2016 Comprehensive FORMULARY

Transcription

1 1 016 Comprehensive FORMULARY (Complete list of covered drugs) Erickson Advantage Champion (HMO-POS SNP) Erickson Advantage Freedom (HMO-POS) Erickson Advantage Guardian (HMO-POS SNP) Erickson Advantage Signature with s (HMO-POS) Please read: This document contains information about the drugs we cover in this plan. For more recent information or if you have other questions, please contact Erickson Advantage Customer Service at: Toll-Free , TTY a.m. to 8 p.m. local time, 7 days a week Medicare Approved Formulary File ID , Version 17 Y0066_15071_119A_FINAL_M10.7 Approved Last updated August 1, 016

2 This document includes a complete list of the drugs (formulary) for our plan and is current as of August 1, 016. For an updated formulary (drug list), please contact us. Our contact information, along with the date we last updated the formulary, appears on the cover. When this drug list (formulary) refers to we, us, or our, it means UnitedHealthcare. When it refers to plan or our plan, it means Erickson Advantage. Note to existing members: Our list of covered drugs is called a Formulary. We call it the " List" for short. This complete drug list has changed since last year. Please review this document to make sure the plan still covers the drugs you take. You must generally use network pharmacies to use your prescription drug benefit.

3 The Erickson Advantage COMPREHENSIVE FORMULARY (drug list) A formulary is a list of covered drugs selected by your 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 call it the " List" for short. Your plan will generally cover the drugs listed in our formulary (drug list) 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. This document is a complete drug list of the drugs covered by your plan. For your drug to be covered by your plan, it must be included in the complete drug list. In most cases, your prescription must also be filled at one of our network pharmacies. To find out if your drug is covered: 1. See if your drug is included in this complete drug list.. Visit your plan website. Use the online tools to look up your drugs. The information is updated on a regular basis. The Web address appears on the cover.. Call Customer Service. Our contact information appears on the cover.

4 When the drug list may change We try to make as few changes to the drug list as possible during the plan year. If there are changes to the drug list, such as regular or necessary updates, members may see information in their Explanation of Benefits (EOB) statements, member newsletters or other member mailings. If there are changes to the drug list outside of regular or necessary updates, members may receive a special mailing. The drug list may change throughout the year when your plan: Adds a new drug as they become available, including new generic drugs. Removes a drug from the list because it has been found to be ineffective or unsafe. Changes the requirements or limits for a drug. Moves a drug into a different tier. Generally, if you are taking a drug on the 016 drug list that was covered at the beginning of the year, we will not discontinue or reduce coverage of the drug during the 016 coverage year except when a new, less expensive generic drug becomes available or when new information about the safety or effectiveness of a drug is released. Other types of drug list changes, such as removing a drug from the drug list, will not affect members who are currently taking the drug. For those members it will remain available at the same cost for the remainder of the coverage year. We feel it is important for you to have access for the entire coverage year to the list of drugs that were available when you chose your plan, except when you can save additional money or your safety is a concern. If we remove drugs from our drug list, or add prior authorization, quantity limits and/or step therapy restrictions on a drug or move a drug to a higher cost-sharing tier, during the coverage year we must notify affected members at least 60 days before the change becomes effective, or when the member requests a refill of the drug. At this time the member will receive a 60-day supply of the drug. If the Food and Administration (FDA) declares a drug on our drug list to be unsafe, or if the drug s manufacturer removes the drug from the market, your plan will immediately remove the drug from the drug list and notify members who take the drug. The enclosed drug list is current as of the date printed on the cover. To get updated information about the drugs covered by your plan, please call Customer Service or visit our website using the information provided on the cover of this drug list.

5 tiers and drug payment stages The amount you pay for a covered drug will depend on: Your drug payment stage. Your plan has different stages of drug coverage. When you fill a prescription, the amount you pay depends on the coverage stage you re in. The drug tier for your drug. Each covered drug is in one of five drug tiers. Each tier has a copay and/or co-insurance amount. The chart below shows the differences between the tiers. For more information about drug coverage and co-pay or co-insurance amounts for each tier, please review your Evidence of Coverage. 5 Includes 1: Preferred generic : Generic : Preferred brand : Non-preferred brand 5: Specialty tier Lower-cost, commonly used generic drugs. Many generic drugs. Many common brand name drugs, called preferred brands, and some higher-cost generic drugs. Non-preferred generic and non-preferred brand name drugs. In addition, Part D eligible compound medications are covered in. Unique and/or very high-cost drugs. If you qualify for Extra Help If you qualify for Extra Help for your prescription drugs, your co-pays and co-insurance may be lower. Members who qualify for Extra Help will receive the Evidence of Coverage Rider for People Who Get Extra Help Paying for Prescription s (LIS Rider). Please read it to learn about your costs. You can also contact Customer Service. Our contact information appears on the cover. 5

6 6 How to use the drug list There are two ways to find your prescription drugs in this complete drug list: 1. Medical condition: Turn to the Covered drugs by medical condition section, which begins on page 1, to look for drugs based on your medical conditions. For example, if you want to find drugs used to treat high cholesterol, go to the Cardiovascular Agents category and look under Dyslipidemics, HMG CoA Reductase Inhibitors.. Alphabetical list (index): If you are not sure what category to look under, turn to the Index of covered drugs section, which begins on page 9. Find the name of your drug. The page number where you can find the drug will be next to it. Generic drugs Your plan covers both brand name drugs and generic drugs. Generic drugs are approved by the Food and Administration (FDA) as having the same active ingredients as brand name drugs. Generic drugs usually cost less than brand name drugs. Talk with your doctor to see if any of the brand name drugs you take have generic versions. Then review the drug list to make sure you are getting the drug you need for the least amount of money. The drug list shows brand name drugs in bold type (for example, Crestor) and generic drugs in plain type (for example, Simvastatin). 6

7 Dummy actions, restrictions or limits Some covered drugs may have additional requirements or limits on coverage. If your drug has any requirements or limits, there will be a code(s) in the actions, restrictions or limits column of the drug list. The codes and what they mean are shown below. Utilization Management PA - Prior authorization The plan requires you or your doctor to get prior authorization for certain drugs. This means the plan needs more information from your doctor to make sure the drug is being used correctly for a medical condition covered by Medicare. If you don t get approval, the plan may not cover the drug. QL - Quantity limits The plan will cover only a certain amount of this drug for one co-pay/co-insurance or over a certain number of days. These limits may be in place to ensure safe and effective use of the drug. If your doctor prescribes more than this amount or thinks the limit is not right for your situation, you or your doctor can ask the plan to cover the additional quantity. ST - Step therapy There may be effective, lower-cost drugs that treat the same medical condition as this drug. You may be required to try one or more of these other drugs before the plan will cover your drug. If you have already tried other drugs or your doctor thinks they are not right for you, you or your doctor can ask the plan to cover this drug. Other Special Requirements for Coverage B/D - Medicare Part B or Part D Depending on how this drug is used, it may be covered by either Medicare Part B (doctor and outpatient health care) or Medicare Part D (prescription drugs). Your doctor may need to provide the plan with more information about how this drug will be used to make sure it s correctly covered by Medicare. HRM - High Risk Medication This drug is known as a high risk medication (HRM) for Medicare members 65 and older. This drug may cause side effects if taken on a regular basis. We suggest you talk with your doctor to see if an alternative drug is available to treat your condition. Note: If you are 65 or older, you may need to get a prior authorization (PA) or formulary exception from the health plan before the plan will cover a high risk medication (HRM). If you are under 65, the prior authorization (PA) will not apply to you until the first time you get your prescription filled after turning 65. LA - Limited access s are considered limited access if the FDA says the drug can be given out only by certain facilities or doctors. These drugs may require extra handling, provider coordination or patient education that can t be done at a network pharmacy. 7 7

