PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN

Transcription

1 WPS MedicareRx Plan (PDP) 019 Formulary List of Covered s Version 8 PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN This formulary was updated on 11/15/018. For more recent information or other questions, please contact WPS MedicareRx Plan (PDP) at , or for TTY users, , 4 hours a day, seven days a week, or visit 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 WPS. When it refers to plan or our plan, it means WPS MedicareRx Plan. This document includes the list of the drugs (formulary) for our plan, which is current as of 11/15/018. 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 1/1/00, and from time to time during the year. S5753_COMPFORM_1809_C R Pr escr iption Coverag ; X WPS I HEALTH " INSURANCE

2 What is the WPS MedicareRx Plan formulary? A formulary is a list of covered drugs selected by WPS MedicareRx Plan in consultation with a team of health care providers, which represents the prescription therapies believed to be a necessary part of a quality treatment program. WPS MedicareRx Plan will generally cover the drugs listed in our formulary as long as the drug is medically necessary, the prescription is filled at a WPS MedicareRx Plan network pharmacy, and other plan rules are followed. For more information on how to fill your prescriptions, please review your Evidence of Coverage. Can the formulary (drug list) change? Generally, if you are taking a drug on our 019 formulary that was covered at the beginning of the year, we will not discontinue or reduce coverage of the drug during the 019 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, or the drug is removed from the market. 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. Below are changes to the drug list that will also affect members currently taking a drug: s removed from the market. If the Food and Administration deems a drug on our formulary to be unsafe or the drug's manufacturer removes the drug from the market, we will immediately remove the drug from our formulary and provide notice to members who take the drug. Other Changes. We may make other changes that affect members currently taking a drug. For instance, we may add a new generic drug to replace a brand name drug currently on the formulary or add new restrictions to the brand name drug or move it to a different cost-sharing tier. Or we may make changes based on new clinical guidelines. If we remove drugs from our formulary, or add prior authorization, quantity limits, and/or step therapy restrictions on a drug, or move a drug to a higher cost-sharing tier, we must notify affected members of the change at least 30 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 30-day supply of the drug. The enclosed formulary is current as of 11/15/018. To get updated information about the drugs covered by WPS MedicareRx Plan, please contact us. Our contact information appears on the front and back cover pages. i

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 1. 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, Hypertension/Lipids. If you know what your drug is used for, look for the category name in the list that begins on page 1. 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 74. The index provides an alphabetical list of all 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? WPS MedicareRx Plan covers both brand name drugs and generic drugs. A generic drug is approved by the FDA as having the same active ingredient as the brand name drug. Generally, generic drugs cost less than brand name drugs. Are there any restrictions on my coverage? Some covered drugs may have additional requirements or limits on coverage. These requirements and limits may include: Prior Authorization: WPS MedicareRx Plan requires you (or your physician) to get prior authorization for certain drugs. This means that you will need to get approval from WPS MedicareRx Plan before you fill your prescriptions. If you don t get approval, WPS MedicareRx Plan may not cover the drug. Quantity Limits: For certain drugs, WPS MedicareRx Plan limits the amount of the drug that WPS MedicareRx Plan will cover. For example, WPS MedicareRx Plan provides 18 per 8 days per prescription for sumatriptan tablets. This may be in addition to a standard one-month or three-month supply. Step Therapy: In some cases, WPS MedicareRx Plan requires you to first try certain drugs to treat your medical condition before we will cover another drug for that condition. For example, if A and B both treat your medical condition, WPS MedicareRx Plan may not cover B unless you try A first. If A does not work for you, WPS MedicareRx Plan will then cover B. You can find out if your drug has any additional requirements or limits by looking in the formulary that begins on page 1. You can also get more information about the restrictions applied to specific covered drugs by visiting our website. We have posted online documents that explain our prior authorization and therapy restrictions. You may also ask us to send you a copy. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages. You can ask WPS MedicareRx Plan 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 WPS MedicareRx Plan s formulary? on page iii for information about how to request an exception. ii

4 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 WPS MedicareRx Plan does not cover your drug, you have two options: You can ask Member Services for a list of similar drugs that are covered by WPS MedicareRx Plan. When you receive the list, show it to your doctor and ask him or her to prescribe a similar drug that is covered by WPS MedicareRx Plan. You can ask WPS MedicareRx Plan 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 WPS MedicareRx Plan formulary? You can ask WPS MedicareRx Plan 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 cover a formulary drug at a lower cost-sharing level if this drug is not on the specialty tier. If approved, this would lower the amount you must pay for your drug. You can ask us to waive coverage restrictions or limits on your drug. For example, for certain drugs, WPS MedicareRx Plan limits the amount of the drug that we will cover. If your drug has a quantity limit, you can ask us to waive the limit and cover a greater amount. Generally, WPS MedicareRx Plan will only approve your request for an exception if the alternative drugs included on the plan s formulary, the lower cost-sharing drug, 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, tiering, or utilization restriction exception. When you request a formulary, tiering, or utilization restriction exception you should submit a statement from your prescriber or physician supporting your request. Generally, we must make our decision within 7 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 7 hours for a decision. If your request to expedite is granted, we must give you a decision no later than 4 hours after we get a supporting statement from your doctor or other prescriber. iii

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. If your prescription is written for fewer days, we'll allow refills to provide up to a maximum 30-day supply of medication. 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 at least a 31-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 31-day emergency supply of that drug (unless you have a prescription for fewer while you pursue a formulary exception. For those who have been members of the plan for more than 90 days and experience a level of care change, as defined below, you can ask us for a 31-day supply: Entering a long-term care facility from a hospital or other setting; Leave a long-term care facility and return to the community; Are discharged from a hospital to a home; End a skilled nursing facility stay covered under Medicare Part A (where all pharmacy charges are covered) and must revert to coverage under their Part D plan formulary; Revert from hospice status to standard Medicare Part A and B benefits; and Are discharged from psychiatric hospitals with medication regimens that are highly individualized. NOTE: If you have not experienced a change in level of care, you are not eligible to receive a temporary supply of medication. We will evaluate your request using our normal procedures for assessing medication requests that require a prior authorization or a formulary exception. For more information For more detailed information about your WPS MedicareRx Plan prescription drug coverage, please review your Evidence of Coverage and other plan materials. If you have questions about WPS MedicareRx Plan, please contact us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages. If you have general questions about Medicare prescription drug coverage, please call Medicare at MEDICARE ( ) 4 hours a day, 7 days a week. TTY users should call or visit medicare.gov. iv

