LIST OF COVERED DRUGS (FORMULARY) IlliniCare Health (Medicare-Medicaid Plan)

Transcription

1 2018 LIST OF COVERED DRUGS (FORMULARY) IlliniCare Health (Medicare-Medicaid Plan) Note to existing members: This formulary has changed since last year. Please review this document to make sure that it still contains s take. PLEASE READ: THIS DOCUME COAINS IORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN. If have questions, please call IlliniCare Health Member Services at (TTY: 71 from 8 a.m. to 8 p.m., Monday through Friday. After hours, on weekends and on holidays, may be asked to leave a message. Your call be returned within next business day. The call is free. For more information, visit Updated 01/2018 HPMS Approved Formulary File Submission ID: Version Number: 6 H0281_18_LODR_Approved_

2 Notice of Non-Discrimination. IlliniCare Health - MMAI (Medicare-Medicaid Plan) complies with applicable federal civil rights laws and does not discriminate on basis of race, color, national origin, age, disability, or sex. IlliniCare Health does not exclude people or treat m differently because of race, color, national origin, age, disability, or sex. IlliniCare Health: Provides free aids and services to people with disabilities to communicate effectively with us, such as qualified sign language interpreters and written information in or formats (large print, accessible electronic formats, or formats). Provides free language services to people whose primary language is not English, such as qualified interpreters and information written in or languages. If need se services, contact IlliniCare Health's Member Services at (TTY: 71 from 8 a.m. to 8 p.m., Monday through Friday. After hours, on weekends and on holidays, may be asked to leave a message. Your call be returned within next business day. If believe that IlliniCare Health has failed to provide se services or discriminated in anor way on basis of race, color, national origin, age, disability or sex, can file a grievance by calling number above and telling m need help filing a grievance; IlliniCare Health's Member Services is available to help. You can also file a civil rights complaint with U.S. Department of Health and Human Services, Office for Civil Rights, electronically through Office for Civil Rights Complaint Portal, available at or by mail or phone at: U.S. Department of Health and Human Services, 200 Independence Avenue SW., Room 509F, HHH Building, Washington, DC 20201, , (TDD: ). Complaint forms are available at Language Services ATTEION: If speak English, language assistance services, free of charge, are available to. Call (TTY: 71. ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al (TTY: 71. UWAGA: Jeżeli mówisz po polsku, możesz skorzystać z bezpłatnej pomocy językowej. Zadzwoń pod numer (TTY: 71. 注意 : 如果您使用繁體中文, 您可以免費獲得語言援助服務 請電 (TTY:71 주의 : 한국어를사용하시는경우, 언어지원서비스를무료로이용하실수있습니다 (TTY: 71 번으로전화해주십시오. PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng tulong sa wika nang walang bayad. Tumawag sa (TTY: 71. ملحوظة : إذا كنت تتحدث اللغة العربية فإن خدمات المساعدة اللغوية تتوافر لك بالمجان. اتصل برقم ھاتف الصم والبكم: 71. (رقم ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услуги перевода. Звоните (TTY: 71. ચન : જ તમ જર ત બ લત હ, ત ન: ક ભ ષ સહ ય સ વ ઓ તમ ર મ ટ ઉપલ ધ છ. ફ ન કર (TTY: 71. خبردار : اگر آپ اردو بولتے ہيں تو آپ کو زبان کی مدد کی خدمات مفت ميں دستياب ہيں کال کريں (TTY: 71. CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho bạn. Gọi số (TTY: 71. ATTENZIONE: In caso la lingua parlata sia l'italiano, sono disponibili servizi di assistenza linguistica gratuiti. Chiamare il numero (TTY: 71. य न द : य द आप ह द ब लत ह त आपक लए म त म भ ष सह यत सव ए उपल ध ह (TTY: 71 पर क ल कर ATTEION: Si vous parlez français, des services d'aide linguistique vous sont proposés gratuitement. Appelez le (ATS: 71. ΠΡΟΣΟΧΗ: Αν μιλάτε ελληνικά, στη διάθεσή σας βρίσκονται υπηρεσίες γλωσσικής υποστήριξης, οι οποίες παρέχονται δωρεάν. Καλέστε (TTY: 71. ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen zur Verfügung. Rufnummer: (TTY: 71.

3 This is a list of s that members can get in IlliniCare Health. H0281_18_LODR_Approved_ IlliniCare Health MMAI (Medicare-Medicaid Plan) is a health plan that contracts with both Medicare and Illinois Medicaid to provide benefits of both programs to enrollees. The List of Covered Drugs and/or pharmacy and provider networks may change throughout year. We send a notice before we make a change that affects. Benefits may change on January 1 of each year. You can always check IlliniCare Health s upto-date List of Covered Drugs online at Limitations and restrictions may apply. For more information, call IlliniCare Health Member Services at (TTY: 71, 8 a.m. to 8 p.m., Monday through Friday or read IlliniCare Health Member Handbook. Si usted habla español, hay servicios de asistencia de idiomas disponibles para usted sin cargo. Llame al (TTY: 71, de lunes a viernes, de 8:00 a.m. a 8:00 p.m. Después del horario de atención, los fines de semana y los días feriados, es posible que se le pida que deje un mensaje. Le devolveremos la llamada el siguiente día hábil. La llamada es gratuita. You can get this document for free in or formats, such as large print, braille, or audio. Call (TTY: 71, 8 a.m. to 8 p.m., Monday through Friday. After hours, on weekends and on holidays, may be asked to leave a message. Your call be returned within next business day. The call is free. If would like us to send member materials on an ongoing basis in or formats, such as Braille or large print, or in a language or than English, please call Member Services at number at bottom of page. Tell Member Services that would like to place a standing request to get r materials in anor format or language. If have questions, please call IlliniCare Health at (TTY: 71, 8 a.m. to 8? p.m., Monday through Friday. After hours, on weekends and on holidays, may be asked to leave a message. Your call be returned within next business day. The call is free. For more information, visit i

4 Frequently Asked Questions (FAQ) Find answers here to questions have about this List of Covered Drugs. You can read all of FAQ to learn more, or look for a question and answer. 1. prescription s are on List of Covered Drugs? (We call List of Covered Drugs Drug List for short.) The s on List of Covered Drugs that starts on page 1 are s covered by IlliniCare Health. These s are available at pharmacies within our network. A pharmacy is in our network if we have an agreement with m to work with us and provide services. We refer to se pharmacies as network pharmacies. IlliniCare Health cover all medically necessary s on Drug List if: r doctor or or prescriber says need m to get better or stay healthy, and fill prescription at a IlliniCare Health network pharmacy. IlliniCare Health may have additional steps to access certain s (see question #5 below). You can also see an up-to-date list of s that we cover on our website at or call Member Services at (TTY: 71, 8 a.m. to 8 p.m., Monday through Friday. After hours, on weekends and on holidays, may be asked to leave a message. Your call be returned within next business day. The call is free. 2. Does Drug List ever change? Yes. IlliniCare Health may add or remove s on Drug List during year. Generally, Drug List only change if: a cheaper comes along that works as well as a on Drug List now, or we learn that a is not safe. We may also change our rules about s. For example, we could: Decide to require or not require prior approval for a. (Prior approval is permission from IlliniCare Health before can get a.) Add or change amount of a can get (called quantity limits ). Add or change step rapy restrictions on a. (Step rapy means must try one before we cover anor.) If have questions, please call IlliniCare Health at (TTY: 71, 8 a.m. to 8? p.m., Monday through Friday. After hours, on weekends and on holidays, may be asked to leave a message. Your call be returned within next business day. The call is free. For more information, visit ii

