(LIST OF COVERED DRUGS)

Transcription

1 Allwell Dual Medicare (H SNP) and Allwell Dual Medicare Essentials (H SNP) 08 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 88, Version Number 8 This formulary was updated /0/08. For more recent information or other questions, please contact Allwell Dual Medicare (H SNP) and Allwell Dual Medicare Essentials (H SNP) at: State Phone Number FL GA OH State Phone Number SC TX WI or for TTY users, 7, October - February, seven days a week, 8 a.m. to 8 p.m.; February - September 0, Monday - Friday, 8 a.m. to 8 p.m., or visit: State FL GA OH Website Address allwell.sunshinehealth.com allwell.pshpgeorgia.com allwell.buckeyehealthplan.com State SC TX WI Website Address allwell.absolutetotalcare.com allwell.superiorhealthplan.com allwell.mhswi.com Y000_8_8FRMLY_Accepted_08007

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 Sunshine Health, Peach State Health, Buckeye Community Solutions, Absolute Total Care, Superior HealthPlan, 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 /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, 09, and from time to time during the year. What is the Allwell Dual Medicare (H SNP) and Allwell Dual Medicare Essentials (H SNP)? 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 08 formulary that was covered at the beginning of the year, we will not discontinue or reduce coverage of the drug during the 08 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 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. 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. The enclosed formulary is current as of /0/08. To get updated information about the drugs covered by our plan, please contact us. Our contact information appears on the front and back cover pages. i

3 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. 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 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 ii

4 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 on line 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 iii 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: 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)? 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. iii

5 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 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 (unless you have a prescription written for fewer days) when you go to a network pharmacy. 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, we will allow you to refill your prescription until we have provided you with a 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 -day emergency supply of that drug (unless you have a prescription for fewer days) 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. iv

6 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. 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 - February, seven days a week, 8 a.m. to 8 p.m. or from February - September 0, Monday - Friday, 8 a.m. to 8 p.m. Our contact information appears on the front and back cover pages. TTY users should call 7. v

7 Abbreviation Definition Description Mail Order This drug is available at our mail order pharmacy in addition to other network pharmacies. NDS Non-Extended Day Supply This prescription drug is not available for an extended day supply. NT Non-TrOOP This prescription drug is not normally covered in a Medicare Prescription Plan. The amount you pay when you fill a prescription for this drug does not count towards your total drug costs (that is, the amount you pay does not help you qualify for catastrophic coverage). In addition, if you are receiving extra help to pay for your prescriptions, you will not get any extra help to pay for this drug. PA QL RX/OTC Prior Authorization Quantity Limit Prescription and Over-the- Counter (OTC) 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. 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. 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. 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. Additional Gap Coverage 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. Only for Allwell Dual Medicare (H SNP) in Florida: We provide additional coverage of this prescription drug in the coverage gap. Please refer to your Evidence of Coverage for more information about this coverage. vi

8 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) Select Care s (includes some generics and may include some brands used to treat specific chronic conditions) FL GA OH SC TX Allwell Dual Medicare (H SNP) Allwell Dual Medicare (H SNP) Allwell Dual Medicare (H SNP) Allwell Dual Medicare Essentials (H SNP) Allwell Dual Medicare (H SNP) $0 $0 $7 $00 % $0 $0 $7 $7 $00 8% $0 $0 $0 $7 $00 % $0 $0 $ $7 $00 0% $0 $0 $9 $7 $00 % $0 vii

9 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) 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 % $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 NF 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. viii

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11 ế ế ệ ỗ ợ ữ ễ ố ộ ượ ệ ể ủ ả ố ệ ạ ộ ể 注意 : 如果您使用繁體中文, 則可得到免費的語言助手服務 請致電 會員服務電話號碼表 ( 按州排列 ) 上列出的您所在州的會員服務號碼 참조한국어를사용하시면무료로언어지원서비스를이용할수있습니다주차트에있는회원서비스전화번호를통해각주에등록된회원서비스로전화하십시오 الواليات. تنبيه: إذا كنت تتحدث العربية فإن خدمات المساعدة اللغوية تتوفر لك مجانا. اتصل برقم خدمات األعضاء المدرج لواليتك في أرقام هاتف خدم تا األعضاء حسب مخطط ВНИМАНИЕ если вы говорите на русском языке вам могут предоставить бесплатные услуги перевода Позвоните по номеру указанному для вашего штата в таблице номеров телефонов Службы поддержки участников по штатам ધ ય ન આપ : જ તમ ગજર ત બ લત હ ત ભ ષ ક ય સવ ઓ તમન વવન મ લ ય ઉપલબ ધ છ. સ ટટ ચ ટ દ વ ર મ મ બર સવવસ ઝ ટ લલફ ન નબર પર તમ ર ર જ ય મ ટ આપલ મમ બર સવવસ નબર પર ક લ કર 注意 : 日本語を話される場合は無料の言語支援サービスをご利用いただけます 地域別メンバーサービス電話番号表に記載されている お住まいの地域の電話番号にお掛けください

