2019 Comprehensive Formulary (List of Covered Drugs)

Transcription

1 SecureCare (HMO) SecureChoice (PPO) 019 Comprehensive Formulary (List of Covered s) PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN We have made no changes to this formulary since 09/8/018. For more recent information or other questions, please contact SecureCare or SecureChoice Member Services at or, for TTY users, 711, or visit Hours of Operation: October 1 to March 31: 8:00 am to 8:00 pm, 7 days a week April 1 to September 30: 8:00 am to 8:00 pm, Monday through Friday HPMS Approved Formulary File Submission ID , Version Number # 6 Y0038_19_040_C COMPREHENSIVE FORMULARY

2 Note to existing members: This formulary has changed since last year. Please review this document to make sure that it still contains the drugs you take. When this drug list (formulary) refers to we, us, or our, it means The Health Plan. When it refers to plan or our plan, it means SecureCare or SecureChoice. This document includes a list of the drugs (formulary) for our plan which is current as of 09/0/018. 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 January 1, 00, and from time to time during the year. What is the SecureCare and SecureChoice Formulary? A formulary is a list of covered drugs selected by SecureCare and SecureChoice 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. SecureCare and SecureChoice will generally cover the drugs listed in our formulary as long as the drug is medically necessary, the prescription is filled at a SecureCare and SecureChoice 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 SecureCare and SecureChoice Formulary? October 018 ii

3 o 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 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, 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 09/8/018. To get updated information about the drugs covered by SecureCare and SecureChoice, please contact us. Our contact information appears on the front and back cover pages. We update our printed formularies each month, and they are available upon request by calling us at TTY users call 711. You may also view and print an updated formulary on our web site at 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, Hypertension/Lipids. If you know what your drug is used for, look for the category name in the list that begins. 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 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? SecureCare and SecureChoice 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 October 018 iii

4 requirements and limits may include: Prior Authorization: SecureCare and SecureChoice requires you or your physician to get prior authorization for certain drugs. This means that you will need to get approval from SecureCare and SecureChoice before you fill your prescriptions. If you don t get approval, SecureCare and SecureChoice may not cover the drug. Quantity Limits: For certain drugs, SecureCare and SecureChoice limits the amount of the drug that SecureCare and SecureChoice will cover. For example, SecureCare and SecureChoice provides 30 tablets for a 30-day prescription for atorvastatin. This may be in addition to a standard one-month or three-month supply. Step Therapy: In some cases, SecureCare and SecureChoice 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, SecureCare and SecureChoice may not cover B unless you try A first. If A does not work for you, SecureCare and SecureChoice 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 SecureCare and SecureChoice 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 SecureCare and SecureChoice formulary? on the next page for information about how to request an exception. What if my drug is not on the Formulary? If your drug is not included in this formulary (list of covered drugs), you should first contact Member Services and ask if your drug is covered. If you learn that SecureCare and SecureChoice does not cover your drug, you have two options: You can ask Member Services for a list of similar drugs that are covered by SecureCare and SecureChoice. When you receive the list, show it to your doctor and ask him or her to prescribe a similar drug that is covered by SecureCare and SecureChoice. You can ask SecureCare and SecureChoice 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 SecureCare and SecureChoice Formulary? You can ask SecureCare and SecureChoice 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 October 018 iv

5 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, SecureCare and SecureChoice 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, SecureCare and SecureChoice 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, or utilization restriction exception. When you request a formulary or utilization restriction exception you should submit a statement from your prescriber or physician supporting your request. Generally, we must make our decision within 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 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. TRANSITION POLICY: New members in our plan may be taking drugs that are not on our formulary or that are subject to certain restrictions, such as prior authorization or step therapy. Current members may also be affected by changes in our formulary from one year to the next. Members October 018 v

