2017 Comprehensive FORMULARY

Transcription

1 207 Comprehensive FORMULARY (Complete list of covered drugs) UnitedHealthcare Group Medicare Advantage (PPO) North Carolina State Health Plan for Teachers and State Employees Please read: This document contains information about the drugs we cover in this plan. For more recent information or if you have other questions, please call UnitedHealthcare Group Medicare Advantage (PPO) Customer Service at: Toll-Free , TTY 7 8 a.m. - 8 p.m. ET, Monday - Friday Formulary ID Number , Version 2 Y0066_60722_99 Last updated October, 207

2 2 2 This Comprehensive Formulary is a complete list of the drugs covered by our plan. It is current as of October, 207. For a complete up-to-date formulary (drug list), please call us. Our contact information, along with the date we last updated the formulary, is on the cover. When this formulary (drug list) refers to we, us, or our, it means UnitedHealthcare. When it refers to plan or our plan, it means UnitedHealthcare Group Medicare Advantage (PPO). This list of covered drugs is called a Formulary. We call it a drug list for short. Note to existing members: This complete drug list has changed since last year. Please review this document to make sure your drugs are still covered. In most cases, you must use network pharmacies to have your prescriptions covered by the plan.

3 The UnitedHealthcare Group Medicare Advantage (PPO) COMPREHENSIVE FORMULARY (drug list) A formulary (drug list) is a list of covered drugs selected by your plan in consultation with a team of health care providers, which represents the prescription therapies believed to be a necessary part of a quality treatment program. Your plan will generally cover the drugs listed in our drug list as long as the drug is: Medically necessary The prescription is filled at a plan network pharmacy Other plan rules are followed For more information on how to fill your prescriptions, please review your Evidence of Coverage. This document is a complete drug list of the drugs covered by your plan. For your drug to be covered by your plan, it must be included in the complete drug list. To find out if your drug is covered:. See if your drug is included in this complete drug list. 2. Visit your plan website. Use the online tools to look up your drugs. The information is updated on a regular basis. The web address is on the cover.. Or call Customer Service. Our contact information is on the cover. In most cases, your prescription must also be filled at one of our network pharmacies.

4 4 The drug list may change We try to make as few changes to the drug list as possible during the plan year. If there are changes to the drug list, such as regular or necessary updates, members may see information in their Explanation of Benefits (EOB) statements. If there are changes to the drug list outside of regular or necessary updates, members may receive a special mailing. The drug list may change during the year if your plan: Adds new drugs, including generic drugs, as they become available. Removes a drug that has been found to be ineffective or unsafe. Changes the requirements or limits for a drug. Moves a drug into a different tier. Generally, if you are taking a drug on the 207 drug list that was covered at the beginning of the year, we will not discontinue or reduce coverage of the drug during the 207 plan year except when a new, less expensive generic drug becomes available or when new information about the safety or effectiveness of a drug is released. Other types of drug list changes, such as removing a drug from the list, will not affect members who are currently taking the drug. For those members it will remain available at the same cost for the remainder of the plan year. We feel it is important for you to have access for the entire plan year to the list of drugs that were available when you chose your plan, except when you can save additional money or your safety is a concern. If we remove drugs from our drug list, or add prior authorization, quantity limits and/or step therapy restrictions on a drug or move a drug to a higher cost-sharing tier, during the plan year we must notify affected members at least 60 days before the change becomes effective, or when the member requests a refill of the drug. At this time the member will receive a 60-day supply of the drug. If the Food and Administration (FDA) declares a drug on our drug list to be unsafe, or if the drug s manufacturer removes the drug from the market, your plan will immediately remove the drug from the drug list and notify members who take the drug. The enclosed drug list is current as of the date printed on the cover. To get updated information about the drugs covered by your plan, please call Customer Service or visit our website using the information provided on the cover of this drug list. 4

5 tiers The amount you pay for a covered drug will depend on: The drug tier for your drug. Each covered drug is in one of four drug tiers. Each tier has a co-pay and/or co-insurance amount. The chart below shows the differences between the tiers. For more information about co-pay or co-insurance amounts for each tier, please review your Evidence of Coverage. 5 Includes : Preferred generic 2: Preferred brand Most generic drugs. Many common brand name drugs, called preferred brands. : Non-preferred drug 4: Specialty tier Non-preferred generic and non-preferred brand name drugs. In addition, Part D eligible compound medications are covered in. Unique and/or very high-cost brand or generic drugs. If you qualify for Extra Help If you qualify for Extra Help for your prescription drugs, your co-pays and co-insurance may be lower. Members who qualify for Extra Help will receive the Evidence of Coverage Rider for People Who Get Extra Help Paying for Prescription s (LIS Rider). Please read it to learn about your costs. You can also call Customer Service. Our contact information is on the cover. 5

6 6 How to use the drug list There are two ways to find your prescription drugs in this complete drug list:. Medical condition: Turn to the Covered drugs by medical condition section, which begins on page 2, to look for drugs based on your medical conditions. For example, if you want to find drugs used to treat high cholesterol, go to the Cardiovascular Agents category and look under Dyslipidemics, HMG CoA Reductase Inhibitors. 2. Alphabetical list (index): If you are not sure what category to look under, turn to the Index of covered drugs section, which begins on page 60. Find the name of your drug. The page number where you can find the drug will be next to it. Generic drugs Your plan covers both brand name drugs and generic drugs. Generic drugs: Are approved by the Food and Administration (FDA) as having the same active ingredients as brand name drugs. Usually cost less than brand name drugs. Talk with your doctor to see if any of the brand name drugs you take have generic versions. Then review the drug list to make sure you are getting the drug you need for the least amount of money. The drug list shows brand name drugs in bold type (for example, Humalog) and generic drugs in plain type (for example, Simvastatin). 6

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

8 2 8 You can find out if your drug has any additional requirements, restrictions or limits by looking it up in the Covered drugs by medical condition section that begins on page 2. You can also get more information about the restrictions applied to specific covered drugs by visiting our website. We have posted online documents that explain our prior authorization and step therapy restrictions. You may ask us to send you a copy. Our contact information, along with the date we last updated the drug list, is on the cover. You and your doctor may ask the plan for an exception to these requirements, restrictions or limits, or for a list of other, similar drugs that may treat your health condition. See the, How to request an exception to the UnitedHealthcare Group Medicare Advantage (PPO) drug list section on the next page or review your Evidence of Coverage to learn more. If you do not get prior approval from the plan for a drug with a requirement, restriction or limit, you may have to pay the full cost of the drug. If your drug is not on the drug list If your drug is not included in this complete formulary (list of covered drugs), you should call Customer Service and ask if your drug is covered. Our contact information, along with the date we last updated the drug list, is on the cover. If you learn that your plan does not cover your drug, you have two options:. Ask your plan for a list of similar drugs that it covers. Show the list to your doctor and ask him or her to prescribe one of the appropriate drugs from the list. 2. Ask your plan to make an exception and cover your drug. See next page for information about how to request an exception. 8

