Superior HealthPlan STAR+PLUS Medicare-Medicaid Plan (MMP) 2019 List of Covered Drugs (Formulary)

Transcription

1 H6870_19_LOD_Approved_ Superior HealthPlan STAR+PLUS Medicare-Medicaid Plan (MMP) 2019 List of Covered Drugs (Formulary) Introduction This document is called List of Covered Drugs (also known as Drug List). It tells which prescription s and over--counter s and items are covered by Superior HealthPlan STAR+PLUS Medicare-Medicaid Plan (MMP). The Drug List also tells if re are any special rules or restrictions on any s covered by Superior HealthPlan STAR+PLUS Medicare- Medicaid Plan (MMP). Key terms and ir definitions appear in last chapter of Member Handbook. If have questions, please call Superior STAR+PLUS MMP Member Services at (TTY: 71, 8:00 a.m. to 8:00 p.m., Monday through Friday. After hours, on weekends and on holidays, can leave a message. Your call be returned within next business day. The call is free. For more information, visit mmp.superiorhealthplan.com Updated 09/01/2018 HPMS Approved Formulary File Submission ID: Version Number: 7

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

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

4 Table of Contents A. Disclaimers ii B. Frequently Asked Questions (FAQ) iii B1. prescription s are on List of Covered Drugs? (We call List of Covered Drugs Drug List for short.) iii B2. Does Drug List ever change? iii B3. happens when re is a change to Drug List? iv B4. Are re any restrictions or limits on coverage? Or are re any required actions to take to get certain s? B5. How know if want has limitations or if re are required actions to take to get? B6. happens if we change our rules about some s (for example, prior authorization (approval), quantity limits, and/or step rapy restrictions)? v vi vi B7. How can find a on Drug List? vi B8. if want to take is not on Drug List? vi B9. if are a new Superior STAR+PLUS MMP member and can t find r on Drug List or have a problem getting r? vii B10. Can ask for an exception to cover r? viii B11. How can ask for an exception? viii B12. How long does it take to get an exception? viii B13. are generic s? viii B14. are OTC s? viii B15. Does Superior STAR+PLUS MMP cover OTC non- products? ix B16. is r copay? ix B17. are tiers? ix C. List of Covered Drugs ix D. List of Drugs by Medical Condition xii E. Index of Covered Drugs Index 1? If have questions, please call Superior STAR+PLUS MMP at (TTY: 71, 8 a.m. to 8 p.m., Monday through Friday. After hours, on weekends and on holidays, can leave a message. Your call be returned within next business day. The call is free. For more information, visit mmp.superiorhealthplan.com. i

5 A. Disclaimers This is a list of s that members can get in Superior STAR+PLUS MMP. Superior HealthPlan STAR+PLUS Medicare-Medicaid Plan (MMP) is a health plan that contracts with both Medicare and Texas Medicaid to provide benefits of both programs to enrollees. ATTEION: If speak a language or than English, language assistance services, free of charge, are available to. Call (TTY: 71, 8 a.m. to 8 p.m., Monday through Friday. After hours, on weekends and on holidays, can leave a message. Your call be returned within next business day. The call is free. ATENCIÓN: Si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al (TTY: 71 de 8 a. m. a 8 p. m., lunes a viernes. Después de horas hábiles, los fines de semana y los días festivos, es posible que se le pida que deje un mensaje. Le devolveremos la llamada el próximo día hábil. La llamada es gratuita. You can get this document for free in or formats, such as large print, braille, or audio. Call (TTY: 71, 8 a.m. to 8 p.m., Monday through Friday. After hours, on weekends and on holidays, can leave a message. Your call be returned within next business day. The call is free. If would like us to send member materials on an ongoing basis in or formats, such as Braille or large print, or in a language or than English, please call Member Services at number at bottom of page. Tell Member Services that would like to place a standing request to get r materials in anor format or language.? If have questions, please call Superior STAR+PLUS MMP at (TTY: 71, 8 a.m. to 8 p.m., Monday through Friday. After hours, on weekends and on holidays, can leave a message. Your call be returned within next business day. The call is free. For more information, visit mmp.superiorhealthplan.com. ii

6 B. Frequently Asked Questions (FAQ) Find answers here to questions have about this List of Covered Drugs. You can read all of FAQ to learn more, or look for a question and answer. B1. prescription s are on List of Covered Drugs? (We call List of Covered Drugs Drug List for short.) The s on List of Covered Drugs that starts on page 1 are s covered by Superior STAR+PLUS MMP. These s are available at pharmacies within our network. A pharmacy is in our network if we have an agreement with m to work with us and provide services. We refer to se pharmacies as network pharmacies. Superior STAR+PLUS MMP cover all medically necessary s on Drug List if: o r doctor or or prescriber says need m to get better or stay healthy, and o fill prescription at a Superior STAR+PLUS MMP network pharmacy. Superior STAR+PLUS MMP may have additional steps to access certain s (see question B4 below). You can also see an up-to-date list of s that we cover on our website at mmp.superiorhealthplan.com or call Member Services at (TTY: 71. B2. Does Drug List ever change? Yes. Superior STAR+PLUS MMP may add or remove s on Drug List during year. We may also change our rules about s. For example, we could: Decide to require or not require prior approval for a. (Prior approval is permission from Superior STAR+PLUS MMP before can get a.) Add or change amount of a can get (called quantity limits). Add or change step rapy restrictions on a. (Step rapy means must try one before we cover anor.) For more information on se rules, see question B4. If are taking a Medicare Part D that was covered at beginning of year, we generally not remove or change coverage of that during rest of year unless:? If have questions, please call Superior STAR+PLUS MMP at (TTY: 71, 8 a.m. to 8 p.m., Monday through Friday. After hours, on weekends and on holidays, can leave a message. Your call be returned within next business day. The call is free. For more information, visit mmp.superiorhealthplan.com. iii