6 should talk to their doctors to decide if they should switch to a different drug that we cover or request a formulary exception in order to get coverage for the drug. See Section 5 under What is an exception? to learn more about how to request an exception. Please contact Member Services if your drug is not on our formulary, is subject to certain restrictions, such as prior authorization or step therapy, or will no longer be on our formulary next year and you need help switching to a different drug that we cover or requesting a formulary exception. During the period of time members are talking to their doctors to determine the right course of action, we may provide a temporary supply of the non-formulary drug if those members need a refill for the drug during the first 90 days of new membership in our Plan. If you are a current member affected by a formulary change from one year to the next, we will provide a temporary supply of the non-formulary drug if you need a refill for the drug during the first 90 days of the new plan year and provide you with the opportunity to request a formulary exception in advance for the following year. When a member goes to a network pharmacy and we provide a temporary supply of a drug that is not on our formulary, or that has coverage restrictions or limits (but is otherwise considered a Part D drug ), we will cover a 30-day supply (unless the prescription is written for fewer days, in which case the plan will allow multiple fills to provide up to a total of 30 days of medication). After we cover the temporary 30-day supply, we generally will not pay for these drugs as part of our transition policy again. We will provide you with a written notice after we cover your temporary supply. This notice will explain the steps you can take to request an exception and how to work with your doctor to decide if you should switch to an appropriate drug that we cover. If a new member is a resident of a long-term-care facility (like a nursing home), we will cover a temporary 31-day transition supply (unless the prescription is written for fewer. If necessary, we will cover more than one refill of these drugs during the first 90 days a new member is enrolled in our plan. If the resident has been enrolled in our plan for more than 90 days and needs a drug that is not on our formulary, or is subject to other restrictions, such as step therapy or dosage limits, we will cover a temporary 31-day emergency supply of that drug (unless the prescription is for fewer while the new member pursues a formulary exception. Please note that our transition policy applies only to those drugs that are Part D drugs and bought at a network pharmacy. The transition policy cannot be used to buy a non-part D drug or a drug out of network, unless you qualify for out of network access. For more information For more detailed information about your SecureCare and SecureChoice prescription drug coverage, please review your Evidence of Coverage and other plan materials. If you have questions about SecureCare and SecureChoice, 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 October 018 vi

7 SecureCare and SecureChoice Formulary The formulary that begins on page provides coverage information about the drugs covered by SecureCare and SecureChoice. 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., INVOKANA) and generic drugs are listed in lower-case italics (e.g., glimepiride). The information in the column tells you if SecureCare and SecureChoice has any special requirements for coverage of your drug. Prescription drug cost information The amount you pay for a covered drug will depend on your drug payment stage, the drug tier for your drug, and the pharmacy where you fill it. payment stage: Your plan has different stages of drug coverage. The amount that you pay when you fill your covered drug depends on what stage you are in. tier: Your plan has five drug tiers. Each covered drug is in one of the five tiers. Each tier of your plan has a copayment and/or coinsurance amount. 1 - Preferred Generic drug - Generic drug 3 - Preferred Brand drug 4 - Non-Preferred drug 5 - Specialty drug Pharmacy where covered drug is filled: The price that you pay for a prescription will also depend on what pharmacy you use. If you fill a prescription at a preferred network pharmacy, you will pay preferred cost sharing amounts. If you fill a prescription at other network pharmacies, you will pay standard cost sharing amounts. Please see the plan s Pharmacy Directory for pharmacy designation information. For more information about cost share amounts, please refer to the Evidence of Coverage (EOC). The EOC explains the plan s coverage stages and lists the copayment and coinsurance amounts for each tier. If you qualify for Extra Help If you qualify for Extra Help for your prescription drugs, your copays and co-insurance may be lower. Members who qualify for Extra Help will receive the Evidence of Coverage Rider for People Who Get Extra Help Paying for Prescription s (LIS Rider). Please read it to learn about your costs, or call us with questions. October 018 vii