8 8 You can find out if your drug has any additional requirements, restrictions or limits by looking it up in the Covered drugs by medical condition section that begins on page 1. 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 and step therapy restrictions. You may ask us to send you a copy. Our contact information, along with the date we last updated the drug list, appears on the cover. You and your doctor may ask the plan for an exception to these requirements, restrictions or limits or for a list of other, similar drugs that may treat your health condition. See the, How to request an exception to the Erickson Advantage drug list section on the next page or review your Evidence of Coverage to learn more. If you do not get prior approval from the plan for a drug with a requirement, restriction or limit, you may have to pay the full cost of the drug. If your drug is not on the drug list If your drug is not included in this complete formulary (list of covered drugs), you should contact Customer Service and ask if your drug is covered. Our contact information, along with the date we last updated the drug list, appears on the cover. If you learn that your plan does not cover your drug, you have two options: 1. Ask your plan for a list of similar drugs that it covers. Show the list to your doctor and ask him or her to prescribe one of the appropriate drugs from the list.. Ask your plan to make an exception and cover your drug. See next page for information about how to request an exception. 8

9 How to request an exception to the Erickson Advantage drug list At times you may need to ask for drug coverage that s not normally provided by your plan. When you do, your plan will consider your request and respond with a coverage decision (coverage determination). You can ask your plan to make an exception to the coverage rules. There are several types of exceptions that you can ask your plan to make. Formulary exception: You can ask your plan to cover your drug even if it is not on the drug list. 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. ing exception: You can ask your plan 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. Utilization exception: You can ask your plan to waive coverage restrictions or limits on your drug. For example, your plan limits the amount it will cover for certain drugs. If your drug has a quantity limit, you can ask your plan to waive the limit and cover more. Generally, your plan will approve your request for an exception only if the alternative drugs included in your plan s drug list, the lower cost-sharing drug or additional utilization restrictions would not be as effective in treating your condition and/or would cause adverse medical effects. Who can ask for a coverage decision You, your authorized representative or your doctor can ask for an initial coverage decision for a formulary exception, tiering exception or utilization restriction exception. When you are requesting a formulary exception, tiering exception or utilization restriction exception, your prescriber or physician should submit a statement supporting your request. Receiving a coverage decision Generally, your plan will make a coverage decision within 7 hours after receiving your prescribing physician s statement. You can request an expedited, or fast, decision if you or your doctor believes your health requires it. If your plan agrees to a fast decision, you will receive a decision within hours after your plan receives your doctor s or prescribing physician s supporting statement. 9 9

10 10 What to do while you talk to your doctor about changing your drugs or requesting an exception New or continuing members As a new or continuing member in your plan, you may be taking drugs that are not on the drug list. Or you may be taking a drug that is on the drug list, but your ability to get it is limited. For example, you may need prior authorization before you can fill your prescription. You should talk to your doctor to decide if you should switch to an appropriate drug that your plan covers, or request a formulary exception so your plan will cover the drug you are currently taking. While you talk to your doctor to decide what to do, your plan may cover your drug in certain cases during the first 90 days you are a member of your plan. For each of your drugs that is not on the drug list, or if your ability to get your drugs is limited, your plan may cover a temporary 0-day supply (unless you have a prescription written for fewer days) from a network pharmacy. After your first 0-day supply, your plan will not pay for these drugs, even if you have been a member of your plan less than 90 days. Long-term care facility residents If you re a resident of a long-term care facility, your plan may allow you to refill your prescription until we have provided you with a maximum of a 91- and may be up to a 98-day transition supply of the drug consistent with dispensing increment (unless your prescription is written for fewer days). Your plan will also cover more than one refill of these drugs for the first 90 days you are a member of your plan. If you need a drug that s not on the drug list or if you have limited ability to get your drugs, but you are past the first 90 days of membership in the plan, your plan will cover a 1-day emergency supply of the drug (unless your prescription is written for fewer days) while you request a formulary exception. Other transitions You may have an unplanned transition, like a hospital discharge or a change in your level of care, after the first 90 days of your plan membership. If this happens and your doctor prescribes a drug that s not on the drug list, or if it s difficult for you to get your drugs, you are required to use your plan s exception process. You may ask for a one-time emergency supply of up to 0 days to give you time to talk to your doctor about other treatment options or to try to get a formulary exception. 10

11 s with dosages other than 0 days s packaged in an extended day supply Some drugs are packaged from the manufacturer to provide greater than a 0-day supply. When you fill these drugs, you may have to pay more than one co-pay/co-insurance for a single prescription. For more information, please contact Customer Service using the information on the cover. Daily cost share for oral medications filled for less than a 0-day supply Daily cost share applies only if the drug is in the form of a solid oral dose (e.g., tablet or capsule) when dispensed for a supply of less than 0 days under applicable law. The daily cost share requirements do not apply to either of the following: 1. Solid oral doses of antibiotics.. Solid oral doses that are dispensed in their original container or are usually dispensed in their original packaging to help patients comply with usage and dosage directions. For more information For more information about your plan s prescription drug coverage, please review your Evidence of Coverage and other plan materials. If you have questions about your plan, please call us tollfree at , TTY 711, 8 a.m. to 8 p.m. local time, 7 days a week. Or visit us online at If you have general questions about Medicare prescription drug coverage, visit or call Medicare at , TTY , hours a day, 7 days a week

12 1tRACK 1 1 Covered drugs by medical condition The Comprehensive Formulary (drug list) below provides coverage information about the drugs covered by your plan. If you have trouble finding your drug in the list, turn to the Index of covered drugs, which begins on page 9. The first column of the chart lists the drug name. Brand name drugs are listed in bold type (for example, Crestor) and generic drugs are listed in plain type (for example, Simvastatin). The second column of the chart lists which coverage level () your drug is in. The actions, restrictions or limits column shows you if your plan has any special coverage requirements for the drug. If quantity limits (QL) apply to a drug, the restriction amounts are shown in the chart on pages track Analgesics Nonsteroidal Anti-inflammatory s Celecoxib (Capsule) QL Potassium Diclofenac Potassium (Tablet Immediate- Release) Sodium Diclofenac Sodium (1% Gel) Sodium DR Diclofenac Sodium DR (Tablet Delayed-Release) Sodium ER Diclofenac Sodium ER (Tablet Extended-Release Diflunisal Etodolac (00mg Capsule, 00mg Capsule, 00mg Tablet Immediate- Release, 500mg Tablet Immediate-Release) ER Etodolac ER (Tablet Extended-Release PA Flector (Patch) PA, QL Flurbiprofen Ibuprofen (100mg/5ml Suspension, 00mg Tablet, 600mg Tablet, 800mg Tablet) Ketoprofen (Capsule Immediate-Release) Tromethamine Ketorolac Tromethamine (15mg/ml Injection, 0mg/ml Meloxicam (15mg Tablet, 7.5mg Tablet) Meloxicam (7.5mg/5ml Suspension) Nabumetone Naproxen (15mg/5ml Suspension, 50mg Tablet Immediate- Release, 75mg Tablet Immediate-Release, 500mg Tablet Immediate- Release) DR Naproxen DR (Tablet Delayed-Release) (Generic EC-Naprosyn) 1 Bold type = Brand name drug Plain type = Generic drug 1

