LIST OF COVERED DRUGS (FORMULARY) Superior HealthPlan STAR+PLUS Medicare-Medicaid Plan (MMP)

Transcription

1 2018 LIST OF COVERED DRUGS (FORMULARY) Superior HealthPlan STAR+PLUS Medicare-Medicaid Plan (MMP) 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 Superior STAR+PLUS MMP Member Services at (TTY: 71 from 8 a.m. to 8 p.m., Monday through Friday. After hours, on weekends and on holidays, can leave a message. Your call be returned within next business day. The call is free. Updated 06/2018 HPMS Approved Formulary File Submission ID: Version Number: 10 H6870_18_LODR1_Approved_

2 Statement of Non-Discrimination Superior HealthPlan (Superior) STAR+PLUS Medicare-Medicaid Plan (MMP) complies with applicable federal civil rights laws and does not discriminate on basis of race, color, national origin, age, disability, or sex. Superior STAR+PLUS MMP does not exclude people or treat m diferently because of race, color, national origin, age, disability, or sex. Superior STAR+PLUS MMP: Provides free aids and services to people with disabilities to communicate efectively with us, such as qualifed 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 qualifed interpreters and information written in or languages. If need se services, contact Superior STAR+PLUS MMP 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. The call is free. If believe that Superior STAR+PLUS MMP has failed to provide se services or discriminated in anor way on basis of race, color, national origin, age, disability or sex, can fle a grievance by calling number above and telling m need help fling a grievance; Superior STAR+PLUS MMP s Member Services is available to help. You can also fle a civil rights complaint with U.S. Department of Health and Human Services, Ofce for Civil Rights, electronically through Ofce 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 Declaración de no discriminación Superior HealthPlan (Superior) STAR+PLUS Medicare-Medicaid Plan (MMP) cumple con las leyes federales de derechos civiles aplicables y no discrimina por cuestiones de raza, color, nacionalidad, edad, discapacidad o sexo. Superior STAR+PLUS MMP no excluye a ninguna persona ni la trata de manera diferente por motivos de raza, color, nacionalidad, edad, discapacidad o sexo. Superior STAR+PLUS MMP: Brinda asistencia y servicios gratis a las personas con discapacidades para que puedan comunicarse de manera efcaz con nosotros como, por ejemplo, intérpretes de lenguaje de señas califcados e información escrita en otros formatos (letra grande, formatos electrónicos accesibles y otros formatos). Brinda servicios lingüísticos gratis a aquellas personas cuya lengua materna no es el inglés, como intérpretes califcados e información escrita en otros idiomas. Si necesita estos servicios, póngase en contacto con Servicios para afliados de Superior STAR+PLUS MMP al (los usuarios de TTY deben llamar al 71 de 8 a. m. a 8 p. m., de lunes a viernes. Luego del horario de atención, los fnes de semana y los días feriados, es posible que se le pida que deje un mensaje. Le devolveremos la llamada el próximo día hábil. La llamada es gratuita. Si usted considera que Superior STAR+PLUS MMP no le ha brindado estos servicios o lo ha discriminado de alguna otra manera debido a su raza, color, nacionalidad, edad, discapacidad o sexo, puede presentar un reclamo llamando al número que aparece arriba e informando que necesita ayuda para presentar el reclamo; el Departamento de Servicios para afliados de Superior STAR+PLUS MMP está disponible para ayudarlo. También puede presentar una queja sobre derechos civiles ante la Ofcina de Derechos Civiles del Departamento de Salud y Servicios Sociales de los EE. UU. de manera electrónica a través del Ofce for Civil Rights Complaint Portal (Portal de quejas de la Ofcina de Derechos Civiles) disponible en o bien, por correo electrónico o a los teléfonos que fguran a continuación: U.S. Department of Health and Human Services, 200 Independence Avenue SW., Room 509F, HHH Building, Washington, DC 20201, , (TDD: ) Los formularios de quejas se encuentran disponibles en SHP_ A-MMP

