Senior Care Options Program (HMO SNP) 2019 Formulary. (List of Covered Drugs)

Transcription

1 Senior Care Options Program (HMO SNP) 209 Formulary (List of Covered Drugs) PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN HPMS Approved Formulary File Submission ID , Version Number 6 This formulary was updated on 08/23/208. For more recent information or other questions, please contact Senior Care Options Program (HMO SNP) Member Services, at or, for TTY users, 7, 8 a.m. 8 p.m., 7 days a week, or visit 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 Commonwealth Care Alliance. When it refers to plan or our plan, it means 209 Senior Care Options Program. This document includes list of the drugs (formulary) for our plan which is current as of 08/23/208. This formulary document applies to all SCO members. 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, 2020, and from time to time during the year. You will receive notice when necessary. Senior Care Options Program (HMO SNP) is a Special Needs Plan with a Medicare contract and a contract with the Commonwealth of Massachusetts/Executive Office of Health and Human Services MassHealth (Medicaid) program. Enrollment in Senior Care Options Program depends on contract renewal. Enrollment is voluntary. Commonwealth Care Alliance complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color national origin, age, disability, or sex. Commonwealth Care Alliance cumple con las leyes federales de derechos civiles aplicables y no discrimina por motivos de raza, color, nacionalidad, edad, discapacidad o sexo. ATTENTION: If you speak Spanish, language assistance services, free of charge, are available to you. Call (TTY: call MassRelay at 7). ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al (TTY: llamar a MassRelay al 7). H2225_CF209_C

2 What is the Senior Care Options Program (HMO SNP) Formulary? A formulary is a list of covered drugs selected by Senior Care Options Program 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. Senior Care Options Program will generally cover the drugs listed in our formulary as long as the drug is medically necessary, the prescription is filled at a Senior Care Options Program 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 209 formulary that was covered at the beginning of the year, we will not discontinue or reduce coverage of the drug during the 209 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 Drug 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 Drug 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. 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 Senior Care Options Program Formulary? Drugs removed from the market. If the Food and Drug Administration deems a drug on our formulary to be unsafe or the drug s manufacturer removes the drug from the market, we will immediately remove the drug from our formulary and provide notice to members who take the drug. Other changes. We may make other changes that affect members currently taking a drug. For instance, we may make changes based on new clinical guidelines. If we remove drugs from our formulary, [or] add prior authorization, quantity limits and/or step therapy restrictions on a drug, we must notify affected members of the change at least 30 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 3-day supply of the drug. The enclosed formulary is current as of 08/23/208. To get updated information about the drugs covered by Senior Care Options Program, please contact us. Our contact information appears on the front and back cover pages. If we make a change to the formulary during the 209 coverage year for reasons other than those listed above, we will send a formulary sheet to tell you about the change. How do I use the Formulary? There are two ways to find your drug within the formulary: ii

3 Medical Condition The formulary begins on page 2. 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. If you know what your drug is used for, look for the category name in the list that begins on page number 2. 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 0. 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? Senior Care Options Program 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? Effective January, 209, Commonwealth Care Alliance will limit coverage of blood glucose meters and test strips to the following Abbott Diabetes Care Products: FreeStyle Lite meters FreeStyle Freedom Lite meter Freestyle Precision Neo meter Freestyle Precision Xtra meter Freestyle Insulinx Meter FreeStyle Lite test strips *compatible with either Lite meter* Some covered drugs may have additional requirements or limits on coverage. These requirements and limits may include: Prior Authorization: Senior Care Options Program requires you or your physician to get prior authorization for certain drugs. This means that you will need to get approval from Senior Care Options Program before you fill your prescriptions. If you don t get approval, Senior Care Options Program may not cover the drug. Quantity Limits: For certain drugs, Senior Care Options Program limits the amount of the drug that Senior Care Options Program will cover. For example, Senior Care Options Program provides 60 units per prescription for PRADAXA. This may be in addition to a standard one-month or threemonth supply. Step Therapy: In some cases, Senior Care Options Program requires you to first try certain drugs to iii

4 treat your medical condition before we will cover another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, Senior Care Options Program may not cover Drug B unless you try Drug A first. If Drug A does not work for you, Senior Care Options Program will then cover Drug B. You can find out if your drug has any additional requirements or limits by looking in the formulary that begins on page 2. You can also get more information about the restrictions applied to specific covered drugs by visiting our website. We have posted online documents that explain our prior authorization restriction and step therapy restrictions. You may also ask us to send you a copy. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages. You can ask Senior Care Options Program 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 Senior Care Options Program s formulary? on page iv for information about how to request an exception. What are over-the counter (OTC) drugs? OTC drugs are non-prescription drugs that are not normally covered by a Medicare Prescription Drug Plan. Senior Care Options Program pays for certain OTC drugs. Senior Care Options Program will provide these OTC drugs at no cost to you. The cost to Senior Care Options Program of these OTC drugs will not count toward your total Part D drug costs (that is, the cost of the OTC drugs does not count for the coverage gap). 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 Senior Care Options Program does not cover your drug, you have two options: You can ask Member Services for a list of similar drugs that are covered by Senior Care Options Program. When you receive the list, show it to your doctor and ask him or her to prescribe a similar drug that is covered by Senior Care Options Program. You can ask Senior Care Options Program 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 Senior Care Options Program s Formulary? You can ask Senior Care Options Program 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 waive coverage restrictions or limits on your drug. For example, for certain drugs, Senior Care Options Program 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. iv

5 Generally, Senior Care Options Program will only approve your request for an exception if the alternative drugs included on the plan s formulary, or additional utilization restrictions would not be as effective in treating your condition and/or would cause you to have adverse medical effects. You should contact us to ask us for an initial coverage decision for a formulary, or utilization restriction exception. When you request a formulary or utilization restriction exception you should submit a statement from your prescriber or physician supporting your request. Generally, we must make our decision within 72 hours of getting your prescriber s supporting statement. You can request an expedited (fast) exception if you or your doctor believe that your health could be seriously harmed by waiting up to 72 hours for a decision. If your request to expedite is granted, we must give you a decision no later than 24 hours after we get a supporting statement from your doctor or other prescriber. What do I do before I can talk to my doctor about changing my drugs or requesting an exception? As a new or continuing member in our plan you may be taking drugs that are not on our formulary. Or, you may be taking a drug that is on our formulary but your ability to get it is limited. For example, you may need a prior authorization from us before you can fill your prescription. You should talk to your doctor to decide if you should switch to an appropriate drug that we cover or request a formulary exception so that we will cover the drug you take. While you talk to your doctor to determine the right course of action for you, we may cover your drug in certain cases during the first 90 days you are a member of our plan. For each of your drugs that is not on our formulary or if your ability to get your drugs is limited, we will cover a temporary 3-day supply. If your prescription is written for fewer days, we ll allow refills to provide up to a maximum 3-day supply of medication. After your first 3-day supply, we will not pay for these drugs, even if you have been a member of the plan less than 90 days. If you are a resident of a long-term care facility 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 3-day emergency supply of that drug while you pursue a formulary exception. We will provide an emergency supply of at least 3 days (unless the prescription is written for fewer days) for all non-formulary medications including those that may have step therapy or prior authorization requirements. An unplanned level of care transition could be any of the following: a discharge or admission to a Long Term Care facility a discharge or admission to a hospital, or a nursing facility skilled level change. For more information For more detailed information about your Senior Care Options Program prescription drug coverage, please review your Evidence of Coverage and other plan materials. If you have questions about Senior Care Options Program, please contact us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages. If you have general questions about Medicare prescription drug coverage, please call Medicare at MEDICARE ( ) 24 hours a day/7 days a week. TTY users should call Or, visit v

