(LIST OF COVERED DRUGS)

Transcription

1 Allwell Medicare (H), Allwell Medicare (PPO), Allwell Cardio Medicare (H SNP), Allwell CHF/ Diabetes Medicare (H SNP), Allwell Medicare Essentials I (H), Allwell Medicare Essentials II (H), Allwell Medicare Premier (H), and Allwell Medicare Select (H) 08 Formulary (LIST OF COVERED DRUGS) PLEASE READ: THIS DOCUMENT CONTAINS IORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN HPMS Approved Formulary File Submission ID 88, Version Number This formulary was updated on 06/0/08. For more recent information or other questions, please contact Allwell Medicare (H), Allwell Medicare (PPO), Allwell Cardio Medicare (H SNP), Allwell CHF/Diabetes Medicare (H SNP), Allwell Medicare Essentials I (H), Allwell Medicare Essentials II (H), Allwell Medicare Premier (H), and Allwell Medicare Select (H) at: State Phone Number State Phone Number AR AZ MS FL OH GA IN SC KS TX LA WA or, for TTY users, 7, October February, seven days a week, 8 a.m. to 8 p.m.; February September 0, Monday Friday, 8 a.m. to 8 p.m., or visit: State AR AZ FL GA IN KS LA Website Address allwell.arhealthwellness.com allwell.healthnetadvantage.com allwell.sunshinehealth.com allwell.pshpgeorgia.com allwell.mhsindiana.com allwell.sunfowerhealthplan.com allwell.louisianahealthconnect.com State MS OH SC TX WA Website Address allwell.homestatehealth.com allwell.magnoliahealthplan.com allwell.buckeyehealthplan.com allwell.pahealthwellness.com allwell.absolutetotalcare.com allwell.superiorhealthplan.com allwell.coordinatedcarehealth.com Y000_8_8FRMLY_FINAL_988

2 Note to existing members: This formulary has changed since last year. Please review this document to make sure that it still contains the drugs you take. When this drug list (formulary) refers to we, us, or our, it means Arkansas Health & Wellness, Health Net of AZ, Sunshine Health, Peach State Health, MHS IND, Sunflower State, Louisiana Healthcare Connections, Home State, Magnolia Health, Buckeye Community Solutions, Pennsylvania Health & Wellness, Absolute Total Care, Superior HealthPlan, and Coordinated Care of WA. When it refers to plan or our plan, it means Allwell Medicare (H), Allwell Medicare (PPO), Allwell Cardio Medicare (H SNP), Allwell CHF/Diabetes Medicare (H SNP), Allwell Medicare Essentials I (H), Allwell Medicare Essentials II (H), Allwell Medicare Premier (H), and Allwell Medicare Select (H). This document includes list of the drugs (formulary) for our plan which is current as of 06/0/08. For an updated formulary, please contact us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages. You must generally use network pharmacies to use your prescription drug benefit. Benefits, formulary, pharmacy network, and/or copayments/coinsurance may change on January, 09, and from time to time during the year. What is the Allwell Medicare (H), Allwell Medicare (PPO), Allwell Cardio Medicare (H SNP), Allwell CHF/Diabetes Medicare (H SNP), Allwell Medicare Essentials I (H), Allwell Medicare Essentials II (H), Allwell Medicare Premier (H), and Allwell Medicare Select (H) Formulary? A formulary is a list of covered drugs selected by our plan in consultation with a team of health care providers, which represents the prescription therapies believed to be a necessary part of a quality treatment program. We will generally cover the drugs listed in our formulary as long as the drug is medically necessary, the prescription is filled at a plan network pharmacy, and other plan rules are followed. For more information on how to fill your prescriptions, please review your Evidence of Coverage. Can the Formulary (drug list) change? Generally, if you are taking a drug on our 08 formulary that was covered at the beginning of the year, we will not discontinue or reduce coverage of the drug during the 08 coverage year except when a new, less expensive generic drug becomes available or when new adverse information about the safety or effectiveness of a drug is released. Other types of formulary changes, such as removing a drug from our formulary, will not affect members who are currently taking the drug. It will remain available at the same cost-sharing for those members taking it for the remainder of the coverage year. We feel it is important that you have continued access for the remainder of the coverage year to the formulary drugs that were available when you chose our plan, except for cases in which you can save additional money or we can ensure your safety. If we remove drugs from our formulary, or add prior authorization, quantity limits and/or step therapy restrictions on a drug or move a drug to a higher cost-sharing tier, we must notify affected members of i

3 the change at least 60 days before the change becomes effective, or at the time the member requests a refill of the drug, at which time the member will receive a 60-day supply of the drug. If the Food and Administration deems a drug on our formulary to be unsafe or the drug s manufacturer removes the drug from the market, we will immediately remove the drug from our formulary and provide notice to members who take the drug. The enclosed formulary is current as of 06/0/08. To get updated information about the drugs covered by our plan, please contact us. Our contact information appears on the front and back cover pages. If we make any other negative changes to a drug you are taking, we will notify you via mail. We will also post the changes on our website. How do I use the Formulary? There are two ways to find your drug within the formulary: Medical Condition The formulary begins on page. The drugs in this formulary are grouped into categories depending on the type of medical conditions that they are used to treat. For example, drugs used to treat a heart condition are listed under the category, CARDIOVASCULAR AGENTS - MISC. If you know what your drug is used for, look for the category name in the list that begins on page. Then look under the category name for your drug. Alphabetical Listing If you are not sure what category to look under, you should look for your drug in the Index that begins on page Index. The Index provides an alphabetical list of all of the drugs included in this document. Both brand name drugs and generic drugs are listed in the Index. Look in the Index and find your drug. Next to your drug, you will see the page number where you can find coverage information. Turn to the page listed in the Index and find the name of your drug in the first column of the list. What are generic drugs? Our plan covers both brand name drugs and generic drugs. A generic drug is approved by the FDA as having the same active ingredient as the brand name drug. Generally, generic drugs cost less than brand name drugs. Are there any restrictions on my coverage? Some covered drugs may have additional requirements or limits on coverage. These requirements and limits may include: ii

4 Prior Authorization: Our plan requires you or your physician to get prior authorization for certain drugs. This means that you will need to get approval from us before you fill your prescriptions. If you don t get approval, we may not cover the drug. Quantity : For certain drugs, our plan limits the amount of the drug that we will cover. For example, our plan provides one tablet per day per prescription for simvastatin 0. This may be in addition to a standard one-month or three-month supply. Step Therapy: In some cases, our plan requires you to first try certain drugs to treat your medical condition before we will cover another drug for that condition. For example, if A and B both treat your medical condition, we may not cover B unless you try A first. If A does not work for you, we will then cover B. You can find out if your drug has any additional requirements or limits by looking in the formulary that begins on page. You can also get more information about the restrictions applied to specific covered drugs by visiting our Web site. We have posted on line documents that explain our prior authorization and step therapy restrictions. You may also ask us to send you a copy. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages. You can ask us to make an exception to these restrictions or limits or for a list of other, similar drugs that may treat your health condition. See the section, How do I request an exception to the Allwell Medicare (H), Allwell Medicare (PPO), Allwell Cardio Medicare (H SNP), Allwell CHF/Diabetes Medicare (H SNP), Allwell Medicare Essentials I (H), Allwell Medicare Essentials II (H), Allwell Medicare Premier (H), and Allwell Medicare Select (H) formulary? on page iv for information about how to request an exception. What if my drug is not on the Formulary? If your drug is not included in this formulary (list of covered drugs), you should first contact Member Services and ask if your drug is covered. If you learn that our plan does not cover your drug, you have two options: You can ask Member Services for a list of similar drugs that are covered by our plan. When you receive the list, show it to your doctor and ask him or her to prescribe a similar drug that is covered by us. You can ask us to make an exception and cover your drug. See below for information about how to request an exception. iii

