(LIST OF COVERED DRUGS)

Transcription

1 Allwell Dual Medicare (H SNP) and Allwell Medicare Plus (H) 208 Formulary (LIST OF COVERED DRUGS) PLEASE READ: THIS DOCUMENT CONTAINS IORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN HPMS Approved Formulary File Submission ID 8483, Version Number 4 This formulary was updated on 07/0/208. For more recent information or other questions, please contact Allwell Dual Medicare (H SNP) and Allwell Medicare Plus (H) at: State Phone Number AZ PA SC WA or, for TTY users, 7, October February 4, seven days a week, 8 a.m. to 8 p.m.; February 5 September 30, Monday Friday, 8 a.m. to 8 p.m., or visit: State AZ PA SC WA Website Address allwell.healthnetadvantage.com allwell.pahealthwellness.com allwell.absolutetotalcare.com allwell.coordinatedcarehealth.com Y0020_8_5556FRMLY Accepted 2207

2 Note to existing members: This formulary has changed since last year. Please review this document to make sure that it still contains the drugs you take. When this drug list (formulary) refers to we, us, or our, it means Bridgeway Health Solutions, Pennsylvania Health & Wellness, Absolute Total Care, and Coordinated Care of WA. When it refers to plan or our plan, it means Allwell Dual Medicare (H SNP) and Allwell Medicare Plus (H). This document includes a list of the drugs (formulary) for our plan which is current as of 07/0/208. For an updated formulary, please contact us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages. You must generally use network pharmacies to use your prescription drug benefit. Benefits, formulary, pharmacy network, and/or copayments/coinsurance may change on January, 209, and from time to time during the year. What is the Allwell Dual Medicare (H SNP) and Allwell Medicare Plus (H) Formulary? A formulary is a list of covered drugs selected by our plan in consultation with a team of health care providers, which represents the prescription therapies believed to be a necessary part of a quality treatment program. We will generally cover the drugs listed in our formulary as long as the drug is medically necessary, the prescription is filled at a plan network pharmacy, and other plan rules are followed. For more information on how to fill your prescriptions, please review your Evidence of Coverage. Can the Formulary (drug list) change? Generally, if you are taking a drug on our 208 formulary that was covered at the beginning of the year, we will not discontinue or reduce coverage of the drug during the 208 coverage year except when a new, less expensive generic drug becomes available or when new adverse information about the safety or effectiveness of a drug is released. Other types of formulary changes, such as removing a drug from our formulary, will not affect members who are currently taking the drug. It will remain available at the same cost-sharing for those members taking it for the remainder of the coverage year. We feel it is important that you have continued access for the remainder of the coverage year to the formulary drugs that were available when you chose our plan, except for cases in which you can save additional money or we can ensure your safety. If we remove drugs from our formulary, or add prior authorization, quantity limits and/or step therapy restrictions on a drug, we must notify affected members of the change at least 60 days before the change becomes effective, or at the time the member requests a refill of the drug, at which time the member will receive a 60-day supply of the drug. If the Food and Administration deems a drug on our formulary to be unsafe or the drug s manufacturer removes the drug from the market, we will immediately remove the drug from our formulary and provide notice to members who take the drug. The enclosed formulary is current as of 07/0/208. To get updated information about the drugs covered by our plan, please contact us. Our contact information appears on the front and back cover pages. i

3 If we make any other negative changes to a drug you are taking, we will notify you via mail. We will also post the changes on our website. How do I use the Formulary? There are two ways to find your drug within the formulary: Medical Condition The formulary begins on page. The drugs in this formulary are grouped into categories depending on the type of medical conditions that they are used to treat. For example, drugs used to treat a heart condition are listed under the category, CARDIOVASCULAR AGENTS - MISC. If you know what your drug is used for, look for the category name in the list that begins on page. Then look under the category name for your drug. Alphabetical Listing If you are not sure what category to look under, you should look for your drug in the Index that begins on page Index. The Index provides an alphabetical list of all of the drugs included in this document. Both brand name drugs and generic drugs are listed in the Index. Look in the Index and find your drug. Next to your drug, you will see the page number where you can find coverage information. Turn to the page listed in the Index and find the name of your drug in the first column of the list. What are generic drugs? Our plan covers both brand name drugs and generic drugs. A generic drug is approved by the FDA as having the same active ingredient as the brand name drug. Generally, generic drugs cost less than brand name drugs. Are there any restrictions on my coverage? Some covered drugs may have additional requirements or limits on coverage. These requirements and limits may include: Prior Authorization: Our plan requires you or your physician to get prior authorization for certain drugs. This means that you will need to get approval from us before you fill your prescriptions. If you don t get approval, we may not cover the drug. Quantity : For certain drugs, our plan limits the amount of the drug that we will cover. For example, our plan provides one tablet per day per prescription for simvastatin 40. This may be in addition to a standard one-month or three-month supply. Step Therapy: In some cases, our plan requires you to first try certain drugs to treat your medical condition before we will cover another drug for that condition. For example, if A ii

4 and B both treat your medical condition, we may not cover B unless you try A first. If A does not work for you, we will then cover B. You can find out if your drug has any additional requirements or limits by looking in the formulary that begins on page. You can also get more information about the restrictions applied to specific covered drugs by visiting our Web site. We have posted on line documents that explain our prior authorization and step therapy restrictions. You may also ask us to send you a copy. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages. You can ask us to make an exception to these restrictions or limits or for a list of other, similar drugs that may treat your health condition. See the section, How do I request an exception to the Allwell Dual Medicare (H SNP) and Allwell Medicare Plus (H) formulary? on page iii for information about how to request an exception. What if my drug is not on the Formulary? If your drug is not included in this formulary (list of covered drugs), you should first contact Member Services and ask if your drug is covered. If you learn that our plan does not cover your drug, you have two options: You can ask Member Services for a list of similar drugs that are covered by our plan. When you receive the list, show it to your doctor and ask him or her to prescribe a similar drug that is covered by us. You can ask us to make an exception and cover your drug. See below for information about how to request an exception. How do I request an exception to the Allwell Dual Medicare (H SNP) and Allwell Medicare Plus (H) Formulary? You can ask us to make an exception to our coverage rules. There are several types of exceptions that you can ask us to make. You can ask us to cover a drug even if it is not on our formulary. If approved, this drug will be covered at a pre-determined cost-sharing level, and you would not be able to ask us to provide the drug at a lower cost-sharing level. You can ask us to waive coverage restrictions or limits on your drug. For example, for certain drugs, our plan limits the amount of the drug that we will cover. If your drug has a quantity limit, you can ask us to waive the limit and cover a greater amount. iii

5 Generally, we will only approve your request for an exception if the alternative drugs included on the plan s formulary, or additional utilization restrictions would not be as effective in treating your condition and/or would cause you to have adverse medical effects. You should contact us to ask us for an initial coverage decision for a formulary or utilization restriction exception. When you request a formulary or utilization restriction exception you should submit a statement from your prescriber or physician supporting your request. Generally, we must make our decision within 72 hours of getting your prescriber s supporting statement. You can request an expedited (fast) exception if you or your doctor believe that your health could be seriously harmed by waiting up to 72 hours for a decision. If your request to expedite is granted, we must give you a decision no later than 24 hours after we get a supporting statement from your doctor or other prescriber. What do I do before I can talk to my doctor about changing my drugs or requesting an exception? As a new or continuing member in our plan you may be taking drugs that are not on our formulary. Or, you may be taking a drug that is on our formulary but your ability to get it is limited. For example, you may need a prior authorization from us before you can fill your prescription. You should talk to your doctor to decide if you should switch to an appropriate drug that we cover or request a formulary exception so that we will cover the drug you take. While you talk to your doctor to determine the right course of action for you, we may cover your drug in certain cases during the first 90 days you are a member of our plan. For each of your drugs that is not on our formulary or if your ability to get your drugs is limited, we will cover a temporary 30-day supply (unless you have a prescription written for fewer days) when you go to a network pharmacy. After your first 30-day supply, we will not pay for these drugs, even if you have been a member of the plan less than 90 days. If you are a resident of a long-term care facility, we will allow you to refill your prescription until we have provided you with a 98-day transition supply, consistent with dispensing increment, (unless you have a prescription written for fewer days). We will cover more than one refill of these drugs for the first 90 days you are a member of our plan. If you need a drug that is not on our formulary or if your ability to get your drugs is limited, but you are past the first 90 days of membership in our plan, we will cover a 3-day emergency supply of that drug (unless you have a prescription for fewer days) while you pursue a formulary exception. Level of care changes If you experience a change in your level of care, we will cover a transition supply of your drugs. A level of care change occurs when you are discharged from a hospital or moved to or from a long-term care facility. If you move home from a long-term care facility or hospital and need a transition supply, we will cover one 30-day supply. If your prescription is written for fewer days, we will allow multiple fills to provide up to a total of a 30-day supply. If you move from home or a hospital to a long-term care facility and need a transition supply, we will cover one 3-day supply. If your prescription is written for fewer days, we will allow multiple fills to provide up to a total of a 3-day supply. iv