6 Senior Care Options Program s Formulary The formulary that begins on the next page provides coverage information about the drugs covered by Senior Care Options Program. If you have trouble finding your drug in the list, turn to the Index that begins on page 0. The first column of the chart lists the drug name. Brand name drugs are capitalized (e.g., EMEND) and generic drugs are listed in lower-case italics (e.g., valsartan). The information in the Requirements/Limits column tells you if Senior Care Options Program has any special requirements for coverage of your drug. vi

7 List of Abbreviations EA: Each. LD: Limited Distribution. The symbol LD next to a drug name indicates that the drug has been noted as being restricted to certain pharmacies by the Food and Drug Administration. These drugs can only be obtained at specialty designated pharmacies able to appropriately handle the drugs. For more information consult your Pharmacy Directory or call Member Services at , 8 a.m. 8 p.m., 7 days a week. TTY/TDD users should call 7. NDS: Non Extended Day Supply. You may be able to receive greater than a -month supply of most of the drugs on your Formulary via retail or mail order. Drugs noted with NDS are limited to a -month supply for both Retail and Mail Order. : Prior approval (or prior authorization). For some drugs, you or your physician or other prescriber must get approval from Commonwealth Care Alliance before you fill your prescription. If you don t get approval, Commonwealth Care Alliance may not cover the drug. _BvD: Prior Authorization Restriction for Part B vs Part D Determination: This drug may be eligible for payment under Medicare Part B or Medicare Part D. You [or your physician] are required to get prior authorization from Commonwealth Care Alliance (CCA) to determine that this drug is covered under Medicare Part D before you fill your prescription for this drug. Without prior approval, CCA may not cover this drug. _BVD does not apply to MassHealth Only members. _NSO: Prior Authorization Restriction for New Starts Only. If this drug is new to you, you (or your physician) are required to get prior authorization for Commonwealth Care Alliance before you fill your prescription for this drug. Without prior approval, Commonwealth Care Alliance may not cover this drug. _NSO does not apply to MassHealth Only members. QL: Quantity Limit. Sometimes Commonwealth Care Alliance limits the amount of a drug you can get. ST: Step Therapy. Sometimes Commonwealth Care Alliance requires you to do step therapy. This means you will have to try drugs in a certain order for your medical conditions. You might have to try one drug before we will cover another drug. If your doctor thinks the first drug doesn t work for you, then we will cover the second. ST_NSO: Step Therapy for New Starts Only If this drug is new to the member, you are required to first try certain drugs to treat your medical condition before we will cover another drug for that condition. ST_NSO does not apply to MassHealth Only members.

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

9 guanfacine 2mg er guanfacine 3mg er guanfacine 4mg er STIMULANTS - MISC. armodafinil 50mg armodafinil 200mg armodafinil 250mg armodafinil 50mg dexmethylphenidate 0mg er cap dexmethylphenidate 0mg dexmethylphenidate 5mg er cap dexmethylphenidate 2.5mg dexmethylphenidate 20mg er cap dexmethylphenidate 30mg er cap dexmethylphenidate 40mg er cap dexmethylphenidate 5mg er cap dexmethylphenidate 5mg metadate 20mg er methylphenidate 0mg cr cap methylphenidate 0mg er methylphenidate 0mg la cap methylphenidate 0mg METHYLPHENIDATE 8MG SR methylphenidate mg/ml oral soln methylphenidate 20mg cr cap methylphenidate 20mg er methylphenidate 20mg la cap methylphenidate 20mg METHYLPHENIDATE 27MG SR methylphenidate 2mg/ml oral soln methylphenidate 30mg cr cap methylphenidate 30mg la cap METHYLPHENIDATE 36MG SR methylphenidate 40mg cr cap methylphenidate 40mg la cap methylphenidate 50mg cr cap METHYLPHENIDATE 54MG SR methylphenidate 5mg methylphenidate 60mg cr cap modafinil 00mg modafinil 200mg AMINOGLYCOSIDES AMINOGLYCOSIDES QL=30 EA/30 Days QL=30 EA/30 Days QL=30 EA/30 Days QL=30 EA/30 Days QL=60 EA/30 Days QL=60 EA/30 Days You can find information on what the symbols and abbreviations on this le mean by going to the beginning of this le. 3

10 amikacin 250mg/ml inj GENTAMICIN SULFATE 0.8MG/ML INJ gentamicin sulfate.2mg/ml inj GENTAMICIN SULFATE.6MG/ML INJ GENTAMICIN SULFATE MG/ML INJ gentamicin sulfate 40mg/ml inj neomycin sulfate 500mg paromomycin 250mg cap STREPTOMYCIN 00MG INJ TOBI PODHALER KIT 28MG CK TOBRAMYCIN 0MG/ML INJ tobramycin 40mg/ml inj tobramycin 60mg/ml inh soln ANALGESICS - ANTI-INFLAMMATORY ANTI-TNF-ALPHA - MONOCLONAL ANTIBODIES HUMIRA 0MG/0.ML HUMIRA 0MG/0.2ML HUMIRA 20MG/0.2ML HUMIRA 20MG/0.4ML HUMIRA 40MG/0.4ML AUTO-INJECTOR HUMIRA 40MG/0.4ML HUMIRA 40MG/0.8ML AUTO-INJECTOR HUMIRA 40MG/0.8ML HUMIRA PEDIATRIC CROHN'S STARTER CK (3) 40MG/0.8ML INJ HUMIRA PEDIATRIC CROHN'S STARTER CK (3) 80MG/0.8ML INJ HUMIRA PEDIATRIC CROHN'S STARTER CK (6) 40MG/0.8ML INJ HUMIRA PEDIATRIC CROHN'S STARTER CK (2) 40MG/0.4ML, 80MG/0.8ML HUMIRA PEN - CROHN'S STARTER CK 40MG/0.8ML INJ HUMIRA PEN - PSORIASIS STARTER CK 40MG/0.8ML INJ SIMPONI 00MG/ML AUTO-INJECTOR SIMPONI 00MG/ML INJ SIMPONI 50MG/0.5ML AUTO-INJECTOR SIMPONI 50MG/0.5ML GOLD COMPOUNDS RIDAURA 3MG CAP INTERLEUKIN- BLOCKERS ARCALYST 220MG INJ You can find information on what the symbols and abbreviations on this le mean by going to the beginning of this le. 4

