Upper Peninsula Health Plan MI Health Link (Medicare Medicaid Plan) 2019 Formulary (List of Covered Drugs)

Transcription

1 H977_P7003_M Upper Peninsula Health Plan MI Health Link (Medicare Medicaid Plan) 209 Formulary (List of Covered Drugs) PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE S WE COVER IN THIS PLAN HPMS Approved Formulary File Submission ID: v3 No changes have been made since 04/0/209. If you have questions, please call Upper Peninsula Health Plan MI Health Link (Medicare- Medicaid Plan) at (TTY 7) 7 days a week, 8 a.m. to 9 p.m. eastern Time. The call is free. For more information visit

2 Upper Peninsula Health Plan MI Health Link (Medicare- Medicaid Plan) 209 List of Covered Drugs (Formulary) Introduction This document is called the List of Covered Drugs (also known as the Drug List). It tells you which prescription drugs and over-the-counter drugs are covered by Upper Peninsula Health Plan (UPHP) Health Link (Medicare-Medicaid Plan). The Drug List also tells you if there are any special rules or restrictions on any drugs covered by UPHP MI Health Link (MMP). Key terms and their definitions appear in the last chapter of the Member Handbook.? If you have questions, please call Upper Peninsula Health Plan MI Health Link (Medicare (TTY 7) 7 days a week, 8 a.m. to 9 p.m. Eastern Time. The call is free. For more information visit You can find information on what the symbols and abbreviations in this table mean by going to the Legend on page 2. 2

3 Table of Contents A. Disclaimers... 4 B. Frequently Asked Questions (FAQ)... 4 B. What prescription drugs are on the List of Covered Drugs? (We call the List of Covered Drugs the Drug List for short.)...4 B2. Does the Drug List ever change?...5 B3. What happens when there is change to the Drug List?...5 B4. Are there any restrictions or limits on drug coverage? Or are there any required actions to take to get certain drugs?...6 B5. How will you know if the drug you want has limitations or if there are required actions to take to get the drug?...7 B6. What happens if we change our rules about some drugs (for example, prior authorization (approval), quantity limits, and/or step therapy restrictions)?...7 B7. How can you find a drug on the Drug List?...7 B8. What if the drug you want to take is not on the Drug List?...8 B9. What if you are a new UPHP MI Health Link (MMP) member and can t find your drug on the Drug List or have a problem getting your drug?...8 B0. Can you ask for an exception to cover your drug?...9 B. How can you ask for an exception?...9 B2. How long does it take to get an exception?...9 B3. What are generic drugs?... 9 B4. What are OTC drugs?...9 B5. What is your copay?... 0 B6. What are drug tiers?... 0 C. List of Covered Drugs... 0 D. List of Drugs by Medical Condition... Alphabetical Listing... 3? If you have questions, please call Upper Peninsula Health Plan MI Health Link (Medicare (TTY 7) 7 days a week, 8 a.m. to 9 p.m. Eastern Time. The call is free. For more information visit You can find information on what the symbols and abbreviations in this table mean by going to the Legend on page 2. 3

4 A. Disclaimers This is a list of drugs that members can get in UPHP MI Health Link (MMP). Upper Peninsula Health Plan MI Health Link (Medicare-Medicaid Plan) is a health plan that contracts with both Medicare and Michigan Medicaid to provide benefits of both programs to enrollees. The List of Covered Drugs and/or pharmacy and provider networks may change throughout the year. We will send you a notice before we make a change that affects you. Benefits may change on January of each year. You can always check UPHP MI Health Link (MMP) s up-to-date List of Covered Drugs online at Limitations, restrictions, and patient pay amounts may apply. This means that you may have to pay for some services and that you need to follow certain rules to have UPHP MI Health Link (MMP) pay for your services. For more information, call UPHP MI Health Link (MMP) Customer Service or read the UPHP MI Health Link (MMP) Member Handbook. You can also get this document for free in other formats, such as large print, braille, or audio. Call Customer Service at (TTY 7) 7 Days a week, 8 a.m. to 9 p.m. Eastern Time. The call is free. You can make a standing request to get this document, now and in the future, in a language other than English or in an alternate format. B. Frequently Asked Questions (FAQ) Find answers here to questions you have about this List of Covered Drugs. You can read all of the FAQ to learn more, or look for a question and answer. B. What prescription drugs are on the List of Covered Drugs? (We call the List of Covered Drugs the Drug List for short.) The drugs on the List of Covered Drugs that starts on page 3 are the drugs covered by UPHP MI Health Link (MMP). These drugs are available at pharmacies within our network. A pharmacy is in our network if we have an agreement with them to work with us and provide you services. We refer to these pharmacies as network pharmacies. UPHP MI Health Link (MMP) will cover all medically necessary drugs on the Drug List if:? If you have questions, please call Upper Peninsula Health Plan MI Health Link (Medicare (TTY 7) 7 days a week, 8 a.m. to 9 p.m. Eastern Time. The call is free. For more information visit You can find information on what the symbols and abbreviations in this table mean by going to the Legend on page 2. 4

5 o o your doctor or other prescriber says you need them to get better or stay healthy, and you fill the prescription at a UPHP MI Health Link (MMP) network pharmacy. UPHP MI Health Link (MMP may have additional steps to access certain drugs (see question B4 below). You can also see an up-to-date list of drugs that we cover on our website at or call Customer Service toll-free at (TTY 7) 7 days a week, 8 a.m. to 9 p.m. Eastern Time. The call is free. B2. Does the Drug List ever change? Yes. UPHP MI Health Link (MMP) may add or remove drugs on the Drug List during the year. We may also change our rules about drugs. For example, we could: Decide to require or not require prior approval for a drug. (Prior approval is permission from UPHP MI Health Link (MMP) before you can get a drug.) Add or change the amount of a drug you can get (called quantity limits ). Add or change step therapy restrictions on a drug. (Step therapy means you must try one drug before we will cover another drug.) For more information on these drug rules, see question B4. If you are taking a drug that was covered at the beginning of the year, we will generally not remove or change coverage of that drug during the rest of the year unless: a new, cheaper drug comes along that works as well as a drug on the Drug List now, or we learn that a drug is not safe, or a drug is removed from the market. Questions B3 and B6 below have more information on what happens when the Drug List changes. You can always check UPHP MI Health Link (MMP) s up to date Drug List online at You can also call Customer Service to check the current Drug List at (TTY 7) 7 days a week, 8 a.m. to 9 p.m. Eastern Time.. The call is free. B3. What happens when there is change to the Drug List? Some changes to the Drug List will happen immediately. For example:? If you have questions, please call Upper Peninsula Health Plan MI Health Link (Medicare (TTY 7) 7 days a week, 8 a.m. to 9 p.m. Eastern Time. The call is free. For more information visit You can find information on what the symbols and abbreviations in this table mean by going to the Legend on page 2. 5