6 WPS MedicareRx Plan s formulary The formulary that begins on the next page provides coverage information about the drugs covered by WPS MedicareRx Plan. If you have trouble finding your drug in the list, turn to the index that begins on page 74. The first column of the chart lists the drug name. Brand name drugs are capitalized (e.g., AUGMENTIN) and generic drugs are listed in lower-case italics (e.g., amoxicillin). The information in the column tells you if WPS MedicareRx Plan has any special requirements for coverage of your drug. WPS MedicareRx Plan This table defines the standard copay structure during the initial coverage phase. Depending upon your income level, your actual cost-sharing may be less. For more information, consult your Evidence of Coverage. WPS MedicareRx Plan 1 (PDP) WPS MedicareRx Plan (PDP) Monthly Premium: $68.10 per month Monthly Premium: $11.10 per month Annual Deductible: $415 per year for prescription Annual Deductible: This plan does not have a deductible drugs* Prescription Benefits Initial Coverage: After you pay your yearly deductible, you pay the following until your total yearly drug costs reach $3,80. Total yearly drug costs are the total drug costs paid by both you and our Part D plan. You may get your drugs at network retail pharmacies and mail-order pharmacies. Phase 1: Initial Coverage (after you pay your deductible, if applicable) Preferred Retail Rx 30-Day Supply Standard Retail Rx 30-Day Supply Preferred Mail-Order Rx 90-Day Supply 1 Preferred generic drugs Generic drugs 3 Preferred brand drugs 4 Nonpreferred drugs 5 Specialty drugs You pay $0 You pay $5 You pay $0 1 Preferred You pay $13 You pay $4 You pay 45% of the cost You pay 5% of the You pay $18 You pay $47 You pay 50% of the cost You pay 5% of the You pay $3.50 You pay $105 You pay 45% of the cost Not available Prescription Benefits Initial Coverage: You pay the following until your total yearly drug costs reach $3,80. Total yearly drug costs are the total drug costs paid by both you and our Part D plan. You may get your drugs at network retail pharmacies and mail-order pharmacies. generic drugs Generic drugs 3 Preferred brand drugs 4 Nonpreferred drugs 5 Specialty drugs Preferred Retail Rx 30-Day Supply Standard Retail Rx 30-Day Supply Preferred Mail-Order Rx 90-Day Supply You pay $0 You pay $5 You pay $0 You pay $11 You pay $4 You pay 45% of the cost You pay 33% of the cost You pay $16 You pay $47 You pay 50% of the cost You pay 33% of the cost cost cost If you receive a three-month supply at retail (if available), you will pay three times your one-month copay. *During the deductible stage, you pay the full cost of drugs until you have paid $415. You pay $7.50 You pay $105 You pay 45% of the cost Not available v

7 Below is a list of abbreviations that may appear on the following pages in the column that tells you if there are any special requirements for coverage of your drug. List of Abbreviations B/D PA: This prescription drug may be covered under Medicare Part B or D depending upon the circumstances. Information may need to be submitted describing the use and setting of the drug to make the determination. LA: Limited Availability. This prescription may be available only at certain pharmacies. For more information, please call Customer Service at , 4 hours a day, 7 days a week. TTY users should call MO: Mail-Order. This prescription drug is available through our mail-order service, as well as through our retail network pharmacies. Consider using mail order for your long-term (maintenance) medications (such as high blood pressure medications). Retail network pharmacies may be more appropriate for short-term prescriptions (such as antibiotics). PA: Prior Authorization. The Plan requires you or your physician to get prior authorization for certain drugs. This means that you will need to get approval before you fill your prescriptions. If you don t get approval, we may not cover the drug. QL: Quantity Limit. For certain drugs, the Plan limits the amount of the drug that we will cover. ST: Step Therapy. In some cases, the Plan requires you to first try certain drugs to treat your medical condition before we will cover another drug for that condition. For example, if A and B both treat your medical condition, we may not cover B unless you try A first. If A does not work for you, we will then cover B. vi

8 Name ANTI - INFECTIVES ANTIFUNGAL AGENTS ABELCET 5 B/D PA; MO AMBISOME 5 B/D PA; MO amphotericin b 4 B/D PA; MO caspofungin 5 B/D PA clotrimazole mucous membrane CRESEMBA INTRAVENOUS CRESEMBA ORAL fluconazole fluconazole in dextrose(iso-o) fluconazole in nacl (iso-osm) piggyback 00 mg/100 ml fluconazole in nacl (iso-osm) piggyback 400 mg/00 ml 5 flucytosine griseofulvin microsize griseofulvin ultramicrosize itraconazole oral capsule ketoconazole oral MYCAMINE NOXAFIL ORAL nystatin oral suspension Name 1 nystatin oral tablet SPORANOX ORAL SOLUTION terbinafine hcl oral voriconazole voriconazole oral ANTIVIRALS abacavir abacavir-lamivudine abacavirlamivudinezidovudine acyclovir oral capsule acyclovir oral suspension 00 mg/5 ml acyclovir oral tablet acyclovir sodium recon soln 500 mg acyclovir sodium solution B/D PA 4 B/D PA; MO adefovir amantadine hcl APTIVUS ORAL CAPSULE APTIVUS ORAL SOLUTION atazanavir oral capsule 150 mg, 00 mg atazanavir oral capsule 300 mg 5 ATRIPLA

9 Name BARACLUDE ORAL SOLUTION BIKTARVY cidofovir 5 B/D PA; MO CIMDUO COMPLERA CRIXIVAN ORAL CAPSULE 00 MG, 400 MG DELSTRIGO DESCOVY didanosine oral capsule,delayed release(dr/ec) 00 mg, 50 mg, 400 mg EDURANT efavirenz oral capsule 00 mg efavirenz oral capsule 50 mg efavirenz oral tablet EMTRIVA entecavir EPCLUSA (8 per 8 EPIVIR HBV ORAL SOLUTION EVOTAZ famciclovir fosamprenavir FUZEON SUBCUTANEOUS RECON SOLN ganciclovir sodium B/D PA; MO Name GENVOYA HARVONI (8 per 8 INTELENCE ORAL TABLET 100 MG, 00 MG INTELENCE ORAL TABLET 5 MG INVIRASE ORAL CAPSULE INVIRASE ORAL TABLET 5 ISENTRESS HD ISENTRESS ORAL POWDER IN PACKET ISENTRESS ORAL TABLET ISENTRESS ORAL TABLET,CHEWAB LE 100 MG ISENTRESS ORAL TABLET,CHEWAB LE 5 MG JULUCA KALETRA ORAL TABLET MG KALETRA ORAL TABLET MG lamivudine lamivudinezidovudine LEXIVA ORAL SUSPENSION lopinavir-ritonavir

10 Name moderiba moderiba oral tablets,dose pack 00 mg (8)- 400 mg (8), mg (8)-mg (8) moderiba oral tablets,dose pack 400 mg (7)- 400 mg (7) moderiba oral tablets,dose pack 600 mg (7)- 600 mg (7) moderiba oral tablets,dose pack mg (8)-mg (8), mg (8)-mg (8) nevirapine oral suspension nevirapine oral tablet nevirapine oral tablet extended release 4 hr NORVIR ORAL CAPSULE NORVIR ORAL POWDER IN PACKET NORVIR ORAL SOLUTION 5 3 ODEFSEY oseltamivir PIFELTRO PREVYMIS INTRAVENOUS 5 Name PREVYMIS ORAL ; QL (30 PREZCOBIX PREZISTA ORAL SUSPENSION PREZISTA ORAL TABLET 150 MG, 75 MG PREZISTA ORAL TABLET 600 MG, 800 MG RELENZA DISKHALER RESCRIPTOR RETROVIR INTRAVENOUS REYATAZ ORAL POWDER IN PACKET ribasphere oral capsule ribasphere oral tablet 00 mg, 400 mg ribasphere oral tablet 600 mg ribasphere ribapak oral tablets,dose pack 00 mg (8)- 400 mg (8) ribasphere ribapak oral tablets,dose pack 00 mg (7)- 400 mg (7) 3

