Passport Advantage (HMO SNP) 2016 Comprehensive Formulary. List of Covered Drugs

Transcription

1 Passport Advantage (HMO SNP) 206 Comprehensive Formulary List of Covered Drugs PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN HPMS Approved Formulary File Submission ID , Version Number 0 This formulary was updated on 5/0/206. For more recent information or other questions, please contact Passport Advantage Member Services, at (844) or, for TTY users, 7, 8:00 a.m. to 8:00 p.m. Eastern Time, seven days a week, or visit H9870_ADVG5338

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 Passport Advantage (HMO SNP). When it refers to plan or our plan, it means Passport Advantage. This document includes a list of the drugs (formulary) for our plan which is current as of 5//206. 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, 207 and from time to time during the year. What is the Passport Advantage (HMO SNP) Formulary? A formulary is a list of covered drugs selected by Passport Advantage 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. Passport Advantage will generally cover the drugs listed in our formulary as long as the drug is medically necessary, the prescription is filled at a Passport Advantage (HMO SNP) 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 206 formulary that was covered at the beginning of the year, we will not discontinue or reduce coverage of the drug during the 206 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 Drug 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 5//206. To get updated information about the drugs covered by Passport Advantage, please contact us. Our contact information appears on the front and back cover pages. In the event that Passport Advantage has CMS-approved non-maintenance changes to the formulary throughout the plan year (i.e. remove drugs from our formulary, add prior authorization, quantity limits and/or step therapy restrictions on a drug), we will update our formulary and post it on our website. You will also be notified in writing if you are affected by the changes via errata sheets. We also maintain and update our online formulary on a monthly basis.

3 How do I use the Formulary? There are two ways to find your drug within the formulary: Medical Condition The formulary begins on page 7. 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 7. 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 04. 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? Passport Advantage (HMO SNP) 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: Passport Advantage 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 Limits: For certain drugs, Passport Advantage limits the amount of the drug that we will cover. For example, Passport Advantage provides 8 s per prescription for sumatriptan. This may be in addition to a standard one month or three month supply. Step Therapy: In some cases, Passport Advantage requires you to first try certain drugs to treat your medical condition before we will cover another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, we may not cover Drug B unless you try Drug A first. If Drug A does not work for you, we will then cover Drug B. You can find out if your drug has any additional requirements or limits by looking in the formulary that begins on page 7. 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. 2

4 You can ask Passport Advantage (HMO SNP) 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 Passport Advantage s formulary? on this page 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 Passport Advantage does not cover your drug, you have two options: You can ask Member Services for a list of similar drugs that are covered by Passport Advantage. When you receive the list, show it to your doctor and ask him or her to prescribe a similar drug that is covered by Passport Advantage. You can ask Passport Advantage 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 Passport Advantage s Formulary? You can ask Passport Advantage 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, Passport Advantage limits the amount of the drug that we will cover. If your drug has a quantity limit, you can ask us to waive the limit and cover a greater amount. Generally, Passport Advantage 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. 3

5 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 9 to 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. We will provide a one-time 3-day transition supply per drug, which will cover a temporary supply if you have a change in your medications due to a level of care change. A level of care change may include: Entering a long-term care (LTC) facility from a hospital with a discharge list of medications from the hospital formulary with very short term planning taken into account (i.e., under 8 hours) Discharge from a hospital to a home with very short-term planning taken into account Ending a skilled nursing facility Medicare Part A stay (where payments include all pharmacy charges) Giving up a hospice status to revert to standard Medicare benefits Ending a long-term care (LTC) facility stay and returning to the community Discharge from a psychiatric hospital with a drug regimen that is highly individualized For more information For more detailed information about your Passport Advantage (HMO SNP) prescription drug coverage, please review your Evidence of Coverage and other plan materials. If you have questions about Passport Advantage (HMO SNP), please contact us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages. 4

6 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 Passport Advantage s Formulary The formulary that begins on page 7 provides coverage information about the drugs covered by Passport Advantage. If you have trouble finding your drug in the list, turn to the Index that begins on page 04. The first column of the chart lists the drug name. Brand name drugs are capitalized (e.g., LIDODERM) and generic drugs are listed in lower-case italics (e.g., lidocaine). The information in the Requirements/Limits column tells you if Passport Advantage has any special requirements for coverage of your drug. Limited Distribution (LD): The symbol (LD) in the Requirements/Limits column next to a drug name indicates that the drug has been noted as being restricted to certain pharmacies by the Food and Drug Administration. These drugs can only be obtained at specialty designated pharmacies able to appropriately handle the drugs. Prior Authorization (): The symbol () in the Requirements/Limits column indicates that prior authorization may apply. 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. Prior Authorization Restriction for Part B vs Part D Determination (): The symbol ( BvD) in the Requirements/Limits column next to a drug indicates that the drug may be eligible for payment under Medicare Part B or Part D. You (or your physician) are required to get prior authorization from Passport Advantage to determine that this drug is covered under Medicare Part D before you fill your prescription for this drug. Without prior approval, we may not cover this drug. Prior Authorization Restriction for New Starts Only ( NSO): The symbol ( NSO) in the Requirements/Limits column indicates that prior authorization may apply on certain medications for new members of the plan. If you are a new member, you (or your physician) are required to get prior authorization from Passport Advantage before you fill your prescription for this drug. Without prior approval, we may not cover this drug. Quantity Limits (QL): The symbol (QL) in the Requirements/Limits column indicates that quantities dispensed may be limited. For certain drugs, Passport Advantage limits the amount of the drug that we will cover. Step Therapy (ST): The symbol (ST) in the Requirements/Limits column indicates that step therapy may apply. In some cases, Passport Advantage requires you to first try certain drugs to treat your medical condition before we will cover another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, we may not cover Drug B unless you try Drug A first. If Drug A does not work for you, we will then cover Drug B. 5

7 Non-Mail-Order Drug (): The symbol () in the Requirements/Limits column indicates that the drug is not available via your mail-order benefit. Passport Advantage (HMO SNP) is an HMO Special Needs Plan with a Medicare contract. Enrollment in Passport Advantage depends on contract renewal. This plan is available to anyone who has full Kentucky Medicaid benefits and Medicare Part B, resides in Jefferson, Hardin, Bullitt, or Nelson counties, and does not have ESRD at the time of enrollment. Premium, co-pays, co-insurance, and deductibles may vary based on the level of Extra Help you receive. Please contact the plan for further details. The formulary, pharmacy network and/or provider network may change at any time. You will receive notice when necessary. This information is available for free in other languages. Please call our customer service number at days a week from 8 a.m. to 8 p.m. Eastern Time. TTY/TDD users should call 7. This document may be available in an alternative format, such as Braille, large print, or audio. Please contact our Member Services at for more information. 6

8 ADHD/ ANTI-NARCOLEPSY/ ANTI-OBESITY/ ANOREXIANTS AMPHETAMINES amphetamine 0mg er cap amphetamine 0mg amphetamine 2.5mg amphetamine 5mg er cap amphetamine 5mg amphetamine 20mg er cap amphetamine 20mg amphetamine 25mg er cap amphetamine 30mg er cap amphetamine 30mg amphetamine 5mg er cap amphetamine 5mg amphetamine 7.5mg dexedrine 0mg dexedrine 5mg dextroamphetamine sulfate 0mg er cap dextroamphetamine sulfate 0mg dextroamphetamine sulfate 5mg er cap dextroamphetamine sulfate 5mg er cap dextroamphetamine sulfate 5mg methamphetamine 5mg VYVANSE 0MG CAP VYVANSE 20MG CAP VYVANSE 30MG CAP VYVANSE 40MG CAP VYVANSE 50MG CAP VYVANSE 60MG CAP VYVANSE 70MG CAP ATTENTION-DEFICIT/ HYPERACTIVITY DISORDER (ADHD) AGENTS guanfacine mg er guanfacine 2mg er guanfacine 3mg er guanfacine 4mg er STRATTERA 00MG CAP QL=60 Caps/30 Days STRATTERA 0MG CAP QL=60 Caps/30 Days STRATTERA 8MG CAP QL=60 Caps/30 Days STRATTERA 25MG CAP QL=60 Caps/30 Days STRATTERA 40MG CAP QL=60 Caps/30 Days STRATTERA 60MG CAP QL=60 Caps/30 Days STRATTERA 80MG CAP QL=60 Caps/30 Days dexmethylphenidate 0mg er cap STIMULANTS - MISC. dexmethylphenidate 0mg 7