7 a new, cheaper comes along that works as well as a on Drug List now, or we learn that a is not safe, or a is removed from market. Questions B3 and B6 below have more information on what happens when Drug List changes. You can always check Superior STAR+PLUS MMP s up to date Drug List online at mmp.superiorhealthplan.com. You can also call Member Services to check current Drug List at (TTY: 71. B3. happens when re is a change to Drug List? Some changes to Drug List happen immediately. For example: A new generic becomes available. Sometimes, a new and cheaper comes along that works as well as a on Drug List now. When that happens, we may remove current, but r for new stay same. When we add new generic, we may also decide to keep current on list but change its coverage rules or limits. o We may not tell before we make this change, but we send information about specific change or changes we made. o You or r provider can ask for an exception from se changes. We send a notice with steps can take to ask for an exception. Please see question B10 for more information on exceptions. A is taken off market. If Food and Drug Administration (FDA) says a are taking is not safe or s manufacturer takes a off market, we take it off Drug List. If are taking, we let know. If have any questions after being notified of change, should contact doctor who prescribed for. We may make or changes that affect s take. We tell in advance about se or changes to Drug List. These changes might happen if: The FDA provides new guidance or re are new clinical guidelines about a. We add a generic that is not new to market and o Replace a brand name currently on Drug List or? If have questions, please call Superior STAR+PLUS MMP at (TTY: 71, 8 a.m. to 8 p.m., Monday through Friday. After hours, on weekends and on holidays, can leave a message. Your call be returned within next business day. The call is free. For more information, visit mmp.superiorhealthplan.com. iv

8 o Change coverage rules or limits for brand name. When se changes happen, we tell at least 30 days before we make change to Drug List or when ask for a refill. This give time to talk to r doctor or or prescriber. He or she can help decide if re is a similar on Drug List can take instead or wher to ask for an exception. Then can: Get a 30-day supply of before change to Drug List is made, or Ask for an exception from se changes. Please see question B10 for more information about exceptions. B4. Are re any restrictions or limits on coverage or any required actions to take to get certain s? Yes, some s have coverage rules or have limits on amount can get. In some cases or r doctor or or prescriber must do something before can get. For example: Prior approval (or prior authorization): For some s, or r doctor or or prescriber must get approval from Superior STAR+PLUS MMP before fill r prescription. Superior STAR+PLUS MMP may not cover if do not get approval. Quantity limits: Sometimes Superior STAR+PLUS MMP limits amount of a can get. Step rapy: Sometimes Superior STAR+PLUS MMP requires to do step rapy. This means have to try s in a certain order for r medical condition. You might have to try one before we cover anor. If r doctor thinks first doesn t work for, n we cover second. You can find out if r has any additional requirements or limits by looking in tables on pages 1 Index 1. You can also get more information by visiting our web site at mmp.superiorhealthplan.com. We have posted online documents that explain our prior authorization and step rapy restrictions. You may also ask us to send a copy. You can ask for an exception from se limits. This give time to talk to r doctor or or prescriber. He or she can help decide if re is a similar on Drug List can take instead or wher to ask for an exception. Please see questions B10- B12 for more information about exceptions.? If have questions, please call Superior STAR+PLUS MMP at (TTY: 71, 8 a.m. to 8 p.m., Monday through Friday. After hours, on weekends and on holidays, can leave a message. Your call be returned within next business day. The call is free. For more information, visit mmp.superiorhealthplan.com. v

9 B5. How know if want has limitations or if re are required actions to take to get? The List of Covered Drugs on page 1 has a column labeled. B6. happens if we change our rules about some s (for example, prior authorization (approval), quantity limits, and/or step rapy restrictions)? In some cases, we tell in advance if we add or change prior approval, quantity limits, and/or step rapy restrictions on a. See question B3 for more information about this advance notice and situations where we may not be able to tell in advance when our rules about s on Drug List change. B7. How can find a on Drug List? There are two ways to find a : You can search alphabetically (if know how to spell ), or You can search by medical condition. To search alphabetically, go to Index of Covered Drugs section. You can find it in Index that begins on page Index 1. To search by medical condition, find section labeled List of s by medical condition on page 1. The s in this section are grouped into categories depending on type of medical conditions y are used to treat. For example, if have a heart condition, should look in category, CARDIOVASCULAR AGES - MISC. - Drugs to Treat Heart and Circulation Conditions. That is where find s that treat heart conditions. B8. if want to take is not on Drug List? If don t see r on Drug List, call Member Services at (TTY: 71 and ask about it. If learn that Superior STAR+PLUS MMP not cover, can do one of se things: Ask Member Services for a list of s like one want to take. Then show list to r doctor or or prescriber. He or she can prescribe a on Drug List that is like one want to take. Or You can ask health plan to make an exception to cover r. Please see questions B10-B12 for more information about exceptions.? If have questions, please call Superior STAR+PLUS MMP at (TTY: 71, 8 a.m. to 8 p.m., Monday through Friday. After hours, on weekends and on holidays, can leave a message. Your call be returned within next business day. The call is free. For more information, visit mmp.superiorhealthplan.com. vi

10 B9. if are a new Superior STAR+PLUS MMP member and can t find r on Drug List or have a problem getting r? We can help. We may cover a temporary 30-day supply of r during first 90 days are a member of Superior STAR+PLUS MMP. This give time to talk to r doctor or or prescriber. He or she can help decide if re is a similar on Drug List can take instead or wher to ask for an exception. If r prescription is written for fewer days, we allow multiple fills to provide up to a maximum of 30 days of medication. We cover a 30-day supply of r if: are taking a that is not on our Drug List, or health plan rules do not let get amount ordered by r prescriber, or requires prior approval by Superior STAR+PLUS MMP, or are taking a that is part of a step rapy restriction. If are in a nursing home or or long-term care facility and need a that is not on Drug List or if cannot easily get need, we can help. If have been in plan for more than 90 days, live in a long-term care facility, and need a supply right away: We cover one 31-day supply of need (unless have a prescription for fewer days), wher or not are a new Superior STAR+PLUS MMP member. This is in addition to temporary supply during first 90 days are a member of Superior STAR+PLUS MMP. Level of Care Changes If r level of care changes, we cover a temporary supply of r s. A level of care change happens when are released from a hospital. It also happens when move to or from a long-term care facility. If move home from a long-term care facility or hospital and need a temporary supply, we cover one 30-day supply. If r prescription is written for fewer days, we allow refills to provide up to a total of a 30-day supply. If move from home or a hospital to a long-term care facility and need a temporary supply, we cover one 31-day supply. If r prescription is written for fewer days, we allow refills to provide up to a total of a 31-day supply.? If have questions, please call Superior STAR+PLUS MMP at (TTY: 71, 8 a.m. to 8 p.m., Monday through Friday. After hours, on weekends and on holidays, can leave a message. Your call be returned within next business day. The call is free. For more information, visit mmp.superiorhealthplan.com. vii