5 (For more information on se rules, see page iii.) We tell when a are taking is removed from Drug List. We also tell when we change our rules for covering a. Questions 3, 4, and 7 below have more information on what happens when Drug List changes. You can always check IlliniCare Health s up to date Drug List online at You can also call Member Services to check current Drug List at (TTY: 71, 8 a.m. to 8 p.m., Monday through Friday. After hours, on weekends and on holidays, may be asked to leave a message. Your call be returned within next business day. The call is free. 3. happens when a cheaper comes along that works as well as a on Drug List now? If are taking a that is removed because a cheaper that works just as well comes along, we tell. We tell at least 60 days before we remove it from Drug List or when ask for a refill. Then can get a 60-day supply of before change to Drug List is made. We mail a notice if are taking a and we change our rules for covering it. You receive notice by mail at least 60 days before we change rules or remove from our Drug List. We also put se types of changes on our website at 4. happens when we find out a is not safe? If Food and Drug Administration (FDA) says a are taking is not safe, we take it off Drug List right away. We also send a letter telling that. If have any questions after being notified of change, should contact doctor who prescribed for. 5. Are re any restrictions or limits on coverage? Or are re any required actions to take in order to get certain s? Yes, some s have coverage rules or have limits on amount can get. In some cases, or r doctor or or prescriber must do something before can get. For example, If have questions, please call IlliniCare Health at (TTY: 71, 8 a.m. to 8? p.m., Monday through Friday. After hours, on weekends and on holidays, may be asked to leave a message. Your call be returned within next business day. The call is free. For more information, visit iii

6 Prior approval (or prior authorization): For some s, or r doctor or or prescriber must get approval from IlliniCare Health before fill r prescription. If don t get approval, IlliniCare Health may not cover. Quantity limits: Sometimes IlliniCare Health limits amount of a can get. Step rapy: Sometimes IlliniCare Health requires to do step rapy. This means have to try s in a certain order for r medical condition. You might have to try one before we cover anor. If r doctor thinks first doesn t work for, n we cover second. You can find out if r has any additional requirements or limits by looking in tables on pages 1- Index 1. You can also get more information by visiting our web site at We have posted online documents that explain our prior authorization and step rapy restrictions. You may also ask us to send a copy. You can ask for an exception from se limits. Please see question 11 for more information on exceptions. If are in a nursing home or or long-term care facility and need a that is not on Drug List, or if cannot easily get need, we can help. We cover a 31-day emergency supply of need (unless have a prescription for fewer days), wher or not are a new IlliniCare Health member. This give time to talk to r doctor or or prescriber. He or she can help decide if re is a similar on Drug List can take instead or wher to ask for an exception. Please see question 11 for more information about exceptions. 6. How know if want has limitations or if re are required actions to take to get? The List of Covered Drugs on page 1 has a column labeled. 7. happens if we change our rules on how we cover some s? For example, if we add prior authorization (approval), quantity limits, and/or step rapy restrictions on a. We tell if we add prior approval, quantity limits, and/or step rapy restrictions on a. We tell at least 60 days before restriction is added or when next ask for a refill. If have questions, please call IlliniCare Health at (TTY: 71, 8 a.m. to 8? p.m., Monday through Friday. After hours, on weekends and on holidays, may be asked to leave a message. Your call be returned within next business day. The call is free. For more information, visit iv

7 Then, can get a 60-day supply of before change to Drug List is made. This gives time to talk to r doctor or or prescriber about what to do next. 8. How can find a on Drug List? There are two ways to find a : You can search alphabetically (if know how to spell ), or You can search by medical condition. To search alphabetically, go to Alphabetical Listing section. You can find it in Index that begins on page Index 1. To search by medical condition, find section labeled List of s by medical condition on page 1. The s in this section are grouped into categories depending on type of medical conditions y are used to treat. For example, if have a heart condition, should look in category, CARDIOVASCULAR AGES - MISC. - Drugs to Treat Heart and Circulation Conditions. That is where find s that treat heart conditions. 9. if want to take is not on Drug List? If don t see r on Drug List, call Member Services at (TTY: 71, 8 a.m. to 8 p.m., Monday through Friday and ask about it. The call is free. If learn that IlliniCare Health not cover, can do one of se things: Ask Member Services for a list of s like one want to take. Then show list to r doctor or or prescriber. He or she can prescribe a on Drug List that is like one want to take. Or You can ask health plan to make an exception to cover r. Please see question 11 for more information about exceptions. 10. if are a new IlliniCare Health member and can t find r on Drug List or have a problem getting r? We can help. We may cover a temporary 30-day supply of r during first 90 days are a member of IlliniCare Health. This give time to talk to r doctor or or prescriber. He or she can help decide if re is a similar on Drug List can take instead or wher to ask for an exception. If have questions, please call IlliniCare Health at (TTY: 71, 8 a.m. to 8? p.m., Monday through Friday. After hours, on weekends and on holidays, may be asked to leave a message. Your call be returned within next business day. The call is free. For more information, visit v

8 We cover a 30-day supply of r if: are taking a that is not on our Drug List, or health plan rules do not let get amount ordered by r prescriber, or requires prior approval by IlliniCare Health, or are taking a that is part of a step rapy restriction. If live in a nursing home or or long-term care facility, may refill r prescription for as long as 98 days. You may refill multiple times during r first 90 days in plan. This gives r prescriber time to change r s to ones on Drug List or ask for an exception. Level of Care Changes If r level of care changes, we cover a transition supply of r s. A level of care change happens when are released from a hospital. It also happens when move to or from a long-term care facility. If move home from a long-term care facility or hospital and need a transition supply, we cover one 30-day supply. If r prescription is written for fewer days, we allow refills to provide up to a total of a 30-day supply. If move from home or a hospital to a long-term care facility and need a transition supply, we cover one 31-day supply. If r prescription is written for fewer days, we allow refills to provide up to a total of a 31-day supply. 11. Can ask for an exception to cover r? Yes. You can ask IlliniCare Health to make an exception to cover a that is not on Drug List. You can also ask us to change rules on r. For example, IlliniCare Health may limit amount of a we cover. If r has a limit, can ask us to change limit and cover more. Or examples: You can ask us to drop step rapy restrictions or prior approval requirements. 12. How long does it take to get an exception? First, we must get a statement from r prescriber supporting r ask for an exception. After we get statement, we give a decision on r exception request within 72 hours. If have questions, please call IlliniCare Health at (TTY: 71, 8 a.m. to 8? p.m., Monday through Friday. After hours, on weekends and on holidays, may be asked to leave a message. Your call be returned within next business day. The call is free. For more information, visit vi

