2019 Prescription Drug Formulary. Mutual of Omaha CareAdvantage Complete (HMO)

Transcription

1 Mutual of Omaha CareAdvantage Complete (HMO) 019 Prescription Formulary This formulary was updated on 0/0/019. For more recent information or other questions, please contact Mutual of Omaha Medicare Advantage Company Customer Service at or, for TTY users, 711, 8:00 a.m. to 8:00 p.m. You may reach a messaging service on weekends and holidays from April 1 through September 30. Please leave a message, and your call will be returned the next business day, or visit mutualofomahacareadvantage.com. Serving the Kentucky counties of Boone, Campbell and Kenton and the Ohio counties of Butler, Clermont, Hamilton and Warren

2 Mutual of Omaha CareAdvantage Complete (HMO) 019 Formulary (List of Covered s) PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN 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 Mutual of Omaha Medicare Advantage Company. When it refers to plan or our plan, it means Mutual of Omaha CareAdvantage Complete (HMO). This document includes a list of the drugs (formulary) for our plan, which is current as of March 019. For an updated formulary, please contact us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages. You must generally use network pharmacies to use your prescription drug benefit. Benefits, formulary, pharmacy network, and/or copayments/coinsurance may change on January 1, 00, and from time to time during the year. HPMS Approved Formulary File Submission ID: 193 Version Number 7 H681_18-003_C i

3 What is the Mutual of Omaha CareAdvantage Complete (HMO) Formulary? A formulary is a list of covered drugs selected by Mutual of Omaha CareAdvantage Complete 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. Mutual of Omaha CareAdvantage Complete will generally cover the drugs listed in our formulary as long as the drug is medically necessary, the prescription is filled at a Mutual of Omaha CareAdvantage Complete 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, when new information about the safety or effectiveness of a drug is released, or the drug is removed from the market. (See bullets below for more information on changes that affect members currently taking the drug.) 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: New generic drugs. We may immediately remove a brand name drug on our List if we are replacing it with a new generic drug that will appear on the same or lower cost sharing tier and with the same or fewer restrictions. Also, when adding the new generic drug, we may decide to keep the brand name drug on our List, but immediately move it to a different cost-sharing tier or add new restrictions. If you are currently taking that brand name drug, we may not tell you in advance before we make that change, but we will later provide you with information about the specific change(s) we have made. o If we make such a change, you or your prescriber can ask us to make an exception and continue to cover the brand name drug for you. The notice we provide you will also include information on the steps you may take to request an exception, and you can also find information in the section below entitled How do I request an exception to the Mutual of Omaha CareAdvantage Complete (HMO) s Formulary? 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 generic drug that is not new to market to replace a brand name drug ii

4 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 March 019. To get updated information about the drugs covered by Mutual of Omaha CareAdvantage Complete, please contact us. Our contact information appears on the front and back cover pages. If we make other types of formulary changes than those listed above (non-maintenance changes) we will mail written notification to affected members in the form of Formulary Errata Sheets. How do I use the Formulary? There are two ways to find your drug within the formulary: Medical Condition The formulary begins on page. The drugs in this formulary are grouped into categories depending on the type of medical conditions that they are used to treat. For example, drugs used to treat a heart condition are listed under the category, Cardiovascular.. If you know what your drug is used for, look for the category name in the list that begins on page number. 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 81. The Index provides an alphabetical list of all of the drugs included in this document. Both brand name drugs and generic drugs are listed in the Index. Look in the Index and find your drug. Next to your drug, you will see the page number where you can find coverage information. Turn to the page listed in the Index and find the name of your drug in the first column of the list. What are generic drugs? Mutual of Omaha CareAdvantage Complete 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. iii