11 B10. Can ask for an exception to cover r? Yes. You can ask Superior STAR+PLUS MMP to make an exception to cover a that is not on Drug List. You can also ask us to change rules on r. For example, Superior STAR+PLUS MMP may limit amount of a we cover. If r has a limit, can ask us to change limit and cover more. Or examples: You can ask us to drop step rapy restrictions or prior approval requirements. B11. How can ask for an exception? To ask for an exception, call Member Services. A Member Services representative work with and r provider to help ask for an exception. You can also read Chapter 9, Sections of Member Handbook to learn more about exceptions. B12. How long does it take to get an exception? First, we must get a statement from r prescriber supporting r request for an exception. After we get statement, we give a decision on r exception request within 72 hours. If or r prescriber think r health may be harmed if have to wait 72 hours for a decision, can ask for an expedited exception. This is a faster decision. If r prescriber supports r request, we give a decision within 24 hours of getting r prescriber s supporting statement. B13. are generic s? Generic s are made up of same active ingredients as brand name s. They usually less than brand name and usually don t have well-known names. Generic s are approved by Food and Drug Administration (FDA). Superior STAR+PLUS MMP covers both brand name s and generic s. B14. are OTC s? OTC stands for over--counter. Superior STAR+PLUS MMP covers some OTC s when y are written as prescriptions by r provider. You can read Superior STAR+PLUS MMP Drug List to see what OTC s are covered.? If have questions, please call Superior STAR+PLUS MMP at (TTY: 71, 8 a.m. to 8 p.m., Monday through Friday. After hours, on weekends and on holidays, can leave a message. Your call be returned within next business day. The call is free. For more information, visit mmp.superiorhealthplan.com. viii

12 B15. Does Superior STAR+PLUS MMP cover OTC non- products? Superior STAR+PLUS MMP covers some OTC non- products when y are written as prescriptions by r provider. Examples of OTC non- products include PEDIATRIC SMALL MASK MISC or AEROCHAMBER/FLOWSIGNAL MISC. You can read Superior STAR+PLUS MMP Drug List to see what OTC non- products are covered. B16. is r copay? As a Superior STAR+PLUS MMP member, have no copays for prescription and OTC s as long as follow Superior STAR+PLUS MMP s rules. B17. are tiers? Tiers are groups of s on our Drug List. Tier 1 s are generic s. Tier 2 s are brand name s. Tier 3 s are non-medicare prescription or over--counter s. Copays for Tiers 1, 2 and 3 are all. C. List of Covered Drugs The following list of covered s gives information about s covered by Superior STAR+PLUS MMP. If have trouble finding r in list, turn to Index of Covered Drugs that begins on page Index 1. The index alphabetically lists all s covered by Superior STAR+PLUS MMP. The first column of chart lists name of. Brand name s are capitalized (e.g., ELIQUIS TABS) and generic s are listed in lower-case italics (e.g., warfarin sodium tabs). The information in necessary column tells if Superior STAR+PLUS MMP has any rules for covering r. Here are meanings of codes used in column:? If have questions, please call Superior STAR+PLUS MMP at (TTY: 71, 8 a.m. to 8 p.m., Monday through Friday. After hours, on weekends and on holidays, can leave a message. Your call be returned within next business day. The call is free. For more information, visit mmp.superiorhealthplan.com. ix

13 Abbreviation this means How it works AL Age Limit This may need prior authorization if r age does not meet maker, FDA or clinical guidelines. B/D LA Medicare Part B vs. Part D Limited Access This may need prior authorization to decide if it should be covered under Medicare Part B or Part D. This is a Medicare rule. Your doctor or or prescriber may need to give more facts to help us make this decision. This prescription may be available only at certain pharmacies. For more information consult r Pharmacy Directory or call Member Services at (TTY: 71, Monday through Friday, 8:00 a.m. to 8:00 p.m. After hours, on weekends and on holidays, can leave a message. Your call be returned within next business day. Mail Order This is available at our mail order pharmacy in addition to or network pharmacies. Non-Extended Day Supply This prescription may not be available for an extended day supply. Call Member Services to ask if is available as an extended supply. Not Covered This is not covered on Drug List. You can ask for an exception for to be covered. Not Part D This is not a Part D. PA Prior Authorization This requires prior authorization. This means that or r doctor must get approval from us before fill r prescription. If don t get approval, we may not cover. QL Quantity Limit This has a limit on amount that our plan cover.? If have questions, please call Superior STAR+PLUS MMP at (TTY: 71, 8 a.m. to 8 p.m., Monday through Friday. After hours, on weekends and on holidays, can leave a message. Your call be returned within next business day. The call is free. For more information, visit mmp.superiorhealthplan.com. x

14 Abbreviation RX/OTC this means Prescription and Over-- Counter (OTC) How it works This is made in both prescription form and OTC form. SL Safety Limit This has a maximum daily dose limit for safety supported by FDA. This means that we not cover more than maximum daily dose. For example, FDA maximum daily dose of ibuprofen is Therefore, we only cover four tablets per day for ibuprofen 800. ST Step Therapy This requires step rapy. This means have to try s in a certain order for r medical condition. You might have to try one before we cover anor. If r doctor thinks first doesn t work for, n we cover second. * Non-Preferred Drug We provide a 72-hour supply of this. This require prior authorization for continued coverage. Note: The next to a means is not a Part D. The amount pay when fill a prescription for this does not count towards r total s (that is, amount pay does not help qualify for catastrophic coverage). In addition, if are getting Extra Help to pay for r prescriptions, not get any Extra Help to pay for se s. For more information on Extra Help, please see call-out box below. Extra Help is a Medicare program that helps people with limited incomes and resources reduce Medicare Part D prescription s, such as premiums, deductibles, and copays. Extra Help is also called Low-Income Subsidy, or LIS. These s also have different rules for appeals. An appeal is a formal way of asking us to review a coverage decision and to change it if think we made a mistake. For example, we might decide that a that want is not covered or is no longer covered by Medicare or Texas Medicaid.? If have questions, please call Superior STAR+PLUS MMP at (TTY: 71, 8 a.m. to 8 p.m., Monday through Friday. After hours, on weekends and on holidays, can leave a message. Your call be returned within next business day. The call is free. For more information, visit mmp.superiorhealthplan.com. xi