11 NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS) celecoxib 00mg cap QL=60 EA/30 Days celecoxib 200mg cap QL=60 EA/30 Days celecoxib 400mg cap QL=60 EA/30 Days celecoxib 50mg cap QL=60 EA/30 Days diclofenac potassium 50mg diclofenac sodium 00mg er diclofenac sodium 25mg dr diclofenac sodium 50mg dr diclofenac sodium 50mg/misoprostol 0.2mg diclofenac sodium 75mg dr diclofenac sodium 75mg/misoprostol 0.2mg etodolac 200mg cap etodolac 300mg cap etodolac 400mg er etodolac 400mg etodolac 500mg er etodolac 500mg etodolac 600mg er FENOPROFEN 400MG CAP flurbiprofen 00mg flurbiprofen 50mg ibu 600mg ibu 800mg ibuprofen 20mg/ml susp ibuprofen 400mg ibuprofen 600mg ibuprofen 800mg KETOPROFEN 75MG CAP ketorolac tromethamine 0mg QL=20 EA/5 Days MECLOFENAMATE 00MG CAP MECLOFENAMATE 50MG CAP mefenamic acid 250mg cap meloxicam 5mg meloxicam 7.5mg nabumetone 500mg nabumetone 750mg naproxen 250mg naproxen 25mg/ml susp naproxen 375mg dr naproxen 375mg naproxen 500mg dr naproxen 500mg naproxen sodium 275mg You can find information on what the symbols and abbreviations on this le mean by going to the beginning of this le. 5

12 naproxen sodium 550mg oxaprozin 600mg piroxicam 0mg cap piroxicam 20mg cap sulindac 50mg sulindac 200mg PHOSPHODIESTERASE 4 (PDE4) INHIBITORS OTEZLA 28-DAY STARTER CK OTEZLA 30MG PYRIMIDINE SYNTHESIS INHIBITORS leflunomide 0mg leflunomide 20mg SELECTIVE COSTIMULATION MODULATORS ORENCIA 25MG/ML AUTO-INJECTOR ORENCIA 25MG/ML ORENCIA 50MG/0.4ML ORENCIA 87.5MG/0.7ML SOLUBLE TUMOR NECROSIS FACTOR RECEPTOR AGENTS ENBREL 25MG INJ ENBREL 25MG/0.5ML ENBREL 50MG/ML SURECLICK INJ ENBREL 50MG/ML ANALGESICS - NONNARCOTIC SALICYLATES diflunisal 500mg OPIOID AGONISTS codeine sulfate 5mg codeine sulfate 30mg codeine sulfate 60mg duramorph 0.5mg/ml inj duramorph mg/ml inj fentanyl 0.02mg/hr patch fentanyl 0.025mg/hr patch fentanyl 0.05mg/hr patch fentanyl 0.075mg/hr patch fentanyl 0.mg/hr patch fentanyl 0.2mg lozenge fentanyl 0.4mg lozenge fentanyl 0.6mg lozenge fentanyl 0.8mg lozenge fentanyl.2mg lozenge ANALGESICS - OPIOID QL=240 EA/30 Days QL=240 EA/30 Days QL=80 EA/30 Days QL=0 EA/30 Days QL=0 EA/30 Days QL=0 EA/30 Days QL=0 EA/30 Days QL=0 EA/30 Days QL=20 EA/30 Days QL=20 EA/30 Days QL=20 EA/30 Days QL=20 EA/30 Days QL=20 EA/30 Days You can find information on what the symbols and abbreviations on this le mean by going to the beginning of this le. 6

13 fentanyl.6mg lozenge hydromorphone 0mg/ml (ml) inj hydromorphone 0mg/ml (5ml) inj hydromorphone 2mg er hydromorphone 6mg er hydromorphone mg/ml oral soln hydromorphone 2mg hydromorphone 2mg/ml syringe hydromorphone 32mg er hydromorphone 4mg hydromorphone 8mg er hydromorphone 8mg LEVORPHANOL 2MG methadone 0mg methadone 5mg morphine sulfate 00mg er cap morphine sulfate 00mg er morphine sulfate 0mg er cap MORPHINE SULFATE 0MG/ML MORPHINE SULFATE 20MG ER CAP morphine sulfate 5mg er morphine sulfate 5mg morphine sulfate 200mg er morphine sulfate 20mg er cap morphine sulfate 20mg/ml oral soln morphine sulfate 2mg/ml oral soln MORPHINE SULFATE 2MG/ML MORPHINE SULFATE 30MG ER (24 HR) CAP morphine sulfate 30mg er cap morphine sulfate 30mg er morphine sulfate 30mg MORPHINE SULFATE 45MG ER CAP morphine sulfate 4mg/ml oral soln MORPHINE SULFATE 4MG/ML morphine sulfate 50mg er cap MORPHINE SULFATE 5MG/ML morphine sulfate 60mg er (24 hr) cap MORPHINE SULFATE 60MG ER CAP morphine sulfate 60mg er MORPHINE SULFATE 75MG ER CAP morphine sulfate 80mg er cap MORPHINE SULFATE 8MG/ML MORPHINE SULFATE 90MG ER CAP oxycodone 0mg QL=20 EA/30 Days QL=60 EA/30 Days QL=60 EA/30 Days QL=2400 ML/30 Days QL=450 EA/30 Days QL=60 EA/30 Days QL=240 EA/30 Days QL=60 EA/30 Days QL=20 EA/30 Days QL=240 EA/30 Days QL=360 EA/30 Days QL=360 EA/30 Days QL=60 EA/30 Days QL=20 EA/30 Days QL=60 EA/30 Days QL=60 EA/30 Days QL=20 EA/30 Days QL=80 EA/30 Days QL=20 EA/30 Days QL=60 EA/30 Days QL=80 ML/30 Days QL=800 ML/30 Days QL=60 EA/30 Days QL=60 EA/30 Days QL=20 EA/30 Days QL=80 EA/30 Days QL=60 EA/30 Days QL=900 ML/30 Days QL=60 EA/30 Days QL=60 EA/30 Days QL=60 EA/30 Days QL=20 EA/30 Days QL=60 EA/30 Days QL=60 EA/30 Days QL=60 EA/30 Days QL=80 EA/30 Days You can find information on what the symbols and abbreviations on this le mean by going to the beginning of this le. 7

14 oxycodone 5mg oxycodone mg/ml oral soln oxycodone 20mg oxycodone 20mg/ml oral soln oxycodone 30mg oxycodone 5mg cap oxycodone 5mg OXYCONTIN 0MG ER OXYCONTIN 5MG ER OXYCONTIN 20MG ER OXYCONTIN 30MG ER OXYCONTIN 40MG ER OXYCONTIN 60MG ER OXYCONTIN 80MG ER oxymorphone 0mg oxymorphone 5mg tramadol 00mg er tramadol 00mg er (matrix delivery) tramadol 200mg er tramadol 200mg er (matrix delivery) tramadol 300mg er tramadol 300mg er (matrix delivery) tramadol 50mg OPIOID COMBINATIONS acetaminophen 2.7mg/ml/hydrocodone bitartrate 0.5mg/ml oral soln acetaminophen 24mg/ml/codeine phosphate 2.4mg/ml oral soln acetaminophen 300mg/codeine phosphate 5mg acetaminophen 300mg/codeine phosphate 30mg acetaminophen 300mg/codeine phosphate 60mg acetaminophen 300mg/hydrocodone bitartrate 0mg acetaminophen 300mg/hydrocodone bitartrate 5mg acetaminophen 300mg/hydrocodone bitartrate 7.5mg acetaminophen 325mg/hydrocodone bitartrate 0mg acetaminophen 325mg/hydrocodone bitartrate 2.5mg acetaminophen 325mg/hydrocodone bitartrate 5mg QL=80 EA/30 Days QL=5400 ML/30 Days QL=80 EA/30 Days QL=270 ML/30 Days QL=80 EA/30 Days QL=360 EA/30 Days QL=360 EA/30 Days QL=60 EA/30 Days QL=60 EA/30 Days QL=60 EA/30 Days QL=60 EA/30 Days QL=60 EA/30 Days QL=60 EA/30 Days QL=20 EA/30 Days QL=360 EA/30 Days QL=360 EA/30 Days QL=60 EA/30 Days QL=60 EA/30 Days QL=60 EA/30 Days QL=60 EA/30 Days QL=60 EA/30 Days QL=60 EA/30 Days QL=240 EA/30 Days QL=5400 ML/30 Days QL=4980 ML/30 Days QL=390 EA/30 Days QL=390 EA/30 Days QL=390 EA/30 Days QL=390 EA/30 Days QL=390 EA/30 Days QL=390 EA/30 Days QL=360 EA/30 Days QL=360 EA/30 Days QL=360 EA/30 Days You can find information on what the symbols and abbreviations on this le mean by going to the beginning of this le. 8