6 For more information For more detailed information about your plan s prescription drug coverage, please review your Evidence of Coverage and other plan materials. If you have questions about our plan, please contact us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages. If you have general questions about Medicare prescription drug coverage, please call Medicare at MEDICARE ( ) 24 hours a day/7 days a week. TTY users should call Or, visit Allwell Dual Medicare (H SNP) and Allwell Medicare Plus (H) Formulary The formulary that begins on page provides coverage information about the drugs covered by our plan. If you have trouble finding your drug in the list, turn to the Index that begins on page Index. The first column of the chart lists the drug name. Brand name drugs are capitalized (e.g., ELIQUIS TABS) and generic drugs are listed in lower-case italics (e.g., warfarin sodium tabs). The information in the column tells you if our plan has any special requirements for coverage of your drug. Abbreviations The abbreviations below may appear in the Requirement/ column on the formulary. Abbreviation Definition Description AL Age Limit This drug may require prior authorization if your age does not meet manufacturer, FDA, or clinical recommendations. B/D Medicare Part B vs. Part D This drug may be covered under Medicare Part B or Part D depending upon the circumstances. Information may need to be submitted describing the use and setting of the drug to make the determination. LA Limited Access This prescription may be available only at certain pharmacies. For more information consult your Pharmacy Directory or call Member Services from October - February 4, seven days a week, 8 a.m. to 8 p.m. or from February 5 - September 30, Monday - Friday, 8 a.m. to 8 p.m. Our contact information appears on the front and back cover pages. TTY users should call 7. Mail Order This drug is available at our mail order pharmacy in addition to other network pharmacies. v

7 Abbreviation Definition Description NDS Non-Extended Day Supply This prescription drug is not available for an extended day supply. NT Non-TrOOP This prescription drug is not normally covered in a Medicare Prescription Plan. The amount you pay when you fill a prescription for this drug does not count towards your total drug costs (that is, the amount you pay does not help you qualify for catastrophic coverage). In addition, if you are receiving extra help to pay for your prescriptions, you will not get any extra help to pay for this drug. PA QL RX/OTC Prior Authorization Quantity Limit Prescription and Over-the- Counter (OTC) This drug requires prior authorization. This means that you or your prescriber must get approval from us before you fill your prescription. If you don t get approval, we may not cover the drug. This drug has a limit on the amount that we will cover. For example, we cover one tablet per day per prescription for simvastatin 40. This may be in addition to a standard onemonth or three-month supply limit. This drug is available both in a prescription form and in an OTC form. Other than some insulins and insulin supplies, only prescription drugs are covered by our Medicare Part D plans. SL Safety Limit This drug has a maximum daily dose limit for safety supported by the FDA. This means that we will not cover more than the maximum daily dose. For example, the FDA maximum daily dose of ibuprofen is Therefore, we will only cover four tablets per day for ibuprofen 800. ST Step Therapy This drug requires step therapy. This means that you must first try certain drugs to treat your medical condition before we cover another drug for that condition. For example, if A and B both treat your medical condition, we may not cover B unless you try A first. If A does not work for you, we will then cover B. vi

8 Formulary tier descriptions Allwell Dual Medicare (H SNP) and Allwell Medicare Plus (H) covers both brand-name drugs and generic drugs. Generally, generic drugs cost less than brand-name drugs. The table below tells you the copayment or coinsurance amount (i.e., the share of the drug's cost that you will pay during the initial coverage stage) for a one-month supply of covered drugs. For more detailed information about your outof-pocket costs for prescriptions, including any deductible that may apply, please refer to your Evidence of Coverage and other plan materials. State AZ PA SC WA Plan Name Allwell Dual Medicare (H SNP) Allwell Dual Medicare (H SNP) Allwell Dual Medicare (H SNP) Allwell Medicare Plus (H) Generic and Brand (includes generic drugs and brand drugs) 25% - OR $0, $.25, $3.35 copay or 5% of the total cost for generic drugs $0, $3.70, $8.35 copay or 5% of the total cost for brand name drugs (depending upon your level of Extra Help) 25% - OR $0, $.25, $3.35 copay or 5% of the total cost for generic drugs $0, $3.70, $8.35 copay or 5% of the total cost for brand name drugs (depending upon your level of Extra Help) 25% - OR $0, $.25, $3.35 copay or 5% of the total cost for generic drugs $0, $3.70, $8.35 copay or 5% of the total cost for brand name drugs (depending upon your level of Extra Help) 25% - OR $0, $.25, $3.35 copay or 5% of the total cost for generic drugs $0, $3.70, $8.35 copay or 5% of the total cost for brand name drugs (depending upon your level of Extra Help) Note: If is displayed in the column, this means the drug is not covered on the formulary. You may request an exception from us to cover these non-formulary drugs. If an exception request is approved for a non-formulary drug; the copayment applies. vii

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

11 Name ADHD/ANTI-NARCOLEPSY/ANTI- OBESITY/ANOREXIANTS - s to Treat ADHD, Sleep and Eating Disorders Amphetamines ADDERALL TABS (Amphetamine- Dextroamphetamine) ADDERALL XR CP24 (Amphetamine- Dextroamphetamine) amphetaminedextroamphetamine cp24 amphetaminedextroamphetamine tabs DESOXYN TABS PA; (Methamphetamine HCl) DEXEDRINE CP24 (Dextroamphetamine Sulfate) dextroamphetamine sulfate cp24 5, 0, 5 dextroamphetamine sulfate tabs 5, 0 methamphetamine hcl tabs PA; Attention-Deficit/Hyperactivity Disorder (ADHD) atomoxetine hcl caps 0 SL(0 ea daily); atomoxetine hcl caps 00 SL( ea daily); atomoxetine hcl caps 8 SL(5.55 ea daily); atomoxetine hcl caps 25 SL(4 ea daily); atomoxetine hcl caps 40 SL(2.5 ea daily); atomoxetine hcl caps 60 SL(.66 ea daily); atomoxetine hcl caps 80 SL(.25 ea daily); clonidine hcl (adhd) tb2 guanfacine hcl (adhd) tb24 INTUNIV TB24 (Guanfacine HCl (ADHD)) yrs old; yrs old; Name KAPVAY TB2 (Clonidine HCl (ADHD)) STRATTERA CAPS 0 MG (Atomoxetine HCl) STRATTERA CAPS 00 MG (Atomoxetine HCl) STRATTERA CAPS 8 MG (Atomoxetine HCl) STRATTERA CAPS 25 MG (Atomoxetine HCl) STRATTERA CAPS 40 MG (Atomoxetine HCl) STRATTERA CAPS 60 MG (Atomoxetine HCl) STRATTERA CAPS 80 MG (Atomoxetine HCl) Stimulants - Misc. CONCERTA TBCR (Methylphenidate HCl) dexmethylphenidate hcl cp24 0, 5, 20 dexmethylphenidate hcl tabs 5, 0, 2.5 FOCALIN TABS (Dexmethylphenidate HCl) FOCALIN XR CP24 0 MG, 5 MG, 20 MG (Dexmethylphenidate HCl) METADATE CD CPCR 0 MG, 40 MG, 50 MG, 60 MG (Methylphenidate HCl) METADATE CD CPCR 20 MG (Methylphenidate HCl) METADATE CD CPCR 30 MG (Methylphenidate HCl) methylphenidate hcl cp24 or 20, 30, 40, 60 methylphenidate hcl cpcr or 0, 40, 50, 60 methylphenidate hcl cpcr or 20 methylphenidate hcl cpcr or Allwell Defined Standard DSNP Formulary Updated 07/0/208 SL(0 ea daily); SL( ea daily); SL(5.55 ea daily); SL(4 ea daily); SL(2.5 ea daily); SL(.66 ea daily); SL(.25 ea daily); QL( ea daily); QL(2 ea daily); QL( ea daily); QL(2 ea daily);