12 Name ADHD/ANTI-NARCOLEPSY/ANTI- OBESITY/ANOREXIANTS - s to Treat ADHD, Sleep and Eating Disorders Amphetamines amphetaminedextroamphetamine cp ---, , , , , amphetaminedextroamphetamine tabs ---, , , , , , 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); ; atomoxetine hcl caps 00 SL( ea daily); ; atomoxetine hcl caps 8 SL(. ea daily); ; atomoxetine hcl caps SL( ea daily); ; atomoxetine hcl caps 0 SL(. ea daily); ; atomoxetine hcl caps 0 SL(. ea daily); ; Name atomoxetine hcl caps 80 clonidine hcl (adhd) tb guanfacine hcl (adhd) tb Stimulants - Misc. dexmethylphenidate hcl cp 0,, 0 dexmethylphenidate hcl tabs, 0,. methylphenidate hcl cp or 0, 0, 0 methylphenidate hcl cp or 0 methylphenidate hcl cpcr or 0, 0, 0, 0 methylphenidate hcl cpcr or 0 methylphenidate hcl cpcr or 0 methylphenidate hcl tabs or, 0, 0 methylphenidate hcl tb or 7, methylphenidate hcl tbcr or 8, 7,, methylphenidate hcl tbcr or 0 modafinil tabs 00 modafinil tabs 00 SL(. ea daily); ; AL(Up to yrs old); ; ; QL( ea daily); QL( ea daily); QL( ea daily); Non-Osmotic Release QL( ea daily); PA; ; PA; QL( ea daily); ; ALLERGENIC EXTRACTS/BIOLOGICALS MISC Biologicals Misc ADAGEN SOLN LA; AMINOGLYCOSIDES - s to Treat Bacterial Infections Aminoglycosides amikacin sulfate soln ij gm/ml, 00 /ml 08 Allwell (DSNP) Formulary Updated /0/08

13 Name 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 PODHALER CAPS tobramycin nebu in B/D; tobramycin sulfate soln ij 0 /ml, 80 /ml,. gm/0ml tobramycin sulfate solr ij. gm ANALGESICS - ANTI-INFLAMMATORY - s to Treat Pain, Swelling, Muscle and Joint Conditions Anti-TNF-alpha - Monoclonal Antibodies HUMIRA PEDIATRIC CROHNS DISEASE STARTER PACK PSKT HUMIRA PEN PNKT HUMIRA PEN-CD/UC/HS STARTER PNKT HUMIRA PEN-PS/UV STARTER PNKT HUMIRA PSKT SIMPONI ARIA SOLN SIMPONI SOAJ SIMPONI SOSY Antirheumatic - Enzyme Inhibitors XELJANZ TABS Antirheumatic Antimetabolites Name OTREXUP SOAJ 0 /0.ML, /0.ML, 0 /0.ML, /0.ML,. /0.ML, 7. /0.ML,. /0.ML RASUVO SOAJ 0 /0.ML, /0.ML, /0.ML, 0 /0.ML, 7. /0.ML,. /0.ML, 7. /0.ML,. /0.ML RASUVO SOAJ 0 /0.ML Gold Compounds RIDAURA CAPS Interleukin- Blockers ARCALYST SOLR PA PA PA LA Interleukin- Receptor Antagonist (IL-Ra) KINERET SOSY Interleukin-beta Blockers ILARIS SOLN ILARIS SOLR Interleukin- Receptor Inhibitors ACTEMRA SOLN ACTEMRA SOSY KEVZARA SOAJ KEVZARA SOSY LA LA Nonsteroidal Anti-inflammatory Agents (NSAIDs) celecoxib caps diclofenac potassium tabs diclofenac sodium tb or Allwell (DSNP) Formulary Updated /0/08

14 Name diclofenac sodium tbec or, 0, 7 diclofenac w/ misoprostol tbec etodolac caps 00, 00 etodolac tabs 00, 00 etodolac tb 00, 00, 00 flurbiprofen tabs or 0, 00 ibuprofen susp or 00 /ml ibuprofen tabs or 00 ibuprofen tabs or 00 ibuprofen tabs or 800 indomethacin caps or, 0 indomethacin cpcr or 7 ketoprofen caps 0, 7 ketorolac tromethamine soln ij /ml, 0 /ml ketorolac tromethamine soln im 0 /ml, 0 /ml mefenamic acid caps or meloxicam tabs or, 7. nabumetone tabs naproxen sodium tabs or 7, 0 naproxen tabs or 0, 7, 00 naproxen tbec or 7, 00 oxaprozin tabs RX/OTC; ; SL(8 ea daily); ; SL(. ea daily); ; SL( ea daily); ; AL(Up to yrs old); ; AL(Up to yrs old); AL(Up to yrs old); AL(Up to yrs old); ; ; ; Name piroxicam caps or 0, 0 sulindac tabs or 0, ; 00 tolmetin sodium caps 00 tolmetin sodium tabs 00 Phosphodiesterase (PDE) Inhibitors OTEZLA TABS OTEZLA TBPK Pyrimidine Synthesis Inhibitors leflunomide tabs or 0, 0 Selective Costimulation Modulators ORENCIA CLICKJECT SOAJ ORENCIA SOLR ORENCIA SOSY Soluble Tumor Necrosis Factor Receptor Agents ENBREL MINI SOCT ENBREL SOLR ENBREL SOSY ENBREL SURECLICK SOAJ 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 fentanyl citrate lpop bu 00 QL(8 mcg fentanyl citrate lpop bu 00 mcg, 00 mcg, 800 mcg, 00 mcg, 00 mcg ea daily); QL( ea daily); 08 Allwell (DSNP) Formulary Updated /0/08