9 How to request an exception to the UnitedHealthcare Group Medicare Advantage (PPO) drug list At times you may need to ask for drug coverage that s not normally provided by your plan. When you do, your plan will consider your request and respond with a coverage decision (coverage determination). You can ask your plan to make an exception to the coverage rules. There are several types of exceptions that you can ask us to make. 9 Formulary exception: You can ask your plan to cover your drug even if it is not on the drug list. If approved, this drug will be covered at a pre-determined cost-sharing level, and you would not be able to ask us to provide the drug at a lower cost-sharing level. ing exception: You can ask your plan to cover a formulary drug at a lower cost-sharing level if this drug is not on the specialty tier. Utilization exception: You can ask your plan to waive coverage restrictions or limits on your drug. For example, your plan limits the amount it will cover for certain drugs. If your drug has a quantity limit, you can ask your plan to waive the limit and cover more. Generally, your plan will approve your request for an exception only if the alternative drugs included in your plan s drug list, the lower cost-sharing drug or additional utilization restrictions would not be as effective in treating your condition and/or would cause adverse medical effects. Who can ask for a coverage decision You, your authorized representative or your doctor can ask for an initial coverage decision for a formulary exception, tiering exception or utilization restriction exception. When you are requesting a formulary exception, tiering exception or utilization restriction exception, your prescriber or physician should submit a statement supporting your request. Receiving a coverage decision Generally, your plan will make a coverage decision within 72 hours after receiving your prescribing physician s statement. You can request an expedited, or fast, decision if you or your doctor believes your health requires it. If your plan agrees to a fast decision, you will receive a decision within 24 hours after your plan receives your doctor s or prescribing physician s supporting statement. 9

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

11 s with dosages other than a one-month supply s packaged in an extended day supply Some drugs are packaged from the manufacturer to provide more than a one-month supply. When you fill these drugs, you may have to pay more than one co-pay/co-insurance for a single prescription. For more information, please call Customer Service using the information on the cover. Daily cost share for oral medications filled for less than a one-month supply Daily cost share applies only if the drug is in the form of a solid oral dose (e.g., tablet or capsule) when dispensed for a supply of less than one month under applicable law. The daily cost share requirements do not apply to either of the following:. Solid oral doses of antibiotics. 2. Solid oral doses that are dispensed in their original container or are usually dispensed in their original packaging to help patients comply with usage and dosage directions. For more information For more information about your plan s prescription drug coverage, please review your Evidence of Coverage and other plan materials. If you have questions about your plan, please call us toll-free at , TTY 7, 8 a.m. - 8 p.m. ET, Monday - Friday. Or visit us online at If you have general questions about Medicare prescription drug coverage, visit or call Medicare at , TTY , 24 hours a day, 7 days a week.

12 track Arthrotec 75 Diclofenac Sodium Diclofenac Sodium DR Diclofenac Sodium/Misoprostol Etodolac Etodolac ER 2 Covered drugs by medical condition The Comprehensive Formulary (drug list) below provides coverage information about the drugs covered by your plan. If you have trouble finding your drug in the list, turn to the Index of covered drugs, which begins on page 60. The first column of the chart lists the drug name. Brand name drugs are listed in bold type (for example, Humalog) and generic drugs are listed in plain type (for example, Simvastatin). The second column of the chart lists which coverage level () your drug is in. The column shows you if your plan has any special coverage requirements for the drug. If quantity limits (QL) apply to a drug, the restriction amounts are shown in the chart on pages track Analgesics Nonsteroidal Anti-inflammatory s DS Anaprox DS 50 Arthrotec 50 (Tablet Delayed-Release) Arthrotec 75 (Tablet Delayed-Release) Cambia (Packet) Celebrex (Capsule) QL Celecoxib (Capsule) QL Daypro Potassium Diclofenac Potassium (Tablet Immediate- Release) Diclofenac Sodium (% Gel,.5% PA Transdermal Diclofenac Sodium DR (Tablet Delayed- Release) Sodium ER Diclofenac Sodium ER (Tablet Extended- Release 24 Diclofenac Sodium/ Misoprostol (Tablet Delayed-Release) Diflunisal EC-Naprosyn (Tablet Delayed-Release) Etodolac (200mg Capsule, 00mg Capsule, 400mg Tablet Immediate-Release, 500mg Tablet Immediate-Release) Etodolac ER (Tablet Feldene (Capsule) Calcium Fenoprofen Calcium (400mg Capsule) Bold type = Brand name drug Plain type = Generic drug 2

13 2tRACK Ketoprofen Ketoprofen ER Ketorolac Tromethamine Mefenamic Acid Naproxen DR Naproxen Sodium Naproxen Sodium ER Naproxen Sodium CR 2 Last updated October, 207 Calcium Fenoprofen Calcium (600mg Flector (Patch) PA, QL Flurbiprofen Ibuprofen (00mg/5ml Suspension, 400mg Tablet, 600mg Tablet, 800mg Ketoprofen (Capsule Immediate-Release) Ketoprofen ER (Capsule Extended- Release 24 Ketorolac Tromethamine (5mg/ ml Injection, 0mg/ml PA, HRM Injection, 60mg/2ml Injection) Lodine 4 Sodium Meclofenamate Sodium (Capsule) Mefenamic Acid (Capsule) Meloxicam Mobic Nabumetone Naprelan (75mg Tablet Extended- Release 24 Hour, 4 500mg Tablet Naprelan (750mg Tablet Extended- Release 24 Naprosyn Naproxen (25mg/5ml Suspension, 250mg Tablet Immediate- Release, 75mg Tablet Immediate-Release, 500mg Tablet Immediate-Release) Naproxen DR (Tablet Delayed-Release) (Generic EC-Naprosyn) Naproxen Sodium (Tablet Immediate- Release) (Generic Anaprox DS) Naproxen Sodium ER (Tablet Extended- Release 24 (Generic Naprelan) Naproxen Sodium CR (Tablet Extended- Release 24 (Generic Naprelan) Oxaprozin Pennsaid (Transdermal 4 PA Piroxicam (Capsule) Ponstel (Capsule) Sulindac You can find information on what the symbols and abbreviations in this table mean by going to page 7.