15 acetaminophen 325mg/hydrocodone bitartrate 7.5mg acetaminophen 325mg/oxycodone 0mg acetaminophen 325mg/oxycodone 2.5mg acetaminophen 325mg/oxycodone 5mg acetaminophen 325mg/oxycodone 7.5mg acetaminophen 325mg/tramadol 37.5mg aspirin 325mg/oxycodone 4.84mg endocet 0-325mg endocet 5-325mg endocet mg hydrocodone 0mg/ibuprofen 200mg hydrocodone 5mg/ibuprofen 200mg hydrocodone bitartrate 7.5mg/ibuprofen 200mg IBUPROFEN 400MG/OXYCODONE 5MG lorcet 0-325mg lorcet 5-325mg lorcet mg vicodin 0-300mg vicodin 5-300mg vicodin mg OPIOID RTIAL AGONISTS BUNAVAIL MG FILM BUNAVAIL MG FILM BUNAVAIL 6.3-MG FILM buprenorphine 2mg sl buprenorphine 8mg sl butorphanol tartrate 0mg/ml nasal spray SUBOXONE 2-3MG STRIP SUBOXONE 2-0.5MG STRIP SUBOXONE 4-MG STRIP SUBOXONE 8-2MG STRIP ZUBSOLV.4-2.9MG SL ZUBSOLV MG SL ZUBSOLV MG SL ZUBSOLV MG SL ZUBSOLV MG SL ANDROGENS-ANABOLIC ANABOLIC STEROIDS ANADROL-50 50MG oxandrolone 0mg oxandrolone 2.5mg ANDROGENS QL=360 EA/30 Days QL=360 EA/30 Days QL=360 EA/30 Days QL=360 EA/30 Days QL=360 EA/30 Days QL=360 EA/30 Days QL=360 EA/30 Days QL=360 EA/30 Days QL=360 EA/30 Days QL=360 EA/30 Days QL=480 EA/30 Days QL=480 EA/30 Days QL=480 EA/30 Days QL=240 EA/30 Days QL=360 EA/30 Days QL=360 EA/30 Days QL=360 EA/30 Days QL=390 EA/30 Days QL=390 EA/30 Days QL=390 EA/30 Days QL=0 ML/30 Days QL=60 EA/30 Days QL=90 EA/30 Days QL=90 EA/30 Days QL=90 EA/30 Days QL=60 EA/30 Days You can find information on what the symbols and abbreviations on this le mean by going to the beginning of this le. 9

16 ANDRODERM 2MG/24HR TCH ANDRODERM 4MG/24HR TCH ANDROGEL.62% (.25GM) GEL ANDROGEL.62% (2.5GM) GEL ANDROGEL.62% GEL danazol 00mg cap danazol 200mg cap danazol 50mg cap testosterone % (25mg) gel testosterone % (50mg) gel testosterone % gel pump testosterone cypionate 00mg/ml inj testosterone cypionate 200mg/ml inj testosterone enanthate 200mg/ml inj ANORECTAL AGENTS INTRARECTAL STEROIDS colocort 00mg/60ml enema hydrocortisone.67mg/ml enema UCERIS 2MG/ACT FOAM RECTAL COMBINATIONS hydrocortisone/pramoxine -% rectal cream RECTAL STEROIDS procto-med 2.5% cream procto-pak % rectal cream proctosol 2.5% cream proctozone hc 2.5% cream ANTHELMINTICS ANTHELMINTICS ALBENZA 200MG ivermectin 3mg ANTIANGINAL AGENTS ANTIANGINALS-OTHER RANEXA 000MG ER RANEXA 500MG ER NITRATES isosorbide dinitrate 0mg isosorbide dinitrate 20mg isosorbide dinitrate 30mg ISOSORBIDE DINITRATE 40MG ER isosorbide dinitrate 5mg isosorbide mononitrate 0mg QL=60 EA/30 Days QL=30 EA/30 Days QL=75 GM/30 Days QL=50 GM/30 Days QL=50 GM/30 Days QL=300 GM/30 Days QL=300 GM/30 Days QL=300 GM/30 Days NDS You can find information on what the symbols and abbreviations on this le mean by going to the beginning of this le. 0

17 isosorbide mononitrate 20mg er isosorbide mononitrate 20mg isosorbide mononitrate 30mg er isosorbide mononitrate 60mg er minitran 0.mg/hr patch minitran 0.2mg/hr patch minitran 0.4mg/hr patch minitran 0.6mg/hr patch NITRO-BID 2% OINTMENT NITRO-DUR 0.3MG/HR TCH NITRO-DUR 0.8MG/HR TCH nitroglycerin 0.mg/hr patch nitroglycerin 0.2mg/hr patch nitroglycerin 0.3mg sl nitroglycerin 0.4mg sl nitroglycerin 0.4mg/act spray nitroglycerin 0.4mg/hr patch nitroglycerin 0.6mg sl nitroglycerin 0.6mg/hr patch ANTIANXIETY AGENTS - MISC. buspirone 0mg buspirone 5mg buspirone 30mg buspirone 5mg buspirone 7.5mg hydroxyzine 0mg hydroxyzine 25mg hydroxyzine 2mg/ml oral soln hydroxyzine 50mg HYDROXYZINE MOATE 00MG CAP hydroxyzine pamoate 25mg cap hydroxyzine pamoate 50mg cap BENZODIAZEPINES alprazolam 0.25mg odt alprazolam 0.25mg alprazolam 0.5mg er alprazolam 0.5mg odt alprazolam 0.5mg alprazolam mg er alprazolam mg odt alprazolam mg alprazolam 2mg er ANTIANXIETY AGENTS You can find information on what the symbols and abbreviations on this le mean by going to the beginning of this le.