6 A new generic drug becomes available. Sometimes, a new and cheaper drug comes along that works as well as a drug on the Drug List now. When that happens, we may remove the current drug, but your cost for the new drug will stay the same or will be lower. When we add the new generic drug, we may also decide to keep the current drug on the list but change its coverage rules or limits. o o We may not tell you before we make this change, but we will send you information about the specific change or changes we made. You or your provider can ask for an exception from these changes. We will send you a notice with the steps you can take to ask for an exception. Please see question B0 for more information on exceptions. A drug is taken off the market. If the Food and Drug Administration (FDA) says a drug you are taking is not safe or the drug s manufacturer takes a drug off the market, we will take it off the Drug List. If you are taking the drug, we will let you know can let you know what to do. We may make other changes that affect the drugs you take. We will tell you in advance about these other changes to the Drug List. These changes might happen if: The FDA provides new guidance or there are new clinical guidelines about a drug. We add a generic drug that is not new to the market and o o Replace a brand name drug currently on the Drug List or Change the coverage rules or limits for the brand name drug. When these changes happen, we will tell you at least 30 days before we make the change to the Drug List or when you ask for a refill. This will give you time to talk to your doctor or other prescriber. He or she can help you decide if there is a similar drug on the Drug List you can take instead or whether to ask for an exception. Then you can: Get a 30-day supply of the drug before the change to the Drug List is made, or Ask for an exception from these changes. Please see question B0 for more information about exceptions. B4. Are there any restrictions or limits on drug coverage? Or are there any required actions to take to get certain drugs? Yes, some drugs have coverage rules or have limits on the amount you can get. In some cases you or your doctor or other prescriber must do something before you can get the drug. For example Prior approval (or prior authorization): For some drugs, you or your doctor or other prescriber must get approval from UPHP MI Health Link (MMP) before you fill? If you have questions, please call Upper Peninsula Health Plan MI Health Link (Medicare (TTY 7) 7 days a week, 8 a.m. to 9 p.m. Eastern Time. The call is free. For more information visit You can find information on what the symbols and abbreviations in this table mean by going to the Legend on page 2. 6

7 your prescription. If you don t get approval, UPHP MI Health Link (MMP) may not cover the drug if you do not get approval. Quantity limits: Sometimes UPHP MI Health Link (MMP) limits the amount of a drug you can get. Step therapy: Sometimes UPHP MI Health Link (MMP) requires you to do step therapy. This means you will have to try drugs in a certain order for your medical condition. You might have to try one drug before we will cover another drug. If your prescriber thinks the first drug doesn t work for you, then we will cover the second. You can find out if your drug has any additional requirements or limits by looking in the tables on pages 3. You can also get more information by visiting our web site at We have posted online a document that explains our prior authorization and step therapy restrictions. You may also ask us to send you a copy. You can also ask for an exception from these limits. This will give you time to talk to your doctor or other prescriber. He or she can help you decide if there is a similar drug on the Drug List you can take instead or whether to ask for an exception. Please see questions B0-B2 for more information about exceptions. B5. How will you know if the drug you want has limitations or if there are required actions to take to get the drug? The List of Covered Drugs on page 3 has a column labeled Necessary actions, restrictions, or limits on use. B6. What happens if we change our rules about some drugs (for example, prior authorization (approval), quantity limits, and/or step therapy restrictions)? In some cases, we will tell you in advance if we add or change prior approval, quantity limits, and/or step therapy restrictions on a drug. See question B3 for more information about this advance notice and situations where we may not be able to tell you in advance when our rules about drugs on the Drug List change. B7. How can you find a drug on the Drug List? There are two ways to find a drug: You can search alphabetically (if you know how to spell the drug), or You can search by medical condition.? To search alphabetically, go to the Alphabetical Listing section. You can find it starting on page 3. The section 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 If you have questions, please call Upper Peninsula Health Plan MI Health Link (Medicare (TTY 7) 7 days a week, 8 a.m. to 9 p.m. Eastern Time. The call is free. For more information visit You can find information on what the symbols and abbreviations in this table mean by going to the Legend on page 2. 7

8 information. Turn to the page listed in the Index and find the name of your drug in the first column of the list. To search by medical condition, find the section labeled List of drugs by medical condition on page 3. The drugs in this section are grouped into categories depending on the type of medical conditions they are used to treat. For example, if you have a heart condition, you should look in the category, Cardiovascular Agents. That is where you will find drugs that treat heart conditions. B8. What if the drug you want to take is not on the Drug List? If you don t see your drug on the Drug List, call Customer Service at (TTY 7) 7 days a week, 8 a.m. to 9 p.m. Eastern Time and ask about it. If you learn that UPHP MI Health Link (MMP) will not cover the drug, you can do one of these things: Ask Customer Service for a list of drugs like the one you want to take. Then show the list to your doctor or other prescriber. He or she can prescribe a drug on the Drug List that is like the one you want to take. Or You can ask the health plan to make an exception to cover your drug. Please see questions B0-B2 for more information about exceptions. B9. What if you are a new UPHP MI Health Link (MMP) member and can t find your drug on the Drug List or have a problem getting your drug? We can help. We may cover a temporary 30-day supply of your drug during the first 90 days you are a member of UPHP MI Health Link (MMP). This will give you time to talk to your doctor or other prescriber. He or she can help you decide if there is a similar drug on the Drug List you can take instead or whether to ask for an exception. If your prescription is written for fewer days, we will allow multiple fills to provide up to a maximum of 30 days of medication. We will cover a 30-day supply of your drug if: you are taking a drug that is not on our Drug List, or health plan rules do not let you get the amount ordered by your prescriber, or the drug requires prior approval by UPHP MI Health Link (MMP), or you are taking a drug that is part of a step therapy restriction. If you are in a nursing home or other long-term care facility, and need a drug that is not on the Drug List or if you cannot easily get the drug you need, we can help. If you have been in the plan for more than 90 days, live in a long-term care facility, and need a supply right away:? If you have questions, please call Upper Peninsula Health Plan MI Health Link (Medicare (TTY 7) 7 days a week, 8 a.m. to 9 p.m. Eastern Time. The call is free. For more information visit You can find information on what the symbols and abbreviations in this table mean by going to the Legend on page 2. 8

9 We will cover one 3 supply of the drug you need (unless you have a prescription for fewer days), whether or not you are a new UPHP MI Health Link (MMP) member. This is in addition to the temporary supply during the first 90 days you are a member of UPHP MI Health Link (MMP). B0. Can you ask for an exception to cover your drug? Yes. You can ask UPHP MI Health Link (MMP) to make an exception to cover a drug that is not on the Drug List. You can also ask us to change the rules on your drug. For example, UPHP MI Health Link (MMP) may limit the amount of a drug we will cover. If your drug has a limit, you can ask us to change the limit and cover more. Other examples: You can ask us to drop step therapy restrictions or prior approval requirements.? B. How can you ask for an exception? To ask for an exception, call Customer Service. A Customer Service representative will work with you and your provider to help you ask for an exception. You can also read Chapter 9, of the Member Handbook to learn more about exceptions. B2. How long does it take to get an exception? First, we must get a statement from your prescriber supporting your request for an exception. After we get the statement, we will give you a decision on your exception request within 72 hours. If you or your prescriber think your health may be harmed if you have to wait 72 hours for a decision, you can ask for an expedited exception. This is a faster decision. If your prescriber supports your request, we will give you a decision within 24 hours of getting your prescriber s supporting statement. B3. What are generic drugs? Generic drugs are made up of the same active ingredients as brand name drugs. They usually cost less than the brand name drug and usually don t have well-known names. Generic drugs are approved by the Food and Drug Administration (FDA). UPHP MI Health Link (MMP) covers both brand name drugs and generic drugs. B4. What are OTC drugs? OTC stands for over-the-counter. UPHP MI Health Link (MMP) covers some OTC drugs when they are written as prescriptions by your provider. If you have questions, please call Upper Peninsula Health Plan MI Health Link (Medicare (TTY 7) 7 days a week, 8 a.m. to 9 p.m. Eastern Time. The call is free. For more information visit You can find information on what the symbols and abbreviations in this table mean by going to the Legend on page 2. 9