14 track Conzip Duragesic Embeda Exalgo Fentanyl Fentanyl Hydromorphone HCl ER Hydromorphone HCl ER 4 Last updated October, 207 Sodium Tolmetin Sodium (400mg Capsule, 600mg Vivlodex (Capsule) QL Voltaren (Gel) 2 PA Zipsor (Capsule) ST Zorvolex (Capsule) ST Opioid Analgesics, Long-acting Conzip (Capsule QL, MED Dolophine QL, MED Duragesic (00mcg/ hr Patch 72 Hour, 75mcg/hr Patch 72 4 QL, MED Duragesic (2mcg/hr Patch 72 Hour, 25mcg/hr Patch 72 QL, MED Hour, 50mcg/hr Patch 72 Embeda (Capsule Extended-Release) 2 QL, MED Exalgo (2mg Tablet Hour Abuse- Deterrent, 8mg Tablet QL, MED Hour Abuse- Deterrent) Exalgo (6mg Tablet Hour Abuse- Deterrent, 2mg Tablet Extended- Release 24 Hour Abuse-Deterrent) Fentanyl (00mcg/hr Patch 72 Hour, 2mcg/hr Patch 72 Hour, 25mcg/hr Patch 72 Hour, 7.5mcg/hr Patch 72 Hour, 50mcg/hr Patch 72 Hour, 75mcg/hr Patch 72 Fentanyl (62.5mcg/hr Patch 72 Hour, 87.5mcg/hr Patch 72 Hydromorphone HCl ER (2mg Tablet Hour Abuse-Deterrent, 8mg Tablet Extended- Release 24 Hour Abuse-Deterrent) Hydromorphone HCl ER (6mg Tablet Hour Abuse-Deterrent) 4 QL, MED QL, MED 4 QL, MED QL, MED 4 QL, MED Bold type = Brand name drug Plain type = Generic drug 4

15 4tRACK Hysingla ER Kadian Kadian Levorphanol Tartrate Methadone HCl Morphabond ER Morphabond ER Morphine Sulfate ER 4 Last updated October, HCl ER Hydromorphone HCl ER (2mg Tablet Hour Abuse- Deterrent) Hysingla ER (Tablet Hour Abuse- Deterrent) Kadian (00mg Capsule Extended- Release 24 Hour, 200mg Capsule Hour, 40mg Capsule Hour, 50mg Capsule Hour, 60mg Capsule Hour, 80mg Capsule Kadian (0mg Capsule Extended- Release 24 Hour, 20mg Capsule Hour, 0mg Capsule Levorphanol Tartrate 4 QL, MED 2 QL, MED 4 QL, MED QL, MED QL, MED HCl Methadone HCl (0mg Tablet, 5mg Tablet, 0mg/5ml Oral Solution, 5mg/5ml Oral Methadone HCl (0mg/ml Injection) Morphabond ER (00mg Tablet Extended-Release 2 Hour Abuse- Deterrent, 60mg Tablet Extended- Release 2 Hour Abuse-Deterrent) Morphabond ER (5mg Tablet Extended-Release 2 Hour Abuse- Deterrent, 0mg Tablet Extended- Release 2 Hour Abuse-Deterrent) Morphine Sulfate ER (00mg Capsule (Generic Kadian) QL, MED 4 4 QL, MED QL, MED 4 QL, MED You can find information on what the symbols and abbreviations in this table mean by going to page 7. 5

16 5tRACK MS Contin 5 6 Last updated October, 207 Sulfate ER Morphine Sulfate ER (00mg Tablet Extended-Release, 5mg Tablet Extended- Release, 200mg Tablet Extended-Release, 0mg Tablet Extended- Release, 60mg Tablet Extended-Release) (Generic MS Contin) QL, MED Sulfate ER Morphine Sulfate ER (0mg Capsule Hour, 20mg Capsule Hour, 0mg Capsule Hour, 50mg Capsule Hour, 60mg Capsule Hour, 80mg Capsule (Generic Kadian), (20mg Capsule Extended- Release 24 Hour, 0mg Capsule Hour, 45mg Capsule Hour, 60mg Capsule Hour, 75mg Capsule Hour, 90mg Capsule (Generic Avinza) MS Contin (00mg Tablet Extended- Release, 200mg Tablet Extended- Release, 60mg Tablet Extended-Release) QL, MED 4 QL, MED Bold type = Brand name drug Plain type = Generic drug 6

17 6tRACK Nucynta ER Opana ER Oxycodone HCl ER OxyContin Oxymorphone HCl ER Tramadol HCl ER Xtampza ER Zohydro ER Abstral Acetaminophen/Codeine Butorphanol Tartrate 6 Last updated October, Contin MS Contin (5mg Tablet Extended- Release, 0mg Tablet Extended-Release) Nucynta ER (Tablet Extended-Release 2 Opana ER (Tablet Extended-Release 2 Hour Abuse- Deterrent) Oxycodone HCl ER (Tablet Extended- Release 2 Hour Abuse-Deterrent) OxyContin (Tablet Extended-Release 2 Hour Abuse- Deterrent) Oxymorphone HCl ER (Tablet Extended- Release 2 Tramadol HCl ER (00mg Capsule Hour, 200mg Capsule Hour, 00mg Capsule QL, MED 2 QL, MED 2 QL, MED QL, MED 2 QL, MED QL, MED QL, MED HCl ER Tramadol HCl ER (00mg Tablet Hour, 200mg Tablet Hour, 00mg Tablet QL, MED Xtampza ER (Capsule Extended-Release 2 Hour Abuse- QL, ST, MED Deterrent) Zohydro ER (Capsule Extended-Release 2 PA, QL, Hour Abuse- MED Deterrent) Opioid Analgesics, Short-acting Abstral (Tablet Sublingual) 4 PA, QL Acetaminophen/ Codeine (20mg-2mg/5ml Oral Solution, QL, MED 00mg-5mg Tablet, 00mg-0mg Tablet, 00mg-60mg Actiq (Lollipop) 4 PA, QL Tartrate Butorphanol Tartrate (0mg/ml Nasal QL, MED Butorphanol Tartrate (mg/ml Injection, 2mg/ml Injection) You can find information on what the symbols and abbreviations in this table mean by going to page 7. 7

18 7tRACK Dilaudid Fentanyl Citrate Oral Transmucosal Hydrocodone/Ibuprofen Hydromorphone HCl Hydromorphone HCl Hydromorphone HCl 7 8 Last updated October, 207 Sulfate Codeine Sulfate QL, MED Dilaudid (mg/ml Liquid, 2mg Tablet, 4mg Tablet, 8mg QL, MED Duramorph Endocet QL, MED Citrate Oral Transmucosal Fentanyl Citrate Oral Transmucosal (200mcg Lollipop, 600mcg Lollipop, 600mcg Lollipop, 800mcg Lollipop) 4 PA, QL Fentanyl Citrate Oral Transmucosal (200mcg Lollipop, PA, QL 400mcg Lollipop) Fentora 4 PA, QL Hycet (Oral QL, MED Bitartrate/Acetaminophen Hydrocodone Bitartrate/ Acetaminophen (0mg-00mg Tablet, 5mg-00mg Tablet, 7.5mg-00mg Tablet, 7.5mg-25mg/5ml Oral QL, MED Hydrocodone/Acetaminophen Acetaminophen (0mg-25mg Tablet, 2.5mg-25mg Tablet, 5mg-25mg Tablet, 7.5mg-25mg QL, MED Hydrocodone/ Ibuprofen QL, MED Hydromorphone HCl (0mg/ml Injection, 50mg/5ml Injection) Hydromorphone HCl (mg/ml Liquid, 2mg Tablet Immediate- Release, 4mg Tablet QL, MED Immediate-Release, 8mg Tablet Immediate- Release) Hydromorphone HCl (2mg/ml Injection) Ibudone QL, MED Lazanda (Nasal 4 PA, QL Lorcet QL, MED HD Lorcet HD QL, MED Plus Lorcet Plus QL, MED Sulfate Morphine Sulfate (00mg/5ml Oral Solution, 0mg/5ml Oral Solution, 20mg/ 5ml Oral QL, MED Bold type = Brand name drug Plain type = Generic drug 8

