Formulary. IEHP DualChoice Cal MediConnect Plan. June. (Medicare-Medicaid Plan) IEHP (4347) TTY

Transcription

1 Formulary IEHP DualChoice Cal MediConnect Plan (Medicare-Medicaid Plan) IEHP (4347) TTY June 08

2 IEHP DualChoice Cal MediConnect Plan (Medicare-Medicaid Plan) 08 List of Covered Drugs (Formulary) This is a list of drugs that members can get in IEHP DualChoice. IEHP DualChoice Cal MediConnect Plan (Medicare-Medicaid Plan) is a health plan that contracts with both Medicare and Medi-Cal to provide benefits of both programs to enrollees. The List of Covered Drugs and/or pharmacy and provider networks may change throughout the year. We will send you a notice before we make a change that affects you. Benefits and/or copays may change on January of each year. You can always check IEHP DualChoice s up-to-date List of Covered Drugs online at or by calling IEHP (4347), 8am-8pm (PST), 7 days a week, including holidays. TTY/TDD users should call This call is free. Limitations, copays, and restrictions may apply. For more information, call IEHP DualChoice Member Services or read the IEHP DualChoice Member Handbook. Copays for prescription drugs may vary based on the level of Extra Help you get. Please contact the plan for more details. If you speak other languages, language assistance services, free of charge, are available to you. Call IEHP (4347), 8am-8pm (PST), 7ays a week, including holidays. TTY/TDD users should call The call is free. Si usted habla otro idioma o necesita asistencia de un intérprete, tenemos disponible para usted servicios de interpretación libres de costo. Llame al IEHP (4347), 8am 8pm (Hora del Pacífico), los 7 días de la semana, incluidos los días festivos. Los usuarios de TTY/TDD deben llamar al La llamada es gratuita. You can get this document for free in other formats, such as large print, braille, or audio. Call IEHP (4347), 8am-8pm (PST), 7 days a week, including holidays. TTY/TDD users should call The call is free. To make a standing request to receive materials in a language other than English or in an alternate format, please call IEHP DualChoice Member Services at IEHP (4347), 8am-8pm (PST), 7 days a week, including holidays. TTY/TDD users should call ? If you have questions, please call IEHP DualChoice at IEHP (4347), 8am-8pm (PST), 7 days a week, including holidays. TTY/TDD users should call The call is free. For more information, visit

3 Frequently Asked Questions (FAQ) Find answers here to questions you have about this List of Covered Drugs. You can read all of the FAQ to learn more, or look for a question and answer.. What prescription drugs are on the List of Covered Drugs? (We call the List of Covered Drugs the Drug List for short.) The drugs on the Drug List are the drugs covered by IEHP DualChoice. The drugs are available at pharmacies within our network. A pharmacy is in our network if we have an agreement with them to work with us and provide you services. We refer to these pharmacies as network pharmacies. IEHP DualChoice will cover all medically necessary drugs on the Drug List if: your doctor or other prescriber says you need them to get better or stay healthy, and you fill the prescription at an IEHP DualChoice network pharmacy. In some cases, you have to do something before you can get a drug (see question 5 below). You can also see an up-to-date list of drugs that we cover on our website at or call Member Services at IEHP (4347).. Does the Drug List ever change? Yes. IEHP DualChoice may add or remove drugs on the Drug List during the year. Generally, the Drug List will only change if: a cheaper drug comes along that works as well as a drug on the Drug List now, or we learn that a drug is not safe. We may also change our rules about drugs. For example, we could: Decide to require or not require prior approval for a drug. (Prior approval is permission from IEHP DualChoice before you can get a drug.) Add or change the amount of a drug you can get (called quantity limits ). Add or change step therapy restrictions on a drug. (Step therapy means you must try one drug before we will cover another drug.) (For more information on these drug rules, see page 3.) We will tell you when a drug you are taking is removed from the Drug List. We will also tell you when we change our rules for covering a drug. Questions 3, 4, and 7 below have more information on what happens when the Drug List changes.? If you have questions, please call IEHP DualChoice at IEHP (4347), 8am-8pm (PST), 7 days a week, including holidays. TTY/TDD users should call The call is free. For more information, visit

4 You can always check IEHP DualChoice s up to date Drug List online at You can also call Member Services to check the current Drug List at IEHP (4347). 3. What happens when a cheaper drug comes along that works as well as a drug on the Drug List now? If you are taking a drug that is removed because a cheaper drug that works just as well comes along, we will tell you. We will tell you at least 60 days before we remove it from the Drug List or when you ask for a refill. Then you can get a 60-day supply of the drug before the drug is removed from the drug list. You will receive a letter at least 60-days before the change is effective. This information is also available on our website at 4. What happens when we find out a drug is not safe? If the Food and Drug Administration (FDA) says a drug you are taking is not safe, we will take it off the Drug List right away. We will also send you a letter telling you that. Please contact the prescribing doctor after you receive your letter. 5. Are there any restrictions or limits on drug coverage? Or are there any required actions to take in order to get certain drugs? Yes, some drugs have coverage rules or have limits on the amount you can get. In some cases you or your doctor or other prescriber must do something before you can get the drug. For example: Prior approval (or prior authorization): For some drugs, you or your doctor or other prescriber must get approval from IEHP DualChoice before you fill your prescription. If you don t get approval, IEHP DualChoice may not cover the drug. Quantity limits: Sometimes IEHP DualChoice limits the amount of a drug you can get. Step therapy: Sometimes IEHP DualChoice requires you to do step therapy. This means you will have to try drugs in a certain order for your medical condition. You might have to try one drug before we will cover another drug. If your doctor thinks the first drug doesn t work for you, then we will cover the second. You can find out if your drug has any additional requirements or limits by looking in the tables on pages. You can also get more information by visiting our web site at We have posted online documents that explain our prior authorization and step therapy restrictions. We have posted online documents that explain our prior authorization restrictions. You may also ask us to send you a copy. You can ask for an exception from these limits. Please see Question for more information on exceptions.? If you have questions, please call IEHP DualChoice at IEHP (4347), 8am-8pm (PST), 7 days a week, including holidays. TTY/TDD users should call The call is free. For more information, visit 3

5 If you are in a nursing home or other long-term care facility and need a drug that is not on the Drug List, or if you cannot easily get the drug you need, we can help. We will cover a 3-day emergency supply of the drug you need (unless you have a prescription for fewer, whether or not you are a new IEHP DualChoice member. This will give you time to talk to your doctor or other prescriber. He or she can help you decide if there is a similar drug on the Drug List you can take instead or whether to ask for an exception. Please see Question for more information about exceptions. 6. How will you know if the drug you want has limitations or if there are required actions to take to get the drug? The List of Covered Drugs on page has a column labeled Necessary actions, restrictions, or limits on use. 7. What happens if we change our rules on how we cover some of the drugs? For example, if we add prior authorization (approval), quantity limits, and/or step therapy restrictions on a drug. We will tell you if we add prior approval, quantity limits, and/or step therapy restrictions on a drug. We will tell you at least 60 days before the restriction is added or when you next ask your pharmacy for a refill. Then, you can get a 60-day supply of the drug before the change to the coverage rules is made. This gives you time to talk to your doctor or other prescriber about what to do next. 8. How can you find a drug on the Drug List? There are two ways to find a drug: You can search alphabetically (if you know how to spell the drug), or You can search by medical condition. To search alphabetically, go to the Alphabetical Listing section. You can find it in the index that begins on page 9. Look in the index and find your drug. Next to your drug, you will see the page number where you can find the coverage information. Turn to the page listed in the index and find the name of your drug in the first column of the list. To search by medical condition, find the section labeled List of drugs by medical condition on page. The drugs in this section are grouped into categories depending on the type of medical conditions they are used to treat. For example, if you have a heart condition, you should look in the category, Cardiovascular Agents. That is where you will find drugs that treat heart conditions.? If you have questions, please call IEHP DualChoice at IEHP (4347), 8am-8pm (PST), 7 days a week, including holidays. TTY/TDD users should call The call is free. For more information, visit 4