9 dexmethylphenidate 5mg er cap dexmethylphenidate 2.5mg dexmethylphenidate 20mg er cap dexmethylphenidate 30mg er cap dexmethylphenidate 40mg er cap dexmethylphenidate 5mg er cap dexmethylphenidate 5mg metadate 20mg er methylphenidate 0mg chew methylphenidate 0mg er cap methylphenidate 0mg er methylphenidate 0mg METHYLPHENIDATE 8MG ER methylphenidate mg/ ml soln methylphenidate 2.5mg chew methylphenidate 20mg er cap methylphenidate 20mg er methylphenidate 20mg METHYLPHENIDATE 27MG ER methylphenidate 2mg/ ml soln methylphenidate 30mg er cap METHYLPHENIDATE 36MG ER methylphenidate 40mg er cap methylphenidate 50mg er cap METHYLPHENIDATE 54MG ER methylphenidate 5mg chew methylphenidate 5mg methylphenidate 60mg er cap modafinil 00mg modafinil 200mg NUVIGIL 50MG NUVIGIL 200MG NUVIGIL 250MG NUVIGIL 50MG AMINOGLYCOSIDES AMINOGLYCOSIDES amikacin sulfate 250mg/ ml inj gentamicin sulfate 0.8mg/ ml inj GENTAMICIN SULFATE 0.9MG/ ML gentamicin sulfate.2mg/ ml inj GENTAMICIN SULFATE.4MG/ ML gentamicin sulfate.6mg/ ml inj gentamicin sulfate 0mg/ ml inj gentamicin sulfate mg/ ml inj gentamicin sulfate 40mg/ ml inj QL=60 Tabs/30 Days QL=60 Tabs/30 Days QL=30 Tabs/30 Days QL=30 Tabs/30 Days QL=30 Tabs/30 Days QL=30 Tabs/30 Days 8

10 neomycin sulfate 500mg paromomycin 250mg cap STREPTOMYCIN 400MG/ ML TOBI PODHALER KIT 28MG CK tobramycin 0mg/ ml inj tobramycin 40mg/ ml inj tobramycin 60mg/ ml neb soln ANALGESICS - ANTI-INFLAMMATORY ANTIRHEUMATIC - ENZYME INHIBITORS XELJANZ 5MG QL=60 Tabs/30 Days ANTIRHEUMATIC ANTIMEOLITES RHEUMATREX DOSE (2) 2.5MG CK RHEUMATREX DOSE (6) 2.5MG CK RHEUMATREX DOSE (20) 2.5MG CK RHEUMATREX DOSE (6) 2.5MG CK RHEUMATREX DOSE (8) 2.5MG CK ANTI-TNF-ALPHA - MONOCLONAL ANTIBODIES HUMIRA 0MG/ 0.2ML SYR HUMIRA 20MG/ 0.4ML SYR HUMIRA 40MG/ 0.8ML AUTO-ECTOR HUMIRA 40MG/ 0.8ML SYR HUMIRA PEDIATRIC CROHN'S STARTER CK (3) 40MG/ 0.8ML HUMIRA PEDIATRIC CROHN'S STARTER CK (6) 40MG/ 0.8ML HUMIRA PEN - CROHN'S STARTER CK 40MG/ 0.8ML SIMPONI 00MG/ ML AUTO-ECTOR SIMPONI 00MG/ ML SYR SIMPONI 50MG/ 0.5ML AUTO-ECTOR SIMPONI 50MG/ 0.5ML SYR GOLD COMPOUNDS RIDAURA 3MG CAP ARCALYST 220MG INTERLEUKIN- BLOCKERS INTERLEUKIN- RECEPTOR ANTAGONIST (IL-RA) KINERET 00MG/ 0.67ML SYR ILARIS 80MG INTERLEUKIN-BETA BLOCKERS INTERLEUKIN-6 RECEPTOR INHIBITORS ACTEMRA 62MG/ 0.9ML SYR ACTEMRA 200MG/ 0ML NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS) celecoxib 00mg cap QL=60 Caps/30 Days celecoxib 200mg cap QL=60 Caps/30 Days 9

11 celecoxib 400mg cap QL=60 Caps/30 Days celecoxib 50mg cap QL=60 Caps/30 Days diclofenac potassium 50mg diclofenac sodium 00mg er diclofenac sodium 25mg dr diclofenac sodium 50mg dr diclofenac sodium 50mg/ misoprostol 0.2mg diclofenac sodium 75mg dr diclofenac sodium 75mg/ misoprostol 0.2mg etodolac 200mg cap etodolac 300mg cap etodolac 400mg er etodolac 400mg etodolac 500mg er etodolac 500mg etodolac 600mg er FENOPROFEN 400MG CAP fenoprofen 600mg flurbiprofen 00mg flurbiprofen 50mg ibuprofen 20mg/ ml susp ibuprofen 400mg ibuprofen 600mg ibuprofen 800mg INDOCIN 25MG/ 5ML SUSP indomethacin 25mg cap indomethacin 50mg cap indomethacin 75mg er cap ketoprofen 50mg cap ketoprofen 75mg cap ketorolac tromethamine 0mg QL=20 Tabs/5 Days ketorolac tromethamine 5mg/ ml inj ketorolac tromethamine 30mg/ ml inj MECLOFENAMATE 00MG CAP MECLOFENAMATE 50MG CAP mefenamic acid 250mg cap MELOXICAM.5MG/ ML SUSP meloxicam 5mg meloxicam 7.5mg MOBIC 7.5MG/ 5ML SUSP nabumetone 500mg nabumetone 750mg naproxen 250mg NAPROXEN 25MG/ ML SUSP naproxen 375mg dr naproxen 375mg 0

12 naproxen 500mg dr naproxen 500mg naproxen sodium 275mg naproxen sodium 550mg oxaprozin 600mg piroxicam 0mg cap piroxicam 20mg cap sulindac 50mg sulindac 200mg tolmetin 400mg cap TOLMETIN 600MG PHOSPHODIESTERASE 4 (PDE4) INHIBITORS OTEZLA 28-DAY STARTER CK QL=55 Tabs/28 Days OTEZLA 30MG QL=60 Tabs/30 Days OTEZLA STARTER CK QL=60 Tabs/30 Days PYRIMIDINE SYNTHESIS INHIBITORS leflunomide 0mg leflunomide 20mg SELECTIVE COSTIMULATION MODULATORS ORENCIA 25MG/ ML SYR ORENCIA 250MG SOLUBLE TUMOR NECROSIS FACTOR RECEPTOR AGENTS ENBREL 25MG ENBREL 25MG/ 0.5ML SYR ENBREL 50MG/ ML SURECLICK ENBREL 50MG/ ML SYR ANALGESICS - NONNARCOTIC SALICYLATES diflunisal 500mg codeine sulfate 5mg ANALGESICS - OPIOID OPIOID AGONISTS QL=240 Tabs/30 Days codeine sulfate 30mg QL=240 Tabs/30 Days codeine sulfate 60mg QL=240 Tabs/30 Days duramorph 0.5mg/ ml inj duramorph mg/ ml inj EMBEDA 00-4MG ER CAP QL=60 Caps/30 Days EMBEDA MG ER CAP QL=60 Caps/30 Days EMBEDA 30-.2MG ER CAP QL=60 Caps/30 Days EMBEDA 50-2MG ER CAP QL=60 Caps/30 Days EMBEDA MG ER CAP QL=60 Caps/30 Days EMBEDA MG ER CAP QL=60 Caps/30 Days EXALGO 32MG ER QL=60 Tabs/30 Days fentanyl 0.02mg/ hr patch QL=0 Patches/30 Days fentanyl 0.025mg/ hr patch QL=0 Patches/30 Days

