FORMULARY Comprehensive. (Complete list of covered drugs)

Transcription

1 207 Comprehensive FORMULARY (Complete list of covered drugs) HealthSelect Medicare Rx (PDP) provided through the Employees Retirement System of Texas (ERS) 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 HealthSelect Medicare Rx Customer Service at: Toll-Free (866) , TTY 7 7 a.m. - 7 p.m. CT, Monday - Friday, 7 a.m. - p.m. CT, Saturday Formulary ID Number , Version 24 Y0066_60722_99 Last updated November, 207

2 2 2 This Comprehensive Formulary is a complete list of the drugs covered by our plan. It is current as of November, 207. For more information, please call Customer Service toll-free at (866) , TTY 7, 7 a.m. - 7 p.m. CT, Monday - Friday, 7 a.m. - p.m. CT, Saturday. The date we last updated the drug list is on the cover. When this formulary (drug list) refers to we, us, or our, it means HealthSelect Medicare Rx. When it refers to plan or our plan, it means HealthSelect Medicare Rx. 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 HealthSelect Medicare Rx 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 at Use the online tools to look up your drugs. The information is updated on a regular basis.. Or call Customer Service toll-free at (866) , TTY 7, 7 a.m. - 7 p.m. CT, Monday - Friday, 7 a.m. - p.m. CT, Saturday. 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 payment stages and drug tiers The amount you pay for a covered drug will depend on: Your drug payment stage. Your plan has different stages of drug coverage. When you fill a prescription, the amount you pay depends on the coverage stage you re in. The drug tier for your drug. Each covered drug is in one of three drug tiers. Each tier has a copay and/or coinsurance amount. The chart below shows the differences between the tiers. For more information about drug coverage and copay or coinsurance amounts for each tier, please review your Evidence of Coverage. 5 : Preferred generic 2: Preferred brand : Non-preferred drug Includes All covered generic drugs. Many common brand name drugs, called preferred brands. Non-preferred brand name drugs. In addition, Part D eligible compound medications are covered in. If you qualify for Extra Help If you qualify for Extra Help for your prescription drugs, your copays and coinsurance 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 toll-free at (866) , TTY 7, 7 a.m. - 7 p.m. CT, Monday - Friday, 7 a.m. - p.m. CT, Saturday. 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 29. 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 copay/coinsurance 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 SP - Specialty s This drug is considered a specialty drug, meaning it s not eligible for a lower cost-sharing level. 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. Please call Customer Service toll-free at (866) , TTY 7, 7 a.m. - 7 p.m. CT, Monday - Friday, 7 a.m. - p.m. CT, Saturday. Or visit us online at 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 HealthSelect Medicare Rx 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 formulary (list of covered prescription drugs), you should call Customer Service and ask if your drug is covered. Call us toll-free at (866) , TTY 7, 7 a.m. - 7 p.m. CT, Monday - Friday, 7 a.m. - p.m. CT, Saturday. Or visit us online at 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 HealthSelect Medicare Rx 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 approved this would lower the amount you must pay for your drug. Specialty drugs (SP) are not eligible for a lower cost-sharing level. 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 copay/coinsurance for a single prescription. For more information, please call Customer Service toll-free at (866) , TTY 7, 7 a.m. - 7 p.m. CT, Monday - Friday, 7 a.m. - p.m. CT, Saturday. 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 (866) , TTY 7, 7 a.m. - 7 p.m. CT, Monday - Friday, 7 a.m. - p.m. CT, Saturday. 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 Butalbital/Acetaminophen/Caffeine Butalbital/Aspirin/Caffeine Diclofenac Sodium Diclofenac Sodium DR Diclofenac Sodium 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 29. 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 Analgesics Allzital Bupap Butalbital/Acetaminophen Acetaminophen Butalbital/ Acetaminophen/ Caffeine (50mg-00mg-40mg Capsule, 50mg-25mg-40mg Capsule, 50mg-25mg-40mg Butalbital/Aspirin/ Caffeine (Capsule) PA, QL, HRM PA, QL, HRM PA, QL, HRM PA, QL, HRM PA, QL, HRM Tencon PA, QL, HRM LQ Vanatol LQ (Oral PA, QL, HRM Zebutal (Capsule) PA, QL, HRM Nonsteroidal Anti-inflammatory s Cambia (Packet) Celecoxib (Capsule) QL Potassium Diclofenac Potassium (Tablet Immediate- Release) Diclofenac Sodium (% Gel,.5% PA Transdermal Diclofenac Sodium DR (Tablet Delayed- Release) Diclofenac Sodium ER (Tablet Extended- Release 24 Bold type = Brand name drug Plain type = Generic drug 2