6 9. What if the drug you want to take is not on the Drug List? If you don t see your drug on the Drug List, call Member Services at IEHP (4347), 8am-8pm (PST), 7 days a week, including holidays. TTY/TDD users should call and ask about it. If you learn that IEHP DualChoice will not cover the drug, you can do one of these things: Ask Member Services for a list of drugs like the one you want to take. Then show the list to your doctor or other prescriber. He or she can prescribe a drug on the Drug List that is like the one you want to take. Or You can ask the health plan to make an exception to cover your drug. Please see question for more information about exceptions. 0. What if you are a new IEHP DualChoice member and can t find your drug on the Drug List or have a problem getting your drug? We can help. We may cover a temporary 3-day supply of your drug during the first 90 days you are a member of IEHP DualChoice. This will give you time to talk to your doctor or other prescriber. He or she can help you decide if there is a similar drug on the Drug List you can take instead or whether to ask for an exception. We will cover a 3-day supply of your drug if: you are taking a drug that is not on our Drug List, or health plan rules do not let you get the amount ordered by your prescriber, or the drug requires prior approval by IEHP DualChoice, or you are taking a drug that is part of a step therapy restriction. If you live in a nursing home or other long-term care facility, you may refill your prescription for as long as 98 days. You may refill the drug multiple times during your first 90 days in the plan. This gives your prescriber time to change your drugs to those on the Drug List or ask for an exception. As a new member in our plan or continuing member who was affected by a formulary change from one year to the next, you may be taking drugs that are not on our formulary. Or, you may be taking drugs that are on our formulary that are hard for you to get. For example, you may need our approval before you can get your drug. Either way, talk to your doctor. He or she can help you choose the right course of action. This could be changing to a drug we do cover or seeking a formulary exception so that we will cover the drug. 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 is hard for you to get, we will cover a temporary 3-day supply (unless you have a prescription written for fewer when you go to a? If you have questions, please call IEHP DualChoice at IEHP (4347), 8am-8pm (PST), 7 days a week, including holidays. TTY/TDD users should call The call is free. For more information, visit 5

7 network pharmacy. After your first 3-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 cover your prescription refill until we have provided you with a 98-day transition supply, consistent with dispensing increment, (unless you have a prescription written for fewer. We will cover more than one refill of these drugs for the first 90 days of your membership. If you need a drug that is not on our formulary or it is hard for you to get, 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 while you ask for a formulary exception.. Can you ask for an exception to cover your drug? Yes. You can ask IEHP DualChoice to make an exception to cover a drug that is not on the Drug List. You can also ask us to change the rules on your drug. For example, IEHP DualChoice may limit the amount of a drug we will cover. If your drug has a limit, you can ask us to change the limit and cover more. Other examples: You can ask us to drop step therapy restrictions or prior approval requirements.. How long does it take to get an exception? First, we must get a statement from your prescriber supporting your request for an exception. After we get the statement, we will give you a decision on your exception request within 7 hours. If you or your prescriber think your health may be harmed if you have to wait 7 hours for a decision, you can ask for an expedited exception. This is a faster decision. If your prescriber supports your request, we will give you a decision within 4 hours of getting your prescriber s supporting statement. 3. How can you ask for an exception? To ask for an exception, call IEHP DualChoice Member Services. IEHP DualChoice Member Services will work with you and your provider to help you ask for an exception.? If you have questions, please call IEHP DualChoice at IEHP (4347), 8am-8pm (PST), 7 days a week, including holidays. TTY/TDD users should call The call is free. For more information, visit 6

8 4. What are generic drugs? Generic drugs are made up of the same ingredients as brand name drugs. They usually cost less than the brand name drug and their names are less commonly known. Generic drugs are approved by the Food and Drug Administration (FDA). IEHP DualChoice covers both brand name drugs and generic drugs. 5. What are OTC drugs? OTC stands for over-the-counter. IEHP DualChoice covers some OTC drugs when they are written as prescriptions by your provider. You can read the IEHP DualChoice Drug List to see what OTC drugs are covered. 6. Does IEHP DualChoice cover OTC non-drug products? IEHP DualChoice covers some OTC non-drug products when they are written as prescriptions by your provider. You can read the IEHP DualChoice Drug List to see what OTC non-drug products are covered. 7. What is your copay? You can read the IEHP DualChoice Drug List to learn about the copay for each drug. IEHP DualChoice members living in nursing homes or other long-term care facilities will have no copays. Some members getting long-term care in the community will also have no copays. Copays are listed by tiers. Tiers are groups of drugs with the same copay. Tier drugs may be generic drugs or non-medicare drugs that are covered by Medi-Cal. The copay is from $0 to $3.35, depending on your level of Medi-Cal eligibility. Tier drugs are brand name drugs. The copay is from $0 to $8.35, depending on your level of Medi-Cal eligibility. Tier 3 drugs have a copay of $0.? If you have questions, please call IEHP DualChoice at IEHP (4347), 8am-8pm (PST), 7 days a week, including holidays. TTY/TDD users should call The call is free. For more information, visit 7

9 List of Covered Drugs The list of covered drugs below gives you information about the drugs covered by IEHP DualChoice. If you have trouble finding your drug in the list, turn to the Index that begins on page 9. The first column of the chart lists the name of the drug. Brand name drugs are capitalized (e.g., NEXIUM) and generic drugs are listed in lower-case italics (e.g., omeprazole). The information in the Necessary actions, restrictions, or limits on use column tells you if IEHP DualChoice has any rules for covering your drug. Below are the meanings of the codes used in the Necessary actions, restrictions, or limits on use column: UPPERCASE BOLD= Brand name drugs lowercase italics= Generic drugs Drug Tier = Tier = Tier 3= Tier 3 NC= Not Covered NF= Non-Formulary Requirements / Limits PA= Prior Authorization B vs D= Part B vs D Prior Authorization QL= Quantity Limit ST= Step Therapy Tier : Drugs in this tier are generic drugs (including brand drugs treated as generic). The copay is a set payment you make for these generic drugs. For example, the copay is from $0 to $3.35. This amount depends on your income. Tier : Drugs in this tier are brand name drugs. The copay is from $0 to $8.35. This amount depends on your income. Tier 3: Drugs in this tier are drugs that are non-medicare drugs/over-the-counter (OTC) drugs. These drugs are covered by Medi-Cal. They have a $0 co-pay. NC: Not covered. These are drugs not covered by IEHP DualChoice. NF: Non-Formulary. Drugs that are not on our prescribed drugs list (known as a Formulary). PA: Prior Authorization. IEHP DualChoice requires you or your physician to get approval from us first before filling a certain drug. This extra step is called prior authorization. If you don't get approval, IEHP DualChoice may not cover the drug. B vs D: Part B vs D Prior Authorization. This is a drug that has a special PA requirement. It may be covered under one or two benefit programs: ) Medicare Part B, and/or ) Medicare Part D. This depends on many factors. Your physician may need to give us more details about the use and setting of the drug.? If you have questions, please call IEHP DualChoice at IEHP (4347), 8am-8pm (PST), 7 days a week, including holidays. TTY/TDD users should call The call is free. For more information, visit 8