18 alprazolam 2mg odt alprazolam 2mg alprazolam 3mg er chlordiazepoxide 0mg cap chlordiazepoxide 25mg cap chlordiazepoxide 5mg cap clorazepate dipotassium 5mg clorazepate dipotassium 3.75mg clorazepate dipotassium 7.5mg diazepam 0mg DIAZEM MG/ML ORAL SOLN diazepam 2mg diazepam 5mg diazepam 5mg/ml oral soln lorazepam 0.5mg lorazepam mg lorazepam 2mg lorazepam 2mg/ml conc oxazepam 0mg cap oxazepam 5mg cap OXAZEM 30MG CAP ANTIARRHYTHMICS TYPE I-A disopyramide 00mg cap disopyramide 50mg cap NORCE 00MG ER CAP NORCE 50MG ER CAP quinidine gluconate 324mg er QUINIDINE SULFATE 200MG QUINIDINE SULFATE 300MG ANTIARRHYTHMICS TYPE I-B mexiletine 50mg cap mexiletine 200mg cap mexiletine 250mg cap ANTIARRHYTHMICS TYPE I-C flecainide acetate 00mg flecainide acetate 50mg flecainide acetate 50mg propafenone 50mg propafenone 225mg er cap propafenone 225mg propafenone 300mg propafenone 325mg er cap ANTIARRHYTHMICS You can find information on what the symbols and abbreviations on this le mean by going to the beginning of this le. 2

19 propafenone 425mg sr cap ANTIARRHYTHMICS TYPE III amiodarone 200mg amiodarone 400mg dofetilide 25mcg cap dofetilide 250mcg cap dofetilide 500mcg cap MULTAQ 400MG pacerone 200mg pacerone 400mg ANTIASTHMATIC AND BRONCHODILATOR AGENTS ANTIASTHMATIC - MONOCLONAL ANTIBODIES NUCALA 00MG INJ XOLAIR 50MG INJ ANTI-INFLAMMATORY AGENTS cromolyn sodium 0mg/ml inh soln BRONCHODILATORS - ANTICHOLINERGICS ATROVENT 7MCG INH INCRUSE 62.5MCG INH ipratropium bromide 0.02% inh soln SPIRIVA.25MCG RESPIMAT INH ST QL=4 GM/30 Days LEUKOTRIENE MODULATORS montelukast 0mg montelukast 4mg chew montelukast 4mg granules montelukast 5mg chew zafirlukast 0mg zafirlukast 20mg zileuton 600mg er SELECTIVE PHOSPHODIESTERASE 4 (PDE4) INHIBITORS DALIRESP 250MCG DALIRESP 500MCG STEROID INHALANTS ARNUITY 00MCG INH QL=30 EA/30 Days ARNUITY 200MCG INH QL=30 EA/30 Days ARNUITY 50MCG INH QL=30 EA/30 Days budesonide 0.25mg/ml inh soln QL=20 ML/30 Days budesonide 0.25mg/ml inh soln QL=20 ML/30 Days budesonide 0.5mg/ml inh soln QL=20 ML/30 Days FLOVENT 00MCG DISKUS QL=60 EA/30 Days FLOVENT 0MCG HFA INH QL=24 GM/30 Days FLOVENT 220MCG HFA INH QL=24 GM/30 Days You can find information on what the symbols and abbreviations on this le mean by going to the beginning of this le. 3

20 FLOVENT 250MCG DISKUS QL=60 EA/30 Days FLOVENT 44MCG HFA INH QL=2.20 GM/30 Days FLOVENT 50MCG DISKUS QL=60 EA/30 Days SYMTHOMIMETICS ADVAIR 00-50MCG DISKUS QL=60 EA/30 Days ADVAIR 5-2MCG HFA INH QL=2 GM/30 Days ADVAIR 230-2MCG HFA INH QL=2 GM/30 Days ADVAIR MCG DISKUS QL=60 EA/30 Days ADVAIR 45-2MCG HFA INH QL=2 GM/30 Days ADVAIR MCG DISKUS QL=60 EA/30 Days albuterol 0.2mg/ml (0.63mg/3ml) inh soln albuterol 0.47mg/ml (.25mg/3ml) inh soln albuterol 0.4mg/ml (2mg/5ml) oral oral soln albuterol 0.83mg/ml (0.083%) inh soln albuterol mg/ml (0.5%) inh soln albuterol 2mg ALBUTEROL 4MG ER albuterol 4mg ALBUTEROL 8MG ER ANORO MCG ELLIPTA INH QL=60 EA/30 Days BREO 00-25MCG ELLIPTA INH QL=60 EA/30 Days BREO MCG ELLIPTA INH QL=60 EA/30 Days COMBIVENT RESPIMAT 20-00MCG INH DULERA 00-5MCG INH QL=3 GM/30 Days DULERA 200-5MCG INH QL=3 GM/30 Days FLUTICASONE PROPIONATE/SALMETEROL XINAFOATE 3-4MCG/ACT POWDER INH FLUTICASONE PROPIONATE/SALMETEROL XINAFOATE 232-4MCG/ACT POWDER INH FLUTICASONE PROPIONATE/SALMETEROL XINAFOATE 55-4MCG/ACT POWDER INH ipratropium/albuterol mg/3ml inh soln levalbuterol 0.3mg inh soln levalbuterol 0.63mg inh soln levalbuterol.25mg inh soln levalbuterol 2.5mg inh soln METAPROTERENOL SULFATE 0MG METAPROTERENOL SULFATE 20MG METAPROTERENOL SULFATE 2MG/ML ORAL SOLN SEREVENT 50MCG/DOSE INH STIOLTO MCG INH QL=4 GM/30 Days terbutaline sulfate 2.5mg terbutaline sulfate 5mg You can find information on what the symbols and abbreviations on this le mean by going to the beginning of this le. 4

21 TRELEGY MCG ELLIPTA INH VENTOLIN 08MCG INH XANTHINES theophylline 00mg er theophylline 200mg er theophylline 300mg er theophylline 400mg er theophylline 5.33mg/ml oral soln theophylline 600mg er ANTICOAGULANTS COUMARIN ANTICOAGULANTS jantoven 0mg jantoven mg jantoven 2.5mg jantoven 2mg jantoven 3mg jantoven 4mg jantoven 5mg jantoven 6mg jantoven 7.5mg warfarin sodium 0mg warfarin sodium mg warfarin sodium 2.5mg warfarin sodium 2mg warfarin sodium 3mg warfarin sodium 4mg warfarin sodium 5mg warfarin sodium 6mg warfarin sodium 7.5mg DIRECT FACTOR XA INHIBITORS ELIQUIS 2.5MG ELIQUIS 30-DAY STARTER CK ELIQUIS 5MG XARELTO 0MG XARELTO 5MG XARELTO 20MG XARELTO STARTER CK HERINS AND HERINOID-LIKE AGENTS enoxaparin sodium 00mg/ml syringe enoxaparin sodium 20mg/0.8ml syringe enoxaparin sodium 50mg/ml syringe enoxaparin sodium 30mg/0.3ml syringe QL=60 EA/30 Days QL=36 GM/30 Days QL=60 ML/30 Days QL=48 ML/30 Days QL=60 ML/30 Days QL=8 ML/30 Days You can find information on what the symbols and abbreviations on this le mean by going to the beginning of this le. 5

