requires step therapy. This means that you must first try certain drugs to treat your medical condition before we cover another drug for that condition. For example, if A and B both treat your medical condition, we may not cover B unless you try A first. If A does not work for you, we will then cover B. Additional Gap Coverage Only for Allwell Dual Medicare (H SNP) in Florida: We provide additional coverage of this prescription drug in the coverage gap. Please refer to our Evidence of Coverage for more information about this coverage. Formulary tier descriptions Prescription drugs are grouped into one of six tiers. To find out which tier your drug is in, look in the column of the formulary that begins on page. The table below tells you the copayment or coinsurance amount (i.e., the share of the drug's cost that you will pay during the initial coverage stage) for a one-month supply of drugs in each tier. For more detailed information about your out-of-pocket costs for prescriptions, including any deductible that may apply, please refer to your Evidence of Coverage and other plan materials. State Plan Name Preferred Generic (includes preferred generic drugs) Generic (includes generic drugs) Preferred Brand (includes preferred brand drugs and may include some generic drugs) Nonpreferred (includes nonpreferred brand drugs and may include some generic drugs) Specialty (includes high cost brand and generic drugs) 6 Select Care s (includes some generics and may include some brands used to treat specific chronic conditions) AZ Allwell Dual Medicare (H SNP) $0 $0 $7 $00 9% $0 viii

9 State Plan Name 6 Preferred Generic (includes preferred generic drugs) Generic (includes generic drugs) Preferred Brand (includes preferred brand drugs and may include some generic drugs) Nonpreferred (includes nonpreferred brand drugs and may include some generic drugs) Specialty (includes high cost brand and generic drugs) Select Care s (includes some generics and may include some brands used to treat specific chronic conditions) FL GA IN KS MS OH Allwell Dual Medicare (H SNP) Allwell Dual Medicare (H SNP) Allwell Dual Medicare (H SNP) Allwell Dual Medicare (H SNP) Allwell Dual Medicare (H SNP) Allwell Dual Medicare (H SNP) Allwell Dual Medicare (H SNP) $0 $0 $7 $00 % $0 $0 $7 $7 $00 7% $0 $0 $0 $7 $00 0% $0 $0 $0 $7 $00 0% $0 $0 $ $7 $00 9% $0 $0 $0 $7 $00 9% $0 $0 $0 $7 $00 % $0 ix

10 State Plan Name 6 Preferred Generic (includes preferred generic drugs) Generic (includes generic drugs) Preferred Brand (includes preferred brand drugs and may include some generic drugs) Nonpreferred (includes nonpreferred brand drugs and may include some generic drugs) Specialty (includes high cost brand and generic drugs) Select Care s (includes some generics and may include some brands used to treat specific chronic conditions) SC TX TX TX TX Allwell Dual Medicare Essentials (H SNP) Allwell Dual Medicare (H SNP) in El Paso County Allwell Dual Medicare (H SNP) in Fort Bend County Allwell Dual Medicare (H SNP) in Collin, Rockwall, Cameron, Hidalgo, Dallas, Smith, Tarrant, Bexar, Guadalupe, Nueces and Wilson Counties Allwell Dual Medicare (H SNP) in Williamson County $0 $ $7 $00 8% $0 $0 $ $7 $00 8% $0 $0 $9 $7 $00 9% $0 $ $9 $7 $00 % $0 $ $ $7 $00 % $0 x

11 State Plan Name Preferred Generic (includes preferred generic drugs) Generic (includes generic drugs) Preferred Brand (includes preferred brand drugs and may include some generic drugs) Nonpreferred (includes nonpreferred brand drugs and may include some generic drugs) Specialty (includes high cost brand and generic drugs) 6 Select Care s (includes some generics and may include some brands used to treat specific chronic conditions) WI Allwell Dual Medicare (H SNP) $0 $0 $7 $00 8% $0 s in this tier are not eligible for exceptions for payment at a lower tier. We provide additional coverage of these prescription drugs in the coverage gap. Please refer to your Evidence of Coverage for more information about this coverage. Note: If is displayed in the column, this means the drug is not covered on the formulary. You may request an exception from us to cover these non-formulary drugs. If an exception request is approved for a non-formulary drug; the copayment applies. You may not ask us to provide the drug at a lower cost-sharing level. xi

12 Section 7 Non-Discrimination Language Notice of Non-Discrimination Allwell complies with applicable federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Allwell does not exclude people or treat them diferently because of race, color, national origin, age, disability, or sex. Allwell: Provides free aids and services to people with disabilities to communicate efectively with us, such as qualifed sign language interpreters and written information in other formats (large print, accessible electronic formats, other formats). Provides free language services to people whose primary language is not English, such as qualifed interpreters and information written in other languages. If you need these services, contact Allwell s Member Services telephone number listed for your state on the Member Services Telephone Numbers by State Chart. From October to March, you can call us 7 days a week from 8 a.m. to 8 p.m. From April to September 0, you can call us Monday through Friday from 8 a.m. to 8 p.m. A messaging system is used after hours, weekends, and on federal holidays. If you believe that Allwell has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can fle a grievance by calling the number in the chart below and telling them you need help fling a grievance; Allwell s Member Services is available to help you. You can also fle a civil rights complaint with the U.S. Department of Health and Human Services, Ofce for Civil Rights, electronically through the Ofce for Civil Rights Complaint Portal, available at or by mail or phone at: U.S. Department of Health and Human Services, 00 Independence Avenue SW, Room 09F, HHH Building, Washington, DC 00, (TDD: ). Complaint forms are available at Member Services Telephone Numbers by State Chart State Telephone Number and Plan Type Arizona (H and H SNP); (Bridgeway H SNP) (TTY: 7) Arkansas (H) (TTY: 7) Florida (H and H SNP) (TTY: 7) Georgia (H); (H SNP) (TTY: 7) Illinois (H) (TTY: 7) Indiana (H, H SNP and PPO) (TTY: 7) Kansas (H); (H SNP) (TTY: 7) Louisiana (H) (TTY: 7) Mississippi (H); (H SNP) (TTY: 7) Missouri (H); (H SNP) (TTY: 7) New Mexico (H SNP) (TTY: 7) Ohio (H and H SNP) (TTY: 7) Pennsylvania (H); (H SNP) (TTY: 7) South Carolina (H and H SNP) (TTY: 7) Texas (H); (H SNP) (TTY: 7) Wisconsin (H SNP) (TTY: 7) ALL_9_80FLY_C_ACCEPTED_08008