10 QL: Quantity Limit. For certain drugs, IEHP DualChoice limits the amount of the drug that it will cover. This may be in addition to a standard one month or three month supply. ST: Step Therapy. In some cases, IEHP DualChoice requires you to first try certain drugs to treat your medical condition. This is the process before we will cover another drug for that condition. For example, either Drug A or Drug B may treat your medical condition. IEHP DualChoice may not cover Drug B unless you try Drug A first. If Drug A does not work for you, IEHP DualChoice will then cover Drug B Note: A drug in Tier 3 means the drug is not a Part D drug. You will not be required to pay a copay for these drugs. These drugs also have different rules for appeals. An appeal is a formal way of asking us to review a decision we made about your coverage and to change it if you think we made a mistake. For example, we might decide that a drug that you want is not covered or is no longer covered by Medicare or Medi-Cal. If you or your doctor disagrees with our decision, you can appeal. If you ever have a question, call Member Services at IEHP (4347). You can also read the Member Handbook to learn how to appeal a decision.? If you have questions, please call IEHP DualChoice at IEHP (4347), 8am-8pm (PST), 7 days a week, including holidays. TTY/TDD users should call The call is free. For more information, visit 9

11 0 IEHP DualChoice Cal MediConnect Plan (Medicare-Medicaid Plan) 08 Formulary Table of Contents Additional Demonstration Drugs... Analgesics... 0 Anesthetics... Anti-Addiction/ Substance Abuse Treatment Agents... Antibacterials... Anticonvulsants... 8 Antidementia Agents... 3 Antidepressants... 3 Antiemetics Antifungals Antigout Agents Anti-Inflammatory Agents Antimigraine Agents Antimyasthenic Agents Antimycobacterials Antineoplastics Antiparasitics Antiparkinson Agents Antipsychotics Antispasticity Agents Antivirals Anxiolytics... 5 Bipolar Agents... 5 Blood Glucose Regulators Blood Products/ Modifiers/ Volume Expanders Cardiovascular Agents Central Nervous System Agents Dental and Oral Agents Dermatological Agents Electrolytes/Minerals/Metals/Vitamins Gastrointestinal Agents Genetic Or Enzyme Disorder: Replacement, Modifiers, Treatment Genitourinary Agents... 7

12 Hormonal Agents, Stimulant/ Replacement/ Modifying (Adrenal)... 7 Hormonal Agents, Stimulant/ Replacement/ Modifying (Pituitary) Hormonal Agents, Stimulant/ Replacement/ Modifying (Sex Hormones/ Modifiers) Hormonal Agents, Stimulant/ Replacement/ Modifying (Thyroid) Hormonal Agents, Suppressant (Adrenal) Hormonal Agents, Suppressant (Pituitary) Hormonal Agents, Suppressant (Thyroid) Immunological Agents Inflammatory Bowel Disease Agents Metabolic Bone Disease Agents Ophthalmic Agents Otic Agents Respiratory Tract/ Pulmonary Agents Skeletal Muscle Relaxants Sleep Disorder Agents Index... 9

13 List of Drugs by Medical Condition The drugs in this section are grouped into categories depending on the type of medical conditions they are used to treat. For example, if you have a heart condition, you should look in the category, Cardiovascular Agents. That is where you will find drugs that treat heart conditions. Drug Name Tier Requirements / Limits Additional Demonstration Drugs Additional Demonstration Drugs ABREVA 0% CREAM 0 % 3 QL ( GM per 5 ACEPHEN 0 MG SUPPOSITORY 0 MG 3 QL (50 EA per 30 ACEPHEN 35 MG SUPPOSITORY 35 MG 3 QL (50 EA per 30 acetaminophen 60 mg/5 ml sol outer 60 mg/5 ml (5 ml) 3 QL (40 ML per 30 ACID REDUCER 0 MG TABLET MAX STRENGTH 0 MG 3 ACNE MEDICATION 0% GEL 0 % 3 ACNE MEDICATION 0% LOTION 0 % 3 ACNE MEDICATION 5% GEL 5 % 3 ACNE MEDICATION 5% LOTION 5 % 3 ALL DAY ALLERGY 0 MG TABLET INDOOR/OUTDOOR 0 MG 3 ALL DAY PAIN RLF 0 MG CAPLET CAPLET 0 MG 3 ALLERGY MULTI-SYMPTOM CAPLET CAPLET MG 3 QL (60 EA per 30 ALLERGY RELIEF 0 MG ODT NON-DROWSY 0 MG 3 QL (30 EA per 30 ALLI 60 MG CAPSULE STARTER PACK 60 MG 3 PA; QL (90 EA per 30 ALMACONE CHEWABLE TABLET MG 3 AMLACTIN MOISTURIZING BODY LOT FRAGRANCE/F, LOTION % ANTACID PLUS ANTI-GAS RELF LIQ REGULAR STR, ORIGINAL MG/5 ML 3 3 ANTACID-SIMETHICONE LIQUID MG/5 ML 3 ANTI-DANDRUFF % SHAMPOO % 3 ANTI-DIARRHEAL MG CAPLET CPLT EASY TO SWALLOW MG 3 ANTIFUNGAL % CREAM % 3 QL (60 GM per 30 AQUANIL HC % LOTION % 3 QL (0 ML per 30 ARTIFICIAL TEARS.4 % DROPS.4 % 3 ARTIFICIAL TEARS DROPS % 3 ARTIFICIAL TEARS EYE OINTMENT 83-5 % 3

14 aspirin ec 35 mg tablet orange 35 mg 3 QL (00 EA per 30 aspirin ec 8 mg tablet 8 mg 3 QL (00 EA per 30 AYR SALINE 0.65% NOSE DROPS 0.65 % 3 bacitracin 500 unit/gm ointmnt 500 unit/gram 3 bacitracin zn 500 unit/gm oint 500 unit/gram 3 bacitracin-polymyxin ointment 500-0,000 unit/gram 3 QL (30 GM per 30 bacitracin-polymyxin ointment u-d,44x.94gm pkt 500-0,000 unit/gram 3 benzonatate 00 mg capsule 00 mg 3 QL (90 EA per 30 benzoyl peroxide.5% gel (otc).5 % 3 benzoyl peroxide 5% wash (otc) 5 % 3 bromphenir-pseudoephed-dm syr (rx) mg/5 ml 3 calamine lotion 8-8 % 3 CALCIUM 600 MG TABLET 600 MG CALCIUM (,500 MG) 3 calcium carb 500 (,50) mg tb 500 mg calcium (,50 mg) 3 calcium carbonate 648 mg tab 60 mg calcium (648 mg) 3 calcium gluconate 500 mg tab 45 mg (500 mg) 3 calcium gluconate 650 mg tab 60 mg (650 mg) 3 CALPHRON 667 MG TABLET 667 MG 3 cetirizine hcl 0 mg chew tab children s, outer, u-d 0 mg 3 QL (30 EA per 30 cetirizine hcl 5 mg chew tab children s, outer, u-d 5 mg 3 QL (30 EA per 30 cetirizine hcl 5 mg tablet 5 mg 3 CHILD ALL DAY ALLERGY MG/ML CHILDREN'S, GRAPE MG/ML CHILD PAIN RLF 60 MG/5 ML SUS A/F 60 MG/5 ML 3 QL (40 ML per 30 CHILD PAIN-FEVER 80 MG TAB CHW 80 MG 3 QL (00 EA per 30 CHILD TRIAMINIC COLD-ALLERGY -.5 MG/5 ML 3 CHILDREN IBUPROFEN 00 MG/5 ML A/F, BUBBLE GUM 00 MG/5 ML chlorpheniramine er mg tab mg 3 cimetidine 00 mg tablet blister pack (otc) 00 mg 3 CITRUCEL 500 MG CAPLET 500 MG QL (40 ML per 30 clotrimazole % cream w/7 applicators % 3 QL (90 GM per 30 clotrimazole % solution (otc) % 3 QL (60 ML per 30 You can find information on what the symbols and abbreviations in this table mean by going to page 8 3