11 Name ribasphere ribapak oral tablets,dose pack 400 mg (7)- 400 mg (7), 600 mg (7)- 400 mg (7), 600 mg (7)- 600 mg (7) ribasphere ribapak oral tablets,dose pack mg (8)-mg (8), mg (8)-mg (8), mg (8)-mg (8) ribavirin oral capsule ribavirin oral tablet 00 mg 5 rimantadine ritonavir SELZENTRY stavudine oral capsule STRIBILD SYMFI SYMFI LO SYMTUZA SYNAGIS ; LA tenofovir disoproxil fumarate TIVICAY ORAL TABLET 10 MG TIVICAY ORAL TABLET 5 MG, 50 MG TRIUMEQ TROGARZO ; LA TRUVADA Name valacyclovir oral tablet 1 gram valacyclovir oral tablet 500 mg ; QL (10 ; QL (60 valganciclovir VEMLIDY VIDEX GRAM PEDIATRIC VIDEX 4 GRAM PEDIATRIC VIDEX EC ORAL CAPSULE,DELAY ED RELEASE(DR/EC) 15 MG VIRACEPT ORAL TABLET VIRAMUNE ORAL SUSPENSION VIREAD ORAL POWDER VIREAD ORAL TABLET 150 MG, 00 MG, 50 MG ZERIT ORAL RECON SOLN 4 MO 4 MO 4 MO zidovudine CEPHALOSPORINS cefaclor oral capsule cefaclor oral suspension for reconstitution 15 mg/5 ml, 50 mg/5 ml cefaclor oral suspension for reconstitution 375 mg/5 ml 4

12 Name cefaclor oral tablet extended release 1 hr cefadroxil oral capsule cefadroxil oral suspension for reconstitution 50 mg/5 ml, 500 mg/5 ml cefadroxil oral tablet cefazolin in dextrose (iso-os) piggyback 1 gram/50 ml, gram/50 ml cefazolin injection recon soln 1 gram, 500 mg cefazolin injection recon soln 10 gram, 100 gram, 0 gram, 300 g cefazolin cefdinir cefepime cefepime in dextrose,iso-osm piggyback 1 gram/50 ml cefepime in dextrose,iso-osm piggyback gram/100 ml cefixime Name cefotaxime injection recon soln 1 gram, gram, 500 mg cefotetan cefoxitin in dextrose, iso-osm cefoxitin recon soln 1 gram, gram cefoxitin recon soln 10 gram cefpodoxime cefprozil ceftazidime injection recon soln 1 gram, gram ceftazidime injection recon soln 6 gram ceftriaxone in dextrose,iso-os ceftriaxone injection recon soln 1 gram, gram, 50 mg, 500 mg ceftriaxone injection recon soln 10 gram ceftriaxone cefuroxime axetil oral tablet cefuroxime sodium injection recon soln 750 mg cefuroxime sodium recon soln 1.5 gram 5

13 Name cefuroxime sodium recon soln 7.5 gram cephalexin SUPRAX ORAL CAPSULE SUPRAX ORAL SUSPENSION FOR RECONSTITUTIO N 500 MG/5 ML SUPRAX ORAL TABLET,CHEWAB LE 4 MO 4 4 MO TEFLARO ERYTHROMYCINS / OTHER MACROLIDES azithromycin azithromycin oral packet azithromycin oral suspension for reconstitution azithromycin oral tablet 50 mg, 50 mg (6 pack), 500 mg, 600 mg azithromycin oral tablet 500 mg (3 pack) clarithromycin e.e.s. 400 oral tablet ery-tab oral tablet,delayed release (dr/ec) 50 mg, 333 mg Name ERY-TAB ORAL TABLET,DELAYE D RELEASE (DR/EC) 500 MG erythrocin (as stearate) oral tablet 50 mg ERYTHROCIN INTRAVENOUS RECON SOLN 500 MG erythromycin ethylsuccinate oral suspension for reconstitution erythromycin ethylsuccinate oral tablet erythromycin oral capsule,delayed release(dr/ec) erythromycin oral tablet MISCELLANEOUS ANTIINFECTIVES ALBENZA ALINIA ORAL SUSPENSION FOR RECONSTITUTIO N ALINIA ORAL TABLET amikacin injection solution 1,000 mg/4 ml, 500 mg/ ml atovaquone atovaquoneproguanil aztreonam 6

14 Name baciim bacitracin intramuscular BENZNIDAZOLE 3 BETHKIS 5 B/D PA; MO; QL (4 per 8 CAPASTAT 4 CAYSTON ; LA; QL (84 per 8 chloramphenicol sod succinate chloroquine phosphate clindamycin hcl clindamycin in 5 % dextrose clindamycin palmitate hcl clindamycin pediatric clindamycin phosphate injection clindamycin phosphate COARTEM colistin (colistimethate na) dapsone oral DAPTOMYCIN INTRAVENOUS RECON SOLN 350 MG 3 Name daptomycin recon soln 500 mg DARAPRIM 5 PA; MO EMVERM ertapenem ethambutol gentamicin in nacl (iso-osm) piggyback 100 mg/100 ml, 60 mg/50 ml, 80 mg/50 ml gentamicin in nacl (iso-osm) piggyback 80 mg/100 ml gentamicin injection gentamicin sulfate (ped) (pf) hydroxychloroquine imipenem-cilastatin IMPAVIDO INVANZ INJECTION INVANZ INTRAVENOUS isoniazid injection 4 MO isoniazid oral ivermectin lincomycin linezolid linezolid in dextrose 5% 4 5 7

15 Name linezolid-0.9% sodium chloride mefloquine meropenem metro i.v. metronidazole in nacl (iso-os) 5 metronidazole oral NEBUPENT 3 B/D PA; MO; QL (1 per 8 neomycin paromomycin 4 MO PASER PENTAM 4 MO polymyxin b sulfate praziquantel PRIFTIN PRIMAQUINE pyrazinamide quinine sulfate rifabutin rifampin SIRTURO ; LA STREPTOMYCIN SYNERCID 5 tigecycline 5 tinidazole tobramycin in 0.5 % nacl tobramycin sulfate injection recon soln 5 B/D PA; MO; QL (80 per 8 Name tobramycin sulfate injection solution TRECATOR VANCOMYCIN IN 0.9 % SODIUM CHL INTRAVENOUS PIGGYBACK vancomycin recon soln 1,000 mg, 10 gram, 5 gram, 500 mg, 750 mg vancomycin oral capsule 15 mg vancomycin oral capsule 50 mg XIFAXAN ORAL TABLET 00 MG XIFAXAN ORAL TABLET 550 MG PENICILLINS amoxicillin oral capsule amoxicillin oral suspension for reconstitution amoxicillin oral tablet amoxicillin oral tablet,chewable 15 mg, 50 mg amoxicillin-pot clavulanate ampicillin oral capsule 500 mg ampicillin sodium injection 3 ; QL (9 per 30 ; QL (90 8

16 Name ampicillin sodium ampicillin-sulbactam injection recon soln 1.5 gram, 3 gram ampicillin-sulbactam injection recon soln 15 gram ampicillin-sulbactam recon soln 1.5 gram ampicillin-sulbactam recon soln 3 gram AUGMENTIN ORAL SUSPENSION FOR RECONSTITUTIO N MG/5 ML BICILLIN C-R BICILLIN L-A dicloxacillin nafcillin in dextrose iso-osm piggyback 1 gram/50 ml nafcillin in dextrose iso-osm piggyback gram/100 ml nafcillin injection recon soln 1 gram, gram nafcillin injection recon soln 10 gram nafcillin Name oxacillin in dextrose(iso-osm) piggyback 1 gram/50 ml oxacillin in dextrose(iso-osm) piggyback gram/50 ml oxacillin injection recon soln 1 gram oxacillin injection recon soln 10 gram oxacillin injection recon soln gram penicillin g potassium penicillin g procaine intramuscular syringe 1. million unit/ ml penicillin g procaine intramuscular syringe 600,000 unit/ml 5 penicillin g sodium penicillin v potassium pfizerpen-g piperacillintazobactam recon soln.5 gram, gram, 4.5 gram, 40.5 gram QUINOLONES ciprofloxacin 9