13 2tRACK Etodolac ER Fenoprofen Calcium Fenoprofen Calcium Indomethacin ER Ketoprofen Ketorolac Tromethamine Meclofenamate Sodium Mefenamic Acid Naproxen Naproxen DR Naproxen Sodium 2 Last updated November, 207 Sodium/Misoprostol Diclofenac Sodium/ Misoprostol (Tablet Delayed-Release) Diflunisal Etodolac (200mg Capsule, 00mg Capsule, 400mg Tablet Immediate-Release, 500mg Tablet Immediate-Release) Etodolac ER (Tablet Extended-Release 24 Fenoprofen Calcium (400mg Capsule) Fenoprofen Calcium (600mg Flector (Patch) PA, QL Flurbiprofen Ibuprofen (00mg/5ml Suspension, 400mg Tablet, 600mg Tablet, 800mg Indocin (Suspension) PA, HRM Indomethacin (25mg Capsule, 50mg Capsule) PA, HRM Indomethacin ER (Capsule Extended- PA, HRM Release) Ketoprofen (Capsule Immediate-Release) ER Ketoprofen ER (Capsule Extended- Release 24 Ketorolac Tromethamine (0mg Tablet, 5mg/ml Injection, 0mg/ml PA, HRM Injection, 60mg/2ml Injection) Meclofenamate Sodium (Capsule) Mefenamic Acid (Capsule) Meloxicam Nabumetone Naprelan (750mg Tablet Extended- Release 24 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) You can find information on what the symbols and abbreviations in this table mean by going to page 7.

14 track Conzip Embeda Fentanyl Hydromorphone HCl ER Levorphanol Tartrate Methadone HCl Methadone HCl Morphine Sulfate ER Nucynta ER 4 Last updated November, 207 Sodium ER Naproxen Sodium ER (Tablet Extended- Release 24 (Generic Naprelan) Oxaprozin Pennsaid (Transdermal PA, SP Piroxicam (Capsule) Sulindac Tivorbex (Capsule) PA, QL, HRM Sodium Tolmetin Sodium (400mg Capsule, 600mg Vivlodex (Capsule) QL Zipsor (Capsule) Opioid Analgesics, Long-acting Conzip (Capsule Extended-Release 24 QL, MED Embeda (Capsule Extended-Release) 2 QL, MED Fentanyl (Patch 72 QL, MED HCl ER Hydromorphone HCl ER (2mg Tablet Extended-Release 24 Hour Abuse-Deterrent, 6mg Tablet Extended- Release 24 Hour Abuse-Deterrent, 8mg Tablet Extended- Release 24 Hour Abuse-Deterrent) Hydromorphone HCl ER (2mg Tablet Extended-Release 24 Hour Abuse- Deterrent) Levorphanol Tartrate Methadone HCl (0mg Tablet, 5mg Tablet, 0mg/5ml Oral Solution, 5mg/5ml Oral Methadone HCl (0mg/ml Injection) Morphine Sulfate ER (Tablet Extended- Release, Capsule Extended-Release) Nucynta ER (Tablet Extended-Release 2 QL, MED QL, MED QL, MED QL, MED QL, MED 2 QL, MED Bold type = Brand name drug Plain type = Generic drug 4

15 4tRACK Oxycodone HCl ER OxyContin Oxymorphone HCl ER Tramadol HCl ER Tramadol HCl ER Abstral Acetaminophen/Codeine Ascomp/Codeine Butalbital/Acetaminophen/Caffeine/Codeine Butalbital/Aspirin/Caffeine/Codeine Butorphanol Tartrate Butorphanol Tartrate Carisoprodol/Aspirin/Codeine Codeine Sulfate 4 Last updated November, ER 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 Extended-Release 24 Hour, 200mg Capsule Extended-Release 24 Hour, 00mg Capsule Extended-Release 24 Tramadol HCl ER (00mg Tablet Extended-Release 24 Hour, 200mg Tablet Extended-Release 24 Hour, 00mg Tablet Extended-Release 24 2 QL, MED QL, MED 2 QL, MED QL, MED QL, MED QL, MED ER Xtampza ER (Capsule Extended-Release 2 Hour Abuse- Deterrent) QL, MED Opioid Analgesics, Short-acting Abstral (Tablet Sublingual) PA, QL, SP Acetaminophen/ Codeine (20mg-2mg/5ml Oral Solution, QL, MED 00mg-5mg Tablet, 00mg-0mg Tablet, 00mg-60mg Ascomp/Codeine PA, QL, (Capsule) HRM, MED Butalbital/ Acetaminophen/ PA, QL, Caffeine/Codeine HRM, MED (Capsule) Butalbital/Aspirin/ Caffeine/Codeine (Capsule) Butorphanol Tartrate (0mg/ml Nasal Butorphanol Tartrate (mg/ml Injection, 2mg/ml Injection) Carisoprodol/Aspirin/ Codeine Codeine Sulfate PA, QL, HRM, MED QL, MED PA, QL, HRM, MED QL, MED You can find information on what the symbols and abbreviations in this table mean by going to page 7. 5