13 Section 7 Non-Discrimination Language Multi-Language Interpreter Services

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15 ܗܪ Allwell is contracted with Medicare for H, H SNP and PPO plans, and with some state Medicaid programs. Enrollment in Allwell depends on contract renewal.

16 Name ADHD/ANTI-NARCOLEPSY/ANTI- OBESITY/ANOREXIANTS - s to Treat ADHD, Sleep and Eating Disorders Amphetamines ADDERALL TABS (Amphetamine- Dextroamphetamine) ADDERALL XR CP (Amphetamine- Dextroamphetamine) amphetaminedextroamphetamine cp ---, , , , , amphetaminedextroamphetamine tabs ---, , , , , , DESOXYN TABS PA; (Methamphetamine HCl) DEXEDRINE CP (Dextroamphetamine Sulfate) dextroamphetamine sulfate cp, 0, dextroamphetamine sulfate tabs, 0 methamphetamine hcl tabs PA; Attention-Deficit/Hyperactivity Disorder (ADHD) atomoxetine hcl caps 0 SL(0 ea daily); ; Name atomoxetine hcl caps 00 atomoxetine hcl caps 8 atomoxetine hcl caps atomoxetine hcl caps 0 atomoxetine hcl caps 60 atomoxetine hcl caps 80 clonidine hcl (adhd) tb guanfacine hcl (adhd) tb INTUNIV TB (Guanfacine HCl (ADHD)) KAPVAY TB (Clonidine HCl (ADHD)) STRATTERA CAPS 0 MG (Atomoxetine HCl) STRATTERA CAPS 00 MG (Atomoxetine HCl) STRATTERA CAPS 8 MG (Atomoxetine HCl) STRATTERA CAPS MG (Atomoxetine HCl) STRATTERA CAPS 0 MG (Atomoxetine HCl) STRATTERA CAPS 60 MG (Atomoxetine HCl) STRATTERA CAPS 80 MG (Atomoxetine HCl) Stimulants - Misc. CONCERTA TBCR (Methylphenidate HCl) dexmethylphenidate hcl cp 0,, 0 dexmethylphenidate hcl tabs, 0,. FOCALIN TABS (Dexmethylphenidate HCl) FOCALIN XR CP 0 MG, MG, 0 MG (Dexmethylphenidate HCl) SL( ea daily); ; SL(. ea daily); ; SL( ea daily); ; SL(. ea daily); ; SL(.66 ea daily); ; SL(. ea daily); ; AL(Up to 6 yrs old); ; AL(Up to 6 yrs old); SL(0 ea daily); SL( ea daily); SL(. ea daily); SL( ea daily); SL(. ea daily); SL(.66 ea daily); SL(. ea daily); 09 Allwell (DSNP) Formulary Updated 09/0/08

17 Name METADATE CD CPCR 0 MG, 0 MG, 0 MG, 60 MG (Methylphenidate HCl) METADATE CD CPCR 0 MG (Methylphenidate HCl) METADATE CD CPCR 0 MG (Methylphenidate HCl) methylphenidate hcl cp or 0, 0, 0 methylphenidate hcl cp or 60 methylphenidate hcl cpcr or 0, 0, 0, 60 methylphenidate hcl cpcr or 0 methylphenidate hcl cpcr or 0 methylphenidate hcl tabs or, 0, 0 methylphenidate hcl tb or 7, 6 methylphenidate hcl tbcr or 8, 7, 6, methylphenidate hcl tbcr or 0 modafinil tabs 00 modafinil tabs 00 PROVIGIL TABS 00 MG (Modafinil) PROVIGIL TABS 00 MG (Modafinil) RITALIN LA CP 0 MG, 0 MG, 0 MG (Methylphenidate HCl) RITALIN TABS (Methylphenidate HCl) QL( ea daily); QL( ea daily); ; QL( ea daily); QL( ea daily); QL( ea daily); Non-Osmotic Release QL( ea daily); PA; ; PA; QL( ea daily); ; PA; PA; QL( ea daily); QL( ea daily); ALLERGENIC EXTRACTS/BIOLOGICALS MISC Biologicals Misc ADAGEN SOLN ;LA; Name AMINOGLYCOSIDES - s to Treat Bacterial Infections Aminoglycosides amikacin sulfate soln ij gm/ml, 00 /ml BETHKIS NEBU B/D; gentamicin in saline soln 0.9%-/ml gentamicin sulfate soln ij 0 ; /ml KITABIS PAK NEBU B/D; neomycin sulfate tabs or paromomycin sulfate caps TOBI NEBU (Tobramycin) B/D TOBI PODHALER CAPS tobramycin nebu in B/D; tobramycin sulfate soln ij 0 /ml, 80 /ml,. gm/0ml tobramycin sulfate solr ij. gm ANALGESICS - ANTI-ILAMMATORY - s to Treat Pain, Swelling, Muscle and Joint Conditions Anti-T-alpha - Monoclonal Antibodies HUMIRA PEDIATRIC CROHNS DISEASE PA; STARTER PACK PSKT HUMIRA PEN PNKT PA; HUMIRA PEN-CD/UC/HS STARTER PNKT 0 MG/0.8ML HUMIRA PEN-PS/UV STARTER PNKT HUMIRA PSKT SIMPONI ARIA SOLN PA; PA; PA; PA; 09 Allwell (DSNP) Formulary Updated 09/0/08