17 Name ciprofloxacin (mixture) ciprofloxacin hcl oral ciprofloxacin in 5 % dextrose levofloxacin in d5w piggyback 50 mg/50 ml levofloxacin in d5w piggyback 500 mg/100 ml, 750 mg/150 ml levofloxacin levofloxacin oral moxifloxacin in nacl (iso-osm) moxifloxacin oral ofloxacin oral tablet 300 mg ofloxacin oral tablet 400 mg SULFA'S / RELATED AGENTS sulfadiazine 4 MO sulfamethoxazoletrimethoprim sulfatrim TETRACYCLINES demeclocycline 4 MO doxy-100 doxycycline hyclate doxycycline hyclate oral capsule Name doxycycline hyclate oral tablet 100 mg, 150 mg, 0 mg, 75 mg doxycycline hyclate oral tablet 50 mg doxycycline monohydrate oral capsule doxycycline monohydrate oral suspension for reconstitution doxycycline monohydrate oral tablet minocycline oral capsule minocycline oral tablet 10 mondoxyne nl morgidox okebo oral capsule 75 mg tetracycline URINARY TRACT AGENTS methenamine hippurate methenamine mandelate nitrofurantoin nitrofurantoin macrocrystal nitrofurantoin monohyd/m-cryst trimethoprim

18 Name ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS ADJUNCTIVE AGENTS dexrazoxane hcl recon soln 50 mg dexrazoxane hcl recon soln 500 mg 5 B/D PA 5 B/D PA; MO ELITEK KEPIVANCE leucovorin calcium injection recon soln 100 mg, 00 mg, 350 mg, 50 mg leucovorin calcium injection recon soln 500 mg leucovorin calcium oral LEVOLEUCOVORI N INTRAVENOUS RECON SOLN 175 MG levoleucovorin recon soln 50 mg levoleucovorin solution B/D PA; MO B/D PA 5 B/D PA 5 B/D PA 5 B/D PA mesna B/D PA; MO MESNEX ORAL VISTOGARD XGEVA 5 B/D PA; MO ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS ABRAXANE 5 B/D PA; MO Name adriamycin solution adrucil solution.5 gram/50 ml adrucil solution 5 gram/100 ml, 500 mg/10 ml B/D PA B/D PA B/D PA; MO AFINITOR (30 per 30 AFINITOR DISPERZ 5 PA; MO ALECENSA (40 per 30 ALIMTA 5 B/D PA; MO ALIQOPA 5 B/D PA; MO; LA ALUNBRIG ORAL TABLET 180 MG, 90 MG ALUNBRIG ORAL TABLET 30 MG ALUNBRIG ORAL TABLETS,DOSE PACK (30 per 30 (60 per 30 (30 per 30 anastrozole ARRANON 5 B/D PA ARZERRA 5 B/D PA; MO AVASTIN 5 B/D PA; MO azacitidine 5 B/D PA; MO azathioprine B/D PA; MO azathioprine sodium B/D PA BAVENCIO 5 B/D PA; MO; LA 11

19 Name BELEODAQ 5 B/D PA; MO BENDEKA 5 B/D PA; MO BESPONSA 5 B/D PA; MO; LA bexarotene 5 PA; MO bicalutamide BICNU 5 B/D PA; MO bleomycin B/D PA; MO BLINCYTO INTRAVENOUS KIT 5 B/D PA; MO BORTEZOMIB 5 B/D PA; MO BOSULIF ORAL TABLET 100 MG BOSULIF ORAL TABLET 400 MG, 500 MG BRAFTOVI ORAL CAPSULE 50 MG BRAFTOVI ORAL CAPSULE 75 MG (90 per 30 (30 per 30 5 PA; MO; LA; QL (10 per 30 5 PA; MO; LA; QL (180 per 30 busulfan 5 B/D PA CABOMETYX 5 PA; MO; LA CALQUENCE 5 PA; MO; LA; QL (60 per 30 CAPRELSA ORAL TABLET 100 MG CAPRELSA ORAL TABLET 300 MG carboplatin solution 5 PA; MO; LA; QL (60 per 30 5 PA; MO; LA; QL (30 per 30 B/D PA; MO Name carmustine 5 B/D PA; MO cisplatin B/D PA; MO cladribine 5 B/D PA; MO clofarabine 5 B/D PA COMETRIQ 5 PA; MO COSMEGEN 5 B/D PA; MO COTELLIC 5 PA; MO; LA; QL (63 per 8 cyclophosphamide cyclophosphamide oral capsule cyclosporine cyclosporine modified cyclosporine oral capsule B/D PA; MO B/D PA; MO B/D PA B/D PA; MO B/D PA; MO CYRAMZA 5 B/D PA; MO cytarabine B/D PA; MO cytarabine (pf) injection solution 100 mg/5 ml (0 mg/ml), gram/0 ml (100 mg/ml) cytarabine (pf) injection solution 0 mg/ml B/D PA; MO B/D PA dacarbazine B/D PA; MO dactinomycin B/D PA DARZALEX 5 B/D PA; MO; LA daunorubicin solution B/D PA decitabine 5 B/D PA; MO 1

20 Name docetaxel solution 160 mg/16 ml (10 mg/ml), 0 mg/ ml (10 mg/ml) docetaxel solution 160 mg/8 ml (0 mg/ml), 0 mg/ml (1 ml), 80 mg/4 ml (0 mg/ml), 80 mg/8 ml (10 mg/ml) DOCETAXEL INTRAVENOUS SOLUTION 0 MG/ML doxorubicin recon soln 10 mg doxorubicin recon soln 50 mg doxorubicin solution doxorubicin, pegliposomal 5 B/D PA 5 B/D PA; MO 5 B/D PA B/D PA B/D PA; MO B/D PA; MO 5 B/D PA; MO DROXIA EMCYT EMPLICITI 5 B/D PA; MO epirubicin solution B/D PA; MO ERBITUX 5 B/D PA; MO ERIVEDGE (30 per 30 ERLEADA 5 PA; MO ERWINAZE 5 B/D PA; MO ETOPOPHOS 4 B/D PA; MO Name etoposide B/D PA; MO exemestane FARESTON FARYDAK ORAL CAPSULE 10 MG FARYDAK ORAL CAPSULE 15 MG, 0 MG (1 per 1 (6 per 1 FASLODEX 5 B/D PA; MO FIRMAGON KIT W DILUENT SYRINGE SUBCUTANEOUS RECON SOLN 10 MG FIRMAGON KIT W DILUENT SYRINGE SUBCUTANEOUS RECON SOLN 80 MG 5 B/D PA; MO 3 B/D PA; MO floxuridine B/D PA fludarabine recon soln fludarabine solution fluorouracil B/D PA; MO B/D PA B/D PA; MO flutamide FOLOTYN 5 B/D PA; MO GAZYVA 5 B/D PA; MO gemcitabine recon soln 1 gram, 00 mg B/D PA; MO 13