13 track Last updated August 1, Sodium Naproxen Sodium (Tablet Immediate-Release) Oxaprozin Piroxicam (Capsule) Sulindac Voltaren (Gel) PA Opioid Analgesics, Long-acting Embeda (Capsule Extended-Release) QL Fentanyl (100mcg/hr Patch 7 Hour, 1mcg/hr Patch 7 Hour, 5mcg/hr Patch 7 Hour, 50mcg/hr QL Patch 7 Hour, 75mcg/hr Patch 7 ER Hydromorphone ER (1mg Tablet Extended- Release Hour Abuse- Deterrent, 16mg Tablet 5 QL Extended-Release Hour Abuse-Deterrent) ER Hydromorphone ER (mg Tablet Extended- Release Hour Abuse- 5 QL Deterrent) ER Hydromorphone ER (8mg Tablet Extended- Release Hour Abuse- QL Deterrent) Tartrate Levorphanol Tartrate QL Methadone (10mg Tablet, 5mg Tablet, 10mg/5ml Oral Solution, QL 5mg/5ml Oral Methadone (10mg/ ml 5 Sulfate ER Morphine Sulfate ER (Tablet Extended-Release) QL (Generic MS Contin) ER Nucynta ER (Tablet Extended-Release 1 QL ER Opana ER (Tablet Extended-Release 1 QL Hour Abuse-Deterrent) ER Tramadol ER (100mg Tablet Extended-Release Hour, 00mg Tablet Extended-Release (Generic Ultram ER), (00mg Tablet Extended-Release (Generic Ryzolt) QL Opioid Analgesics, Short-acting Abstral (Tablet Sublingual) 5 PA, QL Acetaminophen/Codeine (10mg-1mg/5ml Oral Solution, 00mg-15mg Tablet, 00mg-0mg QL Tablet, 00mg-60mg Tablet) Tartrate Butorphanol Tartrate (10mg/ml Nasal QL Tartrate Butorphanol Tartrate (1mg/ml Injection, mg/ ml Sulfate Codeine Sulfate QL Duramorph ( Endocet QL You can find information on what the symbols and abbreviations in this table mean by going to page 7. 1

14 track 1 Last updated August 1, 016 Bitartrate/Acetaminophen Hydrocodone Bitartrate/ Acetaminophen (7.5mg-5mg/15ml Oral Hydrocodone/Acetaminophen Acetaminophen (10mg-5mg Tablet,.5mg-5mg Tablet, 5mg-5mg Tablet, 7.5mg-5mg Tablet) Hydrocodone/Ibuprofen (7.5mg-00mg Tablet) Hydromorphone (1mg/ml Liquid) Hydromorphone (mg Tablet Immediate- Release, mg Tablet Immediate-Release, 8mg Tablet Immediate- Release) Hydromorphone (500mg/50ml QL QL QL QL QL Lorcet QL HD Lorcet HD QL Plus Lorcet Plus QL Lortab (10mg-5mg Tablet, 5mg-5mg Tablet, 7.5mg-5mg Tablet) Sulfate Morphine Sulfate (100mg/5ml Oral Solution, 10mg/5ml Oral Solution, 0mg/5ml Oral QL QL Sulfate Morphine Sulfate (10mg/ml Injection, mg/ml Injection, mg/ ml Injection, 8mg/ml Sulfate Morphine Sulfate (15mg Tablet Immediate- Release, 0mg Tablet Immediate-Release) Nalbuphine ( Oxycodone (100mg/ 5ml Concentrate, 5mg/ 5ml Oral Oxycodone (10mg Tablet Immediate- Release, 15mg Tablet Immediate-Release, 0mg Tablet Immediate- Release, 0mg Tablet Immediate-Release, 5mg Tablet Immediate- Release) Oxycodone/Acetaminophen Acetaminophen (10mg-5mg Tablet,.5mg-5mg Tablet, 5mg-5mg Tablet, 7.5mg-5mg Tablet) Oxycodone/Aspirin Oxycodone/Ibuprofen Tramadol (Tablet Immediate-Release) /Acetaminophen Tramadol / Acetaminophen QL QL QL QL QL QL QL QL Trezix (Capsule) QL Anesthetics Bold type = Brand name drug Plain type = Generic drug 1

15 track Last updated August 1, 016 Local Anesthetics Lidocaine (5% Ointment) Lidocaine (5% Patch) PA, QL Lidocaine (0.5% Injection, % Lidocaine (% External Lidocaine (Gel) B/D, PA Viscous Lidocaine Viscous ( Lidocaine/Prilocaine (.5%-.5% Cream) Anti-Addiction/Substance Abuse Treatment Agents Alcohol Deterrents/Anti-craving Calcium DR Acamprosate Calcium DR (Tablet Delayed-Release) Disulfiram Naltrexone Vivitrol ( 5 PA Opioid Dependence Treatments Buprenorphine (0.mg/ml Buprenorphine (mg Tablet Sublingual, 8mg QL Tablet Sublingual) /Naloxone Buprenorphine / Naloxone (Tablet Sublingual) PA, QL Naloxone ( Narcan (Liquid) Suboxone (Film) PA, QL Smoking Cessation Agents Buproban (Tablet Extended-Release 1 Chantix Continuing Month Pak Chantix Continuing Month Pak Starting Month Pak Chantix Starting Month Pak Inhaler Nicotrol Inhaler Antibacterials Aminoglycosides Sulfate Amikacin Sulfate ( Bethkis (Nebulized Gentak (Ophthalmic Ointment) Sulfate Gentamicin Sulfate (0.1% Cream, 0.1% Ointment, 0.% Ophthalmic Ointment, 0.% Ophthalmic Sulfate Gentamicin Sulfate (10mg/ml Injection, 0mg/ml Sulfate/0.9% Sodium Chloride Gentamicin Sulfate/0.9% Sodium Chloride ( Gentamicin Isotonic Gentamicin ( Sulfate Neomycin Sulfate Sulfate Paromomycin Sulfate (Capsule) Sulfate Streptomycin Sulfate ( 15 5 B/D, PA You can find information on what the symbols and abbreviations in this table mean by going to page 7. 15

16 5tRACK 5 16 Last updated August 1, 016 TOBI (Nebulized Podhaler TOBI Podhaler (Capsule) Tobradex (Ophthalmic Ointment) Tobramycin (Nebulized Sulfate Tobramycin Sulfate (0.% Ophthalmic Sulfate Tobramycin Sulfate (10mg/ml Injection, 80mg/ml Tobrex (0.% Ophthalmic Ointment) Antibacterials, Other Altabax (Ointment) BACiiM ( Bacitracin (50000unit Bacitracin (500unit/gm Ophthalmic Ointment) Nasal Bactroban Nasal (Ointment) Sodium Succinate Chloramphenicol Sodium Succinate ( Clindamycin (Capsule Immediate- Release) Palmitate Clindamycin Palmitate (Oral Phosphate Clindamycin Phosphate (% Cream) Phosphate Clindamycin Phosphate (600mg/ml 5 B/D, PA 5 PA 5 B/D, PA PA Phosphate D5W Clindamycin Phosphate in D5W ( Sodium Colistimethate Sodium ( Cubicin ( 5 Dalvance ( 5 PA Lincocin ( Lincomycin ( Linezolid (100mg/5ml Suspension, 600mg/ 00ml Linezolid (600mg Tablet) Hippurate Methenamine Hippurate Metronidazole (0.75% Cream, 0.75% Gel, 1% Gel, 0.75% Lotion) Metronidazole (50mg Tablet Immediate- Release, 500mg Tablet Immediate-Release, 75mg Capsule Immediate-Release) in NaCl 0.79% Metronidazole in NaCl 0.79% ( Vaginal Metronidazole Vaginal (Gel) Mupirocin (% Cream) Mupirocin (% Ointment) B Sulfates Neomycin/Polymyxin B Sulfates (Irrigation Nitrofurantoin (Suspension) 5 5 PA 5 PA, QL Bold type = Brand name drug Plain type = Generic drug 16