18 Name SIMPONI SOAJ SIMPONI SOSY Antirheumatic - Enzyme Inhibitors XELJANZ TABS Antirheumatic Antimetabolites OTREXUP SOAJ 0 MG/0.ML, MG/0.ML, 0 MG/0.ML, MG/0.ML,. MG/0.ML, 7. MG/0.ML,. MG/0.ML RASUVO SOAJ 0 MG/0.ML, MG/0.ML, MG/0.ML, 0 MG/0.6ML, 7. MG/0.ML,. MG/0.ML, 7. MG/0.ML,. MG/0.ML RASUVO SOAJ 0 MG/0.ML Gold Compounds RIDAURA CAPS Interleukin- Blockers ARCALYST SOLR Interleukin-beta Blockers ILARIS SOLN ILARIS SOLR PA; PA; PA; PA PA PA ; ;LA PA; ;LA PA; ;LA Interleukin-6 Receptor Inhibitors ACTEMRA SOLN IV 00 MG/0ML PA; ACTEMRA SOSY SC 6 MG/0.9ML PA; KEVZARA SOSY 0 MG/.ML, 00 MG/.ML PA; Nonsteroidal Anti-inflammatory Agents (NSAIDs) ANAPROX DS TABS (Naproxen Sodium) Name ARTHROTEC 0 TBEC (Diclofenac w/ Misoprostol) ARTHROTEC 7 TBEC (Diclofenac w/ Misoprostol) CELEBREX CAPS (Celecoxib) celecoxib caps DAYPRO TABS (Oxaprozin) diclofenac potassium tabs diclofenac sodium tb or 00 diclofenac sodium tbec or, 0, 7 diclofenac w/ misoprostol tbec EC-NAPROSYN TBEC (Naproxen) etodolac caps 00, 00 etodolac tabs 00, 00 etodolac tb 00, 00, 600 FELDENE CAPS (Piroxicam) flurbiprofen tabs or 0, 00 ibuprofen susp or 00 /ml ibuprofen tabs or 00 ibuprofen tabs or 600 ibuprofen tabs or 800 indomethacin caps or, 0 indomethacin cpcr or 7 ketoprofen caps 0, 7 ketorolac tromethamine soln ij /ml, 0 /ml ; RX/OTC; ; SL(8 ea daily); ; SL(. ea daily); ; SL( ea daily); ; AL(Up to 6 yrs old); ; AL(Up to 6 yrs old); AL(Up to 6 yrs old); 09 Allwell (DSNP) Formulary Updated 09/0/08

19 Name ketorolac tromethamine soln im 0 /ml, 60 /ml LODINE TABS (Etodolac) mefenamic acid caps or meloxicam tabs or, 7. BIC TABS (Meloxicam) nabumetone tabs NAPROSYN TABS 00 MG (Naproxen) naproxen sodium tabs or 7, 0 naproxen tabs or 0, 7, 00 naproxen tbec or 7, 00 oxaprozin tabs AL(Up to 6 yrs old); ; ; ; piroxicam caps or 0, 0 PONSTEL CAPS (Mefenamic Acid) sulindac tabs or 0, ; 00 tolmetin sodium caps 00 tolmetin sodium tabs 00 Pyrimidine Synthesis Inhibitors ARAVA TABS (Leflunomide) leflunomide tabs or 0, 0 Soluble Tumor Necrosis Factor Receptor Agents ENBREL MINI SOCT PA; ENBREL SOLR ENBREL SOSY ENBREL SURECLICK SOAJ PA; PA; PA; Name ANALGESICS - NonNarcotic - s to Treat Pain, Muscle and Joint Conditions Salicylates diflunisal tabs ; ANALGESICS - OPIOID - s to Treat Pain, Muscle and Joint Conditions Opioid Agonists ACTIQ LPOP 00 MCG PA; ;QL(8 (Fentanyl Citrate) ACTIQ LPOP 00 MCG, 600 MCG, 800 MCG, 00 MCG, 600 MCG (Fentanyl Citrate) DILAUDID LIQD OR MG/ML (Hydromorphone HCl) DILAUDID SOLN IJ MG/ML (Hydromorphone HCl) DILAUDID TABS OR MG, MG (Hydromorphone HCl) DILAUDID TABS OR 8 MG (Hydromorphone HCl) DILAUDID-HP SOLN (Hydromorphone HCl) DOLOPHINE TABS (Methadone HCl) DURAGESIC PT7 (Fentanyl) fentanyl citrate lpop bu 00 mcg fentanyl citrate lpop bu 00 mcg, 600 mcg, 800 mcg, 00 mcg, 600 mcg fentanyl pt7 mcg/hr, mcg/hr, 0 mcg/hr, 7 mcg/hr, 00 mcg/hr hydromorphone hcl liqd or /ml ea daily); PA; ;QL( ea daily); QL(0 ml daily); QL(9 ea daily); QL(6. ea daily); 09 Allwell (DSNP) Formulary Updated 09/0/08 QL(6 ea daily); Limit 0 patches per month;ql(0. ea daily); PA; ;QL(8 ea daily); PA; ;QL( ea daily); Limit 0 patches per month;ql(0. ea daily); QL(0 ml daily);