8 CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho bạn. Gọi số (TTY: 711). Discrimination is Against the Law The Health Plan complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. The Health Plan does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. The Plan: Provides free aids and services to people with disabilities to communicate effectively with us, such as: o o Qualified sign language interpreters Written information in other formats (large print, audio, accessible electronic formats, other formats) Provides free language services to people whose primary language is not English, such as: o Qualified interpreters o Information written in other languages If you need these services, contact The Health Plan Customer Service Department. If you believe that The Plan has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: The Health Plan Appeals Coordinator, 1110 Main Street, Wheeling, WV 6003, Phone: , TTY: 711, Fax , info@healthplan.org. You can file a grievance in person or by mail, fax, or . If you need help filing a grievance The Health Plan Customer Service Department is available to help you. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, electronically through the Office for Civil Rights Complaint Portal, available at or by mail or phone at: U.S. Department of Health and Human Services 00 Independence Avenue, SW Room 509F, HHH Building Washington, D.C , (TDD). Complaint forms are available at ATTENTION: If you speak English, language assistance services, free of charge, are available to you. Call (TTY: 711). ATENCIÓN: Si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al (TTY: 711). 注意 : 如果您使用繁體中文, 您可以免費獲得語言援助服務 請致電 (TTY:711) ATTENTION: Si vous parlez français, des services d'aide linguistique vous sont proposés gratuitement. Appelez le (ATS: 711). ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen zur Verfügung. Rufnummer: (TTY: 711). 주의 : 한국어를사용하시는경우, 언어지원서비스를무료로이용하실수있습니다 (TTY: 711). 번으로전화해주십시오. ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услуги перевода. Звоните (телетайп: 711). ملحوظة: إذا كنت تتحدث اذكر اللغة فا ن خدمات المساعدة اللغویة تتوافر لك بالمجان. اتصل برقم (رقم ھاتف الصم والبكم: 711).!य न द': य(द आप!ह द% ब लत ह1 त आपक लए म 7त म' भ ष सह यत स व ए उपल>ध ह (TTY: 711) पर क ल कर' ATTENZIONE: In caso la lingua parlata sia l'italiano, sono disponibili servizi di assistenza linguistica gratuiti. Chiamare il numero (TTY: 711). ATENÇÃO: Se fala português, encontram-se disponíveis serviços linguísticos, grátis. Ligue para (TTY: 711). ATANSYON: Si w pale Kreyòl Ayisyen, gen sèvis èd pou lang ki disponib gratis pou ou. Rele (TTY: 711). UWAGA: Jeżeli mówisz po polsku, możesz skorzystać z bezpłatnej pomocy językowej. Zadzwoń pod numer (TTY: 711). 注意事項 : 日本語を話される場合 無料の言語支援をご利用いただけます (TTY: 711) まで お電話にてご連絡ください Wann du Deitsch (Pennsylvania German / Dutch) schwetzscht, kannscht du mitaus Koschte ebber gricke, ass dihr helft mit die englisch Schprooch. Ruf selli Nummer uff: Call (TTY: 711). AANDACHT: Als u nederlands spreekt, kunt u gratis gebruikmaken van de taalkundige diensten. Bel (TTY: 711). ATENȚIE: Dacă vorbiți limba română, vă stau la dispoziție servicii de asistență lingvistică, gratuit. Sunați la (TTY: 711). УВАГА! Якщо ви розмовляєте українською мовою, ви можете звернутися до безкоштовної служби мовної підтримки. Телефонуйте за номером (телетайп: 711). XIYYEEFFANNAA: Afaan dubbattu Oroomiffa, tajaajila gargaarsa afaanii, kanfaltiidhaan ala, ni argama. Bilbilaa (TTY: 711).

9 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. 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. 1

10 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 ketoconazole oral MYCAMINE NOXAFIL ORAL nystatin oral suspension 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

11 ATRIPLA BARACLUDE ORAL SOLUTION BIKTARVY cidofovir 5 B/D PA; MO CIMDUO COMPLERA CRIXIVAN ORAL CAPSULE 00 MG, 400 MG 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 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

12 moderiba oral tablets,dose pack 00 mg (8)- 400 mg (8), mg (8)-mg (8) moderiba dose pack oral tablets,dose pack 400 mg (7)- 400 mg (7) moderiba dose pack oral tablets,dose pack 600 mg (7)- 600 mg (7) moderiba dose pack oral tablets,dose pack mg (8)-mg (8), mg (8)-mg (8) 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 PREVYMIS INTRAVENOUS PREVYMIS ORAL ; QL (30 per 30 PREZCOBIX PREZISTA ORAL SUSPENSION 5 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) ribasphere ribapak oral tablets,dose pack 400 mg (7)- 400 mg (7), 600 mg (7)- 400 mg (7), 600 mg (7)- 600 mg (7) 5 4

13 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 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 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 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 cefaclor oral tablet extended release 1 hr cefadroxil oral capsule 5

14 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 cefotaxime injection recon soln 1 gram, gram, 500 mg cefotaxime injection recon soln 10 gram 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 4 MO 6