15 If or r doctor disagrees with our decision, can appeal. To ask for instructions on how to appeal, call Member Services at (TTY: 71. You can also read Chapter 9 of Member Handbook to learn how to appeal a decision. D. List of Drugs by Medical Condition The s in this section are grouped into categories depending on type of medical conditions y are used to treat. For example, if have a heart condition, should look in category, CARDIOVASCULAR AGES - MISC. - Drugs to Treat Heart and Circulation Conditions. That is where find s that treat heart conditions.? If have questions, please call Superior STAR+PLUS MMP at (TTY: 71, 8 a.m. to 8 p.m., Monday through Friday. After hours, on weekends and on holidays, can leave a message. Your call be returned within next business day. The call is free. For more information, visit mmp.superiorhealthplan.com. xii

16 Name of ADHD/AI-NARCOLEPSY/AI- OBESITY/ANOREXIAS - Drugs to Treat ADHD, Sleep and Eating Disorders Amphetamines ADDERALL TABS (Amphetamine- Dextroamphetamine) ADDERALL XR CP24 (Amphetamine- Dextroamphetamine) amphetaminedextroamphetamine cp24 amphetaminedextroamphetamine tabs DESOXYN TABS (Methamphetamine HCl) DEXEDRINE CP24 (Dextroamphetamine Sulfate) dextroamphetamine sulfate cp24 5, 10, 15 dextroamphetamine sulfate tabs 5, 10 methamphetamine hcl tabs Analeptics caffeine citrate soln iv caffeine citrate soln or Anti-Obesity Agents XENICAL CAPS PA; PA; ; ; Name of Attention-Deficit/Hyperactivity Disorder (ADHD) atomoxetine hcl caps 10 SL(10 ea daily); atomoxetine hcl caps 100 atomoxetine hcl caps 18 atomoxetine hcl caps 25 atomoxetine hcl caps 40 atomoxetine hcl caps 60 atomoxetine hcl caps 80 clonidine hcl (adhd) tb12 guanfacine hcl (adhd) tb24 IUNIV TB24 (Guanfacine HCl (ADHD)) KAPVAY TB12 (Clonidine HCl (ADHD)) STRATTERA CAPS 10 MG (Atomoxetine HCl) STRATTERA CAPS 100 MG (Atomoxetine HCl) STRATTERA CAPS 18 MG (Atomoxetine HCl) STRATTERA CAPS 25 MG (Atomoxetine HCl) SL(1 ea daily); SL(5.55 ea daily); SL(4 ea daily); SL(2.5 ea daily); SL(1.66 ea daily); SL(1.25 ea daily); old); old); SL(10 ea daily); SL(1 ea daily); SL(5.55 ea daily); SL(4 ea daily); You can find information on what symbols and abbreviations in this table mean by going to 1

17 Name of 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 dexmethylphenidate hcl tabs FOCALIN TABS (Dexmethylphenidate HCl) FOCALIN XR CP24 (Dexmethylphenidate HCl) METADATE CD CPCR 10 MG, 40 MG, 50 MG, 60 MG (Methylphenidate HCl) METADATE CD CPCR 20 MG (Methylphenidate HCl) METADATE CD CPCR 30 MG (Methylphenidate HCl) methylphenidate hcl cp24 or 10, 20, 30, 40, 60 methylphenidate hcl cpcr or 10, 40, 50, 60 methylphenidate hcl cpcr or 20 methylphenidate hcl cpcr or 30 METHYLPHENIDATE HCL ER TBCR SL(2.5 ea daily); SL(1.66 ea daily); SL(1.25 ea daily); QL(1 ea daily); QL(2 ea daily); QL(1 ea daily); QL(2 ea daily); Name of methylphenidate hcl tabs or 5, 10, 20 methylphenidate hcl tb24 or 27, 36 methylphenidate hcl tbcr or 18, 27, 36, 54 methylphenidate hcl tbcr or 20 modafinil tabs 100 modafinil tabs 200 PROVIGIL TABS 100 MG (Modafinil) PROVIGIL TABS 200 MG (Modafinil) RITALIN LA CP24 10 MG, 20 MG, 30 MG, 40 MG (Methylphenidate HCl) RITALIN LA CP24 60 MG RITALIN TABS (Methylphenidate HCl) QL(3 ea daily); Non-Osmotic Release QL(3 ea daily); PA; PA; QL(1 ea daily); PA; PA; QL(1 ea daily); QL(3 ea daily); ALLERGENIC EXTRACTS/BIOLOGICALS MISC Biologicals Misc ;LA; ADAGEN SOLN AMINOGLYCOSIDES - Drugs to Treat Bacterial Infections Aminoglycosides You can find information on what symbols and abbreviations in this table mean by going to 2