10 You can read the UPHP MI Health Link (MMP) Drug List to see what OTC drugs are covered. B5. What is your copay? As a UPHP MI Health Link (MMP) member, you have no copays for prescription and OTC drugs as long as you follow UPHP MI Health Link (MMP) s rules. B6. What are drug tiers? Tiers are groups of drugs. Tier and Tier 2 may include OTC drugs. Drug Tier Type of Drug Copay Amount Tier Generic drugs ($0) Tier 2 Brand drugs ($0) All tiers have ($0) copay. C. List of Covered Drugs The following list of covered drugs gives you information about the drugs covered by UPHP MI Health Link (MMP). If you have trouble finding your drug in the list, turn to the Index of Covered Drugs that begins on page 3. The index alphabetically lists all drugs covered by UPHP MI Health Link (MMP). The first column of the chart lists the name of the drug. Brand name drugs are capitalized (e.g., JANUVIA, and generic drugs are listed in lower-case italics (e.g., sitagliptin). The information in the necessary actions, restrictions, or limits on use column tells you if UPHP MI Health Link (MMP) has any rules for covering your drug. Note: The * next to a drug means the drug is not a Part D drug. These drugs have different rules for appeals. An appeal is a formal way of asking us to review a coverage decision and to change it if you think we made a mistake. For example, we might decide that a drug that you want is not covered or is no longer covered by Medicare or Michigan Medicaid. If you or your prescriber disagrees with our decision, you can appeal. To ask for instructions on how to appeal, call Customer Service at (TTY 7) 7 days a week, 8 a.m. to 9 p.m. Eastern Time. You can also read Chapter 9, in the Member Handbook to learn how to appeal a decision.? If you have questions, please call Upper Peninsula Health Plan MI Health Link (Medicare (TTY 7) 7 days a week, 8 a.m. to 9 p.m. Eastern Time. The call is free. For more information visit You can find information on what the symbols and abbreviations in this table mean by going to the Legend on page 2. 0

11 D. List of Drugs by Medical Condition The drugs in this section are grouped into categories depending on the type of medical conditions they are used to treat. For example, if you have a heart condition, you should look in the category, CARDIOVASCULAR AGENTS. That is where you will find drugs that treat heart conditions. in this table mean by going to the information below.? If you have questions, please call Upper Peninsula Health Plan MI Health Link (Medicare (TTY 7) 7 days a week, 8 a.m. to 9 p.m. Eastern Time. The call is free. For more information visit You can find information on what the symbols and abbreviations in this table mean by going to the Legend on page 2.

12 LEGEND NAME Generics 2 Brands SYMBOL NAME DESCRIPTION QL Quantity Limit Quantity limit, dispense limit for 30 days, unless otherwise noted PA Prior Authorization You (or your physician) are required to get prior authorization before you fill your prescription for this drug. Without prior approval, we may not cover this drug. ST Step Therapy Step therapy exception required BD * (G) M Covered under Medicare Part B or D Non-Part D drugs or OTC items that are covered by Medicaid Only the generic version of this drug is covered. The brand name version is not covered. The brand name version of this drug is in Tier 2. The generic version is in Tier Covered under Medicare Part B or D Non-Part D drugs or OTC items that are covered by Medicaid Only the generic version of this drug is covered. The brand name version is not covered. The brand name version of this drug is in Tier 2. The generic version is in Tier 2

13 Analgesics butalbital-acetaminophn PA, QL (80 PER 30 DAYS) butalbital-acetaminophn PA, QL (360 PER 30 DAYS) MARTEN-TAB 2 PA, QL (360 PER 30 DAYS) tencon PA, QL (360 PER 30 DAYS) Nonsteroidal Anti-inflammatory Drugs diclofenac potassium diclofenac sodium % gel QL (000 PER 30 DAYS) diclofenac sodium (sod dr 25 mg tab, sod dr 50 mg tab, sod dr 75 mg tab, sod ec 25 mg tab, sod ec 50 mg tab, sod ec 75 mg tab, sodium 3% gel) diclofenac sodium er diflunisal ec-naproxen etodolac (200 mg capsule, 300 mg capsule, 400 mg tablet, 500 mg tablet) fenoprofen 600 mg tablet flurbiprofen (50 mg tablet, 00 mg tablet) ibu ibuprofen (00 mg/5 ml susp, 400 mg tablet, 600 mg tablet, 800 mg tablet) indomethacin (25 mg capsule, 50 mg capsule) ketoprofen (25 mg capsule, 50 mg capsule, 75 mg capsule) PA ketorolac 0 mg tablet PA, QL (20 PER 30 OVER TIME) ketorolac tromethamine (5 mg/ml vial, 30 mg/ml vial, 60 mg/2 ml carpuject, 60 mg/2 ml vial, 300 mg/0 ml vial) meclofenamate sodium (50 mg capsule, 00 mg capsule) PA on this table mean by going to page 2. 3

14 mefenamic acid 250 mg capsule meloxicam (7.5 mg/5 ml susp, 7.5 mg tablet, 5 mg tablet) nabumetone (500 mg tablet, 750 mg tablet) naproxen (25 mg/5 ml suspen, 250 mg tablet, dr 375 mg tablet, 375 mg tablet, 500 mg kit, 500 mg tablet, dr 500 mg tablet) naproxen sodium (275 mg tab, 550 mg tab) naproxen sodium ds oxaprozin piroxicam (0 mg capsule, 20 mg capsule) profeno SPRIX 2 QL (5 PER 30 OVER TIME) sulindac (50 mg tablet, 200 mg tablet) tolmetin sodium (200 mg tab, 400 mg cap, 600 mg tab) Opioid Analgesics, Long-acting EMBEDA 2 fentanyl hydromorphone er (er 6 mg tab, er 32 mg tab) INFUMORPH 2 methadone hcl (hcl 5 mg tablet, 5 mg/5 ml solution, 0 mg/5 ml solution, hcl 0 mg/ml vial, 0 mg/ml oral conc, hcl 0 mg tablet, hcl 200 mg/20 ml vl) methadone intensol METHADOSE 0 MG/ML ORAL CONC 2 on this table mean by going to page 2. 4

15 morphine sulfate er (sulf er 5 mg tablet, sulf er 30 mg tablet, sulf er 60 mg tablet, sulf er 00 mg tablet, sulf er 200 mg tablet, sulfate er 0 mg cap, sulfate er 20 mg cap, sulfate er 30 mg cap, sulfate er 40 mg cap, sulfate er 50 mg cap, sulfate er 60 mg cap, sulfate er 80 mg cap, sulfate er 00 mg cap) oxymorphone hcl er XTAMPZA ER 2 Opioid Analgesics, Short-acting ABSTRAL 2 PA acetaminophen-codeine (acetamin-codein mg/2.5, acetaminop-codeine 20-2 mg/5, acetaminophen-cod #2 tablet, acetaminophen-cod #3 tablet, acetaminophen-cod #4 tablet) butorphanol tartrate ( mg/ml vial, 2 mg/ml vial, 0 mg/ml spray) codeine sulfate DURAMORPH 2 endocet fentanyl citrate (00 mcg/2 ml vial, 00 mcg/2 ml ampul, 00 mcg/2 ml syringe, 00 mcg/2 ml carpujct, 250 mcg/5 ml ampul, 250 mcg/5 ml vial, 500 mcg/0 ml vial,,000 mcg/20 ml ampul,,000 mcg/20 ml vial, 2,500 mcg/50 ml vial) fentanyl citrate (cit,200 mcg, cit,600 mcg, citrate 200 mcg, citrate 400 mcg, citrate 600 mcg, citrate 800 mcg) PA FENTORA 2 PA on this table mean by going to page 2. 5