15 COLACE CLEAR 50 MG SOFTGEL 50 MG 3 QL (00 EA per 30 CONCEPTROL GEL 4 % 3 CONDOMS LUBRICATED 3 QL (4 EA per 30 CVS LUBRICANT EYE OINTMENT % 3 cyanocobalamin 30,000 mcg/30 outer, latex-free, mdv,000 mcg/ml 3 DIOCTO 60 MG/5 ML SYRUP 60 MG/5 ML 3 QL (480 ML per 30 diphenhydramine 50 mg capsule (otc) 50 mg 3 QL (00 EA per 30 docusate sodium 50 mg/5 ml liq 00's, u-d 50 mg/5 ml 3 QL (480 ML per 30 DOK 00 MG TABLET 00 MG 3 QL (00 EA per 30 D-VI-SOL 400 UNITS/ML DROP 400 UNIT/ML 3 EAR DROPS 6.5% 6.5 % 3 QL (30 ML per 30 ED CHLORPED JR SYRUP MG/5 ML 3 ED-A-HIST PSE TABLET.5-60 MG 3 ED-APAP 60 MG/5 ML LIQUID 60 MG/5 ML 3 QL (40 ML per 30 ED-CHLORTAN 4 MG TABLET 4 MG 3 famotidine 0 mg tablet 0 mg 3 FC FEMALE CONDOM 3 QL (6 EA per 30 FER-IN-SOL 5 MG/ML DROPS 5 MG IRON (75 MG)/ML 3 QL (50 ML per 30 ferrous sulf 0 mg/5 ml elix 0 mg (44 mg iron)/5 ml 3 QL (480 ML per 30 ferrous sulf 0 mg/5 ml liq 0 mg (44 mg iron)/5 ml 3 QL (480 ML per 30 ferrous sulf 300 mg/5 ml liq 300 mg (60 mg iron)/5 ml 3 QL (50 ML per 30 ferrous sulf ec 34 mg tablet 34 mg (65 mg iron) 3 QL (90 EA per 30 ferrous sulf ec 35 mg tablet u-d, outer 35 mg (65 mg iron) 3 QL (90 EA per 30 ferrous sulfate 35 mg tablet 35 mg (65 mg iron) 3 QL (90 EA per 30 FEVERALL 80 MG SUPPOSITORY INFANT'S, OUTER 80 MG 3 QL (50 EA per 30 FIBERCON 65 MG CAPLET 65 MG 3 FLEET BISACODYL EC 5 MG TAB 5 MG 3 QL (60 EA per 30 FLEET ENEMA 6'S, LATEX-FREE 9-7 GRAM/8 ML 3 FLEET GLYCERIN ADULT SUPPOS 3 FLEET PEDIA-LAX ENEMA GRAM/59 ML 3 FLEET PEDIA-LAX STOOL SOFTENER 50 MG/5 ML 3 FLEET PEDIA-LAX SUPPOSITORIES 3 folic acid mg tablet (rx) mg 3 4

16 folic acid 400 mcg tablet s/f, p/f, lactose-free 400 mcg 3 FOR STY RELIEF EYE OINTMENT 3 FUNGOID-D % CREAM % 3 GAS RELIEF 80 MG TABLET CHEW LACTOSE-FREE 80 MG 3 QL (60 EA per 30 GAVISCON MG TAB CHEW MG 3 GENTEAL MILD-MODERATE EYE DROP P/F, STRL 0.3 % 3 glucose 4 gram tablet chew na/f, caffeine free 4 gram 3 GS ALLERGY RELIEF 5 MG CAP 5 MG 3 QL (00 EA per 30 GS ALLERGY RELIEF 5 MG TABLET 5 MG 3 QL (00 EA per 30 GS ANTI-ITCH % CREAM % 3 QL (60 GM per 30 gs aspirin 35 mg tablet 35 mg 3 QL (00 EA per 30 gs aspirin 8 mg chewable tab 8 mg 3 QL (00 EA per 30 GS CHILD ALLERGY.5 MG/5 ML.5 MG/5 ML 3 QL (40 ML per 30 GS LICE KILLING SHAMPOO W/NIT COMB % 3 QL (47 ML per 30 GS STOMACH RLF 6 MG CHEW TAB GLUTEN-FREE 6 MG guaifen-codeine 00-0 mg/5 ml (otc) 0-00 mg/5 ml 3 QL (480 ML per 30 GYNOL II 3% GEL 3 % 3 HM DOUBLE ANTIBIOTIC OINTMENT 500-0,000 UNIT/GRAM hm vitamin e 400 unit softgel gluten-free 400 unit 3 hydrocortisone 0.5% cream (otc) 0.5 % 3 QL (30 GM per 30 hydrocortisone 0.5% cream 0.5 % 3 QL (30 GM per 30 hydrocortisone 0.5% ointment 0.5 % 3 QL (30 GM per 30 hydrocortisone % cream % 3 QL (30 GM per 30 hydrocortisone % ointment (otc) % 3 QL (30 GM per 30 HYDROMET SYRUP 5-.5 MG/5 ML 3 QL (480 ML per 30 ibuprofen 00 mg softgel liquid filled caps 00 mg 3 QL (00 EA per 30 ibuprofen 00 mg tablet coated 00 mg 3 QL (00 EA per 30 INFANT PAIN RLF 80 MG/0.8 ML A/F, CHERRY, INFANT S 80 MG/0.8 ML ISOPTO TEARS 0.5% EYE DROPS 0.5 % 3 KAOPECTATE 6 MG/5 ML SUSP 6 MG/5 ML QL (5 ML per 30 You can find information on what the symbols and abbreviations in this table mean by going to page 8 5

17 KONSYL 50 MG CAPSULE 0.5 GRAM 3 KONSYL PSYLLIUM FIBER PACKET GLUTN-F, ORANGE, OUTER 3.4 GRAM KONSYL PSYLLIUM FIBER POWDER GLUTEN FREE, ORANGE 3.4 GRAM/ GRAM KPN TABLET 3 KRO NASAL ALLERGY 4HR SPRAY 55 MCG 3 LAMISIL AT % CREAM ATHLETE'S FOOT % 3 LAXATIVE 5 MG TABLET 5 MG 3 QL (60 EA per 30 LICE TREATMENT % CREME RINSE NIT REMOVAL COMB % LOHIST-D LIQUID -30 MG/5 ML 3 loperamide mg/5 ml liquid mg/5 ml 3 loratadine 0 mg tablet non-drowsy 0 mg 3 loratadine 5 mg/5 ml soln child s, a/f, s/f, d/f 5 mg/5 ml QL (36 ML per 30 LOTRIMIN AF % CREAM % 3 QL (60 GM per 30 magnesium citrate solution saline laxative 3 magnesium oxide 50 mg caplet p/f, s/f, gluten/f 50 mg 3 QL (30 EA per 30 magnesium oxide 400 mg tablet 400 mg 3 QL (30 EA per 30 magnesium oxide 40 mg tablet 53mg elem magnesium 40 mg 3 QL (30 EA per 30 magnesium oxide 500 mg tablet p/f, s/f, lactose-free 500 mg 3 QL (30 EA per 30 MAPAP 60 MG/5 ML LIQUID 60 MG/5 ML 3 QL (40 ML per 30 meclizine.5 mg caplet caplet (otc).5 mg 3 QL (60 EA per 30 MEPHYTON 5 MG TABLET 5 MG 3 MICONAZOLE 7 00 MG VAG SUPP 00 MG 3 QL (7 EA per 30 MICONAZOLE 7 CREAM W/APPLICATOR % 3 QL (45 GM per 30 MILK OF MAGNESIA CONCENTRATED,400 MG/0 ML 3 MILK OF MAGNESIA SUSPENSION 400 MG/5 ML 3 MOTION SICKNESS 5 MG TABLET 5 MG 3 QL (60 EA per 30 MURO-8 % EYE DROPS % 3 NAPHCON-A EYE DROPS DROPTAINER % 3 NASAL DECONGESTANT 30 MG TAB 30 MG 3 QL (60 EA per 30 NASAL SPRAY 0.05% EXTRA MOISTURIZING 0.05 % 3 niacin 00 mg tablet 00 mg 3