5 How do I request an exception to the Allwell Medicare (H), Allwell Medicare (PPO), Allwell Cardio Medicare (H SNP), Allwell CHF/Diabetes Medicare (H SNP), Allwell Medicare Essentials I (H), Allwell Medicare Essentials II (H), Allwell Medicare Premier (H), and Allwell Medicare Select (H) Formulary? You can ask us to make an exception to our coverage rules. There are several types of exceptions that you can ask us to make. You can ask us to cover a drug even if it is not on our formulary. If approved, this drug will be covered at a pre-determined cost-sharing level, and you would not be able to ask us to provide the drug at a lower cost-sharing level. You can ask us to cover a formulary drug at a lower cost-sharing level if this drug is not on the specialty tier. If approved this would lower the amount you must pay for your drug. You can ask us to waive coverage restrictions or limits on your drug. For example, for certain drugs, our plan limits the amount of the drug that we will cover. If your drug has a quantity limit, you can ask us to waive the limit and cover a greater amount. Generally, we will only approve your request for an exception if the alternative drugs included on the plan s formulary, the lower cost-sharing drug or additional utilization restrictions would not be as effective in treating your condition and/or would cause you to have adverse medical effects. You should contact us to ask us for an initial coverage decision for a formulary, tiering or utilization restriction exception. When you request a formulary, tiering or utilization restriction exception you should submit a statement from your prescriber or physician supporting your request. Generally, we must make our decision within 7 hours of getting your prescriber s supporting statement. You can request an expedited (fast) exception if you or your doctor believe that your health could be seriously harmed by waiting up to 7 hours for a decision. If your request to expedite is granted, we must give you a decision no later than hours after we get a supporting statement from your doctor or other prescriber. What do I do before I can talk to my doctor about changing my drugs or requesting an exception? As a new or continuing member in our plan you may be taking drugs that are not on our formulary. Or, you may be taking a drug that is on our formulary but your ability to get it is limited. For example, you may need a prior authorization from us before you can fill your prescription. You should talk to your doctor to decide if you should switch to an appropriate drug that we cover or request a formulary exception so that we will cover the drug you take. While you talk to your doctor to determine the right course of action for you, we may cover your drug in certain cases during the first 90 days you are a member of our plan. iv

6 For each of your drugs that is not on our formulary or if your ability to get your drugs is limited, we will cover a temporary 0-day supply (unless you have a prescription written for fewer days) when you go to a network pharmacy. After your first 0-day supply, we will not pay for these drugs, even if you have been a member of the plan less than 90 days. If you are a resident of a long-term care facility, we will allow you to refill your prescription until we have provided you with a 98-day transition supply, consistent with dispensing increment, (unless you have a prescription written for fewer days). We will cover more than one refill of these drugs for the first 90 days you are a member of our plan. If you need a drug that is not on our formulary or if your ability to get your drugs is limited, but you are past the first 90 days of membership in our plan, we will cover a -day emergency supply of that drug (unless you have a prescription for fewer days) while you pursue a formulary exception. Level of care changes If you experience a change in your level of care, we will cover a transition supply of your drugs. A level of care change occurs when you are discharged from a hospital or moved to or from a long-term care facility. If you move home from a long-term care facility or hospital and need a transition supply, we will cover one 0-day supply. If your prescription is written for fewer days, we will allow multiple fills to provide up to a total of a 0-day supply. If you move from home or a hospital to a long-term care facility and need a transition supply, we will cover one -day supply. If your prescription is written for fewer days, we will allow multiple fills to provide up to a total of a -day supply. For more information For more detailed information about your plan s prescription drug coverage, please review your Evidence of Coverage and other plan materials. If you have questions about our plan, please contact us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages. If you have general questions about Medicare prescription drug coverage, please call Medicare at MEDICARE ( ) hours a day/7 days a week. TTY users should call Or, visit Allwell Medicare (H), Allwell Medicare (PPO), Allwell Cardio Medicare (H SNP), Allwell CHF/Diabetes Medicare (H SNP), Allwell Medicare Essentials I (H), Allwell Medicare Essentials II (H), Allwell Medicare Premier (H), and Allwell Medicare Select (H) Formulary The formulary that begins on page provides coverage information about the drugs covered by our plan. If you have trouble finding your drug in the list, turn to the Index that begins on page Index. v

7 The first column of the chart lists the drug name. Brand name drugs are capitalized (e.g., ELIQUIS TABS) and generic drugs are listed in lower-case italics (e.g., warfarin sodium tabs). The information in the column tells you if our plan has any special requirements for coverage of your drug. Abbreviations The abbreviations below may appear in the Requirement/ column on the formulary. Abbreviation Definition Description AL Age Limit This drug may require prior authorization if your age does not meet manufacturer, FDA, or clinical recommendations. B/D Medicare Part B vs. Part D This drug may be covered under Medicare Part B or Part D depending upon the circumstances. Information may need to be submitted describing the use and setting of the drug to make the determination. LA Limited Access This prescription may be available only at certain pharmacies. For more information consult your Pharmacy Directory or call Member Services from October - February, seven days a week, 8 a.m. to 8 p.m. or from February - September 0, Monday - Friday, 8 a.m. to 8 p.m. Our contact information appears on the front and back cover pages. TTY users should call 7. Mail Order This drug is available for up to a 90-day supply at a mail order pharmacy in addition to certain other network pharmacies. Consider getting a 90-day supply of your long-term (maintenance) medications (such as high blood pressure medications). Retail network pharmacies may be more appropriate for short-term prescriptions (such as antibiotics). NT Non-TrOOP This prescription drug is not normally covered in a Medicare Prescription Plan. The amount you pay when you fill a prescription for this drug does not count towards your total drug costs (that is, the amount you pay does not help you qualify for catastrophic coverage). In addition, if you are receiving extra help to pay for your prescriptions, you will not get any extra help to pay for this drug. Prior Authorization This drug requires prior authorization. This means that you or your prescriber must get approval from us before you fill your prescription. If you don t get approval, we may not cover the drug. vi

8 Abbreviation Definition Description QL Quantity Limit This drug has a limit on the amount that we will cover. For example, we cover one tablet per day per prescription for simvastatin 0. This may be in addition to a standard onemonth or three-month supply limit. RX/OTC Prescription and Over-the- Counter (OTC) This drug is available both in a prescription form and in an OTC form. Other than some insulins and insulin supplies, only prescription drugs are covered by our Medicare Part D plans. SL Safety Limit This drug has a maximum daily dose limit for safety supported by the FDA. This means that we will not cover more than the maximum daily dose. For example, the FDA maximum daily dose of ibuprofen is 00. Therefore, we will only cover four tablets per day for ibuprofen 800. ST Step Therapy This drug requires step therapy. This means that you must first try certain drugs to treat your medical condition before we cover another drug for that condition. Additional Gap Coverage For example, if A and B both treat your medical condition, we may not cover B unless you try A first. If A does not work for you, we will then cover B. Only for Allwell Medicare (H) in Broward, Duval, Hillsborough, Lake, Miami-Dade, Orange, Osceola, Pinellas, Polk, and Volusia Counties: We provide additional coverage of this prescription drug in the coverage gap. Please refer to your Evidence of Coverage for more information about this coverage. vii