9 If or r prescriber think r health may be harmed if have to wait 72 hours for a decision, can ask for an expedited exception. This is a faster decision. If r prescriber supports r request, we give a decision within 24 hours of getting r prescriber s supporting statement. 13. How can ask for an exception? To ask for an exception, call Member Services. A Member Services representative work with and r provider to help ask for an exception. 14. are generic s? Generic s are made up of same active ingredients as brand name s. They usually less than brand name and usually don t have well-known names. Generic s are approved by Food and Drug Administration (FDA). IlliniCare Health covers both brand name s and generic s. 15. are OTC s? OTC stands for over--counter. IlliniCare Health covers some OTC s when y are written as prescriptions by r provider. You can read IlliniCare Health Drug List to see what OTC s are covered. 16. Does IlliniCare Health cover OTC non- products? IlliniCare Health covers some OTC non- products when y are written as prescriptions by r provider. You can read IlliniCare Health Drug List to see what OTC non- products are covered. 17. is r copay? You can read IlliniCare Health Drug List to learn about copay for each. IlliniCare Health members living in nursing homes or or long-term care facilities have no copays. Some members getting long-term care in community also have no copays. If have questions, please call IlliniCare Health at (TTY: 71, 8 a.m. to 8? p.m., Monday through Friday. After hours, on weekends and on holidays, may be asked to leave a message. Your call be returned within next business day. The call is free. For more information, visit vii

10 As an IlliniCare Health member, have no copays for prescription and OTC s as long as follow IlliniCare Health s rules. 18. are tiers? Tiers are groups of s on our Drug List. Tier 1 s are generic s. Tier 2 s are brand s. Tier 3 s are Non-Medicare prescription or over--counter s. All tiers do not have a copay. List of Covered Drugs The list of covered s that begins on page 1 gives information about s covered by IlliniCare Health. If have trouble finding r in list, turn to Index that begins on page Index 1. The first column of chart lists name of. Brand name s are capitalized (e.g., ELIQUIS TABS) and generic s are listed in lower-case italics (e.g., warfarin sodium tabs). The information in necessary column tells if IlliniCare Health has any rules for covering r. Here are meanings of codes used in column: Abbreviation this means How it works AL Age Limit This may need prior authorization if r age does not meet maker, FDA or clinical guidelines. B/D Medicare Part B vs. Part D This may need prior authorization to decide if it should be covered under Medicare Part B or Part D. This is a Medicare rule. Your doctor or or prescriber may need to give more facts to help us make this decision. If have questions, please call IlliniCare Health at (TTY: 71, 8 a.m. to 8? p.m., Monday through Friday. After hours, on weekends and on holidays, may be asked to leave a message. Your call be returned within next business day. The call is free. For more information, visit viii

11 Abbreviation LA this means Limited Access How it works This prescription may be available only at certain pharmacies. For more information consult r Pharmacy Directory or call Member Services at (TTY: 71, Monday through Friday, 8:00 a.m. to 8:00 p.m. After hours, on weekends and on holidays, can leave a message. Your call be returned within next business day. Mail Order This is available at our mail order pharmacy in addition to or network pharmacies. NDS Non-Extended Day Supply This prescription is not available for an extended day supply. Not Covered This is not covered on Drug List. You can ask for an exception for to be covered. Not Part D This is not a Part D. You not be required to pay a copay for se s. PA Prior Authorization This requires prior authorization. This means that or r doctor must get approval from us before fill r prescription. If don t get approval, we may not cover. QL Quantity Limit This has a limit on amount that our plan cover. RX/OTC Prescription and Over-- Counter (OTC) This is made in both prescription form and OTC form. SL Safety Limit This has a maximum daily dose limit for safety supported by FDA. This means that we not cover more than maximum daily dose. For example, FDA maximum daily dose of ibuprofen is 3200 mg. Therefore, we only cover four tablets per day for ibuprofen 800 mg. If have questions, please call IlliniCare Health at (TTY: 71, 8 a.m. to 8? p.m., Monday through Friday. After hours, on weekends and on holidays, may be asked to leave a message. Your call be returned within next business day. The call is free. For more information, visit ix

12 Abbreviation this means How it works ST Step Therapy This requires step rapy. This means have to try s in a certain order for r medical condition. You might have to try one before we cover anor. If r doctor thinks first doesn t work for, n we cover second. Note: The next to a means is not a Part D. The amount pay when fill a prescription for this does not count towards r total s (that is, amount pay does not help qualify for catastrophic coverage). In addition, if are getting Extra Help to pay for r prescriptions, not get any Extra Help to pay for se s. These s also have different rules for appeals. An appeal is a formal way of asking us to review a coverage decision and to change it if think we made a mistake. For example, we might decide that a that want is not covered or is no longer covered by Medicare or Medicaid. If or r doctor disagrees with our decision, can appeal. To ask for instructions on how to appeal, call Member Services at (TTY: 71, 8 a.m. to 8 p.m., Monday through Friday. After hours, on weekends and on holidays, may be asked to leave a message. Your call be returned within next business day. The call is free. You can also read Member Handbook to learn how to appeal a decision. List of Drugs by Medical Condition The s in this section are grouped into categories depending on type of medical conditions y are used to treat. For example, if have a heart condition, should look in category, CARDIOVASCULAR AGES - MISC. - Drugs to Treat Heart and Circulation Conditions. That is where find s that treat heart conditions. If have questions, please call IlliniCare Health at (TTY: 71, 8 a.m. to 8? p.m., Monday through Friday. After hours, on weekends and on holidays, may be asked to leave a message. Your call be returned within next business day. The call is free. For more information, visit x

13 Name of ADHD/AI-NARCOLEPSY/AI- OBESITY/ANOREXIAS - Drugs to Treat ADHD, Sleep and Eating Disorders Amphetamines ADDERALL TABS (Amphetamine- Dextroamphetamine) ADDERALL XR CP24 (Amphetamine- Dextroamphetamine) amphetaminedextroamphetamine cp24 amphetaminedextroamphetamine tabs DESOXYN TABS (Methamphetamine HCl) DEXEDRINE CP24 (Dextroamphetamine Sulfate) dextroamphetamine sulfate cp24 10 mg, 5 mg, 15 mg dextroamphetamine sulfate tabs 10 mg, 5 mg methamphetamine hcl tabs PA; PA; Attention-Deficit/Hyperactivity Disorder (ADHD) atomoxetine hcl caps 10 SL(10 ea daily); mg atomoxetine hcl caps 100 mg atomoxetine hcl caps 18 mg SL(1 ea daily); SL(5.55 ea daily); Name of atomoxetine hcl caps 25 mg atomoxetine hcl caps 40 mg atomoxetine hcl caps 60 mg atomoxetine hcl caps 80 mg clonidine hcl (adhd) tb12 guanfacine hcl (adhd) tb24 IUNIV TB24 (Guanfacine HCl (ADHD)) KAPVAY TB12 (Clonidine HCl (ADHD)) STRATTERA CAPS 10 MG (Atomoxetine HCl) STRATTERA CAPS 100 MG (Atomoxetine HCl) STRATTERA CAPS 18 MG (Atomoxetine HCl) STRATTERA CAPS 25 MG (Atomoxetine HCl) STRATTERA CAPS 40 MG (Atomoxetine HCl) STRATTERA CAPS 60 MG (Atomoxetine HCl) STRATTERA CAPS 80 MG (Atomoxetine HCl) Stimulants - Misc. CONCERTA TBCR SL(4 ea daily); SL(2.5 ea daily); SL(1.66 ea daily); SL(1.25 ea daily); AL; Up to 64 yrs old; AL; Up to 64 yrs old; SL(10 ea daily); SL(1 ea daily); SL(5.55 ea daily); SL(4 ea daily); SL(2.5 ea daily); SL(1.66 ea daily); SL(1.25 ea daily); You can find information on what symbols and abbreviations in this table mean by going to 1