15 Name fentanyl pt7 00 mcg/hr fentanyl pt7 mcg/hr fentanyl pt7 mcg/hr fentanyl pt7 0 mcg/hr, 7 mcg/hr hydromorphone hcl liqd or /ml hydromorphone hcl soln ij 0 /ml, 0 /ml, 00 /0ml hydromorphone hcl soln ij /ml hydromorphone hcl tabs or hydromorphone hcl tabs or hydromorphone hcl tabs or 8 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 methadone hcl tabs or morphine sulfate cp or 0 morphine sulfate cp or 00 morphine sulfate cp or 0 QL(0. ea daily); Limit patches per month;ql(. ea daily); QL(0.9 ea daily); Limit patches per month;ql(0. ea daily); QL(0 ml daily); QL( ea daily); QL(. ea daily); QL(. ea daily); QL( ea daily); PA; QL(0. ea daily); PA; QL(0.7 ea daily); QL(. ml daily); ; QL(.7 ml daily); ; QL(.7 ea daily); QL(. ea daily); QL(0 ea daily); QL( ea daily); QL(0 ea daily); Name morphine sulfate cp or 0 morphine sulfate cp or 0 morphine sulfate cp or 0 morphine sulfate cp or 80 morphine sulfate soln ij 0. /ml 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 morphine sulfate tbcr or 0 morphine sulfate tbcr or 0 oxycodone hcl caps or oxycodone hcl conc or 00 /ml oxycodone hcl tabs or 0 oxycodone hcl tabs or oxycodone hcl tabs or 0 oxycodone hcl tabs or 0 oxycodone hcl tabs or oxymorphone hcl tabs 0 oxymorphone hcl tabs oxymorphone hcl tb 08 Allwell (DSNP) Formulary Updated /0/08 QL(.7 ea daily); QL( ea daily); QL(. ea daily); QL(. ea daily); QL(00 ml daily); QL(0 ml daily); QL(0 ml daily); QL( ea daily); QL(. ea daily); QL(.7 ea daily); QL(. ea daily); QL(.7 ea daily); QL(.7 ml daily); QL(. ea daily); QL(8.9 ea daily); QL(. ea daily); QL(. ea daily); QL(.7 ea daily); QL(.7 ea daily); QL(. ea daily); QL(. ea daily);

16 Name oxymorphone hcl tb 7. SUBSYS LIQD 00 MCG SUBSYS LIQD 00 MCG SUBSYS LIQD 00 MCG SUBSYS LIQD 00 MCG SUBSYS LIQD 00 MCG, 00 MCG, 800 MCG tramadol hcl tabs or 0 tramadol hcl tb or 00 tramadol hcl tb or 00 tramadol hcl tb or 00 ZOHYDRO ER CA 0 ZOHYDRO ER CA ZOHYDRO ER CA 0 ZOHYDRO ER CA 0 ZOHYDRO ER CA 0 ZOHYDRO ER CA 0 Opioid Combinations acetaminophen w/ codeine soln 0/ml-/ml acetaminophen w/ codeine tabs 00- acetaminophen w/ codeine tabs 00-0 acetaminophen w/ codeine tabs 00-0 butalbital-aspirin-caffeine w/cod caps QL(8.89 ea daily); PA; QL( ea daily); PA; QL( ea daily) PA; QL( ea daily); QL(8 ea daily); QL( ea daily); SL(8 ea daily); ; SL( ea daily); SL(. ea daily); SL( ea daily); PA; QL(.8 ea daily); PA; QL(. ea daily); PA; QL(8. ea daily); PA; QL(. ea daily); PA; QL(. ea daily); PA; QL(.7 ea daily); SL(0 ml daily); ; SL(. ea daily); ; SL( ea daily); ; SL( ea daily); ; AL(Up to yrs old); SL( ea daily); Name hydrocodoneacetaminophen soln./ml-08/ml, /0ml-7/0ml, 7./ml-/ml hydrocodoneacetaminophen tabs - 00, 0-00, hydrocodoneacetaminophen tabs -, 0-, 7.- hydrocodone-ibuprofen tabs oxycodone w/ acetaminophen tabs 0- oxycodone w/ acetaminophen tabs -,.-, 7.- oxycodone-aspirin tabs tramadol-acetaminophen tabs 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 butorphanol tartrate soln na 0 /ml Limit mls per month;sl(8. ml 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); PA; QL( ea daily); PA; QL( ea daily); Limit 0mls per month;ql(7 ml daily); ANDROGENS-ANABOLIC - s to Regulate Hormones Anabolic Steroids ANADROL-0 TABS 08 Allwell (DSNP) Formulary Updated /0/08

17 Name oxandrolone tabs or 0 oxandrolone tabs or. Androgens ANDRODERM PT ANDROGEL GEL 0. /.GM, 0. /.GM (Testosterone) ANDROGEL PUMP GEL (Testosterone) AVEED SOLN danazol caps or 0, 00, 00 fluoxymesterone tabs methyltestosterone caps or testosterone cypionate soln testosterone enanthate soln im testosterone gel %,. %, 0 /gm, /.gm, 0. /.gm, 0. /.gm TESTOSTERONE GEL %, 0 /GM, /.GM TESTOSTERONE PUMP GEL VOGELXO GEL VOGELXO PUMP GEL ; LA ; ; ; ; ANORECTAL AGENTS - Rectal s to Treat Pain, Swelling and Itching Intrarectal Steroids hydrocortisone (intrarectal) enem UCERIS FOAM RE /ACT Rectal Steroids hydrocortisone (rectal) crea Name Vasodilating Agents RECTIV OINT ANTHELMINTICS - s to Treat Worm Infections Anthelmintics albendazole tabs or ; ALBENZA TABS (Albendazole) ivermectin tabs or ANTI-INFECTIVE AGENTS - MISC. - s to Treat Bacterial Infections Anti-infective Agents - Misc. colistimethate sodium solr ij IMPAVIDO CAPS metronidazole caps or 7 SL(0. ea daily); metronidazole in nacl soln metronidazole tabs or 0 metronidazole tabs or 00 NEBUPENT SOLR PENTAM 00 SOLR tinidazole tabs or 0, 00 trimethoprim tabs or XIFAXAN TABS 00 SL( ea daily); ; SL(8 ea daily); ; B/D; ; XIFAXAN TABS 0 QL( ea daily); Anti-infective Misc. - Combinations sulfamethoxazoletrimethoprim soln iv ; 80/ml-00/ml sulfamethoxazoletrimethoprim susp or 0/ml-00/ml 08 Allwell (DSNP) Formulary Updated /0/08