3 SPANISH: ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al (TTY: 71. CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành VIETNAMESE: cho bạn. Gọi số (TTY: 71. CHINESE: KOREAN: ARABIC: URDU: 注意 : 如果您使用繁體中文, 您可以免費獲得語言援助服務 請致電 (TTY: 71 주의 : 한국어를사용하시는경우, 언어지원서비스를무료로이용하실수있습니다 (TTY: 71 번으로전화해주십시오. ملحوظة: إذا كنت تتحدث اذكر اللغة فا ن خدمات المساعدة اللغویة تتوافر لك بالمجان. اتصل برقم (رقم ھاتف الصم والبكم: 71. خبردار: اگر آپ اردو بولتے ہیں تو آپ کو زبان کی مدد کی خدمات مفت میں دستیاب ہیں کال کریں 71. (TTY: PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng a TAGALOG: serbisyo ng tulong sa wika nang walang bayad. Tumawag sa (TTY: 71. FRENCH: HINDI: PERSIAN/ FARSI: GERMAN: GUJARATI: RUSSIAN: JAPANESE: LAOTIAN: ATTEION : Si vous parlez français, des services d'aide linguistique vous sont proposés gratuitement. Appelez le (ATS : 71. ध य न द : य द आप ह द ब लत ह त आपक लए म फ त म भ ष सह यत स व ए उपलब ध ह (TTY:71 पर क ल कर توجھ: اگر بھ زبان فارسی گفتگو می کنید تسھیلات زبانی بصورت شما فراھم می باشد. با (TTY: تماس بگیرید. برای رایگان ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen zur Verfügung. Rufnummer: (TTY: 71. ચન : જ તમ જર ત બ લત હ, ત ન: લ ક ભ ષ સહ ય સ વ ઓ તમ ર મ ટ ઉપલબ ધ છ. ફ ન કર (TTY: 71. ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услуги перевода. Звоните (телетайп: 71. 注意事項 : 日本語を話される場合 無料の言語支援をご利用いただけます (TTY: 71 まで お電話にてご連絡ください ໂປດຊາບ: ຖາວາ ທານເວ າພາສາ ລາວ, ການບລການຊວຍເຫ ອດານພາສາ, ໂດຍບເສຽຄາ, ແມນມ ພ ອມໃຫ ທ ານ. ໂທຣ (TTY: 71. SHP_ C-MMP

4 This is a list of s that members can get in Superior STAR+PLUS MMP. H6870_18_LODR1_Approved_ Superior HealthPlan STAR+PLUS Medicare-Medicaid Plan (MMP) is a health plan that contracts with both Medicare and Texas 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 Superior STAR+PLUS MMP s up-to-date List of Covered Drugs online at Limitations and restrictions may apply. For more information, call Superior STAR+PLUS MMP Member Services or read Superior STAR+PLUS MMP Member Handbook. If speak Spanish, language assistance services, free of charge, are available to. Call (TTY: 71, 8 a.m. to 8 p.m., Monday through Friday. After hours, on weekends and on holidays, can leave a message. Your call be returned within next business day. The call is free. Si usted habla español, hay servicios de asistencia de idiomas disponibles para usted sin cargo. Llame al (TTY: 71, lunes a viernes, de 8 a.m. a 8 p.m. Después de horas hábiles, los fines de semana y los días festivos, es posible que se le pida que deje un mensaje. Le devolveremos su llamada el próximo día hábil. La llamada es gratuita. You can get this document for free in or formats, such as large print, braille, or audio. Call Member Services at (TTY: 71 from 8 a.m. to 8 p.m., Monday through Friday. After hours, on weekends and on holidays, can 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 Superior STAR+PLUS MMP at (TTY: 71, 8 a.m. to 8 p.m., Monday through Friday. After hours, on weekends and on holidays, can leave a message. Your call be returned within next business day. The call is free. For more information, visit i

5 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 Superior STAR+PLUS MMP. 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. Superior STAR+PLUS MMP 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 Superior STAR+PLUS MMP network pharmacy. Superior STAR+PLUS MMP 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 from 8 a.m. to 8 p.m., Monday through Friday. After hours, on weekends and on holidays, can leave a message. Your call be returned within next business day. 2. Does Drug List ever change? Yes. Superior STAR+PLUS MMP 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 Superior STAR+PLUS MMP 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 Superior STAR+PLUS MMP at (TTY: 71, 8 a.m. to 8 p.m., Monday through Friday. After hours, on weekends and on holidays, can leave a message. Your call be returned within next business day. The call is free. For more information, visit ii

6 (For more information on se rules, see page iii.) We tell when a Medicare Part D are taking is removed from Drug List. We also tell when we change our rules for covering a Medicare Part D. Questions 3, 4, and 7 below have more information on what happens when Drug List changes. You can always check Superior STAR+PLUS MMP s up to date Drug List online at You can also call Member Services to check current Drug List at (TTY: 71 from 8 a.m. to 8 p.m., Monday through Friday. After hours, on weekends and on holidays, can leave a message. Your call be returned within next business day. 3. happens when a cheaper comes along that works as well as a on Drug List now? If are taking a Medicare Part D 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 must do something before can get. For example: Prior approval (or prior authorization): For some s, or r doctor or or prescriber must get approval from Superior STAR+PLUS MMP before fill r prescription. If don t get approval, Superior STAR+PLUS MMP may not cover.? If have questions, please call Superior STAR+PLUS MMP at (TTY: 71, 8 a.m. to 8 p.m., Monday through Friday. After hours, on weekends and on holidays, can leave a message. Your call be returned within next business day. The call is free. For more information, visit iii

7 Quantity limits: Sometimes Superior STAR+PLUS MMP limits amount of a can get. Step rapy: Sometimes Superior STAR+PLUS MMP 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 Superior STAR+PLUS MMP 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. 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.? If have questions, please call Superior STAR+PLUS MMP at (TTY: 71, 8 a.m. to 8 p.m., Monday through Friday. After hours, on weekends and on holidays, can leave a message. Your call be returned within next business day. The call is free. For more information, visit iv