19 8tRACK Morphine Sulfate Morphine Sulfate Nalbuphine HCl Nucynta Opana Opana Oxycodone/Acetaminophen Oxycodone/Aspirin Oxycodone/Ibuprofen Oxymorphone HCl Percocet 8 Last updated October, Sulfate Morphine Sulfate (0mg/ml Injection, 4mg/ml Injection, 8mg/ml Injection) Morphine Sulfate (5mg Tablet Immediate-Release, QL, MED 0mg Tablet Immediate-Release) Morphine Sulfate (2mg/ml Injection) Nalbuphine HCl Norco QL, MED Nucynta (00mg 4 QL, MED Nucynta (50mg Tablet, 75mg QL, MED Opana (0mg Tablet Immediate-Release) 4 QL, MED Opana (5mg Tablet Immediate-Release) QL, MED HCl Oxycodone HCl (00mg/5ml Concentrate, 0mg Tablet Immediate- Release, 5mg Tablet Immediate-Release, 20mg Tablet Immediate-Release, 0mg Tablet Immediate-Release, 5mg Tablet Immediate- Release, 5mg Capsule Immediate-Release, 5mg/5ml Oral Oxycodone/ Acetaminophen (0mg-25mg Tablet, 2.5mg-25mg Tablet, 5mg-25mg Tablet, 7.5mg-25mg Tablet, 25mg/5ml-5mg/5ml Oral Oxycodone/Aspirin Oxycodone/Ibuprofen Oxymorphone HCl (Tablet Immediate- Release) Percocet (0mg-25mg Tablet, 5mg-25mg Tablet, 7.5mg-25mg QL, MED QL, MED QL, MED QL, MED QL, MED 4 QL, MED You can find information on what the symbols and abbreviations in this table mean by going to page 7. 9

20 9tRACK Primlev Primlev Roxicodone Roxicodone Tramadol HCl Tramadol HCl/Acetaminophen Tylenol/Codeine #4 Lidocaine Lidocaine HCl Lidocaine/Prilocaine Xylocaine Acamprosate Calcium DR 9 20 Last updated October, 207 Percocet (2.5mg-25mg Primlev (0mg-00mg Tablet, 7.5mg-00mg Primlev (5mg-00mg Roxicodone (5mg Tablet, 5mg Roxicodone (0mg QL, MED 4 QL, MED QL, MED QL, MED 4 QL, MED Subsys (Liquid) 4 PA, QL Synalgos-DC (Capsule) Tramadol HCl (Tablet Immediate-Release) Tramadol HCl/ Acetaminophen QL, MED QL, MED QL, MED Trezix (Capsule) QL, MED # Tylenol/Codeine # QL, MED Tylenol/Codeine #4 QL, MED Ultracet QL, MED Ultram QL, MED Vicodin QL, MED ES Vicodin ES QL, MED HP Vicodin HP QL, MED Xodol (0mg-00mg Tablet, 7.5mg-00mg 4 QL, MED Xodol (5mg-00mg QL, MED Zamicet (Oral QL, MED Anesthetics Local Anesthetics Lidocaine (5% Ointment) Lidocaine (5% Patch) PA, QL HCl Lidocaine HCl (0.5% Injection, % Injection, B/D, PA 2% Injection) Lidocaine HCl (4% External HCl Lidocaine HCl (Gel) Viscous Lidocaine Viscous ( Lidocaine/Prilocaine (2.5%-2.5% Cream) Lidoderm (Patch) PA, QL Xylocaine (2% Injection) B/D, PA Xylocaine (4% External Anti-Addiction/Substance Abuse Treatment Agents Alcohol Deterrents/Anti-craving Acamprosate Calcium DR (Tablet Delayed- Release) Antabuse Disulfiram Bold type = Brand name drug Plain type = Generic drug 20

21 0 track Buprenorphine HCl Buprenorphine HCl Buprenorphine HCl/Naloxone HCl Butrans Chantix Starting Month Pak Zyban Amikacin Sulfate Bethkis Gentak Gentamicin Sulfate Gentamicin Sulfate/0.9% Sodium Chloride 0 Last updated October, HCl Naltrexone HCl Vivitrol 4 Opioid Dependence Treatments Belbuca (Film) PA, QL, MED Bunavail (Film) PA, QL Buprenex 4 Buprenorphine (Patch Weekly) QL, MED Buprenorphine HCl (0.mg/ml Injection) Buprenorphine HCl (2mg Tablet Sublingual, 8mg Tablet QL Sublingual) Buprenorphine HCl/ Naloxone HCl (Tablet QL Sublingual) Butrans (Patch Weekly) 2 QL, MED Evzio HCl Naloxone HCl Narcan (Liquid) 2 Suboxone (Film) QL Zubsolv (Tablet Sublingual) PA, QL Smoking Cessation Agents HCl SR Bupropion HCl SR (50mg Tablet Extended-Release 2 Chantix 2 Continuing Month Pak Chantix Continuing Month Pak 2 Chantix Starting Month Pak 2 Inhaler Nicotrol Inhaler NS Nicotrol NS (Nasal Zyban (Tablet Extended-Release 2 Antibacterials Aminoglycosides Amikacin Sulfate Bethkis (Nebulized 4 B/D, PA, QL Gentak (Ophthalmic Ointment) Gentamicin Sulfate (0.% Cream, 0.% Ointment, 0.% Ophthalmic Solution, 0mg/ml Injection, 40mg/ml Injection) Gentamicin Sulfate/ 0.9% Sodium Chloride You can find information on what the symbols and abbreviations in this table mean by going to page 7. 2

22 track Neomycin Sulfate Paromomycin Sulfate Streptomycin Sulfate TOBI TOBI Podhaler Tobradex Tobramycin Tobramycin Sulfate Tobrex Tobrex Cleocin Cleocin in D5W Cleocin Pediatric Granules Cleocin Phosphate Clindamycin HCl Clindamycin Palmitate HCl Clindamycin Phosphate Clindamycin Phosphate in D5W 22 Last updated October, 207 Gentamicin Isotonic Gentamicin Neomycin Sulfate Paromomycin Sulfate (Capsule) Streptomycin Sulfate TOBI (Nebulized 4 B/D, PA, QL TOBI Podhaler (Capsule) 4 PA, QL Tobradex (0.%-0.% Ophthalmic Ointment) 2 Tobramycin (Nebulized 4 B/D, PA, QL Tobramycin Sulfate (0.% Ophthalmic Solution, 0mg/ml Injection, 80mg/2ml Injection) Tobrex (0.% Ophthalmic Ointment) 2 Tobrex (0.% Ophthalmic Antibacterials, Other BACiiM Bacitracin (50000unit Injection, 500unit/gm Ophthalmic Ointment) Bactroban (Cream) Nasal Bactroban Nasal (Ointment) PA Sodium Succinate Chloramphenicol Sodium Succinate Cleocin (00mg Suppository, 50mg Capsule, 00mg Capsule, 75mg Capsule, 2% Cream) Cleocin in D5W Cleocin Pediatric Granules (Oral Cleocin Phosphate Clindamycin HCl (Capsule Immediate- Release) Clindamycin Palmitate HCl (Oral Clindamycin Phosphate (2% Cream, 00mg/2ml Injection, 600mg/4ml Injection, 900mg/6ml Injection) Clindamycin Phosphate in D5W Clindesse (Cream) Sodium Colistimethate Sodium Cubicin 4 Dalvance 4 PA Bold type = Brand name drug Plain type = Generic drug 22