16 5tRACK Hydrocodone Bitartrate/Acetaminophen Hydrocodone/Acetaminophen Hydrocodone/Ibuprofen Hydromorphone HCl Hydromorphone HCl Hydromorphone HCl Morphine Sulfate Morphine Sulfate Morphine Sulfate Morphine Sulfate Nalbuphine HCl Nucynta Nucynta 5 6 Last updated November, 207 Duramorph Endocet QL, MED Citrate Oral Transmucosal Fentanyl Citrate Oral Transmucosal (Lollipop) PA, QL Hydrocodone Bitartrate/ Acetaminophen (0mg-00mg Tablet, 5mg-00mg Tablet, QL, MED 7.5mg-00mg Tablet, 7.5mg-25mg/5ml Oral Hydrocodone/ Acetaminophen (0mg-25mg Tablet, 2.5mg-25mg Tablet, QL, MED 5mg-25mg Tablet, 7.5mg-25mg 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 Lorcet QL, MED HD Lorcet HD QL, MED Plus Lorcet Plus QL, MED HCl Meperidine HCl (00mg Tablet, 50mg Tablet, 50mg/5ml Oral Morphine Sulfate (00mg/5ml Oral Solution, 0mg/5ml Oral Solution, 20mg/ 5ml Oral Morphine Sulfate (0mg/ml Injection, 4mg/ml Injection, 8mg/ml Injection) Morphine Sulfate (5mg Tablet Immediate-Release, 0mg Tablet Immediate-Release) Morphine Sulfate (2mg/ml Injection) Nalbuphine HCl Nucynta (00mg Nucynta (50mg Tablet, 75mg PA, QL, HRM, MED QL, MED QL, MED QL, MED, SP QL, MED Bold type = Brand name drug Plain type = Generic drug 6

17 6tRACK Oxycodone/Acetaminophen Oxycodone/Aspirin Oxycodone/Ibuprofen Oxymorphone HCl Pentazocine/Naloxone HCl Primlev Tramadol HCl/Acetaminophen Lidocaine Lidocaine HCl 6 Last updated November, 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) Pentazocine/Naloxone HCl QL, MED QL, MED QL, MED QL, MED QL, MED PA, QL, HRM, MED Primlev (0mg-00mg Tablet, 7.5mg-00mg Primlev (5mg-00mg QL, MED, SP QL, MED Subsys (Liquid) PA, QL, SP Talwin PA, HRM HCl Tramadol HCl (Tablet Immediate-Release) QL, MED Tramadol HCl/ Acetaminophen QL, MED Trezix (Capsule) QL, MED Vicodin QL, MED ES Vicodin ES QL, MED HP Vicodin HP 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 ( You can find information on what the symbols and abbreviations in this table mean by going to page 7. 7

18 7tRACK Acamprosate Calcium DR Buprenorphine HCl Buprenorphine HCl Buprenorphine HCl/Naloxone HCl Butrans Bupropion HCl SR Chantix Starting Month Pak Amikacin Sulfate Bethkis Gentak Gentamicin Sulfate Gentamicin Sulfate/0.9% Sodium Chloride 7 8 Last updated November, 207 Lidocaine/Prilocaine (2.5%-2.5% Cream) Anti-Addiction/Substance Abuse Treatment Agents Alcohol Deterrents/Anti-craving Acamprosate Calcium DR (Tablet Delayed- Release) Disulfiram HCl Naltrexone HCl Vivitrol SP Opioid Dependence Treatments Belbuca (Film) QL, MED Bunavail (Film) QL 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) QL, MED Evzio SP HCl Naloxone HCl Narcan (Liquid) 2 Suboxone (Film) 2 QL Zubsolv (Tablet Sublingual) 2 QL Smoking Cessation Agents 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 Antibacterials Aminoglycosides Amikacin Sulfate Bethkis (Nebulized B/D, PA, QL, 2 SP Gentak (Ophthalmic Ointment) Gentamicin Sulfate (0.% Cream, 0.% Ointment, 0.% Ophthalmic Solution, 0mg/ml Injection, 40mg/ml Injection) Gentamicin Sulfate/ 0.9% Sodium Chloride Bold type = Brand name drug Plain type = Generic drug 8