8 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 from 8 a.m. to 8 p.m., Monday through Friday and ask about it. If learn that Superior STAR+PLUS MMP 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 Superior STAR+PLUS MMP 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 Superior STAR+PLUS MMP. 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. 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 If have questions, please call Superior STAR+PLUS MMP at (TTY: 71, 8 a.m. to 8 p.m., Monday through Friday. After hours, on weekends and on holidays, can leave a message. Your call be returned within next business day. The call is free. For more information, visit v

9 requires prior approval by Superior STAR+PLUS MMP, 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 Superior STAR+PLUS MMP 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, Superior STAR+PLUS MMP 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 request for an exception. After we get statement, we give a decision on r exception request within 72 hours. 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? If have questions, please call Superior STAR+PLUS MMP at (TTY: 71, 8 a.m. to 8 p.m., Monday through Friday. After hours, on weekends and on holidays, can leave a message. Your call be returned within next business day. The call is free. For more information, visit vi

10 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). Superior STAR+PLUS MMP covers both brand name s and generic s. 15. are OTC s? OTC stands for over--counter. Superior STAR+PLUS MMP covers some OTC s when y are written as prescriptions by r provider. You can read Superior STAR+PLUS MMP Drug List to see what OTC s are covered. 16. is r copay? As a Superior STAR+PLUS MMP member, have no copays for prescription and OTC s as long as follow Superior STAR+PLUS MMP s rules. 17. 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. Copays for Tiers 1, 2 and 3 are all.? If have questions, please call Superior STAR+PLUS MMP at (TTY: 71, 8 a.m. to 8 p.m., Monday through Friday. After hours, on weekends and on holidays, can leave a message. Your call be returned within next business day. The call is free. For more information, visit vii

11 List of Covered Drugs The list of covered s that begins on page 1 gives information about s covered by Superior STAR+PLUS MMP. 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 Superior STAR+PLUS MMP 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 LA Medicare Part B vs. Part D Limited Access 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. 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 a.m. to 8 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.? If have questions, please call Superior STAR+PLUS MMP at (TTY: 71, 8 a.m. to 8 p.m., Monday through Friday. After hours, on weekends and on holidays, can leave a message. Your call be returned within next business day. The call is free. For more information, visit viii

12 Abbreviation PA this means Prior Authorization How it works 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 Therefore, we only cover four tablets per day for ibuprofen 800. 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. * Non-Preferred Drug We provide a 72-hour supply of this. This require prior authorization for continued coverage.? 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 Texas 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 from 8 a.m. to 8 p.m., Monday through Friday. After hours, on weekends and on holidays, can leave a If have questions, please call Superior STAR+PLUS MMP at (TTY: 71, 8 a.m. to 8 p.m., Monday through Friday. After hours, on weekends and on holidays, can leave a message. Your call be returned within next business day. The call is free. For more information, visit ix

13 message. Your call be returned within next business day. 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 Superior STAR+PLUS MMP at (TTY: 71, 8 a.m. to 8 p.m., Monday through Friday. After hours, on weekends and on holidays, can leave a message. Your call be returned within next business day. The call is free. For more information, visit x

14 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 5, 10, 15 dextroamphetamine sulfate tabs 5, 10 methamphetamine hcl tabs Analeptics caffeine citrate soln iv caffeine citrate soln or Anti-Obesity Agents XENICAL CAPS PA; PA; ; ; Name of Attention-Deficit/Hyperactivity Disorder (ADHD) atomoxetine hcl caps 10 SL(10 ea daily); atomoxetine hcl caps 100 atomoxetine hcl caps 18 atomoxetine hcl caps 25 atomoxetine hcl caps 40 atomoxetine hcl caps 60 atomoxetine hcl caps 80 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) 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); yrs old; yrs old; SL(10 ea daily); SL(1 ea daily); SL(5.55 ea daily); SL(4 ea daily); You can find information on what symbols and abbreviations in this table mean by going to 1

15 Name of STRATTERA CAPS 40 MG (Atomoxetine HCl) STRATTERA CAPS 60 MG (Atomoxetine HCl) STRATTERA CAPS 80 MG (Atomoxetine HCl) Stimulants - Misc. CONCERTA TBCR dexmethylphenidate hcl cp24 10, 15, 20 dexmethylphenidate hcl tabs 5, 10, 2.5 FOCALIN TABS (Dexmethylphenidate HCl) FOCALIN XR CP24 10 MG, 15 MG, 20 MG (Dexmethylphenidate HCl) METADATE CD CPCR 10 MG, 40 MG, 50 MG, 60 MG (Methylphenidate HCl) METADATE CD CPCR 20 MG (Methylphenidate HCl) METADATE CD CPCR 30 MG (Methylphenidate HCl) methylphenidate hcl cp24 or 20, 30, 40, 60 methylphenidate hcl cpcr or 10, 40, 50, 60 methylphenidate hcl cpcr or 20 methylphenidate hcl cpcr or 30 SL(2.5 ea daily); SL(1.66 ea daily); SL(1.25 ea daily); QL(1 ea daily); QL(2 ea daily); QL(1 ea daily); QL(2 ea daily); Name of methylphenidate hcl tabs or 5, 10, 20 methylphenidate hcl tb24 or 27, 36 methylphenidate hcl tbcr or 18, 27, 36, 54 methylphenidate hcl tbcr or 20 modafinil tabs 100 modafinil tabs 200 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) QL(3 ea daily); Non-Osmotic Release QL(3 ea daily); 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 You can find information on what symbols and abbreviations in this table mean by going to 2