5 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: Mutual of Omaha CareAdvantage Complete requires you or your physician to get prior authorization for certain drugs. This means that you will need to get approval from Mutual of Omaha CareAdvantage Complete before you fill your prescriptions. If you don t get approval, Mutual of Omaha CareAdvantage Complete may not cover the drug. Quantity Limits: For certain drugs, Mutual of Omaha CareAdvantage Complete limits the amount of the drug that Mutual of Omaha CareAdvantage Complete will cover. For example, Mutual of Omaha CareAdvantage Complete provides 18 tablets per prescription for sumatriptan tablets. This may be in addition to a standard one-month or three-month supply. Step Therapy: In some cases, Mutual of Omaha CareAdvantage Complete 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, Mutual of Omaha CareAdvantage Complete may not cover B unless you try A first. If A does not work for you, Mutual of Omaha CareAdvantage Complete will then cover B. You can find out if your drug has any additional requirements or limits by looking in the formulary that begins on page. You can also get more information about the restrictions applied to specific covered drugs by visiting our Web site. We have posted on line documents that explain our prior authorization and step therapy restrictions. You may also ask us to send you a copy. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages. You can ask Mutual of Omaha CareAdvantage Complete 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 Mutual of Omaha CareAdvantage Complete formulary? on page v for information about how to request an exception. What if my drug is not on the Formulary? If your drug is not included in this formulary (list of covered drugs), you should first contact Customer Service and ask if your drug is covered. If you learn that Mutual of Omaha CareAdvantage Complete does not cover your drug, you have two options: You can ask Customer Service for a list of similar drugs that are covered by Mutual of Omaha CareAdvantage Complete. When you receive the list, show it to your doctor and ask him or her to prescribe a similar drug that is covered by Mutual of Omaha CareAdvantage Complete. iv

6 You can ask Mutual of Omaha CareAdvantage Complete 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 Mutual of Omaha CareAdvantage Complete (HMO) Formulary? You can ask Mutual of Omaha CareAdvantage Complete 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, Mutual of Omaha CareAdvantage Complete 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, Mutual of Omaha CareAdvantage Complete 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. 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 v

7 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 and 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 while you pursue a formulary exception. Members who have a change in level of care (setting) will be allowed up to a one-time 30-day transition supply per drug. Examples include beneficiaries who are entering a long-term care facility, are discharged from a hospital to home, or ending a long-term care stay and returning to the community. For more information For more detailed information about your Mutual of Omaha CareAdvantage Complete prescription drug coverage, please review your Evidence of Coverage and other plan materials. If you have questions about Mutual of Omaha CareAdvantage Complete, 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 Mutual of Omaha CareAdvantage Complete Formulary The formulary below provides coverage information about the drugs covered by Mutual of Omaha CareAdvantage Complete. If you have trouble finding your drug in the list, turn to the Index that begins on page 81. The first column of the chart lists the drug name. Brand name drugs are capitalized (e.g., COUMADIN) and generic drugs are listed in lower-case italics (e.g., warfarin). The information in the column tells you if Mutual of Omaha CareAdvantage Complete has any special requirements for coverage of your drug. vi

8 List of Abbreviations B/D PA: This prescription drug may be covered under Medicare Part B or D depending on 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 consult your Pharmacy Directory or call Customer Service at from 8 a.m. to 8 p.m. Central Time, seven days a week. TTY users should call 711 toll free. You may reach a messaging service on weekends and holidays from April 1 through September 30. Please leave a message, and your call will be returned the next business day. 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. For information regarding copayment amounts and/or coinsurance percentages, refer to Chapter 6, Section 5. in your Evidence of Coverage. 1

9 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 GENVOYA HARVONI (8 per 8 INTELENCE ORAL TABLET 100 MG, 00 MG INTELENCE ORAL TABLET 5 MG INVIRASE ORAL TABLET 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 moderiba 3

10 moderiba oral tablets,dose pack 600 mg (7)- 600 mg (7) moderiba oral tablets,dose pack mg (8)-mg (8) nevirapine oral suspension nevirapine oral tablet nevirapine oral tablet extended release 4 hr NORVIR ORAL POWDER IN PACKET NORVIR ORAL SOLUTION 5 ODEFSEY oseltamivir PIFELTRO PREVYMIS INTRAVENOUS PREVYMIS ORAL ; QL (30 per 30 PREZCOBIX PREZISTA ORAL SUSPENSION PREZISTA ORAL TABLET 150 MG, 75 MG PREZISTA ORAL TABLET 600 MG, 800 MG REBETOL ORAL SOLUTION 5 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 (7)- 400 mg (7) ribasphere ribapak oral tablets,dose pack mg (8)-mg (8), mg (8)-mg (8), mg (8)-mg (8) ribasphere ribapak oral tablets,dose pack 600 mg (7)- 400 mg (7), 600 mg (7)- 600 mg (7) ribavirin oral capsule ribavirin oral tablet 00 mg 5 rimantadine ritonavir SELZENTRY 4