23 2 track Furadantin Linezolid Linezolid Linezolid Methenamine Hippurate Metronidazole in NaCl 0.79% Metronidazole Vaginal Neomycin/Polymyxin B Sulfates Nitrofurantoin Nitrofurantoin Macrocrystals Nitrofurantoin Monohydrate 2 Last updated October, 207 Daptomycin 4 Flagyl (250mg Tablet, 500mg Tablet, 75mg Capsule) Furadantin 4 (Suspension) Hiprex Lincocin HCl Lincomycin HCl Linezolid (00mg/5ml Suspension) 4 PA Linezolid (600mg 4 PA, QL Linezolid (600mg/ 00ml Injection) PA Macrobid (Capsule) Macrodantin (Capsule) Methenamine Hippurate MetroCream (Cream) MetroGel (Gel) MetroGel-Vaginal (Gel) MetroLotion (Lotion) Metronidazole (0.75% Cream, 0.75% Gel, % Gel, 0.75% Lotion, 250mg Tablet Immediate-Release, 500mg Tablet Immediate-Release, 75mg Capsule Immediate-Release) Metronidazole in NaCl 0.79% Metronidazole Vaginal (Gel) Monurol (Packet) Mupirocin (2% Cream, 2% Ointment) Neomycin/Polymyxin B Sulfates (Irrigation Nitrofurantoin (Suspension) Nitrofurantoin Macrocrystals (Capsule) (Generic Macrodantin) Nitrofurantoin Monohydrate (00mg Capsule) (Generic Macrobid) Noritate (Cream) 4 Nuvessa (Gel) Orbactiv 4 2 You can find information on what the symbols and abbreviations in this table mean by going to page 7. 2

24 track Primsol Sivextro Sulfamylon Sulfamylon Vancomycin HCl Vancomycin HCl Cefaclor Cefaclor Cefaclor ER Cefadroxil Cefazolin Sodium Cefdinir 24 Last updated October, 207 B Sulfate Polymyxin B Sulfate Primsol (Oral Sivextro (200mg Injection, 200mg 4 PA Sulfamylon (5% Packet) 4 Sulfamylon (85mg/ gm Cream) Synercid 4 Tigecycline 4 Tindamax Tinidazole Trimethoprim Tygacil 4 HCl Vancocin HCl 4 (Capsule) Vancomycin HCl (000mg Injection, 0gm Injection, 500mg Injection) Vancomycin HCl (25mg Capsule, 4 250mg Capsule) Vandazole (Gel) Vibativ Xifaxan 4 PA Zyvox (00mg/5ml Suspension, 600mg/ 00ml Injection) 4 PA Zyvox (600mg 4 PA, QL Beta-lactam, Cephalosporins Avycaz 4 PA Cedax (80mg/5ml Suspension, 400mg Capsule) Cefaclor (25mg/5ml Suspension, 75mg/ 5ml Suspension) Cefaclor (250mg Capsule Immediate- Release, 500mg Capsule Immediate- Release, 250mg/5ml Suspension) Cefaclor ER (Tablet Extended-Release 2 Cefadroxil (gm Tablet, 250mg/5ml Suspension, 500mg/ 5ml Suspension, 500mg Capsule) Cefazolin Sodium Cefdinir (25mg/5ml Suspension, 250mg/ 5ml Suspension, 00mg Capsule) Cefepime Cefixime (Suspension) Sodium Cefotaxime Sodium Bold type = Brand name drug Plain type = Generic drug 24

25 4 track Cefpodoxime Proxetil Cefprozil Cefuroxime Axetil Cefuroxime Sodium Fortaz Suprax Suprax Suprax Azactam in Iso-Osmotic Dextrose 4 Last updated October, Cefotetan Sodium Cefoxitin Sodium (0gm Injection, gm Injection, 2gm Injection) Cefpodoxime Proxetil (00mg Tablet, 200mg Tablet, 00mg/5ml Suspension, 50mg/5ml Suspension) Cefprozil (25mg/5ml Suspension, 250mg/ 5ml Suspension, 250mg Tablet, 500mg Ceftazidime Ceftin (Suspension) Sodium Ceftriaxone Sodium (0gm Injection, gm Injection, 2gm Injection, 250mg Injection, 500mg Injection) Cefuroxime Axetil Cefuroxime Sodium Cephalexin (25mg/ 5ml Suspension, 250mg/5ml Suspension, 250mg Capsule, 500mg Capsule, 750mg Capsule, 250mg Tablet, 500mg Fortaz (gm Injection, 2gm Injection, 6gm Injection) Maxipime Suprax (00mg Tablet Chewable, 200mg 2 Tablet Chewable) Suprax (00mg/5ml Suspension) Suprax (200mg/5ml 4 Suspension) Suprax (400mg Capsule, 500mg/5ml 2 Suspension) Tazicef Teflaro 4 Zerbaxa 4 PA Beta-lactam, Other Azactam in Iso- Osmotic Dextrose Aztreonam Doribax You can find information on what the symbols and abbreviations in this table mean by going to page 7. 25

26 5 track Amoxicillin Amoxicillin/Clavulanate Potassium ER Ampicillin-Sulbactam 5 26 Last updated October, 207 Imipenem/Cilastatin Invanz Meropenem Merrem IV Primaxin IV Beta-lactam, Penicillins Amoxicillin (25mg Tablet Chewable, 250mg Tablet Chewable, 25mg/5ml Suspension, 200mg/ 5ml Suspension, 250mg/5ml Suspension, 400mg/ 5ml Suspension, 250mg Capsule, 500mg Capsule, 500mg Tablet, 875mg Amoxicillin/Clavulanate Potassium Clavulanate Potassium (200mg-28.5mg Tablet Chewable, 400mg-57mg Tablet Chewable, 200mg/ 5ml-28.5mg/5ml Suspension, 250mg/ 5ml-62.5mg/5ml Suspension, 400mg/ 5ml-57mg/5ml Suspension, 600mg/ 5ml-42.9mg/5ml Suspension, 250mg-25mg Tablet Immediate-Release, 500mg-25mg Tablet Immediate-Release, 875mg-25mg Tablet Immediate-Release) (Generic Augmentin) Amoxicillin/ Clavulanate Potassium ER (Tablet Extended- Release 2 Ampicillin (Capsule) Sodium Ampicillin Sodium (0gm Injection, 25mg Injection, gm Injection) Ampicillin-Sulbactam (0gm-5gm Injection, gm-0.5gm Injection, 2gm-gm Injection) Bold type = Brand name drug Plain type = Generic drug 26