16 Name of amikacin sulfate soln ij 1 gm/4ml, 500 /2ml BETHKIS NEBU gentamicin in saline soln 0.9%-1/ml gentamicin sulfate soln ij 40 /ml KITABIS PAK NEBU neomycin sulfate tabs or paromomycin sulfate caps TOBI NEBU (Tobramycin) TOBI PODHALER CAPS tobramycin nebu in tobramycin sulfate soln ij 40 /ml, 80 /2ml, 1.2 gm/30ml tobramycin sulfate solr ij 1.2 gm B/D; NDS; 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 Name of HUMIRA PEN PNKT 40 MG/0.8ML HUMIRA PEN-CROHNS DISEASESTARTER PNKT HUMIRA PEN-PSORIASIS STARTER PNKT HUMIRA PSKT SIMPONI ARIA SOLN SIMPONI SOAJ SIMPONI SOSY PA; NDS; PA; NDS; PA; NDS; PA; NDS; PA; NDS; PA; NDS; PA; NDS; Antirheumatic - Enzyme Inhibitors PA; NDS; XELJANZ TABS Antirheumatic Antimetabolites OTREXUP SOAJ 10 MG/0.4ML, 15 MG/0.4ML, 20 MG/0.4ML, 25 MG/0.4ML, 12.5 MG/0.4ML, 17.5 MG/0.4ML, 22.5 MG/0.4ML RASUVO SOAJ 10 MG/0.2ML, 15 MG/0.3ML, 20 MG/0.4ML, 25 MG/0.5ML, 30 MG/0.6ML, 7.5 MG/0.15ML, 12.5 MG/0.25ML, 17.5 MG/0.35ML, 22.5 MG/0.45ML Gold Compounds You can find information on what symbols and abbreviations in this table mean by going to PA PA 3

17 Name of RIDAURA CAPS NDS; Interleukin-1 Blockers NDS; LA ARCALYST SOLR Interleukin-1 Receptor Antagonist (IL-1Ra) PA; NDS; KINERET SOSY Interleukin-1beta Blockers PA; NDS; LA ILARIS SOLN PA; NDS; LA ILARIS SOLR Interleukin-6 Receptor Inhibitors PA; NDS; ACTEMRA SOLN PA; NDS; ACTEMRA SOSY PA; NDS; KEVZARA SOSY Nonsteroidal Anti-inflammatory Agents (NSAIDs) ANAPROX DS TABS (Naproxen Sodium) ARTHROTEC 50 TBEC (Diclofenac w/ Misoprostol) ARTHROTEC 75 TBEC (Diclofenac w/ Misoprostol) CELEBREX CAPS (Celecoxib) celecoxib caps Name of DAYPRO TABS (Oxaprozin) diclofenac potassium tabs diclofenac sodium tb24 or 100 diclofenac sodium tbec or 25, 50, 75 diclofenac w/ misoprostol tbec EC-NAPROSYN TBEC (Naproxen) etodolac caps etodolac tabs etodolac tb24 FELDENE CAPS (Piroxicam) flurbiprofen tabs or 50, 100 ibuprofen caps or 200 ibuprofen chew or 100 ibuprofen susp or 100 /5ml ibuprofen susp or 100 /5ml ; ; RX/OTC; Over-counter;RX/OT C; ; You can find information on what symbols and abbreviations in this table mean by going to 4

18 Name of ibuprofen susp or 40 /ml, 50 /1.25ml ibuprofen tabs or 200 ibuprofen tabs or 400 ibuprofen tabs or 600 ibuprofen tabs or 800 indomethacin caps or 25, 50 indomethacin cpcr or 75 ketoprofen caps 50, 75 ketorolac tromethamine soln ij 15 /ml, 30 /ml ketorolac tromethamine soln im 30 /ml, 60 /2ml LODINE TABS (Etodolac) mefenamic acid caps or meloxicam tabs or 15, 7.5 BIC TABS 15 MG, 7.5 MG (Meloxicam) ; SL(8 ea daily); SL(5.33 ea daily); SL(4 ea daily); yrs old; yrs old; yrs old; yrs old; Name of nabumetone tabs NAPROSYN TABS 500 MG (Naproxen) naproxen sodium tabs or 220 naproxen sodium tabs or 275, 550 naproxen tabs or 250, 375, 500 naproxen tbec or 375, 500 oxaprozin tabs piroxicam caps or 10, 20 PONSTEL CAPS (Mefenamic Acid) sulindac tabs or 150, 200 tolmetin sodium caps 400 tolmetin sodium tabs 200 ; Phosphodiesterase 4 (PDE4) Inhibitors OTEZLA TABS PA; NDS; OTEZLA TBPK PA; NDS; You can find information on what symbols and abbreviations in this table mean by going to 5