21 Name gemcitabine recon soln gram gemcitabine solution 1 gram/6.3 ml (38 mg/ml), 00 mg/5.6 ml (38 mg/ml) GEMCITABINE INTRAVENOUS SOLUTION 100 MG/ML gemcitabine solution gram/5.6 ml (38 mg/ml) gengraf oral capsule 100 mg, 5 mg B/D PA B/D PA; MO 3 B/D PA B/D PA B/D PA; MO gengraf oral solution B/D PA; MO GILOTRIF (30 per 30 GLEOSTINE HALAVEN 5 B/D PA; MO HERCEPTIN 5 B/D PA; MO HEXALEN hydroxyurea IBRANCE (1 per 8 ICLUSIG ORAL TABLET 15 MG ICLUSIG ORAL TABLET 45 MG (60 per 30 (30 per 30 idarubicin B/D PA Name IDHIFA 5 PA; MO; LA; QL (30 per 30 ifosfamide recon soln ifosfamide solution imatinib oral tablet 100 mg imatinib oral tablet 400 mg IMBRUVICA ORAL CAPSULE 140 MG IMBRUVICA ORAL CAPSULE 70 MG IMBRUVICA ORAL TABLET B/D PA; MO B/D PA (180 per 30 (60 per 30 (10 per 30 (30 per 30 (30 per 30 IMFINZI 5 B/D PA; MO; LA INLYTA ORAL TABLET 1 MG INLYTA ORAL TABLET 5 MG (180 per 30 (10 per 30 IRESSA (30 per 30 irinotecan solution 100 mg/5 ml B/D PA; MO 14

22 Name irinotecan solution 40 mg/ ml irinotecan solution 500 mg/5 ml 5 B/D PA; MO 5 B/D PA ISTODAX 5 B/D PA; MO IXEMPRA 5 B/D PA; MO JAKAFI (60 per 30 JEVTANA 5 B/D PA; MO KADCYLA 5 PA; MO KEYTRUDA INTRAVENOUS SOLUTION 5 PA; MO KISQALI 5 PA; MO KISQALI FEMARA CO-PACK 5 PA; MO KYPROLIS 5 B/D PA; MO LARTRUVO 5 B/D PA; MO; LA LENVIMA 5 PA; MO letrozole LEUKERAN leuprolide subcutaneous kit LONSURF 5 PA; MO LUPRON DEPOT 5 PA; MO LUPRON DEPOT (NTH) LUPRON DEPOT (4 MONTH) LUPRON DEPOT (6 MONTH) 5 PA; MO 5 PA; MO 5 PA; MO Name LUPRON DEPOT- PED LUPRON DEPOT- PED (NTH) LYNPARZA ORAL CAPSULE LYNPARZA ORAL TABLET 5 PA; MO 5 PA; MO (480 per 30 (10 per 30 LYSODREN MARQIBO 3 B/D PA; MO MATULANE megestrol oral suspension 400 mg/10 ml (10 ml) megestrol oral suspension 400 mg/10 ml (40 mg/ml), 65 mg/5 ml PA PA; MO megestrol oral tablet PA; MO MEKINIST ORAL TABLET 0.5 MG MEKINIST ORAL TABLET MG (90 per 30 (30 per 30 MEKTOVI 5 PA; MO; LA; QL (180 per 30 melphalan B/D PA; MO melphalan hcl 5 B/D PA mercaptopurine methotrexate sodium B/D PA; MO methotrexate sodium (pf) injection recon soln B/D PA 15

23 Name methotrexate sodium (pf) injection solution mitomycin recon soln 0 mg, 5 mg mitomycin recon soln 40 mg B/D PA; MO B/D PA; MO 5 B/D PA; MO mitoxantrone B/D PA; MO MUSTARGEN 4 B/D PA; MO mycophenolate mofetil hcl mycophenolate mofetil oral capsule mycophenolate mofetil oral suspension for reconstitution mycophenolate mofetil oral tablet mycophenolate sodium B/D PA B/D PA; MO 5 B/D PA; MO B/D PA; MO B/D PA; MO MYLOTARG 5 B/D PA; MO; LA NERLYNX 5 PA; MO; LA NEXAVAR 5 PA; MO; LA; QL (10 per 30 nilutamide NINLARO ORAL CAPSULE.3 MG NINLARO ORAL CAPSULE 3 MG NINLARO ORAL CAPSULE 4 MG (6 per 8 (4 per 8 (3 per 8 NULOJIX 5 B/D PA; MO Name octreotide acetate injection solution 1,000 mcg/ml, 500 mcg/ml octreotide acetate injection solution 100 mcg/ml, 00 mcg/ml, 50 mcg/ml octreotide acetate injection syringe 100 mcg/ml (1 ml), 50 mcg/ml (1 ml) octreotide acetate injection syringe 500 mcg/ml (1 ml) ODOMZO 5 PA; MO; LA; QL (30 per 30 ONCASPAR 5 B/D PA; MO ONIVYDE 5 B/D PA; MO OPDIVO 5 PA; MO oxaliplatin recon soln 100 mg oxaliplatin recon soln 50 mg oxaliplatin solution B/D PA; MO B/D PA B/D PA; MO paclitaxel B/D PA; MO PERJETA 5 B/D PA; MO POMALYST 5 PA; MO; LA PORTRAZZA 5 B/D PA; MO POTELIGEO 5 PA; MO PROGRAF INTRAVENOUS 3 B/D PA; MO PURIXAN 16

24 Name RAPAMUNE ORAL SOLUTION 5 B/D PA; MO REVLIMID 5 PA; MO; LA; QL (8 per 8 RITUXAN 5 PA; MO RITUXAN HYCELA 5 PA; MO ROMIDEPSIN 5 B/D PA RUBRACA 5 PA; MO; LA; QL (10 per 30 RYDAPT 5 PA; MO SANDIMMUNE ORAL SOLUTION SANDOSTATIN LAR DEPOT INTRAMUSCULA R SUSPENSION,EXT ENDED REL RECON 3 B/D PA; MO SIGNIFOR SIMULECT INTRAVENOUS RECON SOLN 10 MG SIMULECT INTRAVENOUS RECON SOLN 0 MG sirolimus oral tablet 0.5 mg, 1 mg sirolimus oral tablet mg 3 B/D PA 3 B/D PA; MO B/D PA; MO 5 B/D PA; MO SOLTAMOX SOMATULINE DEPOT Name SPRYCEL ORAL TABLET 100 MG, 140 MG, 50 MG, 80 MG SPRYCEL ORAL TABLET 0 MG SPRYCEL ORAL TABLET 70 MG (30 per 30 (90 per 30 (60 per 30 STIVARGA (84 per 8 SUTENT (30 per 30 SYLVANT 5 B/D PA; MO SYNRIBO 5 B/D PA; MO TABLOID tacrolimus oral B/D PA; MO TAFINLAR (10 per 30 TAGRISSO 5 PA; MO; LA; QL (30 per 30 tamoxifen TARCEVA ORAL TABLET 100 MG, 150 MG TARCEVA ORAL TABLET 5 MG TARGRETIN TOPICAL TASIGNA ORAL CAPSULE 150 MG, 00 MG (30 per 30 (60 per 30 5 PA; MO (11 per 8 17