16 hydrocodone-acetaminophen (hydrocodoneacetamin /5, hydrocodone-acetamin , hydrocodone-acetamin 5-27/0, hydrocodone-acetamin mg, hydrocodone-acetamin mg, hydrocodone-acetamin , hydrocodone-acetamin , hydrocodone-acetamin mg, hydrocodone-acetamin mg, hydrocodone-acetamn /5) hydromorphone hcl (hcl mg/ml amp, mg/ml solution, 2 mg/ml carpujct, 2 mg/ml isecure, 2 mg/ml vial, 2 mg tablet, hcl 2 mg/ml amp, hcl 4 mg/ml amp, 4 mg tablet, 5 mg/5 ml soln, 8 mg tablet, 0 mg/ml vial, hcl 0 mg/ml vl, hcl 0 mg/ml amp, 50 mg/5 ml vial, 500 mg/50 ml via, 500 mg/50 ml vl) LAZANDA 2 PA lorcet lorcet hd lorcet plus lortab (5-325 mg tablet, mg tablet, mg tablet) morphine sulfate (0.5 mg/ml vial, sulfate mg/ml vial, mg/ml vial p-f, 2 mg/ml carpuject, 2 mg/ml syringe, 2 mg/ml isecure syr, 4 mg/ml carpuject, 4 mg/ml syringe, 4 mg/ml isecure syr, 5 mg/ml vial, 5 mg/ml syringe, 8 mg/ml isecure syrng, 8 mg/ml syringe, 0 mg/ml syringe, 0 mg/ml isecure syrg, sulf 0 mg/5 ml soln, sulf 20 mg/5 ml soln, sulf 00 mg/5 ml conc, sulfate ir 5 mg tab, sulfate ir 30 mg tab) nalbuphine hcl (0 mg/ml ampul, 20 mg/ml ampul, 00 mg/0 ml vial, 200 mg/0 ml vial) OXAYDO 2 on this table mean by going to page 2. 6

17 oxycodone hcl (oxycodon 0 mg/0.5 ml oral syr, oxycodone hcl 5 mg/5 ml soln, oxycodone hcl 5 mg capsule, oxycodone hcl 5 mg tablet, oxycodone hcl 0 mg tablet, oxycodone hcl 5 mg tablet, oxycodone hcl 20 mg tablet, oxycodone hcl 30 mg tablet, oxycodone hcl 00 mg/5 ml conc) oxycodone hcl-aspirin oxycodone hcl-ibuprofen oxycodone-acetaminophen (oxycodonacetaminophen , oxycodonacetaminophen , oxycodoneacetaminophen 5-325, oxycodoneacetaminophen 0-325) tramadol hcl 50 mg tablet tramadol hcl-acetaminophen vicodin vicodin es vicodin hp Anesthetics Local Anesthetics ANODYNE LPT PA, QL (30 PER 30 DAYS) chloroprocaine hcl DERMACINRX EMPRICAINE PA, QL (30 PER 30 DAYS) glydo QL (30 PER 30 DAYS) LEVA SET PA, QL (30 PER 30 DAYS) LIDO-PRILO CAINE PACK PA, QL (30 PER 30 DAYS) lidocaine 5% patch PA lidocaine 5% ointment PA, QL (50 PER 30 DAYS) on this table mean by going to page 2. 7

18 lidocaine hcl (0.5% vial, % 20 mg/2 ml vl, % vial, % 50 mg/5 ml, % 20 mg/2 ml, % 50 mg/5 ml vl, % ampul, % 300 mg/30 ml,.5% ampul, 2% ampul, 2% 40 mg/2 ml, 2% 00 mg/5 ml, 2% 40 mg/2 ml vl, 2% vial, 4% ampul) lidocaine hcl (jel urojet ac, jelly, jelly uro-jet) PA, QL (30 PER 30 DAYS) lidocaine hcl 4% solution PA, QL (50 PER 30 DAYS) lidocaine hcl-epinephrine lidocaine-epinephrine lidocaine-prilocaine PA, QL (30 PER 30 DAYS) LIDOPRIL PA, QL (30 PER 30 DAYS) LIDOPRIL XR PA, QL (30 PER 30 DAYS) liprozonepak PA, QL (30 PER 30 DAYS) livixil pak PA, QL (30 PER 30 DAYS) medolor pak PA, QL (30 PER 30 DAYS) polocaine (% vial, 2% vial) polocaine-mpf PRILOLID PA, QL (30 PER 30 DAYS) prilovix PA, QL (30 PER 30 DAYS) XYLOCAINE DENTAL-EPINEPHRINE 2 Anti-Addiction/Substance Abuse Treatment Agents Alcohol Deterrents/Anti-craving acamprosate calcium disulfiram (250 mg tablet, 500 mg tablet) VIVITROL 2 Opioid Dependence Treatments buprenorphine hcl (2 mg tablet, 8 mg tablet) buprenorphin-naloxon 8-2 mg sl QL (90 PER 30 DAYS) on this table mean by going to page 2. 8

19 buprenorphn-naloxn mg sl QL (360 PER 30 DAYS) LUCEMYRA 2 QL (480 PER 30 DAYS) naltrexone 50 mg tablet SUBOXONE 2 MG-3 MG SL FILM 2 QL (60 PER 30 DAYS) SUBOXONE 2 MG-0.5 MG SL FILM 2 QL (360 PER 30 DAYS) SUBOXONE 4 MG- MG SL FILM 2 QL (80 PER 30 DAYS) SUBOXONE 8 MG-2 MG SL FILM 2 QL (90 PER 30 DAYS) Opioid Reversal Agents naloxone hcl (0.4 mg/ml carpuject, 0.4 mg/ml vial, 2 mg/2 ml syringe, 4 mg/0 ml vial) NARCAN 4 MG NASAL SPRAY 2 Smoking Cessation Agents bupropion hcl sr 50 mg tablet QL (90 PER 30 DAYS) CHANTIX (0.5 MG TABLET, MG CONT MONTH BOX, MG TABLET, STARTING MONTH BOX) 2 QL (504 PER 365 OVER TIME) NICOTROL 2 QL (2688 PER 365 OVER TIME) NICOTROL NS 2 QL (360 PER 365 OVER TIME) Anti-inflammatory Agents Glucocorticoids procto-med hc procto-pak proctosol-hc proctozone-hc triamcinolone 0.47 mg/g spray on this table mean by going to page 2. 9

20 Antibacterials Aminoglycosides amikacin sulfate (sulf gram/4 ml vial, sulf 500 mg/2 ml vial, sulf,000 mg/4 ml vl, sulfate,000 mg/4 ml) gentak gentamicin sulfate (0.% ointment, 0.% cream, 0.3% eye ointment, 0.3% eye drop, 3 mg/ml eye drop, 0 mg/ml vial, 20 mg/2 ml vial, ped 20 mg/2 ml vial, 40 mg/ml vial, 80 mg/2 ml vial, 800 mg/20 ml vial) gentamicin sulfate in ns (isoton 60 mg/50 ml, 70 mg/ns 50 ml pb, iso 00 mg/00 ml, isoton 80 mg/00 ml, 80 mg/ns 50 ml pb, isoton 80 mg/50 ml, 80 mg/ns 00 ml pb, 90 mg/ns 00 ml pb, 00 mg/ns 00 ml, isoton 00 mg/50 ml) neomycin 500 mg tablet neomycin-polymyxin b (40 mg/ml amp, 40 mg/ml vl) paromomycin 250 mg capsule streptomycin sulf gm vial tobramycin 0.3% eye drop tobramycin sulfate (.2 gm vial,.2 gram/30 ml vial, 0 mg/ml vial, 40 mg/ml vial, 80 mg/2 ml vial,,200 mg/30 ml vial) TOBREX 0.3% EYE OINTMENT 2 Antibacterials, Other baciim bacitracin (500 unit/gm ophth, 50,000 unit vial) BACTROBAN NASAL 2 chloramphenicol sod succinate on this table mean by going to page 2. 20