18 niacin 50 mg tablet 50 mg 3 niacin 50 mg tablet 50 mg 3 niacin 500 mg tablet 500 mg 3 NIACIN FLUSH FREE 500 MG CAP GLUTEN-FREE, P/F, S/F 400 MG NIACIN (500 MG) niacin sa 50 mg capsule (otc) 50 mg 3 niacin tr 500 mg capsule 500 mg 3 NICODERM CQ 4 MG/4HR PATCH 4 MG/4 HR 3 QL (80 EA per 365 NICODERM CQ MG/4HR PATCH MG/4 HR 3 QL (80 EA per 365 NICODERM CQ 7 MG/4HR PATCH 7 MG/4 HR 3 QL (80 EA per 365 NICORETTE MG MINI LOZENGE MINT MG 3 QL (3600 EA per 365 NICORETTE 4 MG MINI LOZENGE 4 MG 3 QL (3600 EA per 365 nicotine mg chewing gum original mg 3 QL (430 EA per 365 nicotine mg lozenge inner mg 3 QL (3600 EA per 365 nicotine 4 mg chewing gum original 4 mg 3 QL (430 EA per 365 nicotine 4 mg lozenge outer 4 mg 3 QL (3600 EA per 365 nicotine transdermal system 4 hour patch kit -4-7 mg/4 hr 3 QL ( EA per 365 OCEAN 0.65% NASAL SPRAY 0.65 % 3 omega-3,000 mg softgel softgel,000 mg 3 omeprazole dr 0 mg tablet 0 mg 3 QL (60 EA per 30 ONETOUCH DELICA 33G LANCETS 33 GAUGE 3 ONETOUCH VERIO TEST STRIP 4 VIALS OF 5 3 OPCON-A EYE DROPS % 3 OPTION.5 MG TABLET.5 MG 3 QL ( EA per 30 PANOXYL 0% ACNE FOAMING WASH 0 % 3 PEDIALYTE SOLUTION 3 QL (08 ML per 30 PEG3350 POWDER 4 ONCE-DAILY DOSES 7 GRAM/DOSE 3 QL (57 GM per 30 PERSONAL BEST PEAK FLOW MTR 3 QL ( EA per 80 phentermine 5 mg capsule 5 mg 3 PA; QL (30 EA per 30 phentermine 30 mg capsule 30 mg 3 PA; QL (30 EA per 30 phentermine 37.5 mg tablet 37.5 mg 3 PA; QL (30 EA per 30 PHENYLHISTINE DH LIQUID (OTC) MG/5 ML 3 QL (480 ML per 30 PRENATAL TABLET (OTC) 7 MG IRON- 0.8 MG 3 You can find information on what the symbols and abbreviations in this table mean by going to page 8 3 7

19 prenatal tablet 7 mg iron- 800 mcg 3 PRENATAL VITAMINS TABLET PHOSPHORUS FREE 8 MG IRON- 800 MCG PREVACID 4HR DR 5 MG CAPSULE NA/F 5 MG 3 QL (60 EA per 30 PROMETHAZINE VC-CODEINE SYRUP MG/5 ML 3 QL (480 ML per 30 promethazine-codeine syrup mg/5 ml 3 QL (480 ML per 30 promethazine-dm solution mg/5 ml 3 promethazine-phenylephrine syr mg/5 ml 3 pyridoxine 00 mg/ml vial 5's, mdv 00 mg/ml 3 pyridoxine 5 mg tablet 5 mg 3 QC 3 DAY VAGINAL 4% CREAM 00 MG/5 GRAM (4 %) 3 QL (5 GM per 30 ra calamine lotion 3 REESE'S PINWORM 44 MG/ML SUSP 50 MG/ML 3 REFRESH LACRI-LUBE OINTMENT % 3 REFRESH P.M. OINTMENT % 3 REFRESH TEARS 0.5% EYE DROPS 0.5 % 3 REGULOID POWDER 3 RETAINE PM EYE OINTMENT 80-0 % 3 RID COMPLETE --3 LICE KIT % 3 QL ( EA per 30 RYNEX PSE LIQUID -5 MG/5 ML 3 QL (0 ML per 30 SCALPICIN % ANTI-ITCH LIQUID % 3 QL (74 ML per 30 SENEXON 8.8 MG/5 ML LIQUID 8.8 MG/5 ML 3 SENNA 8.6 MG TABLET 8.6 MG 3 SILPHEN COUGH SYRUP.5 MG/5 ML 3 QL (40 ML per 30 simethicone 40 mg/0.6 ml drop infant, a/f 40 mg/0.6 ml 3 QL (30 ML per 30 SLO-NIACIN 500 MG TABLET 500 MG 3 SM ANTI-DIARRHEAL MG SOFTGEL EASY TO SWALLOW, SFGL MG SM EYE WASH SOLUTION 3 SM FOAMING ANTACID TABLET CHEW 80-0 MG 3 SM PAIN REL JR STR TAB CHEW 60 MG 3 QL (00 EA per 30 SM VITAMIN D3 4,000 UNIT SFTGL SOFTGEL, GLUTEN-FREE 4,000 UNIT sodium bicarb 35 mg tablet 35 mg

20 sodium bicarb 650 mg tablet 0 gr 650 mg 3 sodium chloride 5% eye drop 5 % 3 sodium chloride 5% eye oint sterile 5 % 3 SOOTHE 6 MG CAPLET CAPLET 6 MG 3 STOMACH RELIEF MAX STR LIQUID MAX. STRENGTH 55 MG/5 ML STOOL SOFTENER 00 MG CAPSULE 00 MG 3 QL (00 EA per 30 STOOL SOFTENER 50 MG SOFTGEL SOFTGEL 50 MG 3 QL (00 EA per 30 SUDOGEST 60 MG TABLET 60 MG 3 QL (60 EA per 30 SUDOGEST COLD & ALLERGY TAB 4-60 MG 3 QL (60 EA per 30 SUPHEDRIN LIQUID 5 MG/5 ML 3 QL (40 ML per 30 SV VITAMIN D3,000 UNIT SFTGL SOFTGEL, P/F, S/F,000 UNIT SV VITAMIN D3 400 UNIT SOFTGEL SOFTGEL, P/F, S/F 400 UNIT SYSTANE NIGHTTIME EYE OINT 94-3 % 3 TEARS NATURALE FORTE DROPS % 3 TESSALON PERLE 00 MG CAP 00 MG 3 QL (80 EA per 30 thiamine 50 mg tablet 50 mg 3 thiamine hcl 50 mg tablet 50 mg 3 TRAVEL SICKNESS 5 MG TAB CHEW 5 MG 3 QL (60 EA per 30 TRIPLE ANTIBIOTIC OINTMENT ORIGINAL STRENGTH 3.5MG-400 UNIT- 5,000 UNIT/GRAM TRI-VITA DROPS, UNIT-MG-UNIT/ML 3 VAGISTAT-3 COMBO PACK 00 MG- % (9 GRAM) 3 QL ( EA per 30 VCF CONTRACEPTIVE FOAM.5 % 3 VIT D.5 MG (50,000 UNIT) 50,000 UNIT 3 vitamin a 0,000 unit capsule soluble 0,000 unit 3 vitamin b- 00 mg tablet 00 mg 3 VITAMIN B- 00 MG TABLET 00 MG 3 VITAMIN B-,000 MCG TABLET,000 MCG 3 VITAMIN B- 00 MG TABLET GLUTEN-FREE 00 MG 3 VITAMIN B-6 00 MG TABLET 00 MG 3 VITAMIN B-6 50 MG TABLET 50 MG 3 You can find information on what the symbols and abbreviations in this table mean by going to page