20 Name hydromorphone hcl soln ij 0 /ml, 0 /ml, 00 /0ml hydromorphone hcl soln ij /ml hydromorphone hcl tabs or, hydromorphone hcl tabs or 8 HYDRORPHONE HYDROCHLORIDE SOLN 0 MG/ML (Hydromorphone HCl) KADIAN CP 0 MG, 0 MG, 0 MG, 0 MG (Morphine Sulfate) KADIAN CP 00 MG (Morphine Sulfate) KADIAN CP 60 MG (Morphine Sulfate) KADIAN CP 80 MG (Morphine Sulfate) LAZANDA SOLN 00 MCG/ACT LAZANDA SOLN 00 MCG/ACT LAZANDA SOLN 00 MCG/ACT methadone hcl soln or 0 /ml methadone hcl soln or /ml methadone hcl tabs or, 0 morphine sulfate cp or 0, 0, 0, 0 morphine sulfate cp or 00 morphine sulfate cp or 60 morphine sulfate cp or 80 morphine sulfate soln ij 0. /ml QL(9 ea daily); QL(6. ea daily); QL( ea daily); ;QL( ea daily); QL(. ea daily); QL(. ea daily); PA; ;QL( ea daily); PA; ;QL(0. ea daily); PA; ;QL(0.7 ea daily); QL(. ml daily); ; QL( ml daily); ; QL(6 ea daily); QL( ea daily); ;QL( ea daily); QL(. ea daily); QL(. ea daily); Name morphine sulfate soln ij /ml morphine sulfate soln or 0 /ml morphine sulfate soln or 0 /ml morphine sulfate soln or 0 /ml, 00 /ml morphine sulfate tbcr or 00, 00 morphine sulfate tbcr or, 0, 60 MS CONTIN TBCR 00 MG, 00 MG (Morphine Sulfate) MS CONTIN TBCR MG, 0 MG, 60 MG (Morphine Sulfate) OPANA TABS OR MG, 0 MG (Oxymorphone HCl) oxycodone hcl caps or oxycodone hcl conc or 00 /ml oxycodone hcl tabs or 0 oxycodone hcl tabs or, 0,, 0 oxymorphone hcl tabs, 0 oxymorphone hcl tb oxymorphone hcl tb 7. ROXICODONE TABS 0 MG (Oxycodone HCl) ROXICODONE TABS MG, MG (Oxycodone HCl) SUBSYS LIQD 00 MCG SUBSYS LIQD 00 MCG SUBSYS LIQD 00 MCG QL(00 ml daily); QL(0 ml daily); QL(0 ml daily); QL( ea daily); QL( ea daily); QL( ea daily); QL( ea daily); QL(6 ea daily); QL(6 ea daily); QL(6 ml daily); QL(. ea daily); QL(6 ea daily); QL(6 ea daily); QL(. ea daily); QL(8.89 ea daily); QL(. ea daily); QL(6 ea daily); PA; ;QL(6 ea daily); PA; ;QL( ea daily) PA; ;QL(8 ea daily); 09 Allwell (DSNP) Formulary Updated 09/0/08

21 Name SUBSYS LIQD 00 MCG, 600 MCG, 800 MCG, 600 MCG tramadol hcl tabs or 0 tramadol hcl tb or 00 tramadol hcl tb or 00 tramadol hcl tb or 00 ULTRAM ER TB (Tramadol HCl) ULTRAM TABS (Tramadol HCl) ZOHYDRO ER CA 0 MG, MG ZOHYDRO ER CA 0 MG, 0 MG, 0 MG, 0 MG Opioid Combinations acetaminophen w/ codeine soln 0/ml-/ml acetaminophen w/ codeine tabs 00- acetaminophen w/ codeine tabs 00-0 acetaminophen w/ codeine tabs butalbital-aspirin-caffeine w/cod caps FIORINAL/CODEINE # CAPS (Butalbital-Aspirin- Caffeine w/cod) hydrocodoneacetaminophen soln./ml-08/ml, /0ml-7/0ml, 7./ml-/ml hydrocodoneacetaminophen tabs - 00, 0-00, hydrocodoneacetaminophen tabs -, 0-, 7.- PA; ;QL( ea daily); SL(8 ea daily); ; SL( ea daily); SL(. ea daily); SL( ea daily); SL( ea daily); SL(8 ea daily); PA; QL( ea daily); PA; QL( ea daily); SL(0 ml daily); ; SL(. ea daily); ; SL( ea daily); ; SL(6 ea daily); ; AL(Up to 6 yrs old); SL(6 ea daily); AL(Up to 6 yrs old); SL(6 ea daily); Limit mls per month;sl(8. ml daily); SL(. ea daily); ; SL(. ea daily); ; Name hydrocodone-ibuprofen tabs IBUDONE TABS (Hydrocodone-Ibuprofen) NORCO TABS (Hydrocodone- Acetaminophen) oxycodone w/ acetaminophen tabs 0- oxycodone w/ acetaminophen tabs -,.-, 7.- oxycodone-aspirin tabs PERCOCET TABS (Oxycodone w/ Acetaminophen) REPREXAIN TABS (Hydrocodone-Ibuprofen) tramadol-acetaminophen tabs TYLENOL/CODEINE # TABS (Acetaminophen w/ Codeine) TYLENOL/CODEINE # TABS (Acetaminophen w/ Codeine) ULTRACET TABS (Tramadol-Acetaminophen) XODOL TABS (Hydrocodone- Acetaminophen) Opioid Partial Agonists buprenorphine hcl subl sl buprenorphine hcl subl sl 8 buprenorphine hclnaloxone hcl dihydrate subl -0. buprenorphine hclnaloxone hcl dihydrate subl 8- butorphanol tartrate soln ij /ml QL( ea daily); QL( ea daily); SL(. ea daily); SL(. ea daily); SL(. ea daily); ; SL(. ea daily); 09 Allwell (DSNP) Formulary Updated 09/0/08 6 QL( ea daily); SL(8 ea daily); SL( ea daily); SL(6 ea daily); SL(8 ea daily); SL(. ea daily); QL( ea daily); QL( ea daily); QL( ea daily); QL( ea daily);