17 6tRACK 6 Last updated August 1, Macrocrystals Nitrofurantoin Macrocrystals (100mg Capsule, 50mg Capsule) (Generic Macrodantin) Monohydrate Nitrofurantoin Monohydrate (100mg Capsule) (Generic Macrobid) B Sulfate Polymyxin B Sulfate ( Sulfamylon (85mg/gm Cream) Synercid ( 5 Tinidazole Trimethoprim Tygacil ( 5 Vancocin (Capsule) 5 PA Vancomycin (1000mg Injection, 10gm Injection, 500mg Vancomycin (15mg Capsule, 50mg Capsule) Vandazole (Gel) 5 PA Xifaxan 5 PA Zyvox (100mg/5ml Suspension, 600mg/ 00ml 5 PA Zyvox (600mg Tablet) 5 PA, QL Beta-lactam, Cephalosporins Cefaclor (50mg Capsule Immediate-Release, 500mg Capsule Immediate-Release) Cefadroxil (50mg/5ml Suspension, 500mg/5ml Suspension, 500mg Capsule) Sodium Cefazolin Sodium (10gm Injection, 1gm Injection, 500mg Injection, 1gm/ 50ml Cefdinir (15mg/5ml Suspension, 50mg/5ml Suspension, 00mg Capsule) Cefepime (1gm Injection, gm Cefepime (1gm/50ml Injection, gm/50ml Cefixime (Suspension) Sodium Cefotaxime Sodium ( Cefotetan ( Sodium Cefoxitin Sodium (10gm Injection, 1gm Injection, gm Sodium Cefoxitin Sodium (1gm-% Injection, gm-.% Proxetil Cefpodoxime Proxetil (100mg Tablet, 00mg Tablet, 100mg/5ml Suspension, 50mg/5ml Suspension) Cefprozil (15mg/5ml Suspension, 50mg/5ml Suspension, 50mg Tablet, 500mg Tablet) Ceftazidime ( You can find information on what the symbols and abbreviations in this table mean by going to page 7. 17

18 7tRACK 7 18 Last updated August 1, 016 Ceftazidime/Dextrose ( Sodium Ceftriaxone Sodium (10gm Injection, 1gm Injection, gm Injection, 50mg Injection, 500mg Axetil Cefuroxime Axetil Sodium Cefuroxime Sodium ( Cephalexin (15mg/5ml Suspension, 50mg/5ml Suspension, 50mg Capsule, 500mg Capsule, 750mg Capsule) Fortaz (1gm Injection, gm Injection, gm Injection, 6gm Suprax (100mg Tablet Chewable, 00mg Tablet Chewable, 100mg/5ml Suspension, 00mg/5ml Suspension) Suprax (00mg Capsule, 500mg/5ml Suspension) Tazicef ( Zerbaxa ( 5 PA Beta-lactam, Other in Iso-Osmotic Dextrose Azactam in Iso-Osmotic Dextrose ( Aztreonam ( Doribax ( Imipenem/Cilastatin ( Invanz ( Meropenem ( Beta-lactam, Penicillins Amoxicillin (Capsule, Oral Suspension, Tablet, Tablet Chewable) Potassium Amoxicillin/Clavulanate Potassium (Oral Suspension, Tablet Chewable, Tablet Immediate-Release) (Generic Augmentin) Potassium ER Amoxicillin/Clavulanate Potassium ER (Tablet Extended-Release 1 Ampicillin (15mg/5ml Suspension, 50mg/5ml Suspension, 50mg Capsule, 500mg Capsule) Sodium Ampicillin Sodium (10gm Injection, 15mg Injection, 1gm Ampicillin-Sulbactam (10gm-5gm Injection, 1gm-0.5gm Injection, gm-1gm in Dextrose Bactocill in Dextrose (1gm/50ml in Dextrose Bactocill in Dextrose (gm/50ml C-R Bicillin C-R ( L-A Bicillin L-A ( Sodium Dicloxacillin Sodium (Capsule) in Dextrose Nafcillin in Dextrose ( 1 5 Bold type = Brand name drug Plain type = Generic drug 18

19 8tRACK 8 Last updated August 1, Sodium Nafcillin Sodium ( Sodium Oxacillin Sodium (10gm Sodium Oxacillin Sodium (gm G Potassium Penicillin G Potassium ( G Procaine Penicillin G Procaine ( G Sodium Penicillin G Sodium ( V Potassium Penicillin V Potassium (15mg/5ml Oral Solution, 50mg/5ml Oral Solution, 50mg Tablet, 500mg Tablet) Piperacillin/Tazobactam ( Macrolides Azasite (Ophthalmic Azithromycin (100mg/5ml Oral Suspension, 00mg/ 5ml Oral Suspension, 50mg Tablet, 500mg Tablet, 600mg Tablet) Azithromycin (500mg Clarithromycin (15mg/ 5ml Suspension, 50mg/ 5ml Suspension, 50mg Tablet, 500mg Tablet) ER Clarithromycin ER (Tablet Extended-Release Dificid 5 PA E.E.S. 00 Granules E.E.S. Granules (Suspension) 00 EryPed 00 (Suspension) 00 EryPed 00 (Suspension) Ery-Tab (Tablet Delayed- Release) Lactobionate Erythrocin Lactobionate ( Erythromycin (50mg Capsule Delayed-Release) Erythromycin (5mg/gm Ophthalmic Ointment) Base Erythromycin Base Ethylsuccinate Erythromycin Ethylsuccinate Ilotycin (Ophthalmic Ointment) Zmax (Suspension) Quinolones Avelox (00mg/ 50ml-0.8% Besivance (Suspension) Ciloxan (0.% Ointment) Ciprofloxacin (50mg/ 5ml Suspension, 500mg/ 5ml Suspension, 00mg/ 0ml ER Ciprofloxacin ER (Tablet Extended-Release You can find information on what the symbols and abbreviations in this table mean by going to page 7. 19