21 VITAMIN C 500 MG TABLET S/F, P/F,GLUTEN-FREE 500 MG 3 vitamin d 400 unit tablet s/f,l/f,y/f,gluten/f 400 unit 3 vitamin d3,000 unit tablet gluten/f, d/f,000 unit 3 vitamin d3 0,000 unit softgel softgel, p/f, s/f 0,000 unit 3 VITAMIN D3,000 UNIT SOFTGEL,000 UNIT 3 vitamin d3,000 unit tablet s/f, p/f,000 unit 3 VITAMIN D3 400 UNIT TABLET S/F,P/F 400 UNIT 3 vitamin d3 5,000 unit capsule s/f, p/f 5,000 unit 3 vitamin d3 5,000 unit tablet 5,000 unit 3 vitamin d3 50,000 unit capsule gluten-free 50,000 unit 3 V-R NASAL ALLERGY SYM SPRAY 5. MG/SPRAY (4 %) 3 WAL-MUCIL 00% NATURAL FIBER 3.4 GRAM/7 GRAM 3 WAL-MUCIL 00% NATURAL FIBER S/F,4 DOSES, ORANGE 3.4 GRAM/5.8 GRAM ZADITOR 0.05% (0.035%) DROPS UP TO HOURS (OTC) 0.05 % (0.035 %) ZANTAC 50 MG TABLET MAXIMUM STRENGTH 50 MG 3 ZANTAC 75 MG TABLET 75 MG 3 Analgesics Analgesics acetaminophen-codeine oral solution 0- mg/5 ml QL (4650 ML per 3 acetaminophen-codeine oral tablet mg QL (43 EA per 3 acetaminophen-codeine oral tablet mg QL (37 EA per 3 acetaminophen-codeine oral tablet mg QL (86 EA per 3 endocet oral tablet 0-35 mg QL (86 EA per 3 hydrocodone-acetaminophen oral tablet 0-35 mg, 5-35 mg, mg QL (48 EA per 3 hydrocodone-ibuprofen oral tablet mg QL (55 EA per 3 oxycodone-acetaminophen oral tablet 0-35 mg QL (86 EA per 3 oxycodone-acetaminophen oral tablet 5-35 mg QL (48 EA per 3 Nonsteroidal Anti-Inflammatory Drugs celecoxib oral capsule 00 mg, 00 mg, 400 mg, 50 mg ST; QL (6 EA per 3 diclofenac sodium oral tablet, delayed release (dr/ec) 5 mg, 75 mg ibuprofen oral tablet 800 mg

22 indomethacin oral capsule 5 mg PA; QL (4 EA per 3 meloxicam oral tablet 5 mg, 7.5 mg QL (3 EA per 3 nabumetone oral tablet 500 mg, 750 mg naproxen oral tablet 375 mg, 500 mg Opioid Analgesics, Long-Acting DURAMORPH (PF) INJECTION SOLUTION 0.5 MG/ML, MG/ML fentanyl transdermal patch 7 hour 00 mcg/hr, mcg/hr, 5 mcg/hr, 50 mcg/hr, 75 mcg/hr B vs D QL (0 EA per 30 morphine concentrate oral solution 00 mg/5 ml (0 mg/ml) QL (86 ML per 3 morphine oral capsule, extend. release pellets 0 mg, 00 mg, 0 mg, 30 mg, 50 mg, 60 mg, 80 mg QL (6 EA per 3 morphine oral solution 0 mg/5 ml QL (860 ML per 3 morphine oral solution 0 mg/5 ml (4 mg/ml) QL (930 ML per 3 morphine oral tablet 5 mg, 30 mg QL (86 EA per 3 morphine oral tablet extended release 00 mg QL (6 EA per 3 morphine oral tablet extended release 5 mg, 30 mg, 60 mg QL (93 EA per 3 morphine oral tablet extended release 00 mg QL (3 EA per 3 tramadol oral tablet extended release 4 hr 00 mg QL (93 EA per 3 tramadol oral tablet extended release 4 hr 00 mg QL (3 EA per 3 Opioid Analgesics, Short-Acting fentanyl citrate buccal lozenge on a handle,00 mcg,,600 mcg, 00 mcg, 400 mcg, 600 mcg, 800 mcg PA; QL (4 EA per 3 hydromorphone oral tablet mg, 4 mg QL (79 EA per 3 hydromorphone oral tablet 8 mg QL (4 EA per 3 LAZANDA NASAL SPRAY, NON-AEROSOL 00 MCG/SPRAY, 300 MCG/SPRAY, 400 MCG/SPRAY ; QL (3 EA per 3 oxycodone oral tablet 0 mg, 5 mg, 0 mg, 30 mg, 5 mg QL (86 EA per 3 tramadol oral tablet 50 mg QL (48 EA per 3 Anesthetics Local Anesthetics lidocaine (pf) injection solution 5 mg/ml (0.5 %) lidocaine hcl injection solution 0 mg/ml ( %) You can find information on what the symbols and abbreviations in this table mean by going to page 8

23 lidocaine hcl mucous membrane jelly % lidocaine hcl mucous membrane solution 4 % (40 mg/ml) lidocaine topical adhesive patch, medicated 5 % PA; QL (93 EA per 3 lidocaine topical ointment 5 % QL (60 GM per 3 lidocaine viscous mucous membrane solution % lidocaine-prilocaine topical cream.5-.5 % Anti-Addiction/ Substance Abuse Treatment Agents Alcohol Deterrents/Anti-Craving acamprosate oral tablet, delayed release (dr/ec) 333 mg disulfiram oral tablet 50 mg, 500 mg Opioid Dependence Treatments buprenorphine hcl injection syringe 0.3 mg/ml buprenorphine hcl sublingual tablet mg, 8 mg QL (93 EA per 3 buprenorphine-naloxone sublingual tablet -0.5 mg, 8- mg QL (93 EA per 3 naltrexone oral tablet 50 mg Opioid Reversal Agents naloxone injection solution 0.4 mg/ml naloxone injection syringe 0.4 mg/ml, mg/ml NARCAN NASAL SPRAY, NON-AEROSOL 4 MG/ACTUATION Smoking Cessation Agents bupropion hcl (smoking deters) oral tablet extended release hr 50 mg CHANTIX CONTINUING MONTH BOX ORAL TABLET MG CHANTIX ORAL TABLET 0.5 MG, MG CHANTIX STARTING MONTH BOX ORAL TABLETS, DOSE PACK 0.5 MG ()- MG (4) NICOTROL INHALATION CARTRIDGE 0 MG NICOTROL NS NASAL SPRAY, NON-AEROSOL 0 MG/ML Antibacterials Aminoglycosides amikacin injection solution 500 mg/ ml gentamicin in nacl (iso-osm) intravenous piggyback 00 mg/00 ml, 60 mg/50 ml, 80 mg/00 ml, 80 mg/50 ml gentamicin injection solution 40 mg/ml