21 CLEOCIN 00 MG VAGINAL OVULE 2 clindacin etz % pledget clindacin p clindamycin hcl (75 mg capsule, 50 mg capsule, 300 mg capsule) clindamycin palmitate hcl clindamycin pediatric clindamycin phosphate (ph % solution, ph % gel, 2% vaginal cream, ph 9 g/60 ml vial, ph 300 mg/2 ml vl, 300 mg/2 ml addvan, ph 600 mg/4 ml vl, ph 900 mg/6 ml vl, phos % pledget, phosp % lotion, phosphate % foam, phosphate % gel, 600 mg/4 ml addvan, 900 mg/6 ml addvan) clindamycin phosphate-d5w clindamycin-0.9% nacl colistimethate daptomycin IMPAVIDO 2 linezolid 00 mg/5 ml susp QL (800 PER 28 DAYS) linezolid 600 mg tablet QL (56 PER 28 DAYS) linezolid-d5w mafenide acetate methenamine hippurate METRO IV 2 metronidazole (vaginal 0.75% gl, 250 mg tablet, 375 mg capsule, 500 mg/00 ml, 500 mg tablet) mupirocin 2% ointment nitrofurantoin mcr 00 mg cap QL (360 PER 365 OVER TIME) nitrofurantoin mcr 25 mg cap QL (440 PER 365 OVER TIME) nitrofurantoin mcr 50 mg cap QL (720 PER 365 OVER TIME) on this table mean by going to page 2. 2

22 nitrofurantoin 25 mg/5 ml susp QL (7200 PER 365 OVER TIME) nitrofurantoin mono-macro QL (80 PER 365 OVER TIME) polymyxin b sulfate vial PRIMSOL 2 silver sulfadiazine % cream SIVEXTRO (200 MG VIAL, 200 MG TABLET) 2 QL (6 PER 30 OVER TIME) SSD 2 SYNERCID 2 tigecycline trimethoprim 00 mg tablet TRIMPEX 2 vancomycin hcl ( gm vial, hcl g/200 ml bag, gm add-van vial, hcl 5 gm vial, hcl 0 gm vial, hcl 00 gm smartpak, hcl 25 mg capsule, hcl 250 mg capsule, hcl 250 mg vial, 500 mg a-v vial, 500 mg vial, hcl 750 mg vial) vancomycin-d5w 500 mg/00 ml VANDAZOLE 2 VIBATIV 2 XIFAXAN 2 PA Beta-lactam, Cephalosporins AVYCAZ 2 cefaclor (250 mg capsule, 500 mg capsule) cefaclor er cefadroxil ( gm tablet, 250 mg/5 ml susp, 500 mg/5 ml susp, 500 mg capsule) cefazolin sodium ( gm add-van vial, gm vial, 0 gm vial, 20 gm bulk vial, sod 00 gm bulk bag, sod 300 gm bulk bag, 500 mg vial) cefazolin sodium-dextrose ( g/50, 2 g/50, 2 g/00) on this table mean by going to page 2. 22

23 cefdinir (25 mg/5 ml susp, 250 mg/5 ml susp, 300 mg capsule) cefditoren pivoxil cefepime hcl ( gm vial, 2 gram vial) cefixime cefotaxime sodium cefotetan cefotetan & dextrose cefoxitin cefoxitin sodium cefpodoxime proxetil (50 mg/5 ml susp, 00 mg tablet, 00 mg/5 ml susp, 200 mg tablet) cefprozil (25 mg/5 ml susp, 250 mg/5 ml susp, 250 mg tablet, 500 mg tablet) ceftazidime ( gm piggyback, gm vial, 2 gm vial, 2 gm piggyback, 6 gm vial) ceftibuten 80 mg/5 ml susp ceftriaxone ( gm-d5w bag, gm piggyback, gm vial, 2 gm piggyback, 2 gm-d5w bag, 2 gm add vial, 2 gm vial, 0 gm vial, 00 gram bulk bag, 250 mg vial, 500 mg vial) cefuroxime cefuroxime sodium cephalexin (25 mg/5 ml susp, 250 mg tablet, 250 mg capsule, 250 mg/5 ml susp, 500 mg tablet, 500 mg capsule, 750 mg capsule) SUPRAX (00 MG TABLET CHEWABLE, 200 MG TABLET CHEWABLE, 400 MG CAPSULE, 500 MG/5 ML SUSPENSION) tazicef ( gram vial, gm add-vantage vial, 2 gram vial, 6 gram vial) TEFLARO 2 2 on this table mean by going to page 2. 23

24 Beta-lactam, Other AZACTAM-ISO-OSMOTIC DEXTROSE 2 aztreonam doripenem 500 mg vial ertapenem imipenem-cilastatin sodium INVANZ ( GM VIAL, GM ADD-VANTAGE VIAL) meropenem meropenem-0.9% nacl VABOMERE 2 Beta-lactam, Penicillins amoxicillin (25 mg tab chew, 25 mg/5 ml susp, 200 mg/5 ml susp, 250 mg capsule, 250 mg tab chew, 250 mg/5 ml susp, 400 mg/5 ml susp, 500 mg tablet, 500 mg capsule, 875 mg tablet) amoxicillin-clavulanate pot er amoxicillin-clavulanate potass ( mg tab chew, mg/5 ml sus, mg/5 ml sus, mg tablet, mg/5 ml susp, mg tab chew, mg tablet, mg/5 ml sus, mg tablet) ampicillin sodium ( gm add-vantage vl, gm vial, 2 gm add-vantage vl, 2 gm vial, 0 gm vial, 0 gm bottle, 25 mg vial, 250 mg vial, 500 mg vial) ampicillin trihydrate (25 mg/5 ml susp, 250 mg capsule, 250 mg/5 ml susp, 500 mg capsule) ampicillin-sulbactam (.5 gm vl, 3 gm vial, 5 gm vl) AUGMENTIN MG/5 ML 2 2 on this table mean by going to page 2. 24

25 BICILLIN C-R 2 BICILLIN L-A 2 dicloxacillin sodium nafcillin nafcillin sodium ( gm add-van vial, gm vial, 2 gm vial, 2 gm add-vant vial, 0 gm bulk vial) penicillin g potassium penicillin g sodium penicillin gk-iso-osm dextrose penicillin v potassium (25 mg/5 ml soln, 250 mg tablet, 250 mg/5 ml soln, 500 mg tablet) piperacillin-tazobactam (piperacil-tazo 2.25 gm add vl, piperacil-tazobact 2.25 gm vl, piperacil-tazobact gm vl, piperaciltazobact 4.5 gm vial, piperacil-tazobact 3.5 gm vl, piperacil-tazobact 40.5 gram) ZOSYN (2.25 GM/50 ML BAG, GM/50 ML, 4.5 GM/00 ML BAG) 2 Macrolides AZASITE 2 azithromycin ( gm pwd packet, 00 mg/5 ml susp, 200 mg/5 ml susp, 250 mg tablet, 500 mg tablet, 600 mg tablet, i.v. 500 mg vial) clarithromycin (25 mg/5 ml sus, 250 mg tablet, 250 mg/5 ml sus, 500 mg tablet) clarithromycin er DIFICID 2 ery ERY-TAB 2 ERYPED ERYTHROCIN LACTOBIONATE (500 MG VIAL, 500 MG ADDVNT VL) 2 on this table mean by going to page 2. 25