18 Name sulfamethoxazoletrimethoprim tabs or 80-00, Antiprotozoal Agents ALINIA TABS 00 atovaquone susp Carbapenems ertapenem sodium solr imipenem-cilastatin solr 0-0 imipenem-cilastatin solr INVANZ SOLR IJ (Ertapenem Sodium) meropenem solr gm meropenem solr 00 VABOMERE SOLR ; ; ; Name tigecycline solr TYGACIL SOLR (Tigecycline) Leprostatics dapsone tabs or, 00 Lincosamides clindamycin hcl caps or 7, 0, 00 clindamycin palmitate hydrochloride solr clindamycin phosphate in dw soln clindamycin phosphate soln ij 0 /ml, 9000 /0ml clindamycin phosphate soln ij 00 /ml, 900 /ml clindamycin phosphate soln iv 00 /ml lincomycin hcl soln ij ; ; ; Chloramphenicols chloramphenicol sodium succinate solr Cyclic Lipopeptides daptomycin solr 00 Glycopeptides ORBACTIV SOLR vancomycin hcl caps or, 0 VANCOMYCIN HCL IN DEXTROSE SOLN %- GM/00ML, %- 00/00ML, %- 70/0ML vancomycin hcl solr iv gm, gm, 0 gm vancomycin hcl solr iv 00 Glycylcyclines TIGECYCLINE SOLR Monobactams aztreonam solr CAYSTON SOLR Oxazolidinones linezolid soln iv 00 /00ml LINEZOLID SOLN IV 00/00ML-0.9% linezolid susr or 00 /ml linezolid tabs or 00 SIVEXTRO SOLR IV SIVEXTRO TABS OR ZYVOX SOLN IV 00 /00ML Polymyxins polymyxin b sulfate solr ij LA 08 Allwell (DSNP) Formulary Updated /0/08 7

19 Name Streptogramins SYNERCID SOLR ANTIANGINAL AGENTS - s to Treat Chest Pain Antianginals-Other RANEXA TB PA; Nitrates isosorbide dinitrate tabs isosorbide dinitrate tbcr isosorbide mononitrate tabs 0, 0 isosorbide mononitrate tb 0, 0, 0 NITROGLYCERIN LINGUAL AERS nitroglycerin pt td 0. /hr, 0. /hr, 0. /hr, 0. /hr nitroglycerin soln tl 0. /spray nitroglycerin subl sl 0., 0., 0. 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 Benzodiazepines alprazolam tabs or 0., 0.,, AL(Up to yrs old); ; AL(Up to yrs old); AL(Up to yrs old); AL(Up to yrs old); ; ; Name alprazolam tb or 0.,,, alprazolam tbdp or 0., 0.,, 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 ANTIARRHYTHMICS - s to treat abnormal heart rhythms Antiarrhythmics Type I-A disopyramide phosphate AL(Up to yrs caps old); quinidine gluconate tbcr or quinidine sulfate tabs ; Antiarrhythmics Type I-B mexiletine hcl caps Antiarrhythmics Type I-C flecainide acetate tabs 00 flecainide acetate tabs 0 flecainide acetate tabs 0 propafenone hcl cp,, propafenone hcl tabs 0,, 00 Antiarrhythmics Type III SL( ea daily); SL(. ea daily); SL(8 ea daily); 08 Allwell (DSNP) Formulary Updated /0/08 8

20 Name amiodarone hcl tabs or 00, 00, 00 dofetilide caps MULTAQ TABS ; 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 LA XOLAIR SOLR LA Bronchodilators - Anticholinergics ATROVENT HFA AERS ipratropium bromide soln in SPIRIVA HANDIHALER CAPS SPIRIVA RESPIMAT AERS TUDORZA PRESSAIR AEPB TUDORZA PRESSAIR AEPB Leukotriene Modulators montelukast sodium chew, Limit inhalers per month;ql(0.8 gm daily); B/D; QL( ea daily); Limit inhaler per month (0 actuations);sl( 0. gm daily); Limit inhaler per month (0 actuations);ql( 0.0 ea daily); Limit inhalers per month (0 actuations);ql( 0.07 ea daily); Name montelukast sodium tabs 0 zafirlukast tabs zileuton tb SL( ea daily); Selective Phosphodiesterase (PDE) Inhibitors DALIRESP TABS QL( ea daily); Steroid Inhalants AEROSPAN AERS Limit inhalers per month (0 actuations);sl( 0. gm daily) budesonide (inhalation) B/D; susp 0. /ml, 0. /ml FLOVENT DISKUS AEPB 00 MCG/BLIST SL(0 ea daily); FLOVENT DISKUS AEPB 0 MCG/BLIST SL(8 ea daily); FLOVENT DISKUS AEPB 0 MCG/BLIST SL(0 ea daily); FLOVENT HFA AERO 0 MCG/ACT, 0 MCG/ACT Limit inhalers per month;ql(0.8 gm daily); FLOVENT HFA AERO MCG/ACT QVAR AERS Sympathomimetics ADVAIR DISKUS AEPB ADVAIR HFA AERO albuterol sulfate nebu in 0. /ml, 0.08 %, 0. %,. /ml albuterol sulfate syrp or /ml Limit inhaler per month;ql(0. gm daily); Limit inhalers per month;ql(0.87 gm daily); QL( gm daily); B/D; ; ; 08 Allwell (DSNP) Formulary Updated /0/08 9