19 8tRACK Neomycin Sulfate Paromomycin Sulfate Streptomycin Sulfate TOBI Podhaler Tobradex Tobramycin Tobramycin Sulfate Tobrex Bactroban Nasal Chloramphenicol Sodium Succinate Clindamycin HCl Clindamycin Palmitate HCl Clindamycin Phosphate Clindamycin Phosphate in D5W Linezolid Linezolid Methenamine Hippurate 8 Last updated November, Gentamicin Isotonic Gentamicin Neomycin Sulfate Paromomycin Sulfate (Capsule) Streptomycin Sulfate TOBI Podhaler (Capsule) PA, QL, SP Tobradex (Ophthalmic 2 Ointment) Tobramycin (Nebulized B/D, PA, QL Tobramycin Sulfate (0.% Ophthalmic Solution, 0mg/ml Injection, 80mg/2ml Injection) Tobrex (0.% Ophthalmic Ointment) Antibacterials, Other BACiiM Bacitracin (50000unit Injection, 500unit/gm Ophthalmic Ointment) Bactroban Nasal (Ointment) PA Chloramphenicol Sodium Succinate Cleocin (00mg Suppository) 2 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 Dalvance SP Daptomycin HCl Lincomycin HCl Linezolid (00mg/5ml Suspension, 600mg/ 00ml Injection) Linezolid (600mg QL Methenamine Hippurate You can find information on what the symbols and abbreviations in this table mean by going to page 7. 9

20 9tRACK Metronidazole in NaCl 0.79% Metronidazole Vaginal Neomycin/Polymyxin B Sulfates Nitrofurantoin Nitrofurantoin Macrocrystals Nitrofurantoin Monohydrate Sivextro Sulfamylon Cefaclor Cefaclor 9 20 Last updated November, 207 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) SP Nuvessa (Gel) B Sulfate Polymyxin B Sulfate Primsol (Oral Sivextro (200mg Injection, 200mg SP Sulfamylon (85mg/ gm Cream) Synercid SP Tigecycline SP Tinidazole Trimethoprim Tygacil SP HCl Vancomycin HCl (000mg Injection, 0gm Injection, 500mg Injection, 25mg Capsule, 250mg Capsule) Vandazole (Gel) Xifaxan PA, SP Zyvox (600mg/00ml Injection) SP Beta-lactam, Cephalosporins Cefaclor (25mg/5ml Suspension, 75mg/ 2 5ml Suspension) Cefaclor (250mg Capsule Immediate- Release, 500mg Capsule Immediate- Release, 250mg/5ml Suspension) Bold type = Brand name drug Plain type = Generic drug 20

21 0 track Cefadroxil Cefazolin Sodium Cefdinir Cefpodoxime Proxetil Cefprozil Ceftriaxone Sodium Cefuroxime Axetil Cefuroxime Sodium Cephalexin Suprax Suprax 0 Last updated November, ER 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 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 (25mg/5ml Suspension, 250mg/ 5ml Suspension) 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 Suprax (00mg Tablet Chewable, 200mg 2 Tablet Chewable) Suprax (400mg Capsule, 500mg/5ml 2 Suspension) Tazicef Teflaro SP Zerbaxa SP Beta-lactam, Other You can find information on what the symbols and abbreviations in this table mean by going to page 7. 2

22 track Amoxicillin Amoxicillin/Clavulanate Potassium ER Ampicillin-Sulbactam 22 Last updated November, 207 in Iso-Osmotic Dextrose Azactam in Iso- Osmotic Dextrose Aztreonam Doribax 2 Imipenem/Cilastatin Invanz Meropenem 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 22

23 2 track Bactocill in Dextrose Nafcillin Sodium Oxacillin Sodium Penicillin G Potassium Penicillin G Procaine Penicillin G Sodium Penicillin V Potassium Piperacillin/Tazobactam Azasite Azithromycin Clarithromycin Clarithromycin ER Ery-Tab EryPed 200 EryPed 400 Erythrocin Lactobionate Erythrocin Stearate 2 Last updated November, Augmentin (25mg/ 5ml-.25mg/5ml Suspension) 2 SP Bactocill in Dextrose C-R Bicillin C-R L-A Bicillin L-A Sodium Dicloxacillin Sodium (Capsule) Nafcillin Sodium Oxacillin Sodium Penicillin G Potassium Penicillin G Procaine Penicillin G Sodium Penicillin V Potassium (25mg/5ml Oral Solution, 250mg/5ml Oral Solution, 250mg Tablet, 500mg Piperacillin/ Tazobactam 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 SP Granules E.E.S. Granules (Suspension) Ery-Tab (Tablet Delayed-Release) EryPed 200 (Suspension) EryPed 400 (Suspension) SP Erythrocin Lactobionate Erythrocin Stearate You can find information on what the symbols and abbreviations in this table mean by going to page 7. 2