14 Name of dexmethylphenidate hcl cp24 15 mg, 20 mg, 10 mg dexmethylphenidate hcl tabs 10 mg, 2.5 mg, 5 mg FOCALIN TABS (Dexmethylphenidate HCl) FOCALIN XR CP24 15 MG, 10 MG, 20 MG (Dexmethylphenidate HCl) METADATE CD CPCR 20 MG (Methylphenidate HCl) METADATE CD CPCR 30 MG (Methylphenidate HCl) METADATE CD CPCR 50 MG, 40 MG, 60 MG, 10 MG (Methylphenidate HCl) methylphenidate hcl cp24 or 20 mg, 40 mg, 60 mg, 30 mg methylphenidate hcl cpcr or 20 mg methylphenidate hcl cpcr or 30 mg methylphenidate hcl cpcr or 50 mg, 10 mg, 40 mg, 60 mg methylphenidate hcl tabs or 10 mg, 5 mg, 20 mg methylphenidate hcl tb24 or 27 mg, 36 mg methylphenidate hcl tbcr or 20 mg methylphenidate hcl tbcr or 27 mg, 36 mg, 54 mg, 18 mg QL(2 ea daily); QL(1 ea daily); QL(2 ea daily); QL(1 ea daily); QL(3 ea daily); Non-Osmotic Release QL(3 ea daily); Name of modafinil tabs 100 mg modafinil tabs 200 mg PROVIGIL TABS 100 MG (Modafinil) PROVIGIL TABS 200 MG (Modafinil) RITALIN LA CP24 20 MG, 30 MG, 40 MG (Methylphenidate HCl) RITALIN LA CP24 60 MG RITALIN TABS (Methylphenidate HCl) PA; PA; QL(1 ea daily); PA; PA; QL(1 ea daily); QL(3 ea daily); ALLERGENIC EXTRACTS/BIOLOGICALS MISC Biologicals Misc NDS; LA ADAGEN SOLN AMINOGLYCOSIDES - Drugs to Treat Bacterial Infections Aminoglycosides amikacin sulfate soln ij 1 gm/4ml, 500 mg/2ml BETHKIS NEBU gentamicin in saline soln 0.9%-1mg/ml gentamicin sulfate soln ij 40 mg/ml B/D; NDS; You can find information on what symbols and abbreviations in this table mean by going to 2

15 Name of KITABIS PAK NEBU neomycin sulfate tabs or paromomycin sulfate caps TOBI NEBU (Tobramycin) TOBI PODHALER CAPS tobramycin nebu in tobramycin sulfate soln ij 40 mg/ml, 1.2 gm/30ml, 80 mg/2ml tobramycin sulfate solr ij 1.2 gm B/D B/D NDS; B/D ANALGESICS - AI-ILAMMATORY - Drugs to Treat Pain, Swelling, Muscle and Joint Conditions Anti-T-alpha - Monoclonal Antibodies HUMIRA PEDIATRIC PA; NDS; CROHNS DISEASE STARTER PACK PSKT PA; NDS; HUMIRA PEN PNKT HUMIRA PEN-CROHNS DISEASESTARTER PNKT HUMIRA PEN-PSORIASIS STARTER PNKT HUMIRA PSKT PA; NDS; PA; NDS; PA; NDS; Name of SIMPONI ARIA SOLN SIMPONI SOAJ SIMPONI SOSY PA; NDS; PA; NDS; PA; NDS; Antirheumatic - Enzyme Inhibitors PA; NDS; XELJANZ TABS Antirheumatic Antimetabolites PA OTREXUP SOAJ RASUVO SOAJ 12.5 MG/0.25ML, 7.5 MG/0.15ML, 22.5 MG/0.45ML, 15 MG/0.3ML, 17.5 MG/0.35ML, 10 MG/0.2ML, 20 MG/0.4ML, 30 MG/0.6ML, 25 MG/0.5ML PA Gold Compounds NDS; RIDAURA CAPS Interleukin-1 Blockers NDS; LA ARCALYST SOLR Interleukin-1 Receptor Antagonist (IL-1Ra) PA; NDS; KINERET SOSY Interleukin-1beta Blockers You can find information on what symbols and abbreviations in this table mean by going to 3

16 Name of ILARIS SOLN ILARIS SOLR PA; NDS; LA PA; NDS; LA Interleukin-6 Receptor Inhibitors ACTEMRA SOLN PA; NDS; ACTEMRA SOSY PA; NDS; Nonsteroidal Anti-inflammatory Agents (NSAIDs) ADVIL CAPS (Ibuprofen) ; ADVIL MIGRAINE CAPS (Ibuprofen) ADVIL TABS (Ibuprofen) ALEVE ARTHRITIS TABS (Naproxen Sodium) ALEVE TABS (Naproxen Sodium) ANAPROX DS TABS (Naproxen Sodium) ARTHROTEC 50 TBEC (Diclofenac w/ Misoprostol) ARTHROTEC 75 TBEC (Diclofenac w/ Misoprostol) CELEBREX CAPS (Celecoxib) celecoxib caps CHILDRENS ADVIL SUSP (Ibuprofen) CHILDRENS TRIN SUSP (Ibuprofen) DAYPRO TABS (Oxaprozin) ; ; ; ; RX/OTC; ; RX/OTC; ; Name of diclofenac potassium tabs diclofenac sodium tb24 or 100 mg diclofenac sodium tbec or 50 mg, 25 mg, 75 mg diclofenac w/ misoprostol tbec EC-NAPROSYN TBEC (Naproxen) etodolac caps etodolac tabs etodolac tb24 FELDENE CAPS (Piroxicam) flurbiprofen tabs or 50 mg, 100 mg ibuprofen caps or 200 mg ibuprofen susp or 100 mg/5ml ibuprofen tabs or 200 mg ibuprofen tabs or 400 mg ; RX/OTC; ; SL(8 ea daily); You can find information on what symbols and abbreviations in this table mean by going to 4

17 Name of ibuprofen tabs or 600 mg ibuprofen tabs or 800 mg indomethacin caps or 25 mg, 50 mg indomethacin cpcr or 75 mg ketoprofen caps or 50 mg, 75 mg ketorolac tromethamine soln ij 30 mg/ml, 15 mg/ml ketorolac tromethamine soln im 60 mg/2ml, 30 mg/ml LODINE TABS (Etodolac) mefenamic acid caps or meloxicam tabs or 7.5 mg, 15 mg BIC TABS 7.5 MG, 15 MG (Meloxicam) nabumetone tabs NAPROSYN TABS 500 MG (Naproxen) naproxen sodium tabs or 220 mg naproxen sodium tabs or 550 mg, 275 mg SL(5.33 ea daily); SL(4 ea daily); AL; Up to 64 yrs old; AL; Up to 64 yrs old; AL; Up to 64 yrs old; AL; Up to 64 yrs old; ; Name of naproxen tabs or 250 mg, 375 mg, 500 mg naproxen tbec or 500 mg, 375 mg oxaprozin tabs piroxicam caps or 20 mg, 10 mg PONSTEL CAPS (Mefenamic Acid) sulindac tabs or 200 mg, 150 mg tolmetin sodium caps 400 mg tolmetin sodium tabs 200 mg Phosphodiesterase 4 (PDE4) Inhibitors PA; NDS; OTEZLA TABS PA; NDS; OTEZLA TBPK Pyrimidine Synsis Inhibitors ARAVA TABS (Leflunomide) leflunomide tabs or 20 mg, 10 mg Selective Costimulation Modulators ORENCIA CLICKJECT PA; NDS; SOAJ You can find information on what symbols and abbreviations in this table mean by going to 5