22 enoxaparin sodium 40mg/0.4ml syringe enoxaparin sodium 60mg/0.6ml syringe enoxaparin sodium 80mg/0.8ml syringe fondaparinux sodium 2.5mg/ml (0.4ml) syringe fondaparinux sodium 2.5mg/ml (0.6ml) syringe fondaparinux sodium 2.5mg/ml (0.8ml) syringe fondaparinux sodium 5mg/ml syringe FRAGMIN 0000UNIT/ML FRAGMIN 2500UNIT/0.5ML FRAGMIN 5000UNIT/0.6ML FRAGMIN 8000UNIT/0.72ML FRAGMIN 2500UNIT/0.2ML FRAGMIN 5000UNIT/0.2ML FRAGMIN 7500UNIT/0.3ML FRAGMIN 95000UNIT/3.8ML INJ heparin sodium porcine 0000unit/ml inj heparin sodium porcine 000unit/ml inj heparin sodium porcine 20000unit/ml inj heparin sodium porcine 5000unit/ml inj THROMBIN INHIBITORS PRADAXA 0MG CAP PRADAXA 50MG CAP PRADAXA 75MG CAP ANTICONVULSANTS AM GLUTAMATE RECEPTOR ANTAGONISTS FYCOM 0.5MG/ML SUSP FYCOM 0MG FYCOM 2MG FYCOM 2MG FYCOM 4MG FYCOM 6MG FYCOM 8MG ANTICONVULSANTS - BENZODIAZEPINES clonazepam 0.25mg odt clonazepam 0.25mg odt clonazepam 0.5mg odt clonazepam 0.5mg clonazepam mg odt clonazepam mg clonazepam 2mg odt clonazepam 2mg DIASTAT 0MG APPLICATOR DIASTAT 2.5MG APPLICATOR QL=24 ML/30 Days QL=36 ML/30 Days QL=48 ML/30 Days NSO NSO NSO NSO NSO NSO NSO You can find information on what the symbols and abbreviations on this le mean by going to the beginning of this le. 6

23 DIASTAT 20MG APPLICATOR ONFI 0MG NSO ONFI 2.5MG/ML SUSP NSO ONFI 20MG NSO ANTICONVULSANTS - MISC. APTIOM 200MG NSO APTIOM 400MG NSO APTIOM 600MG NSO APTIOM 800MG NSO BANZEL 200MG BANZEL 400MG BANZEL 40MG/ML SUSP BRIVIACT 00MG NSO QL=60 EA/30 Days BRIVIACT 0MG NSO QL=60 EA/30 Days BRIVIACT 0MG/ML ORAL SOLN NSO BRIVIACT 25MG NSO QL=60 EA/30 Days BRIVIACT 50MG NSO QL=60 EA/30 Days BRIVIACT 75MG NSO QL=60 EA/30 Days carbamazepine 00mg chew carbamazepine 00mg er cap carbamazepine 00mg er carbamazepine 200mg er cap carbamazepine 200mg er carbamazepine 200mg carbamazepine 20mg/ml susp carbamazepine 300mg er cap carbamazepine 400mg er epitol 200mg gabapentin 00mg cap gabapentin 300mg cap gabapentin 400mg cap gabapentin 50mg/ml oral soln gabapentin 600mg gabapentin 800mg LAMICTAL XR BLUE KIT LAMICTAL XR GREEN KIT LAMICTAL XR ORANGE KIT lamotrigine 00mg er lamotrigine 00mg odt lamotrigine 00mg lamotrigine 50mg lamotrigine 200mg er lamotrigine 200mg odt lamotrigine 200mg You can find information on what the symbols and abbreviations on this le mean by going to the beginning of this le. 7

24 lamotrigine 250mg er lamotrigine 25mg (35) starter pack lamotrigine 25mg chew lamotrigine 25mg er lamotrigine 25mg odt lamotrigine 25mg lamotrigine 300mg er lamotrigine 50mg er lamotrigine 50mg odt lamotrigine 5mg chew lamotrigine 25mg (42)/00mg (7) starter pack lamotrigine 25mg (84)/00mg (4) starter pack levetiracetam 000mg levetiracetam 00mg/ml oral soln levetiracetam 250mg levetiracetam 500mg er levetiracetam 500mg levetiracetam 750mg er levetiracetam 750mg LYRICA 00MG CAP LYRICA 50MG CAP LYRICA 200MG CAP LYRICA 20MG/ML ORAL SOLN LYRICA 225MG CAP LYRICA 25MG CAP LYRICA 300MG CAP LYRICA 50MG CAP LYRICA 75MG CAP oxcarbazepine 50mg oxcarbazepine 300mg oxcarbazepine 600mg oxcarbazepine 60mg/ml susp OXTELLAR 50MG XR OXTELLAR 300MG XR OXTELLAR 600MG XR primidone 250mg primidone 50mg QUDEXY 00MG XR CAP QUDEXY 50MG XR CAP QUDEXY 200MG XR CAP QUDEXY 25MG XR CAP QUDEXY 50MG XR CAP roweepra 000mg roweepra 500mg er NSO NSO NSO NSO NSO You can find information on what the symbols and abbreviations on this le mean by going to the beginning of this le. 8

25 roweepra 500mg roweepra 750mg er roweepra 750mg SPRITAM 000MG ODT SPRITAM 250MG ODT SPRITAM 500MG ODT SPRITAM 750MG ODT TOPIRAMATE 00MG ER CAP topiramate 00mg TOPIRAMATE 50MG ER CAP topiramate 5mg cap TOPIRAMATE 200MG ER CAP topiramate 200mg topiramate 25mg cap TOPIRAMATE 25MG ER CAP topiramate 25mg TOPIRAMATE 50MG ER CAP topiramate 50mg TROKENDI 00MG XR CAP TROKENDI 200MG XR CAP TROKENDI 25MG XR CAP TROKENDI 50MG XR CAP VIMT 00MG VIMT 0MG/ML ORAL SOLN VIMT 50MG VIMT 200MG VIMT 50MG zonisamide 00mg cap zonisamide 25mg cap zonisamide 50mg cap CARBAMATES felbamate 20mg/ml susp felbamate 400mg felbamate 600mg GABA MODULATORS SABRIL 500MG tiagabine 2mg tiagabine 6mg tiagabine 2mg tiagabine 4mg vigabatrin 50mg/ml oral soln HYDANTOINS DILANTIN 30MG ER CAP NSO NSO NSO NSO NSO NSO NSO NSO NSO NSO NSO NSO NSO QL=60 EA/30 Days QL=60 EA/30 Days QL=60 EA/30 Days QL=60 EA/30 Days NSO NSO You can find information on what the symbols and abbreviations on this le mean by going to the beginning of this le. 9

26 PEGANONE 250MG phenytoin 25mg/ml susp phenytoin 50mg chew phenytoin sodium 00mg er cap phenytoin sodium 200mg er cap phenytoin sodium 300mg er cap SUCCINIMIDES CELONTIN 300MG CAP ethosuximide 250mg cap ethosuximide 50mg/ml oral soln VALPROIC ACID divalproex sodium 25mg dr cap divalproex sodium 25mg dr divalproex sodium 250mg dr divalproex sodium 250mg er divalproex sodium 500mg dr divalproex sodium 500mg er valproic acid 250mg cap valproic acid 50mg/ml oral soln ANTIDEPRESSANTS ALPHA-2 RECEPTOR ANTAGONISTS (TETRACYCLICS) mirtazapine 5mg odt mirtazapine 5mg mirtazapine 30mg odt mirtazapine 30mg mirtazapine 45mg odt mirtazapine 45mg mirtazapine 7.5mg ANTIDEPRESSANTS - MISC. APLENZIN 74MG ER APLENZIN 348MG ER APLENZIN 522MG ER bupropion 00mg sr bupropion 00mg bupropion 50mg sr (2 hr) bupropion 50mg xl (24 hr) bupropion 200mg sr bupropion 300mg xl bupropion 75mg MAPROTILINE 25MG MAPROTILINE 50MG MAPROTILINE 75MG ST ST ST You can find information on what the symbols and abbreviations on this le mean by going to the beginning of this le. 20