13 fentanyl 0.05mg/ hr patch QL=0 Patches/30 Days fentanyl 0.075mg/ hr patch QL=0 Patches/30 Days fentanyl 0.mg/ hr patch QL=0 Patches/30 Days fentanyl 0.2mg lozenge QL=20 Lozenges/30 Days fentanyl 0.4mg lozenge QL=20 Lozenges/30 Days fentanyl 0.6mg lozenge QL=20 Lozenges/30 Days fentanyl 0.8mg lozenge QL=20 Lozenges/30 Days fentanyl.2mg lozenge QL=20 Lozenges/30 Days fentanyl.6mg lozenge QL=20 Lozenges/30 Days hydromorphone 0mg/ ml inj hydromorphone 2mg er QL=60 Tabs/30 Days hydromorphone 6mg er QL=60 Tabs/30 Days hydromorphone mg/ ml soln QL=2400 ML/30 Days hydromorphone 2mg QL=450 Tabs/30 Days HYDROMORPHONE 32MG ER QL=60 Tabs/30 Days hydromorphone 4mg QL=240 Tabs/30 Days hydromorphone 8mg er QL=60 Tabs/30 Days hydromorphone 8mg QL=20 Tabs/30 Days HYSINGLA 00MG ER QL=30 Tabs/30 Days HYSINGLA 20MG ER QL=30 Tabs/30 Days HYSINGLA 20MG ER QL=30 Tabs/30 Days HYSINGLA 30MG ER QL=30 Tabs/30 Days HYSINGLA 40MG ER QL=30 Tabs/30 Days HYSINGLA 60MG ER QL=30 Tabs/30 Days HYSINGLA 80MG ER QL=30 Tabs/30 Days LAZANDA 00MCG/ ACT NASAL SPRAY QL=30 Bottles/30 Days LAZANDA 400MCG/ ACT NASAL SPRAY QL=30 Bottles/30 Days LEVORPHANOL 2MG QL=240 Tabs/30 Days meperidine 00mg QL=360 Tabs/30 Days meperidine 50mg QL=720 Tabs/30 Days methadone 0mg QL=360 Tabs/30 Days methadone mg/ ml soln QL=3600 ML/30 Days methadone 2mg/ ml soln QL=800 ML/30 Days methadone 5mg QL=360 Tabs/30 Days morphine sulfate 00mg er cap QL=60 Caps/30 Days morphine sulfate 00mg er QL=20 Tabs/30 Days morphine sulfate 0mg er cap QL=60 Caps/30 Days MORPHINE SULFATE 0MG/ ML SYR MORPHINE SULFATE 20MG ER CAP QL=60 Caps/30 Days morphine sulfate 5mg er QL=20 Tabs/30 Days morphine sulfate 5mg QL=80 Tabs/30 Days morphine sulfate 200mg er QL=20 Tabs/30 Days morphine sulfate 20mg er cap QL=60 Caps/30 Days morphine sulfate 20mg/ ml soln QL=80 ML/30 Days morphine sulfate 2mg/ ml soln QL=800 ML/30 Days MORPHINE SULFATE 2MG/ ML SYR 2

14 MORPHINE SULFATE 30MG ER (24 HR) CAP QL=60 Caps/30 Days morphine sulfate 30mg er cap QL=60 Caps/30 Days morphine sulfate 30mg er QL=20 Tabs/30 Days morphine sulfate 30mg QL=80 Tabs/30 Days MORPHINE SULFATE 45MG ER CAP QL=60 Caps/30 Days morphine sulfate 4mg/ ml soln QL=900 ML/30 Days MORPHINE SULFATE 4MG/ ML SYR morphine sulfate 50mg er cap QL=60 Caps/30 Days morphine sulfate 60mg er (24 hr) cap QL=60 Caps/30 Days MORPHINE SULFATE 60MG ER CAP QL=60 Caps/30 Days morphine sulfate 60mg er QL=20 Tabs/30 Days MORPHINE SULFATE 75MG ER CAP QL=60 Caps/30 Days morphine sulfate 80mg er cap QL=60 Caps/30 Days MORPHINE SULFATE 8MG/ ML SYR MORPHINE SULFATE 90MG ER CAP QL=60 Caps/30 Days NUCYNTA 00MG ER QL=60 Tabs/30 Days NUCYNTA 50MG ER QL=60 Tabs/30 Days NUCYNTA 200MG ER QL=60 Tabs/30 Days NUCYNTA 250MG ER QL=60 Tabs/30 Days NUCYNTA 50MG ER QL=60 Tabs/30 Days oxycodone 0mg QL=80 Tabs/30 Days oxycodone 5mg QL=80 Tabs/30 Days oxycodone mg/ ml soln QL=5400 ML/30 Days oxycodone 20mg QL=80 Tabs/30 Days oxycodone 20mg/ ml soln QL=270 ML/30 Days oxycodone 30mg QL=80 Tabs/30 Days oxycodone 5mg cap QL=360 Caps/30 Days oxycodone 5mg QL=360 Tabs/30 Days OXYCONTIN 0MG ER QL=60 Tabs/30 Days OXYCONTIN 5MG ER QL=60 Tabs/30 Days OXYCONTIN 20MG ER QL=60 Tabs/30 Days OXYCONTIN 30MG ER QL=60 Tabs/30 Days OXYCONTIN 40MG ER QL=60 Tabs/30 Days OXYCONTIN 60MG ER QL=60 Tabs/30 Days OXYCONTIN 80MG ER QL=20 Tabs/30 Days oxymorphone 0mg er QL=60 Tabs/30 Days oxymorphone 0mg QL=360 Tabs/30 Days oxymorphone 5mg er QL=60 Tabs/30 Days oxymorphone 20mg er QL=60 Tabs/30 Days oxymorphone 30mg er QL=60 Tabs/30 Days oxymorphone 40mg er QL=60 Tabs/30 Days oxymorphone 5mg er QL=60 Tabs/30 Days oxymorphone 5mg QL=360 Tabs/30 Days oxymorphone 7.5mg er QL=60 Tabs/30 Days tramadol 00mg er QL=60 Tabs/30 Days tramadol 200mg er QL=60 Tabs/30 Days 3