11 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 valacyclovir oral tablet 1 gram valacyclovir oral tablet 500 mg ; QL (10 per 30 ; QL (60 per 30 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 4 MO 4 MO VIREAD ORAL POWDER VIREAD ORAL TABLET 150 MG, 00 MG, 50 MG XOFLUZA 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 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 5

12 cefazolin injection recon soln 10 gram, 100 gram, 0 gram, 300 g cefazolin cefdinir cefepime in dextrose,iso-osm piggyback 1 gram/50 ml cefepime in dextrose,iso-osm piggyback gram/100 ml cefepime injection cefixime cefotaxime injection recon soln 1 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 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 6

13 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 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 albendazole ALBENZA ALINIA ORAL SUSPENSION FOR RECONSTITUTIO N ALINIA ORAL TABLET amikacin injection solution 1,000 mg/4 ml, 500 mg/ ml ARIKAYCE 5 PA; MO; LA atovaquone atovaquoneproguanil aztreonam 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 7

14 clindamycin palmitate hcl clindamycin pediatric clindamycin phosphate injection clindamycin phosphate COARTEM colistin (colistimethate na) dapsone oral DAPTOMYCIN INTRAVENOUS RECON SOLN 350 MG daptomycin recon soln 500 mg 3 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 isoniazid injection 4 MO isoniazid oral ivermectin lincomycin linezolid linezolid in dextrose 5% linezolid-0.9% sodium chloride mefloquine meropenem metro i.v. metronidazole in nacl (iso-os) 5 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 8

15 rifabutin rifampin SIRTURO ; LA STREPTOMYCIN SYNERCID 5 tigecycline 5 tinidazole TOBI PODHALER INHALATION CAPSULE TOBI PODHALER INHALATION CAPSULE, W/INHALATION DEVICE tobramycin in 0.5 % nacl tobramycin sulfate injection recon soln tobramycin sulfate injection solution 5 QL (4 per 8 ; QL (4 per 8 5 B/D PA; MO; QL (80 per 8 TRECATOR VANCOMYCIN IN 0.9 % SODIUM CHL INTRAVENOUS PIGGYBACK VANCOMYCIN INJECTION vancomycin recon soln 1,000 mg, 10 gram, 5 gram, 500 mg, 750 mg 3 3 VANCOMYCIN INTRAVENOUS RECON SOLN 1.5 GRAM vancomycin oral capsule 15 mg vancomycin oral capsule 50 mg VIBATIV INTRAVENOUS RECON SOLN 750 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 ampicillin sodium ampicillin-sulbactam injection recon soln 1.5 gram, 3 gram 3 5 ; QL (9 per 30 ; QL (90 per 30 9

16 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 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 POT IN DEXTROSE INTRAVENOUS PIGGYBACK 1 MILLION UNIT/50 ML, MILLION UNIT/50 ML PENICILLIN G POT IN DEXTROSE INTRAVENOUS PIGGYBACK 3 MILLION UNIT/50 ML penicillin g potassium penicillin g procaine intramuscular syringe 1. million unit/ ml penicillin g procaine intramuscular syringe 600,000 unit/ml 5 3 penicillin g sodium penicillin v potassium pfizerpen-g 10

17 piperacillintazobactam recon soln.5 gram, gram, 4.5 gram, 40.5 gram QUINOLONES ciprofloxacin 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 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 mondoxyne nl morgidox okebo oral capsule 75 mg tetracycline VIBRAMYCIN ORAL SYRUP URINARY TRACT AGENTS 11

18 methenamine hippurate methenamine mandelate nitrofurantoin nitrofurantoin macrocrystal nitrofurantoin monohyd/m-cryst trimethoprim 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 KHAPZORY 5 B/D PA 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 CALCIUM INTRAVENOUS RECON SOLN 175 MG B/D PA; MO B/D PA 5 B/D PA levoleucovorin calcium recon soln 50 mg levoleucovorin calcium solution 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 abiraterone (10 per 30 ABRAXANE 5 B/D PA; MO adriamycin recon soln 10 mg 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 B/D PA; MO AFINITOR (30 per 30 AFINITOR DISPERZ 5 PA; MO ALECENSA (40 per 30 ALIMTA 5 B/D PA; MO 1

19 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 ARSENIC TRIOXIDE 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 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 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 COPIKTRA 5 PA; MO; LA COSMEGEN 5 B/D PA; MO COTELLIC 5 PA; MO; LA; QL (63 per 8 cyclophosphamide B/D PA; MO 13