25 Name TASIGNA ORAL CAPSULE 50 MG (10 per 30 TECENTRIQ 5 B/D PA; MO; LA TEMODAR INTRAVENOUS 5 B/D PA; MO temsirolimus 5 B/D PA; MO THALOMID 5 PA; MO thiotepa 5 B/D PA; MO TIBSOVO 5 PA; MO toposar B/D PA; MO topotecan recon soln topotecan solution 5 B/D PA 5 B/D PA; MO TORISEL 5 B/D PA; MO TREANDA INTRAVENOUS RECON SOLN 5 B/D PA; MO TRELSTAR 5 B/D PA; MO tretinoin (chemotherapy) TRISENOX INTRAVENOUS SOLUTION MG/ML 5 B/D PA; MO TYKERB 5 PA; MO; LA; QL (180 per 30 UNITUXIN 5 B/D PA; MO VALSTAR 5 B/D PA; MO VANTAS 4 B/D PA; MO VECTIBIX 5 B/D PA; MO VELCADE 5 B/D PA; MO Name VENCLEXTA ORAL TABLET 10 MG, 50 MG VENCLEXTA ORAL TABLET 100 MG VENCLEXTA STARTING PACK 3 PA; MO; LA 5 PA; MO; LA 5 PA; MO; LA; QL (4 per 180 VERZENIO 5 PA; MO; LA; QL (60 per 30 vinblastine solution vincasar pfs solution 1 mg/ml vincasar pfs solution mg/ ml B/D PA; MO B/D PA B/D PA; MO vincristine B/D PA; MO vinorelbine B/D PA; MO VOTRIENT (10 per 30 VYXEOS 5 B/D PA; MO XALKORI (60 per 30 XATMEP 5 B/D PA; MO XERMELO 5 PA; MO; LA; QL (90 per 30 XTANDI (10 per 30 YERVOY 5 B/D PA; MO YONDELIS 5 B/D PA; MO 18

26 Name YONSA (10 per 30 ZALTRAP 5 B/D PA; MO ZANOSAR 4 B/D PA; MO ZEJULA 5 PA; MO; LA; QL (90 per 30 ZELBORAF (40 per 30 ZOLADEX 4 B/D PA; MO ZOLINZA ZORTRESS ORAL TABLET 0.5 MG, 0.5 MG, 0.75 MG 5 B/D PA; MO ZYDELIG (60 per 30 ZYKADIA (150 per 30 ZYTIGA ORAL TABLET 50 MG ZYTIGA ORAL TABLET 500 MG (10 per 30 (60 per 30 AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH ANTICONVULSANTS APTIOM ORAL TABLET 00 MG, 400 MG, 800 MG APTIOM ORAL TABLET 600 MG 4 MO BANZEL Name BRIVIACT INTRAVENOUS BRIVIACT ORAL carbamazepine oral capsule, er multiphase 1 hr carbamazepine oral suspension 100 mg/5 ml carbamazepine oral tablet carbamazepine oral tablet extended release 1 hr carbamazepine oral tablet,chewable CELONTIN ORAL CAPSULE 300 MG clonazepam oral tablet 0.5 mg, 1 mg clonazepam oral tablet mg clonazepam oral tablet,disintegrating 0.15 mg, 0.5 mg, 0.5 mg, 1 mg clonazepam oral tablet,disintegrating mg 4 1 MO 1 MO PA; MO; QL (90 per 30 PA; MO; QL (300 per 30 PA; MO; QL (90 per 30 PA; MO; QL (300 per 30 DIASTAT 4 MO DIASTAT ACUDIAL 4 MO diazepam rectal DILANTIN 30 MG 19

27 Name divalproex oral capsule, delayed rel sprinkle divalproex oral tablet extended release 4 hr divalproex oral tablet,delayed release (dr/ec) 1 MO epitol ethosuximide felbamate oral suspension felbamate oral tablet fosphenytoin FYCOMPA ORAL SUSPENSION FYCOMPA ORAL TABLET gabapentin oral capsule 100 mg gabapentin oral capsule 300 mg gabapentin oral capsule 400 mg gabapentin oral solution 50 mg/5 ml gabapentin oral solution 50 mg/5 ml (5 ml), 300 mg/6 ml (6 ml) gabapentin oral tablet 600 mg 1 PA; MO; QL (1080 per 30 1 PA; MO; QL (360 per 30 1 PA; MO; QL (70 per 30 PA; MO; QL (160 per 30 PA; QL (160 1 PA; MO; QL (180 per 30 Name gabapentin oral tablet 800 mg lamotrigine oral tablet lamotrigine oral tablet extended release 4hr lamotrigine oral tablet, chewable dispersible lamotrigine oral tablet,disintegrating lamotrigine oral tablets,dose pack levetiracetam in nacl (iso-os) piggyback 1,000 mg/100 ml, 1,500 mg/100 ml levetiracetam in nacl (iso-os) piggyback 500 mg/100 ml levetiracetam levetiracetam oral solution 100 mg/ml levetiracetam oral solution 500 mg/5 ml (5 ml) levetiracetam oral tablet levetiracetam oral tablet extended release 4 hr 1 PA; MO; QL (10 per 30 1 MO 4 MO 4 MO 0

28 Name LYRICA ORAL CAPSULE 100 MG, 150 MG, 00 MG, 5 MG, 50 MG, 75 MG LYRICA ORAL CAPSULE 5 MG, 300 MG LYRICA ORAL SOLUTION ONFI ORAL SUSPENSION ONFI ORAL TABLET 10 MG, 0 MG 3 PA; MO; QL (90 per 30 3 PA; MO; QL (60 per 30 3 PA; MO; QL (900 per 30 (480 per 30 (60 per 30 oxcarbazepine PEGANONE phenobarbital PA; MO phenobarbital sodium injection solution 130 mg/ml phenobarbital sodium injection solution 65 mg/ml phenytoin oral suspension 100 mg/4 ml phenytoin oral suspension 15 mg/5 ml phenytoin oral tablet,chewable phenytoin sodium extended phenytoin sodium solution primidone Name roweepra roweepra xr SABRIL ORAL TABLET ; LA SPRITAM 4 MO subvenite oral tablet 100 mg, 00 mg, 5 mg subvenite oral tablet 150 mg subvenite starter (blue) kit subvenite starter (green) kit subvenite starter (orange) kit 1 tiagabine 4 MO topiramate oral capsule, sprinkle topiramate oral tablet PA; MO 1 PA; MO valproate sodium valproic acid valproic acid (as sodium salt) oral solution 50 mg/5 ml valproic acid (as sodium salt) oral solution 50 mg/5 ml (5 ml), 500 mg/10 ml (10 ml) vigabatrin ; LA vigadrone ; LA VIMPAT INTRAVENOUS VIMPAT ORAL SOLUTION 3

29 Name VIMPAT ORAL TABLET zonisamide PA; MO ANTIPARKINSONISM AGENTS APOKYN ; LA benztropine injection benztropine oral PA; MO bromocriptine 4 MO carbidopa carbidopa-levodopa 4 MO entacapone NEUPRO 4 MO pramipexole rasagiline ropinirole selegiline hcl tolcapone MIGRAINE / CLUSTER HEADACHE THERAPY dihydroergotamine injection dihydroergotamine nasal ; QL (8 per 8 eletriptan ; QL (18 per 8 ergotamine-caffeine migergot naratriptan ; QL (18 per 8 rizatriptan ; QL (36 per 8 Name sumatriptan nasal spray,non-aerosol 0 mg/actuation sumatriptan nasal spray,non-aerosol 5 mg/actuation sumatriptan succinate oral sumatriptan succinate subcutaneous cartridge sumatriptan succinate subcutaneous pen injector sumatriptan succinate subcutaneous solution carbidopa-levodopaentacapone sumatriptannaproxen ; QL (18 per 8 ; QL (36 per 8 ; QL (18 per 8 ; QL (8 per 8 ; QL (8 per 8 ; QL (8 per 8 ; QL (18 per 8 zolmitriptan ; QL (18 per 8 MISCELLANEOUS NEUROLOGICAL THERAPY AMPYRA 5 PA; MO; LA dalfampridine 5 PA; MO; LA donepezil oral tablet 10 mg, 5 mg donepezil oral tablet 3 mg donepezil oral tablet,disintegrating 1 MO 4 MO 1 MO galantamine GILENYA ORAL CAPSULE 0.5 MG 5 PA; MO