15 tramadol 300mg er QL=60 Tabs/30 Days tramadol 50mg QL=240 Tabs/30 Days OPIOID COMBINATIONS acetaminophen 2.7mg/ ml/ hydrocodone bitartrate QL=5400 ML/30 Days 0.5mg/ ml soln acetaminophen 24mg/ ml/ codeine phosphate 2.4mg/ ml QL=4980 ML/30 Days soln acetaminophen 300mg/ codeine phosphate 5mg QL=390 Tabs/30 Days acetaminophen 300mg/ codeine phosphate 30mg QL=390 Tabs/30 Days acetaminophen 300mg/ codeine phosphate 60mg QL=390 Tabs/30 Days acetaminophen 300mg/ hydrocodone bitartrate 0mg QL=390 Tabs/30 Days acetaminophen 300mg/ hydrocodone bitartrate 5mg QL=390 Tabs/30 Days acetaminophen 300mg/ hydrocodone bitartrate 7.5mg QL=390 Tabs/30 Days acetaminophen 325mg/ hydrocodone bitartrate 0mg QL=360 Tabs/30 Days acetaminophen 325mg/ hydrocodone bitartrate 2.5mg QL=360 Tabs/30 Days acetaminophen 325mg/ hydrocodone bitartrate 5mg QL=360 Tabs/30 Days acetaminophen 325mg/ hydrocodone bitartrate 7.5mg QL=360 Tabs/30 Days acetaminophen 325mg/ oxycodone 0mg QL=360 Tabs/30 Days acetaminophen 325mg/ oxycodone 2.5mg QL=360 Tabs/30 Days acetaminophen 325mg/ oxycodone 5mg QL=360 Tabs/30 Days acetaminophen 325mg/ oxycodone 7.5mg QL=360 Tabs/30 Days acetaminophen 325mg/ tramadol 37.5mg QL=360 Tabs/30 Days aspirin 325mg/ oxycodone 4.84mg QL=360 Tabs/30 Days endocet 0-325mg QL=360 Tabs/30 Days endocet 5-325mg QL=360 Tabs/30 Days endocet mg QL=360 Tabs/30 Days hydrocodone 0mg/ ibuprofen 200mg QL=480 Tabs/30 Days hydrocodone 5mg/ ibuprofen 200mg QL=480 Tabs/30 Days hydrocodone bitartrate 7.5mg/ ibuprofen 200mg QL=480 Tabs/30 Days ibuprofen 400mg/ oxycodone 5mg QL=240 Tabs/30 Days lorcet 0-325mg QL=360 Tabs/30 Days lorcet 5-325mg QL=360 Tabs/30 Days lorcet mg QL=360 Tabs/30 Days lor 0-325mg QL=360 Tabs/30 Days lor 5-325mg QL=360 Tabs/30 Days lor mg QL=360 Tabs/30 Days reprexain 0-200mg QL=480 Tabs/30 Days vicodin 0-300mg QL=390 Tabs/30 Days vicodin 5-300mg QL=390 Tabs/30 Days vicodin mg QL=390 Tabs/30 Days buprenorphine 0.3mg/ ml inj OPIOID RTIAL AGONISTS buprenorphine 2mg sl QL=90 Tabs/30 Days buprenorphine 2mg/ naloxone 0.5mg sl QL=90 Tabs/30 Days buprenorphine 8mg sl QL=90 Tabs/30 Days buprenorphine 8mg/ naloxone 2mg sl QL=90 Tabs/30 Days 4

16 butorphanol tartrate 0mg/ ml nasal spray butorphanol tartrate mg/ ml inj butorphanol tartrate 2mg/ ml inj BUTRANS 0MCG/ HR TCH BUTRANS 5MCG/ HR TCH BUTRANS 20MCG/ HR TCH BUTRANS 5MCG/ HR TCH BUTRANS 7.5MCG/ HR TCH naloxone 0.5mg/ pentazocine 50mg SUBOXONE 2-3MG STRIP SUBOXONE 2-0.5MG STRIP SUBOXONE 4-MG STRIP SUBOXONE 8-2MG STRIP ANDROGENS-ANABOLIC ANABOLIC STEROIDS ANADROL-50 50MG oxandrolone 0mg oxandrolone 2.5mg ANDROGENS ANDRODERM 2MG/ 24HR TCH ANDRODERM 4MG/ 24HR TCH ANDROGEL % (25MG) GEL ANDROGEL % (50MG) GEL ANDROGEL.62% (.25GM) GEL ANDROGEL.62% (2.5GM) GEL ANDROGEL.62% GEL danazol 00mg cap danazol 200mg cap danazol 50mg cap testosterone cypionate 00mg/ ml inj testosterone cypionate 200mg/ ml inj testosterone enanthate 200mg/ ml inj ANORECTAL AGENTS INTRARECTAL STEROIDS colocort 00mg/ 60ml enema hydrocortisone.67mg/ ml enema UCERIS 2MG/ ACT FOAM RECTAL STEROIDS procto-pak % rectal cream proctosol 2.5% cream proctozone hc 2.5% cream ANTHELMINTICS ANTHELMINTICS ALBENZA 200MG ivermectin 3mg QL=4 Bottles/30 Days QL=4 Patches/28 Days QL=4 Patches/28 Days QL=4 Patches/28 Days QL=4 Patches/28 Days QL=4 Patches/28 Days QL=360 Tabs/30 Days QL=60 Film/30 Days QL=90 Film/30 Days QL=90 Film/30 Days QL=90 Film/30 Days QL=60 Patches/30 Days QL=30 Patches/30 Days QL=30 Packets/30 Days QL=60 Packets/30 Days QL=30 Packets/30 Days QL=60 Packets/30 Days QL=2 Bottles/30 Days 5

17 ANTIANGINAL AGENTS ANTIANGINALS-OTHER RANEXA 000MG ER RANEXA 500MG ER NITRATES isosorbide dinitrate 0mg isosorbide dinitrate 20mg ISOSORBIDE DINITRATE 30MG ISOSORBIDE DINITRATE 40MG ER isosorbide dinitrate 5mg isosorbide mononitrate 0mg isosorbide mononitrate 20mg er isosorbide mononitrate 20mg isosorbide mononitrate 30mg er isosorbide mononitrate 60mg er minitran 0.mg/ hr patch minitran 0.2mg/ hr patch minitran 0.4mg/ hr patch minitran 0.6mg/ hr patch NITRO-DUR 0.3MG/ HR TCH NITRO-DUR 0.8MG/ HR TCH nitroglycerin 0.mg/ hr patch nitroglycerin 0.2mg/ hr patch nitroglycerin 0.4mg/ act spray nitroglycerin 0.4mg/ hr patch nitroglycerin 0.6mg/ hr patch NITROSTAT 0.3MG SL NITROSTAT 0.4MG SL NITROSTAT 0.6MG SL ANTIANXIETY AGENTS ANTIANXIETY AGENTS - MISC. buspirone 0mg buspirone 5mg buspirone 5mg hydroxyzine 0mg hydroxyzine 25mg HYDROXYZINE 25MG/ ML hydroxyzine 2mg/ ml soln hydroxyzine 50mg hydroxyzine 50mg/ ml inj HYDROXYZINE MOATE 00MG CAP hydroxyzine pamoate 25mg cap hydroxyzine pamoate 50mg cap meprobamate 200mg meprobamate 400mg 6

18 BENZODIAZEPINES alprazolam 0.25mg odt alprazolam 0.25mg alprazolam 0.5mg er alprazolam 0.5mg odt alprazolam 0.5mg alprazolam mg er alprazolam mg odt alprazolam mg alprazolam 2mg er alprazolam 2mg odt alprazolam 2mg alprazolam 3mg er chlordiazepoxide 0mg cap chlordiazepoxide 25mg cap chlordiazepoxide 5mg cap clorazepate dipotassium 5mg clorazepate dipotassium 3.75mg clorazepate dipotassium 7.5mg diazepam 0mg DIAZEM MG/ ML SOLN diazepam 2mg diazepam 5mg diazepam 5mg/ ml soln lorazepam 0.5mg lorazepam mg lorazepam 2mg lorazepam 2mg/ ml conc oxazepam 0mg cap oxazepam 5mg cap oxazepam 30mg cap ANTIARRHYTHMICS ANTIARRHYTHMICS TYPE I-A disopyramide 00mg cap disopyramide 50mg cap NORCE 00MG ER CAP NORCE 50MG ER CAP PROCAINAMIDE 00MG/ ML PROCAINAMIDE 500MG/ ML quinidine gluconate 324mg er QUINIDINE GLUCONATE 80MG/ ML QUINIDINE SULFATE 200MG QUINIDINE SULFATE 300MG ANTIARRHYTHMICS TYPE I-B mexiletine 50mg cap 7