22 Name butorphanol tartrate soln na 0 /ml Limit 0mls per month;ql(7 ml daily); ANDROGENS-ANABOLIC - s to Regulate Hormones Anabolic Steroids ANADROL-0 TABS ; OXANDRIN TABS 0 MG (Oxandrolone) ; OXANDRIN TABS. MG (Oxandrolone) oxandrolone tabs or 0 ; oxandrolone tabs or. Androgens ANDRODERM PT ANDROGEL GEL 0 MG/GM, MG/.GM (Testosterone) AVEED SOLN AXIRON SOLN (Testosterone) danazol caps or 0, 00, 00 DEPO-TESTOSTERONE SOLN (Testosterone Cypionate) fluoxymesterone tabs methyltestosterone caps or TESTIM GEL (Testosterone) testosterone cypionate soln testosterone enanthate soln im testosterone gel %, 0 /gm, /.gm testosterone soln 0 /act ; LA ; ; ; Name ANORECTAL AGENTS - Rectal s to Treat Pain, Swelling and Itching Intrarectal Steroids CORTENEMA ENEM (Hydrocortisone (Intrarectal)) hydrocortisone (intrarectal) enem UCERIS FOAM RE MG/ACT Rectal Steroids ANUSOL-HC CREA (Hydrocortisone (Rectal)) hydrocortisone (rectal) crea PROCTOCORT CREA % (Hydrocortisone (Rectal)) Vasodilating Agents RECTIV OINT ANTHELMINTICS - s to Treat Worm Infections Anthelmintics ALBENZA TABS ivermectin tabs or STROMECTOL TABS (Ivermectin) ANTI-IECTIVE AGENTS - MISC. - s to Treat Bacterial Infections Anti-infective Agents - Misc. colistimethate sodium solr ij COLY-MYCIN M SOLR (Colistimethate Sodium) FLAGYL CAPS 7 MG SL(0.6 ea (Metronidazole) daily); FLAGYL TABS 0 MG SL(6 ea daily); (Metronidazole) FLAGYL TABS 00 MG (Metronidazole) IMPAVIDO CAPS SL(8 ea daily); ; 09 Allwell (DSNP) Formulary Updated 09/0/08 7

23 Name metronidazole caps or 7 metronidazole in nacl soln metronidazole tabs or 0 metronidazole tabs or 00 NEBUPENT SOLR ORBACTIV SOLR PENTAM 00 SOLR TINDAMAX TABS (Tinidazole) tinidazole tabs or 0, 00 trimethoprim tabs or SL(0.6 ea daily); SL(6 ea daily); ; SL(8 ea daily); ; B/D; ; VANCOCIN HCL CAPS PA; MG (Vancomycin HCl) VANCOCIN HCL CAPS PA; ; 0 MG (Vancomycin HCl) vancomycin hcl caps or PA; vancomycin hcl caps or PA; ; 0 VANCOMYCIN HCL IN DEXTROSE SOLN GM/00ML-%, %- 70MG/0ML, 00MG/00ML-% vancomycin hcl solr iv 0 gm, 000, 000 vancomycin hcl solr iv 00 Anti-infective Misc. - Combinations BACTRIM DS TABS (Sulfamethoxazole- Trimethoprim) BACTRIM TABS (Sulfamethoxazole- Trimethoprim) sulfamethoxazoletrimethoprim soln iv ; 80/ml-00/ml Name sulfamethoxazoletrimethoprim susp or 0/ml-00/ml sulfamethoxazoletrimethoprim tabs or 80-00, Antiprotozoal Agents ALINIA TABS 00 MG atovaquone susp MEPRON SUSP (Atovaquone) Carbapenems ertapenem sodium solr imipenem-cilastatin solr 0-0 imipenem-cilastatin solr INVANZ SOLR IJ (Ertapenem Sodium) meropenem solr MERREM SOLR (Meropenem) PRIMAXIN IV SOLR (Imipenem-Cilastatin) VABOMERE SOLR Chloramphenicols chloramphenicol sodium succinate solr Cyclic Lipopeptides CUBICIN RF SOLR (Daptomycin) CUBICIN SOLR (Daptomycin) daptomycin solr 00 Glycylcyclines TIGECYCLINE SOLR tigecycline solr ; ; ; ; ; 09 Allwell (DSNP) Formulary Updated 09/0/08 8

24 Name TYGACIL SOLR (Tigecycline) Leprostatics dapsone tabs or, 00 Lincosamides CLEOCIN CAPS OR 7 MG, 0 MG, 00 MG (Clindamycin HCl) CLEOCIN IN DW SOLN (Clindamycin Phosphate in DW) CLEOCIN PEDIATRIC GRANULES SOLR (Clindamycin Palmitate Hydrochloride) CLEOCIN PHOSPHATE SOLN IJ 600 MG/ML, 900 MG/6ML (Clindamycin Phosphate) CLEOCIN PHOSPHATE SOLN IV 00MG/0ML- %, 600MG/0ML-%, 900MG/0ML-% (Clindamycin Phosphate in DW) CLEOCIN PHOSPHATE SOLN IV 600 MG/ML (Clindamycin Phosphate) clindamycin hcl caps or 7, 0, 00 clindamycin palmitate hydrochloride solr clindamycin phosphate in dw soln clindamycin phosphate soln ij 0 /ml, 9000 /60ml clindamycin phosphate soln ij 600 /ml, 900 /6ml clindamycin phosphate soln iv 600 /ml LINCOCIN SOLN (Lincomycin HCl) lincomycin hcl soln ij ; ; ; Name Monobactams AZACTAM SOLR (Aztreonam) aztreonam solr CAYSTON SOLR Oxazolidinones linezolid soln iv 600 /00ml LINEZOLID SOLN IV 600MG/00ML-0.9% linezolid susr or 00 /ml linezolid tabs or 600 SIVEXTRO SOLR IV SIVEXTRO TABS OR ZYVOX SOLN IV 00 MG/00ML ZYVOX SOLN IV 600 MG/00ML (Linezolid) ZYVOX SUSR OR 00 MG/ML (Linezolid) ZYVOX TABS OR 600 MG (Linezolid) Polymyxins polymyxin b sulfate solr ij Streptogramins SYNERCID SOLR PA; ;LA ; ; ; ; ; ANTIANGINAL AGENTS - s to Treat Chest Pain Antianginals-Other RANEXA TB PA; Nitrates ISORDIL TITRADOSE TABS MG (Isosorbide Dinitrate) isosorbide dinitrate tabs 09 Allwell (DSNP) Formulary Updated 09/0/08 9