21 Name 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 DULERA AERO ipratropium-albuterol soln levalbuterol hcl nebu in 0. /ml, 0. /ml,. /ml,. /0.ml PROAIR HFA AERS PROAIR RESPICLICK AEPB PROVENTIL HFA AERS SEREVENT DISKUS AEPB STIOLTO RESPIMAT AERS STRIVERDI RESPIMAT AERS terbutaline sulfate tabs or,. TRELEGY ELLIPTA AEPB ; QL( ea daily); Limit inhaler per month;sl( ea daily); Limit inhalers per month (Institutional Pack);SL( ea daily); Limit inhaler per month;sl(0. gm daily); QL( gm daily); B/D; B/D; QL( ea daily); Limit inhaler per month;sl(0. gm daily); Limit inhaler per month (0 actuations);sl( 0. gm daily); Name UTIBRON NEOHALER CAPS Xanthines aminophylline soln theophylline tb 00, 00, 00, 0 theophylline tb 00, 00 ; ANTICOAGULANTS - Blood Thinners Coumarin Anticoagulants warfarin sodium tabs Direct Factor Xa Inhibitors BEVYXXA CAPS ELIQUIS STARTER PACK TABS ELIQUIS TABS ; QL( ea daily) XARELTO STARTER PACK TBPK XARELTO TABS 0,, 0 Heparins And Heparinoid-Like Agents enoxaparin sodium soln fondaparinux sodium soln. /0.ml fondaparinux sodium soln /0.ml, 0 /0.8ml, 7. /0.ml 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.ML, 8000 UNT/0.7ML, 9000 UNIT/.8ML heparin sodium (porcine) soln Thrombin Inhibitors 08 Allwell (DSNP) Formulary Updated /0/08 0

22 Name argatroban soln 0 /.ml 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 (anticonvulsant) gel DIAZEPAM GEL RE 0,. DIAZEPAM RECTAL GEL GEL ONFI SUSP. /ML ONFI TABS 0 ONFI TABS 0 Anticonvulsants - Misc. APTIOM TABS 00 APTIOM TABS 00, 00, 800 BANZEL SUSP 0 /ML Name BANZEL TABS 00 BANZEL TABS 00 BRIVIACT SOLN IV 0 /ML BRIVIACT SOLN OR 0 /ML BRIVIACT TABS OR 0 BRIVIACT TABS OR 00 BRIVIACT TABS OR BRIVIACT TABS OR 0 BRIVIACT TABS OR 7 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 gabapentin caps or 00, 00, 00 gabapentin soln or 0 /ml, 00 /ml gabapentin tabs or 00, 800 LAMICTAL XR KIT lamotrigine chew, lamotrigine tabs, 00, 0, 00 lamotrigine tb 00, 0 lamotrigine tb, 0, 00, 00 SL(0 ml daily) SL(0 ml daily); SL(0 ea daily); SL( ea daily); SL(8 ea daily); SL( ea daily); PA; SL(.7 ea daily); ; ; ; ; ; ; ; 08 Allwell (DSNP) Formulary Updated /0/08

23 Name levetiracetam in sodium chloride soln levetiracetam soln iv 00 /ml levetiracetam soln or 00 /ml, 00 /ml levetiracetam tabs or 0, 00, 70, 000 levetiracetam tb or 00, 70 LYRICA CAPS 0, 00, LYRICA CAPS, 0, 7, 00 LYRICA CAPS 00 LYRICA SOLN 0 /ML oxcarbazepine susp oxcarbazepine tabs POTIGA TABS 00 POTIGA TABS 00 POTIGA TABS 0 primidone tabs or 0, 0 SPRITAM TBD 000 SPRITAM TBD 0 SPRITAM TBD 00 SPRITAM TBD 70 topiramate cpsp or, topiramate tabs or, 0, 00, 00 VIMPAT SOLN IV 00 /0ML QL( ea daily); QL( ea daily); SL( ea daily); SL(0 ml daily); SL( ea daily); SL( ea daily); SL( ea daily); ; PA; SL( ea daily); PA; SL( ea daily); PA; SL( ea daily); PA; SL( ea daily); ; Name VIMPAT SOLN OR 0 /ML VIMPAT TABS OR 0, 00, 0, 00 zonisamide caps Carbamates felbamate susp 00 /ml felbamate tabs 00 felbamate tabs 00 GABA Modulators GABITRIL TABS, (Tiagabine HCl) SABRIL PACK (Vigabatrin) SABRIL TABS tiagabine hcl tabs, tiagabine hcl tabs, vigabatrin pack Hydantoins fosphenytoin sodium soln 00 pe/ml fosphenytoin sodium soln 00 pe/0ml PEGANONE TABS phenytoin chew or 0 phenytoin sodium extended caps 0, 00, 00, 00 phenytoin sodium soln ij phenytoin susp or /ml Succinimides CELONTIN CAPS ; ; LA LA ; LA ; ; ; 08 Allwell (DSNP) Formulary Updated /0/08

24 Name ethosuximide caps or 0 ethosuximide soln or 0 /ml Valproic Acid 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, Antidepressants - Misc. bupropion hcl tabs or 00 SL(. ea daily); bupropion hcl tabs or 7 SL( ea daily); bupropion hcl tb or 00 SL( ea daily); ; bupropion hcl tb or 0 SL(. ea daily); ; bupropion hcl tb or 00 SL( ea daily); ; bupropion hcl tb or 0 SL( ea daily); bupropion hcl tb or 00 SL(. ea BUPROPION HYDROCHLORIDE ER TB FORFIVO XL TB daily); ST; ST; Name maprotiline hcl tabs, 0 maprotiline hcl tabs 7 ; ; Monoamine Oxidase Inhibitors (MAOIs) EMSAM PT MARPLAN TABS phenelzine sulfate tabs or ; tranylcypromine sulfate tabs Selective Serotonin Reuptake Inhibitors (SSRIs) citalopram hydrobromide SL(0 ml daily); soln 0 /ml citalopram hydrobromide SL( ea daily); tabs 0 ; citalopram hydrobromide SL( ea daily); tabs 0 ; citalopram hydrobromide SL( ea daily); tabs 0 ; escitalopram oxalate soln /ml escitalopram oxalate tabs ;, 0, 0 fluoxetine hcl caps or 0 ;, 0, 0 fluoxetine hcl cpdr or 90 ; fluoxetine hcl soln or 0 /ml fluoxetine hcl tabs or 0, 0 fluvoxamine maleate cp 00, 0 fluvoxamine maleate tabs, 0, 00 paroxetine hcl tabs 0, 0, 0, 0 paroxetine hcl tb,., 7. PAXIL SUSP 0 /ML sertraline hcl conc or 0 /ml ; ; ; 08 Allwell (DSNP) Formulary Updated /0/08