19 mexiletine 200mg cap mexiletine 250mg cap ANTIARRHYTHMICS TYPE I-C flecainide acetate 00mg flecainide acetate 50mg flecainide acetate 50mg propafenone 50mg propafenone 225mg er cap propafenone 225mg propafenone 300mg propafenone 325mg er cap propafenone 425mg sr cap ANTIARRHYTHMICS TYPE III amiodarone 200mg amiodarone 400mg amiodarone 50mg/ ml inj MULTAQ 400MG NEXTERONE 50MG/ 00ML NEXTERONE 360MG/ 200ML pacerone 200mg pacerone 400mg TIKOSYN 25MCG CAP TIKOSYN 250MCG CAP TIKOSYN 500MCG CAP XOLAIR 50MG ANTIASTHMATIC AND BRONCHODILATOR AGENTS ANTIASTHMATIC - MONOCLONAL ANTIBODIES ANTI-INFLAMMATORY AGENTS CROMOLYN SODIUM 0MG/ ML NEB SOLN BRONCHODILATORS - ANTICHOLINERGICS ATROVENT 7MCG INH INCRUSE 62.5MCG INH ipratropium bromide 0.02% inh soln SPIRIVA.25MCG/ ACT INH SPIRIVA 8MCG INH POWDER SPIRIVA 2.5MCG INH montelukast 0mg LEUKOTRIENE MODULATORS montelukast 4mg chew montelukast 4mg granules montelukast 5mg chew zafirlukast 0mg zafirlukast 20mg SELECTIVE PHOSPHODIESTERASE 4 (PDE4) INHIBITORS DALIRESP 500MCG 8

20 ARNUITY 00MCG INH STEROID INHALANTS QL= Inhalers/30 Days ARNUITY 200MCG INH QL= Inhalers/30 Days ASMANEX 00MCG (20ACT) HFA INH QL= Inhalers/30 Days ASMANEX 0MCG (30ACT) INH QL= Inhalers/30 Days ASMANEX 200MCG (20ACT) HFA INH QL= Inhalers/30 Days ASMANEX 220MCG (20ACT) INH QL= Inhalers/30 Days ASMANEX 220MCG (30ACT) INH QL= Inhalers/30 Days ASMANEX 220MCG (60ACT) INH QL= Inhalers/30 Days budesonide 0.25mg/ ml inh soln QL=60 Neb/30 Days budesonide 0.25mg/ ml inh soln QL=60 Neb/30 Days budesonide 0.5mg/ ml inh soln QL=60 Neb/30 Days FLOVENT 00MCG DISKUS QL= Inhalers/30 Days FLOVENT 0MCG HFA INH QL=2 Inhalers/30 Days FLOVENT 220MCG HFA INH QL=2 Inhalers/30 Days FLOVENT 250MCG DISKUS QL= Inhalers/30 Days FLOVENT 44MCG HFA INH QL= Inhalers/30 Days FLOVENT 50MCG DISKUS QL= Inhalers/30 Days PULMICORT MG/ 2ML INH SOLN QL=60 Neb/30 Days ADVAIR 00-50MCG DISKUS SYMTHOMIMETICS QL= Inhalers/30 Days ADVAIR 5-2MCG HFA QL= Inhalers/30 Days ADVAIR 230-2MCG HFA QL= Inhalers/30 Days ADVAIR MCG DISKUS QL= Inhalers/30 Days ADVAIR 45-2MCG HFA QL= Inhalers/30 Days ADVAIR MCG DISKUS QL= Inhalers/30 Days albuterol 0.2mg/ ml (0.63mg/ 3ml) neb soln albuterol 0.47mg/ ml (.25mg/ 3ml) neb soln albuterol 0.4mg/ ml (2mg/ 5ml) oral soln albuterol 0.83mg/ ml (0.083%) neb soln albuterol mg/ ml (0.5%) neb soln albuterol 2mg albuterol 4mg er albuterol 4mg albuterol 8mg er BREO MCG INH QL= Inhalers/30 Days BREO ELLIPTA 00-25MCG INH QL= Inhalers/30 Days COMBIVENT RESPIMAT 20-00MCG INH DULERA 00-5MCG INH QL= Inhalers/30 Days DULERA 200-5MCG INH QL= Inhalers/30 Days FORADIL 2MCG INH POWDER ipratropium/ albuterol mg/ 3ml neb soln levalbuterol 0.3mg neb soln levalbuterol 0.63mg neb soln levalbuterol.25mg neb soln METAPROTERENOL SULFATE 2MG/ ML SOLN 9

21 SEREVENT 50MCG/ DOSE INH STIOLTO MCG INH terbutaline sulfate mg/ ml inj terbutaline sulfate 2.5mg terbutaline sulfate 5mg VENTOLIN 08MCG INH QL=4 Inhalers/30 Days XANTHINES aminophylline 25mg/ ml inj ELIXOPHYLLIN 80MG/ 5ML SOLN theophylline 00mg er theophylline 200mg er theophylline 300mg er theophylline 400mg er theophylline 450mg er theophylline 5.33mg/ ml soln theophylline 600mg er ANTICOAGULANTS COUMARIN ANTICOAGULANTS jantoven 0mg jantoven mg jantoven 2.5mg jantoven 2mg jantoven 3mg jantoven 4mg jantoven 5mg jantoven 6mg jantoven 7.5mg warfarin sodium 0mg warfarin sodium mg warfarin sodium 2.5mg warfarin sodium 2mg warfarin sodium 3mg warfarin sodium 4mg warfarin sodium 5mg warfarin sodium 6mg warfarin sodium 7.5mg DIRECT FACTOR XA INHIBITORS ELIQUIS 2.5MG ELIQUIS 5MG XARELTO 0MG XARELTO 5MG XARELTO 20MG XARELTO STARTER CK HERINS AND HERINOID-LIKE AGENTS enoxaparin sodium 00mg/ ml (0.3ml) syr QL=34 Syringes/7 Days 20