30 Name glatiramer subcutaneous syringe 0 mg/ml glatiramer subcutaneous syringe 40 mg/ml glatopa subcutaneous syringe 0 mg/ml glatopa subcutaneous syringe 40 mg/ml (30 per 30 (1 per 8 (30 per 30 (1 per 8 LEMTRADA 5 PA; MO memantine oral capsule,sprinkle,er 4hr memantine oral solution memantine oral tablet PA; MO PA; MO PA; MO NAMZARIC 3 PA; MO NUEDEXTA 3 PA; MO OCREVUS 5 PA; MO; LA RADICAVA 5 PA; MO rivastigmine rivastigmine tartrate TECFIDERA 5 PA; MO; LA tetrabenazine oral tablet 1.5 mg tetrabenazine oral tablet 5 mg (40 per 30 (10 per 30 TYSABRI 5 PA; MO; LA MUSCLE RELAXANTS / ANTISPASMODIC THERAPY Name baclofen oral tablet 10 mg, 0 mg cyclobenzaprine oral tablet 4 PA; MO dantrolene LIORESAL INTRATHECAL SOLUTION,000 MCG/ML, 500 MCG/ML LIORESAL INTRATHECAL SOLUTION 50 MCG/ML MESTINON ORAL SYRUP neostigmine methylsulfate solution 0.5 mg/ml neostigmine methylsulfate solution 1 mg/ml pyridostigmine bromide regonol revonto 3 B/D PA; MO 3 B/D PA tizanidine NARCOTIC ANALGESICS acetaminophen-caffdihydrocod oral capsule acetaminophencodeine oral solution 10 mg-1 mg /5 ml (5 ml), 300 mg-30 mg /1.5 ml ; QL (300 QL (4500 per 30 3

31 Name acetaminophencodeine oral solution 10-1 mg/5 ml acetaminophencodeine oral tablet mg, mg acetaminophencodeine oral tablet mg buprenorphine hcl injection solution buprenorphine hcl injection syringe buprenorphine hcl sublingual duramorph (pf) injection solution 0.5 mg/ml duramorph (pf) injection solution 1 mg/ml endocet oral tablet mg,.5-35 mg, 5-35 mg, mg ; QL (4500 ; QL (360 ; QL (180 ; QL (66 QL (66 per 30 ; QL (4000 QL (000 per 30 ; QL (360 fentanyl citrate (10 per 30 fentanyl citrate (pf) injection FENTANYL CITRATE (PF) INTRAVENOUS SYRINGE 100 MCG/ ML (50 MCG/ML) ; QL (400 3 QL (400 per 30 Name fentanyl transdermal patch 7 hour 100 mcg/hr, 1 mcg/hr, 5 mcg/hr, 37.5 mcg/hour, 50 mcg/hr, 6.5 mcg/hour, 75 mcg/hr fentanyl transdermal patch 7 hour 87.5 mcg/hour hydrocodoneacetaminophen oral solution mg/15 ml hydrocodoneacetaminophen oral tablet mg, mg, mg hydrocodoneacetaminophen oral tablet mg,.5-35 mg, 5-35 mg, mg hydrocodoneibuprofen oral tablet mg, 5-00 mg, mg hydromorphone (pf) injection solution 10 (mg/ml) (5 ml), 10 mg/ml hydromorphone (pf) injection solution mg/ml hydromorphone injection solution 1 mg/ml hydromorphone injection solution mg/ml PA; MO; QL (10 per 30 (10 per 30 ; QL (5550 ; QL (390 ; QL (360 ; QL (50 ; QL (40 QL (100 per 30 QL (400 per 30 ; QL (100 4

32 Name hydromorphone injection solution 4 mg/ml hydromorphone injection syringe 1 mg/ml hydromorphone injection syringe mg/ml hydromorphone injection syringe 4 mg/ml hydromorphone oral liquid hydromorphone oral tablet hydromorphone oral tablet extended release 4 hr 1 mg, 8 mg hydromorphone oral tablet extended release 4 hr 16 mg, 3 mg ; QL (600 QL (400 per 30 QL (100 per 30 ; QL (600 ; QL (400 ; QL (180 PA; MO; QL (60 per 30 (60 per 30 ibuprofen-oxycodone ; QL (8 levorphanol tartrate ; QL (10 lorcet (hydrocodone) ; QL (360 lorcet hd ; QL (360 lorcet plus oral tablet mg methadone injection solution ; QL (360 QL (150 per 30 methadone intensol PA; MO; QL (90 per 30 Name methadone oral concentrate methadone oral solution 10 mg/5 ml methadone oral solution 5 mg/5 ml methadone oral tablet 10 mg methadone oral tablet 5 mg methadose oral concentrate morphine (pf) injection solution 0.5 mg/ml morphine (pf) injection solution 1 mg/ml morphine (pf) patient control.analgesia soln 150 mg/30 ml morphine (pf) patient control.analgesia soln 30 mg/30 ml morphine concentrate oral solution morphine injection solution 8 mg/ml morphine injection syringe 10 mg/ml PA; MO; QL (90 per 30 PA; MO; QL (600 per 30 PA; MO; QL (100 per 30 PA; MO; QL (10 per 30 PA; MO; QL (40 per 30 PA; MO; QL (90 per 30 QL (4000 per 30 ; QL (000 B/D PA; MO; QL (400 per 30 B/D PA; QL (000 per 30 ; QL (900 QL (50 per 30 ; QL (00 5

33 Name morphine injection syringe mg/ml morphine injection syringe 4 mg/ml morphine injection syringe 5 mg/ml morphine injection syringe 8 mg/ml morphine cartridge 10 mg/ml morphine cartridge mg/ml morphine cartridge 4 mg/ml morphine solution 10 mg/ml morphine syringe mg/ml morphine syringe 4 mg/ml morphine oral capsule, er multiphase 4 hr morphine oral capsule,extend.relea se pellets 10 mg, 100 mg, 0 mg, 30 mg, 50 mg, 60 mg, 80 mg morphine oral solution ; QL (1000 ; QL (500 QL (400 per 30 QL (50 per 30 QL (00 per 30 QL (1000 per 30 QL (500 per 30 ; QL (00 QL (1000 per 30 QL (500 per 30 PA; MO; QL (60 per 30 PA; MO; QL (90 per 30 ; QL (900 morphine oral tablet ; QL (180 Name morphine oral tablet extended release 100 mg morphine oral tablet extended release 15 mg, 00 mg, 30 mg, 60 mg oxycodone oral capsule oxycodone oral concentrate oxycodone oral solution oxycodone oral tablet 10 mg, 15 mg, 0 mg, 30 mg oxycodone oral tablet 5 mg oxycodoneacetaminophen oral tablet mg,.5-35 mg, 5-35 mg, mg PA; MO; QL (60 per 30 PA; MO; QL (10 per 30 ; QL (360 ; QL (180 ; QL (100 ; QL (180 ; QL (360 ; QL (360 oxycodone-aspirin ; QL (360 oxymorphone oral tablet 10 mg oxymorphone oral tablet 5 mg ; QL (360 ; QL (180 vicodin ; QL (390 vicodin es ; QL (390 vicodin hp ; QL (390 NON-NARCOTIC ANALGESICS 6