15 SUPRAX ORAL SUSPENSION FOR RECONSTITUTIO N 500 MG/5 ML SUPRAX ORAL TABLET,CHEWAB LE 4 4 MO TEFLARO ERYTHROMYCINS / OTHER MACROLIDES azithromycin 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 ALBENZA ALINIA ORAL SUSPENSION FOR RECONSTITUTIO N ALINIA ORAL TABLET amikacin injection solution 1,000 mg/4 ml, 500 mg/ ml 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

16 clindamycin palmitate hcl clindamycin pediatric clindamycin phosphate injection clindamycin phosphate COARTEM colistin (colistimethate na) dapsone oral 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% linezolid-0.9% sodium chloride mefloquine meropenem metro i.v. metronidazole in nacl (iso-os) 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 8

17 rifampin SIRTURO ; LA STREPTOMYCIN SYNERCID 5 tigecycline 5 tinidazole tobramycin in 0.5 % nacl tobramycin sulfate injection recon soln tobramycin sulfate injection solution 5 B/D PA; MO; QL (80 per 8 TRECATOR VANCOMYCIN IN 0.9 % SODIUM CHL INTRAVENOUS PIGGYBACK vancomycin 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 3 ; QL (9 per 30 ; QL (60 per 30 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 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 9 BICILLIN C-R BICILLIN L-A dicloxacillin nafcillin in dextrose iso-osm piggyback 1 gram/50 ml

18 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 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 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 10

19 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 URINARY TRACT AGENTS 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 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 B/D PA; MO B/D PA 5 B/D PA 11

20 levoleucovorin recon soln 50 mg levoleucovorin 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 ABRAXANE 5 B/D PA; MO 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 (30 per 30 (60 per 30 ALUNBRIG ORAL TABLETS,DOSE PACK (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 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 1

21 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 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 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 5 B/D PA 5 B/D PA; MO 5 B/D PA B/D PA B/D PA; MO B/D PA; MO 13

22 doxorubicin, pegliposomal 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 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 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; MO 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 14

23 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 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 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 KYPROLIS INTRAVENOUS RECON SOLN 30 MG, 60 MG 5 PA; MO 5 B/D PA; MO LARTRUVO 5 B/D PA; MO; LA LENVIMA 5 PA; MO 15

24 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) LUPRON DEPOT- PED LUPRON DEPOT- PED (NTH) LYNPARZA ORAL CAPSULE LYNPARZA ORAL TABLET 5 PA; MO 5 PA; MO 5 PA; MO 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 (90 per 30 MEKINIST ORAL TABLET MG (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 mitomycin recon soln 40 mg B/D PA 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 16

25 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 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 B/D PA; MO oxaliplatin recon soln 50 mg oxaliplatin solution 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 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 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 17

26 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 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 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 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 18

27 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 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 YONSA 5 PA; QL (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 19

28 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 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 4 1 MO 1 MO PA; MO; QL (90 per 30 clonazepam oral tablet mg clonazepam oral tablet,disintegrating 0.15 mg, 0.5 mg, 0.5 mg, 1 mg clonazepam oral tablet,disintegrating mg 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 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 1 PA; MO; QL (1080 per 30 0

29 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 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 1 PA; MO; QL (360 per 30 1 PA; MO; QL (70 per 30 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 1 MO 4 MO 4 MO 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 1 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

30 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 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 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 4 MO pramipexole rasagiline ropinirole selegiline hcl tolcapone MIGRAINE / CLUSTER HEADACHE THERAPY dihydroergotamine injection

31 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 sumatriptan succinate subcutaneous solution 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 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 glatopa subcutaneous syringe 0 mg/ml glatopa subcutaneous syringe 40 mg/ml 5 PA; MO (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 3

32 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 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 (300 per 30 QL (4500 per 30 ; QL (4500 per 30 ; QL (360 per 30 ; QL (180 per 30 ; QL (66 per 30 QL (66 per 30 ; QL (4000 per 30 QL (000 per 30 ; QL (360 per 30 fentanyl citrate (10 per 30 4

33 fentanyl citrate (pf) injection fentanyl citrate (pf) syringe 100 mcg/ ml (50 mcg/ml) 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 ; QL (400 per 30 QL (400 per 30 PA; MO; QL (10 per 30 (10 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 hydromorphone injection solution 1 mg/ml 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 (400 per 30 ; 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 ; QL (10 per 30 lorcet (hydrocodone) ; QL (360 per 30 lorcet hd ; QL (360 per 30 5