22 enoxaparin sodium 00mg/ ml (0.4ml) syr QL=34 Syringes/7 Days enoxaparin sodium 00mg/ ml (0.6ml) syr QL=34 Syringes/7 Days enoxaparin sodium 00mg/ ml (0.8ml) syr QL=34 Syringes/7 Days enoxaparin sodium 00mg/ ml (ml) syr QL=34 Syringes/7 Days enoxaparin sodium 00mg/ ml inj QL=34 Syringes/7 Days enoxaparin sodium 50mg/ ml (0.8ml) syr QL=34 Syringes/7 Days enoxaparin sodium 50mg/ ml (ml) syr QL=34 Syringes/7 Days fondaparinux sodium 2.5mg/ ml (0.4ml) syr fondaparinux sodium 2.5mg/ ml (0.6ml) syr fondaparinux sodium 2.5mg/ ml (0.8ml) syr fondaparinux sodium 5mg/ ml syr FRAGMIN 0000UNIT/ ML SYR FRAGMIN 2500UNIT/ 0.5ML SYR FRAGMIN 5000UNIT/ 0.6ML SYR FRAGMIN 8000UNIT/ 0.72ML SYR FRAGMIN 2500UNIT/ 0.2ML SYR FRAGMIN 5000UNIT/ 0.2ML SYR FRAGMIN 7500UNIT/ 0.3ML SYR FRAGMIN 95000UNIT/ 3.8ML heparin sodium, porcine 0000unit/ ml inj heparin sodium, porcine 000unit/ ml inj HERIN SODIUM, PORCINE 00UNIT/ ML heparin sodium, porcine 20000unit/ ml inj heparin sodium, porcine 40unit/ ml inj heparin sodium, porcine 5000unit/ ml inj heparin sodium, porcine 50unit/ ml inj argatroban 00mg/ ml inj THROMBIN INHIBITORS ARGATROBAN MG/ ML PRADAXA 0MG CAP PRADAXA 50MG CAP PRADAXA 75MG CAP ANTICONVULSANTS FYCOM 0MG AM GLUTAMATE RECEPTOR ANTAGONISTS NSO FYCOM 2MG NSO FYCOM 2MG NSO FYCOM 4MG NSO FYCOM 6MG NSO FYCOM 8MG NSO clonazepam 0.25mg odt ANTICONVULSANTS - BENZODIAZEPINES clonazepam 0.25mg odt clonazepam 0.5mg odt clonazepam 0.5mg 2

23 clonazepam mg odt clonazepam mg clonazepam 2mg odt clonazepam 2mg DIASTAT 0MG PF APPLICATOR DIASTAT 2.5MG PF APPLICATOR DIASTAT 20MG PF APPLICATOR DIAZEM 0MG (2ML) PF APPLICATOR DIAZEM 2.5MG (0.5ML) PF APPLICATOR DIAZEM 20MG (4ML) PF APPLICATOR ONFI 0MG NSO ONFI 2.5MG/ ML SUSP NSO ONFI 20MG NSO APTIOM 200MG ANTICONVULSANTS - MISC. NSO APTIOM 400MG NSO APTIOM 600MG NSO APTIOM 800MG NSO BANZEL 200MG BANZEL 400MG BANZEL 40MG/ ML SUSP carbamazepine 00mg chew carbamazepine 00mg er cap carbamazepine 200mg er cap carbamazepine 200mg er carbamazepine 200mg carbamazepine 20mg/ ml susp carbamazepine 300mg er cap carbamazepine 400mg er epitol 200mg gabapentin 00mg cap gabapentin 300mg cap gabapentin 400mg cap gabapentin 50mg/ ml soln gabapentin 600mg gabapentin 800mg LAMICTAL BLUE KIT LAMICTAL GREEN KIT LAMICTAL ORANGE KIT LAMICTAL XR BLUE KIT LAMICTAL XR GREEN KIT LAMICTAL XR ORANGE KIT lamotrigine 00mg er lamotrigine 00mg odt lamotrigine 00mg lamotrigine 50mg 22

24 lamotrigine 200mg er lamotrigine 200mg odt lamotrigine 200mg lamotrigine 250mg er lamotrigine 25mg chew lamotrigine 25mg er lamotrigine 25mg odt lamotrigine 25mg lamotrigine 300mg er lamotrigine 50mg er lamotrigine 50mg odt lamotrigine 5mg chew levetiracetam 000mg levetiracetam 00mg/ ml inj levetiracetam 00mg/ ml soln LEVETIRACETAM 0MG/ ML LEVETIRACETAM 5MG/ ML levetiracetam 250mg levetiracetam 500mg er levetiracetam 500mg LEVETIRACETAM 5MG/ ML levetiracetam 750mg er levetiracetam 750mg LYRICA 00MG CAP LYRICA 50MG CAP LYRICA 200MG CAP LYRICA 20MG/ ML SOLN LYRICA 225MG CAP LYRICA 25MG CAP LYRICA 300MG CAP LYRICA 50MG CAP LYRICA 75MG CAP oxcarbazepine 50mg oxcarbazepine 300mg oxcarbazepine 600mg oxcarbazepine 60mg/ ml susp OXTELLAR 50MG XR OXTELLAR 300MG XR OXTELLAR 600MG XR POTIGA 200MG NSO QL=90 Tabs/30 Days POTIGA 300MG NSO QL=90 Tabs/30 Days POTIGA 400MG NSO QL=90 Tabs/30 Days POTIGA 50MG NSO QL=90 Tabs/30 Days primidone 250mg primidone 50mg QUDEXY 00MG XR CAP NSO 23

25 QUDEXY 50MG XR CAP NSO QUDEXY 200MG XR CAP NSO QUDEXY 25MG XR CAP NSO QUDEXY 50MG XR CAP NSO TEGRETOL 00MG XR TOPIRAMATE 00MG ER CAP NSO topiramate 00mg TOPIRAMATE 50MG ER CAP NSO topiramate 5mg cap TOPIRAMATE 200MG ER CAP NSO topiramate 200mg topiramate 25mg cap TOPIRAMATE 25MG ER CAP NSO topiramate 25mg TOPIRAMATE 50MG ER CAP NSO topiramate 50mg TROKENDI 00MG XR CAP NSO TROKENDI 200MG XR CAP NSO TROKENDI 25MG XR CAP NSO TROKENDI 50MG XR CAP NSO VIMT 00MG QL=60 Tabs/30 Days VIMT 0MG/ ML SOLN VIMT 50MG QL=60 Tabs/30 Days VIMT 200MG QL=60 Tabs/30 Days VIMT 200MG/ 20ML VIMT 50MG QL=60 Tabs/30 Days zonisamide 00mg cap zonisamide 25mg cap zonisamide 50mg cap felbamate 20mg/ ml susp CARBAMATES felbamate 400mg felbamate 600mg GABITRIL 2MG GABA MODULATORS GABITRIL 6MG SABRIL 500MG SOLN SABRIL 500MG tiagabine 2mg tiagabine 4mg DILANTIN 30MG ER CAP HYDANTOINS fosphenytoin sodium 75mg/ ml inj PEGANONE 250MG phenytoin 25mg/ ml susp phenytoin 50mg chew 24

26 phenytoin sodium 00mg er cap phenytoin sodium 200mg er cap phenytoin sodium 300mg er cap phenytoin sodium 50mg/ ml inj CELONTIN 300MG CAP SUCCINIMIDES ethosuximide 250mg cap ethosuximide 50mg/ ml soln divalproex sodium 25mg dr cap VALPROIC ACID divalproex sodium 25mg dr divalproex sodium 250mg dr divalproex sodium 250mg er divalproex sodium 500mg dr divalproex sodium 500mg er valproic acid 00mg/ ml inj valproic acid 250mg cap valproic acid 50mg/ ml soln ANTIDEPRESSANTS ALPHA-2 RECEPTOR ANTAGONISTS (TETRACYCLICS) mirtazapine 5mg odt mirtazapine 5mg mirtazapine 30mg odt mirtazapine 30mg mirtazapine 45mg odt mirtazapine 45mg mirtazapine 7.5mg APLENZIN 74MG ER ANTIDEPRESSANTS - MISC. ST APLENZIN 348MG ER ST APLENZIN 522MG ER ST bupropion 00mg sr bupropion 00mg bupropion 50mg sr (2 hr) bupropion 50mg xl (24 hr) bupropion 200mg sr bupropion 300mg xl bupropion 75mg MAPROTILINE 25MG MAPROTILINE 50MG MAPROTILINE 75MG BRINTELLIX 0MG MODIFIED CYCLICS ST QL=30 Tabs/30 Days BRINTELLIX 20MG ST QL=30 Tabs/30 Days BRINTELLIX 5MG ST QL=30 Tabs/30 Days 25