20 cyclophosphamide oral capsule cyclosporine cyclosporine modified cyclosporine oral capsule 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 DAURISMO 5 PA; MO decitabine 5 B/D PA; MO 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) 5 B/D PA 5 B/D PA; MO DOCETAXEL INTRAVENOUS SOLUTION 0 MG/ML doxorubicin recon soln 10 mg doxorubicin recon soln 50 mg doxorubicin solution doxorubicin, pegliposomal 14 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 ENVARSUS XR 4 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 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

21 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 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 B/D PA; MO B/D PA B/D PA; MO 3 B/D PA gemcitabine solution gram/5.6 ml (38 mg/ml) gengraf oral capsule 100 mg, 5 mg 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 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 IDHIFA 5 PA; MO; LA; QL (30 per 30 ifosfamide recon soln ifosfamide solution 1 gram/0 ml ifosfamide solution 3 gram/60 ml B/D PA; MO B/D PA; MO B/D PA 15

22 imatinib oral tablet 100 mg imatinib oral tablet 400 mg IMBRUVICA ORAL CAPSULE 140 MG IMBRUVICA ORAL CAPSULE 70 MG IMBRUVICA ORAL TABLET (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 irinotecan solution 40 mg/ ml irinotecan solution 500 mg/5 ml B/D PA; MO 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 LIBTAYO 5 PA; MO; LA LONSURF 5 PA; MO LORBRENA 5 PA; MO LUMOXITI 5 PA; MO; LA LUPRON DEPOT 5 PA; MO LUPRON DEPOT (NTH) LUPRON DEPOT (4 MONTH) LUPRON DEPOT (6 MONTH) LUPRON DEPOT- PED LUPRON DEPOT- PED (NTH) 5 PA; MO 5 PA; MO 5 PA; MO 5 PA; MO 5 PA; MO 16

23 LYNPARZA ORAL TABLET (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 methotrexate sodium (pf) injection solution mitomycin recon soln 0 mg, 5 mg B/D PA B/D PA; MO B/D PA; MO mitomycin recon soln 40 mg 5 B/D PA; MO mitoxantrone 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 octreotide acetate injection solution 1,000 mcg/ml, 500 mcg/ml octreotide acetate injection solution 100 mcg/ml, 00 mcg/ml, 50 mcg/ml 17

24 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 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 18 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 SPRYCEL ORAL TABLET 100 MG, 140 MG, 50 MG, 80 MG SPRYCEL ORAL TABLET 0 MG (30 per 30 (90 per 30

25 SPRYCEL ORAL TABLET 70 MG (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 TALZENNA 5 PA; MO tamoxifen TARCEVA ORAL TABLET 100 MG, 150 MG TARCEVA ORAL TABLET 5 MG TARGRETIN TOPICAL TASIGNA ORAL CAPSULE 150 MG, 00 MG TASIGNA ORAL CAPSULE 50 MG (30 per 30 (60 per 30 5 PA; MO (11 per 8 (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 TRELSTAR INTRAMUSCULA R SUSPENSION FOR RECONSTITUTIO N tretinoin (chemotherapy) TRISENOX INTRAVENOUS SOLUTION MG/ML 5 B/D PA; MO 5 B/D PA; MO 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 19

26 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 VITRAKVI 5 PA; MO; LA VIZIMPRO (30 per 30 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 XOSPATA 5 PA; MO; LA XTANDI (10 per 30 YERVOY 5 B/D PA; MO YONDELIS 5 B/D PA; MO 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 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 4 MO 0

27 APTIOM ORAL TABLET 600 MG BANZEL 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 clobazam oral suspension 4 1 MO 1 MO PA; MO; QL (480 per 30 clobazam oral tablet PA; MO; QL (60 per 30 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 PA; MO; QL (90 per 30 PA; MO; QL (300 per 30 PA; MO; QL (90 per 30 clonazepam oral tablet,disintegrating mg PA; MO; QL (300 per 30 DIASTAT 4 MO DIASTAT ACUDIAL 4 MO diazepam rectal DILANTIN 30 MG divalproex oral capsule, delayed rel sprinkle divalproex oral tablet extended release 4 hr divalproex oral tablet,delayed release (dr/ec) 1 MO EPIDIOLEX 5 PA; MO; LA 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 1 PA; MO; QL (1080 per 30 1 PA; MO; QL (360 per 30 1 PA; MO; QL (70 per 30 1