25 Name sertraline hcl tabs or, 0, 00 Serotonin Modulators nefazodone hcl tabs 00, 0, 00 nefazodone hcl tabs 0, 0 trazodone hcl tabs or 0, 00, 0, 00 TRINTELLIX TABS 0 TRINTELLIX TABS 0 TRINTELLIX TABS VIIBRYD STARTER PACK KIT VIIBRYD TABS ; ; ; ST; QL( ea daily); ST; QL( ea daily); ST; QL( ea daily); ST; ST; Serotonin-Norepinephrine Reuptake Inhibitors DESVENLAFAXINE ER TB 0, 00 ST; desvenlafaxine succinate ; tb duloxetine hcl cpep 0, 0, 0 FETZIMA CP 0 ST; QL( ea daily); FETZIMA CP 0, 80, 0 ST; QL( ea daily); FETZIMA TITRATION PACK CPK ST; KHEDEZLA TB ST; venlafaxine hcl cp 0 venlafaxine hcl cp 7. venlafaxine hcl cp 7 venlafaxine hcl tabs 00 venlafaxine hcl tabs SL(. ea daily); ; SL( ea daily); ; SL( ea daily); ; SL(.7 ea daily); ; SL( ea daily); ; Name venlafaxine hcl tabs 7. venlafaxine hcl tabs 0 venlafaxine hcl tabs 7 venlafaxine hcl tb 0 venlafaxine hcl tb venlafaxine hcl tb 7. venlafaxine hcl tb 7 Tricyclic Agents amitriptyline hcl tabs amoxapine tabs 0 amoxapine tabs, 0, 00 clomipramine hcl caps or, 0, 7 desipramine hcl tabs or 0,, 0, 7, 00, 0 doxepin hcl caps or 0,, 0, 00, 0 doxepin hcl caps or 7 doxepin hcl conc or 0 /ml imipramine hcl tabs or 0,, 0 imipramine pamoate caps nortriptyline hcl caps or 0,, 0, 7 nortriptyline hcl soln or 0 /ml protriptyline hcl tabs trimipramine maleate caps or 00 SL(0 ea daily); ; SL(7. ea daily); ; SL( ea daily); ; SL(. ea daily); ; ST; SL( ea daily); ; SL( ea daily); ; SL( ea daily); ; AL(Up to yrs old); ; ; ; AL(Up to yrs old); AL(Up to yrs old); AL(Up to yrs old); ; AL(Up to yrs old); ; AL(Up to yrs old); ; AL(Up to yrs old); ; ; ; AL(Up to yrs old); ; 08 Allwell (DSNP) Formulary Updated /0/08

26 Name trimipramine maleate caps or, 0 AL(Up to yrs old); ANTIDIABETICS - s to Regulate Blood Sugar Alpha-Glucosidase Inhibitors acarbose tabs QL( ea daily); ; miglitol tabs QL( ea daily); Antidiabetic - Amylin Analogs SYMLINPEN 0 SOPN SYMLINPEN 0 SOPN Antidiabetic Combinations alogliptin-metformin hcl tabs alogliptin-pioglitazone tabs.- alogliptin-pioglitazone tabs.-0 alogliptin-pioglitazone tabs -, -0, -,.- glipizide-metformin hcl tabs.-0 glipizide-metformin hcl tabs -00,.-00 glyburide-metformin tabs.-0 glyburide-metformin tabs -00,.-00 INVOKAMET TABS 0-00, 0-000, INVOKAMET TABS 0-00 INVOKAMET XR TB 0-00, 0-000, PA; Limit mls per month;ql(0. ml daily); PA; Limit mls per month;ql(0. ml daily); PA; SL( ea daily); PA; SL( ea daily); PA; SL(. ea daily); PA; SL( ea daily); SL(8 ea daily); ; SL( ea daily); ; AL(Up to yrs old); SL(8 ea daily); ; AL(Up to yrs old); SL( ea daily); ; SL( ea daily); SL( ea daily); SL( ea daily); Name INVOKAMET XR TB 0-00 JANUMET TABS JANUMET XR TB JANUMET XR TB 0-00, JENTADUETO TABS JENTADUETO XR TB.-000 JENTADUETO XR TB -000 KAZANO TABS KOMBIGLYZE XR TB.-000 KOMBIGLYZE XR TB -00, OSENI TABS.- OSENI TABS.- 0 OSENI TABS -, -0, -,.- pioglitazone hcl-glimepiride tabs pioglitazone hcl-metformin hcl tabs repaglinide-metformin hcl tabs SYNJARDY TABS - 000,.-000 SYNJARDY TABS - 00,.-00 SYNJARDY XR TB -000 SYNJARDY XR TB -000, 0-000,.-000 Biguanides SL( ea daily); SL( ea daily); SL( ea daily); SL( ea daily); SL( ea daily); SL( ea daily); SL( ea daily); PA; SL( ea daily); PA; SL( ea daily); PA; SL( ea daily); PA; SL( ea daily); PA; SL(. ea daily); PA; SL( ea daily); SL(. ea daily); ; SL( ea daily); ; SL( ea daily); ; SL( ea daily); SL( ea daily); SL( ea daily); SL( ea daily); 08 Allwell (DSNP) Formulary Updated /0/08