26 ERYTHROCIN STEARATE 2 erythromycin (0.5% eye ointment, 2% gel, 2% solution, 2% pledgets, 250 mg filmtab, dr 250 mg cap, 500 mg filmtab) erythromycin ethylsuccinate (200 mg/5 ml gran, es 400 mg tab) KETEK 2 PCE 2 Quinolones BAXDELA (300 MG VIAL, 450 MG TABLET) 2 BESIVANCE 2 ciprofloxacin (250 mg/5 ml susp, 400 mg/40 ml vl, 500 mg/5 ml susp) ciprofloxacin er ciprofloxacin hcl (0.2% otic soln, 0.3% eye drop, hcl 00 mg tab, hcl 250 mg tab, hcl 500 mg tab, hcl 750 mg tab) ciprofloxacin-d5w gatifloxacin levofloxacin (0.5% eye drops, 25 mg/ml solution, 250 mg/0 ml soln, 250 mg tablet, 500 mg/20 ml vial, 500 mg tablet, 500 mg/20 ml soln, 750 mg/30 ml vial, 750 mg tablet) levofloxacin-d5w moxifloxacin (0.5% eye drops, 0.5% eye drop, 400 mg/250 ml bag) moxifloxacin hcl 400 mg tablet ofloxacin (0.3% eye drops, 0.3% ear drops, 300 mg tablet, 400 mg tablet) Sulfonamides sulfacetamide sodium (drops, ointment) sulfadiazine 500 mg tablet on this table mean by going to page 2. 26

27 sulfamethoxazole-trimethoprim (ds tablet, inj vial, ss tablet, susp) SULFATRIM 2 Tetracyclines demeclocycline hcl DORYX MPC 2 doxy 00 doxycycline hyclate (hyc dr 50 mg tab, hyc dr 75 mg tab, hyc dr 00 mg tab, hyc dr 50 mg tab, hyc dr 200 mg tab, hyclate 20 mg tab, hyclate 50 mg cap, hyclate 75 mg tab, hyclate 00 mg vl, hyclate 00 mg tab, hyclate 00 mg cap, hyclate 50 mg tab) doxycycline monohydrate (25 mg/5 ml susp, mono 50 mg cap, mono 50 mg tablet, mono 75 mg tablet, mono 75 mg capsule, mono 00 mg tablet, mono 00 mg cap, mono 50 mg cap, mono 50 mg tablet) minocycline hcl (50 mg capsule, hcl 50 mg tablet, 75 mg capsule, hcl 75 mg tablet, 00 mg capsule, hcl 00 mg tablet) mondoxyne nl morgidox (50 mg capsule, 00 mg capsule) NUZYRA (00 MG VIAL, 50 MG TABLET-7 DAY, 50 MG-7 DAY WITH LOAD, 50 MG TABLET) okebo soloxide tetracycline hcl (250 mg capsule, 500 mg capsule) VIBRAMYCIN 50 MG/5 ML SYRUP 2 2 on this table mean by going to page 2. 27

28 Anticonvulsants Anticonvulsants, Other APTIOM 2 BRIVIACT (0 MG/ML ORAL SOLN, 0 MG TABLET, 25 MG TABLET, 50 MG TABLET, 50 MG/5 ML VIAL, 75 MG TABLET, 00 MG TABLET) EPIDIOLEX 2 PA - FOR NEW STARTS ONLY FYCOMPA (0.5 MG/ML ORAL SUSP, 2 MG TABLET, 4 MG TABLET, 6 MG TABLET, 8 MG TABLET, 0 MG TABLET, 2 MG TABLET) levetiracetam (00 mg/ml soln, 250 mg tablet, 500 mg/5 ml vial, 500 mg tablet, 500 mg/5 ml soln, 750 mg tablet,,000 mg tablet) levetiracetam er levetiracetam-nacl phenobarbital (20 mg/5 ml soln, 20 mg/5 ml elix) 2 2 PA - FOR NEW STARTS ONLY phenobarbital sodium PA - FOR NEW STARTS ONLY POTIGA 2 roweepra roweepra xr SPRITAM 2 Calcium Channel Modifying Agents CELONTIN 2 ethosuximide (250 mg/5 ml soln, 250 mg capsule) LYRICA (25 MG CAPSULE, 50 MG CAPSULE, 75 MG CAPSULE, 00 MG CAPSULE, 50 MG CAPSULE, 200 MG CAPSULE, 225 MG CAPSULE) 2 QL (90 PER 30 DAYS) on this table mean by going to page 2. 28

29 LYRICA 300 MG CAPSULE 2 QL (60 PER 30 DAYS) LYRICA 20 MG/ML ORAL SOLUTION 2 QL (900 PER 30 DAYS) zonisamide (25 mg capsule, 50 mg capsule, 00 mg capsule) Gamma-aminobutyric Acid (GABA) Augmenting Agents clobazam (2.5 mg/ml suspension, 0 mg tablet, 20 mg tablet) clonazepam (2 mg odt, 2 mg tablet) QL (300 PER 30 DAYS) clonazepam (0.25 mg odt, 0.25 mg dis tab, 0.25 mg odt, 0.5 mg dis tablet, 0.5 mg tablet, 0.5 mg odt, mg odt, mg tablet, mg dis tablet) DIASTAT 2 DIASTAT ACUDIAL 2 diazepam (2.5 mg gel sys, 0 mg gel syst, 20 mg gel syst) divalproex sodium (dr 25 mg cap sprnk, sod dr 25 mg tab, sod dr 250 mg tab, sod dr 500 mg tab) divalproex sodium er gabapentin (00 mg capsule, 300 mg capsule) QL (90 PER 30 DAYS) QL (360 PER 30 DAYS) gabapentin 400 mg capsule QL (270 PER 30 DAYS) gabapentin (250 mg/5 ml soln, 300 mg/6 ml soln) QL (260 PER 30 DAYS) gabapentin 600 mg tablet QL (80 PER 30 DAYS) gabapentin 800 mg tablet QL (50 PER 30 DAYS) GABITRIL (2 MG TABLET, 6 MG TABLET) 2 ONFI (2.5 MG/ML SUSPENSION, 0 MG TABLET, 20 MG TABLET) phenobarbital (5 mg tablet, 6.2 mg tablet, 30 mg tablet, 32.4 mg tablet, 60 mg tablet, 64.8 mg tablet, 97.2 mg tablet, 00 mg tablet) 2 PA - FOR NEW STARTS ONLY on this table mean by going to page 2. 29

30 primidone (50 mg tablet, 250 mg tablet) SABRIL 500 MG TABLET 2 PA - FOR NEW STARTS ONLY SYMPAZAN 2 tiagabine hcl valproate sodium valproic acid (250 mg capsule, 250 mg/5 ml soln, 500 mg/0 ml sol) vigabatrin 500 mg powder packt PA - FOR NEW STARTS ONLY Glutamate Reducing Agents felbamate (400 mg tablet, 600 mg tablet, 600 mg/5 ml susp) lamotrigine (5 mg disper tablet, 25 mg disper tab, 25 mg tablet, 00 mg tablet, 50 mg tablet, 200 mg tablet, tablet starter kit) lamotrigine (blue) lamotrigine (green) lamotrigine (orange) lamotrigine odt (blue) lamotrigine odt (green) lamotrigine odt (orange) topiramate (5 mg sprinkle cap, 25 mg sprinkle cap, 25 mg tablet, 50 mg tablet, 00 mg tablet, 200 mg tablet) Sodium Channel Agents BANZEL (40 MG/ML SUSPENSION, 200 MG TABLET, 400 MG TABLET) carbamazepine (00 mg tab chew, 00 mg/5 ml susp, 200 mg tablet) carbamazepine er (er 00 mg cap, er 00 mg tablet, er 200 mg tablet, er 200 mg cap, er 300 mg cap, er 400 mg tablet) DILANTIN 30 MG CAPSULE 2 2 on this table mean by going to page 2. 30