27 MONOAMINE OXIDASE INHIBITORS (MAOIS) EMSAM 2MG/24HR TCH EMSAM 6MG/24HR TCH EMSAM 9MG/24HR TCH MARPLAN 0MG phenelzine 5mg tranylcypromine 0mg SELECTIVE SEROTONIN REUPTAKE INHIBITORS (SSRIS) citalopram 0mg citalopram 20mg citalopram 2mg/ml oral soln citalopram 40mg escitalopram 0mg escitalopram mg/ml oral soln escitalopram 20mg escitalopram 5mg fluoxetine 0mg cap fluoxetine 0mg fluoxetine 20mg cap fluoxetine 40mg cap fluoxetine 4mg/ml oral soln fluvoxamine maleate 00mg er cap fluvoxamine maleate 00mg fluvoxamine maleate 50mg er cap fluvoxamine maleate 25mg fluvoxamine maleate 50mg paroxetine 0mg paroxetine 2.5mg er paroxetine 20mg paroxetine 25mg er paroxetine 30mg paroxetine 37.5mg er paroxetine 40mg XIL 0MG/5ML SUSP PEXEVA 0MG PEXEVA 20MG PEXEVA 30MG PEXEVA 40MG sertraline 00mg sertraline 20mg/ml oral soln sertraline 25mg sertraline 50mg SEROTONIN MODULATORS ST ST ST ST ST ST You can find information on what the symbols and abbreviations on this le mean by going to the beginning of this le. 2

28 NEFAZODONE 00MG NEFAZODONE 50MG NEFAZODONE 200MG nefazodone 250mg nefazodone 50mg trazodone 00mg trazodone 50mg trazodone 300mg trazodone 50mg TRINTELLIX 0MG TRINTELLIX 20MG TRINTELLIX 5MG VIIBRYD 0/20MG STARTER CK VIIBRYD 0MG VIIBRYD 20MG VIIBRYD 40MG SEROTONIN-NOREPINEPHRINE REUPTAKE INHIBITORS (SNRIS) desvenlafaxine succinate 00mg er desvenlafaxine succinate 25mg er desvenlafaxine succinate 50mg er duloxetine 20mg dr cap duloxetine 30mg dr cap DULOXETINE 40MG DR CAP duloxetine 60mg dr cap FETZIMA 20MG ER CAP FETZIMA 20MG ER CAP FETZIMA 40MG ER CAP FETZIMA 80MG ER CAP FETZIMA CK venlafaxine 00mg venlafaxine 50mg er cap venlafaxine 50mg er venlafaxine 225mg er venlafaxine 25mg venlafaxine 37.5mg er cap venlafaxine 37.5mg er venlafaxine 37.5mg venlafaxine 50mg venlafaxine 75mg er cap venlafaxine 75mg er venlafaxine 75mg TRICYCLIC AGENTS amitriptyline 00mg ST QL=30 EA/30 Days ST QL=30 EA/30 Days ST QL=30 EA/30 Days ST QL=30 EA/30 Days ST QL=30 EA/30 Days ST QL=30 EA/30 Days ST QL=30 EA/30 Days ST QL=30 EA/30 Days ST QL=30 EA/30 Days ST QL=30 EA/30 Days ST QL=30 EA/30 Days ST QL=30 EA/30 Days ST QL=30 EA/30 Days You can find information on what the symbols and abbreviations on this le mean by going to the beginning of this le. 22

29 amitriptyline 0mg amitriptyline 50mg amitriptyline 25mg amitriptyline 50mg amitriptyline 75mg AMOXAPINE 00MG AMOXAPINE 50MG AMOXAPINE 25MG AMOXAPINE 50MG clomipramine 25mg cap clomipramine 50mg cap clomipramine 75mg cap desipramine 00mg desipramine 0mg desipramine 50mg desipramine 25mg desipramine 50mg desipramine 75mg doxepin 00mg cap doxepin 0mg cap doxepin 0mg/ml oral soln doxepin 50mg cap doxepin 25mg cap doxepin 50mg cap doxepin 75mg cap imipramine 0mg imipramine 25mg imipramine 50mg imipramine pamoate 00mg cap imipramine pamoate 25mg cap imipramine pamoate 50mg cap imipramine pamoate 75mg cap nortriptyline 0mg cap nortriptyline 25mg cap nortriptyline 2mg/ml oral soln nortriptyline 50mg cap nortriptyline 75mg cap protriptyline 0mg protriptyline 5mg trimipramine 00mg cap trimipramine 25mg cap trimipramine 50mg cap ANTIDIABETICS You can find information on what the symbols and abbreviations on this le mean by going to the beginning of this le. 23

30 ALPHA-GLUCOSIDASE INHIBITORS acarbose 00mg acarbose 25mg acarbose 50mg miglitol 00mg miglitol 25mg miglitol 50mg ANTIDIABETIC COMBINATIONS glimepiride 2mg/pioglitazone 30mg glimepiride 4mg/pioglitazone 30mg glipizide 2.5mg/metformin 250mg glipizide 2.5mg/metformin 500mg glipizide 5mg/metformin 500mg glyburide.25mg/metformin 250mg glyburide 2.5mg/metformin 500mg glyburide 5mg/metformin 500mg GLYXAMBI 0-5MG GLYXAMBI 25-5MG JANUMET MG XR JANUMET MG JANUMET MG XR JANUMET MG JANUMET MG XR JENTADUETO MG JENTADUETO MG XR JENTADUETO MG JENTADUETO MG JENTADUETO 5-000MG XR metformin 500mg/pioglitazone 5mg metformin 850mg/pioglitazone 5mg SYNJARDY MG SYNJARDY MG SYNJARDY 5-000MG SYNJARDY 5-500MG SYNJARDY XR 0-000MG SYNJARDY XR MG SYNJARDY XR MG SYNJARDY XR 5-000MG XIGDUO 0-000MG XR XIGDUO 0-500MG XR XIGDUO MG XR XIGDUO 5-000MG XR XIGDUO 5-500MG XR QL=30 EA/30 Days QL=30 EA/30 Days QL=30 EA/30 Days QL=60 EA/30 Days QL=60 EA/30 Days QL=60 EA/30 Days QL=60 EA/30 Days QL=60 EA/30 Days QL=30 EA/30 Days QL=60 EA/30 Days QL=60 EA/30 Days QL=30 EA/30 Days QL=60 EA/30 Days QL=60 EA/30 Days QL=60 EA/30 Days QL=60 EA/30 Days QL=30 EA/30 Days QL=60 EA/30 Days QL=30 EA/30 Days QL=60 EA/30 Days QL=30 EA/30 Days QL=30 EA/30 Days QL=60 EA/30 Days QL=60 EA/30 Days QL=30 EA/30 Days You can find information on what the symbols and abbreviations on this le mean by going to the beginning of this le. 24