19 Name of Pyrimidine Synsis Inhibitors ARAVA TABS (Leflunomide) leflunomide tabs or 10, 20 Selective Costimulation Modulators ORENCIA CLICKJECT PA; NDS; SOAJ PA; NDS; ORENCIA SOLR PA; NDS; ORENCIA SOSY Soluble Tumor Necrosis Factor Receptor Agents PA; NDS; ENBREL MINI SOCT PA; NDS; ENBREL SOLR PA; NDS; ENBREL SOSY ENBREL SURECLICK PA; NDS; SOAJ ANALGESICS - NonNarcotic - Drugs to Treat Pain, Muscle and Joint Conditions Analgesic Combinations aspirin-acetaminophencaffeine tabs Analgesics Or acetaminophen caps or 500 ; ; Name of acetaminophen chew or 80 acetaminophen liqd or 160 /5ml acetaminophen liqd or 500 /15ml acetaminophen soln or 160 /5ml acetaminophen supp re 120, 325, 650 acetaminophen susp or 160 /5ml acetaminophen tabs or 325, 500 acetaminophen tbcr or 650 acetaminophen tbdp or 160 acetaminophen tbdp or 80 TYLENOL 8 HOUR ARTHRITISPAIN TBCR (Acetaminophen) TYLENOL TABS (Acetaminophen) Salicylates aspirin chew or 81 aspirin tabs or 325 ; ; ; ; ; ; ; ; ; ; ; ; You can find information on what symbols and abbreviations in this table mean by going to 6

20 Name of aspirin tbec or 81, 325 diflunisal tabs ; 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, 600 MCG, 800 MCG, 1200 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 (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) ea daily); PA; NDS;QL(4 ea daily); yrs old yrs old; QL(50 ml daily); 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); Name of DURAGESIC PT72 12 MCG/HR (Fentanyl) DURAGESIC PT72 25 MCG/HR (Fentanyl) DURAGESIC PT72 50 MCG/HR, 75 MCG/HR (Fentanyl) fentanyl citrate lpop bu 200 mcg fentanyl citrate lpop bu 400 mcg, 600 mcg, 800 mcg, 1200 mcg, 1600 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 /ml hydromorphone hcl soln ij 10 /ml, 50 /5ml, 500 /50ml hydromorphone hcl soln ij 2 /ml HYDRORPHONE HCL SUPP RE 3 MG 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); PA; NDS;QL(8 ea daily); PA; NDS;QL(4 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); *;; You can find information on what symbols and abbreviations in this table mean by going to 7

21 Name of hydromorphone hcl tabs or 2 hydromorphone hcl tabs or 4 hydromorphone hcl tabs or 8 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 /ml meperidine hcl soln ij 50 /ml, 100 /ml methadone hcl conc or 10 /ml QL(25 ea daily); QL(12.5 ea daily); 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); yrs old yrs old; QL(6.67 ml daily); Name of methadone hcl soln or 10 /5ml methadone hcl soln or 5 /5ml methadone hcl tabs or 10 methadone hcl tabs or 5 methadone hcl tbso or 40 METHADOSE CONC (Methadone HCl) METHADOSE SUGAR- FREE CONC (Methadone HCl) morphine sulfate cp24 or 10 morphine sulfate cp24 or 100 morphine sulfate cp24 or 20 morphine sulfate cp24 or 30 morphine sulfate cp24 or 50 morphine sulfate cp24 or 60 morphine sulfate cp24 or 80 QL(33.34 ml daily); QL(66.67 ml daily); 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); You can find information on what symbols and abbreviations in this table mean by going to 8