25 Name isosorbide dinitrate tbcr isosorbide mononitrate tabs 0, 0 isosorbide mononitrate tb 0, 60, 0 NITRO-DUR PT 0. MG/HR, 0. MG/HR, 0. MG/HR, 0.6 MG/HR (Nitroglycerin) NITROGLYCERIN LINGUAL AERS nitroglycerin pt td 0. /hr, 0. /hr, 0. /hr, 0.6 /hr nitroglycerin soln tl 0. /spray nitroglycerin subl sl 0., 0., 0.6 NITROLINGUAL PUMPSPRAY SOLN (Nitroglycerin) NITROSTAT SUBL (Nitroglycerin) ; ; ; ANTIANXIETY AGENTS - s to Treat Anxiety Antianxiety Agents - Misc. buspirone hcl tabs or, 0,, 0, 7. hydroxyzine hcl soln im 0 /ml hydroxyzine hcl syrp or 0 /ml hydroxyzine hcl tabs or 0,, 0 hydroxyzine pamoate caps or, 0 VISTARIL CAPS (Hydroxyzine Pamoate) Benzodiazepines alprazolam tabs or 0., 0.,, alprazolam tb or 0.,,, ; AL(Up to 6 yrs old); ; AL(Up to 6 yrs old); AL(Up to 6 yrs old); AL(Up to 6 yrs old); ; AL(Up to 6 yrs old); ; Name alprazolam tbdp or 0., 0.,, ATIVAN SOLN (Lorazepam) ATIVAN TABS (Lorazepam) clorazepate dipotassium tabs diazepam conc or /ml diazepam soln or /ml diazepam tabs or,, 0 lorazepam conc or /ml lorazepam soln ij /ml, /ml, 0 /0ml lorazepam tabs or 0.,, oxazepam caps 0,, 0 TRANXENE T TABS (Clorazepate Dipotassium) VALIUM TABS (Diazepam) XANAX TABS (Alprazolam) ; ; ; ; ; ; XANAX XR TB (Alprazolam) ANTIARRHYTHMICS - s to treat abnormal heart rhythms Antiarrhythmics Type I-A disopyramide phosphate AL(Up to 6 yrs caps old); NORPACE CAPS AL(Up to 6 yrs (Disopyramide Phosphate) quinidine gluconate tbcr or quinidine sulfate tabs Antiarrhythmics Type I-B mexiletine hcl caps Antiarrhythmics Type I-C old); ; 09 Allwell (DSNP) Formulary Updated 09/0/08 0

26 Name flecainide acetate tabs 00 flecainide acetate tabs 0 flecainide acetate tabs 0 propafenone hcl cp,, propafenone hcl tabs 0,, 00 RYTHL SR CP (Propafenone HCl) RYTHL TABS (Propafenone HCl) Antiarrhythmics Type III amiodarone hcl tabs or 00, 00, 00 dofetilide caps MULTAQ TABS SL( ea daily); SL(.66 ea daily); SL(8 ea daily); ; TIKOSYN CAPS (Dofetilide) ANTIASTHMATIC AND BRONCHODILATOR AGENTS - s to Treat Lung Conditions Anti-Inflammatory Agents cromolyn sodium nebu in B/D; ; Antiasthmatic - Monoclonal Antibodies CINQAIR SOLN PA; ;LA FASENRA SOSY PA; NUCALA SOLR PA; ;LA XOLAIR SOLR PA; ;LA Bronchodilators - Anticholinergics ATROVENT HFA AERS ipratropium bromide soln in SPIRIVA HANDIHALER CAPS Limit inhalers per month;ql(0.86 gm daily); B/D; ; QL( ea daily); Name SPIRIVA RESPIMAT AERS TUDORZA PRESSAIR AEPB TUDORZA PRESSAIR AEPB Leukotriene Modulators ACCOLATE TABS (Zafirlukast) montelukast sodium chew, montelukast sodium tabs 0 SINGULAIR CHEW MG, MG (Montelukast Sodium) SINGULAIR TABS 0 MG (Montelukast Sodium) zafirlukast tabs Limit inhaler per month (60 actuations);sl( 0. gm daily); Limit inhalers per month (0 actuations);ql( 0.07 ea daily); Limit inhaler per month (60 actuations);ql( 0.0 ea daily); ; zileuton tb ;SL( ea daily); ZYFLO CR TB (Zileuton) ;SL( ea daily); Selective Phosphodiesterase (PDE) Inhibitors DALIRESP TABS QL( ea daily); Steroid Inhalants ARNUITY ELLIPTA AEPB 00 MCG/ACT, 00 MCG/ACT budesonide (inhalation) susp 0. /ml, 0. /ml FLOVENT DISKUS AEPB 00 MCG/BLIST SL( ea daily); B/D; SL(0 ea daily); 09 Allwell (DSNP) Formulary Updated 09/0/08