9 Formulary tier descriptions Prescription drugs are grouped into one of six tiers. To find out which tier your drug is in, look in the column of the formulary that begins on page. The table below tells you the copayment or coinsurance amount (i.e., the share of the drug's cost that you will pay during the initial coverage stage) for a one-month supply of drugs in each tier. For more detailed information about your out-of-pocket costs for prescriptions, including any deductible that may apply, please refer to your Evidence of Coverage and other plan materials. State Plan Name 6 Preferred Generic (includes preferred generic drugs) Generic (includes generic drugs) Preferred Brand (includes preferred brand drugs and may include some generic drugs) Nonpreferred Brand (includes nonpreferred brand drugs and may include some generic drugs) Specialty (includes high cost brand and generic drugs) Select Care s (includes some generics and may include some brands used to treat specific chronic conditions) AR AR AZ AZ AZ Allwell Medicare (H) Allwell Medicare Select (H) Allwell CHF/Diabetes Medicare (H SNP) Allwell Medicare Select (H) Allwell Cardio Medicare (H SNP) $0 $8 $7 $00 8% $0 $0 $8 $7 $00 % $0 $0 $0 $7 $00 % $0 $ $7 $7 $00 % $0 $0 $0 $7 $00 % $0 viii

10 State Plan Name 6 Preferred Generic (includes preferred generic drugs) Generic (includes generic drugs) Preferred Brand (includes preferred brand drugs and may include some generic drugs) Nonpreferred Brand (includes nonpreferred brand drugs and may include some generic drugs) Specialty (includes high cost brand and generic drugs) Select Care s (includes some generics and may include some brands used to treat specific chronic conditions) AZ AZ AZ AZ AZ FL Allwell Medicare Premier (H) in Maricopa and Pinal Counties Allwell Medicare (H) Allwell Medicare Essentials II (H) Allwell Medicare Premier (H) in Pima County Allwell Medicare Essentials I (H) Allwell Medicare (H) in Duval, Hillsborough, Lake, Pinellas, Polk, and Volusia Counties $ $0 $7 $00 % $0 $ $0 $7 $00 0% $0 $0 $0 $7 $00 % $0 $ $ $7 $00 % $0 $0 $0 $7 $00 % $0 $0 $0 $ $80 % $0 ix

11 State Plan Name 6 Preferred Generic (includes preferred generic drugs) Generic (includes generic drugs) Preferred Brand (includes preferred brand drugs and may include some generic drugs) Nonpreferred Brand (includes nonpreferred brand drugs and may include some generic drugs) Specialty (includes high cost brand and generic drugs) Select Care s (includes some generics and may include some brands used to treat specific chronic conditions) FL FL FL FL FL Allwell Medicare (H) in Manatee, Marion, Palm Beach, and Seminole Counties Allwell Medicare (H) in Miami-Dade County Allwell Medicare (H) in Orange and Osceola Counties Allwell Medicare (H) in Broward County Allwell Medicare Premier (H) in Duval, Hernando, Orange, Osceola Pasco, Pinellas, Polk, Volusia Counties $0 $0 $ $9 % $0 $0 $0 $0 $ % $0 $0 $0 $ $8 % $0 $0 $0 $0 $60 % $0 $0 $ $ $90 % $0 x

12 State Plan Name 6 Preferred Generic (includes preferred generic drugs) Generic (includes generic drugs) Preferred Brand (includes preferred brand drugs and may include some generic drugs) Nonpreferred Brand (includes nonpreferred brand drugs and may include some generic drugs) Specialty (includes high cost brand and generic drugs) Select Care s (includes some generics and may include some brands used to treat specific chronic conditions) FL FL FL GA GA Allwell Medicare Premier (H) in Miami-Dade County Allwell Medicare Premier (H) in Hillsborough County Allwell Medicare Premier (H) in Broward County Allwell Medicare (H) in Clayton, DeKalb, Fayette, Fulton, Gwinnett, Henry, and Rockdale Counties Allwell Medicare (H) in Chattahoochee, Harris and Muscogee Counties $0 $0 $0 $60 % $0 $0 $0 $0 $9 % $0 $0 $0 $0 $7 % $0 $0 $7 $7 $00 7% $0 $0 $6 $ $86 7% $0 xi

13 State Plan Name 6 Preferred Generic (includes preferred generic drugs) Generic (includes generic drugs) Preferred Brand (includes preferred brand drugs and may include some generic drugs) Nonpreferred Brand (includes nonpreferred brand drugs and may include some generic drugs) Specialty (includes high cost brand and generic drugs) Select Care s (includes some generics and may include some brands used to treat specific chronic conditions) IN IN IN IN Allwell Medicare (H) in Hamilton, Howard, and Marion Counties Allwell Medicare (H) in Allen, Elkhart, St. Joseph, and Vanderburgh Counties Allwell Medicare (PPO) in Hamilton, Howard, and Marion Counties Allwell Medicare (PPO) in Allen, Elkhart, St. Joseph, and Vanderburgh Counties $ $0 $7 $00 % $0 $ $0 $7 $00 % $0 $ $0 $7 $00 % $0 $ $0 $7 $00 % $0 xii

14 State Plan Name 6 Preferred Generic (includes preferred generic drugs) Generic (includes generic drugs) Preferred Brand (includes preferred brand drugs and may include some generic drugs) Nonpreferred Brand (includes nonpreferred brand drugs and may include some generic drugs) Specialty (includes high cost brand and generic drugs) Select Care s (includes some generics and may include some brands used to treat specific chronic conditions) KS LA MS OH Allwell Medicare (H) Allwell Medicare (H) Allwell Medicare (H) in Barry, Christian, Greene, Jasper, Lawrence, and Newton Counties Allwell Medicare (H) in Cass, Clay, Jackson, and Platte Counties Allwell Medicare (H) Allwell Medicare (H) Allwell Medicare (H) $ $ $7 $00 % $0 $ $ $7 $00 7% $0 $0 $0 $7 $00 % $0 $0 $0 $7 $00 8% $0 $0 $ $ $00 7% $0 $ $ $7 $00 % $0 $0 $0 $7 $00 % $0 xiii

15 State Plan Name Preferred Generic (includes preferred generic drugs) Generic (includes generic drugs) Preferred Brand (includes preferred brand drugs and may include some generic drugs) Nonpreferred Brand (includes nonpreferred brand drugs and may include some generic drugs) Specialty (includes high cost brand and generic drugs) 6 Select Care s (includes some generics and may include some brands used to treat specific chronic conditions) SC Allwell Medicare (H) in Abbeville, Allendale, Bamberg, Barnwell, Beaufort, Calhoun, Charleston, Chester, Chesterfield, Clarendon, Colleton, Dillon, Edgefield, Fairfield, Florence, Georgetown, Hampton, Jasper, Kershaw, Laurens, Lee, Marion, Marlboro, McCormick, Newberry, Orangeburg, Richland, Saluda, Union, and Williamsburg Counties $0 $ $7 $00 % $0 xiv