18 Name of amikacin sulfate soln ij 1 gm/4ml, 500 /2ml BETHKIS NEBU gentamicin in saline soln 0.9%-1/ml gentamicin sulfate soln ij 10 /ml, 40 /ml KITABIS PAK NEBU neomycin sulfate tabs or paromomycin sulfate caps TOBI NEBU (Tobramycin) TOBI PODHALER CAPS tobramycin nebu in tobramycin sulfate soln ij 40 /ml, 80 /2ml, 1.2 gm/30ml tobramycin sulfate solr ij 1.2 gm B/D; B/D; B/D B/D ANALGESICS - AI-ILAMMATORY - Drugs to Treat Pain, Swelling, Muscle and Joint Conditions Anti-T-alpha - Monoclonal Antibodies HUMIRA PEDIATRIC PA; CROHNS DISEASE STARTER PACK PSKT Name of HUMIRA PEN PNKT HUMIRA PEN-CD/UC/HS STARTER PNKT HUMIRA PEN-PS/UV STARTER PNKT HUMIRA PSKT SIMPONI ARIA SOLN SIMPONI SOAJ SIMPONI SOSY PA; PA; PA; PA; PA; PA; PA; Antirheumatic - Enzyme Inhibitors PA; XELJANZ TABS Antirheumatic Antimetabolites OTREXUP SOAJ 10 MG/0.4ML, 15 MG/0.4ML, 20 MG/0.4ML, 25 MG/0.4ML, 12.5 MG/0.4ML, 17.5 MG/0.4ML, 22.5 MG/0.4ML RASUVO SOAJ 10 MG/0.2ML, 15 MG/0.3ML, 20 MG/0.4ML, 25 MG/0.5ML, 30 MG/0.6ML, 7.5 MG/0.15ML, 12.5 MG/0.25ML, 17.5 MG/0.35ML, 22.5 MG/0.45ML Gold Compounds You can find information on what symbols and abbreviations in this table mean by going to PA PA 3

19 Name of RIDAURA CAPS Interleukin-1 Blockers ARCALYST SOLR Interleukin-1beta Blockers ILARIS SOLN ILARIS SOLR Interleukin-6 Receptor Inhibitors ACTEMRA SOSY SC 162 MG/0.9ML KEVZARA SOSY 150 MG/1.14ML, 200 MG/1.14ML ; ;LA PA; ;LA PA; ;LA PA; PA; 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 of diclofenac sodium tb24 or 100 diclofenac sodium tbec or 25, 50, 75 diclofenac w/ misoprostol tbec EC-NAPROSYN TBEC (Naproxen) etodolac caps etodolac tabs etodolac tb24 FELDENE CAPS (Piroxicam) flurbiprofen tabs or 50, 100 ibuprofen caps or 200 ibuprofen chew or 100 ibuprofen susp or 100 /5ml ibuprofen susp or 100 /5ml ibuprofen susp or 40 /ml, 50 /1.25ml ; ; Over-counter;RX/OT C; ; RX/OTC; You can find information on what symbols and abbreviations in this table mean by going to 4

20 Name of ibuprofen tabs or 200 ibuprofen tabs or 400 ibuprofen tabs or 600 ibuprofen tabs or 800 indomethacin caps or 25, 50 indomethacin cpcr or 75 ketoprofen caps 50, 75 ketorolac tromethamine soln ij 15 /ml, 30 /ml ketorolac tromethamine soln im 30 /ml, 60 /2ml LODINE TABS (Etodolac) mefenamic acid caps or meloxicam tabs or 15, 7.5 BIC TABS (Meloxicam) nabumetone tabs NAPROSYN TABS 500 MG (Naproxen) ; SL(8 ea daily); SL(5.33 ea daily); SL(4 ea daily); old); old); old); old); Name of naproxen sodium tabs or 220 naproxen sodium tabs or 275, 550 naproxen tabs or 250, 375, 500 naproxen tbec or 375, 500 oxaprozin tabs piroxicam caps or 10, 20 PONSTEL CAPS (Mefenamic Acid) sulindac tabs or 150, 200 tolmetin sodium caps 400 tolmetin sodium tabs 200 Pyrimidine Synsis Inhibitors ARAVA TABS (Leflunomide) leflunomide tabs or 10, 20 ; Soluble Tumor Necrosis Factor Receptor Agents PA; ENBREL MINI SOCT You can find information on what symbols and abbreviations in this table mean by going to 5

21 Name of ENBREL SOLR ENBREL SOSY ENBREL SURECLICK SOAJ PA; PA; PA; ANALGESICS - NonNarcotic - Drugs to Treat Pain, Muscle and Joint Conditions Analgesic Combinations aspirin-acetaminophencaffeine tabs Analgesics Or acetaminophen caps or 500 acetaminophen chew or 80 acetaminophen liqd or 160 /5ml acetaminophen liqd or 500 /15ml acetaminophen soln or 160 /5ml acetaminophen supp re 120, 325, 650 acetaminophen susp or 160 /5ml acetaminophen tabs or 325, 500 ; ; ; ; ; ; ; ; Name of acetaminophen tbcr or 650 acetaminophen tbdp or 160 acetaminophen tbdp or 80 Salicylates aspirin chew or 81 aspirin tabs or 325 aspirin tbec or 81, 325 diflunisal tabs ; ; ; ; ; ANALGESICS - OPIOID - Drugs to Treat Pain, Muscle and Joint Conditions Opioid Agonists ACTIQ LPOP 200 MCG PA; ;QL(8 (Fentanyl Citrate) ACTIQ LPOP 400 MCG, 600 MCG, 800 MCG, 1200 MCG, 1600 MCG (Fentanyl Citrate) DILAUDID LIQD OR 1 MG/ML (Hydromorphone HCl) DILAUDID SOLN IJ 1 MG/ML, 2 MG/ML, 4 MG/ML (Hydromorphone HCl) DILAUDID TABS OR 2 MG, 4 MG (Hydromorphone HCl) ea daily); PA; ;QL(4 ea daily); QL(50 ml daily); QL(9 ea daily); You can find information on what symbols and abbreviations in this table mean by going to 6