28 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 gabapentin oral tablet 800 mg GRALISE 30-DAY STARTER PACK GRALISE ORAL TABLET EXTENDED RELEASE 4 HR 300 MG GRALISE ORAL TABLET EXTENDED RELEASE 4 HR 600 MG lamotrigine oral tablet lamotrigine oral tablet extended release 4hr lamotrigine oral tablet, chewable dispersible lamotrigine oral tablet,disintegrating lamotrigine oral tablets,dose pack PA; MO; QL (160 per 30 PA; QL (160 per 30 1 PA; MO; QL (180 per 30 1 PA; MO; QL (10 per 30 3 PA; MO; QL (78 per PA; MO; QL (30 per 30 3 PA; MO; QL (90 per 30 1 MO 4 MO 4 MO 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 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

29 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 roweepra roweepra xr SABRIL ORAL TABLET ; LA SPRITAM 4 MO subvenite subvenite starter (blue) kit subvenite starter (green) kit subvenite starter (orange) kit SYMPAZAN ORAL FILM 10 MG, 0 MG 5 PA; QL (60 per 30 tiagabine 4 MO topiramate oral capsule, sprinkle topiramate oral tablet 3 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 oral powder in packet ; LA vigadrone ; LA VIMPAT INTRAVENOUS VIMPAT ORAL SOLUTION VIMPAT ORAL TABLET 3 zonisamide PA; MO ANTIPARKINSONISM AGENTS APOKYN ; LA benztropine injection benztropine oral PA; MO bromocriptine 4 MO carbidopa carbidopa-levodopa carbidopa-levodopaentacapone 4 MO entacapone NEUPRO

30 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 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 ; QL (18 per 8 ; QL (36 per 8 ; QL (18 per 8 ; QL (8 per 8 ; QL (8 per 8 sumatriptan succinate subcutaneous solution sumatriptan succinate subcutaneous syringe 6 mg/0.5 ml sumatriptannaproxen ; 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 AUBAGIO 5 PA; MO COPAXONE SUBCUTANEOUS SYRINGE 40 MG/ML (1 per 8 dalfampridine 5 PA; MO 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 glatiramer subcutaneous syringe 0 mg/ml glatiramer subcutaneous syringe 40 mg/ml 5 PA; MO (30 per 30 (1 per 8 4

31 glatopa subcutaneous syringe 0 mg/ml glatopa subcutaneous syringe 40 mg/ml (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 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 acetaminophencodeine oral solution 10-1 mg/5 ml ; QL (300 per 30 QL (4500 per 30 ; QL (4500 per 30 5

32 acetaminophencodeine oral tablet mg, mg acetaminophencodeine oral tablet mg buprenorphine hcl injection solution buprenorphine hcl injection syringe buprenorphine hcl sublingual buprenorphine transdermal patch weekly 10 mcg/hour, 15 mcg/hour, 0 mcg/hour, 5 mcg/hour 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 (360 per 30 ; QL (180 per 30 PA; MO; QL (4 per 8 ; QL (4000 per 30 QL (000 per 30 ; QL (360 per 30 fentanyl citrate (10 per 30 fentanyl citrate (pf) injection FENTANYL CITRATE (PF) INTRAVENOUS SYRINGE 100 MCG/ ML (50 MCG/ML) ; QL (400 per 30 3 QL (400 per 30 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(15 ml) 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 PA; MO; QL (10 per 30 (10 per 30 QL (5550 per 30 ; QL (5550 per 30 ; QL (390 per 30 ; QL (360 per 30 ; QL (50 per 30 ; QL (40 per 30 QL (100 per 30 QL (400 per 30 6

33 hydromorphone injection solution mg/ml 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 (100 per 30 ; QL (600 per 30 ; QL (400 per 30 QL (100 per 30 ; QL (600 per 30 ; QL (400 per 30 ; QL (180 per 30 PA; MO; QL (60 per 30 (60 per 30 ibuprofen-oxycodone ; QL (8 per 30 levorphanol tartrate oral tablet mg ; QL (10 per 30 lorcet (hydrocodone) ; QL (360 per 30 lorcet hd ; QL (360 per 30 lorcet plus oral tablet mg methadone injection solution ; QL (360 per 30 QL (150 per 30 7 methadone intensol PA; MO; QL (90 per 30 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 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 per 30 B/D PA; MO; QL (400 per 30 B/D PA; QL (000 per 30 ; QL (900 per 30 QL (50 per 30