34 Name buprenorphinenaloxone sublingual tablet -0.5 mg buprenorphinenaloxone sublingual tablet 8- mg butorphanol tartrate injection solution 1 mg/ml butorphanol tartrate injection solution mg/ml butorphanol tartrate nasal ; QL (360 ; QL (90 ; QL (857 ; QL (48 ; QL (10 per 8 celecoxib clonidine (pf) epidural solution 5,000 mcg/10 ml diclofenac potassium diclofenac sodium oral diclofenac sodium topical drops diclofenac sodium topical gel 1 % diclofenacmisoprostol ; QL (300 per 8 ; QL (1000 per 8 diflunisal etodolac fenoprofen oral tablet flurbiprofen ibu 1 MO ibuprofen oral suspension Name ibuprofen oral tablet 400 mg, 600 mg, 800 mg ketoprofen oral capsule 5 mg ketoprofen oral capsule 50 mg, 75 mg ketoprofen oral capsule,ext rel. pellets 4 hr 00 mg 1 MO meclofenamate mefenamic acid meloxicam oral tablet 15 mg meloxicam oral tablet 7.5 mg 1 MO 1 MO; QL (30 nabumetone nalbuphine injection solution 10 mg/ml nalbuphine injection solution 0 mg/ml ; QL (00 ; QL (100 naloxone naltrexone naproxen oral suspension naproxen oral tablet 1 MO naproxen oral tablet,delayed release (dr/ec) naproxen sodium oral tablet 75 mg, 550 mg naproxen sodium oral tablet, er multiphase 4 hr 7

35 Name NARCAN NASAL SPRAY,NON- AEROSOL 4 MG/ACTUATION oxaprozin piroxicam profeno salsalate 1 MO SUBOXONE SUBLINGUAL FILM 1-3 MG SUBOXONE SUBLINGUAL FILM -0.5 MG SUBOXONE SUBLINGUAL FILM 4-1 MG, 8- MG ; QL ( per 8 ; QL (60 ; QL (360 ; QL (90 sulindac 1 MO tolmetin tramadol oral tablet ; QL (40 tramadolacetaminophen ; QL (40 VIVITROL PSYCHOTHERAPEUTIC DRUGS ABILIFY MAINTENA ADASUVE 3 LA amitriptyline PA; MO amoxapine PA; MO aripiprazole oral solution aripiprazole oral tablet ; QL (30 Name aripiprazole oral tablet,disintegrating ; QL (60 ARISTADA ARISTADA INITIO 5 armodafinil 4 PA; MO atomoxetine bupropion hcl oral tablet bupropion hcl oral tablet extended release 4 hr 150 mg bupropion hcl oral tablet extended release 4 hr 300 mg bupropion hcl oral tablet sustainedrelease 1 hr 1 MO ; QL (90 ; QL (30 ; QL (60 buspirone chlorpromazine citalopram oral solution citalopram oral tablet 1 MO; QL (30 clomipramine 4 PA; MO clonidine hcl oral tablet extended release 1 hr clorazepate dipotassium oral tablet 15 mg clorazepate dipotassium oral tablet 3.75 mg clorazepate dipotassium oral tablet 7.5 mg PA; MO; QL (180 per 30 PA; MO; QL (90 per 30 PA; MO; QL (360 per 30 clozapine oral tablet 8

36 Name clozapine oral tablet,disintegrating 100 mg, 1.5 mg, 5 mg desipramine PA; MO desvenlafaxine succinate dextroamphetamine oral solution dextroamphetamineamphetamine diazepam injection solution diazepam injection syringe ; QL (30 PA PA; MO diazepam intensol PA; MO; QL (40 per 30 diazepam oral concentrate diazepam oral solution 5 mg/5 ml (1 mg/ml) PA; MO; QL (40 per 30 PA; MO; QL (100 per 30 diazepam oral tablet PA; MO; QL (10 per 30 doxepin oral 4 PA; MO duloxetine oral capsule,delayed release(dr/ec) 0 mg, 30 mg, 60 mg duloxetine oral capsule,delayed release(dr/ec) 40 mg ; QL (60 ; QL (90 EMSAM ergoloid 4 MO Name escitalopram oxalate oral solution escitalopram oxalate oral tablet 1 MO; QL (30 eszopiclone 4 ST; MO; QL (30 per 30 FANAPT ORAL TABLET 1 MG, MG, 4 MG FANAPT ORAL TABLET 10 MG, 1 MG, 6 MG, 8 MG FANAPT ORAL TABLETS,DOSE PACK FAZACLO ORAL TABLET,DISINTE GRATING 150 MG, 00 MG FETZIMA ORAL CAPSULE,EXT REL 4HR DOSE PACK FETZIMA ORAL CAPSULE,EXTEN DED RELEASE 4 HR 4 MO; QL (60 ; QL (60 4 MO; QL (8 per MO; QL (8 per 8 4 MO; QL (30 flumazenil fluoxetine oral capsule 10 mg fluoxetine oral capsule 0 mg fluoxetine oral capsule 40 mg fluoxetine oral capsule,delayed release(dr/ec) 1 MO; QL (30 1 MO 1 MO; QL (60 ; QL (4 per 8 9

37 Name fluoxetine oral solution fluoxetine oral tablet 10 mg fluoxetine oral tablet 0 mg, 60 mg fluphenazine decanoate ; QL (30 fluphenazine hcl fluvoxamine oral capsule,extended release 4hr fluvoxamine oral tablet 100 mg fluvoxamine oral tablet 5 mg fluvoxamine oral tablet 50 mg GEODON INTRAMUSCULA R 4 MO; QL (60 ; QL (90 ; QL (30 ; QL (60 4 MO guanidine haloperidol 1 MO haloperidol decanoate haloperidol lactate injection haloperidol lactate intramuscular haloperidol lactate oral HETLIOZ (30 per 30 imipramine hcl 4 PA; MO imipramine pamoate 4 PA; MO Name INVEGA SUSTENNA INTRAMUSCULA R SYRINGE 117 MG/0.75 ML, 156 MG/ML, 34 MG/1.5 ML, 78 MG/0.5 ML INVEGA SUSTENNA INTRAMUSCULA R SYRINGE 39 MG/0.5 ML 4 MO INVEGA TRINZA KHEDEZLA ORAL TABLET EXTENDED RELEASE 4HR 100 MG KHEDEZLA ORAL TABLET EXTENDED RELEASE 4HR 50 MG LATUDA ORAL TABLET 10 MG, 0 MG, 40 MG, 60 MG LATUDA ORAL TABLET 80 MG 4 MO; QL (10 4 MO; QL (30 ; QL (30 ; QL (60 lithium carbonate 1 MO lithium citrate oral solution 8 meq/5 ml lorazepam injection solution lorazepam injection syringe PA; MO PA lorazepam intensol PA; MO; QL (150 per 30 30