31 epitol fosphenytoin 00 mg pe/2 ml vl oxcarbazepine (50 mg tablet, 300 mg/5 ml susp, 300 mg tablet, 600 mg tablet) PEGANONE 2 phenytoin (50 mg infatab, 50 mg tablet chew, 00 mg/4 ml susp, 25 mg/5 ml susp) phenytoin sodium extended VIMPAT (0 MG/ML SOLUTION, 50 MG TABLET, 00 MG TABLET, 50 MG TABLET, 200 MG/20 ML VIAL, 200 MG TABLET) 2 Antidementia Agents Antidementia Agents, Other ergoloid mesylates mg tab PA Cholinesterase Inhibitors donepezil hcl (5 mg tablet, 0 mg tablet) donepezil hcl odt galantamine er galantamine hbr galantamine hydrobromide rivastigmine (.5 mg capsule, 3 mg capsule, 4.5 mg capsule, 4.6 mg/24hr patch, 6 mg capsule, 9.5 mg/24hr patch, 3.3 mg/24hr ptch) N-methyl-D-aspartate (NMDA) Receptor Antagonist memantine hcl (hcl 2 mg/ml solution, hcl 5 mg tablet, 5-0 mg titration pk, hcl 0 mg tablet) memantine hcl er QL (30 PER 30 DAYS) on this table mean by going to page 2. 3

32 Antidepressants Antidepressants, Other bupropion hcl (75 mg tablet, 00 mg tablet) bupropion hcl sr (sr 00 mg tablet, sr 200 mg tablet) QL (90 PER 30 DAYS) bupropion hcl xl 50 mg tablet QL (90 PER 30 DAYS) bupropion hcl xl 300 mg tablet QL (30 PER 30 DAYS) mirtazapine (7.5 mg tablet, 5 mg tablet, 5 mg odt, 30 mg tablet, 30 mg odt, 45 mg tablet, 45 mg odt) Monoamine Oxidase Inhibitors EMSAM 2 ST, QL (30 PER 30 DAYS) MARPLAN 2 phenelzine sulfate 5 mg tab tranylcypromine sulfate SSRIs/SNRIs (Selective Serotonin Reuptake Inhibitors/Serotonin and Norepinephrine Reuptake Inhibitor citalopram hbr (0 mg tablet, 0 mg/5 ml soln, 20 mg tablet, 40 mg tablet) desvenlafaxine fum er 00 mg QL (20 PER 30 DAYS) desvenlafaxine fum er 50 mg QL (30 PER 30 DAYS) desvenlafaxine suc er 00 mg QL (20 PER 30 DAYS) desvenlafaxine succinate er (er 25 mg tb, er 50 mg tb) QL (30 PER 30 DAYS) duloxetine hcl (dr 20 mg cap, dr 60 mg cap) QL (60 PER 30 DAYS) duloxetine hcl (dr 30 mg cap, dr 40 mg cap) QL (90 PER 30 DAYS) escitalopram oxalate (oxalate 5 mg/5 ml, 5 mg tablet, 0 mg tablet, 20 mg tablet) FETZIMA MG TITRATION PAK 2 ST, QL (56 PER 365 OVER TIME) FETZIMA (ER 20 MG CAPSULE, ER 40 MG CAPSULE, ER 80 MG CAPSULE, ER 20 MG CAPSULE) 2 ST, QL (30 PER 30 DAYS) on this table mean by going to page 2. 32

33 fluoxetine dr QL (4 PER 28 DAYS) fluoxetine hcl (hcl 0 mg tablet, hcl 0 mg capsule, hcl 20 mg tablet, hcl 20 mg capsule, 20 mg/5 ml solution, hcl 40 mg capsule, hcl 60 mg tablet) fluvoxamine maleate maprotiline hcl nefazodone hcl paroxetine cr PA - FOR NEW STARTS ONLY paroxetine er PA - FOR NEW STARTS ONLY paroxetine hcl PA - FOR NEW STARTS ONLY paroxetine mesylate QL (30 PER 30 DAYS) PAXIL 0 MG/5 ML SUSPENSION 2 PA - FOR NEW STARTS ONLY sertraline hcl (20 mg/ml oral conc, hcl 25 mg tablet, hcl 50 mg tablet, hcl 00 mg tablet) trazodone hcl (50 mg tablet, 00 mg tablet, 50 mg tablet, 300 mg tablet) TRINTELLIX 2 QL (30 PER 30 DAYS) venlafaxine hcl venlafaxine hcl er (er 37.5 mg cap, er 37.5 mg tab, er 75 mg cap, er 75 mg tab, er 50 mg cap, er 50 mg tab, er 225 mg tab) VIIBRYD 0-20 MG STARTER PACK 2 QL (60 PER 365 OVER TIME) VIIBRYD (0 MG TABLET, 20 MG TABLET, 40 MG TABLET) 2 QL (30 PER 30 DAYS) Tricyclics amitriptyline hcl (0 mg tab, 25 mg tab, 50 mg tab, 75 mg tab, 00 mg tab, 50 mg tab) PA - FOR NEW STARTS ONLY amoxapine PA - FOR NEW STARTS ONLY chlordiazepoxide-amitriptyline PA - FOR NEW STARTS ONLY clomipramine hcl (25 mg capsule, 50 mg capsule, 75 mg capsule) PA - FOR NEW STARTS ONLY on this table mean by going to page 2. 33

34 desipramine hcl (0 mg tablet, 25 mg tablet, 50 mg tablet, 75 mg tablet, 00 mg tablet, 50 mg tablet) doxepin hcl (0 mg/ml oral conc, 0 mg capsule, 25 mg capsule, 50 mg capsule, 75 mg capsule, 00 mg capsule, 50 mg capsule) imipramine hcl (0 mg tablet, 25 mg tablet, 50 mg tablet) nortriptyline hcl (hcl 0 mg cap, 0 mg/5 ml soln, 20 mg/0 ml soln, hcl 25 mg cap, hcl 50 mg cap, hcl 75 mg cap) PA - FOR NEW STARTS ONLY PA - FOR NEW STARTS ONLY PA - FOR NEW STARTS ONLY PA - FOR NEW STARTS ONLY perphenazine-amitriptyline PA - FOR NEW STARTS ONLY protriptyline hcl PA - FOR NEW STARTS ONLY trimipramine maleate PA - FOR NEW STARTS ONLY Antiemetics Antiemetics, Other AKYNZEO MG CAPSULE 2 QL (2 PER 30 OVER TIME) compro droperidol (2.5 mg/ml ampul, 2.5 mg/ml vial) meclizine hcl (2.5 mg tablet, 25 mg tablet) PA phenadoz PA PHENERGAN (2.5 MG, 25 MG, 50 MG) 2 PA prochlorperazine prochlorperazine 0 mg/2 ml vl prochlorperazine maleate (5 mg tablet, 0 mg tab) on this table mean by going to page 2. 34