16 State Plan Name 6 Preferred Generic (includes preferred generic drugs) Generic (includes generic drugs) Preferred Brand (includes preferred brand drugs and may include some generic drugs) Nonpreferred Brand (includes nonpreferred brand drugs and may include some generic drugs) Specialty (includes high cost brand and generic drugs) Select Care s (includes some generics and may include some brands used to treat specific chronic conditions) SC TX TX TX TX Allwell Medicare (H) in Greenville, Pickens, and Spartanburg Counties Allwell Medicare (H) in Bexar County Allwell Medicare (H) in Collin, Dallas, Denton, Smith and Tarrant Counties Allwell Medicare (H) in Cameron and Hidalgo Counties Allwell Medicare (H) in El Paso County $0 $8 $7 $00 % $0 $ $ $7 $9 % $0 $0 $ $7 $00 % $0 $ $ $7 $9 % $0 $ $ $7 $9 % $0 xv

17 State Plan Name 6 Preferred Generic Preferred Non- Specialty Select Care Generic (includes Brand preferred (includes s (includes generic (includes Brand high cost (includes preferred generic drugs) drugs) brand and generic drugs) preferred brand drugs and may include some generic drugs) (includes nonpreferred brand drugs and may include some generic drugs) some generics and may include some brands used to treat specific chronic conditions) TX WA Allwell Medicare (H) in Neuces County Allwell Medicare (H) $ $ $7 $00 6% $0 $8 $0 $7 $00 9% $0 s in this tier are not eligible for exceptions for payment at a lower tier. We provide additional coverage of these prescription drugs in the coverage gap. Please refer to your Evidence of Coverage for more information about this coverage. Note: If is displayed in the column, this means the drug is not covered on the formulary. You may request an exception from us to cover these non-formulary drugs. If an exception request is approved for a non-formulary drug; the copayment applies. You may not ask us to provide the drug at a lower cost-sharing level. xvi

18 Section 7 Non-Discrimination Language Notice of Non-Discrimination Allwell complies with applicable federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Allwell does not exclude people or treat them differently because of race, colo -, national origin, age, disability, or sex. Allwell: Provides free aids and services to people with disabilities to communicat e effectively with us, such as qualified sign language interpreters and written information in other formats (large print, accessible electronic format s, other formats). Provides free language services to people whose primary language is not English, such as qualified interpret ers and information written in other languages. If you need these services, contact Allwell's Member Services telephone number listed for your stat e on t he Member Services Telephone Numbers by State Chart. From October t o February, you can call us 7 days a week from 8 a.m. to 8 p.m. From February to September 0, you can call us Monday through Friday from 8 a.m. t o 8 p.m. A messaging system is used after hours, weekends, and on federal holidays. If you believe that All well has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance by calling the number in the chart below and t elling t hem you need help filing a grievance; Allwell's Member Services is available to help you. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Right s, electronically through the Office for Civil Rights Complaint Portal, available at ocr/portaljlobby.jsf or by mail or phone at: U.S. Department of Health and Human Services, 00 Independence Avenu e SW, Room 09F, HHH Building, Washington, DC 00, (TDD: ). Complaint forms are available athttp:// index. html. Member services Telephone Numbers By state chart St a t e T e l ep h one N um b er an d Pl an T ype Arizona, (H and H SNP); (Bridgeway H SNP) Arkansas (HM O) Florida (H); (H SNP) Georgia Indiana Kansas Louisiana Mississippi (H); (H SNP) (H and PPO) (H) (H) (H) Missouri (HM O) Ohio (H); (H SNP) Pen nsylvania (H); (H SNP) South Carolina (H and HM O SN P) Texas (H ); (H SNP) Washington (HM O) Wisconsin (H SN P) Y000_ 8_80MLI_Accepted_0707

19 ế ế ệ ỗ ợ ữ ễ ố ộ ượ ệ ể ủ ả ố ệ ạ ộ ể 注意 : 如果您使用繁體中文, 則可得到免費的語言助手服務 請致電 會員服務電話號碼表 ( 按州排列 ) 上列出的您所在州的會員服務號碼 참조한국어를사용하시면무료로언어지원서비스를이용할수있습니다주차트에있는회원서비스전화번호를통해각주에등록된회원서비스로전화하십시오 الواليات. تنبيه: إذا كنت تتحدث العربية فإن خدمات المساعدة اللغوية تتوفر لك مجانا. اتصل برقم خدمات األعضاء المدرج لواليتك في أرقام هاتف خدم تا األعضاء حسب مخطط ВНИМАНИЕ если вы говорите на русском языке вам могут предоставить бесплатные услуги перевода Позвоните по номеру указанному для вашего штата в таблице номеров телефонов Службы поддержки участников по штатам ધ ય ન આપ : જ તમ ગજર ત બ લત હ ત ભ ષ ક ય સવ ઓ તમન વવન મ લ ય ઉપલબ ધ છ. સ ટટ ચ ટ દ વ ર મ મ બર સવવસ ઝ ટ લલફ ન નબર પર તમ ર ર જ ય મ ટ આપલ મમ બર સવવસ નબર પર ક લ કર 注意 : 日本語を話される場合は無料の言語支援サービスをご利用いただけます 地域別メンバーサービス電話番号表に記載されている お住まいの地域の電話番号にお掛けください

20 Name ADHD/ANTI-NARCOLEPSY/ANTI- OBESITY/ANOREXIANTS - s to Treat ADHD, Sleep and Eating Disorders Amphetamines ADDERALL TABS (Amphetamine- Dextroamphetamine) ADDERALL XR CP (Amphetamine- Dextroamphetamine) amphetaminedextroamphetamine cp ---, , , , , amphetaminedextroamphetamine tabs ; ---, , , , , , DESOXYN TABS ; (Methamphetamine HCl) DEXEDRINE CP (Dextroamphetamine Sulfate) dextroamphetamine sulfate cp, 0, dextroamphetamine sulfate tabs, 0 methamphetamine hcl tabs ; VYVANSE CAPS 0 MG VYVANSE CAPS 0 MG SL(7 ea daily); SL(. ea daily); Name VYVANSE CAPS 0 MG SL(. ea daily); VYVANSE CAPS 0 MG SL(.7 ea daily); VYVANSE CAPS 0 MG SL(. ea daily); VYVANSE CAPS 60 MG SL(.6 ea daily); VYVANSE CAPS 70 MG SL( ea daily); Attention-Deficit/Hyperactivity Disorder (ADHD) atomoxetine hcl caps 0 SL(0 ea daily); ; atomoxetine hcl caps 00 SL( ea daily); ; atomoxetine hcl caps 8 SL(. ea daily); ; atomoxetine hcl caps SL( ea daily); ; atomoxetine hcl caps 0 SL(. ea daily); ; atomoxetine hcl caps 60 SL(.66 ea daily); ; atomoxetine hcl caps 80 SL(. ea daily); ; clonidine hcl (adhd) tb guanfacine hcl (adhd) tb INTUNIV TB (Guanfacine HCl (ADHD)) KAPVAY TB (Clonidine HCl (ADHD)) STRATTERA CAPS 0 MG (Atomoxetine HCl) STRATTERA CAPS 00 MG (Atomoxetine HCl) STRATTERA CAPS 8 MG (Atomoxetine HCl) STRATTERA CAPS MG (Atomoxetine HCl) STRATTERA CAPS 0 MG (Atomoxetine HCl) STRATTERA CAPS 60 MG (Atomoxetine HCl) AL; Up to 6 yrs old; ; AL; Up to 6 yrs old; SL(0 ea daily); SL( ea daily); SL(. ea daily); SL( ea daily); SL(. ea daily); SL(.66 ea daily); 08 Allwell (Value) Formulary Updated 06/0/08