18 Name of ORENCIA SOLR ORENCIA SOSY PA; NDS; PA; NDS; Soluble Tumor Necrosis Factor Receptor Agents PA; NDS; ENBREL SOLR PA; NDS; ENBREL SOSY ENBREL SURECLICK PA; NDS; SOAJ ANALGESICS - NonNarcotic - Drugs to Treat Pain, Muscle and Joint Conditions Analgesics Or acetaminophen caps or 500 mg acetaminophen chew or 80 mg acetaminophen liqd or 160 mg/5ml acetaminophen liqd or 500 mg/15ml, 1000 mg/30ml acetaminophen soln or 160 mg/5ml, 325 mg/10.15ml, 650 mg/20.3ml acetaminophen supp re 120 mg, 325 mg acetaminophen susp or 160 mg/5ml, 80 mg/2.5ml ; ; ; ; ; ; Name of acetaminophen susp or 80 mg/0.8ml acetaminophen tabs or 325 mg, 500 mg FEVERALL IAS SUPP TYLENOL CHILDRENS SUSP (Acetaminophen) TYLENOL EXTRA STRENGTH TABS (Acetaminophen) TYLENOL IAS PAIN+FEVER SUSP (Acetaminophen) TYLENOL IAS SUSP (Acetaminophen) TYLENOL SORE THROAT DAYTIME LIQD (Acetaminophen) TYLENOL TABS (Acetaminophen) Salicylates aspirin chew or 81 mg aspirin tabs or 325 mg aspirin tbec or 81 mg, 325 mg, 324 mg diflunisal tabs ECOTRIN REGULAR STRENGTH TBEC (Aspirin) ; ; ; ; ; ; ; ; ; ; You can find information on what symbols and abbreviations in this table mean by going to 6

19 Name of ANALGESICS - OPIOID - Drugs to Treat Pain, Muscle and Joint Conditions Opioid Agonists ACTIQ LPOP 200 MCG PA; NDS;QL(8 (Fentanyl Citrate) ACTIQ LPOP 400 MCG, 800 MCG, 1200 MCG, 600 MCG, 1600 MCG (Fentanyl Citrate) DEMEROL SOLN IJ 25 MG/ML (Meperidine HCl) DEMEROL SOLN IJ 50 MG/ML, 100 MG/ML (Meperidine HCl) DILAUDID LIQD OR 1 MG/ML (Hydromorphone HCl) DILAUDID SOLN IJ 2 MG/ML DILAUDID SOLN IJ 2 MG/ML (Hydromorphone HCl) DILAUDID TABS OR 2 MG (Hydromorphone HCl) DILAUDID TABS OR 4 MG (Hydromorphone HCl) DILAUDID TABS OR 8 MG (Hydromorphone HCl) DILAUDID-HP SOLN (Hydromorphone HCl) DOLOPHINE TABS 10 MG (Methadone HCl) DOLOPHINE TABS 5 MG (Methadone HCl) DURAGESIC PT MCG/HR (Fentanyl) DURAGESIC PT72 12 MCG/HR (Fentanyl) ea daily); PA; NDS;QL(4 ea daily); AL; Up to 64 yrs old AL; Up to 64 yrs old; QL(50 ml daily); Preservative Free QL(25 ea daily); QL(12.5 ea daily); QL(6.25 ea daily); QL(6.67 ea daily); QL(13.34 ea daily); QL(0.5 ea daily); Limit 43 patches per month;ql(1.44 ea daily); Name of DURAGESIC PT72 25 MCG/HR (Fentanyl) DURAGESIC PT72 50 MCG/HR, 75 MCG/HR (Fentanyl) fentanyl citrate lpop bu 1200 mcg, 800 mcg, 600 mcg, 1600 mcg, 400 mcg fentanyl citrate lpop bu 200 mcg fentanyl pt mcg/hr fentanyl pt72 12 mcg/hr fentanyl pt72 25 mcg/hr fentanyl pt72 50 mcg/hr, 75 mcg/hr hydromorphone hcl liqd or 1 mg/ml hydromorphone hcl soln ij 10 mg/ml, 500 mg/50ml, 50 mg/5ml hydromorphone hcl soln ij 2 mg/ml hydromorphone hcl tabs or 2 mg hydromorphone hcl tabs or 4 mg QL(0.94 ea daily); Limit 15 patches per month;ql(0.5 ea daily); PA; NDS;QL(4 ea daily); PA; NDS;QL(8 ea daily); QL(0.5 ea daily); Limit 43 patches per month;ql(1.44 ea daily); QL(0.94 ea daily); Limit 15 patches per month;ql(0.5 ea daily); QL(50 ml daily); QL(25 ea daily); QL(12.5 ea daily); You can find information on what symbols and abbreviations in this table mean by going to 7

20 Name of hydromorphone hcl tabs or 8 mg KADIAN CP24 10 MG (Morphine Sulfate) KADIAN CP MG (Morphine Sulfate) KADIAN CP24 20 MG (Morphine Sulfate) KADIAN CP24 30 MG (Morphine Sulfate) KADIAN CP24 50 MG (Morphine Sulfate) KADIAN CP24 60 MG (Morphine Sulfate) KADIAN CP24 80 MG (Morphine Sulfate) LAZANDA SOLN 100 MCG/ACT LAZANDA SOLN 300 MCG/ACT LAZANDA SOLN 400 MCG/ACT meperidine hcl soln ij 25 mg/ml meperidine hcl soln ij 50 mg/ml, 100 mg/ml methadone hcl conc or 10 mg/ml methadone hcl soln or 10 mg/5ml methadone hcl soln or 5 mg/5ml QL(6.25 ea daily); QL(20 ea daily); NDS;QL(2 ea daily); QL(10 ea daily); QL(6.67 ea daily); QL(4 ea daily); QL(3.34 ea daily); QL(2.5 ea daily); PA; NDS;QL(1 ea daily); PA; NDS;QL(0.5 ea daily); PA; NDS;QL(0.27 ea daily); AL; Up to 64 yrs old AL; Up to 64 yrs old; QL(6.67 ml daily); QL(33.34 ml daily); QL(66.67 ml daily); Name of methadone hcl tabs or 10 mg methadone hcl tabs or 5 mg METHADOSE CONC (Methadone HCl) METHADOSE SUGAR- FREE CONC (Methadone HCl) morphine sulfate cp24 or 10 mg morphine sulfate cp24 or 100 mg morphine sulfate cp24 or 20 mg morphine sulfate cp24 or 30 mg morphine sulfate cp24 or 50 mg morphine sulfate cp24 or 60 mg morphine sulfate cp24 or 80 mg morphine sulfate soln ij 0.5 mg/ml morphine sulfate soln ij 1 mg/ml morphine sulfate soln or 10 mg/5ml QL(6.67 ea daily); QL(13.34 ea daily); QL(6.67 ml daily); QL(6.67 ml daily); QL(20 ea daily); NDS;QL(2 ea daily); QL(10 ea daily); QL(6.67 ea daily); QL(4 ea daily); QL(3.34 ea daily); QL(2.5 ea daily); QL(100 ml daily); You can find information on what symbols and abbreviations in this table mean by going to 8