22 Name of DILAUDID TABS OR 8 MG (Hydromorphone HCl) DILAUDID-HP SOLN (Hydromorphone HCl) DOLOPHINE TABS (Methadone HCl) DURAGESIC PT72 12 MCG/HR (Fentanyl) DURAGESIC PT72 25 MCG/HR, 100 MCG/HR (Fentanyl) DURAGESIC PT72 50 MCG/HR, 75 MCG/HR (Fentanyl) fentanyl citrate lpop bu 200 mcg fentanyl citrate lpop bu 400 mcg, 600 mcg, 800 mcg, 1200 mcg, 1600 mcg fentanyl pt72 12 mcg/hr fentanyl pt72 25 mcg/hr, 100 mcg/hr fentanyl pt72 50 mcg/hr, 75 mcg/hr hydromorphone hcl liqd or 1 /ml hydromorphone hcl soln ij 1 /ml, 2 /ml, 4 /ml QL(6.25 ea daily); QL(6 ea daily); Limit 43 patches per month;ql(0.34 ea daily); QL(0.34 ea daily); Limit 15 patches per month;ql(0.34 ea daily); PA; ;QL(8 ea daily); PA; ;QL(4 ea daily); Limit 43 patches per month;ql(0.34 ea daily); QL(0.34 ea daily); Limit 15 patches per month;ql(0.34 ea daily); QL(50 ml daily); Name of hydromorphone hcl soln ij 10 /ml, 50 /5ml, 500 /50ml hydromorphone hcl soln ij 2 /ml hydromorphone hcl tabs or 2, 4 hydromorphone hcl tabs or 8 HYDRORPHONE HYDROCHLORIDE SOLN 1 MG/ML HYDRORPHONE HYDROCHLORIDE SOLN 10 MG/ML (Hydromorphone HCl) HYDRORPHONE HYDROCHLORIDE SOLN 2 MG/ML KADIAN CP24 10 MG, 20 MG, 30 MG, 50 MG (Morphine Sulfate) KADIAN CP MG (Morphine Sulfate) KADIAN CP24 60 MG (Morphine Sulfate) KADIAN CP24 80 MG (Morphine Sulfate) LAZANDA SOLN 100 MCG/ACT LAZANDA SOLN 300 MCG/ACT LAZANDA SOLN 400 MCG/ACT Preservative Free QL(9 ea daily); QL(6.25 ea daily); Preservative Free QL(3 ea daily); ;QL(2 ea daily); QL(3.34 ea daily); QL(2.5 ea daily); PA; ;QL(1 ea daily); PA; ;QL(0.5 ea daily); PA; ;QL(0.27 ea daily); You can find information on what symbols and abbreviations in this table mean by going to 7

23 Name of methadone hcl soln or 10 /5ml methadone hcl soln or 5 /5ml methadone hcl tabs or 5, 10 methadone hcl tbso or 40 morphine sulfate cp24 or 10, 20, 30, 50 morphine sulfate cp24 or 100 morphine sulfate cp24 or 60 morphine sulfate cp24 or 80 morphine sulfate soln ij 0.5 /ml morphine sulfate soln ij 1 /ml morphine sulfate soln or 10 /5ml morphine sulfate soln or 20 /5ml morphine sulfate soln or 20 /ml, 100 /5ml RPHINE SULFATE TABS OR 15 MG QL(33.34 ml daily); QL(15 ml daily); QL(6 ea daily); *; QL(3 ea daily); ;QL(2 ea daily); QL(3.34 ea daily); QL(2.5 ea daily); QL(100 ml daily); QL(50 ml daily); QL(10 ml daily); QL(13.34 ea daily); Name of morphine sulfate tbcr or 100, 200 morphine sulfate tbcr or 15, 30, 60 MS COIN TBCR 100 MG, 200 MG (Morphine Sulfate) MS COIN TBCR 15 MG, 30 MG, 60 MG (Morphine Sulfate) OPANA TABS OR 5 MG, 10 MG (Oxymorphone HCl) oxycodone hcl caps or 5 oxycodone hcl conc or 100 /5ml oxycodone hcl tabs or 30 oxycodone hcl tabs or 5, 10, 15, 20 oxymorphone hcl tabs 5, 10 oxymorphone hcl tb12 15 oxymorphone hcl tb ROXICODONE TABS 30 MG (Oxycodone HCl) ROXICODONE TABS 5 MG, 15 MG (Oxycodone HCl) QL(2 ea daily); QL(3 ea daily); QL(2 ea daily); QL(3 ea daily); QL(6 ea daily); QL(6 ea daily); QL(6 ml daily); QL(4.44 ea daily); QL(6 ea daily); QL(6 ea daily); QL(4.44 ea daily); QL(8.89 ea daily); QL(4.44 ea daily); QL(6 ea daily); You can find information on what symbols and abbreviations in this table mean by going to 8

24 Name of SUBSYS LIQD 100 MCG SUBSYS LIQD 1200 MCG SUBSYS LIQD 200 MCG SUBSYS LIQD 400 MCG, 600 MCG, 800 MCG, 1600 MCG tramadol hcl tabs or 50 tramadol hcl tb24 or 100 tramadol hcl tb24 or 200 tramadol hcl tb24 or 300 ULTRAM ER TB24 (Tramadol HCl) ULTRAM TABS (Tramadol HCl) ZOHYDRO ER C12A 10 MG, 15 MG ZOHYDRO ER C12A 20 MG, 30 MG, 40 MG, 50 MG Opioid Combinations acetaminophen w/ codeine soln 120/5ml-12/5ml acetaminophen w/ codeine tabs PA; ;QL(16 ea daily); PA; ;QL(2 ea daily) PA; ;QL(8 ea daily); PA; ;QL(4 ea daily); SL(8 ea daily); SL(3 ea daily); SL(1.5 ea daily); SL(1 ea daily); SL(1 ea daily); SL(8 ea daily); PA; QL(3 ea daily); PA; QL(2 ea daily); SL(150 ml daily); SL(13.3 ea daily); Name of acetaminophen w/ codeine tabs acetaminophen w/ codeine tabs butalbital-aspirin-caffeine w/cod caps FIORINAL/CODEINE #3 CAPS (Butalbital-Aspirin- Caffeine w/cod) hydrocodoneacetaminophen soln 2.5/5ml-108/5ml, 5/10ml-217/10ml, 7.5/15ml-325/15ml hydrocodoneacetaminophen tabs 5-300, , hydrocodoneacetaminophen tabs 5-325, , hydrocodone-ibuprofen tabs IBUDONE TABS (Hydrocodone-Ibuprofen) NORCO TABS (Hydrocodone- Acetaminophen) oxycodone w/ acetaminophen tabs oxycodone-aspirin tabs PERCOCET TABS (Oxycodone w/ Acetaminophen) SL(12 ea daily); SL(6 ea daily); old); SL(6 ea daily); old); SL(6 ea daily); Limit 5535mls per month;sl( ml daily); SL(13.3 ea daily); SL(12.3 ea daily); QL(5 ea daily); QL(5 ea daily); SL(12.3 ea daily); SL(12.3 ea daily); SL(12.3 ea daily); You can find information on what symbols and abbreviations in this table mean by going to 9