21 Name STRATTERA CAPS 80 MG (Atomoxetine HCl) Stimulants - Misc. armodafinil tabs CONCERTA TBCR (Methylphenidate HCl) DAYTRANA PTCH 0 MG/9HR dexmethylphenidate hcl cp 0,, 0 dexmethylphenidate hcl tabs, 0,. FOCALIN TABS (Dexmethylphenidate HCl) FOCALIN XR CP 0 MG, MG, 0 MG (Dexmethylphenidate HCl) METADATE CD CPCR 0 MG, 0 MG, 0 MG, 60 MG (Methylphenidate HCl) METADATE CD CPCR 0 MG (Methylphenidate HCl) METADATE CD CPCR 0 MG (Methylphenidate HCl) methylphenidate hcl cp or 0, 60 methylphenidate hcl cp or 0, 0, 0 methylphenidate hcl cpcr or 0, 0, 0, 60 methylphenidate hcl cpcr or 0 methylphenidate hcl cpcr or 0 methylphenidate hcl tabs or, 0, 0 methylphenidate hcl tb or 8, 7, 6, methylphenidate hcl tbcr or 0 methylphenidate hcl tbcr or 8, 7, 6, SL(. ea daily); ; QL( ea daily); QL( ea daily); ; QL( ea daily); QL( ea daily); QL( ea daily); Non-Osmotic Release Name methylphenidate hcl tbcr or 0 modafinil tabs 00 modafinil tabs 00 NUVIGIL TABS (Armodafinil) PROVIGIL TABS 00 MG (Modafinil) PROVIGIL TABS 00 MG (Modafinil) RITALIN LA CP 0 MG (Methylphenidate HCl) RITALIN LA CP 0 MG, 0 MG, 0 MG (Methylphenidate HCl) RITALIN TABS (Methylphenidate HCl) QL( ea daily); ; ; ; QL( ea daily); ; ; ; ; QL( ea daily); QL( ea daily); ALLERGENIC EXTRACTS/BIOLOGICALS MISC Allergenic Extracts GRASTEK SUBL ORALAIR SUBL RAGWITEK SUBL Biologicals Misc ADAGEN SOLN ; ; ; LA; AMINOGLYCOSIDES - s to Treat Bacterial Infections Aminoglycosides amikacin sulfate soln ij gm/ml, 00 /ml BETHKIS NEBU B/D gentamicin in saline soln 0.9%-/ml gentamicin sulfate soln ij 0 ; /ml KITABIS K NEBU B/D neomycin sulfate tabs or 08 Allwell (Value) Formulary Updated 06/0/08

22 Name paromomycin sulfate caps TOBI NEBU (Tobramycin) B/D TOBI PODHALER CAPS tobramycin nebu in B/D; tobramycin sulfate soln ij 0 /ml, 80 /ml,. gm/0ml tobramycin sulfate solr ij. gm ANALGESICS - ANTI-ILAMMATORY - s to Treat Pain, Swelling, Muscle and Joint Conditions Anti-T-alpha - Monoclonal Antibodies HUMIRA PEDIATRIC CROHNS DISEASE STARTER CK PSKT HUMIRA PEN PNKT 0 MG/0.8ML HUMIRA PEN-CROHNS DISEASESTARTER PNKT HUMIRA PEN-PSORIASIS STARTER PNKT HUMIRA PSKT SIMPONI ARIA SOLN SIMPONI SOAJ SIMPONI SOSY Antirheumatic - Enzyme Inhibitors XELJANZ TABS XELJANZ XR TB Antirheumatic Antimetabolites OTREXUP SOAJ 0 MG/0.ML, MG/0.ML, 0 MG/0.ML, MG/0.ML,. MG/0.ML, 7. MG/0.ML,. MG/0.ML Name RASUVO SOAJ 0 MG/0.ML, MG/0.ML, MG/0.ML, 0 MG/0.6ML, 7. MG/0.ML,. MG/0.ML, 7. MG/0.ML,. MG/0.ML RASUVO SOAJ 0 MG/0.ML Gold Compounds RIDAURA CAPS Interleukin- Blockers ARCALYST SOLR LA Interleukin- Receptor Antagonist (IL-Ra) KINERET SOSY ; Interleukin-beta Blockers ILARIS SOLN ILARIS SOLR Interleukin-6 Receptor Inhibitors ACTEMRA SOLN ACTEMRA SOSY KEVZARA SOSY ; LA ; LA Nonsteroidal Anti-inflammatory Agents (NSAIDs) ANAPROX DS TABS (Naproxen Sodium) ARTHROTEC 0 TBEC (Diclofenac w/ Misoprostol) ARTHROTEC 7 TBEC (Diclofenac w/ Misoprostol) CELEBREX CAPS (Celecoxib) celecoxib caps DAYPRO TABS (Oxaprozin) diclofenac potassium tabs 08 Allwell (Value) Formulary Updated 06/0/08

23 Name diclofenac sodium tb or 00 diclofenac sodium tbec or, 0, 7 diclofenac w/ misoprostol tbec DUEXIS TABS EC-NAPROSYN TBEC (Naproxen) etodolac caps 00, 00 etodolac tabs 00, 00 etodolac tb 00, 00, 600 FELDENE CAPS (Piroxicam) flurbiprofen tabs or 0, 00 ibuprofen susp or 00 /ml ibuprofen tabs or 00 ibuprofen tabs or 600 ibuprofen tabs or 800 INDOCIN SUSP OR MG/ML indomethacin caps or, 0 indomethacin cpcr or 7 ketoprofen caps 0, 7 ketoprofen cp 00 ketorolac tromethamine soln ij /ml, 0 /ml ketorolac tromethamine soln im 0 /ml, 60 /ml ketorolac tromethamine tabs or 0 ; RX/OTC; ; SL(8 ea daily); ; SL(. ea daily); ; SL( ea daily); ; AL; Up to 6 yrs old; AL; Up to 6 yrs old; ; AL; Up to 6 yrs old; AL; Up to 6 yrs old; AL; Up to 6 yrs old; AL; Up to 6 yrs old; ; Name LODINE TABS (Etodolac) mefenamic acid caps or meloxicam tabs or, 7. BIC TABS MG, 7. MG (Meloxicam) nabumetone tabs NAPRELAN TB 7 MG, 00 MG (Naproxen Sodium) NAPRELAN TB 70 MG NAPROSYN TABS 00 MG (Naproxen) naproxen sodium tabs or 7, 0 naproxen sodium tb or 7, 00 naproxen tabs or 0, 7, 00 naproxen tbec or 7, 00 oxaprozin tabs piroxicam caps or 0, 0 PONSTEL CAPS (Mefenamic Acid) sulindac tabs or 0, 00 tolmetin sodium caps 00 tolmetin sodium tabs 00 VIVO TBEC ZIPSOR CAPS ; ; ; ; ; Phosphodiesterase (PDE) Inhibitors OTEZLA TABS OTEZLA TBPK Pyrimidine Synthesis Inhibitors 08 Allwell (Value) Formulary Updated 06/0/08