12 Name methylphenidate hcl tabs or 5, 0, 20 methylphenidate hcl tb24 or 27, 36 methylphenidate hcl tbcr or 8, 27, 36, 54 methylphenidate hcl tbcr or 20 modafinil tabs 00 modafinil tabs 200 PROVIGIL TABS 00 MG (Modafinil) PROVIGIL TABS 200 MG (Modafinil) RITALIN LA CP24 20 MG, 30 MG, 40 MG (Methylphenidate HCl) RITALIN TABS (Methylphenidate HCl) QL(3 ea daily); Non-Osmotic Release QL(3 ea daily); PA; PA; QL( ea daily); PA; PA; QL( ea daily); QL(3 ea daily); ALLERGENIC EXTRACTS/BIOLOGICALS MISC Biologicals Misc ADAGEN SOLN LA; AMINOGLYCOSIDES - s to Treat Bacterial Infections Aminoglycosides amikacin sulfate soln ij gm/4ml, 500 /2ml BETHKIS NEBU B/D; gentamicin in saline soln 0.9%-/ml gentamicin sulfate soln ij 40 /ml KITABIS PAK NEBU B/D neomycin sulfate tabs or paromomycin sulfate caps TOBI NEBU (Tobramycin) B/D Name TOBI PODHALER CAPS tobramycin nebu in B/D tobramycin sulfate soln ij 40 /ml, 80 /2ml,.2 gm/30ml tobramycin sulfate solr ij.2 gm ANALGESICS - ANTI-ILAMMATORY - s to Treat Pain, Swelling, Muscle and Joint Conditions Anti-T-alpha - Monoclonal Antibodies HUMIRA PEDIATRIC CROHNS DISEASE STARTER PACK PSKT HUMIRA PEN PNKT HUMIRA PEN-CROHNS DISEASESTARTER PNKT HUMIRA PEN-PSORIASIS STARTER PNKT HUMIRA PSKT SIMPONI ARIA SOLN SIMPONI SOAJ SIMPONI SOSY Antirheumatic - Enzyme Inhibitors XELJANZ TABS Antirheumatic Antimetabolites OTREXUP SOAJ 0 MG/0.4ML, 5 MG/0.4ML, 20 MG/0.4ML, 25 MG/0.4ML, 2.5 MG/0.4ML, 7.5 MG/0.4ML, 22.5 MG/0.4ML PA 208 Allwell Defined Standard DSNP Formulary Updated 07/0/208 2

13 Name RASUVO SOAJ 0 MG/0.2ML, 5 MG/0.3ML, 20 MG/0.4ML, 25 MG/0.5ML, 30 MG/0.6ML, 7.5 MG/0.5ML, 2.5 MG/0.25ML, 7.5 MG/0.35ML, 22.5 MG/0.45ML Gold Compounds RIDAURA CAPS Interleukin- Blockers ARCALYST SOLR PA LA Interleukin- Receptor Antagonist (IL-Ra) KINERET SOSY Interleukin-beta Blockers ILARIS SOLN ILARIS SOLR Interleukin-6 Receptor Inhibitors ACTEMRA SOLN ACTEMRA SOSY LA LA KEVZARA SOSY 50 MG/.4ML, 200 MG/.4ML Nonsteroidal Anti-inflammatory Agents (NSAIDs) ANAPROX DS TABS (Naproxen Sodium) ARTHROTEC 50 TBEC (Diclofenac w/ Misoprostol) ARTHROTEC 75 TBEC (Diclofenac w/ Misoprostol) CELEBREX CAPS (Celecoxib) celecoxib caps DAYPRO TABS (Oxaprozin) diclofenac potassium tabs Name diclofenac sodium tb24 or 00 diclofenac sodium tbec or 25, 50, 75 diclofenac w/ misoprostol tbec EC-NAPROSYN TBEC (Naproxen) etodolac caps etodolac tabs etodolac tb24 FELDENE CAPS (Piroxicam) flurbiprofen tabs or 50, 00 ibuprofen susp or 00 /5ml ibuprofen tabs or 400 ibuprofen tabs or 600 ibuprofen tabs or 800 indomethacin caps or 25, 50 indomethacin cpcr or 75 ketoprofen caps 50, 75 ketorolac tromethamine soln ij 5 /ml, 30 /ml ketorolac tromethamine soln im 30 /ml, 60 /2ml LODINE TABS (Etodolac) mefenamic acid caps or meloxicam tabs or 5, 7.5 BIC TABS 5 MG, 7.5 MG (Meloxicam) nabumetone tabs RX/OTC; SL(8 ea daily); SL(5.33 ea daily); SL(4 ea daily); yrs old; yrs old; yrs old; yrs old; 208 Allwell Defined Standard DSNP Formulary Updated 07/0/208 3

14 Name NAPROSYN TABS 500 MG (Naproxen) naproxen sodium tabs or 275, 550 naproxen tabs or 250, 375, 500 naproxen tbec or 375, 500 oxaprozin tabs piroxicam caps or 0, 20 PONSTEL CAPS (Mefenamic Acid) sulindac tabs or 50, 200 tolmetin sodium caps 400 tolmetin sodium tabs 200 Phosphodiesterase 4 (PDE4) Inhibitors OTEZLA TABS OTEZLA TBPK Pyrimidine Synthesis Inhibitors ARAVA TABS (Leflunomide) leflunomide tabs or 0, 20 Selective Costimulation Modulators ORENCIA CLICKJECT SOAJ ORENCIA SOLR ORENCIA SOSY Soluble Tumor Necrosis Factor Receptor Agents ENBREL MINI SOCT ENBREL SOLR ENBREL SOSY ENBREL SURECLICK SOAJ Name ANALGESICS - NonNarcotic - s to Treat Pain, Muscle and Joint Conditions Salicylates diflunisal tabs ANALGESICS - OPIOID - s to Treat Pain, Muscle and Joint Conditions Opioid Agonists ACTIQ LPOP 200 MCG QL(8 (Fentanyl Citrate) ACTIQ LPOP 400 MCG, 600 MCG, 800 MCG, 200 MCG, 600 MCG (Fentanyl Citrate) DILAUDID LIQD OR MG/ML (Hydromorphone HCl) DILAUDID SOLN IJ 2 MG/ML (Hydromorphone HCl) DILAUDID TABS OR 2 MG (Hydromorphone HCl) DILAUDID TABS OR 4 MG (Hydromorphone HCl) DILAUDID TABS OR 8 MG (Hydromorphone HCl) DILAUDID-HP SOLN (Hydromorphone HCl) DOLOPHINE TABS 0 MG (Methadone HCl) DOLOPHINE TABS 5 MG (Methadone HCl) DURAGESIC PT72 00 MCG/HR (Fentanyl) DURAGESIC PT72 2 MCG/HR (Fentanyl) DURAGESIC PT72 25 MCG/HR (Fentanyl) DURAGESIC PT72 50 MCG/HR, 75 MCG/HR (Fentanyl) fentanyl citrate lpop bu 200 mcg ea daily); QL(4 ea daily); QL(50 ml daily); QL(25 ea daily); QL(2.5 ea daily); QL(6.25 ea daily); QL(6.67 ea daily); QL(3.34 ea daily); QL(0.5 ea daily); Limit 43 patches per month;ql(.44 ea daily); QL(0.94 ea daily); Limit 5 patches per month;ql(0.5 ea daily); QL(8 ea daily); 208 Allwell Defined Standard DSNP Formulary Updated 07/0/208 4