34 morphine injection syringe 10 mg/ml morphine injection syringe mg/ml morphine injection syringe 4 mg/ml morphine injection syringe 5 mg/ml morphine injection syringe 8 mg/ml morphine solution 10 mg/ml morphine syringe 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 morphine oral solution ; QL (00 per 30 ; QL (1000 per 30 ; QL (500 per 30 QL (400 per 30 QL (50 per 30 ; QL (00 per 30 QL (00 per 30 QL (1000 per 30 QL (500 per 30 PA; MO; QL (60 per 30 PA; MO; QL (90 per 30 ; QL (900 per 30 morphine oral tablet ; QL (180 per 30 morphine oral tablet extended release oxycodone oral capsule oxycodone oral concentrate PA; MO; QL (10 per 30 ; QL (360 per 30 ; QL (180 per 30 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 8 ; QL (100 per 30 ; QL (180 per 30 ; QL (360 per 30 ; QL (360 per 30 oxycodone-aspirin ; QL (360 per 30 OXYCONTIN ORAL TABLET,ORAL ONLY,EXT.REL.1 HR 10 MG, 15 MG, 0 MG, 30 MG, 40 MG, 60 MG OXYCONTIN ORAL TABLET,ORAL ONLY,EXT.REL.1 HR 80 MG oxymorphone oral tablet 10 mg oxymorphone oral tablet 5 mg 3 PA; MO; QL (90 per 30 (60 per 30 ; QL (360 per 30 ; QL (180 per 30 vicodin ; QL (390 per 30 vicodin es ; QL (390 per 30 vicodin hp ; QL (390 per 30 NON-NARCOTIC ANALGESICS

35 buprenorphinenaloxone sublingual film 8- mg 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 (90 per 30 ; QL (360 per 30 ; QL (90 per 30 ; QL (857 per 30 ; QL (48 per 30 ; 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 FLECTOR 4 PA; MO; QL (60 per 30 flurbiprofen 9 ibu 1 MO ibuprofen oral suspension ibuprofen oral tablet 400 mg, 600 mg, 800 mg ketoprofen oral capsule 5 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 per 30 nabumetone nalbuphine injection solution 10 mg/ml nalbuphine injection solution 0 mg/ml ; QL (00 per 30 ; QL (100 per 30 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

36 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 per 30 ; QL (360 per 30 ; QL (90 per 30 sulindac 1 MO tolmetin tramadol oral tablet ; QL (40 per 30 tramadolacetaminophen ; QL (40 per 30 VIVITROL PSYCHOTHERAPEUTIC DRUGS ABILIFY MAINTENA ADASUVE 3 LA amitriptyline PA; MO amoxapine PA; MO aripiprazole oral solution aripiprazole oral tablet ; QL (30 per 30 aripiprazole oral tablet,disintegrating ; QL (60 per 30 ARISTADA ARISTADA INITIO 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 per 30 ; QL (30 per 30 ; QL (60 per 30 buspirone chlorpromazine citalopram oral solution citalopram oral tablet 1 MO; QL (30 per 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 30

37 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 per 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 per 30 ; QL (90 per 30 EMSAM ergoloid 4 MO escitalopram oxalate oral solution escitalopram oxalate oral tablet 1 MO; QL (30 per 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 per 30 ; QL (60 per 30 4 MO; QL (8 per 8 4 ; QL (8 per 8 ; QL (30 per 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 per 30 1 MO 1 MO; QL (60 per 30 ; QL (4 per 8 31

38 fluoxetine oral solution fluoxetine oral tablet 10 mg fluoxetine oral tablet 0 mg, 60 mg fluphenazine decanoate ; QL (30 per 30 fluphenazine hcl fluvoxamine oral capsule,extended release 4hr fluvoxamine oral tablet 100 mg fluvoxamine oral tablet 5 mg fluvoxamine oral tablet 50 mg 4 MO; QL (60 per 30 ; QL (90 per 30 ; QL (30 per 30 ; QL (60 per 30 FORFIVO XL 4 MO; QL (30 per 30 GEODON INTRAMUSCULA R 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 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 LATUDA ORAL TABLET 10 MG, 0 MG, 40 MG, 60 MG LATUDA ORAL TABLET 80 MG ; QL (30 per 30 ; QL (60 per 30 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 lorazepam oral concentrate lorazepam oral tablet 0.5 mg, 1 mg PA; MO; QL (150 per 30 PA; MO; QL (90 per 30 3