24 Name ARAVA TABS (Leflunomide) leflunomide tabs Selective Costimulation Modulators ORENCIA CLICKJECT SOAJ ORENCIA SOLR ORENCIA SOSY Soluble Tumor Necrosis Factor Receptor Agents ENBREL MINI SOCT ENBREL SOLR ENBREL SOSY ENBREL SURECLICK SOAJ ANALGESICS - NonNarcotic - s to Treat Pain, Muscle and Joint Conditions Salicylates diflunisal tabs ; ANALGESICS - OPIOID - s to Treat Pain, Muscle and Joint Conditions Opioid Agonists ABSTRAL SUBL 00 MCG ; QL(6 ea daily) ABSTRAL SUBL 00 MCG ; QL(8 ea daily) ABSTRAL SUBL 00 MCG ; QL(. ea daily) ABSTRAL SUBL 00 MCG, 600 MCG, 800 MCG ; QL( ea daily) ACTIQ LPOP 00 MCG ; QL(8 ea (Fentanyl Citrate) ACTIQ LPOP 00 MCG, 600 MCG, 800 MCG, 00 MCG, 600 MCG (Fentanyl Citrate) codeine sulfate tabs daily); ; QL( ea daily); SL( ea daily); ; Name CODEINE SULFATE TABS MG (Codeine Sulfate) codeine sulfate tabs 0 codeine sulfate tabs 60 DEMEROL TABS OR 00 MG (Meperidine HCl) DEMEROL TABS OR 0 MG (Meperidine HCl) DILAUDID LIQD OR MG/ML (Hydromorphone HCl) DILAUDID SOLN IJ MG/ML (Hydromorphone HCl) DILAUDID TABS OR MG (Hydromorphone HCl) DILAUDID TABS OR MG (Hydromorphone HCl) DILAUDID TABS OR 8 MG (Hydromorphone HCl) DILAUDID-HP SOLN (Hydromorphone HCl) DOLOPHINE TABS 0 MG (Methadone HCl) DOLOPHINE TABS MG (Methadone HCl) DURAGESIC PT7 00 MCG/HR (Fentanyl) DURAGESIC PT7 MCG/HR (Fentanyl) DURAGESIC PT7 MCG/HR (Fentanyl) DURAGESIC PT7 0 MCG/HR, 7 MCG/HR (Fentanyl) EXALGO TA MG (Hydromorphone HCl) SL( ea daily); SL( ea daily); ; SL(6 ea daily); ; AL; Up to 6 yrs old; QL(0 ea daily); AL; Up to 6 yrs old; QL(0 ea daily); QL(0 ml daily); QL( ea daily); QL(. ea daily); QL(6. ea daily); QL(6.67 ea daily); QL(. ea daily); QL(0. ea daily); Limit patches per month;ql(. ea daily); Limit 8 patches per month;ql(0.9 ea daily); Limit patches per month;ql(0. ea daily); QL(.7 ea daily); 08 Allwell (Value) Formulary Updated 06/0/08

25 Name EXALGO TA 6 MG (Hydromorphone HCl) EXALGO TA MG (Hydromorphone HCl) EXALGO TA 8 MG (Hydromorphone HCl) fentanyl citrate lpop bu 00 mcg fentanyl citrate lpop bu 00 mcg, 600 mcg, 800 mcg, 00 mcg, 600 mcg fentanyl pt7 00 mcg/hr fentanyl pt7 mcg/hr fentanyl pt7 mcg/hr fentanyl pt7 0 mcg/hr, 7 mcg/hr FENTORA TABS 00 MCG FENTORA TABS 00 MCG FENTORA TABS 00 MCG, 600 MCG, 800 MCG hydromorphone hcl liqd or /ml hydromorphone hcl soln ij 0 /ml, 0 /ml, 00 /0ml hydromorphone hcl soln ij /ml hydromorphone hcl ta or hydromorphone hcl ta or 6 hydromorphone hcl ta or hydromorphone hcl ta or 8, 8 QL(. ea daily); QL(.7 ea daily); QL(6.7 ea daily); ; QL(8 ea daily); ; QL( ea daily); QL(0. ea daily); Limit patches per month;ql(. ea daily); Limit 8 patches per month;ql(0.9 ea daily); Limit patches per month;ql(0. ea daily); ; QL(6 ea daily); ; QL(8 ea daily); ; QL( ea daily); QL(0 ml daily); QL(.7 ea daily); ; QL(. ea daily); ; QL(.7 ea daily); ; QL(6.7 ea daily); ; Name hydromorphone hcl tabs or hydromorphone hcl tabs or hydromorphone hcl tabs or 8 HYSINGLA ER TA 00 MG, 0 MG HYSINGLA ER TA 0 MG, 60 MG HYSINGLA ER TA 0 MG HYSINGLA ER TA 0 MG HYSINGLA ER TA 80 MG KADIAN CP 0 MG (Morphine Sulfate) KADIAN CP 00 MG (Morphine Sulfate) KADIAN CP 0 MG (Morphine Sulfate) KADIAN CP 0 MG (Morphine Sulfate) KADIAN CP 0 MG KADIAN CP 0 MG (Morphine Sulfate) KADIAN CP 60 MG (Morphine Sulfate) KADIAN CP 80 MG (Morphine Sulfate) LAZANDA SOLN 00 MCG/ACT LAZANDA SOLN 00 MCG/ACT LAZANDA SOLN 00 MCG/ACT meperidine hcl tabs or 00 meperidine hcl tabs or 0 methadone hcl soln or 0 /ml QL( ea daily); QL(. ea daily); QL(6. ea daily); ; QL( ea daily); ; QL( ea daily); ; QL( ea daily); ; QL(.67 ea daily); ; QL(. ea daily); QL(0 ea daily); QL( ea daily); QL(0 ea daily); QL(6.67 ea daily); ; QL( ea daily); QL( ea daily); QL(. ea daily); QL(. ea daily); ; QL( ea daily); ; QL(0. ea daily); ; QL(0.7 ea daily); AL; Up to 6 yrs old; QL(0 ea daily); AL; Up to 6 yrs old; QL(0 ea daily); QL(. ml daily); ; 08 Allwell (Value) Formulary Updated 06/0/08 6