20 9tRACK 9 0 Last updated August 1, 016 Ciprofloxacin (0.% Ophthalmic Solution, 100mg Tablet Immediate- Release, 50mg Tablet Immediate-Release, 500mg Tablet Immediate- Release, 750mg Tablet Immediate-Release) I.V. in D5W Ciprofloxacin I.V. in D5W ( Gatifloxacin (Ophthalmic Levofloxacin (0.5% Ophthalmic Solution, 5mg/ml Oral Levofloxacin (50mg Tablet, 500mg Tablet, 750mg Tablet) Levofloxacin (5mg/ml D5W Levofloxacin in D5W ( Moxeza (Ophthalmic Moxifloxacin (00mg Tablet) Moxifloxacin (00mg/50ml Ofloxacin (0.% Ophthalmic Solution, 0.% Otic Solution, 00mg Tablet) Vigamox (Ophthalmic Sulfonamides Sulfadiazine Silver Sulfadiazine (Cream) 1 Sulfacetamide Sodium Sulfacetamide (10% Ophthalmic SSD (Cream) Sodium Sulfacetamide Sodium (Ophthalmic Ointment) Sulfadiazine Sulfamethoxazole/Trimethoprim Trimethoprim (00mg-0mg/5ml Suspension, 00mg-80mg Tablet) Sulfamethoxazole/Trimethoprim Trimethoprim (00mg-80mg/5ml Sulfamethoxazole/Trimethoprim DS Trimethoprim DS Tetracyclines Demeclocycline 100 Doxy 100 ( Doxycycline (150mg Capsule, 75mg Capsule) Doxycycline (5mg/5ml Suspension) Hyclate Doxycycline Hyclate (100mg Capsule Immediate-Release, 50mg Capsule Immediate- Release) Hyclate Doxycycline Hyclate (100mg Injection, 100mg Tablet Immediate- Release, 0mg Tablet Immediate-Release) 1 Bold type = Brand name drug Plain type = Generic drug 0

21 Celontin 10 track 10 Last updated August 1, Monohydrate Doxycycline Monohydrate (100mg Capsule, 50mg Capsule, 100mg Tablet, 150mg Tablet, 50mg Tablet, 75mg Tablet) Minocycline (100mg Capsule Immediate- Release, 50mg Capsule Immediate-Release, 75mg Capsule Immediate- Release) Minocycline (100mg Tablet Immediate- Release, 50mg Tablet Immediate-Release, 75mg Tablet Immediate- Release) Tetracycline (Capsule) Vibramycin (50mg/5ml Syrup) Anticonvulsants Anticonvulsants, Other BRIVIACT (100mg Tablet, 10mg Tablet, 5mg Tablet, 50mg Tablet, 75mg Tablet, 10mg/ml Oral BRIVIACT (50mg/5ml Fycompa 5 QL QL Levetiracetam (1000mg Tablet Immediate- Release, 50mg Tablet Immediate-Release, 500mg Tablet Immediate- Release, 750mg Tablet Immediate-Release, 100mg/ml Oral Levetiracetam (1000mg/100ml Injection, 1500mg/ 100ml Injection, 500mg/100ml Levetiracetam (500mg/ 5ml ER Levetiracetam ER (Tablet Extended-Release Potiga 5 QL Roweepra Calcium Channel Modifying Agents Celontin (Capsule) Ethosuximide (50mg Capsule, 50mg/5ml Oral Zonisamide (Capsule) Gamma-aminobutyric Acid (GABA) Augmenting Agents AcuDial Diastat AcuDial (Gel) Pediatric Diastat Pediatric (Gel) Diazepam (10mg Gel,.5mg Gel, 0mg Gel) Sodium Divalproex Sodium (Capsule Sprinkle Delayed-Release) You can find information on what the symbols and abbreviations in this table mean by going to page 7. 1

22 11 track 11 Last updated August 1, 016 Sodium DR Divalproex Sodium DR (Tablet Delayed-Release) Sodium ER Divalproex Sodium ER (Tablet Extended-Release Gabapentin (100mg Capsule, 00mg Capsule, 00mg Capsule, 600mg Tablet, 800mg Tablet) Gabapentin (50mg/5ml Oral Gabitril (1mg Tablet, 16mg Tablet) QL Onfi (10mg Tablet) QL Onfi (.5mg/ml Suspension) Onfi (0mg Tablet) 5 QL Phenobarbital (100mg Tablet, 15mg Tablet, 16.mg Tablet, 0mg Tablet,.mg Tablet, 60mg Tablet, 6.8mg Tablet, 97.mg Tablet, 0mg/5ml Elixir) Primidone Sabril (500mg Packet, 500mg Tablet) Tiagabine Sodium Valproate Sodium (100mg/ml Acid Valproic Acid (50mg Capsule, 50mg/5ml Syrup) Glutamate Reducing Agents Felbamate (00mg Tablet, 600mg Tablet) 5 PA, QL, LA Felbamate (600mg/5ml Suspension) Felbatol (600mg/5ml Suspension) Lamotrigine (100mg Tablet Immediate- Release, 150mg Tablet Immediate-Release, 00mg Tablet Immediate- Release, 5mg Tablet Immediate-Release) Lamotrigine (5mg Tablet Chewable, 5mg Tablet Chewable) Topiramate (100mg Tablet Immediate- Release, 00mg Tablet Immediate-Release, 5mg Tablet Immediate- Release, 50mg Tablet Immediate-Release, 15mg Capsule Sprinkle Immediate-Release, 5mg Capsule Sprinkle Immediate-Release) Sodium Channel Agents Aptiom (00mg Tablet) QL Aptiom (00mg Tablet, 600mg Tablet, 800mg Tablet) Banzel (00mg Tablet, 00mg Tablet, 0mg/ ml Suspension) Carbamazepine (100mg Tablet Chewable, 100mg/5ml Suspension, 00mg Tablet Immediate- Release) QL 5 Bold type = Brand name drug Plain type = Generic drug

23 1 track 1 Last updated August 1, 016 ER Carbamazepine ER (Capsule Extended- Release 1 Hour, Tablet Extended-Release 1 Dilantin (Capsule) INFATABS Dilantin INFATABS (Tablet Chewable) Epitol Sodium Fosphenytoin Sodium ( Oxcarbazepine (150mg Tablet, 00mg Tablet, 600mg Tablet) Oxcarbazepine (00mg/ 5ml Suspension) Peganone Phenytek (Capsule) Phenytoin (15mg/5ml Suspension, 50mg Tablet Chewable) Sodium Phenytoin Sodium ( Sodium Extended Phenytoin Sodium Extended (Capsule) Tegretol-XR (100mg Tablet Extended- Release 1 Vimpat (100mg Tablet, 150mg Tablet, 00mg Tablet, 50mg Tablet, QL 10mg/ml Oral Vimpat (00mg/0ml PA Antidementia Agents Cholinesterase Inhibitors Donepezil (10mg Tablet Dispersible, 5mg Tablet Dispersible) Donepezil (10mg Tablet Immediate- Release, mg Tablet Immediate-Release, 5mg Tablet Immediate- Release) QL 1 QL Exelon (Patch QL, ST HBr Galantamine HBr (1mg Tablet, mg Tablet, 8mg Tablet, 16mg Capsule Extended-Release Hour, mg Capsule Extended-Release QL Hour, 8mg Capsule Extended-Release Hour, mg/ml Oral Tartrate Rivastigmine Tartrate (Capsule Immediate- QL Release) Transdermal System Rivastigmine Transdermal System (Patch QL, ST N-methyl-D-aspartate (NMDA) Receptor Antagonist Memantine (10mg Tablet, 5mg Tablet, mg/ PA, QL ml Oral Titration Pak Memantine Titration Pak PA Namenda (10mg Tablet Immediate-Release, 5mg Tablet Immediate- PA, QL Release) Namenda (10mg/5ml Oral PA, QL You can find information on what the symbols and abbreviations in this table mean by going to page 7.