24 track Erythromycin Base Erythromycin Ethylsuccinate PCE Avelox Besivance Ciloxan Cipro Ciprofloxacin Ciprofloxacin ER Ciprofloxacin I.V. in D5W Gatifloxacin Levofloxacin Levofloxacin in D5W Moxeza Moxifloxacin HCl Moxifloxacin HCl 24 Last updated November, 207 Erythromycin (250mg Capsule Delayed- Release, 5mg/gm Ophthalmic Ointment) Erythromycin Base Erythromycin Ethylsuccinate (200mg/5ml Suspension, 400mg PCE (Tablet Delayed- Release) Zmax (Suspension) Quinolones Avelox (400mg/ 250ml-0.8% Injection) Besivance (Suspension) Ciloxan (0.% Ointment) Cipro (500mg/5ml Suspension, 5gm/ 00ml Suspension) Ciprofloxacin (250mg/ 5ml Suspension, 500mg/5ml Suspension, 400mg/ 40ml Injection) Ciprofloxacin ER (Tablet Extended- Release 24 HCl Ciprofloxacin HCl (0.% Ophthalmic Solution, 00mg Tablet Immediate-Release, 250mg Tablet Immediate-Release, 500mg Tablet Immediate-Release, 750mg Tablet Immediate-Release) Ciprofloxacin I.V. in D5W Gatifloxacin (Ophthalmic 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 Solution, 400mg Moxifloxacin HCl (400mg/250ml Injection) 2 Bold type = Brand name drug Plain type = Generic drug 24

25 4 track Vigamox Silver Sulfadiazine Sodium Sulfacetamide Sulfamethoxazole/Trimethoprim DS Demeclocycline HCl Doxycycline Hyclate DR Doxycycline Monohydrate Minocycline HCl 4 Last updated November, Ofloxacin (0.% Ophthalmic Solution, 0.% Otic Solution, 00mg Tablet, 400mg Vigamox (Ophthalmic 2 Sulfonamides 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 00 Doxy 00 Doxycycline (Suspension) Hyclate Doxycycline Hyclate (00mg Capsule Immediate-Release, 50mg Capsule Immediate-Release, 00mg Tablet Immediate-Release, 20mg Tablet Immediate-Release) Doxycycline Hyclate DR (Tablet Delayed- Release) Doxycycline Monohydrate (00mg Capsule, 50mg Capsule, 50mg Capsule, 75mg Capsule, 00mg Tablet, 50mg Tablet, 50mg Tablet, 75mg 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) You can find information on what the symbols and abbreviations in this table mean by going to page 7. 25

26 5 track Morgidox x50mg Solodyn Vibramycin BRIVIACT BRIVIACT Fycompa Levetiracetam Levetiracetam ER 5 26 Last updated November, 207 HCl ER Minocycline HCl ER (Tablet Extended- Release 24 Morgidox x50mg (Capsule) Solodyn (Tablet Extended-Release 24 SP Targadox HCl Tetracycline HCl (Capsule) Vibramycin (50mg/ 5ml Syrup) Anticonvulsants Anticonvulsants, Other BRIVIACT (00mg Tablet, 0mg Tablet, 25mg Tablet, 50mg Tablet, 75mg Tablet, QL, SP 0mg/ml Oral BRIVIACT (50mg/5ml Injection) QL Fycompa (0.5mg/ml Suspension, 0mg Tablet, 2mg Tablet, 2mg Tablet, 4mg Tablet, 6mg Tablet, 8mg 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 Zonisamide (Capsule) Gamma-aminobutyric Acid (GABA) Augmenting Agents Bold type = Brand name drug Plain type = Generic drug 26

27 6 track Gabapentin Gabitril Onfi Onfi Phenobarbital Valproic Acid Felbamate Lamictal Starter Lamictal Starter Lamictal Starter Lamotrigine ER Lamotrigine ODT 6 Last updated November, AcuDial Diastat AcuDial (Gel) Pediatric Diastat Pediatric (Gel) Rectal Gel Diazepam Rectal Gel (Gel) Gabapentin (00mg Capsule, 00mg Capsule, 400mg Capsule, 250mg/5ml Oral Solution, 600mg Tablet, 800mg Gabitril (2mg Tablet, 6mg QL Onfi (0mg Tablet, 20mg QL, SP Onfi (2.5mg/ml Suspension) SP 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, PA, QL, LA, 500mg SP HCl Tiagabine HCl Sodium Valproate Sodium (00mg/ml Injection) Valproic Acid (250mg Capsule, 250mg/5ml Oral Vigabatrin (Packet) PA, QL Glutamate Reducing Agents Felbamate (400mg Tablet, 600mg Tablet, 600mg/5ml Suspension) Lamictal Starter (Blue Kit) Lamictal Starter (Green Kit) SP Lamictal Starter (Orange Kit) 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 Extended-Release 24 Lamotrigine ODT (Tablet Dispersible) You can find information on what the symbols and abbreviations in this table mean by going to page 7. 27