22 Name of morphine sulfate soln ij 0.5 /ml morphine sulfate soln ij 1 /ml morphine sulfate soln or 10 /5ml morphine sulfate soln or 20 /5ml morphine sulfate soln or 20 /ml, 100 /5ml RPHINE SULFATE TABS OR 15 MG RPHINE SULFATE TABS OR 30 MG morphine sulfate tbcr or 100, 200 morphine sulfate tbcr or 15 morphine sulfate tbcr or 30 morphine sulfate tbcr or 60 MS COIN TBCR 100 MG, 200 MG (Morphine Sulfate) MS COIN TBCR 15 MG (Morphine Sulfate) MS COIN TBCR 30 MG (Morphine Sulfate) MS COIN TBCR 60 MG (Morphine Sulfate) QL(100 ml daily); QL(50 ml daily); QL(10 ml daily); QL(13.34 ea daily); QL(6.67 ea daily); QL(2 ea daily); QL(13.34 ea daily); QL(6.67 ea daily); QL(3.34 ea daily); QL(2 ea daily); QL(13.34 ea daily); QL(6.67 ea daily); QL(3.34 ea daily); Name of OPANA TABS OR 10 MG (Oxymorphone HCl) OPANA TABS OR 5 MG (Oxymorphone HCl) oxycodone hcl caps or 5 oxycodone hcl conc or 100 /5ml oxycodone hcl tabs or 10 oxycodone hcl tabs or 15 oxycodone hcl tabs or 20 oxycodone hcl tabs or 30 oxycodone hcl tabs or 5 oxymorphone hcl tabs 10 oxymorphone hcl tabs 5 oxymorphone hcl tb12 15 oxymorphone hcl tb ROXICODONE TABS 15 MG (Oxycodone HCl) ROXICODONE TABS 30 MG (Oxycodone HCl) QL(6.67 ea daily); QL(13.34 ea daily); QL(26.67 ea daily); QL(6.67 ml daily); QL(13.3 ea daily); QL(8.9 ea daily); QL(6.65 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); You can find information on what symbols and abbreviations in this table mean by going to 9

23 Name of ROXICODONE TABS 5 MG (Oxycodone HCl) SUBSYS LIQD 100 MCG SUBSYS LIQD 1200 MCG SUBSYS LIQD 1600 MCG SUBSYS LIQD 200 MCG SUBSYS LIQD 400 MCG, 600 MCG, 800 MCG tramadol hcl tabs or 50 tramadol hcl tb24 or 100 tramadol hcl tb24 or 200 tramadol hcl tb24 or 300 ULTRAM ER TB24 (Tramadol HCl) ULTRAM TABS (Tramadol HCl) ZOHYDRO ER C12A 10 MG ZOHYDRO ER C12A 15 MG ZOHYDRO ER C12A 20 MG 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); PA; NDS;QL(4 ea daily); SL(8 ea daily); SL(3 ea daily); SL(1.5 ea daily); SL(1 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); Name of ZOHYDRO ER C12A 30 MG ZOHYDRO ER C12A 40 MG ZOHYDRO ER C12A 50 MG Opioid Combinations acetaminophen w/ codeine soln 120/5ml-12/5ml acetaminophen w/ codeine tabs acetaminophen w/ codeine tabs acetaminophen w/ codeine tabs butalbital-aspirin-caffeine w/cod caps FIORINAL/CODEINE #3 CAPS (Butalbital-Aspirin- Caffeine w/cod) HYCET SOLN (Hydrocodone- Acetaminophen) hydrocodoneacetaminophen soln 2.5/5ml-108/5ml, 5/10ml-217/10ml, 7.5/15ml-325/15ml hydrocodoneacetaminophen tabs 5-300, , PA; QL(5.6 ea daily); PA; QL(4.2 ea daily); PA; QL(3.37 ea daily); SL(150 ml daily); SL(13.3 ea daily); SL(12 ea daily); SL(6 ea daily); yrs old; SL(6 ea daily); 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); You can find information on what symbols and abbreviations in this table mean by going to 10

24 Name of hydrocodoneacetaminophen tabs 5-325, , hydrocodone-ibuprofen tabs IBUDONE TABS (Hydrocodone-Ibuprofen) NORCO TABS (Hydrocodone- Acetaminophen) oxycodone w/ acetaminophen soln 5/5ml-325/5ml oxycodone w/ acetaminophen tabs 5-325, , , 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) SL(12.3 ea daily); SL(12.3 ea daily); 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); Name of XODOL TABS (Hydrocodone- Acetaminophen) Opioid Partial Agonists BUPRENEX SOLN (Buprenorphine HCl) buprenorphine hcl soln ij 0.3 /ml buprenorphine hcl subl sl 2 buprenorphine hcl subl sl 8 buprenorphine hclnaloxone hcl dihydrate subl butorphanol tartrate soln ij 2 /ml butorphanol tartrate soln na 10 /ml nalbuphine hcl soln ij 10 /ml, 20 /ml SL(13.3 ea daily); PA; QL(16 ea daily); 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 NDS; NDS; NDS; You can find information on what symbols and abbreviations in this table mean by going to 11

25 Name of oxandrolone tabs or 2.5 Androgens ANDRODERM PT24 ANDROGEL GEL 40.5 MG/2.5GM, MG/1.25GM ANDROGEL GEL 50 MG/5GM, 25 MG/2.5GM (Testosterone) ANDROGEL PUMP GEL AVEED SOLN danazol caps or 50, 100, 200 DEPO-TESTOSTERONE SOLN (Testosterone Cypionate) fluoxymesterone tabs or methyltestosterone caps or TESTIM GEL (Testosterone) testosterone cypionate soln testosterone enanthate soln im TESTOSTERONE GEL 1 %, 50 MG/5GM, 25 MG/2.5GM LA Name of testosterone gel 1 %, 50 /5gm, 25 /2.5gm TESTOSTERONE PUMP GEL VOGELXO GEL 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 phenylephrine-mineral oilpetrolatum oint 14%- 74.9%-0.25% Rectal Local Anestics dibucaine (rectal) oint lidocaine (anorectal) crea Rectal Steroids ; ; ; You can find information on what symbols and abbreviations in this table mean by going to 12