21 Name of morphine sulfate soln or 100 mg/5ml, 20 mg/ml morphine sulfate soln or 20 mg/5ml RPHINE SULFATE TABS OR 15 MG RPHINE SULFATE TABS OR 30 MG morphine sulfate tbcr or 15 mg morphine sulfate tbcr or 200 mg, 100 mg morphine sulfate tbcr or 30 mg morphine sulfate tbcr or 60 mg MS COIN TBCR 15 MG (Morphine Sulfate) MS COIN TBCR 200 MG, 100 MG (Morphine Sulfate) MS COIN TBCR 30 MG (Morphine Sulfate) MS COIN TBCR 60 MG (Morphine Sulfate) OPANA TABS OR 10 MG (Oxymorphone HCl) OPANA TABS OR 5 MG (Oxymorphone HCl) oxycodone hcl caps or 5 mg QL(10 ml daily); QL(50 ml daily); QL(13.34 ea daily); QL(6.67 ea daily); QL(13.34 ea daily); QL(2 ea daily); QL(6.67 ea daily); QL(3.34 ea daily); QL(13.34 ea daily); QL(2 ea daily); QL(6.67 ea daily); QL(3.34 ea daily); QL(6.67 ea daily); QL(13.34 ea daily); QL(26.67 ea daily); Name of oxycodone hcl conc or 100 mg/5ml oxycodone hcl tabs or 15 mg oxycodone hcl tabs or 30 mg oxycodone hcl tabs or 5 mg oxymorphone hcl tabs 10 mg oxymorphone hcl tabs 5 mg oxymorphone hcl tb12 15 mg oxymorphone hcl tb mg ROXICODONE TABS 15 MG (Oxycodone HCl) ROXICODONE TABS 30 MG (Oxycodone HCl) ROXICODONE TABS 5 MG (Oxycodone HCl) SUBSYS LIQD 100 MCG SUBSYS LIQD 1200 MCG SUBSYS LIQD 1600 MCG SUBSYS LIQD 200 MCG QL(6.67 ml daily); QL(8.9 ea daily); QL(4.44 ea daily); QL(26.67 ea daily); QL(6.67 ea daily); QL(13.34 ea daily); QL(4.44 ea daily); QL(8.89 ea daily); QL(8.9 ea daily); QL(4.44 ea daily); QL(26.67 ea daily); PA; NDS;QL(16 ea daily); PA; QL(2 ea daily) PA; QL(4 ea daily); PA; NDS;QL(8 ea daily); You can find information on what symbols and abbreviations in this table mean by going to 9

22 Name of SUBSYS LIQD 400 MCG, 600 MCG, 800 MCG tramadol hcl tabs or 50 mg tramadol hcl tb24 or 100 mg tramadol hcl tb24 or 200 mg tramadol hcl tb24 or 300 mg ULTRAM ER TB MG (Tramadol HCl) ULTRAM ER TB MG (Tramadol HCl) ULTRAM ER TB MG (Tramadol HCl) ULTRAM TABS (Tramadol HCl) ZOHYDRO ER C12A 10 MG ZOHYDRO ER C12A 15 MG ZOHYDRO ER C12A 20 MG ZOHYDRO ER C12A 30 MG ZOHYDRO ER C12A 40 MG ZOHYDRO ER C12A 50 MG Opioid Combinations PA; NDS;QL(4 ea daily); SL(8 ea daily); SL(3 ea daily); SL(1.5 ea daily); SL(1 ea daily); SL(3 ea daily); SL(1.5 ea daily); SL(1 ea daily); SL(8 ea daily); PA; QL(16.8 ea daily); PA; QL(11.2 ea daily); PA; QL(8.4 ea daily); PA; QL(5.6 ea daily); PA; QL(4.2 ea daily); PA; QL(3.37 ea daily); Name of acetaminophen w/ codeine soln 120mg/5ml-12mg/5ml acetaminophen w/ codeine tabs 300mg-15mg acetaminophen w/ codeine tabs 300mg-30mg acetaminophen w/ codeine tabs 300mg-60mg butalbital-aspirin-caffeine w/cod caps FIORINAL/CODEINE #3 CAPS (Butalbital-Aspirin- Caffeine w/cod) HYCET SOLN (Hydrocodone- Acetaminophen) hydrocodoneacetaminophen soln 2.5mg/5ml-108mg/5ml, 7.5mg/15ml-325mg/15ml, 5mg/10ml-217mg/10ml hydrocodoneacetaminophen tabs 10mg- 300mg, 5mg-300mg, 7.5mg-300mg hydrocodoneacetaminophen tabs 5mg- 325mg, 10mg-325mg, 7.5mg-325mg hydrocodone-ibuprofen tabs IBUDONE TABS (Hydrocodone-Ibuprofen) NORCO TABS (Hydrocodone- Acetaminophen) SL(150 ml daily); SL(13.3 ea daily); SL(12 ea daily); SL(6 ea daily); AL; Up to 64 yrs old; SL(6 ea daily); AL; Up to 64 yrs old; SL(6 ea daily); Limit 5535mls per month;sl( ml daily); Limit 5535mls per month;sl( ml daily); SL(13.3 ea daily); SL(12.3 ea daily); SL(12.3 ea daily); You can find information on what symbols and abbreviations in this table mean by going to 10

23 Name of oxycodone w/ acetaminophen soln 5mg/5ml-325mg/5ml oxycodone w/ acetaminophen tabs 7.5mg-325mg, 5mg- 325mg, 10mg-325mg, 2.5mg-325mg oxycodone-aspirin tabs PERCOCET TABS (Oxycodone w/ Acetaminophen) REPREXAIN TABS (Hydrocodone-Ibuprofen) tramadol-acetaminophen tabs TYLENOL/CODEINE #3 TABS (Acetaminophen w/ Codeine) TYLENOL/CODEINE #4 TABS (Acetaminophen w/ Codeine) ULTRACET TABS (Tramadol-Acetaminophen) VICOPROFEN TABS (Hydrocodone-Ibuprofen) XODOL TABS (Hydrocodone- Acetaminophen) Opioid Partial Agonists BUPRENEX SOLN (Buprenorphine HCl) buprenorphine hcl soln ij 0.3 mg/ml buprenorphine hcl subl sl 2 mg Limit 1845mls per month;sl(61.5 ml daily) SL(12.3 ea daily); SL(12.3 ea daily); SL(8 ea daily); SL(12 ea daily); SL(6 ea daily); SL(8 ea daily); SL(13.3 ea daily); PA; QL(16 ea daily); Name of buprenorphine hcl subl sl 8 mg buprenorphine hclnaloxone hcl dihydrate subl butorphanol tartrate soln ij 2 mg/ml butorphanol tartrate soln na 10 mg/ml nalbuphine hcl soln ij 20 mg/ml, 10 mg/ml PA; QL(4 ea daily); PA; Limit 210mls per month;ql(7 ml daily); ANDROGENS-ANABOLIC - Drugs to Regulate Hormones Anabolic Steroids ANADROL-50 TABS OXANDRIN TABS 10 MG (Oxandrolone) OXANDRIN TABS 2.5 MG (Oxandrolone) oxandrolone tabs or 10 mg oxandrolone tabs or 2.5 mg Androgens ANDRODERM PT24 ANDROGEL GEL MG/1.25GM, 40.5 MG/2.5GM ANDROGEL GEL 50 MG/5GM, 25 MG/2.5GM (Testosterone) NDS; NDS; NDS; You can find information on what symbols and abbreviations in this table mean by going to 11