15 Name fentanyl citrate lpop bu 400 mcg, 600 mcg, 800 mcg, 200 mcg, 600 mcg fentanyl pt72 00 mcg/hr fentanyl pt72 2 mcg/hr fentanyl pt72 25 mcg/hr fentanyl pt72 50 mcg/hr, 75 mcg/hr hydromorphone hcl liqd or /ml hydromorphone hcl soln ij 0 /ml, 50 /5ml, 500 /50ml hydromorphone hcl soln ij 2 /ml hydromorphone hcl tabs or 2 hydromorphone hcl tabs or 4 hydromorphone hcl tabs or 8 KADIAN CP24 0 MG (Morphine Sulfate) KADIAN CP24 00 MG (Morphine Sulfate) KADIAN CP24 20 MG (Morphine Sulfate) KADIAN CP24 30 MG (Morphine Sulfate) KADIAN CP24 50 MG (Morphine Sulfate) KADIAN CP24 60 MG (Morphine Sulfate) KADIAN CP24 80 MG (Morphine Sulfate) LAZANDA SOLN 00 MCG/ACT LAZANDA SOLN 300 MCG/ACT QL(4 ea daily); QL(0.5 ea daily); Limit 43 patches per month;ql(.44 ea daily); QL(0.94 ea daily); Limit 5 patches per month;ql(0.5 ea daily); QL(50 ml daily); QL(25 ea daily); QL(2.5 ea daily); QL(6.25 ea daily); QL(20 ea daily); QL(2 ea daily); QL(0 ea daily); QL(6.67 ea daily); QL(4 ea daily); QL(3.34 ea daily); QL(2.5 ea daily); QL( ea daily); PA; QL(0.5 ea daily); Name LAZANDA SOLN 400 MCG/ACT methadone hcl soln or 0 /5ml methadone hcl soln or 5 /5ml methadone hcl tabs or 0 methadone hcl tabs or 5 morphine sulfate cp24 or 0 morphine sulfate cp24 or 00 morphine sulfate cp24 or 20 morphine sulfate cp24 or 30 morphine sulfate cp24 or 50 morphine sulfate cp24 or 60 morphine sulfate cp24 or 80 morphine sulfate soln ij 0.5 /ml morphine sulfate soln ij /ml morphine sulfate soln or 0 /5ml morphine sulfate soln or 20 /5ml morphine sulfate soln or 20 /ml, 00 /5ml morphine sulfate tbcr or 00, 200 morphine sulfate tbcr or 5 morphine sulfate tbcr or 30 morphine sulfate tbcr or 60 MS CONTIN TBCR 00 MG, 200 MG (Morphine Sulfate) 208 Allwell Defined Standard DSNP Formulary Updated 07/0/208 5 PA; QL(0.27 ea daily); QL(33.34 ml daily); QL(66.67 ml daily); QL(6.67 ea daily); QL(3.34 ea daily); QL(20 ea daily); QL(2 ea daily); QL(0 ea daily); QL(6.67 ea daily); QL(4 ea daily); QL(3.34 ea daily); QL(2.5 ea daily); QL(00 ml daily); QL(50 ml daily); QL(0 ml daily); QL(2 ea daily); QL(3.34 ea daily); QL(6.67 ea daily); QL(3.34 ea daily); QL(2 ea daily);

16 Name MS CONTIN TBCR 5 MG (Morphine Sulfate) MS CONTIN TBCR 30 MG (Morphine Sulfate) MS CONTIN TBCR 60 MG (Morphine Sulfate) OPANA TABS OR 0 MG (Oxymorphone HCl) OPANA TABS OR 5 MG (Oxymorphone HCl) oxycodone hcl caps or 5 oxycodone hcl conc or 00 /5ml oxycodone hcl tabs or 0 oxycodone hcl tabs or 5 oxycodone hcl tabs or 20 oxycodone hcl tabs or 30 oxycodone hcl tabs or 5 oxymorphone hcl tabs 0 oxymorphone hcl tabs 5 oxymorphone hcl tb2 5 oxymorphone hcl tb2 7.5 ROXICODONE TABS 5 MG (Oxycodone HCl) ROXICODONE TABS 30 MG (Oxycodone HCl) ROXICODONE TABS 5 MG (Oxycodone HCl) SUBSYS LIQD 00 MCG SUBSYS LIQD 200 MCG SUBSYS LIQD 600 MCG QL(3.34 ea daily); QL(6.67 ea daily); QL(3.34 ea daily); QL(6.67 ea daily); QL(3.34 ea daily); QL(26.67 ea daily); QL(6.67 ml daily); QL(3.3 ea daily); QL(8.9 ea daily); QL(6.65 ea daily); QL(4.44 ea daily); QL(26.67 ea daily); QL(6.67 ea daily); QL(3.34 ea daily); QL(4.44 ea daily); QL(8.89 ea daily); QL(8.9 ea daily); QL(4.44 ea daily); QL(26.67 ea daily); PA; QL(6 ea daily); PA; QL(2 ea daily) PA; QL(4 ea daily); Name SUBSYS LIQD 200 MCG SUBSYS LIQD 400 MCG, 600 MCG, 800 MCG tramadol hcl tabs or 50 tramadol hcl tb24 or 00 tramadol hcl tb24 or 200 tramadol hcl tb24 or 300 ULTRAM ER TB24 (Tramadol HCl) ULTRAM TABS (Tramadol HCl) ZOHYDRO ER C2A 0 MG ZOHYDRO ER C2A 5 MG ZOHYDRO ER C2A 20 MG ZOHYDRO ER C2A 30 MG ZOHYDRO ER C2A 40 MG ZOHYDRO ER C2A 50 MG Opioid Combinations acetaminophen w/ codeine soln 20/5ml-2/5ml acetaminophen w/ codeine tabs acetaminophen w/ codeine tabs acetaminophen w/ codeine tabs butalbital-aspirin-caffeine w/cod caps FIORINAL/CODEINE #3 CAPS (Butalbital-Aspirin- Caffeine w/cod) QL(8 ea daily); QL(4 ea daily); SL(8 ea daily); SL(3 ea daily); SL(.5 ea daily); SL( ea daily); SL( ea daily); SL(8 ea daily); PA; QL(6.8 ea daily); PA; QL(.2 ea daily); PA; QL(8.4 ea daily); PA; QL(5.6 ea daily); PA; QL(4.2 ea daily); PA; QL(3.37 ea daily); SL(50 ml daily); SL(3.3 ea daily); SL(2 ea daily); SL(6 ea daily); yrs old; SL(6 ea daily); yrs old; SL(6 ea daily); 208 Allwell Defined Standard DSNP Formulary Updated 07/0/208 6