27 Name FLOVENT DISKUS AEPB 0 MCG/BLIST FLOVENT DISKUS AEPB 0 MCG/BLIST FLOVENT HFA AERO 0 MCG/ACT, 0 MCG/ACT FLOVENT HFA AERO MCG/ACT PULMICORT SUSP 0. MG/ML, 0. MG/ML (Budesonide (Inhalation)) Sympathomimetics ADVAIR DISKUS AEPB ADVAIR HFA AERO albuterol sulfate nebu in 0.6 /ml, 0.08 %, 0. %,. /ml albuterol sulfate syrp or /ml albuterol sulfate tabs or, albuterol sulfate tb or, 8 ANORO ELLIPTA AEPB BREO ELLIPTA AEPB MCG/INH-00MCG/INH, MCG/INH-00MCG/INH BREO ELLIPTA AEPB MCG/INH-00MCG/INH, MCG/INH-00MCG/INH COMBIVENT RESPIMAT AERS ipratropium-albuterol soln SL(8 ea daily); SL(0 ea daily); Limit inhalers per month;ql(0.8 gm daily); Limit inhaler per month;ql(0.6 gm daily); B/D; QL( gm daily); B/D; ; ; ; QL( ea daily); Limit inhalers per month (Institutional Pack);SL( ea daily); Limit inhaler per month;sl( ea daily); Limit inhaler per month;sl(0. gm daily); B/D; ; Name levalbuterol hcl nebu in 0. /ml, 0.6 /ml,. /ml,. /0.ml levalbuterol tartrate aero PROAIR HFA AERS PROAIR RESPICLICK AEPB SEREVENT DISKUS AEPB STIOLTO RESPIMAT AERS STRIVERDI RESPIMAT AERS SYMBICORT AERO.MCG/ACT- 60MCG/ACT SYMBICORT AERO.MCG/ACT-80MCG/ACT SYMBICORT AERO.MCG/ACT- 80MCG/ACT,.MCG/ACT- 60MCG/ACT terbutaline sulfate tabs or,. TRELEGY ELLIPTA AEPB XOPENEX CONCENTRATE NEBU (Levalbuterol HCl) XOPENEX NEBU (Levalbuterol HCl) Xanthines aminophylline soln theophylline tb 00, 00, 00, 0 theophylline tb 00, 600 B/D; QL( ea daily); Limit inhaler per month;ql(0. gm daily); Limit inhaler per month (60 actuations);sl( 0. gm daily); QL(0. gm daily); QL(0.6 gm daily); QL(0. gm daily); B/D; B/D; ; 09 Allwell (DSNP) Formulary Updated 09/0/08

28 Name ANTICOAGULANTS - Blood Thinners Coumarin Anticoagulants COUMADIN TABS (Warfarin Sodium) warfarin sodium tabs Direct Factor Xa Inhibitors BEVYXXA CAPS ELIQUIS STARTER PACK TABS ELIQUIS TABS XARELTO STARTER PACK TBPK XARELTO TABS ; QL( ea daily) Heparins And Heparinoid-Like Agents ARIXTRA SOLN. MG/0.ML (Fondaparinux Sodium) ARIXTRA SOLN ; MG/0.ML, 0 MG/0.8ML, 7. MG/0.6ML (Fondaparinux Sodium) enoxaparin sodium soln fondaparinux sodium soln. /0.ml fondaparinux sodium soln /0.ml, 0 /0.8ml, 7. /0.6ml FRAGMIN SOLN 0000 UNIT/ML, 00 UNIT/0.ML, 000 UNIT/0.ML FRAGMIN SOLN 700 UNIT/0.ML, 00 UNIT/0.ML, 000 UNIT/0.6ML, 8000 UNT/0.7ML, 9000 UNIT/.8ML heparin sodium (porcine) soln LOVENOX SOLN (Enoxaparin Sodium) ; ; Name Thrombin Inhibitors argatroban soln 0 /.ml ARGATROBAN SOLN 0 MG/.ML (Argatroban) IPRIVASK SOLR PRADAXA CAPS ANTICONVULSANTS - s to Treat Seizures AMPA Glutamate Receptor Antagonists FYCOMPA SUSP FYCOMPA TABS Anticonvulsants - Benzodiazepines clonazepam tabs or 0. SL(0 ea daily); ; clonazepam tabs or SL(0 ea daily); ; clonazepam tabs or SL(0 ea daily); ; clonazepam tbdp or 0., 0., 0.,, DIASTAT ACUDIAL GEL DIASTAT PEDIATRIC GEL DIAZEPAM GEL RE 0 MG, 0 MG,. MG DIAZEPAM RECTAL GEL GEL KLONOPIN TABS 0. MG (Clonazepam) KLONOPIN TABS MG (Clonazepam) KLONOPIN TABS MG (Clonazepam) OI SUSP. MG/ML OI TABS 0 MG OI TABS 0 MG SL(0 ea daily); SL(0 ea daily); SL(0 ea daily); ; 09 Allwell (DSNP) Formulary Updated 09/0/08