27 NEFAZODONE 00MG NEFAZODONE 50MG NEFAZODONE 200MG nefazodone 250mg nefazodone 50mg trazodone 00mg trazodone 50mg trazodone 300mg trazodone 50mg VIIBRYD 0MG ST VIIBRYD 20MG ST VIIBRYD 40MG ST MONOAMINE OXIDASE INHIBITORS (MAOIS) EMSAM 2MG/ 24HR TCH EMSAM 6MG/ 24HR TCH EMSAM 9MG/ 24HR TCH MARPLAN 0MG phenelzine 5mg tranylcypromine 0mg SELECTIVE SEROTONIN REUPTAKE INHIBITORS (SSRIS) citalopram 0mg citalopram 20mg citalopram 2mg/ ml soln citalopram 40mg escitalopram 0mg escitalopram mg/ ml soln escitalopram 20mg escitalopram 5mg fluoxetine 0mg cap fluoxetine 0mg fluoxetine 20mg cap fluoxetine 20mg fluoxetine 40mg cap fluoxetine 4mg/ ml soln fluvoxamine maleate 00mg er cap ST fluvoxamine maleate 00mg fluvoxamine maleate 50mg er cap ST fluvoxamine maleate 25mg fluvoxamine maleate 50mg paroxetine 0mg paroxetine 2.5mg er paroxetine 20mg paroxetine 25mg er paroxetine 30mg paroxetine 37.5mg er paroxetine 40mg 26

28 XIL 0MG/ 5ML SUSP PEXEVA 0MG ST PEXEVA 20MG ST PEXEVA 30MG ST PEXEVA 40MG ST sertraline 00mg sertraline 20mg/ ml soln sertraline 25mg sertraline 50mg SEROTONIN MODULATORS VIIBRYD 0/ 20MG STARTER CK ST SEROTONIN-NOREPINEPHRINE REUPTAKE INHIBITORS (SNRIS) DESVENLAFAXINE 00MG ER ST DESVENLAFAXINE 50MG ER ST duloxetine 20mg dr cap QL=60 Caps/30 Days duloxetine 30mg dr cap QL=60 Caps/30 Days DULOXETINE 40MG DR CAP ST QL=30 Caps/30 Days duloxetine 60mg dr cap QL=60 Caps/30 Days FETZIMA 20MG ER CAP ST QL=30 Caps/30 Days FETZIMA 20MG ER CAP ST QL=30 Caps/30 Days FETZIMA 40MG ER CAP ST QL=30 Caps/30 Days FETZIMA 80MG ER CAP ST QL=30 Caps/30 Days FETZIMA CK ST QL=30 Caps/30 Days IRENKA 40MG DR CAP ST QL=30 Caps/30 Days KHEDEZLA 00MG ER ST KHEDEZLA 50MG ER ST PRISTIQ 00MG ER ST PRISTIQ 25MG ER PRISTIQ 50MG ER ST venlafaxine 00mg venlafaxine 50mg er cap venlafaxine 50mg er VENLAFAXINE 225MG ER venlafaxine 25mg venlafaxine 37.5mg er cap venlafaxine 37.5mg er venlafaxine 37.5mg venlafaxine 50mg venlafaxine 75mg er cap venlafaxine 75mg er venlafaxine 75mg amitriptyline 00mg TRICYCLIC AGENTS NSO amitriptyline 0mg NSO amitriptyline 50mg NSO amitriptyline 25mg NSO 27

29 amitriptyline 50mg amitriptyline 75mg AMOXAPINE 00MG AMOXAPINE 50MG AMOXAPINE 25MG AMOXAPINE 50MG clomipramine 25mg cap clomipramine 50mg cap clomipramine 75mg cap desipramine 00mg desipramine 0mg desipramine 50mg desipramine 25mg desipramine 50mg desipramine 75mg doxepin 00mg cap doxepin 0mg cap doxepin 0mg/ ml soln doxepin 50mg cap doxepin 25mg cap doxepin 50mg cap DOXEPIN 75MG CAP imipramine 0mg imipramine 25mg imipramine 50mg imipramine pamoate 00mg cap imipramine pamoate 25mg cap imipramine pamoate 50mg cap imipramine pamoate 75mg cap nortriptyline 0mg cap nortriptyline 25mg cap NORTRIPTYLINE 2MG/ ML SOLN nortriptyline 50mg cap nortriptyline 75mg cap protriptyline 0mg protriptyline 5mg SURMONTIL 00MG CAP SURMONTIL 25MG CAP SURMONTIL 50MG CAP trimipramine 00mg cap trimipramine 25mg cap trimipramine 50mg cap ANTIDIABETICS ALPHA-GLUCOSIDASE INHIBITORS acarbose 00mg NSO NSO NSO NSO NSO NSO NSO NSO NSO NSO NSO NSO NSO NSO NSO NSO NSO NSO NSO NSO NSO NSO NSO NSO NSO 28

30 acarbose 25mg acarbose 50mg GLYSET 00MG GLYSET 25MG GLYSET 50MG ANTIDIABETIC COMBINATIONS AVANDAMET 2-000MG glimepiride 2mg/ pioglitazone 30mg glimepiride 4mg/ pioglitazone 30mg glipizide 2.5mg/ metformin 250mg glipizide 2.5mg/ metformin 500mg glipizide 5mg/ metformin 500mg glyburide.25mg/ metformin 250mg glyburide 2.5mg/ metformin 500mg glyburide 5mg/ metformin 500mg JANUMET MG XR QL=60 Tabs/30 Days JANUMET MG QL=60 Tabs/30 Days JANUMET MG XR QL=60 Tabs/30 Days JANUMET MG QL=60 Tabs/30 Days JANUMET MG XR QL=60 Tabs/30 Days KOMBIGLYZE MG ER QL=30 Tabs/30 Days KOMBIGLYZE 5-000MG ER QL=30 Tabs/30 Days KOMBIGLYZE 5-500MG ER QL=30 Tabs/30 Days metformin 500mg/ pioglitazone 5mg metformin 850mg/ pioglitazone 5mg SYNJARDY MG QL=60 Tabs/30 Days SYNJARDY MG QL=60 Tabs/30 Days SYNJARDY 5-000MG QL=60 Tabs/30 Days SYNJARDY 5-500MG QL=60 Tabs/30 Days XIGDUO 0-000MG XR QL=30 Tabs/30 Days XIGDUO 0-500MG XR QL=30 Tabs/30 Days XIGDUO 5-000MG XR QL=60 Tabs/30 Days XIGDUO 5-500MG XR QL=30 Tabs/30 Days metformin 000mg er BIGUANIDES metformin 000mg metformin 500mg er metformin 500mg metformin 750mg er metformin 850mg GLUCAGEN MG DIABETIC OTHER GLUCAGON MG/ ML KORLYM 300MG PROGLYCEM 50MG/ ML SUSP DIPEPTIDYL PEPTIDASE-4 (DPP-4) INHIBITORS 29