28 7 track Topiramate ER Trokendi XR Trokendi XR Aptiom Aptiom Carbamazepine Carbamazepine ER Oxcarbazepine 7 28 Last updated November, 207 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 PA Sprinkle) Trokendi XR (00mg Capsule Extended- Release 24 Hour, 25mg Capsule Extended-Release 24 PA, QL Hour, 50mg Capsule Extended-Release 24 Trokendi XR (200mg Capsule Extended- PA, QL, SP Release 24 Sodium Channel Agents Aptiom (200mg QL Aptiom (400mg Tablet, 600mg Tablet, QL, SP 800mg Banzel (200mg Tablet, 400mg Tablet, 40mg/ml Suspension) SP Carbamazepine (00mg Tablet Chewable, 00mg/5ml Suspension, 200mg Tablet Immediate- Release) 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 Dilantin (Capsule) 2 INFATABS Dilantin INFATABS (Tablet Chewable) 2 Epitol Sodium Fosphenytoin Sodium Oxcarbazepine (50mg Tablet, 00mg Tablet, 600mg Tablet, 00mg/5ml Suspension) Bold type = Brand name drug Plain type = Generic drug 28

29 8 track Phenytoin Sodium Phenytoin Sodium Extended Vimpat Vimpat Donepezil HCl Donepezil HCl ODT Galantamine HBr Galantamine HBr ER Rivastigmine Transdermal System Memantine HCl Memantine HCl Titration Pak Namenda XR Namenda XR Titration Pack Aplenzin Bupropion HCl 8 Last updated November, XR Oxtellar XR (Tablet Extended-Release 24 PA Peganone Phenytek (Capsule) Phenytoin (25mg/5ml Suspension, 50mg Tablet Chewable) Phenytoin Sodium Phenytoin Sodium Extended (Capsule) Vimpat (00mg Tablet, 50mg Tablet, 200mg Tablet, 50mg QL Tablet, 0mg/ml Oral Vimpat (200mg/20ml Injection) Antidementia Agents Cholinesterase Inhibitors Donepezil HCl (Tablet Immediate-Release) QL Donepezil HCl ODT (Tablet Dispersible) QL Galantamine HBr (2mg Tablet, 4mg Tablet, 8mg Tablet, QL 4mg/ml Oral Galantamine HBr ER (Capsule Extended- QL Release 24 Tartrate Rivastigmine Tartrate (Capsule Immediate- Release) QL 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 XR (Capsule Extended- 2 PA, QL Release 24 Namenda XR Titration Pack (Capsule Extended-Release 24 2 PA, QL Antidepressants Antidepressants, Other Aplenzin (Tablet Extended-Release 24 SP Bupropion HCl (Tablet Immediate-Release) You can find information on what the symbols and abbreviations in this table mean by going to page 7. 29

30 9 track Bupropion HCl XL Chlordiazepoxide/Amitriptyline Forfivo XL Mirtazapine Mirtazapine ODT Olanzapine/Fluoxetine Perphenazine/Amitriptyline Emsam Tranylcypromine Sulfate Desvenlafaxine ER Desvenlafaxine ER Escitalopram Oxalate Fetzima 9 0 Last updated November, 207 HCl SR 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 Chlordiazepoxide/ Amitriptyline PA, HRM Forfivo XL (Tablet Extended-Release 24 2 Mirtazapine (Tablet Immediate-Release) Mirtazapine ODT (Tablet Dispersible) Olanzapine/Fluoxetine (Capsule) Perphenazine/ Amitriptyline PA, HRM Monoamine Oxidase Inhibitors Emsam (Patch 24 QL, SP Marplan Sulfate Phenelzine Sulfate Tranylcypromine Sulfate SSRI/SNRI (Selective Serotonin Reuptake Inhibitors/Serotonin and Norepinephrine Reuptake Inhibitors) Brisdelle (Capsule) HBr Citalopram HBr (0mg Tablet, 20mg Tablet, 40mg Tablet, 0mg/ 5ml Oral Desvenlafaxine ER (00mg Tablet Extended-Release 24 Hour, 25mg Tablet Extended-Release 24 QL Hour, 50mg Tablet Extended-Release 24 (Generic Pristiq) Desvenlafaxine ER (00mg Tablet Extended-Release 24 Hour, 50mg Tablet QL Extended-Release 24 (Generic Khedezla) Escitalopram Oxalate (0mg Tablet, 20mg Tablet, 5mg Tablet, 5mg/5ml Oral Fetzima (Capsule Extended-Release 24 QL, ST Bold type = Brand name drug Plain type = Generic drug 0