24 gentamicin ophthalmic (eye) drops 0.3 % gentamicin topical cream 0. % gentamicin topical ointment 0. % neomycin oral tablet 500 mg neomycin-polymyxin b gu irrigation solution 40 mg-00,000 unit/ml paromomycin oral capsule 50 mg streptomycin intramuscular recon soln gram TOBI PODHALER INHALATION CAPSULE, W/INHALATION DEVICE 8 MG TOBRADEX OPHTHALMIC (EYE) OINTMENT % tobramycin in 0.5 % nacl inhalation solution for nebulization 300 mg/5 ml tobramycin ophthalmic (eye) drops 0.3 % tobramycin sulfate injection solution 0 mg/ml, 40 mg/ml ZANOSAR INTRAVENOUS RECON SOLN GRAM Antibacterials colistin (colistimethate na) injection recon soln 50 mg B vs D SYNERCID INTRAVENOUS RECON SOLN 500 MG B vs D Antibacterials, Other acetic acid otic (ear) solution % alcohol pads topical pads, medicated bacitracin ophthalmic (eye) ointment 500 unit/gram chloramphenicol sod succinate intravenous recon soln gram clindamycin hcl oral capsule 50 mg, 300 mg, 75 mg clindamycin in 5 % dextrose intravenous piggyback 300 mg/50 ml, 600 mg/50 ml, 900 mg/50 ml clindamycin phosphate intravenous solution 600 mg/4 ml clindamycin phosphate topical gel % clindamycin phosphate topical lotion % clindamycin phosphate topical solution % clindamycin phosphate topical swab % clindamycin phosphate vaginal cream % daptomycin intravenous recon soln 500 mg PA ; QL (4 EA per 8 PA; QL (0 ML per day) You can find information on what the symbols and abbreviations in this table mean by going to page 8 3

25 lincomycin injection solution 300 mg/ml linezolid intravenous parenteral solution 600 mg/300 ml PA linezolid oral suspension for reconstitution 00 mg/5 ml PA; QL (680 ML per 8 linezolid oral tablet 600 mg PA; QL (8 EA per 4 metronidazole in nacl (iso-os) intravenous piggyback 500 mg/00 ml metronidazole oral tablet 50 mg, 500 mg metronidazole topical cream 0.75 % metronidazole topical gel 0.75 %, % metronidazole topical lotion 0.75 % metronidazole vaginal gel 0.75 % mupirocin topical ointment % nitrofurantoin macrocrystal oral capsule 00 mg, 5 mg, 50 mg PA nitrofurantoin monohyd/m-cryst oral capsule 00 mg PA nitrofurantoin oral suspension 5 mg/5 ml PA tigecycline intravenous recon soln 50 mg PA trimethoprim oral tablet 00 mg vancomycin intravenous recon soln,000 mg, 0 gram, 500 mg B vs D vancomycin oral capsule 5 mg, 50 mg PA; QL (56 EA per 4 XIFAXAN ORAL TABLET 00 MG, 550 MG Beta-Lactam, Cephalosporins cefaclor oral capsule 50 mg, 500 mg cefaclor oral tablet extended release hr 500 mg cefadroxil oral capsule 500 mg cefadroxil oral suspension for reconstitution 50 mg/5 ml, 500 mg/5 ml cefadroxil oral tablet gram cefazolin injection recon soln gram, 0 gram, 500 mg cefdinir oral capsule 300 mg cefdinir oral suspension for reconstitution 5 mg/5 ml, 50 mg/5 ml cefepime injection recon soln gram, gram cefotaxime injection recon soln gram, gram, 500 mg cefoxitin intravenous recon soln gram, 0 gram, gram cefpodoxime oral suspension for reconstitution 00 mg/5 ml, 50 mg/5 ml 4

26 cefpodoxime oral tablet 00 mg, 00 mg cefprozil oral suspension for reconstitution 5 mg/5 ml, 50 mg/5 ml cefprozil oral tablet 50 mg, 500 mg ceftazidime injection recon soln gram, gram, 6 gram ceftriaxone injection recon soln gram, 0 gram, gram, 50 mg, 500 mg cefuroxime axetil oral tablet 50 mg, 500 mg cefuroxime sodium injection recon soln 750 mg cefuroxime sodium intravenous recon soln.5 gram, 7.5 gram cephalexin oral capsule 50 mg, 500 mg cephalexin oral suspension for reconstitution 5 mg/5 ml, 50 mg/5 ml cephalexin oral tablet 50 mg, 500 mg SUPRAX ORAL CAPSULE 400 MG SUPRAX ORAL TABLET, CHEWABLE 00 MG, 00 MG TEFLARO INTRAVENOUS RECON SOLN 400 MG, 600 MG Beta-Lactam, Other aztreonam injection recon soln gram CAYSTON INHALATION SOLUTION FOR NEBULIZATION 75 MG/ML imipenem-cilastatin intravenous recon soln 50 mg, 500 mg INVANZ INJECTION RECON SOLN GRAM meropenem intravenous recon soln gram, 500 mg Beta-Lactam, Penicillins amoxicillin oral capsule 50 mg, 500 mg amoxicillin oral suspension for reconstitution 5 mg/5 ml, 00 mg/5 ml, 50 mg/5 ml, 400 mg/5 ml amoxicillin oral tablet 500 mg, 875 mg amoxicillin oral tablet, chewable 5 mg, 50 mg amoxicillin-pot clavulanate oral suspension for reconstitution mg/5 ml, mg/5 ml, mg/5 ml, mg/5 ml amoxicillin-pot clavulanate oral tablet 50-5 mg, mg, mg amoxicillin-pot clavulanate oral tablet extended release hr, mg ; QL (84 ML per 8 You can find information on what the symbols and abbreviations in this table mean by going to page 8 5

27 amoxicillin-pot clavulanate oral tablet, chewable mg, mg ampicillin oral capsule 500 mg ampicillin sodium injection recon soln gram, 0 gram, 5 mg ampicillin-sulbactam injection recon soln.5 gram, 5 gram, 3 gram BICILLIN C-R INTRAMUSCULAR SYRINGE,00,000 UNIT/ ML(600K/600K),,00,000 UNIT/ ML(900K/300K) BICILLIN L-A INTRAMUSCULAR SYRINGE,00,000 UNIT/ ML,,400,000 UNIT/4 ML, 600,000 UNIT/ML dicloxacillin oral capsule 50 mg, 500 mg nafcillin injection recon soln gram, 0 gram oxacillin in dextrose(iso-osm) intravenous piggyback gram/50 ml, gram/50 ml oxacillin injection recon soln 0 gram, gram penicillin g pot in dextrose intravenous piggyback million unit/50 ml, 3 million unit/50 ml penicillin g potassium injection recon soln 0 million unit penicillin g procaine intramuscular syringe. million unit/ ml penicillin g sodium injection recon soln 5 million unit penicillin v potassium oral recon soln 5 mg/5 ml, 50 mg/5 ml penicillin v potassium oral tablet 50 mg, 500 mg piperacillin-tazobactam intravenous recon soln.5 gram, gram, 4.5 gram Macrolides AZASITE OPHTHALMIC (EYE) DROPS % azithromycin intravenous recon soln 500 mg azithromycin oral suspension for reconstitution 00 mg/5 ml, 00 mg/5 ml azithromycin oral tablet 50 mg, 50 mg (6 pack), 500 mg, 500 mg (3 pack), 600 mg clarithromycin oral suspension for reconstitution 5 mg/5 ml, 50 mg/5 ml clarithromycin oral tablet 50 mg, 500 mg clarithromycin oral tablet extended release 4 hr 500 mg ery pads topical swab % 6