17 Name hydrocodoneacetaminophen soln 2.5/5ml-08/5ml, 5/0ml-27/0ml, 7.5/5ml-325/5ml hydrocodoneacetaminophen tabs 5-300, 0-300, hydrocodoneacetaminophen tabs 5-325, 0-325, hydrocodone-ibuprofen tabs IBUDONE TABS (Hydrocodone-Ibuprofen) NORCO TABS (Hydrocodone- Acetaminophen) oxycodone w/ acetaminophen tabs oxycodone-aspirin tabs PERCOCET TABS (Oxycodone w/ Acetaminophen) REPREXAIN TABS (Hydrocodone-Ibuprofen) tramadol-acetaminophen tabs TYLENOL/CODEINE #3 TABS (Acetaminophen w/ Codeine) TYLENOL/CODEINE #4 TABS (Acetaminophen w/ Codeine) ULTRACET TABS (Tramadol-Acetaminophen) XODOL TABS (Hydrocodone- Acetaminophen) Opioid Partial Agonists buprenorphine hcl subl sl 2 buprenorphine hcl subl sl 8 Limit 5535mls per month;sl(84. 5 ml daily); SL(3.3 ea daily); SL(2.3 ea daily); SL(2.3 ea daily); SL(2.3 ea daily); SL(2.3 ea daily); SL(8 ea daily); SL(2 ea daily); SL(6 ea daily); SL(8 ea daily); SL(3.3 ea daily); PA; QL(6 ea daily); PA; QL(4 ea daily); Name buprenorphine hclnaloxone hcl dihydrate subl buprenorphine hclnaloxone hcl dihydrate subl 8-2 butorphanol tartrate soln ij 2 /ml butorphanol tartrate soln na 0 /ml PA; QL(6 ea daily); PA; QL(4 ea daily); Limit 20mls per month;ql(7 ml daily); ANDROGENS-ANABOLIC - s to Regulate Hormones Anabolic Steroids ANADROL-50 TABS OXANDRIN TABS 0 MG (Oxandrolone) OXANDRIN TABS 2.5 MG (Oxandrolone) oxandrolone tabs or 0 oxandrolone tabs or 2.5 Androgens ANDRODERM PT24 ANDROGEL GEL 40.5 MG/2.5GM, MG/.25GM ANDROGEL GEL 50 MG/5GM, 25 MG/2.5GM (Testosterone) ANDROGEL PUMP GEL AVEED SOLN danazol caps or 50, 00, 200 DEPO-TESTOSTERONE SOLN (Testosterone Cypionate) fluoxymesterone tabs or methyltestosterone caps or LA 208 Allwell Defined Standard DSNP Formulary Updated 07/0/208 7

18 Name TESTIM GEL (Testosterone) testosterone cypionate soln testosterone enanthate soln im testosterone gel %, 50 /5gm, 25 /2.5gm TESTOSTERONE GEL %, 50 MG/5GM, 25 MG/2.5GM TESTOSTERONE PUMP GEL VOGELXO GEL VOGELXO PUMP GEL ANORECTAL AGENTS - Rectal s to Treat Pain, Swelling and Itching Intrarectal Steroids CORTENEMA ENEM (Hydrocortisone (Intrarectal)) hydrocortisone (intrarectal) enem UCERIS FOAM RE 2 MG/ACT Rectal Steroids ANUSOL-HC CREA (Hydrocortisone (Rectal)) hydrocortisone (rectal) crea PROCTOCORT CREA % (Hydrocortisone (Rectal)) Vasodilating Agents RECTIV OINT ANTHELMINTICS - s to Treat Worm Infections Anthelmintics ALBENZA TABS ivermectin tabs or Name STROMECTOL TABS (Ivermectin) ANTI-IECTIVE AGENTS - MISC. - s to Treat Bacterial Infections Anti-infective Agents - Misc. colistimethate sodium solr ij COLY-MYCIN M SOLR (Colistimethate Sodium) FLAGYL CAPS 375 MG SL(0.6 ea (Metronidazole) daily); FLAGYL TABS 250 MG SL(6 ea daily); (Metronidazole) FLAGYL TABS 500 MG (Metronidazole) IMPAVIDO CAPS metronidazole caps or 375 metronidazole in nacl soln metronidazole tabs or 250 metronidazole tabs or 500 NEBUPENT SOLR ORBACTIV SOLR PENTAM 300 SOLR TINDAMAX TABS (Tinidazole) tinidazole tabs or 250, 500 trimethoprim tabs or VANCOCIN HCL CAPS (Vancomycin HCl) vancomycin hcl caps or 25, 250 VANCOMYCIN HCL IN DEXTROSE SOLN GM/200ML-5%, 5%- 750MG/50ML, 500MG/00ML-5% SL(8 ea daily); SL(0.6 ea daily); SL(6 ea daily); SL(8 ea daily); B/D; 208 Allwell Defined Standard DSNP Formulary Updated 07/0/208 8

19 Name vancomycin hcl solr iv 0 gm, 000, 5000 vancomycin hcl solr iv 500 XIFAXAN TABS 200 MG XIFAXAN TABS 550 MG QL(3 ea daily); Anti-infective Misc. - Combinations BACTRIM DS TABS (Sulfamethoxazole- Trimethoprim) BACTRIM TABS (Sulfamethoxazole- Trimethoprim) sulfamethoxazoletrimethoprim soln sulfamethoxazoletrimethoprim susp sulfamethoxazoletrimethoprim tabs Antiprotozoal Agents ALINIA TABS 500 MG atovaquone susp MEPRON SUSP (Atovaquone) Carbapenems imipenem-cilastatin solr INVANZ SOLR IJ meropenem solr MERREM SOLR (Meropenem) PRIMAXIN IV SOLR (Imipenem-Cilastatin) VABOMERE SOLR Chloramphenicols chloramphenicol sodium succinate solr Cyclic Lipopeptides Name CUBICIN RF SOLR (Daptomycin) CUBICIN SOLR (Daptomycin) daptomycin solr Glycylcyclines TIGECYCLINE SOLR tigecycline solr TYGACIL SOLR (Tigecycline) Leprostatics dapsone tabs or 25, 00 Lincosamides CLEOCIN CAPS OR 75 MG, 50 MG, 300 MG (Clindamycin HCl) CLEOCIN IN D5W SOLN (Clindamycin Phosphate in D5W) CLEOCIN PEDIATRIC GRANULES SOLR (Clindamycin Palmitate Hydrochloride) CLEOCIN PHOSPHATE SOLN IJ 600 MG/4ML, 900 MG/6ML (Clindamycin Phosphate) CLEOCIN PHOSPHATE SOLN IV 300MG/50ML- 5%, 600MG/50ML-5%, 900MG/50ML-5% (Clindamycin Phosphate in D5W) CLEOCIN PHOSPHATE SOLN IV 600 MG/4ML (Clindamycin Phosphate) clindamycin hcl caps or 75, 50, 300 clindamycin palmitate hydrochloride solr clindamycin phosphate in d5w soln 208 Allwell Defined Standard DSNP Formulary Updated 07/0/208 9

20 Name clindamycin phosphate soln ij 50 /ml, 9000 /60ml clindamycin phosphate soln ij 600 /4ml, 900 /6ml clindamycin phosphate soln iv 600 /4ml LINCOCIN SOLN (Lincomycin HCl) lincomycin hcl soln ij Monobactams AZACTAM SOLR (Aztreonam) aztreonam solr CAYSTON SOLR Oxazolidinones linezolid soln iv 600 /300ml LINEZOLID SOLN IV 600MG/300ML-0.9% linezolid susr or 00 /5ml linezolid tabs or 600 SIVEXTRO SOLR IV SIVEXTRO TABS OR ZYVOX SOLN IV 200 MG/00ML ZYVOX SOLN IV 600 MG/300ML (Linezolid) ZYVOX SUSR OR 00 MG/5ML (Linezolid) ZYVOX TABS OR 600 MG (Linezolid) Polymyxins polymyxin b sulfate solr ij Streptogramins SYNERCID SOLR LA Name ANTIANGINAL AGENTS - s to Treat Chest Pain Antianginals-Other RANEXA TB2 PA; Nitrates ISORDIL TITRADOSE TABS 5 MG (Isosorbide Dinitrate) isosorbide dinitrate tabs isosorbide dinitrate tbcr isosorbide mononitrate tabs 0, 20 isosorbide mononitrate tb24 30, 60, 20 NITRO-DUR PT24 0. MG/HR, 0.2 MG/HR, 0.4 MG/HR, 0.6 MG/HR (Nitroglycerin) NITROGLYCERIN LINGUAL AERS nitroglycerin pt24 td 0. /hr, 0.2 /hr, 0.4 /hr, 0.6 /hr nitroglycerin soln tl 0.4 /spray nitroglycerin subl sl 0.3, 0.4, 0.6 NITROLINGUAL PUMPSPRAY SOLN (Nitroglycerin) NITROSTAT SUBL (Nitroglycerin) ANTIANXIETY AGENTS - s to Treat Anxiety Antianxiety Agents - Misc. buspirone hcl tabs or 5, 0, 5, 30, 7.5 hydroxyzine hcl soln im 50 /ml hydroxyzine hcl syrp or 0 /5ml yrs old; yrs old; 208 Allwell Defined Standard DSNP Formulary Updated 07/0/208 0