31 XULTOPHY 00UNIT-3.6MG/ML PEN INJ BIGUANIDES metformin 000mg metformin 500mg er metformin 500mg metformin 750mg er metformin 850mg RIOMET 500MG/5ML ORAL SOLN DIABETIC OTHER GLUCAGEN MG INJ GLUCAGON MG INJ KORLYM 300MG PROGLYCEM 50MG/ML SUSP DIPEPTIDYL PEPTIDASE-4 (DPP-4) INHIBITORS JANUVIA 00MG JANUVIA 25MG JANUVIA 50MG TRADJENTA 5MG INCRETIN MIMETIC AGENTS (GLP- RECEPTOR AGONISTS) OZEMPIC 2MG/.5ML PEN INJ OZEMPIC 2MG/.5ML PEN INJ (MG DOSE) TRULICITY 0.75MG/0.5ML AUTO-INJECTOR TRULICITY.5MG/0.5ML AUTO-INJECTOR VICTOZA 8MG/3ML PEN INJ INSULIN FIASP 00UNIT/ML INJ FIASP 00UNIT/ML PEN INJ HUMULIN R 500UNIT/ML INJ HUMULIN R 500UNIT/ML PEN INJ LANTUS 00UNIT/ML INJ LANTUS 00UNIT/ML SOLOSTAR LEVEMIR 00UNIT/ML FLEXTOUCH LEVEMIR 00UNIT/ML INJ NOVOLIN 00UNIT/ML INJ NOVOLIN N 00UNIT/ML INJ NOVOLIN R 00UNIT/ML INJ NOVOLOG 00UNIT/ML FLEXPEN NOVOLOG 00UNIT/ML INJ NOVOLOG 00UNIT/ML PENFILL NOVOLOG MIX 00UNIT/ML FLEXPEN NOVOLOG MIX 00UNIT/ML INJ TOUJEO 300UNIT/ML PEN INJ QL=5 ML/30 Days QL=30 EA/30 Days QL=30 EA/30 Days QL=30 EA/30 Days QL=30 EA/30 Days You can find information on what the symbols and abbreviations on this le mean by going to the beginning of this le. 25

32 TOUJEO MAX 300UNIT/ML PEN INJ (3ML) TRESIBA 00UNIT/ML PEN INJ TRESIBA 200UNIT/ML PEN INJ INSULIN SENSITIZING AGENTS AVANDIA 2MG AVANDIA 4MG pioglitazone 5mg pioglitazone 30mg pioglitazone 45mg MEGLITINIDE ANALOGUES nateglinide 20mg nateglinide 60mg repaglinide 0.5mg repaglinide mg repaglinide 2mg SODIUM-GLUCOSE CO-TRANSPORTER 2 (SGLT2) INHIBITORS FARXIGA 0MG FARXIGA 5MG JARDIANCE 0MG JARDIANCE 25MG SULFONYLUREAS glimepiride mg glimepiride 2mg glimepiride 4mg glipizide 0mg er glipizide 0mg glipizide 2.5mg er glipizide 5mg er glipizide 5mg tolazamide 250mg tolazamide 500mg TOLBUTAMIDE 500MG ANTIDIARRHEAL/PROBIOTIC AGENTS ANTIPERISTALTIC AGENTS atropine sulfate 0.005mg/ml/diphenoxylate 0.5mg/ml oral soln ANTIDIARRHEALS ANTIPERISTALTIC AGENTS atropine sulfate 0.025mg/diphenoxylate 2.5mg loperamide 2mg cap ANTIDOTES AND SPECIFIC ANTAGONISTS QL=30 EA/30 Days QL=30 EA/30 Days QL=30 EA/30 Days QL=30 EA/30 Days You can find information on what the symbols and abbreviations on this le mean by going to the beginning of this le. 26

33 ANTIDOTES - CHELATING AGENTS CHEMET 00MG CAP EXJADE 25MG SUSP EXJADE 250MG SUSP EXJADE 500MG SUSP FERRIPROX 00MG/ML ORAL SOLN FERRIPROX 500MG JADENU 80MG GRANULE CKET JADENU 80MG JADENU 360MG GRANULE CKET JADENU 360MG JADENU 90MG GRANULE CKET JADENU 90MG OPIOID ANTAGONISTS NALOXONE 0.4MG/ML CARTRIDGE naloxone 0.4mg/ml inj NALOXONE MG/ML naltrexone 50mg NARCAN 4MG/0.ML NASAL SPRAY VIVITROL 380MG INJ ANTIEMETICS 5-HT3 RECEPTOR ANTAGONISTS granisetron mg ondansetron 0.8mg/ml oral soln ondansetron 24mg ondansetron 4mg odt ondansetron 4mg ondansetron 8mg odt ondansetron 8mg ANTIEMETICS - ANTICHOLINERGIC meclizine 2.5mg meclizine 25mg scopolamine mg/3days patch trimethobenzamide 300mg cap ANTIEMETICS - MISCELLANEOUS CESAMET MG CAP dronabinol 0mg cap dronabinol 2.5mg cap dronabinol 5mg cap SUBSTANCE P/NEUROKININ (NK) RECEPTOR ANTAGONISTS aprepitant 25mg cap aprepitant 25mg/80mg pack NDS NDS NDS NDS NDS NDS NDS NDS NDS QL=2 ML/2 Days QL=2 ML/2 Days QL=2 ML/2 Days QL=2 EA/2 Days QL=60 EA/30 Days QL=3 EA/2 Days QL=3 EA/2 Days You can find information on what the symbols and abbreviations on this le mean by going to the beginning of this le. 27

34 aprepitant 40mg cap aprepitant 80mg cap VARUBI 90MG ANTIFUNGALS ANTIFUNGAL - GLUCAN SYNTHESIS INHIBITORS (ECHINOCANDINS) CASPOFUNGIN ACETATE 50MG INJ CASPOFUNGIN ACETATE 70MG INJ ERAXIS 00MG INJ ERAXIS 50MG INJ MYCAMINE 00MG INJ MYCAMINE 50MG INJ ANTIFUNGALS ABELCET 5MG/ML INJ AMBISOME 50MG INJ AMPHOTERICIN B 50MG INJ flucytosine 250mg cap flucytosine 500mg cap griseofulvin 25mg griseofulvin 250mg griseofulvin 25mg/ml susp griseofulvin 500mg nystatin unit terbinafine 250mg IMIDAZOLE-RELATED ANTIFUNGALS fluconazole 00mg fluconazole 0mg/ml susp fluconazole 50mg fluconazole 200mg fluconazole 2mg/ml (00ml) inj fluconazole 2mg/ml inj fluconazole 40mg/ml susp fluconazole 50mg itraconazole 00mg cap ketoconazole 200mg NOXAFIL 00MG DR NOXAFIL 40MG/ML SUSP voriconazole 200mg inj voriconazole 200mg voriconazole 40mg/ml susp voriconazole 50mg ANTIHISTAMINES ANTIHISTAMINES - NON-SEDATING QL=3 EA/2 Days QL=3 EA/2 Days QL=4 EA/28 Days NDS NDS You can find information on what the symbols and abbreviations on this le mean by going to the beginning of this le. 28