35 promethazine hcl (6.25 mg/5 ml syrp, 6.25 mg/5 ml soln, 2.5 mg tablet, 2.5 mg suppos, 25 mg/ml vial, 25 mg suppository, 25 mg tablet, 25 mg/ml ampul, 50 mg/ml vial, 50 mg suppository, 50 mg/ml ampul, 50 mg tablet) PA promethegan PA scopolamine PA Emetogenic Therapy Adjuncts ALOXI 2 ANZEMET 2 QL (5 PER 30 OVER TIME) aprepitant mg pack PA - Part B vs D Determination, QL (6 PER 30 OVER TIME) aprepitant 25 mg capsule PA - Part B vs D Determination, QL (2 PER 30 OVER TIME) aprepitant 40 mg capsule PA - Part B vs D Determination, QL ( PER 30 OVER TIME) aprepitant 80 mg capsule PA - Part B vs D Determination, QL (8 PER 30 OVER TIME) CINVANTI 2 dronabinol PA, QL (60 PER 30 OVER TIME) EMEND 25 MG POWDER PACKET 2 PA - Part B vs D Determination, QL (6 PER 30 OVER TIME) granisetron hcl mg tablet PA - Part B vs D Determination, QL (30 PER 30 OVER TIME) granisetron hcl (0. mg/ml vial, mg/ml vial, 4 mg/4 ml vial) ondansetron hcl (hcl 4 mg/2 ml vial, hcl 4 mg/2 ml syr, hcl 4 mg/2 ml amp, 4 mg/2 ml isecure) QL (240 PER 30 DAYS) ondansetron 4 mg/5 ml solution PA - Part B vs D Determination, QL (450 PER 30 DAYS) ondansetron hcl (4 mg tablet, 8 mg tablet) PA - Part B vs D Determination ondansetron hcl 24 mg tablet PA - Part B vs D Determination, QL (4 PER 28 OVER TIME) on this table mean by going to page 2. 35

36 ondansetron 40 mg/20 ml vial QL (20 PER 30 DAYS) ondansetron odt PA - Part B vs D Determination palonosetron hcl (0.25 mg/5 ml vial, 0.25 mg/2 ml vial) SANCUSO 2 QL (2 PER 30 OVER TIME) SYNDROS 2 PA, QL (20 PER 30 DAYS) Antifungals ABELCET 2 PA - Part B vs D Determination AMBISOME 2 PA - Part B vs D Determination amphotericin b 50 mg vial PA - Part B vs D Determination caspofungin acetate ciclodan 0.77% cream ciclodan 8% solution PA ciclopirox (0.77% gel, 0.77% cream, 0.77% topical susp, % shampoo) ciclopirox 8% solution PA clotrimazole (% solution, % cream, 0 mg troche) clotrimazole-betamethasone (crm, lot) CRESEMBA (86 MG CAPSULE, 372 MG VIAL) econazole nitrate % cream EXELDERM (CREAM, SOLUTION) 2 fluconazole (0 mg/ml susp, 40 mg/ml susp, 50 mg tablet, 00 mg tablet, 50 mg tablet, 200 mg tablet) fluconazole in saline fluconazole-nacl flucytosine (250 mg capsule, 500 mg capsule) griseofulvin (25 mg/5 ml susp, micro 500 mg tab) 2 on this table mean by going to page 2. 36

37 griseofulvin ultramicrosize itraconazole (0 mg/ml solution, 00 mg capsule) JUBLIA 2 ketoconazole (2% foam, 2% shampoo, 2% cream, 200 mg tablet) ketodan 2% foam LAMISIL (25 MG GRANULES PACKET, 87.5 MG GRANULES PACK) miconazole 3 naftifine hcl NAFTIN (% GEL, 2% GEL) 2 NATACYN 2 NOXAFIL (40 MG/ML SUSPENSION, DR 00 MG TABLET, 300 MG/6.7 ML VIAL) nyamyc nystatin (00,000 unit/gm cream, 00,000 unit/ml susp, 00,000 unit/gm oint, 00,000 unit/gm powd, 500,000 unit oral tab, 500,000 unit/5 ml sus) nystatin-triamcinolone (cream, ointm) nystop oxiconazole nitrate OXISTAT % LOTION 2 PA SPORANOX 0 MG/ML SOLUTION 2 PA 2 2 terbinafine hcl 250 mg tablet QL (84 PER 80 OVER TIME) terconazole (0.4% cream, 0.8% cream, 80 mg suppository) TOLSURA 2 PA voriconazole (40 mg/ml susp, 50 mg tablet, 200 mg tablet, 200 mg vial) zazole on this table mean by going to page 2. 37

38 Antigout Agents allopurinol (00 mg tablet, 300 mg tablet) allopurinol sodium colchicine (0.6 mg capsule, 0.6 mg tablet) COLCRYS 2 probenecid probenecid-colchicine ULORIC 2 ST Antimigraine Agents Ergot Alkaloids dihydroergotamine mg/ml amp dihydroergotamine 4 mg/ml spry QL (8 PER 30 OVER TIME) ERGOMAR 2 ergotamine-caffeine migergot Prophylactic AIMOVIG 70 MG/ML AUTOINJECTOR 2 PA, QL (2 PER 30 DAYS) AIMOVIG AUTOINJECTOR (2 PACK) 2 PA, QL (2 PER 30 DAYS) Serotonin (5-HT) b/d Receptor Agonists eletriptan hbr QL (2 PER 30 OVER TIME) frovatriptan succinate QL (2 PER 30 OVER TIME) naratriptan hcl QL (9 PER 30 OVER TIME) rizatriptan (5 mg tablet, 5 mg odt, 0 mg odt, 0 mg tablet) QL (8 PER 30 OVER TIME) sumatriptan (5 mg spray, 20 mg spray) QL (2 PER 30 OVER TIME) sumatriptan succ-naproxen sod QL (9 PER 30 OVER TIME) on this table mean by going to page 2. 38

39 sumatriptan succinate (4 mg/0.5 ml cart, 4 mg/0.5 ml inject) sumatriptan succinate (25 mg tablet, 50 mg tablet, 00 mg tablet) sumatriptan succinate (6 mg/0.5 ml vial, 6 mg/0.5 ml refill, 6 mg/0.5 ml inject, 6 mg/0.5 ml syrng) QL (8 PER 30 OVER TIME) QL (9 PER 30 OVER TIME) QL (5 PER 30 OVER TIME) zolmitriptan (2.5 mg tablet, 5 mg tablet) QL (2 PER 30 OVER TIME) Antimyasthenic Agents Parasympathomimetics guanidine hcl MESTINON 60 MG/5 ML SYRUP 2 pyridostigmine br 60 mg tablet pyridostigmine bromide er REGONOL 2 Antimycobacterials Antimycobacterials, Other dapsone (25 mg tablet, 00 mg tablet) rifabutin Antituberculars CAPASTAT SULFATE 2 cycloserine 250 mg capsule ethambutol hcl isoniazid (50 mg/5 ml solution, 00 mg/ml vial, 00 mg tablet, 300 mg tablet) PASER 2 PRIFTIN 2 pyrazinamide 500 mg tablet on this table mean by going to page 2. 39

40 rifampin (50 mg capsule, 300 mg capsule, iv 600 mg vial) RIFATER 2 SIRTURO 2 TRECATOR 2 Antineoplastics Alkylating Agents BENDEKA 2 BICNU 2 busulfan carboplatin (50 mg/5 ml vial, 50 mg/5 ml vial, 450 mg/45 ml vial, 600 mg/60 ml vial) cisplatin cyclophosphamide (25 mg capsule, 50 mg capsule) cyclophosphamide ( gm vial, 2 gm vial, 500 mg vial) dacarbazine EVOMELA 2 GLEOSTINE 2 HEXALEN 2 ifosfamide ( gm/20 ml vial, gm vial, 3 gm vial, 3 gm/60 ml vial) PA - Part B vs D Determination KISQALI FEMARA CO-PACK 2 PA - FOR NEW STARTS ONLY, QL (9 PER 28 DAYS) LEUKERAN 2 LOMUSTINE 2 MATULANE 2 melphalan hcl MUSTARGEN 2 on this table mean by going to page 2. 40