21 Name hydroxyzine hcl tabs or 0, 25, 50 hydroxyzine pamoate caps or 25, 50 VISTARIL CAPS (Hydroxyzine Pamoate) Benzodiazepines alprazolam tabs or 0.25, 0.5,, 2 alprazolam tb24 or 0.5,, 2, 3 alprazolam tbdp or 0.25, 0.5,, 2 ATIVAN SOLN (Lorazepam) ATIVAN TABS (Lorazepam) clorazepate dipotassium tabs diazepam conc or 5 /ml diazepam soln or /ml diazepam tabs or 2, 5, 0 lorazepam conc or 2 /ml lorazepam soln ij 2 /ml, 4 /ml, 20 /0ml lorazepam tabs or 0.5,, 2 oxazepam caps 0, 5, 30 TRANXENE T TABS (Clorazepate Dipotassium) VALIUM TABS (Diazepam) XANAX TABS (Alprazolam) yrs old; yrs old; yrs old; XANAX XR TB24 (Alprazolam) ANTIARRHYTHMICS - s to treat abnormal heart rhythms Antiarrhythmics Type I-A disopyramide phosphate caps yrs old; Name NORPACE CAPS (Disopyramide Phosphate) quinidine gluconate tbcr or 324 quinidine sulfate tabs Antiarrhythmics Type I-B mexiletine hcl caps Antiarrhythmics Type I-C flecainide acetate tabs 00 flecainide acetate tabs 50 flecainide acetate tabs 50 propafenone hcl cp2 propafenone hcl tabs RYTHL SR CP2 (Propafenone HCl) RYTHL TABS (Propafenone HCl) Antiarrhythmics Type III amiodarone hcl tabs or 00, 200, 400 dofetilide caps MULTAQ TABS yrs old; SL(4 ea daily); SL(2.66 ea daily); SL(8 ea daily); TIKOSYN CAPS (Dofetilide) ANTIASTHMATIC AND BRONCHODILATOR AGENTS - s to Treat Lung Conditions Anti-Inflammatory Agents cromolyn sodium nebu in B/D; Antiasthmatic - Monoclonal Antibodies CINQAIR SOLN PA; LA NUCALA SOLR LA XOLAIR SOLR LA 208 Allwell Defined Standard DSNP Formulary Updated 07/0/208

22 Name Bronchodilators - Anticholinergics ATROVENT HFA AERS ipratropium bromide soln in SPIRIVA HANDIHALER CAPS SPIRIVA RESPIMAT AERS TUDORZA PRESSAIR AEPB TUDORZA PRESSAIR AEPB Leukotriene Modulators ACCOLATE TABS (Zafirlukast) montelukast sodium chew 4, 5 montelukast sodium tabs 0 SINGULAIR CHEW 4 MG, 5 MG (Montelukast Sodium) SINGULAIR TABS 0 MG (Montelukast Sodium) zafirlukast tabs Limit 2 inhalers per month;ql(0.86 gm daily); B/D; QL( ea daily); Limit inhaler per month (60 actuations);sl( 0.4 gm daily); Limit inhaler per month (60 actuations);ql( 0.04 ea daily); Limit 2 inhalers per month (30 actuations);ql( 0.07 ea daily); zileuton tb2 SL(4 ea daily); ZYFLO CR TB2 (Zileuton) SL(4 ea daily); Selective Phosphodiesterase 4 (PDE4) Inhibitors DALIRESP TABS 250 MCG QL( ea daily) DALIRESP TABS 500 QL( ea daily); MCG Name Steroid Inhalants AEROSPAN AERS budesonide (inhalation) susp 0.25 /2ml, 0.5 /2ml FLOVENT DISKUS AEPB 00 MCG/BLIST FLOVENT DISKUS AEPB 250 MCG/BLIST FLOVENT DISKUS AEPB 50 MCG/BLIST FLOVENT HFA AERO 0 MCG/ACT, 220 MCG/ACT FLOVENT HFA AERO 44 MCG/ACT PULMICORT SUSP 0.25 MG/2ML, 0.5 MG/2ML (Budesonide (Inhalation)) QVAR AERS Sympathomimetics ADVAIR DISKUS AEPB ADVAIR HFA AERO albuterol sulfate nebu in 0.63 /3ml, %, 0.5 %,.25 /3ml albuterol sulfate syrp or 2 /5ml albuterol sulfate tabs or 2, 4 albuterol sulfate tb2 or 4, 8 ANORO ELLIPTA AEPB Limit 2 inhalers per month (20 actuations);sl( 0.6 gm daily) B/D; SL(20 ea daily); SL(8 ea daily); SL(40 ea daily); Limit 2 inhalers per month;ql(0.8 gm daily); Limit inhaler per month;ql(0.36 gm daily); B/D; Limit 3 inhalers per month;ql(0.87 gm daily); QL(4 gm daily); B/D; QL(2 ea daily); 208 Allwell Defined Standard DSNP Formulary Updated 07/0/208 2

23 Name BREO ELLIPTA AEPB 25MCG/INH-00MCG/INH, 25MCG/INH-200MCG/INH BREO ELLIPTA AEPB 25MCG/INH-00MCG/INH, 25MCG/INH-200MCG/INH COMBIVENT RESPIMAT AERS DULERA AERO ipratropium-albuterol soln levalbuterol hcl nebu in 0.3 /3ml, 0.63 /3ml,.25 /3ml,.25 /0.5ml PROAIR HFA AERS PROAIR RESPICLICK AEPB PROVENTIL HFA AERS SEREVENT DISKUS AEPB STIOLTO RESPIMAT AERS STRIVERDI RESPIMAT AERS terbutaline sulfate tabs or 5, 2.5 TRELEGY ELLIPTA AEPB UTIBRON NEOHALER CAPS XOPENEX CONCENTRATE NEBU (Levalbuterol HCl) XOPENEX NEBU (Levalbuterol HCl) Limit inhaler per month;sl(2 ea daily); Limit 2 inhalers per month (Institutional Pack);SL(2 ea daily); Limit inhaler per month;sl(0.2 gm daily); QL(4 gm daily); B/D; B/D; QL(2 ea daily); Limit inhaler per month;ql(0.4 gm daily); Limit inhaler per month (60 actuations);sl( 0.4 gm daily); B/D; B/D; Name Xanthines aminophylline soln theophylline tb2 00, 200, 300, 450 theophylline tb24 400, 600 ANTICOAGULANTS - Blood Thinners Coumarin Anticoagulants COUMADIN TABS (Warfarin Sodium) warfarin sodium tabs Direct Factor Xa Inhibitors BEVYXXA CAPS ELIQUIS STARTER PACK TABS ELIQUIS TABS XARELTO STARTER PACK TBPK XARELTO TABS QL( ea daily) Heparins And Heparinoid-Like Agents ARIXTRA SOLN 2.5 MG/0.5ML (Fondaparinux Sodium) ARIXTRA SOLN 5 MG/0.4ML, 0 MG/0.8ML, 7.5 MG/0.6ML (Fondaparinux Sodium) enoxaparin sodium soln fondaparinux sodium soln 2.5 /0.5ml fondaparinux sodium soln 5 /0.4ml, 0 /0.8ml, 7.5 /0.6ml FRAGMIN SOLN 0000 UNIT/ML, 2500 UNIT/0.2ML, 5000 UNIT/0.2ML 208 Allwell Defined Standard DSNP Formulary Updated 07/0/208 3