26 Name of ANUSOL-HC CREA (Hydrocortisone (Rectal)) hydrocortisone (rectal) crea PROCTOCORT CREA 1 % (Hydrocortisone (Rectal)) Vasodilating Agents RECTIV OI AACIDS Antacid Combinations alum & mag hydroxsimethicone chew alum & mag hydroxsimethicone susp 200/5ml-20/5ml- 200/5ml, 400/5ml- 40/5ml-400/5ml aluminum hydroxide-mag carb susp 95/15ml- 358/15ml GAVISCON SUSP 95MG/15ML-358MG/15ML (Aluminum Hydroxide-Mag Carb) Antacids - Aluminum Salts ALUMINUM HYDROXIDE SUSP OR Antacids - Bicarbonate sodium bicarbonate (antacid) tabs Antacids - Calcium Salts ; ; ; ; Name of calcium carbonate (antacid) chew 500, 750 calcium carbonate (antacid) susp 1250 /5ml Antacids - Magnesium Salts MAGNESIUM CAPS 500 MG magnesium oxide tabs 250 magnesium oxide tabs 400, 420 ; ; ; AHELMIICS - Drugs to Treat Worm Infections Anlmintics ALBENZA TABS ivermectin tabs or STROMECTOL TABS (Ivermectin) AI-IECTIVE AGES - MISC. - Drugs to Treat Bacterial Infections Anti-infective Agents - Misc. colistimethate sodium solr ij COLY-MYCIN M SOLR (Colistimethate Sodium) FLAGYL CAPS 375 MG (Metronidazole) FLAGYL TABS 250 MG (Metronidazole) SL(10.6 ea daily); SL(16 ea daily); You can find information on what symbols and abbreviations in this table mean by going to 13

27 Name of FLAGYL TABS 500 MG (Metronidazole) IMPAVIDO CAPS metronidazole caps or 375 metronidazole in nacl soln metronidazole tabs or 250 metronidazole tabs or 500 NEBUPE SOLR ORBACTIV SOLR PEAM 300 SOLR TINDAMAX TABS (Tinidazole) tinidazole tabs or 250, 500 trimethoprim tabs or VANCOCIN HCL CAPS (Vancomycin HCl) vancomycin hcl caps or 125, 250 SL(8 ea daily); NDS; SL(10.6 ea daily); SL(16 ea daily); SL(8 ea daily); B/D; NDS; PA; NDS; PA; NDS; Name of VANCOMYCIN HCL IN DEXTROSE SOLN 1GM/200ML-5%, 5%- 750MG/150ML, 500MG/100ML-5% vancomycin hcl solr iv 10 gm, 500, 1000, 5000 XIFAXAN TABS 200 MG XIFAXAN TABS 550 MG Anti-infective Misc. - Combinations BACTRIM DS TABS (Sulfamethoxazole- Trimethoprim) BACTRIM TABS (Sulfamethoxazole- Trimethoprim) sulfamethoxazoletrimethoprim soln sulfamethoxazoletrimethoprim susp sulfamethoxazoletrimethoprim tabs Antiprotozoal Agents ALINIA TABS 500 MG atovaquone susp MEPRON SUSP (Atovaquone) Carbapenems NDS; NDS;QL(3 ea daily); NDS; NDS; You can find information on what symbols and abbreviations in this table mean by going to 14

28 Name of imipenem-cilastatin solr INVANZ SOLR IJ meropenem solr MERREM SOLR (Meropenem) PRIMAXIN IV ADD- VAAGE SOLR (Imipenem-Cilastatin) PRIMAXIN IV SOLR (Imipenem-Cilastatin) VABOMERE SOLR Chloramphenicols chloramphenicol sodium succinate solr Cyclic Lipopeptides CUBICIN RF SOLR (Daptomycin) CUBICIN SOLR (Daptomycin) daptomycin solr Glycylcyclines TIGECYCLINE SOLR tigecycline solr TYGACIL SOLR (Tigecycline) NDS; NDS; NDS; NDS; NDS; NDS; NDS; Name of Leprostatics dapsone tabs or 25, 100 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%, 600MG/50ML-5%, 900MG/50ML-5% (Clindamycin Phosphate in D5W) CLEOCIN PHOSPHATE SOLN IV 600 MG/4ML (Clindamycin Phosphate) clindamycin hcl caps or 75, 150, 300 clindamycin palmitate hydrochloride solr clindamycin phosphate in d5w soln clindamycin phosphate soln ij 150 /ml, 9000 /60ml You can find information on what symbols and abbreviations in this table mean by going to 15