26 Name methadone hcl soln or /ml methadone hcl tabs or 0 methadone hcl tabs or morphine sulfate beads cp 0 morphine sulfate beads cp 0 morphine sulfate beads cp morphine sulfate beads cp 60 morphine sulfate beads cp 7 morphine sulfate beads cp 90 morphine sulfate cp or 0 morphine sulfate cp or 00 morphine sulfate cp or 0 morphine sulfate cp or 0 morphine sulfate cp or 0 morphine sulfate cp or 60 morphine sulfate cp or 80 morphine sulfate soln ij 0. /ml morphine sulfate soln ij /ml morphine sulfate soln or 0 /ml morphine sulfate soln or 0 /ml morphine sulfate soln or 0 /ml, 00 /ml morphine sulfate tbcr or 00, 00 morphine sulfate tbcr or QL(66.67 ml daily); ; QL(6.67 ea daily); QL(. ea daily); QL(.67 ea daily); ; QL(6.67 ea daily); ; QL(. ea daily); ; QL(. ea daily); ; QL(.67 ea daily); ; QL(. ea daily); ; QL(0 ea daily); QL( ea daily); QL(0 ea daily); QL(6.67 ea daily); QL( ea daily); QL(. ea daily); QL(. ea daily); QL(00 ml daily); QL(0 ml daily); QL(0 ml daily); QL( ea daily); QL(. ea daily); Name morphine sulfate tbcr or 0 morphine sulfate tbcr or 60 MS CONTIN TBCR 00 MG, 00 MG (Morphine Sulfate) MS CONTIN TBCR MG (Morphine Sulfate) MS CONTIN TBCR 0 MG (Morphine Sulfate) MS CONTIN TBCR 60 MG (Morphine Sulfate) NUCYNTA ER TB 00 MG NUCYNTA ER TB 0 MG NUCYNTA ER TB 00 MG NUCYNTA ER TB 0 MG NUCYNTA ER TB 0 MG NUCYNTA TABS 00 MG NUCYNTA TABS 0 MG NUCYNTA TABS 7 MG ONA ER (CRUSH RESISTANT) TA 0 MG ONA TABS OR 0 MG (Oxymorphone HCl) ONA TABS OR MG (Oxymorphone HCl) oxycodone hcl caps or oxycodone hcl conc or 00 /ml oxycodone hcl tabs or 0 oxycodone hcl tabs or oxycodone hcl tabs or 0 QL(6.67 ea daily); QL(. ea daily); QL( ea daily); QL(. ea daily); QL(6.67 ea daily); QL(. ea daily); QL(6.67 ea daily); QL(. ea daily); QL(. ea daily); QL( ea daily); QL(. ea daily); QL(6.67 ea daily); QL(. ea daily); QL(8.88 ea daily); QL( ea daily) QL(6.67 ea daily); QL(. ea daily); QL(6.67 ea daily); QL(6.67 ml daily); QL(. ea daily); QL(8.9 ea daily); QL(6.67 ea daily); 08 Allwell (Value) Formulary Updated 06/0/08 7

27 Name oxycodone hcl tabs or 0 oxycodone hcl tabs or oxymorphone hcl tabs 0 oxymorphone hcl tabs oxymorphone hcl tb 0 oxymorphone hcl tb oxymorphone hcl tb 0 oxymorphone hcl tb 0 oxymorphone hcl tb 0 oxymorphone hcl tb oxymorphone hcl tb 7. ROXICODONE TABS MG (Oxycodone HCl) ROXICODONE TABS 0 MG (Oxycodone HCl) ROXICODONE TABS MG (Oxycodone HCl) SUBSYS LIQD 00 MCG SUBSYS LIQD 00 MCG SUBSYS LIQD 00 MCG SUBSYS LIQD 00 MCG, 600 MCG, 800 MCG, 600 MCG tramadol hcl tabs or 0 tramadol hcl tb or 00 tramadol hcl tb or 00 tramadol hcl tb or 00 QL(. ea daily); QL(6.67 ea daily); QL(6.67 ea daily); QL(. ea daily); QL(.6 ea daily); QL(. ea daily); QL(. ea daily); QL(. ea daily); QL( ea daily); QL(. ea daily); QL(8.89 ea daily); QL(8.9 ea daily); QL(. ea daily); QL(6.67 ea daily); ; QL(6 ea daily); ; QL( ea daily) ; QL(8 ea daily); ; QL( ea daily); SL(8 ea daily); ; SL( ea daily); SL(. ea daily); SL( ea daily); Name ULTRAM ER TB (Tramadol HCl) ULTRAM TABS (Tramadol HCl) ZOHYDRO ER CA 0 MG ZOHYDRO ER CA MG ZOHYDRO ER CA 0 MG ZOHYDRO ER CA 0 MG ZOHYDRO ER CA 0 MG ZOHYDRO ER CA 0 MG Opioid Combinations acetaminophen w/ codeine soln 0/ml-/ml acetaminophen w/ codeine tabs 00- acetaminophen w/ codeine tabs 00-0 acetaminophen w/ codeine tabs butalbital-acetaminophencaffeine w/ codeine caps butalbital-aspirin-caffeine w/cod caps FIORICET/CODEINE CAPS (Butalbital- Acetaminophen-Caffeine w/ Codeine) FIORINAL/CODEINE # CAPS (Butalbital-Aspirin- Caffeine w/cod) HYCET SOLN (Hydrocodone- Acetaminophen) SL( ea daily); SL(8 ea daily); ; QL(6.8 ea daily); ; QL(. ea daily); ; QL(8. ea daily); ; QL(.6 ea daily); ; QL(. ea daily); ; QL(.7 ea daily); Limit 00mls per month;sl(0 ml daily); ; SL(. ea daily); ; SL( ea daily); ; SL(6 ea daily); ; AL; Up to 6 yrs old; SL(6 ea daily); AL; Up to 6 yrs old; SL(6 ea daily); AL; Up to 6 yrs old; SL(6 ea daily); AL; Up to 6 yrs old; SL(6 ea daily); Limit mls per month;sl(8. ml daily); 08 Allwell (Value) Formulary Updated 06/0/08 8

28 Name hydrocodoneacetaminophen soln 0/ml-/ml hydrocodoneacetaminophen soln./ml-08/ml, /0ml-7/0ml, 7./ml-/ml hydrocodoneacetaminophen tabs - 00, 0-00, hydrocodoneacetaminophen tabs -, 0-, 7.- hydrocodone-ibuprofen tabs IBUDONE TABS (Hydrocodone-Ibuprofen) NORCO TABS (Hydrocodone- Acetaminophen) oxycodone w/ acetaminophen soln /ml-/ml oxycodone w/ acetaminophen tabs 0- oxycodone w/ acetaminophen tabs -,.-, 7.- oxycodone-aspirin tabs PERCOCET TABS (Oxycodone w/ Acetaminophen) REPREXAIN TABS (Hydrocodone-Ibuprofen) tramadol-acetaminophen tabs TYLENOL/CODEINE # TABS (Acetaminophen w/ Codeine) Limit mls per month;sl(8. ml daily); ; Limit mls per month;sl(8. ml daily); SL(. ea daily); ; SL(. ea daily); ; SL(. ea daily); Limit 8mls per month;sl(6. ml daily); SL(. ea daily); SL(. ea daily); ; SL(. ea daily); SL(8 ea daily); SL( ea daily); Name TYLENOL/CODEINE # TABS (Acetaminophen w/ Codeine) ULTRACET TABS (Tramadol-Acetaminophen) XODOL TABS (Hydrocodone- Acetaminophen) Opioid Partial Agonists BUNAVAIL FILM.MG- 0.MG,.MG-0.7MG BUNAVAIL FILM 6.MG- MG buprenorphine hcl subl sl buprenorphine hcl subl sl 8 buprenorphine hclnaloxone hcl dihydrate subl -0. buprenorphine hclnaloxone hcl dihydrate subl 8- BUPRENORPHINE PTWK 0 MCG/HR BUPRENORPHINE PTWK MCG/HR BUPRENORPHINE PTWK 0 MCG/HR BUPRENORPHINE PTWK MCG/HR BUPRENORPHINE PTWK 7. MCG/HR butorphanol tartrate soln ij /ml SL(6 ea daily); SL(8 ea daily); SL(. ea daily); ; ; QL(6 ea daily); ; QL( ea daily); ; QL(6 ea daily); ; QL( ea daily); Limit 8 patches per 8 days;sl(0.9 ea daily); Limit patches per 8 days;sl(0.9 ea daily); Limit patches per 8 days;sl(0. ea daily); Limit 6 patches per 8 days;sl(0.8 ea daily); Limit 0 patches per 8 days;sl(0.9 ea daily); 08 Allwell (Value) Formulary Updated 06/0/08 9