24 Name FRAGMIN SOLN 7500 UNIT/0.3ML, 2500 UNIT/0.5ML, 5000 UNIT/0.6ML, 8000 UNT/0.72ML, UNIT/3.8ML heparin sodium (porcine) soln LOVENOX SOLN (Enoxaparin Sodium) Thrombin Inhibitors argatroban soln 250 /2.5ml IPRIVASK SOLR PRADAXA CAPS ANTICONVULSANTS - s to Treat Seizures AMPA Glutamate Receptor Antagonists FYCOMPA SUSP FYCOMPA TABS Anticonvulsants - Benzodiazepines clonazepam tabs or 0.5 SL(40 ea daily); clonazepam tabs or SL(20 ea daily); clonazepam tabs or 2 SL(0 ea daily); clonazepam tbdp or 0.25, 0.25, 0.5,, 2 DIASTAT ACUDIAL GEL DIASTAT PEDIATRIC GEL DIAZEPAM GEL RE 0 MG, 20 MG, 2.5 MG DIAZEPAM RECTAL GEL GEL KLONOPIN TABS 0.5 MG (Clonazepam) KLONOPIN TABS MG (Clonazepam) SL(40 ea daily); SL(20 ea daily); Name KLONOPIN TABS 2 MG (Clonazepam) OI SUSP 2.5 MG/ML OI TABS 0 MG OI TABS 20 MG Anticonvulsants - Misc. APTIOM TABS 200 MG APTIOM TABS 400 MG, 600 MG, 800 MG BANZEL SUSP 40 MG/ML BANZEL TABS 200 MG BANZEL TABS 400 MG BRIVIACT SOLN IV 50 MG/5ML BRIVIACT SOLN OR 0 MG/ML BRIVIACT TABS OR 0 MG BRIVIACT TABS OR 00 MG BRIVIACT TABS OR 25 MG BRIVIACT TABS OR 50 MG BRIVIACT TABS OR 75 MG carbamazepine chew or 00 carbamazepine cp2 or 00, 200, 300 carbamazepine susp or 00 /5ml carbamazepine tabs or 200 carbamazepine tb2 or 00, 200, 400 CARBATROL CP2 (Carbamazepine) SL(0 ea daily); SL(20 ml daily) SL(20 ml daily); SL(20 ea daily); SL(2 ea daily); SL(8 ea daily); SL(4 ea daily); PA; SL(2.67 ea daily); 208 Allwell Defined Standard DSNP Formulary Updated 07/0/208 4

25 Name gabapentin caps or 00, 300, 400 gabapentin soln or 250 /5ml, 300 /6ml gabapentin tabs or 600, 800 KEPPRA SOLN (Levetiracetam) KEPPRA TABS (Levetiracetam) KEPPRA XR TB24 (Levetiracetam) LAMICTAL CHEWABLE DISPERSIBLE CHEW (Lamotrigine) LAMICTAL TABS (Lamotrigine) LAMICTAL XR KIT LAMICTAL XR TB24 25 MG, 50 MG, 00 MG, 200 MG, 250 MG, 300 MG (Lamotrigine) lamotrigine chew 5, 25 lamotrigine tabs 25, 00, 50, 200 lamotrigine tb24 25, 50, 00, 200, 250, 300 levetiracetam in sodium chloride soln levetiracetam soln iv 500 /5ml LEVETIRACETAM SOLN IV 500MG/00ML- 820MG/00ML, 000MG/00ML- 750MG/00ML, 500MG/00ML- 540MG/00ML (Levetiracetam in Sodium Chloride) levetiracetam soln or 00 /ml, 500 /5ml Name levetiracetam tabs or 250, 500, 750, 000 levetiracetam tb24 or 500, 750 LYRICA CAPS 50 MG, 200 MG, 225 MG LYRICA CAPS 25 MG, 50 MG, 75 MG, 00 MG LYRICA CAPS 300 MG LYRICA SOLN 20 MG/ML MYSOLINE TABS (Primidone) NEURONTIN CAPS (Gabapentin) NEURONTIN SOLN (Gabapentin) NEURONTIN TABS (Gabapentin) oxcarbazepine susp oxcarbazepine tabs POTIGA TABS 200 MG POTIGA TABS 300 MG POTIGA TABS 400 MG POTIGA TABS 50 MG primidone tabs or 50, 250 SPRITAM TB3D 000 MG SPRITAM TB3D 250 MG SPRITAM TB3D 500 MG SPRITAM TB3D 750 MG TEGRETOL SUSP (Carbamazepine) QL(2 ea daily); QL(3 ea daily); SL(2 ea daily); SL(30 ml daily); SL(6 ea daily); SL(4 ea daily); SL(3 ea daily); SL(24 ea daily); PA; SL(3 ea daily); PA; SL(2 ea daily); PA; SL(6 ea daily); PA; SL(4 ea daily); 208 Allwell Defined Standard DSNP Formulary Updated 07/0/208 5

26 Name TEGRETOL TABS (Carbamazepine) TEGRETOL-XR TB2 (Carbamazepine) TOPAMAX SPRINKLE CPSP (Topiramate) TOPAMAX TABS (Topiramate) topiramate cpsp or 5, 25 topiramate tabs or 25, 50, 00, 200 TRILEPTAL SUSP (Oxcarbazepine) TRILEPTAL TABS (Oxcarbazepine) VIMPAT SOLN IV 200 MG/20ML VIMPAT SOLN OR 0 MG/ML VIMPAT TABS OR 50 MG, 00 MG, 50 MG, 200 MG ZONEGRAN CAPS (Zonisamide) zonisamide caps Carbamates felbamate susp felbamate tabs FELBATOL SUSP (Felbamate) FELBATOL TABS (Felbamate) GABA Modulators GABITRIL TABS 2 MG, 6 MG (Tiagabine HCl) GABITRIL TABS 2 MG, 4 MG (Tiagabine HCl) SABRIL PACK (Vigabatrin) SABRIL TABS tiagabine hcl tabs LA LA Name vigabatrin pack Hydantoins CEREBYX SOLN 00 MG PE/2ML (Fosphenytoin Sodium) CEREBYX SOLN 500 MG PE/0ML (Fosphenytoin Sodium) DILANTIN-25 SUSP (Phenytoin) fosphenytoin sodium soln 00 pe/2ml fosphenytoin sodium soln 500 pe/0ml PEGANONE TABS PHENYTEK CAPS (Phenytoin Sodium Extended) phenytoin chew or 50 phenytoin sodium extended caps 30, 00, 200, 300 phenytoin sodium soln ij phenytoin susp or 25 /5ml Succinimides CELONTIN CAPS ethosuximide caps or 250 ethosuximide soln or 250 /5ml ZARONTIN CAPS (Ethosuximide) ZARONTIN SOLN (Ethosuximide) Valproic Acid DEPACON SOLN (Valproate Sodium) DEPAKENE CAPS (Valproic Acid) LA 208 Allwell Defined Standard DSNP Formulary Updated 07/0/208 6