29 Name of clindamycin phosphate soln ij 600 /4ml, 900 /6ml clindamycin phosphate soln iv 600 /4ml LINCOCIN SOLN (Lincomycin HCl) lincomycin hcl soln ij Monobactams AZACTAM SOLR (Aztreonam) aztreonam solr CAYSTON SOLR Oxazolidinones linezolid soln iv 600 /300ml LINEZOLID SOLN IV 600MG/300ML-0.9% linezolid susr or 100 /5ml linezolid tabs or 600 SIVEXTRO SOLR IV SIVEXTRO TABS OR PA; NDS; LA; NDS; NDS; NDS; NDS; NDS; 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 isosorbide dinitrate tbcr isosorbide mononitrate tabs 10, 20 isosorbide mononitrate tb24 30, 60, 120 PA; You can find information on what symbols and abbreviations in this table mean by going to 16

30 Name of NITRO-DUR PT MG/HR, 0.2 MG/HR, 0.4 MG/HR, 0.6 MG/HR (Nitroglycerin) NITROGLYCERIN LINGUAL AERS nitroglycerin pt24 td 0.1 /hr, 0.2 /hr, 0.4 /hr, 0.6 /hr nitroglycerin soln tl 0.4 /spray nitroglycerin subl sl 0.3, 0.4, 0.6 NITROLINGUAL PUMPSPRAY SOLN (Nitroglycerin) NITROMIST AERS NITROSTAT SUBL (Nitroglycerin) AIANXIETY AGES - Drugs to Treat Anxiety Antianxiety Agents - Misc. buspirone hcl tabs or 5, 10, 15, 30, 7.5 hydroxyzine hcl soln im 50 /ml hydroxyzine hcl syrp or 10 /5ml hydroxyzine hcl tabs or 10, 25, 50 yrs old; yrs old; yrs old; Name of hydroxyzine pamoate caps or 25, 50 VISTARIL CAPS (Hydroxyzine Pamoate) Benzodiazepines alprazolam tabs or 0.25, 0.5, 1, 2 alprazolam tb24 or 0.5, 1, 2, 3 alprazolam tbdp or 0.25, 0.5, 1, 2 ATIVAN SOLN IJ 2 MG/ML (Lorazepam) ATIVAN SOLN IJ 4 MG/ML (Lorazepam) ATIVAN TABS OR 0.5 MG, 1 MG, 2 MG (Lorazepam) clorazepate dipotassium tabs diazepam conc or 5 /ml diazepam soln or 1 /ml diazepam tabs or 2, 5, 10 lorazepam conc or 2 /ml lorazepam soln ij 2 /ml, 20 /10ml lorazepam soln ij 4 /ml You can find information on what symbols and abbreviations in this table mean by going to yrs old; yrs old; 17

31 Name of lorazepam tabs or 0.5, 1, 2 oxazepam caps 10, 15, 30 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 quinidine sulfate tabs Antiarrhythmics Type I-B mexiletine hcl caps Antiarrhythmics Type I-C flecainide acetate tabs 100 flecainide acetate tabs 150 yrs old; yrs old; SL(4 ea daily); SL(2.66 ea daily); Name of flecainide acetate tabs 50 propafenone hcl cp12 propafenone hcl tabs RYTHL SR CP12 (Propafenone HCl) RYTHL TABS (Propafenone HCl) Antiarrhythmics Type III amiodarone hcl tabs or 100, 200, 400 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 You can find information on what symbols and abbreviations in this table mean by going to 18

32 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, 5 montelukast sodium tabs 10 SINGULAIR CHEW 4 MG, 5 MG (Montelukast Sodium) SINGULAIR TABS 10 MG (Montelukast Sodium) 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 2 inhalers per month (30 actuations);ql( 0.07 ea daily); Limit 1 inhaler per month (60 actuations);ql( 0.04 ea daily); Name of zafirlukast tabs Selective Phosphodiesterase 4 (PDE4) Inhibitors DALIRESP TABS 250 QL(1 ea daily) MCG DALIRESP TABS 500 MCG Steroid Inhalants AEROSPAN AERS budesonide (inhalation) susp 0.25 /2ml, 0.5 /2ml FLOVE DISKUS AEPB 100 MCG/BLIST FLOVE DISKUS AEPB 250 MCG/BLIST FLOVE DISKUS AEPB 50 MCG/BLIST FLOVE HFA AERO 110 MCG/ACT, 220 MCG/ACT FLOVE HFA AERO 44 MCG/ACT PULMICORT SUSP 0.25 MG/2ML, 0.5 MG/2ML (Budesonide (Inhalation)) QVAR AERS QL(1 ea daily); Limit 2 inhalers per month (120 actuations);sl( 0.6 gm daily) B/D; SL(20 ea daily); SL(8 ea daily); SL(40 ea daily); Limit 2 inhalers per month;ql(0.8 gm daily); Limit 1 inhaler per month;ql(0.36 gm daily); B/D; Limit 3 inhalers per month;ql(0.87 gm daily); You can find information on what symbols and abbreviations in this table mean by going to 19