24 Name of ANDROGEL PUMP GEL ANDROID CAPS (Methyltestosterone) AVEED SOLN danazol caps or 200 mg, 50 mg, 100 mg DEPO-TESTOSTERONE SOLN (Testosterone Cypionate) fluoxymesterone tabs or methyltestosterone caps or TESTIM GEL (Testosterone) LA testosterone cypionate soln testosterone enanthate soln im testosterone gel 1 %, 25 mg/2.5gm, 50 mg/5gm TESTOSTERONE GEL 1 %, 25 MG/2.5GM, 50 MG/5GM TESTOSTERONE PUMP GEL TESTRED CAPS (Methyltestosterone) VOGELXO GEL Name of VOGELXO PUMP GEL ANORECTAL AGES - Rectal Drugs to Treat Pain, Swelling and Itching Intrarectal Steroids CORTENEMA ENEM (Hydrocortisone (Intrarectal)) hydrocortisone (intrarectal) enem UCERIS FOAM RE 2 MG/ACT Rectal Combinations phenylephrine in hard fat supp Rectal Local Anestics dibucaine (rectal) oint lidocaine (anorectal) crea LMX 5 CREA (Lidocaine (Anorectal)) NUPERCAINAL OI (Dibucaine (Rectal)) RECTICARE CREA (Lidocaine (Anorectal)) Rectal Steroids ANUSOL-HC CREA (Hydrocortisone (Rectal)) hydrocortisone (rectal) crea PROCTOCORT CREA 1 % (Hydrocortisone (Rectal)) ; ; ; ; ; You can find information on what symbols and abbreviations in this table mean by going to 12

25 Name of Vasodilating Agents RECTIV OI AACIDS - Ulcer and Stomach Acid Drugs Antacid Combinations alum & mag hydroxsimethicone chew 200mg- 25mg-200mg alum & mag hydroxsimethicone liqd 400mg/5ml-40mg/5ml- 400mg/5ml, 200mg/5ml- 20mg/5ml-200mg/5ml alum & mag hydroxsimethicone susp 400mg/5ml-400mg/5ml- 40mg/5ml-40mg/5ml- 400mg/5ml-400mg/5ml, 200mg/5ml-200mg/5ml- 20mg/5ml-20mg/5ml- 200mg/5ml-200mg/5ml, 200mg/5ml-20mg/5ml- 200mg/5ml, 400mg/5ml- 40mg/5ml-400mg/5ml aluminum hydroxide-mag carb susp 254mg/5ml mg/5ml, 95mg/15ml- 358mg/15ml calcium carbonate-mag hydrox chew 300mg- 700mg GAVISCON CHEW 14.2MG-80MG GAVISCON EXTRA STRENGTH RELIEF FORMULA SUSP (Aluminum Hydroxide-Mag Carb) ; ; ; ; ; ; Name of GAVISCON EXTRA STRENGTH SUSP 254MG/5ML-237.5MG/5ML (Aluminum Hydroxide-Mag Carb) GAVISCON SUSP 95MG/15ML-358MG/15ML (Aluminum Hydroxide-Mag Carb) GELUSIL CHEW 200MG- 25MG-200MG (Alum & Mag Hydrox-Simethicone) HYVEE ADVANCED AACID MAXIMUM STRENGTH SUSP (Alum & Mag Hydrox- Simethicone) MI-ACID CHEW Antacids - Aluminum Salts ALUMINUM HYDROXIDE SUSP OR Antacids - Bicarbonate sodium bicarbonate (antacid) tabs Antacids - Calcium Salts calcium carbonate (antacid) chew 1000 mg, 750 mg, 500 mg calcium carbonate (antacid) susp 1250 mg/5ml TUMS CHEW (Calcium Carbonate (Antacid)) TUMS CHEWY BITES CHEW (Calcium Carbonate (Antacid)) ; ; ; ; ; ; ; ; ; You can find information on what symbols and abbreviations in this table mean by going to 13

26 Name of TUMS E-X 750 CHEW (Calcium Carbonate (Antacid)) TUMS EXTRA STRENGTH 750 CHEW (Calcium Carbonate (Antacid)) TUMS KIDS CHEW (Calcium Carbonate (Antacid)) TUMS LASTING EFFECTS CHEW (Calcium Carbonate (Antacid)) TUMS SOTHIES CHEW (Calcium Carbonate (Antacid)) TUMS ULTRA 1000 CHEW (Calcium Carbonate (Antacid)) Antacids - Magnesium Salts magnesium oxide tabs 420 mg, 400 mg ; ; ; ; ; ; ; AHELMIICS - Drugs to Treat Worm Infections Anlmintics ALBENZA TABS ivermectin tabs or pyrantel pamoate susp or STROMECTOL TABS (Ivermectin) AI-IECTIVE AGES - MISC. - Drugs to Treat Bacterial Infections Anti-infective Agents - Misc. Name of AZACTAM SOLR (Aztreonam) aztreonam solr CAYSTON SOLR colistimethate sodium solr ij COLY-MYCIN M SOLR (Colistimethate Sodium) FLAGYL CAPS 375 MG (Metronidazole) FLAGYL TABS 250 MG (Metronidazole) FLAGYL TABS 500 MG (Metronidazole) metronidazole caps or 375 mg metronidazole in nacl soln metronidazole tabs or 250 mg metronidazole tabs or 500 mg NEBUPE SOLR ORBACTIV SOLR PEAM 300 SOLR TINDAMAX TABS (Tinidazole) PA; NDS; LA SL(10.6 ea daily); SL(16 ea daily); SL(8 ea daily); SL(10.6 ea daily); SL(16 ea daily); SL(8 ea daily); B/D; NDS; You can find information on what symbols and abbreviations in this table mean by going to 14

27 Name of tinidazole tabs or 500 mg, 250 mg trimethoprim tabs or VANCOCIN HCL CAPS (Vancomycin HCl) vancomycin hcl caps or 250 mg, 125 mg VANCOMYCIN HCL IN DEXTROSE SOLN 500MG/100ML-5%, 1GM/200ML-5%, 5%- 750MG/150ML vancomycin hcl solr iv 1000 mg, 10 gm, 5000 mg vancomycin hcl solr iv 500 mg XIFAXAN TABS 200 MG XIFAXAN TABS 550 MG PA; NDS; PA; NDS; Anti-infective Misc. - Combinations BACTRIM DS TABS (Sulfamethoxazole- Trimethoprim) BACTRIM TABS (Sulfamethoxazole- Trimethoprim) sulfamethoxazoletrimethoprim soln sulfamethoxazoletrimethoprim susp NDS; NDS;QL(3 ea daily); Name of sulfamethoxazoletrimethoprim tabs Antiprotozoal Agents ALINIA TABS 500 MG atovaquone susp MEPRON SUSP (Atovaquone) Carbapenems imipenem-cilastatin solr INVANZ SOLR IJ meropenem solr MERREM SOLR (Meropenem) PRIMAXIN IV ADD- VAAGE SOLR (Imipenem-Cilastatin) PRIMAXIN IV SOLR (Imipenem-Cilastatin) Chloramphenicols chloramphenicol sodium succinate solr Cyclic Lipopeptides CUBICIN RF SOLR (Daptomycin) CUBICIN SOLR (Daptomycin) NDS; NDS; NDS; NDS; You can find information on what symbols and abbreviations in this table mean by going to 15