31 JANUVIA 00MG QL=30 Tabs/30 Days JANUVIA 25MG QL=30 Tabs/30 Days JANUVIA 50MG QL=30 Tabs/30 Days ONGLYZA 2.5MG QL=30 Tabs/30 Days ONGLYZA 5MG QL=30 Tabs/30 Days INCRETIN MIMETIC AGENTS (GLP- RECEPTOR AGONISTS) BYDUREON 2MG BYDUREON 2MG SYR VICTOZA 8MG/ 3ML SYR INSULIN HUMULIN R 500UNIT/ ML LANTUS 00UNIT/ ML LANTUS 00UNIT/ ML SOLOSTAR LEVEMIR 00UNIT/ ML FLEXTOUCH LEVEMIR 00UNIT/ ML NOVOLIN 00UNIT/ ML NOVOLIN N 00UNIT/ ML NOVOLIN R 00UNIT/ ML NOVOLOG 00UNIT/ ML FLEXPEN NOVOLOG 00UNIT/ ML NOVOLOG 00UNIT/ ML PENFILL NOVOLOG MIX 00UNIT/ ML FLEXPEN NOVOLOG MIX 00UNIT/ ML TOUJEO 300UNIT/ ML SYR INSULIN SENSITIZING AGENTS AVANDIA 2MG AVANDIA 4MG pioglitazone 5mg pioglitazone 30mg pioglitazone 45mg MEGLITINIDE ANALOGUES nateglinide 20mg nateglinide 60mg repaglinide 0.5mg repaglinide mg repaglinide 2mg SODIUM-GLUCOSE CO-TRANSPORTER 2 (SGLT2) INHIBITORS FARXIGA 0MG QL=30 Tabs/30 Days FARXIGA 5MG QL=30 Tabs/30 Days JARDIANCE 0MG QL=30 Tabs/30 Days JARDIANCE 25MG QL=30 Tabs/30 Days CHLORPROMIDE 00MG SULFONYLUREAS CHLORPROMIDE 250MG glimepiride mg 30

32 glimepiride 2mg glimepiride 4mg glipizide 0mg er glipizide 0mg glipizide 2.5mg er glipizide 5mg er glipizide 5mg glyburide.25mg glyburide.5mg glyburide 2.5mg glyburide 3mg glyburide 5mg glyburide 6mg tolazamide 250mg tolazamide 500mg TOLBUTAMIDE 500MG ANTIDIARRHEALS ANTIPERISTALTIC AGENTS atropine sulfate 0.005mg/ ml/ diphenoxylate 0.5mg/ ml soln atropine sulfate 0.025mg/ diphenoxylate 2.5mg loperamide 2mg cap ANTIDOTES ANTIDOTES fomepizole 000mg/ ml inj CHEMET 00MG CAP ANTIDOTES - CHELATING AGENTS EXJADE 25MG SUSP EXJADE 250MG SUSP EXJADE 500MG SUSP FERRIPROX 00MG/ ML SOLN FERRIPROX 500MG LD JADENU 80MG JADENU 360MG JADENU 90MG NALOXONE MG/ ML SYR OPIOID ANTAGONISTS naltrexone 50mg granisetron 0.mg/ ml inj ANTIEMETICS 5-HT3 RECEPTOR ANTAGONISTS granisetron mg QL=9 Tabs/2 Days granisetron mg/ ml inj ondansetron 0.8mg/ ml soln ondansetron 24mg 3

33 ondansetron 2mg/ ml inj ondansetron 2mg/ ml syr ondansetron 4mg odt ondansetron 4mg ondansetron 8mg odt ondansetron 8mg meclizine 2.5mg ANTIEMETICS - ANTICHOLINERGIC meclizine 25mg TRANSDERM SCOP MG/ 3DAYS TCH trimethobenzamide 300mg cap AKYNZEO MG CAP ANTIEMETICS - MISCELLANEOUS QL= Caps/7 Days CESAMET MG CAP dronabinol 0mg cap dronabinol 2.5mg cap dronabinol 5mg cap SUBSTANCE P/ NEUROKININ (NK) RECEPTOR ANTAGONISTS EMEND 25MG CAP QL=3 Caps/2 Days EMEND 40MG CAP QL=3 Caps/2 Days EMEND 80MG CAP QL=3 Caps/2 Days EMEND TRI-FOLD CK QL=3 Caps/2 Days ANTIFUNGALS ANTIFUNGAL - GLUCAN SYNTHESIS INHIBITORS (ECHINOCANDINS) CANCIDAS 50MG CANCIDAS 70MG ERAXIS 00MG MYCAMINE 00MG MYCAMINE 50MG ABELCET 5MG/ ML ANTIFUNGALS AMBISOME 50MG AMPHOTERICIN B 5MG/ ML flucytosine 250mg cap flucytosine 500mg cap griseofulvin 25mg griseofulvin 250mg griseofulvin 25mg/ ml susp griseofulvin 500mg nystatin unit terbinafine 250mg IMIDAZOLE-RELATED ANTIFUNGALS fluconazole 00mg fluconazole 0mg/ ml susp fluconazole 50mg 32

34 fluconazole 200mg fluconazole 2mg/ ml inj fluconazole 40mg/ ml susp fluconazole 50mg itraconazole 00mg cap ketoconazole 200mg NOXAFIL 00MG DR NOXAFIL 40MG/ ML SUSP voriconazole 0mg/ ml inj voriconazole 200mg voriconazole 40mg/ ml susp voriconazole 50mg ANTIHISTAMINES ANTIHISTAMINES - ETHANOLAMINES arbinoxa 4mg arbinoxa 4mg/ 5ml soln carbinoxamine maleate 0.8mg/ ml soln carbinoxamine maleate 4mg clemastine fumarate 2.68mg diphenhydramine 2.5mg/ ml soln diphenhydramine 50mg/ ml inj ANTIHISTAMINES - NON-SEDATING cetirizine mg/ ml soln desloratadine 5mg levocetirizine 0.5mg/ ml soln levocetirizine 5mg ANTIHISTAMINES - PHENOTHIAZINES phenadoz 2.5mg rectal supp phenergan 2.5mg rectal supp phenergan 25mg rectal supp phenergan 50mg rectal supp phenylephrine mg/ ml/ promethazine.25mg/ ml soln promethazine.25mg/ ml soln promethazine 2.5mg rectal supp promethazine 2.5mg promethazine 25mg rectal supp promethazine 25mg promethazine 25mg/ ml inj promethazine 50mg rectal supp promethazine 50mg promethazine 50mg/ ml inj promethegan 25mg rectal supp promethegan 50mg rectal supp ANTIHISTAMINES - PIPERIDINES cyproheptadine 0.4mg/ ml soln 33

35 cyproheptadine 4mg ANTIHYPERLIPIDEMICS ANTIHYPERLIPIDEMICS - MISC. KYNAMRO 200MG/ ML SYR omega-3 acid ethyl esters (usp) 000mg cap VASCE GM CAP BILE ACID SEQUESTRANTS cholestyramine resin 66.7mg/ ml susp colestipol 000mg colestipol 5000mg granules prevalite 4gm/ dose susp WELCHOL 3.75GM SUSP WELCHOL 625MG FIBRIC ACID DERIVATIVES fenofibrate 30mg cap fenofibrate 34mg cap fenofibrate 45mg FENOFIBRATE 50MG CAP fenofibrate 60mg fenofibrate 200mg cap fenofibrate 43mg cap fenofibrate 48mg FENOFIBRATE 50MG CAP fenofibrate 54mg fenofibrate 67mg cap gemfibrozil 600mg TRIGLIDE 60MG TRILIPIX 35MG DR CAP TRILIPIX 45MG DR CAP HMG COA REDUCTASE INHIBITORS atorvastatin 0mg atorvastatin 20mg atorvastatin 40mg atorvastatin 80mg CRESTOR 0MG CRESTOR 20MG CRESTOR 40MG CRESTOR 5MG fluvastatin 20mg cap fluvastatin 40mg cap fluvastatin 80mg er LESCOL 80MG XL lovastatin 0mg lovastatin 20mg lovastatin 40mg QL=30 Tabs/30 Days QL=45 Tabs/30 Days QL=30 Tabs/30 Days QL=30 Tabs/30 Days 34