29 Name butorphanol tartrate soln na 0 /ml BUTRANS PTWK 0 MCG/HR BUTRANS PTWK MCG/HR BUTRANS PTWK 0 MCG/HR BUTRANS PTWK MCG/HR BUTRANS PTWK 7. MCG/HR pentazocine w/ naloxone tabs SUBOXONE FILM MG- MG SUBOXONE FILM MG- MG, 8MG-MG, MG- 0.MG ZUBSOLV SUBL 0.7MG- 0.8MG ZUBSOLV SUBL.MG- 0.6MG,.MG-.9MG,.9MG-0.7MG ZUBSOLV SUBL.7MG-.MG ZUBSOLV SUBL 8.6MG-.MG Limit 0mls per month;ql(7 ml daily); Limit 8 patches per 8 days;sl(0.9 ea daily); Limit patches per 8 days;sl(0.9 ea daily); Limit patches per 8 days;sl(0. ea daily); Limit 6 patches per 8 days;sl(0.8 ea daily); Limit 0 patches per 8 days;sl(0.9 ea daily); AL; Up to 6 yrs old; QL(9.07 ea daily); ; QL( ea daily); ; QL( ea daily); ; ; QL( ea daily); ; QL( ea daily); ; QL( ea daily); ANDROGENS-ANABOLIC - s to Regulate Hormones Anabolic Steroids ANADROL-0 TABS Name oxandrolone tabs or 0 oxandrolone tabs or. Androgens ANDRODERM PT ANDROGEL GEL 0. MG/.GM, 0. MG/.GM ANDROGEL GEL 0 MG/GM, MG/.GM (Testosterone) ANDROGEL PUMP GEL AVEED SOLN AXIRON SOLN (Testosterone) danazol caps or 0, 00, 00 DEPO-TESTOSTERONE SOLN (Testosterone Cypionate) fluoxymesterone tabs or FORTESTA GEL methyltestosterone caps or NATESTO GEL TESTIM GEL (Testosterone) testosterone cypionate soln testosterone enanthate soln im TESTOSTERONE GEL %, 0 MG/ACT, 0 MG/GM, MG/.GM testosterone gel %, 0 /gm, /.gm TESTOSTERONE PUMP GEL testosterone soln 0 /act ; LA ; ; ; ; ; 08 Allwell (Value) Formulary Updated 06/0/08 0

30 Name VOGELXO GEL VOGELXO PUMP GEL ANORECTAL AGENTS - Rectal s to Treat Pain, Swelling and Itching Intrarectal Steroids CORTENEMA ENEM (Hydrocortisone (Intrarectal)) CORTIFOAM FOAM hydrocortisone (intrarectal) enem UCERIS FOAM RE MG/ACT Rectal Steroids ANUSOL-HC CREA (Hydrocortisone (Rectal)) hydrocortisone (rectal) crea PROCTOCORT CREA % (Hydrocortisone (Rectal)) Vasodilating Agents RECTIV OINT ; ANTHELMINTICS - s to Treat Worm Infections Anthelmintics ALBENZA TABS BILTRICIDE TABS (Praziquantel) ivermectin tabs or praziquantel tabs or ; STROMECTOL TABS (Ivermectin) ANTI-IECTIVE AGENTS - MISC. - s to Treat Bacterial Infections Anti-infective Agents - Misc. colistimethate sodium solr ij Name COLY-MYCIN M SOLR (Colistimethate Sodium) FLAGYL CAPS 7 MG (Metronidazole) FLAGYL TABS 0 MG (Metronidazole) FLAGYL TABS 00 MG (Metronidazole) IMVIDO CAPS metronidazole caps or 7 metronidazole in nacl soln metronidazole tabs or 0 metronidazole tabs or 00 NEBUPENT SOLR ORBACTIV SOLR PENTAM 00 SOLR TINDAMAX TABS (Tinidazole) tinidazole tabs or 0, 00 trimethoprim tabs or VANCOCIN HCL CAPS (Vancomycin HCl) vancomycin hcl caps or, 0 VANCOMYCIN HCL IN DEXTROSE SOLN GM/00ML-%, %- 70MG/0ML, 00MG/00ML-% vancomycin hcl solr iv 0 gm, 00, 000, 000 XIFAXAN TABS 00 MG SL(0.6 ea daily); SL(6 ea daily); SL(8 ea daily); SL(0.6 ea daily); SL(6 ea daily); ; SL(8 ea daily); ; B/D; ; ; ; XIFAXAN TABS 0 MG QL( ea daily); Anti-infective Misc. - Combinations 08 Allwell (Value) Formulary Updated 06/0/08

31 Name BACTRIM DS TABS (Sulfamethoxazole- Trimethoprim) BACTRIM TABS (Sulfamethoxazole- Trimethoprim) sulfamethoxazoletrimethoprim soln iv 80/ml-00/ml sulfamethoxazoletrimethoprim susp or 0/ml-00/ml sulfamethoxazoletrimethoprim tabs or 80-00, Antiprotozoal Agents ALINIA TABS 00 MG atovaquone susp MEPRON SUSP (Atovaquone) Carbapenems DORIBAX SOLR 00 MG DORIPENEM SOLR 00 MG imipenem-cilastatin solr 0-0 imipenem-cilastatin solr INVANZ SOLR IJ meropenem solr MERREM SOLR (Meropenem) PRIMAXIN IV ADD- VANTAGE SOLR (Imipenem-Cilastatin) PRIMAXIN IV SOLR (Imipenem-Cilastatin) VABOMERE SOLR Chloramphenicols ; ; ; Name chloramphenicol sodium succinate solr Cyclic Lipopeptides CUBICIN RF SOLR (Daptomycin) CUBICIN SOLR (Daptomycin) daptomycin solr Glycylcyclines TIGECYCLINE SOLR tigecycline solr TYGACIL SOLR (Tigecycline) Leprostatics dapsone tabs or, 00 Lincosamides CLEOCIN CAPS OR 7 MG, 0 MG, 00 MG (Clindamycin HCl) CLEOCIN IN DW SOLN (Clindamycin Phosphate in DW) CLEOCIN PEDIATRIC GRANULES SOLR (Clindamycin Palmitate Hydrochloride) CLEOCIN PHOSPHATE SOLN IJ 600 MG/ML, 900 MG/6ML (Clindamycin Phosphate) CLEOCIN PHOSPHATE SOLN IV 00MG/0ML- %, 600MG/0ML-%, 900MG/0ML-% (Clindamycin Phosphate in DW) CLEOCIN PHOSPHATE SOLN IV 600 MG/ML (Clindamycin Phosphate) clindamycin hcl caps or 7, 0, 00 ; ; 08 Allwell (Value) Formulary Updated 06/0/08