28 ERY-TAB ORAL TABLET, DELAYED RELEASE (DR/EC) 333 MG ERYTHROCIN (AS STEARATE) ORAL TABLET 50 MG ERYTHROCIN INTRAVENOUS RECON SOLN 500 MG erythromycin ophthalmic (eye) ointment 5 mg/gram (0.5 %) erythromycin oral capsule, delayed release(dr/ec) 50 mg erythromycin oral tablet 50 mg, 500 mg erythromycin with ethanol topical gel % erythromycin with ethanol topical solution % Quinolones ciprofloxacin (mixture) oral tablet, er multiphase 4 hr,000 mg, 500 mg ciprofloxacin hcl ophthalmic (eye) drops 0.3 % ciprofloxacin hcl oral tablet 00 mg, 50 mg, 500 mg, 750 mg ciprofloxacin in 5 % dextrose intravenous piggyback 00 mg/00 ml ciprofloxacin lactate intravenous solution 400 mg/40 ml levofloxacin in d5w intravenous piggyback 500 mg/00 ml, 750 mg/50 ml levofloxacin intravenous solution 5 mg/ml levofloxacin ophthalmic (eye) drops 0.5 % levofloxacin oral solution 50 mg/0 ml levofloxacin oral tablet 50 mg, 500 mg, 750 mg moxifloxacin ophthalmic (eye) drops 0.5 % ofloxacin ophthalmic (eye) drops 0.3 % ofloxacin oral tablet 400 mg ofloxacin otic (ear) drops 0.3 % Sulfonamides silver sulfadiazine topical cream % sulfacetamide sodium (acne) topical suspension 0 % sulfacetamide sodium ophthalmic (eye) drops 0 % sulfadiazine oral tablet 500 mg sulfamethoxazole-trimethoprim intravenous solution mg/5 ml sulfamethoxazole-trimethoprim oral suspension mg/5 ml You can find information on what the symbols and abbreviations in this table mean by going to page 8 7

29 sulfamethoxazole-trimethoprim oral tablet mg, mg Tetracyclines doxy-00 intravenous recon soln 00 mg doxycycline hyclate oral capsule 00 mg doxycycline hyclate oral tablet 00 mg doxycycline monohydrate oral suspension for reconstitution 5 mg/5 ml doxycycline monohydrate oral tablet 50 mg, 75 mg minocycline oral capsule 00 mg, 50 mg, 75 mg minocycline oral tablet 00 mg, 50 mg, 75 mg ORACEA ORAL CAPSULE, IR - DELAY REL, BIPHASE 40 MG QL (3 EA per 3 tetracycline oral capsule 50 mg, 500 mg Anticonvulsants Anticonvulsants, Other BRIVIACT INTRAVENOUS SOLUTION 50 MG/5 ML BRIVIACT ORAL SOLUTION 0 MG/ML ; QL (60 ML per 3 BRIVIACT ORAL TABLET 0 MG ; QL (48 EA per 3 BRIVIACT ORAL TABLET 00 MG, 5 MG, 50 MG, 75 MG ; QL (6 EA per 3 DIASTAT ACUDIAL RECTAL KIT MG, MG 8 DIASTAT RECTAL KIT.5 MG levetiracetam intravenous solution 500 mg/5 ml levetiracetam oral solution 00 mg/ml levetiracetam oral tablet,000 mg, 50 mg, 500 mg, 750 mg levetiracetam oral tablet extended release 4 hr 500 mg QL (55 EA per 3 levetiracetam oral tablet extended release 4 hr 750 mg QL (4 EA per 3 roweepra oral tablet,000 mg, 500 mg, 750 mg roweepra xr oral tablet extended release 4 hr 500 mg, 750 mg SPRITAM ORAL TABLET FOR SUSPENSION,000 MG, 50 MG, 500 MG, 750 MG Calcium Channel Modifying Agents CELONTIN ORAL CAPSULE 300 MG ethosuximide oral capsule 50 mg

30 ethosuximide oral solution 50 mg/5 ml LYRICA ORAL CAPSULE 00 MG, 50 MG, 00 MG, 5 MG, 50 MG, 75 MG ; QL (93 EA per 3 LYRICA ORAL CAPSULE 5 MG, 300 MG ; QL (6 EA per 3 LYRICA ORAL SOLUTION 0 MG/ML ; QL (930 ML per 3 zonisamide oral capsule 00 mg, 5 mg, 50 mg Gamma-Aminobutyric Acid (GABA) Augmenting Agents clonazepam oral tablet 0.5 mg, mg, mg QL (30 EA per 3 clonazepam oral tablet, disintegrating 0.5 mg, 0.5 mg, 0.5 mg, mg, mg QL (30 EA per 3 clorazepate dipotassium oral tablet 5 mg, 3.75 mg, 7.5 mg QL (86 EA per 3 diazepam intensol oral concentrate 5 mg/ml PA; QL (48 ML per 3 diazepam oral solution 5 mg/5 ml ( mg/ml) PA; QL (40 ML per 3 diazepam oral tablet 0 mg, mg, 5 mg QL (4 EA per 3 divalproex oral capsule, delayed rel sprinkle 5 mg divalproex oral tablet extended release 4 hr 50 mg, 500 mg divalproex oral tablet, delayed release (dr/ec) 5 mg, 50 mg, 500 mg gabapentin oral capsule 00 mg, 300 mg, 400 mg QL (79 EA per 3 gabapentin oral solution 50 mg/5 ml QL (3 ML per 3 gabapentin oral tablet 600 mg QL (86 EA per 3 gabapentin oral tablet 800 mg QL (4 EA per 3 GABITRIL ORAL TABLET MG, 6 MG lorazepam oral tablet 0.5 mg, mg, mg QL (55 EA per 3 ONFI ORAL SUSPENSION.5 MG/ML ; QL (496 ML per 3 ONFI ORAL TABLET 0 MG, 0 MG ; QL (6 EA per 3 phenobarbital oral elixir 0 mg/5 ml (4 mg/ml) PA phenobarbital oral tablet 00 mg, 5 mg, 6. mg, 30 mg, 3.4 mg, 60 mg, 64.8 mg, 97. mg primidone oral tablet 50 mg, 50 mg PA SABRIL ORAL TABLET 500 MG ; QL (86 EA per 3 You can find information on what the symbols and abbreviations in this table mean by going to page 8 9

31 tiagabine oral tablet mg, 6 mg, mg, 4 mg valproate sodium intravenous solution 500 mg/5 ml (00 mg/ml) valproic acid (as sodium salt) oral solution 50 mg/5 ml valproic acid oral capsule 50 mg vigabatrin oral powder in packet 500 mg PA Glutamate Reducing Agents felbamate oral suspension 600 mg/5 ml felbamate oral tablet 400 mg, 600 mg FYCOMPA ORAL SUSPENSION 0.5 MG/ML ; QL (744 ML per 3 FYCOMPA ORAL TABLET 0 MG, MG, MG, 4 MG, 6 MG, 8 MG lamotrigine oral tablet 00 mg, 50 mg, 00 mg, 5 mg lamotrigine oral tablet extended release 4hr 00 mg, 00 mg, 5 mg, 50 mg, 300 mg, 50 mg lamotrigine oral tablet, chewable dispersible 5 mg, 5 mg topiramate oral capsule, sprinkle 5 mg, 5 mg 30 ; QL (3 EA per 3 topiramate oral tablet 00 mg, 00 mg, 50 mg QL (6 EA per 3 topiramate oral tablet 5 mg Sodium Channel Agents APTIOM ORAL TABLET 00 MG, 400 MG, 800 MG ; QL (3 EA per 3 APTIOM ORAL TABLET 600 MG ; QL (6 EA per 3 BANZEL ORAL SUSPENSION 40 MG/ML QL (480 ML per 3 BANZEL ORAL TABLET 00 MG, 400 MG QL (48 EA per 3 carbamazepine oral suspension 00 mg/5 ml carbamazepine oral tablet 00 mg carbamazepine oral tablet extended release hr 00 mg, 00 mg, 400 mg carbamazepine oral tablet, chewable 00 mg DILANTIN ORAL CAPSULE 30 MG fosphenytoin injection solution 00 mg pe/ ml oxcarbazepine oral suspension 300 mg/5 ml (60 mg/ml) oxcarbazepine oral tablet 50 mg, 300 mg, 600 mg PEGANONE ORAL TABLET 50 MG