24 1 track 1 Last updated August 1, 016 Titration Pak Namenda Titration Pak PA XR Namenda XR (Capsule Extended-Release PA, QL XR Titration Pack Namenda XR Titration Pack (Capsule Extended-Release PA, QL Antidepressants Antidepressants, Other Bupropion (Tablet Immediate-Release) SR Bupropion SR (Tablet Extended-Release 1 XL Bupropion XL (Tablet Extended-Release Mirtazapine (Tablet Immediate-Release) ODT Mirtazapine ODT (Tablet Dispersible) Monoamine Oxidase Inhibitors Emsam (Patch 5 QL Marplan Sulfate Phenelzine Sulfate Sulfate Tranylcypromine Sulfate SSRI/SNRI (Selective Serotonin Reuptake Inhibitors/Serotonin and Norepinephrine Reuptake Inhibitors) HBr Citalopram HBr (10mg Tablet, 0mg Tablet, 1 0mg Tablet) HBr Citalopram HBr (10mg/ 5ml Oral Oxalate Escitalopram Oxalate (10mg Tablet, 0mg Tablet, 5mg Tablet) Oxalate Escitalopram Oxalate (5mg/5ml Oral Fetzima (Capsule Extended-Release Titration Pack Fetzima Titration Pack (Capsule Extended- Release Hour Therapy Pack) DR Fluoxetine DR (Capsule Delayed-Release) Fluoxetine (10mg Capsule Immediate- Release, 0mg Capsule Immediate-Release, 0mg Capsule Immediate- Release, 0mg/5ml Oral Maleate Fluvoxamine Maleate Maprotiline Nefazodone Paroxetine (Tablet Immediate-Release) Paxil (10mg/5ml Suspension) Pristiq (Tablet Extended-Release Sertraline (100mg Tablet, 5mg Tablet, 50mg Tablet) 1 QL, ST ST QL 1 Bold type = Brand name drug Plain type = Generic drug

25 Aloxi 1 track 1 Last updated August 1, Sertraline (0mg/ml Concentrate) Trazodone 1 Trintellix QL Venlafaxine (Tablet Immediate-Release) ER Venlafaxine ER (150mg Capsule Extended-Release Hour, 7.5mg Capsule Extended-Release Hour, 75mg Capsule Extended-Release Viibryd QL Starter Pack Viibryd Starter Pack (Kit) Tricyclics Amitriptyline Amoxapine Clomipramine (Capsule) Desipramine Doxepin (100mg Capsule, 10mg Capsule, 150mg Capsule, 5mg Capsule, 50mg Capsule, 75mg Capsule, 10mg/ml Concentrate) Imipramine Pamoate Imipramine Pamoate (Capsule) QL Nortriptyline (10mg Capsule, 5mg Capsule, 50mg Capsule, 75mg Capsule, 10mg/5ml Oral Protriptyline Surmontil (Capsule) Maleate Trimipramine Maleate (Capsule) Antiemetics Antiemetics, Other Compro (Suppository) Pamoate Hydroxyzine Pamoate (Capsule) Meclizine Metoclopramide (10mg Tablet, 5mg Tablet) Metoclopramide (5mg/5ml Oral Metoclopramide (5mg/ml Perphenazine Prochlorperazine (Suppository) Edisylate Prochlorperazine Edisylate ( Maleate Prochlorperazine Maleate Transderm-Scop (Patch 7 Emetogenic Therapy Adjuncts Aloxi ( 5 Anzemet (100mg Tablet, 50mg Tablet) 1 5 B/D, PA You can find information on what the symbols and abbreviations in this table mean by going to page 7. 5

26 15 track 15 6 Last updated August 1, 016 Cesamet (Capsule) 5 PA Dronabinol (10mg Capsule) Dronabinol (.5mg Capsule, 5mg Capsule) 5 PA, QL PA, QL Emend (Capsule, Pack) PA Emend (150mg Granisetron (0.1mg/ ml Injection, 1mg/ml Granisetron (1mg Tablet) Ondansetron (mg Tablet, mg Tablet, 8mg Tablet) Ondansetron (mg/ ml Ondansetron (mg/ 5ml Oral ODT Ondansetron ODT (Tablet Dispersible) Sancuso (Patch) 5 Antifungals Antifungals B/D, PA, QL B/D, PA B/D, PA B/D, PA Abelcet ( 5 B/D, PA AmBisome ( 5 B/D, PA B Amphotericin B ( B/D, PA Ancobon (Capsule) 5 Cancidas ( 5 Ciclopirox (0.77% Gel, 0.77% Suspension, 1% Shampoo) Nail Lacquer Ciclopirox Nail Lacquer (External Olamine Ciclopirox Olamine (Cream) Clotrimazole (1% Cream, 1% External Solution, 10mg Troche) Nitrate Econazole Nitrate (Cream) Eraxis ( 5 Exelderm (1% Cream, 1% External Fluconazole (100mg Tablet, 150mg Tablet, 00mg Tablet, 50mg Tablet, 10mg/ml Suspension, 0mg/ml Suspension) in Dextrose Fluconazole in Dextrose ( in NaCl Fluconazole in NaCl ( Flucytosine (Capsule) 5 Microsize Griseofulvin Microsize (15mg/5ml Suspension, 500mg Tablet) Ultramicrosize Griseofulvin Ultramicrosize Itraconazole (Capsule) PA, QL Jublia (External Ketoconazole (% Cream, % Shampoo, 00mg Tablet) Ketoconazole (% Foam) Lamisil (15mg Packet, 187.5mg Packet) Mentax (Cream) Bold type = Brand name drug Plain type = Generic drug 6

27 16 track 16 Last updated August 1, Miconazole (Suppository) Mycamine ( 5 Naftifine (1% Cream) Naftifine (% Cream) Naftin (1% Gel, % Gel, % Cream) Natacyn (Suspension) Noxafil (100mg Tablet Delayed-Release) Noxafil (0mg/ml Suspension) Nyamyc (Powder) Nystatin (Cream, Ointment, Powder, Suspension, Tablet) Nystop (Powder) 5 PA ONMEL 5 PA Nitrate Oxiconazole Nitrate (Cream) Oxistat (1% Cream, 1% Lotion) Sporanox (10mg/ml Oral Terbinafine Terconazole (0.% Cream, 0.8% Cream, 80mg Suppository) Vfend (00mg Tablet, 50mg Tablet, 0mg/ml Suspension) Voriconazole (00mg 5 5 PA 5 Voriconazole (00mg Tablet, 50mg Tablet, 0mg/ml Suspension) Zazole (0.8% Cream) Antigout Agents Antigout Agents Allopurinol 1 Colchicine (0.6mg Tablet) (Generic Colcrys) 5 QL Colcrys QL Probenecid Probenecid/Colchicine Uloric ST Antimigraine Agents Ergot Alkaloids Mesylate Dihydroergotamine Mesylate (1mg/ml Migergot (Suppository) Serotonin (5-HT) 1b/1d Receptor Agonists Naratriptan QL Benzoate Rizatriptan Benzoate (Tablet Immediate- Release) Benzoate ODT Rizatriptan Benzoate ODT (Tablet Dispersible) Sumatriptan (Nasal Succinate Sumatriptan Succinate (100mg Tablet, 5mg Tablet, 50mg Tablet) Succinate Sumatriptan Succinate (6mg/0.5ml QL QL QL QL QL You can find information on what the symbols and abbreviations in this table mean by going to page 7. 7