25 Name of 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 buprenorphine hclnaloxone hcl dihydrate subl buprenorphine hclnaloxone hcl dihydrate subl 8-2 butorphanol tartrate soln ij 2 /ml butorphanol tartrate soln na 10 /ml QL(5 ea daily); SL(8 ea daily); SL(12 ea daily); SL(6 ea daily); SL(8 ea daily); SL(13.3 ea daily); QL(12 ea daily); QL(3 ea daily); QL(12 ea daily); QL(4 ea daily); Limit 210mls per month;ql(7 ml daily); ANDROGENS-ANABOLIC - Drugs to Regulate Hormones Anabolic Steroids ANADROL-50 TABS ; Name of OXANDRIN TABS 10 MG (Oxandrolone) OXANDRIN TABS 2.5 MG (Oxandrolone) oxandrolone tabs or 10 oxandrolone tabs or 2.5 Androgens ANDRODERM PT24 ANDROGEL GEL 40.5 MG/2.5GM, MG/1.25GM ANDROGEL GEL 50 MG/5GM, 25 MG/2.5GM (Testosterone) ANDROGEL PUMP GEL AVEED SOLN AXIRON SOLN (Testosterone) danazol caps or 50, 100, 200 DEPO-TESTOSTERONE SOLN (Testosterone Cypionate) fluoxymesterone tabs methyltestosterone caps or TESTIM GEL (Testosterone) ; ; You can find information on what symbols and abbreviations in this table mean by going to LA 10

26 Name of testosterone cypionate soln testosterone enanthate soln im testosterone gel 1 %, 50 /5gm, 25 /2.5gm testosterone soln 30 /act ANORECTAL AGES - Rectal Drugs to Treat Pain, Swelling and Itching Intrarectal Steroids CORTENEMA ENEM (Hydrocortisone (Intrarectal)) hydrocortisone (intrarectal) enem UCERIS FOAM RE 2 MG/ACT Rectal Combinations phenylephrine in hard fat supp phenylephrine-mineral oilpetrolatum oint 14%- 74.9%-0.25% Rectal Local Anestics dibucaine (rectal) oint lidocaine (anorectal) crea Rectal Steroids ; ; ; ; Name of ANUSOL-HC CREA (Hydrocortisone (Rectal)) hydrocortisone (rectal) crea PROCTOCORT CREA 1 % (Hydrocortisone (Rectal)) Vasodilating Agents RECTIV OI AACIDS Antacid Combinations alum & mag hydroxsimethicone chew alum & mag hydroxsimethicone susp 200/5ml-20/5ml- 200/5ml, 400/5ml- 40/5ml-400/5ml aluminum hydroxide-mag carb susp 95/15ml- 358/15ml Antacids - Aluminum Salts ALUMINUM HYDROXIDE SUSP OR Antacids - Bicarbonate sodium bicarbonate (antacid) tabs 325, 650 Antacids - Calcium Salts calcium carbonate (antacid) chew 500, 750 calcium carbonate (antacid) susp 1250 /5ml ; ; ; ; ; You can find information on what symbols and abbreviations in this table mean by going to 11

27 Name of Antacids - Magnesium Salts MAGNESIUM CAPS 500 MG magnesium oxide tabs 250 magnesium oxide tabs 400, 420 ; AHELMIICS - Drugs to Treat Worm Infections Anlmintics ALBENZA TABS ivermectin tabs or STROMECTOL TABS (Ivermectin) AI-IECTIVE AGES - MISC. - Drugs to Treat Bacterial Infections Anti-infective Agents - Misc. colistimethate sodium solr ij COLY-MYCIN M SOLR (Colistimethate Sodium) FLAGYL CAPS 375 MG (Metronidazole) FLAGYL TABS 250 MG (Metronidazole) FLAGYL TABS 500 MG (Metronidazole) IMPAVIDO CAPS SL(10.6 ea daily); SL(16 ea daily); SL(8 ea daily); ; Name of metronidazole caps or 375 metronidazole in nacl soln metronidazole tabs or 250 metronidazole tabs or 500 NEBUPE SOLR ORBACTIV SOLR PEAM 300 SOLR TINDAMAX TABS (Tinidazole) tinidazole tabs or 250, 500 trimethoprim tabs or VANCOCIN HCL CAPS 125 MG (Vancomycin HCl) VANCOCIN HCL CAPS 250 MG (Vancomycin HCl) vancomycin hcl caps or 125 vancomycin hcl caps or 250 SL(10.6 ea daily); SL(16 ea daily); SL(8 ea daily); B/D; PA; PA; ; PA; PA; ; You can find information on what symbols and abbreviations in this table mean by going to 12

28 Name of VANCOMYCIN HCL IN DEXTROSE SOLN 1GM/200ML-5%, 5%- 750MG/150ML, 500MG/100ML-5% vancomycin hcl solr iv 10 gm, 750, 1000, 5000 vancomycin hcl solr iv 500 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 ertapenem sodium solr ; ; Name of imipenem-cilastatin solr INVANZ SOLR IJ (Ertapenem Sodium) meropenem solr MERREM SOLR (Meropenem) PRIMAXIN IV SOLR (Imipenem-Cilastatin) VABOMERE SOLR Chloramphenicols chloramphenicol sodium succinate solr Cyclic Lipopeptides CUBICIN RF SOLR (Daptomycin) CUBICIN SOLR (Daptomycin) daptomycin solr 500 Glycylcyclines tigecycline solr TIGECYCLINE SOLR TYGACIL SOLR (Tigecycline) Leprostatics You can find information on what symbols and abbreviations in this table mean by going to 13