27 6 track Bactocill in Dextrose Nafcillin Sodium Oxacillin Sodium Penicillin G Potassium Penicillin G Potassium in Iso-Osmotic Dextrose Penicillin G Procaine Penicillin G Sodium Penicillin V Potassium Piperacillin/Tazobactam Azasite Azithromycin Azithromycin Clarithromycin Clarithromycin ER Ery-Tab EryPed 200 EryPed Last updated October, Augmentin (Suspension) Bactocill in Dextrose C-R Bicillin C-R L-A Bicillin L-A Sodium Dicloxacillin Sodium (Capsule) Nafcillin Sodium Oxacillin Sodium 4 (0gm Injection) Penicillin G Potassium Penicillin G Potassium in Iso- 2 Osmotic Dextrose Penicillin G Procaine Penicillin G Sodium 4 Penicillin V Potassium (25mg/5ml Oral Solution, 250mg/5ml Oral Solution, 250mg Tablet, 500mg Piperacillin/ Tazobactam Unasyn Bulk Pack Unasyn Bulk Pack Zosyn 4 Macrolides Azasite (Ophthalmic Azithromycin (00mg/ 5ml Suspension, 200mg/5ml Suspension, 250mg Tablet, 500mg Tablet, 600mg Tablet, 500mg Injection) Azithromycin (gm Packet) Clarithromycin (25mg/5ml Suspension, 250mg/ 5ml Suspension, 250mg Tablet, 500mg Clarithromycin ER (Tablet Extended- Release 24 Dificid E.E.S. 400 Granules E.E.S. Granules (Suspension) Ery-Tab (Tablet Delayed-Release) EryPed 200 (Suspension) EryPed 400 (Suspension) 4 You can find information on what the symbols and abbreviations in this table mean by going to page 7. 27

28 7 track Erythrocin Stearate Erythromycin Erythromycin Base Erythromycin Ethylsuccinate PCE Zithromax Zithromax Tri-Pak Zithromax Z-Pak Besivance Ciloxan Cipro Cipro I.V. in D5W Ciprofloxacin Ciprofloxacin ER Ciprofloxacin HCl 7 28 Last updated October, 207 Lactobionate Erythrocin Lactobionate Erythrocin Stearate Erythromycin (250mg Capsule Delayed- Release, 5mg/gm Ophthalmic Ointment) Erythromycin Base Erythromycin Ethylsuccinate (200mg/5ml Suspension, 400mg PCE (Tablet Delayed- Release) Zithromax (00mg/ 5ml Suspension, 200mg/5ml Suspension, gm Packet, 250mg Tablet, 500mg Tablet, 600mg Tablet, 500mg Injection) Zithromax Tri-Pak Zithromax Z-Pak Zmax (Suspension) Quinolones Avelox (400mg Tablet, 400mg/ 250ml-0.8% Injection) Besivance (Suspension) Ciloxan (0.% Ointment, 0.% Ophthalmic Cipro (250mg Tablet, 500mg Tablet, 500mg/5ml Suspension, 5gm/ 00ml Suspension) Cipro I.V. in D5W Ciprofloxacin (250mg/ 5ml Suspension, 500mg/5ml Suspension, 400mg/ 40ml Injection) Ciprofloxacin ER (Tablet Extended- Release 24 Ciprofloxacin HCl (0.% Ophthalmic Solution, 00mg Tablet Immediate-Release, 250mg Tablet Immediate-Release, 500mg Tablet Immediate-Release, 750mg Tablet Immediate-Release) Bold type = Brand name drug Plain type = Generic drug 28

29 8 track Floxin Otic Gatifloxacin Levofloxacin in D5W Moxeza Moxifloxacin HCl Moxifloxacin HCl Moxifloxacin HCl Ocuflox Ofloxacin Zymaxid Sodium Sulfacetamide Sulfamethoxazole/Trimethoprim DS Demeclocycline HCl 8 Last updated October, I.V. in D5W Ciprofloxacin I.V. in D5W Floxin Otic (Otic Gatifloxacin (Ophthalmic Levaquin Levofloxacin (0.5% Ophthalmic Solution, 250mg Tablet, 500mg Tablet, 750mg Tablet, 25mg/ml Injection, 25mg/ml Oral Levofloxacin in D5W Moxeza (Ophthalmic Moxifloxacin HCl (0.5% Ophthalmic Moxifloxacin HCl (400mg Moxifloxacin HCl (400mg/250ml Injection) Ocuflox (Ophthalmic Ofloxacin (0.% Ophthalmic Solution, 0.% Otic Solution, 00mg Tablet, 400mg Vigamox (Ophthalmic Zymaxid (Ophthalmic Sulfonamides Bactrim DS Bactrim DS Bleph-0 (Ophthalmic Silvadene (Cream) Sulfadiazine Silver Sulfadiazine (Cream) Sodium Sulfacetamide (Ophthalmic SSD (Cream) Sodium Sulfacetamide Sodium (0% Ophthalmic Ointment) Sulfadiazine Sulfamethoxazole/Trimethoprim Trimethoprim (200mg-40mg/5ml Suspension, 400mg-80mg Tablet, 400mg-80mg/5ml Injection) Sulfamethoxazole/ Trimethoprim DS Tetracyclines Demeclocycline HCl You can find information on what the symbols and abbreviations in this table mean by going to page 7. 29

30 9 track Doryx MPC Doxycycline Hyclate Doxycycline Hyclate DR Doxycycline Hyclate DR Minocycline HCl ER Morgidox x50mg Oracea Solodyn 9 0 Last updated October, 207 Doryx (Tablet Delayed-Release) Doryx MPC (Tablet Delayed-Release) 00 Doxy 00 Doxycycline (Suspension) Doxycycline Hyclate (00mg Capsule Immediate-Release, 50mg Capsule Immediate-Release, 00mg Tablet Immediate-Release, 20mg Tablet Immediate-Release) Doxycycline Hyclate DR (00mg Tablet Delayed-Release, 50mg Tablet Delayed- Release, 75mg Tablet Delayed-Release) Doxycycline Hyclate DR (200mg Tablet Delayed-Release, 50mg Tablet Delayed- Release) Monohydrate Doxycycline Monohydrate (00mg Capsule, 50mg Capsule, 50mg Capsule, 75mg Capsule, 00mg Tablet, 50mg Tablet, 50mg Tablet, 75mg Minocin (Capsule) 4 HCl Minocycline HCl (00mg Capsule Immediate-Release, 50mg Capsule Immediate-Release, 75mg Capsule Immediate-Release, 00mg Tablet Immediate-Release, 50mg Tablet Immediate-Release, 75mg Tablet Immediate-Release) Minocycline HCl ER (Tablet Extended- Release 24 Morgidox x50mg (Capsule) Oracea (Capsule Delayed-Release) Solodyn (Tablet 4 Targadox Bold type = Brand name drug Plain type = Generic drug 0