31 20 track Fluoxetine DR Fluoxetine HCl Fluoxetine HCl Fluvoxamine Maleate Fluvoxamine Maleate ER Khedezla Maprotiline HCl Nefazodone HCl Paroxetine HCl Paxil Sertraline HCl Venlafaxine HCl ER 20 Last updated November, 207 Titration Pack Fetzima Titration Pack (Capsule Extended-Release 24 Hour Therapy Pack) Fluoxetine DR (Capsule Delayed- Release) 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 Extended-Release 24 Maprotiline HCl Nefazodone HCl Paroxetine HCl (Tablet Immediate-Release) ST QL PA, HRM HCl ER Paroxetine HCl ER (Tablet Extended- Release 24 PA, HRM Paxil (0mg/5ml Suspension) 2 PA, HRM Pexeva PA, HRM Pristiq (Tablet Extended-Release 24 2 QL 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 Extended-Release 24 Hour, 7.5mg Capsule Extended-Release 24 Hour, 75mg Capsule Extended-Release 24 Hour, 50mg Tablet Extended-Release 24 Hour, 7.5mg Tablet Extended-Release 24 Hour, 75mg Tablet Extended-Release 24 You can find information on what the symbols and abbreviations in this table mean by going to page 7.

32 2 track Amitriptyline HCl Desipramine HCl Doxepin HCl Imipramine HCl Imipramine Pamoate Nortriptyline HCl Trimipramine Maleate Metoclopramide ODT Prochlorperazine Edisylate Prochlorperazine Maleate Tigan Transderm-Scop Trimethobenzamide HCl 2 2 Last updated November, 207 HCl ER Venlafaxine HCl ER (225mg Tablet Extended-Release 24 Viibryd QL Starter Pack Viibryd Starter Pack (Kit) QL Tricyclics Amitriptyline HCl PA, HRM Amoxapine PA, HRM HCl Clomipramine HCl (Capsule) PA, HRM Desipramine HCl PA, HRM Doxepin HCl (00mg Capsule, 0mg Capsule, 50mg Capsule, 25mg Capsule, 50mg PA, HRM Capsule, 75mg Capsule, 0mg/ml Concentrate) Imipramine HCl PA, HRM Imipramine Pamoate (Capsule) PA, HRM Nortriptyline HCl (0mg Capsule, 25mg Capsule, 50mg Capsule, 75mg PA, HRM Capsule, 0mg/5ml Oral HCl Protriptyline HCl PA, HRM Trimipramine Maleate (Capsule) PA, HRM Antiemetics Antiemetics, Other Akynzeo (Capsule) B/D, PA Compro (Suppository) Pamoate Hydroxyzine Pamoate (Capsule) PA, HRM HCl Meclizine HCl PA, HRM HCl Metoclopramide HCl (0mg Tablet, 5mg Tablet, 5mg/5ml Oral Solution, 5mg/ml Injection) Metoclopramide ODT (Tablet Dispersible) Perphenazine Prochlorperazine (Suppository) Prochlorperazine Edisylate Prochlorperazine Maleate Tigan (00mg/ml Injection) PA, HRM Transderm-Scop (Patch 72 Trimethobenzamide HCl (Capsule) PA, HRM Emetogenic Therapy Adjuncts Bold type = Brand name drug Plain type = Generic drug 2