29 Name of dapsone tabs or 25, 100 Lincosamides CLEOCIN CAPS OR 75 MG, 150 MG, 300 MG (Clindamycin HCl) CLEOCIN IN D5W SOLN (Clindamycin Phosphate in D5W) CLEOCIN PEDIATRIC GRANULES SOLR (Clindamycin Palmitate Hydrochloride) CLEOCIN PHOSPHATE SOLN IJ 300 MG/2ML (Clindamycin Phosphate) CLEOCIN PHOSPHATE SOLN IJ 600 MG/4ML, 900 MG/6ML (Clindamycin Phosphate) CLEOCIN PHOSPHATE SOLN IV 300 MG/2ML, 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) clindamycin hcl caps or 75, 150, 300 clindamycin palmitate hydrochloride solr clindamycin phosphate in d5w soln Name of clindamycin phosphate soln ij 150 /ml, 300 /2ml, 9000 /60ml clindamycin phosphate soln ij 600 /4ml, 900 /6ml clindamycin phosphate soln iv 150 /ml, 300 /2ml, 600 /4ml, 900 /6ml LINCOCIN SOLN (Lincomycin HCl) lincomycin hcl soln ij Monobactams AZACTAM SOLR (Aztreonam) aztreonam solr CAYSTON SOLR Oxazolidinones linezolid soln iv 600 /300ml LINEZOLID SOLN IV 600MG/300ML-0.9% linezolid susr or 100 /5ml linezolid tabs or 600 SIVEXTRO SOLR IV PA; ;LA ; ; You can find information on what symbols and abbreviations in this table mean by going to 14

30 Name of SIVEXTRO TABS OR ZYVOX SOLN IV 200 MG/100ML ZYVOX SOLN IV 600 MG/300ML (Linezolid) ZYVOX SUSR OR 100 MG/5ML (Linezolid) ZYVOX TABS OR 600 MG (Linezolid) Polymyxins polymyxin b sulfate solr ij ; ; ; Streptogramins SYNERCID SOLR AIANGINAL AGES - Drugs to Treat Chest Pain Antianginals-Or RANEXA TB12 Nitrates ISORDIL TITRADOSE TABS 5 MG (Isosorbide Dinitrate) isosorbide dinitrate tabs isosorbide dinitrate tbcr isosorbide mononitrate tabs 10, 20 PA; Name of isosorbide mononitrate tb24 30, 60, 120 NITRO-DUR PT MG/HR, 0.2 MG/HR, 0.4 MG/HR, 0.6 MG/HR (Nitroglycerin) NITROGLYCERIN LINGUAL AERS nitroglycerin pt24 td 0.1 /hr, 0.2 /hr, 0.4 /hr, 0.6 /hr nitroglycerin soln tl 0.4 /spray nitroglycerin subl sl 0.3, 0.4, 0.6 NITROLINGUAL PUMPSPRAY SOLN (Nitroglycerin) NITROSTAT SUBL (Nitroglycerin) AIANXIETY AGES - Drugs to Treat Anxiety Antianxiety Agents - Misc. buspirone hcl tabs or 5, 10, 15, 30, 7.5 hydroxyzine hcl soln im 50 /ml hydroxyzine hcl syrp or 10 /5ml hydroxyzine hcl tabs or 10, 25, 50 old); old); old); You can find information on what symbols and abbreviations in this table mean by going to 15

31 Name of hydroxyzine pamoate caps or 25, 50 VISTARIL CAPS (Hydroxyzine Pamoate) Benzodiazepines alprazolam tabs or 0.25, 0.5, 1, 2 alprazolam tb24 or 0.5, 1, 2, 3 alprazolam tbdp or 0.25, 0.5, 1, 2 ATIVAN SOLN (Lorazepam) ATIVAN TABS (Lorazepam) clorazepate dipotassium tabs diazepam conc or 5 /ml diazepam soln or 5 /5ml diazepam tabs or 2, 5, 10 lorazepam conc or 2 /ml lorazepam soln ij 2 /ml, 4 /ml, 20 /10ml lorazepam tabs or 0.5, 1, 2 old); old); Name of oxazepam caps 10, 15, 30 OXAZEPAM CAPS 30 MG TRANXENE T TABS (Clorazepate Dipotassium) VALIUM TABS (Diazepam) XANAX TABS (Alprazolam) XANAX XR TB24 (Alprazolam) AIARRHYTHMICS - Drugs to treat abnormal heart rhythms Antiarrhythmics Type I-A disopyramide phosphate caps NORPACE CAPS (Disopyramide Phosphate) quinidine gluconate tbcr or 324 quinidine sulfate tabs Antiarrhythmics Type I-B mexiletine hcl caps Antiarrhythmics Type I-C flecainide acetate tabs 100 flecainide acetate tabs 150 old); old); SL(4 ea daily); SL(2.66 ea daily); You can find information on what symbols and abbreviations in this table mean by going to 16

32 Name of flecainide acetate tabs 50 propafenone hcl cp12 propafenone hcl tabs RYTHL SR CP12 (Propafenone HCl) RYTHL TABS (Propafenone HCl) Antiarrhythmics Type III amiodarone hcl tabs or 100, 200, 400 dofetilide caps MULTAQ TABS TIKOSYN CAPS (Dofetilide) SL(8 ea daily); AIASTHMATIC AND BRONCHODILATOR AGES - Drugs to Treat Lung Conditions Anti-Inflammatory Agents B/D; cromolyn sodium nebu in Antiasthmatic - Monoclonal Antibodies PA; ;LA CINQAIR SOLN PA FASENRA SOSY PA; ;LA NUCALA SOLR Name of XOLAIR SOLR Bronchodilators - Anticholinergics ATROVE HFA AERS ipratropium bromide soln in SPIRIVA HANDIHALER CAPS SPIRIVA RESPIMAT AERS TUDORZA PRESSAIR AEPB TUDORZA PRESSAIR AEPB Leukotriene Modulators ACCOLATE TABS (Zafirlukast) montelukast sodium chew 4, 5 montelukast sodium tabs 10 SINGULAIR CHEW 4 MG, 5 MG (Montelukast Sodium) PA; ;LA Limit 2 inhalers per month;ql(0.86 gm daily); B/D; You can find information on what symbols and abbreviations in this table mean by going to QL(1 ea daily); Limit 1 inhaler per month (60 actuations);sl( 0.14 gm daily); Limit 2 inhalers per month (30 actuations);ql( 0.07 ea daily); Limit 1 inhaler per month (60 actuations);ql( 0.04 ea daily); 17