31 20 track Vibramycin BRIVIACT BRIVIACT Fycompa Keppra Keppra Keppra XR Levetiracetam Levetiracetam ER Zarontin Zarontin 20 Last updated October, 207 HCl Tetracycline HCl (Capsule) Vibramycin (00mg Capsule, 25mg/5ml Suspension, 50mg/ 5ml Syrup) Anticonvulsants Anticonvulsants, Other BRIVIACT (00mg Tablet, 0mg Tablet, 25mg Tablet, 50mg Tablet, 75mg Tablet, 0mg/ml Oral BRIVIACT (50mg/5ml Injection) Fycompa (0.5mg/ml Suspension, 0mg Tablet, 2mg Tablet, 2mg Tablet, 4mg Tablet, 6mg Tablet, 8mg Keppra (000mg Tablet, 500mg Tablet, 750mg Tablet, 00mg/ml Oral Keppra (250mg Keppra XR (Tablet 4 QL QL 4 4 Levetiracetam (000mg Tablet Immediate-Release, 250mg Tablet Immediate-Release, 500mg Tablet Immediate-Release, 750mg Tablet Immediate-Release, 00mg/ml Oral Solution, 500mg/5ml Injection) Levetiracetam (000mg/00ml Injection, 500mg/ 00ml Injection, 500mg/00ml Injection) Levetiracetam ER (Tablet Extended- Release 24 Roweepra Spritam (Tablet Disintegrating Soluble) Calcium Channel Modifying Agents Celontin (Capsule) Ethosuximide (250mg Capsule, 250mg/5ml Oral Zarontin (250mg Capsule) Zarontin (250mg/5ml Oral You can find information on what the symbols and abbreviations in this table mean by going to page 7.

32 2 track Depakene Gabitril Gabitril Neurontin Onfi Phenobarbital Valproic Acid Felbamate Felbamate Felbatol 2 2 Last updated October, 207 Zonegran (Capsule) 4 Zonisamide (Capsule) Gamma-aminobutyric Acid (GABA) Augmenting Agents Depacon Depakene (250mg Capsule) Depakene (250mg/ 4 5ml Oral AcuDial Diastat AcuDial (Gel) Pediatric Diastat Pediatric (Gel) Gabapentin (00mg Capsule, 00mg Capsule, 400mg Capsule, 250mg/5ml Oral Solution, 600mg Tablet, 800mg Gabitril (2mg Tablet, 6mg QL Gabitril (2mg Tablet, 4mg Mysoline 4 Neurontin (00mg Capsule, 00mg Capsule, 400mg Capsule, 250mg/5ml Oral Neurontin (600mg Tablet, 800mg 4 Onfi (0mg Tablet, 20mg 4 QL Onfi (2.5mg/ml Suspension) 4 Phenobarbital (00mg Tablet, 5mg Tablet, 6.2mg Tablet, 0mg Tablet, 2.4mg Tablet, PA, HRM 60mg Tablet, 64.8mg Tablet, 97.2mg Tablet, 20mg/5ml Elixir) Primidone Sabril (500mg Packet, 500mg 4 PA, QL, LA HCl Tiagabine HCl Sodium Valproate Sodium (00mg/ml Injection) Valproic Acid (250mg Capsule, 250mg/5ml Oral Glutamate Reducing Agents Felbamate (400mg Tablet, 600mg Felbamate (600mg/ 5ml Suspension) 4 Felbatol (400mg Tablet, 600mg Tablet, 600mg/5ml 4 Suspension) Lamictal 4 Chewable Dispersible Lamictal Chewable Dispersible (25mg 4 Tablet Chewable) Bold type = Brand name drug Plain type = Generic drug 2

33 22 track Lamictal ODT Lamictal Starter Lamictal Starter Lamictal Starter Lamictal XR Lamotrigine ER Lamotrigine ODT Qudexy XR Qudexy XR 22 Last updated October, 207 Chewable Dispersible Lamictal Chewable Dispersible (5mg Tablet Chewable) Lamictal ODT (Tablet Dispersible) Lamictal Starter (Blue Kit) Lamictal Starter 4 (Green Kit) Lamictal Starter (Orange Kit) Lamictal XR (00mg Tablet Extended- Release 24 Hour, 200mg Tablet Hour, 250mg Tablet 4 Hour, 25mg Tablet Hour, 00mg Tablet Hour, 50mg Tablet XR Lamictal XR (Kit) Lamotrigine (00mg Tablet Immediate- Release, 50mg Tablet Immediate-Release, 200mg Tablet Immediate-Release, 25mg Tablet Immediate-Release, 25mg Tablet Chewable, 5mg Tablet Chewable) Lamotrigine ER (Tablet Lamotrigine ODT (Tablet Dispersible) Qudexy XR (00mg Capsule Extended- Release 24 Hour Sprinkle, 25mg Capsule Extended- Release 24 Hour Sprinkle, 50mg Capsule Extended- Release 24 Hour Sprinkle) Qudexy XR (50mg Capsule Extended- Release 24 Hour Sprinkle, 200mg Capsule Extended- Release 24 Hour Sprinkle) PA 4 PA You can find information on what the symbols and abbreviations in this table mean by going to page 7.

34 2 track Topamax Topamax Sprinkle Topamax Sprinkle Topiramate Topiramate ER Trokendi XR Aptiom Aptiom Banzel Carbamazepine 2 4 Last updated October, 207 Topamax (00mg Tablet, 200mg Topamax (25mg Tablet, 50mg Topamax Sprinkle (5mg Capsule Sprinkle) Topamax Sprinkle (25mg Capsule Sprinkle) Topiramate (00mg Tablet Immediate- Release, 200mg Tablet Immediate-Release, 25mg Tablet Immediate-Release, 50mg Tablet Immediate-Release, 5mg Capsule Sprinkle Immediate- Release, 25mg Capsule Sprinkle Immediate-Release) Topiramate ER (Capsule Extended- Release 24 Hour Sprinkle) 4 4 PA XR Trokendi XR (00mg Capsule Extended- Release 24 Hour, 25mg Capsule Hour, 50mg Capsule PA, QL Trokendi XR (200mg Capsule Extended- 4 PA, QL Release 24 Sodium Channel Agents Aptiom (200mg QL Aptiom (400mg Tablet, 600mg Tablet, 4 QL 800mg Banzel (200mg Tablet, 400mg Tablet, 4 40mg/ml Suspension) Carbamazepine (00mg Tablet Chewable, 00mg/5ml Suspension, 200mg Tablet Immediate- Release) Bold type = Brand name drug Plain type = Generic drug 4