27 Name metformin hcl tabs or 000 metformin hcl tabs or 00 metformin hcl tabs or 80 metformin hcl tb or 000 metformin hcl tb or 00 metformin hcl tb or 00 metformin hcl tb or 70 Diabetic Other GLUCAGEN HYPOKIT SOLR glucagon (rdna) kit KORLYM TABS PROGLYCEM SUSP SL(. ea daily); ; SL(. ea daily); ; SL( ea daily); ; Osmotic;SL(. ea daily); ; Osmotic;SL( ea daily); ; SL( ea daily); ; SL(. ea daily); ; ; PA; SL( ea daily); LA; Dipeptidyl Peptidase- (DPP-) Inhibitors alogliptin benzoate tabs PA; QL( ea. daily); alogliptin benzoate tabs PA; QL( ea daily); alogliptin benzoate tabs PA; QL( ea. daily); JANUVIA TABS 00 QL( ea daily); JANUVIA TABS QL( ea daily); JANUVIA TABS 0 QL( ea daily); NESINA TABS. PA; QL( ea daily); NESINA TABS PA; QL( ea daily); NESINA TABS. PA; QL( ea daily); ONGLYZA TABS. PA; QL( ea daily); Name ONGLYZA TABS PA; QL( ea daily); TRADJENTA TABS QL( ea daily); Dopamine Receptor Agonists - Antidiabetic CYCLOSET TABS QL( ea daily); Incretin Mimetic Agents (GLP- Receptor BYDUREON BCISE AUIJ ST; BYDUREON PEN PEN BYDUREON SRER BYETTA SOPN VICTOZA SOPN Insulin Sensitizing Agents AVANDIA TABS AVANDIA TABS pioglitazone hcl tabs pioglitazone hcl tabs 0 pioglitazone hcl tabs Insulin HUMALOG JUNIOR KWIKPEN SOPN HUMALOG KWIKPEN SOPN HUMALOG MIX 0/0 KWIKPEN SUPN HUMALOG MIX 0/0 SUSP ST; ST; ST; ST; Limit 9mls per month;ql(0. ml daily); SL( ea daily); SL( ea daily); SL( ea daily); ; SL(. ea daily); ; SL( ea daily); ; Limit mls per month;ql(. ml daily); Limit mls per month;ql(. ml daily); Limit mls per month;ql(. ml daily); Limit mls per month;ql(. ml daily); 08 Allwell (DSNP) Formulary Updated /0/08

28 Name HUMALOG MIX 7/ KWIKPEN SUPN HUMALOG MIX 7/ SUSP HUMALOG SOCT HUMALOG SOLN HUMULIN 70/0 KWIKPEN SUPN HUMULIN 70/0 SUSP HUMULIN N KWIKPEN SUPN HUMULIN N SUSP HUMULIN R SOLN HUMULIN R U-00 (CONCENTRATED) SOLN HUMULIN R U-00 KWIKPEN SOPN LANTUS SOLN LANTUS SOLOSTAR SOPN LEVEMIR FLEXTOUCH SOPN LEVEMIR SOLN TOUJEO MAX SOLOSTAR SOPN Limit mls per month;ql(. ml daily); Limit mls per month;ql(. ml daily); Limit mls per month;ql(. ml daily); Limit mls per month;ql(. ml daily); Limit mls per month;ql(. ml daily); Limit mls per month;ql(. ml daily); Limit mls per month;ql(. ml daily); Limit mls per month;ql(. ml daily); Limit mls per month;ql(. ml daily); Limit mls per month;ql(. ml daily); Limit mls per month;ql(. ml daily); Limit mls per month;ql(. ml daily); Limit mls per month;ql(. ml daily); Limit mls per month;ql(. ml daily); Limit mls per month;ql(. ml daily); Limit mls per month;ql(0. ml daily); Name TOUJEO SOLOSTAR Limit mls per SOPN month;ql(0. ml daily); TRESIBA FLEXTOUCH Limit mls per SOPN 00 UNIT/ML month;ql(. ml daily); TRESIBA FLEXTOUCH Limit 7mls per SOPN 00 UNIT/ML month;ql(0.9 ml daily); Meglitinide Analogues nateglinide tabs QL( ea daily); ; repaglinide tabs 0. SL( ea daily); ; repaglinide tabs SL( ea daily); ; repaglinide tabs SL(8 ea daily); ; Sodium-Glucose Co-Transporter (SGLT) INVOKANA TABS JARDIANCE TABS Sulfonylureas glimepiride tabs glimepiride tabs glimepiride tabs glipizide tabs or 0 glipizide tabs or glipizide tb or 0 glipizide tb or. glipizide tb or glyburide micronized tabs. glyburide micronized tabs SL(8 ea daily); ; SL( ea daily); ; SL( ea daily); ; SL( ea daily); ; SL(8 ea daily); ; SL( ea daily); ; SL(8 ea daily); ; SL( ea daily); ; AL(Up to yrs old); SL(8 ea daily); ; AL(Up to yrs old); SL( ea daily); ; 08 Allwell (DSNP) Formulary Updated /0/08 7