29 Name Anticonvulsants - Misc. APTIOM TABS 00 MG APTIOM TABS 00 MG, 600 MG, 800 MG BANZEL SUSP 0 MG/ML BANZEL TABS 00 MG BANZEL TABS 00 MG ; ; Name KEPPRA TABS (Levetiracetam) KEPPRA XR TB (Levetiracetam) LAMICTAL CHEWABLE DISPERSIBLE CHEW (Lamotrigine) LAMICTAL TABS (Lamotrigine) LAMICTAL XR KIT BRIVIACT SOLN IV 0 MG/ML BRIVIACT SOLN OR 0 MG/ML BRIVIACT TABS OR 0 MG BRIVIACT TABS OR 00 MG BRIVIACT TABS OR MG BRIVIACT TABS OR 0 MG BRIVIACT TABS OR 7 MG carbamazepine chew or 00 carbamazepine cp or 00, 00, 00 carbamazepine susp or 00 /ml carbamazepine tabs or 00 carbamazepine tb or 00, 00, 00 CARBATROL CP (Carbamazepine) gabapentin caps or 00, 00, 00 gabapentin soln or 0 /ml, 00 /6ml gabapentin tabs or 600, 800 KEPPRA SOLN (Levetiracetam) ;SL(0 ml daily) PA; ;SL(0 ml daily); PA; ;SL(0 ea daily); PA; ;SL( ea daily); PA; ;SL(8 ea daily); PA; ;SL( ea daily); PA; ;SL(.67 ea daily); ; ; ; ; LAMICTAL XR TB MG, 0 MG, 00 MG, 00 MG, 0 MG, 00 MG (Lamotrigine) lamotrigine chew, lamotrigine tabs, 00, 0, 00 lamotrigine tb 00, 0 lamotrigine tb, 0, 00, 00 levetiracetam in sodium chloride soln levetiracetam soln iv 00 /ml LEVETIRACETAM SOLN IV 00MG/00ML- 80MG/00ML, 000MG/00ML- 70MG/00ML, 00MG/00ML- 0MG/00ML (Levetiracetam in Sodium Chloride) levetiracetam soln or 00 /ml, 00 /ml levetiracetam tabs or 0, 00, 70, 000 levetiracetam tb or 00, 70 LYRICA CAPS 0 MG, 00 MG, MG LYRICA CAPS MG, 0 MG, 7 MG, 00 MG ; ; ; ; QL( ea daily); QL( ea daily); 09 Allwell (DSNP) Formulary Updated 09/0/08

30 Name LYRICA CAPS 00 MG LYRICA SOLN 0 MG/ML MYSOLINE TABS (Primidone) NEURONTIN CAPS (Gabapentin) NEURONTIN SOLN (Gabapentin) NEURONTIN TABS (Gabapentin) oxcarbazepine susp oxcarbazepine tabs POTIGA TABS 00 MG POTIGA TABS 00 MG POTIGA TABS 00 MG POTIGA TABS 0 MG primidone tabs or 0, 0 SPRITAM TBD 000 MG SPRITAM TBD 0 MG SPRITAM TBD 00 MG SPRITAM TBD 70 MG TEGRETOL SUSP (Carbamazepine) TEGRETOL TABS (Carbamazepine) TEGRETOL-XR TB (Carbamazepine) TOPAMAX SPRINKLE CPSP (Topiramate) TOPAMAX TABS (Topiramate) topiramate cpsp or, SL( ea daily); SL(0 ml daily); ;SL(6 ea daily); SL( ea daily); SL( ea daily); SL( ea daily); ; PA; SL( ea daily); PA; SL( ea daily); PA; SL(6 ea daily); PA; SL( ea daily); Name topiramate tabs or, 0, 00, 00 TRILEPTAL SUSP (Oxcarbazepine) TRILEPTAL TABS (Oxcarbazepine) VIMPAT SOLN IV 00 MG/0ML VIMPAT SOLN OR 0 MG/ML VIMPAT TABS OR 0 MG, 00 MG, 0 MG, 00 MG ZONEGRAN CAPS (Zonisamide) zonisamide caps Carbamates felbamate susp 600 /ml felbamate tabs 00 felbamate tabs 600 FELBATOL SUSP (Felbamate) FELBATOL TABS (Felbamate) GABA Modulators GABITRIL TABS (Tiagabine HCl) SABRIL PACK (Vigabatrin) SABRIL TABS tiagabine hcl tabs, 6 tiagabine hcl tabs, vigabatrin pack Hydantoins CEREBYX SOLN 00 MG PE/ML (Fosphenytoin Sodium) ; ; ; ;LA ;LA ; ;LA 09 Allwell (DSNP) Formulary Updated 09/0/08

31 Name CEREBYX SOLN 00 MG PE/0ML (Fosphenytoin Sodium) DILANTIN- SUSP (Phenytoin) fosphenytoin sodium soln 00 pe/ml fosphenytoin sodium soln 00 pe/0ml PEGANONE TABS PHENYTEK CAPS (Phenytoin Sodium Extended) phenytoin chew or 0 phenytoin sodium extended caps phenytoin sodium soln ij phenytoin susp or /ml Succinimides CELONTIN CAPS ethosuximide caps or 0 ethosuximide soln or 0 /ml ZARONTIN CAPS (Ethosuximide) ZARONTIN SOLN (Ethosuximide) Valproic Acid DEPACON SOLN (Valproate Sodium) DEPAKENE CAPS (Valproic Acid) DEPAKENE SOLN (Valproate Sodium) DEPAKOTE ER TB (Divalproex Sodium) DEPAKOTE SPRINKLES CSDR (Divalproex Sodium) DEPAKOTE TBEC (Divalproex Sodium) ; ; ; ; ; Name divalproex sodium csdr divalproex sodium tb 0, 00 divalproex sodium tbec, 0, 00 valproate sodium soln iv 00 /ml, 00 /ml valproate sodium soln or 0 /ml valproic acid caps ; ; ; ANTIDEPRESSANTS - s to Treat Depression Alpha- Receptor Antagonists (Tetracyclics) mirtazapine tabs, 0 ;,, 7. mirtazapine tbdp, 0, REMERON SOLTAB TBDP (Mirtazapine) REMERON TABS (Mirtazapine) Antidepressants - Misc. bupropion hcl tabs or 00 SL(. ea daily); bupropion hcl tabs or 7 SL(6 ea daily); bupropion hcl tb or 00 SL( ea daily); ; bupropion hcl tb or 0 SL(.66 ea daily); ; bupropion hcl tb or 00 SL( ea daily); ; bupropion hcl tb or 0 SL( ea daily); bupropion hcl tb or 00 FORFIVO XL TB maprotiline hcl tabs, 0 maprotiline hcl tabs 7 SL(. ea daily); ST; ; ; 09 Allwell (DSNP) Formulary Updated 09/0/08 6