35 24 track Carbatrol Dilantin-25 Oxcarbazepine Oxtellar XR Phenytoin Sodium Phenytoin Sodium Extended Tegretol Tegretol-XR Trileptal Trileptal Vimpat Vimpat 24 Last updated October, ER Carbamazepine ER (00mg Capsule Extended-Release 2 Hour, 200mg Capsule Extended-Release 2 Hour, 00mg Capsule Extended-Release 2 Hour, 00mg Tablet Extended-Release 2 Hour, 200mg Tablet Extended-Release 2 Hour, 400mg Tablet Extended-Release 2 Carbatrol (Capsule Extended-Release 2 Cerebyx 4 Dilantin (Capsule) 2 INFATABS Dilantin INFATABS (Tablet Chewable) 2 Dilantin-25 (Suspension) 2 Epitol Sodium Fosphenytoin Sodium Oxcarbazepine (50mg Tablet, 00mg Tablet, 600mg Tablet, 00mg/5ml Suspension) Oxtellar XR (Tablet PA Peganone Phenytek (Capsule) Phenytoin (25mg/5ml Suspension, 50mg Tablet Chewable) Phenytoin Sodium Phenytoin Sodium Extended (Capsule) Tegretol (00mg/5ml Suspension, 200mg Tegretol-XR (Tablet Extended-Release 2 Trileptal (50mg Tablet, 00mg Trileptal (00mg/5ml Suspension, 600mg 4 Vimpat (00mg Tablet, 50mg Tablet, 200mg Tablet, 50mg QL Tablet, 0mg/ml Oral Vimpat (200mg/20ml Injection) Antidementia Agents Cholinesterase Inhibitors Aricept QL HCl Donepezil HCl (Tablet Immediate-Release) QL You can find information on what the symbols and abbreviations in this table mean by going to page 7. 5

36 25 track Exelon Galantamine HBr Galantamine HBr ER Razadyne Razadyne ERazadyne Rivastigmine Tartrate Rivastigmine Transdermal System Memantine HCl Memantine HCl Titration Pak Namenda Namenda Titration Pak Namenda XR Titration Pack Aplenzin Bupropion HCl Bupropion HCl SR Bupropion HCl XL Forfivo XL Mirtazapine Mirtazapine ODT Olanzapine/Fluoxetine 25 6 Last updated October, 207 HCl ODT Donepezil HCl ODT (Tablet Dispersible) QL Exelon (Patch 24 QL Galantamine HBr (2mg Tablet, 4mg Tablet, 8mg Tablet, QL 4mg/ml Oral Galantamine HBr ER (Capsule Extended- QL Release 24 Razadyne QL ER (Capsule Extended- QL Release 24 Rivastigmine Tartrate (Capsule Immediate- QL Release) Rivastigmine Transdermal System QL (Patch 24 N-methyl-D-aspartate (NMDA) Receptor Antagonist Memantine HCl (0mg Tablet, 5mg Tablet, PA, QL 2mg/ml Oral Memantine HCl Titration Pak PA Namenda (Tablet Immediate-Release) PA, QL Namenda Titration Pak PA XR Namenda XR (Capsule Extended- Release 24 Namenda XR Titration Pack (Capsule Antidepressants Antidepressants, Other Aplenzin (Tablet Bupropion HCl (Tablet Immediate-Release) Bupropion HCl SR (00mg Tablet Extended-Release 2 Hour, 50mg Tablet Extended-Release 2 Hour, 200mg Tablet Extended-Release 2 Bupropion HCl XL (Tablet Extended- Release 24 Forfivo XL (Tablet Mirtazapine (Tablet Immediate-Release) Mirtazapine ODT (Tablet Dispersible) Olanzapine/Fluoxetine (Capsule) 2 PA, QL 2 PA, QL 4 Bold type = Brand name drug Plain type = Generic drug 6

37 26 track Wellbutrin XL Emsam Tranylcypromine Sulfate Desvenlafaxine ER Effexor XR Escitalopram Oxalate Fetzima Fetzima Titration Pack Fluoxetine DR 26 Last updated October, Remeron Soltab Remeron Soltab (Tablet Dispersible) Symbyax (Capsule) SR Wellbutrin SR (Tablet Extended-Release 2 Wellbutrin XL (Tablet 4 Monoamine Oxidase Inhibitors Emsam (Patch 24 4 QL Marplan Nardil Parnate 4 Sulfate Phenelzine Sulfate Tranylcypromine Sulfate SSRI/SNRI (Selective Serotonin Reuptake Inhibitors/Serotonin and Norepinephrine Reuptake Inhibitors) Brisdelle (Capsule) Celexa HBr Citalopram HBr (0mg Tablet, 20mg Tablet, 40mg Tablet, 0mg/ 5ml Oral ER Desvenlafaxine ER (00mg Tablet Hour, 25mg Tablet Hour, 50mg Tablet (Generic Pristiq) Desvenlafaxine ER (00mg Tablet Hour, 50mg Tablet (Generic Khedezla) Effexor XR (Capsule Escitalopram Oxalate (0mg Tablet, 20mg Tablet, 5mg Tablet, 5mg/5ml Oral Fetzima (Capsule Fetzima Titration Pack (Capsule Hour Therapy Pack) Fluoxetine DR (Capsule Delayed- Release) QL QL, ST QL, ST ST You can find information on what the symbols and abbreviations in this table mean by going to page 7. 7

38 27 track Fluoxetine HCl Fluvoxamine Maleate Fluvoxamine Maleate ER Khedezla Nefazodone HCl Paroxetine HCl Paxil Pristiq Prozac Venlafaxine HCl ER Venlafaxine HCl ER 27 8 Last updated October, 207 HCl Fluoxetine HCl (0mg Capsule Immediate- Release, 20mg Capsule Immediate- Release, 40mg Capsule Immediate- Release, 0mg Tablet, 20mg Tablet, 20mg/ 5ml Oral Fluoxetine HCl (60mg Fluvoxamine Maleate Fluvoxamine Maleate ER (Capsule Extended- Release 24 Khedezla (Tablet QL, ST Lexapro HCl Maprotiline HCl Nefazodone HCl Paroxetine HCl (Tablet Immediate-Release) PA, HRM Paxil (0mg Tablet, 20mg Tablet, 0mg Tablet, 40mg Tablet, PA, HRM 0mg/5ml Suspension) Pristiq (Tablet QL Prozac (0mg Capsule, 20mg Capsule) Prozac (40mg 4 Capsule) Sarafem HCl Sertraline HCl (00mg Tablet, 25mg Tablet, 50mg Tablet, 20mg/ml Concentrate) HCl Trazodone HCl Trintellix QL HCl Venlafaxine HCl (Tablet Immediate- Release) Venlafaxine HCl ER (50mg Capsule Hour, 7.5mg Capsule Hour, 75mg Capsule Hour, 50mg Tablet Hour, 7.5mg Tablet Hour, 75mg Tablet Venlafaxine HCl ER (225mg Tablet Bold type = Brand name drug Plain type = Generic drug 8