28 Dapsone 17 track 17 8 Last updated August 1, 016 Succinate Refill Sumatriptan Succinate Refill (mg/0.5ml Succinate Refill Sumatriptan Succinate Refill (6mg/0.5ml DosePro Sumavel DosePro ( Antimyasthenic Agents Parasympathomimetics Guanidine Mestinon (60mg/5ml Syrup) Timespan Mestinon Timespan (Tablet Extended- Release) Bromide Pyridostigmine Bromide (180mg Tablet Extended- Release) Bromide Pyridostigmine Bromide (60mg Tablet) Antimycobacterials Antimycobacterials, Other Dapsone Rifabutin (Capsule) Antituberculars Sulfate Capastat Sulfate ( Ethambutol Isoniazid (100mg Tablet, 00mg Tablet, 50mg/5ml Syrup) Isoniazid (100mg/ml Paser (Packet) QL QL 5 Priftin Pyrazinamide Rifampin (150mg Capsule, 00mg Capsule) Rifampin (600mg Rifater Sirturo 5 PA Trecator Antineoplastics Alkylating Agents BiCNU ( 5 Busulfex ( 5 Cyclophosphamide (Capsule) Dacarbazine ( Gleostine (Capsule) B/D, PA Hexalen (Capsule) 5 PA Ifosfamide ( 5 Leukeran Matulane (Capsule) 5 LA Melphalan ( Mustargen ( 5 Treanda ( 5 PA Valchlor (Gel) 5 PA, LA Zanosar ( Antiandrogens Bicalutamide Flutamide (Capsule) Nilandron 5 Xtandi (Capsule) 5 PA, QL Bold type = Brand name drug Plain type = Generic drug 8

29 18 track 18 Last updated August 1, Zytiga 5 PA, QL Antiangiogenic Agents Pomalyst (Capsule) 5 PA Revlimid (Capsule) 5 PA, LA Thalomid (Capsule) 5 PA Antiestrogens/Modifiers Emcyt (Capsule) Fareston 5 Faslodex ( 5 Soltamox (Oral Citrate Tamoxifen Citrate Antimetabolites Adrucil ( B/D, PA Alimta ( 5 PA Cladribine ( 5 B/D, PA Clolar ( 5 Aqueous Cytarabine Aqueous ( Droxia (Capsule) Elitek ( 5 Fluorouracil (.5gm/50ml Folotyn ( 5 Gemcitabine ( Gemzar ( 5 Hydroxyurea (Capsule) B/D, PA B/D, PA Lonsurf 5 PA, QL Mercaptopurine Nipent ( 5 5 Purixan (Suspension) 5 PA Tabloid PA Antineoplastics, Other Abraxane ( 5 PA Alecensa (Capsule) 5 PA, QL Amifostine ( 5 Arranon ( 5 Azacitidine ( 5 PA Beleodaq ( 5 PA Sulfate Bleomycin Sulfate ( Carboplatin ( Cisplatin ( Cosmegen ( 5 Dacogen ( 5 Daunorubicin ( Decitabine ( 5 B/D, PA Dexrazoxane ( 5 PA Docefrez ( 5 Docetaxel (80mg/ml Docetaxel (80mg/8ml Doxil ( 5 Doxorubicin ( Ellence ( 5 Epirubicin ( Erwinaze ( B/D, PA Farydak (Capsule) 5 PA You can find information on what the symbols and abbreviations in this table mean by going to page 7. 9

30 Anastrozole 19 track 19 0 Last updated August 1, 016 Phosphate Fludarabine Phosphate ( Fusilev ( 5 Halaven ( 5 PA Ibrance (Capsule) 5 PA, QL PFS Idamycin PFS ( Idarubicin ( 5 Irinotecan ( Istodax ( 5 PA Kit Ixempra Kit ( 5 Jevtana ( 5 PA Calcium Leucovorin Calcium (100mg Injection, 50mg Calcium Leucovorin Calcium (10mg Tablet, 15mg Tablet, 5mg Tablet, 5mg Tablet) Calcium Levoleucovorin Calcium ( Lynparza (Capsule) 5 PA, QL Mesna ( Mesnex (00mg Tablet) 5 Mitomycin ( 5 Mitoxantrone ( Ninlaro (Capsule) 5 PA, QL Oncaspar ( 5 Oxaliplatin ( 5 Paclitaxel ( Proleukin ( 5 PA Synribo ( 5 PA 5 5 Taxotere ( 5 Thiotepa ( 5 Trisenox ( Velcade ( 5 PA Venclexta (100mg Tablet) Venclexta (10mg Tablet, 50mg Tablet) Starting Pack Venclexta Starting Pack (Tablet Therapy Pack) 5 PA, QL PA, QL 5 PA Vidaza ( 5 PA Sulfate Vinblastine Sulfate ( B/D, PA PFS Vincasar PFS ( B/D, PA Sulfate Vincristine Sulfate ( Tartrate Vinorelbine Tartrate ( B/D, PA Zaltrap ( 5 PA Zinecard ( 5 PA Zolinza (Capsule) 5 PA Zydelig 5 PA, QL Zykadia (Capsule) 5 PA, QL Aromatase Inhibitors, rd Generation Anastrozole 1 Exemestane Letrozole Enzyme Inhibitors Etopophos ( 5 Etoposide ( Hycamtin ( 5 Toposar ( Bold type = Brand name drug Plain type = Generic drug 0

31 0 track 0 Last updated August 1, Topotecan ( 5 Molecular Target Inhibitors Afinitor 5 PA Disperz Afinitor Disperz (Tablet Soluble) 5 PA Bosulif 5 PA Cabometyx 5 PA, QL Caprelsa 5 PA, LA Cometriq (Kit) 5 PA Cotellic 5 PA, QL, LA Erivedge (Capsule) 5 PA Gilotrif 5 PA Iclusig (15mg Tablet) 5 PA, LA Iclusig (5mg Tablet) 5 PA Mesylate Imatinib Mesylate 5 PA Imbruvica (Capsule) 5 PA Inlyta 5 PA Iressa 5 PA, QL Jakafi 5 PA, LA Lenvima (Capsule Therapy Pack) 5 PA Mekinist 5 PA Nexavar 5 PA Odomzo (Capsule) 5 PA, QL, LA Sprycel 5 PA Stivarga 5 PA Sutent (Capsule) 5 PA Tafinlar (Capsule) 5 PA Tarceva 5 PA Tasigna (Capsule) 5 PA Tykerb 5 PA Votrient 5 PA Xalkori (Capsule) 5 PA, LA Zelboraf 5 PA Monoclonal Antibodies Avastin ( 5 PA Cyramza ( 5 PA Darzalex ( 5 PA, LA Empliciti ( 5 PA Erbitux ( 5 PA Herceptin ( 5 PA Kadcyla ( 5 PA Keytruda ( 5 PA Opdivo ( 5 PA Perjeta ( 5 PA Rituxan ( 5 PA Sylvant ( 5 PA Tagrisso 5 PA, QL, LA Tecentriq ( 5 PA Vectibix ( 5 PA Yervoy ( 5 PA Retinoids Bexarotene (Capsule) 5 PA Panretin (Gel) 5 PA Targretin (1% Gel, 75mg Capsule) Tretinoin (10mg Capsule) 5 Antiparasitics Anthelmintics Albenza 5 5 PA You can find information on what the symbols and abbreviations in this table mean by going to page 7. 1