33 22 track Emend Granisetron HCl Granisetron HCl Ondansetron HCl Ondansetron HCl Ondansetron ODT Ciclopirox Ciclopirox Nail Lacquer Ciclopirox Olamine Clotrimazole Cresemba Econazole Nitrate 22 Last updated November, 207 Aloxi 2 SP Anzemet B/D, PA, SP Aprepitant (Therapy Pack, Capsule) PA Cesamet (Capsule) PA, SP Dronabinol (Capsule) PA, QL Emend (25mg Suspension) PA Emend (50mg Injection) Granisetron HCl (0.mg/ml Injection, mg/ml Injection, 4mg/4ml Injection) Granisetron HCl (mg B/D, PA, QL Ondansetron HCl (24mg Tablet, 4mg Tablet, 8mg Tablet, B/D, PA 4mg/5ml Oral Ondansetron HCl (4mg/2ml Injection) Ondansetron ODT (Tablet Dispersible) B/D, PA Sancuso (Patch) SP Syndros (Oral PA, QL, SP Varubi B/D, PA Zuplenz (4mg Film) B/D, PA Zuplenz (8mg Film) B/D, PA, SP Antifungals Antifungals Abelcet B/D, PA, SP AmBisome B/D, PA, SP B Amphotericin B B/D, PA AVC (Cream) Cancidas SP Acetate Caspofungin Acetate SP Ciclopirox (0.77% Gel, 0.77% Suspension, % Shampoo) Ciclopirox Nail Lacquer (External Ciclopirox Olamine (Cream) Clotrimazole (% Cream, % External Solution, 0mg Troche) Cresemba (86mg Capsule) SP Econazole Nitrate (Cream) Eraxis SP Ertaczo (Cream) SP Exelderm (% Cream, % External You can find information on what the symbols and abbreviations in this table mean by going to page 7.

34 2 track Fluconazole in NaCl Griseofulvin Ultramicrosize Kerydin Ketoconazole Mycamine Mycamine Naftifine HCl Naftin Nystatin Nystatin/Triamcinolone Terbinafine HCl Terconazole 2 4 Last updated November, 207 Fluconazole (00mg Tablet, 50mg Tablet, 200mg Tablet, 50mg Tablet, 0mg/ml Suspension, 40mg/ml Suspension) Fluconazole in NaCl Flucytosine (Capsule) Microsize Griseofulvin Microsize (25mg/5ml Suspension, 500mg Griseofulvin Ultramicrosize Gynazole- (Cream) Itraconazole (Capsule) PA, QL Jublia (External Kerydin (External SP Ketoconazole (2% Cream, 2% Foam, 2% Shampoo, 200mg Luzu (Cream) Mentax (Cream) Miconazole (Suppository) Mycamine (00mg Injection) SP Mycamine (50mg Injection) HCl Naftifine HCl (% Cream) Naftifine HCl (2% Cream) Naftin (% Gel, 2% Gel) Natacyn (Suspension) 2 Noxafil (00mg Tablet Delayed-Release, QL, SP 40mg/ml Suspension) Nyamyc (Powder) Nyata (00000unit/gm Powder) Nystatin (Cream, Ointment, Powder, Suspension, Nystatin/ Triamcinolone (0.% Cream, 0.% Ointment) Nystop (Powder) ONMEL PA, SP Oravig SP Nitrate Oxiconazole Nitrate (Cream) Oxistat (% Lotion) Sporanox (0mg/ml Oral PA, SP Terbinafine HCl Terconazole (0.4% Cream, 0.8% Cream, 80mg Suppository) Bold type = Brand name drug Plain type = Generic drug 4

35 24 track Colchicine Colchicine Dihydroergotamine Mesylate Almotriptan Malate Imitrex Naratriptan HCl Onzetra Xsail Rizatriptan Benzoate ODT Sumatriptan Sumatriptan Succinate Sumatriptan Succinate Refill 24 Last updated November, Voriconazole (200mg Injection, 200mg Tablet, 50mg Tablet, 40mg/ml Suspension) Antigout Agents Antigout Agents Allopurinol Sodium Allopurinol Sodium Colchicine (0.6mg Capsule) (Generic QL Mitigare) Colchicine (0.6mg (Generic 2 QL Colcrys) Colcrys 2 QL Mitigare (Capsule) QL Probenecid Probenecid/Colchicine Uloric 2 ST Zurampic Antimigraine Agents Ergot Alkaloids Cafergot 2 Mesylate Dihydroergotamine Mesylate (mg/ml Injection) Dihydroergotamine Mesylate (4mg/ml Nasal Tartrate/Caffeine Ergotamine Tartrate/ Caffeine Migergot (Suppository) SP Serotonin (5-HT) b/d Receptor Agonists Almotriptan Malate QL HBr Eletriptan HBr QL Succinate Frovatriptan Succinate QL Imitrex (5mg/act Nasal 2 QL Naratriptan HCl QL Onzetra Xsail (Exhaler Powder) QL Relpax QL Benzoate Rizatriptan Benzoate (Tablet Immediate- QL Release) Rizatriptan Benzoate ODT (Tablet QL Dispersible) Sumatriptan (Nasal QL Sumatriptan Succinate (00mg Tablet, 25mg Tablet, 50mg Tablet, QL 4mg/0.5ml Injection, 6mg/0.5ml Injection) Sumatriptan Succinate Refill QL You can find information on what the symbols and abbreviations in this table mean by going to page 7. 5