29 Name glyburide micronized tabs glyburide tabs or. glyburide tabs or. glyburide tabs or tolazamide tabs 0 tolazamide tabs 00 tolbutamide tabs AL(Up to yrs old); SL( ea daily); ; AL(Up to yrs old); SL( ea daily); ; AL(Up to yrs old); SL(8 ea daily); ; AL(Up to yrs old); SL( ea daily); ; SL( ea daily); ; SL( ea daily); ; SL( ea daily); ; ANTIDIARRHEAL/PROBIOTIC AGENTS - s to Treat Diarrhea Antiperistaltic Agents diphenoxylate w/ atropine tabs loperamide hcl caps or RX/OTC; ; ANTIDOTES AND SPECIFIC ANTAGONISTS Antidotes - Chelating Agents EXJADE TBSO FERRIPROX TABS 00 JADENU SPRINKLE PACK JADENU TABS LA LA; Antidotes and Specific Antagonists VISTOGARD PACK Opioid Antagonists naloxone hcl sosy ij /ml naltrexone hcl tabs or ; Name ANTIEMETICS - s to Treat Nausea and Vomiting -HT Receptor Antagonists granisetron hcl tabs or B/D; ondansetron hcl soln ij /ml, 0 /0ml ondansetron hcl soln or B/D; /ml ondansetron hcl tabs or B/D ondansetron hcl tabs or B/D;, 8 ondansetron tbdp B/D; ; Antiemetics - Anticholinergic meclizine hcl tabs or,. scopolamine pt7 TRANSDERM-SCOP PT7 TRANSDERM-SCOP PT7 (Scopolamine) Antiemetics - Miscellaneous CESAMET CAPS dronabinol caps 0 dronabinol caps,. SYNDROS SOLN RX/OTC; ; ; B/D; B/D; B/D; B/D; Substance P/Neurokinin (NK) Receptor aprepitant caps 0 PA; ; aprepitant caps 80, VARUBI TABS OR 90 B/D; ; B/D ANTIFUNGALS - s to Treat Fungal Infections Antifungal - Glucan Synthesis Inhibitors ERAXIS SOLR Allwell (DSNP) Formulary Updated /0/08 8

30 Name MYCAMINE SOLR 00 Antifungals ABELCET SUSP AMBISOME SUSR amphotericin b solr ij 0 flucytosine caps 00 griseofulvin microsize susp /ml griseofulvin microsize tabs 00 griseofulvin ultramicrosize tabs nystatin tabs terbinafine hcl tabs or Imidazole-Related Antifungals CRESEMBA CAPS OR 8 CRESEMBA SOLR IV 7 fluconazole in dextrose soln 00/00ml- /ml, 00/00ml- /ml fluconazole in nacl soln 00/00ml-0.9%, 00/00ml-0.9% fluconazole susr or 0 /ml, 0 /ml fluconazole tabs or 0, 00, 0, 00 itraconazole caps or 00 ketoconazole tabs or NOXAFIL SOLN IV 00 /.7ML NOXAFIL SUSP OR 0 /ML NOXAFIL TBEC OR 00 PA PA PA; ; ; ; ; ; Name voriconazole solr iv 00 voriconazole susr or 0 /ml voriconazole tabs or 0, 00 ; ANTIHISTAMINES - s to Treat Allergies Antihistamines - Ethanolamines carbinoxamine maleate soln /ml carbinoxamine maleate tabs clemastine fumarate tabs or.8 diphenhydramine hcl soln ij 0 /ml Antihistamines - Non-Sedating cetirizine hcl soln /ml, /ml desloratadine tabs desloratadine tbdp levocetirizine dihydrochloride soln. /ml levocetirizine dihydrochloride tabs Antihistamines - Phenothiazines promethazine hcl soln ij /ml, 0 /ml promethazine hcl soln or. /ml promethazine hcl supp re,. promethazine hcl syrp or. /ml promethazine hcl tabs or, 0,. Antihistamines - Piperidines cyproheptadine hcl syrp or /ml cyproheptadine hcl tabs or AL(Up to yrs old); ; AL(Up to yrs old); ; AL(Up to yrs old); ; RX/OTC; ; RX/OTC; RX/OTC; ; AL(Up to yrs old); ; AL(Up to yrs old); ; AL(Up to yrs old); AL(Up to yrs old); ; AL(Up to yrs old); ; AL(Up to yrs old); AL(Up to yrs old); 08 Allwell (DSNP) Formulary Updated /0/08 9

31 Name ANTIHYPERLIPIDEMICS - s to Treat High Cholesterol Antihyperlipidemics - Misc. KYNAMRO SOSY LA omega--acid ethyl esters caps VASCEPA CAPS ST; Bile Acid Sequestrants cholestyramine light pack cholestyramine light powd cholestyramine pack or gm cholestyramine powd or gm/dose colesevelam hcl pack colesevelam hcl tabs colestipol hcl gran gm colestipol hcl pack gm colestipol hcl tabs gm WELCHOL PACK (Colesevelam HCl) WELCHOL TABS (Colesevelam HCl) Fibric Acid Derivatives ANTARA CAPS 0 ANTARA CAPS 90 choline fenofibrate cpdr fenofibrate micronized caps 0 fenofibrate micronized caps fenofibrate micronized caps 7,, 00 ; ; ; ; ; ; SL(. ea daily); SL(. ea daily); SL( ea daily); SL(.0 ea daily); Name fenofibrate tabs 8,,, 0 gemfibrozil tabs or H CoA Reductase Inhibitors atorvastatin calcium tabs ; ; fluvastatin sodium caps 0 QL( ea daily); ; fluvastatin sodium caps 0 QL( ea daily); ; fluvastatin sodium tb 80 lovastatin tabs 0, 0 QL( ea daily); ; lovastatin tabs 0 QL( ea daily); ; pravastatin sodium tabs QL( ea daily); ; rosuvastatin calcium tabs QL( ea daily); simvastatin tabs or, QL( ea daily); 0, 0, 0 ; simvastatin tabs or 80 SL( ea daily); ; Intestinal Cholesterol Absorption Inhibitors ezetimibe tabs QL( ea daily); ; Microsomal Triglyceride Transfer Protein (MTP) SL( JUXTAPID CAPS 0 ea daily); LA; JUXTAPID CAPS 0 SL( ea daily); LA; JUXTAPID CAPS 0 SL( ea daily); LA; JUXTAPID CAPS 0 PA; SL(. ea daily); LA; JUXTAPID CAPS SL( ea daily); LA; 08 Allwell (DSNP) Formulary Updated /0/08 0