27 Name DEPAKENE SOLN (Valproate Sodium) DEPAKOTE ER TB24 (Divalproex Sodium) DEPAKOTE SPRINKLES CSDR (Divalproex Sodium) DEPAKOTE TBEC (Divalproex Sodium) divalproex sodium csdr divalproex sodium tb24 divalproex sodium tbec valproate sodium soln iv 00 /ml, 500 /5ml valproate sodium soln or 250 /5ml valproic acid caps ANTIDEPRESSANTS - s to Treat Depression Alpha-2 Receptor Antagonists (Tetracyclics) mirtazapine tabs mirtazapine tbdp REMERON SOLTAB TBDP (Mirtazapine) REMERON TABS (Mirtazapine) Antidepressants - Misc. bupropion hcl tabs or 00 SL(4.5 ea daily); bupropion hcl tabs or 75 SL(6 ea daily); bupropion hcl tb2 or 00 SL(4 ea daily); bupropion hcl tb2 or 50 SL(2.66 ea daily); bupropion hcl tb2 or 200 SL(2 ea daily); bupropion hcl tb24 or 50 SL(3 ea daily); bupropion hcl tb24 or 300 SL(.5 ea daily); Name FORFIVO XL TB24 maprotiline hcl tabs ST; WELLBUTRIN SR TB2 SL(4 ea daily); 00 MG (Bupropion HCl) WELLBUTRIN SR TB2 SL(2.66 ea 50 MG (Bupropion HCl) daily); WELLBUTRIN SR TB2 SL(2 ea daily); 200 MG (Bupropion HCl) WELLBUTRIN XL TB24 SL(3 ea daily); 50 MG (Bupropion HCl) WELLBUTRIN XL TB24 SL(.5 ea 300 MG (Bupropion HCl) daily); Monoamine Oxidase Inhibitors (MAOIs) EMSAM PT24 MARPLAN TABS NARDIL TABS (Phenelzine Sulfate) PARNATE TABS (Tranylcypromine Sulfate) phenelzine sulfate tabs or tranylcypromine sulfate tabs Selective Serotonin Reuptake Inhibitors (SSRIs) CELEXA TABS 0 MG SL(4 ea daily); (Citalopram Hydrobromide) CELEXA TABS 20 MG SL(2 ea daily); (Citalopram Hydrobromide) CELEXA TABS 40 MG SL( ea daily); (Citalopram Hydrobromide) citalopram hydrobromide SL(20 ml daily); soln 0 /5ml citalopram hydrobromide SL(4 ea daily); tabs 0 citalopram hydrobromide SL(2 ea daily); tabs 20 citalopram hydrobromide tabs 40 escitalopram oxalate soln escitalopram oxalate tabs SL( ea daily); 208 Allwell Defined Standard DSNP Formulary Updated 07/0/208 7

28 Name fluoxetine hcl caps or 0, 20, 40 fluoxetine hcl cpdr or 90 fluoxetine hcl soln or 20 /5ml fluoxetine hcl tabs or 0, 20 fluvoxamine maleate cp24 fluvoxamine maleate tabs LEXAPRO SOLN (Escitalopram Oxalate) LEXAPRO TABS (Escitalopram Oxalate) paroxetine hcl tabs paroxetine hcl tb24 PAXIL CR TB24 (Paroxetine HCl) PAXIL SUSP 0 MG/5ML PAXIL TABS 0 MG, 20 MG, 30 MG, 40 MG (Paroxetine HCl) PROZAC CAPS (Fluoxetine HCl) PROZAC WEEKLY CPDR (Fluoxetine HCl) sertraline hcl conc or 20 /ml sertraline hcl tabs or 25, 50, 00 ZOLOFT CONC (Sertraline HCl) ZOLOFT TABS (Sertraline HCl) Serotonin Modulators nefazodone hcl tabs trazodone hcl tabs or 50, 00, 50, 300 TRINTELLIX TABS 0 MG ST; QL(2 ea daily); Name TRINTELLIX TABS 20 MG TRINTELLIX TABS 5 MG VIIBRYD STARTER PACK KIT VIIBRYD TABS ST; QL( ea daily); ST; QL(4 ea daily); ST; ST; Serotonin-Norepinephrine Reuptake Inhibitors CYMBALTA CPEP (Duloxetine HCl) DESVENLAFAXINE ER TB24 50 MG, 00 MG ST; desvenlafaxine succinate tb24 duloxetine hcl cpep 20, 30, 60 EFFEXOR XR CP24 50 SL(.5 ea MG (Venlafaxine HCl) daily); EFFEXOR XR CP SL(6 ea daily); MG (Venlafaxine HCl) EFFEXOR XR CP24 75 SL(3 ea daily); MG (Venlafaxine HCl) FETZIMA CP24 20 MG ST; QL(2 ea daily); FETZIMA CP24 40 MG, 80 MG, 20 MG ST; QL( ea daily); FETZIMA TITRATION PACK C4PK ST; KHEDEZLA TB24 ST; PRISTIQ TB24 (Desvenlafaxine Succinate) venlafaxine hcl cp24 50 venlafaxine hcl cp venlafaxine hcl cp24 75 VENLAFAXINE HCL ER TB MG venlafaxine hcl tabs 00 venlafaxine hcl tabs 25 SL(.5 ea daily); SL(6 ea daily); SL(3 ea daily); ST; SL( ea daily); SL(3.75 ea daily); SL(5 ea daily); 208 Allwell Defined Standard DSNP Formulary Updated 07/0/208 8

29 Name venlafaxine hcl tabs 37.5 venlafaxine hcl tabs 50 venlafaxine hcl tabs 75 venlafaxine hcl tb24 50 venlafaxine hcl tb venlafaxine hcl tb venlafaxine hcl tb24 75 Tricyclic Agents amitriptyline hcl tabs amoxapine tabs ANAFRANIL CAPS (Clomipramine HCl) clomipramine hcl caps or 25, 50, 75 desipramine hcl tabs or 0, 25, 50, 75, 00, 50 doxepin hcl caps or 0, 25, 50, 75, 00, 50 doxepin hcl conc or 0 /ml ELAVIL TABS (Amitriptyline HCl) imipramine hcl tabs or 0, 25, 50 imipramine pamoate caps NORPRAMIN TABS (Desipramine HCl) nortriptyline hcl caps or 0, 25, 50, 75 nortriptyline hcl soln or 0 /5ml PAMELOR CAPS (Nortriptyline HCl) SL(0 ea daily); SL(7.5 ea daily); SL(5 ea daily); SL(.5 ea daily); ST; SL( ea daily); SL(6 ea daily); SL(3 ea daily); yrs old; yrs old; yrs old; yrs old; yrs old; yrs old; yrs old; yrs old; Name protriptyline hcl tabs SURNTIL CAPS (Trimipramine Maleate) TOFRANIL TABS (Imipramine HCl) trimipramine maleate caps or 25, 50, 00 yrs old; yrs old; yrs old; ANTIDIABETICS - s to Regulate Blood Sugar Alpha-Glucosidase Inhibitors acarbose tabs QL(3 ea daily); GLYSET TABS (Miglitol) QL(3 ea daily); miglitol tabs QL(3 ea daily); PRECOSE TABS (Acarbose) Antidiabetic - Amylin Analogs SYMLINPEN 20 SOPN SYMLINPEN 60 SOPN Antidiabetic Combinations ACTOPLUS MET TABS (Pioglitazone HCl- Metformin HCl) ALOGLIPTIN/METFORMIN HCL TABS ALOGLIPTIN/PIOGLITAZO NE TABS 2.5MG-5MG ALOGLIPTIN/PIOGLITAZO NE TABS 2.5MG-30MG ALOGLIPTIN/PIOGLITAZO NE TABS 25MG-5MG, 25MG-30MG, 25MG- 45MG, 2.5MG-45MG DUETACT TABS (Pioglitazone HCl- Glimepiride) QL(3 ea daily); PA; Limit 2mls per month;ql(0.4 ml daily); PA; Limit 2mls per month;ql(0.4 ml daily); SL(3 ea daily); PA; SL(2 ea daily); PA; SL(2 ea daily); PA; SL(.5 ea daily); PA; SL( ea daily); SL(.5 ea daily); 208 Allwell Defined Standard DSNP Formulary Updated 07/0/208 9