28 Name of daptomycin solr Glycylcyclines TIGECYCLINE SOLR tigecycline solr TYGACIL SOLR (Tigecycline) Leprostatics dapsone tabs or 25 mg, 100 mg Lincosamides CLEOCIN CAPS OR 75 MG, 150 MG, 300 MG (Clindamycin HCl) CLEOCIN IN D5W SOLN (Clindamycin Phosphate in D5W) CLEOCIN PEDIATRIC GRANULES SOLR (Clindamycin Palmitate Hydrochloride) CLEOCIN PHOSPHATE SOLN IJ 600 MG/4ML, 900 MG/6ML (Clindamycin Phosphate) CLEOCIN PHOSPHATE SOLN IV 300MG/50ML- 5%, 900MG/50ML-5%, 600MG/50ML-5% (Clindamycin Phosphate in D5W) CLEOCIN PHOSPHATE SOLN IV 600 MG/4ML (Clindamycin Phosphate) NDS; NDS; NDS; NDS; Name of clindamycin hcl caps or 300 mg, 150 mg, 75 mg clindamycin palmitate hydrochloride solr clindamycin phosphate in d5w soln clindamycin phosphate soln ij 150 mg/ml, 9000 mg/60ml clindamycin phosphate soln ij 600 mg/4ml, 900 mg/6ml clindamycin phosphate soln iv 600 mg/4ml LINCOCIN SOLN (Lincomycin HCl) lincomycin hcl soln ij Oxazolidinones linezolid soln iv 600 mg/300ml LINEZOLID SOLN IV 600MG/300ML-0.9% linezolid susr or 100 mg/5ml linezolid tabs or 600 mg SIVEXTRO SOLR IV SIVEXTRO TABS OR NDS; NDS; NDS; NDS; NDS; You can find information on what symbols and abbreviations in this table mean by going to 16

29 Name of ZYVOX SOLN IV 200 MG/100ML ZYVOX SOLN IV 600 MG/300ML (Linezolid) ZYVOX SUSR OR 100 MG/5ML (Linezolid) ZYVOX TABS OR 600 MG (Linezolid) Polymyxins polymyxin b sulfate solr ij NDS; NDS; NDS; Streptogramins NDS; SYNERCID SOLR AIANGINAL AGES - Drugs to Treat Chest Pain Antianginals-Or RANEXA TB12 Nitrates ISORDIL TITRADOSE TABS 5 MG (Isosorbide Dinitrate) isosorbide dinitrate tabs 5 mg, 10 mg, 20 mg, 30 mg isosorbide dinitrate tbcr 40 mg isosorbide mononitrate tabs 20 mg, 10 mg isosorbide mononitrate tb mg, 30 mg, 60 mg PA; Name of NITRO-DUR PT MG/HR, 0.6 MG/HR, 0.2 MG/HR, 0.4 MG/HR (Nitroglycerin) NITROGLYCERIN LINGUAL AERS nitroglycerin pt24 td 0.6 mg/hr, 0.2 mg/hr, 0.4 mg/hr, 0.1 mg/hr nitroglycerin soln tl 0.4 mg/spray nitroglycerin subl sl 0.4 mg, 0.6 mg, 0.3 mg NITROLINGUAL PUMPSPRAY SOLN (Nitroglycerin) NITROMIST AERS NITROSTAT SUBL (Nitroglycerin) AIANXIETY AGES - Drugs to Treat Anxiety Antianxiety Agents - Misc. buspirone hcl tabs or 7.5 mg, 30 mg, 15 mg, 5 mg, 10 mg hydroxyzine hcl soln im 50 mg/ml hydroxyzine hcl syrp or 10 mg/5ml hydroxyzine hcl tabs or 25 mg, 10 mg, 50 mg AL; Up to 64 yrs old; AL; Up to 64 yrs old; AL; Up to 64 yrs old; You can find information on what symbols and abbreviations in this table mean by going to 17

30 Name of hydroxyzine pamoate caps or 25 mg, 50 mg VISTARIL CAPS (Hydroxyzine Pamoate) Benzodiazepines alprazolam tabs or 0.5 mg, 0.25 mg, 2 mg, 1 mg alprazolam tb24 or 2 mg, 1 mg, 3 mg, 0.5 mg alprazolam tbdp or 0.5 mg, 0.25 mg, 1 mg, 2 mg ATIVAN SOLN IJ 2 MG/ML (Lorazepam) ATIVAN SOLN IJ 4 MG/ML (Lorazepam) ATIVAN TABS OR 0.5 MG, 2 MG, 1 MG (Lorazepam) clorazepate dipotassium tabs diazepam conc or 5 mg/ml diazepam soln or 1 mg/ml diazepam tabs or 5 mg, 2 mg, 10 mg lorazepam conc or 2 mg/ml lorazepam soln ij 2 mg/ml, 20 mg/10ml lorazepam soln ij 4 mg/ml AL; Up to 64 yrs old; AL; Up to 64 yrs old; Name of lorazepam tabs or 1 mg, 0.5 mg, 2 mg oxazepam caps TRANXENE T TABS (Clorazepate Dipotassium) VALIUM TABS (Diazepam) XANAX TABS (Alprazolam) XANAX XR TB24 (Alprazolam) AIARRHYTHMICS - Drugs to treat abnormal heart rhythms Antiarrhythmics Type I-A disopyramide phosphate caps NORPACE CAPS (Disopyramide Phosphate) quinidine gluconate tbcr or 324 mg quinidine sulfate tabs Antiarrhythmics Type I-B mexiletine hcl caps Antiarrhythmics Type I-C flecainide acetate tabs 100 mg flecainide acetate tabs 150 mg AL; Up to 64 yrs old; AL; Up to 64 yrs old; SL(4 ea daily); SL(2.66 ea daily); You can find information on what symbols and abbreviations in this table mean by going to 18

31 Name of flecainide acetate tabs 50 mg propafenone hcl cp12 propafenone hcl tabs RYTHL SR CP12 (Propafenone HCl) RYTHL TABS (Propafenone HCl) Antiarrhythmics Type III amiodarone hcl tabs or 100 mg, 200 mg, 400 mg dofetilide caps MULTAQ TABS TIKOSYN CAPS (Dofetilide) SL(8 ea daily); AIASTHMATIC AND BRONCHODILATOR AGES - Drugs to Treat Lung Conditions Anti-Inflammatory Agents B/D; cromolyn sodium nebu in Antiasthmatic - Monoclonal Antibodies PA; LA CINQAIR SOLN PA; NDS; LA NUCALA SOLR PA; NDS; LA XOLAIR SOLR Name of Bronchodilators - Anticholinergics ATROVE HFA AERS ipratropium bromide soln in SPIRIVA HANDIHALER CAPS SPIRIVA RESPIMAT AERS TUDORZA PRESSAIR AEPB TUDORZA PRESSAIR AEPB Leukotriene Modulators ACCOLATE TABS (Zafirlukast) montelukast sodium chew 4 mg, 5 mg montelukast sodium tabs 10 mg SINGULAIR CHEW 5 MG, 4 MG (Montelukast Sodium) SINGULAIR TABS 10 MG (Montelukast Sodium) You can find information on what symbols and abbreviations in this table mean by going to 19 Limit 2 inhalers per month;ql(0.86 gm daily); B/D; QL(1 ea daily); Limit 1 inhaler per month (60 actuations);sl( 0.14 gm daily); Limit 1 inhaler per month (60 actuations);ql( 0.04 ea daily); Limit 2 inhalers per month (30 actuations);ql( 0.07 ea daily);