32 1 track 1 Last updated August 1, 016 Biltricide Ivermectin Antiprotozoals Alinia (100mg/5ml Suspension, 500mg Tablet) Atovaquone (Suspension) 5 Atovaquone/Proguanil (Generic Malarone) Phosphate Chloroquine Phosphate Coartem DARAPRIM Sulfate Hydroxychloroquine Sulfate Mefloquine Mepron (Suspension) 5 Nebupent (Inhalation 00 Pentam 00 ( Phosphate Primaquine Phosphate B/D, PA Sulfate Quinine Sulfate (Capsule) PA Pediculicides/Scabicides Eurax (10% Cream, 10% Lotion) Lindane (Shampoo) Malathion (Lotion) Permethrin (Cream) Antiparkinson Agents Anticholinergics Mesylate Benztropine Mesylate (0.5mg Tablet, 1mg Tablet, mg Tablet) Mesylate Benztropine Mesylate (1mg/ml Trihexyphenidyl (0.mg/ml Elixir, mg Tablet, 5mg Tablet) Antiparkinson Agents, Other Amantadine (100mg Capsule, 100mg Tablet, 50mg/5ml Syrup) Entacapone Tasmar 5 Tolcapone 5 Dopamine Agonists Apokyn ( 5 PA Mesylate Bromocriptine Mesylate (.5mg Tablet, 5mg Capsule) Dihydrochloride Pramipexole Dihydrochloride (Tablet Immediate-Release) Ropinirole (Tablet Immediate-Release) Dopamine Precursors/L-Amino Acid Decarboxylase Inhibitors Carbidopa 5 Carbidopa/Levodopa (Tablet Immediate- Release) ER Carbidopa/Levodopa ER (Tablet Extended-Release) ODT Carbidopa/Levodopa ODT (Tablet Dispersible) 1 1 Bold type = Brand name drug Plain type = Generic drug

33 Azilect track Last updated August 1, 016 Carbidopa/Levodopa/Entacapone Entacapone Monoamine Oxidase B (MAO-B) Inhibitors Azilect Selegiline (5mg Capsule, 5mg Tablet) Zelapar (Tablet Dispersible) Antipsychotics 1st Generation/Typical Chlorpromazine (100mg Tablet, 10mg Tablet, 00mg Tablet, 5mg Tablet, 50mg Tablet, 50mg/ml Decanoate Fluphenazine Decanoate ( Fluphenazine (10mg Tablet, 1mg Tablet,.5mg Tablet, 5mg Tablet) Fluphenazine (.5mg/5ml Elixir, 5mg/ml Concentrate) Fluphenazine (.5mg/ml Haloperidol (0.5mg Tablet, 10mg Tablet, 1mg Tablet, 0mg Tablet, mg Tablet, 5mg Tablet, mg/ ml Concentrate) Decanoate Haloperidol Decanoate ( Lactate Haloperidol Lactate ( 5 Succinate Loxapine Succinate (10mg Capsule, 5mg Capsule) Succinate Loxapine Succinate (5mg Capsule, 50mg Capsule) Molindone Orap Pimozide Thioridazine Thiothixene (Capsule) QL Trifluoperazine nd Generation/Atypical Maintena Abilify Maintena ( 5 Aripiprazole (10mg Tablet, 15mg Tablet, mg Tablet, QL 5mg Tablet) Aripiprazole (0mg Tablet, 0mg Tablet) 5 QL ODT Aripiprazole ODT (Tablet Dispersible) 5 QL Fanapt (10mg Tablet, 1mg Tablet, 6mg 5 QL, ST Tablet, 8mg Tablet) Fanapt (1mg Tablet, mg Tablet, mg QL, ST Tablet) Titration Pack Fanapt Titration Pack ST Geodon (0mg Invega (Tablet Extended-Release 5 QL You can find information on what the symbols and abbreviations in this table mean by going to page 7.

34 track Last updated August 1, 016 Sustenna Invega Sustenna (117mg/0.75ml Injection, 156mg/ml Injection, mg/1.5ml Injection, 78mg/0.5ml Sustenna Invega Sustenna (9mg/0.5ml Trinza Invega Trinza ( 5 PA Latuda 5 QL Nuplazid 5 PA, QL Olanzapine (10mg Olanzapine (10mg Tablet Immediate-Release, 15mg Tablet Immediate- Release,.5mg Tablet Immediate-Release, 0mg Tablet Immediate- Release, 5mg Tablet Immediate-Release, 7.5mg Tablet Immediate- Release) ODT Olanzapine ODT (Tablet Dispersible) ER Paliperidone ER (Tablet Extended-Release Fumarate Quetiapine Fumarate (Tablet Immediate- Release) 5 QL QL 5 QL QL Rexulti 5 QL Consta Risperdal Consta (1.5mg Injection, 5mg Consta Risperdal Consta (7.5mg Injection, 50mg Risperidone (Tablet Immediate-Release) Risperidone (1mg/ml Oral ODT Risperidone ODT (Tablet Dispersible) Saphris (Tablet Sublingual) XR Seroquel XR (Tablet Extended-Release Vraylar (1.5mg Capsule, mg Capsule,.5mg Capsule, 6mg Capsule) Vraylar (Capsule Therapy Pack) Ziprasidone (Capsule) Relprevv Zyprexa Relprevv ( Treatment-Resistant Clozapine (Tablet Immediate-Release) ODT Clozapine ODT (100mg Tablet Dispersible, 1.5mg Tablet Dispersible, 150mg Tablet Dispersible, 5mg Tablet Dispersible) ODT Clozapine ODT (00mg Tablet Dispersible) 5 QL QL 5 QL, ST ST QL 5 QL 5 QL Bold type = Brand name drug Plain type = Generic drug

35 Cidofovir Adefovir Dipivoxil track Last updated August 1, Fazaclo (100mg Tablet Dispersible, 150mg Tablet Dispersible, 00mg Tablet Dispersible) 5 QL Versacloz (Suspension) 5 Antivirals Anti-cytomegalovirus (CMV) Agents Cidofovir ( 5 Ganciclovir ( B/D, PA Valcyte (50mg Tablet, 50mg/ml Oral Valganciclovir 5 Zirgan (Gel) Anti-hepatitis B (HBV) Agents Adefovir Dipivoxil 5 Baraclude (0.05mg/ml Oral Solution, 0.5mg Tablet, 1mg Tablet) Entecavir 5 HBV Epivir HBV (5mg/ml Oral Hepsera 5 Lamivudine (100mg Tablet) Tyzeka 5 Anti-hepatitis C (HCV) Agents Daklinza 5 PA, QL Harvoni 5 PA, QL A Intron A ( 5 PA A w/diluent Intron A w/diluent ( PA Olysio (Capsule) 5 PA, QL Pegasys ( 5 PA ProClick Pegasys ProClick ( 5 PA PegIntron ( 5 PA Redipen PegIntron Redipen ( Ribasphere (00mg Capsule) Ribasphere (00mg Tablet, 00mg Tablet) Ribasphere (600mg Tablet) Ribavirin (00mg Capsule) Ribavirin (00mg Tablet) 5 PA Sovaldi 5 PA, QL Sylatron ( 5 PA Zepatier 5 PA, QL Antiherpetic Agents Acyclovir (00mg Capsule, 00mg/5ml Suspension) Acyclovir (00mg Tablet, 800mg Tablet) Acyclovir (5% Ointment) QL Sodium Acyclovir Sodium ( 5 1 B/D, PA Denavir (Cream) QL Famciclovir QL Trifluridine (Ophthalmic Valacyclovir QL Zovirax (5% Cream) QL Zovirax (5% Ointment) 5 QL You can find information on what the symbols and abbreviations in this table mean by going to page 7. 5