OPTIMA MEDICARE. OPTIMA COMMUNITY COMPLETE (HMO SNP) 2019 Formulary List of Covered Drugs

Transcription

1 OPTIMA MEDICARE OPTIMA COMMUNITY COMPLETE (HMO SNP) 2019 Formulary List of Covered Drugs PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN HPMS Approved Formulary File Submission ID: Version Number 10 This formulary was updated on 03/01/2019. For more recent information or other questions, please contact Optima Community Complete Member Services at or, for TTY users, VA Relay Service at or 711, (October 1, 2018 March 31, 2019, 7 days a week from 8:00 a.m. - 8:00 p.m. ET; April 1, 2019 September 30, 2019, Monday through Friday from 8:00 a.m. - 8:00 p.m. ET), or visit Note to existing members: This formulary has changed since last year. Please review this document to make sure that it still contains the drugs you take. When this drug list (formulary) refers to we, us, or our, it means Optima Health Plan. When it refers to plan or our plan, it means Optima Community Complete. This document includes list of the drugs (formulary) for our plan which is current as of April 1, 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, 2020 and from time to time during the year. H2563_SEN_2019 DSNP Formulary_ January 19_C Formulary ID 19401, Version 10 1

2 What is the Optima Community Complete Formulary? A formulary is a list of covered drugs selected by Optima Community 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. Optima Community Complete will generally cover the drugs listed in our formulary as long as the drug is medically necessary, the prescription is filled at an Optima Community 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 2019 formulary that was covered at the beginning of the year, we will not discontinue or reduce coverage of the drug during the 2019 coverage year except when a new, less expensive generic drug becomes available, when new adverse 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 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: Drugs removed from the market. If the Food and Drug Administration deems a drug on our formulary to be unsafe or the drug s manufacturer removes the drug from the market, we will immediately remove the drug from our formulary and provide notice to members who take the drug. Other changes. We may make other changes that affect members currently taking a drug. For instance, we may add a new generic drug to replace a brand name drug currently on the formulary or add new restrictions to the brand name drug. Or, 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, 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 April 1, To get updated information about the drugs covered by Optima Community Complete, please contact us. Our contact information appears on the front and back cover pages. For any mid-year non-maintenance changes, an Upcoming Changes for Medicare Formulary grid will be posted our website at copies will be sent to all Medicare members and a Negative Change letter will be mailed to each affected member. How do I use the Formulary? There are two (2) ways to find your drug within the formulary: Medical Condition The formulary begins on page 7. The drugs in this formulary are grouped into categories depending on the type of medical conditions that they are used to treat. For example, drugs used to treat a heart condition are listed under the category, Cardiovascular Agents. If you know what your drug is used for, look for the category name in the list that begins on page 7. Then look under the category name for your drug. Formulary ID 19401, Version 10 2

3 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 112. 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? Optima Community 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. 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: Optima Community Complete requires you, or your physician, to get prior authorization for certain drugs. This means that you will need to get approval from Optima Community Complete before you fill your prescriptions. If you don t get approval, Optima Community Complete may not cover the drug. Quantity Limits: For certain drugs, Optima Community Complete limits the amount of the drug that we will cover. For example, Optima Community Complete provides 90 units per prescription for LYRICA CAPS. This may be in addition to a standard one-month or threemonth supply. Step Therapy: In some cases, Optima Community 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 Drug A and Drug B both treat your medical condition, Optima Community Complete may not cover Drug B unless you try Drug A first. If Drug A does not work for you, Optima Community Complete will then cover Drug B. You can find out if your drug has any additional requirements or limits by looking in the formulary that begins on page 7. You can also get more information about the restrictions applied to specific covered drugs by visiting our Web site. We have posted on line documents that explain our prior authorization and step therapy restrictions. You may also ask us to send you a copy. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages. You can ask Optima Community 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 Optima Community Complete formulary? on page 4 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 Optima Community Complete does not cover your drug, you have two (2) options: Formulary ID 19401, Version 10 3

4 You can ask Member Services for a list of similar drugs that are covered by Optima Community 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 Optima Community Complete. You can ask Optima Community 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 Optima Community Complete Formulary? You can ask Optima Community 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 waive coverage restrictions or limits on your drug. For example, for certain drugs, Optima Community 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, Optima Community Complete will only approve your request for an exception if the alternative drugs included on the plan s formulary, or additional utilization restrictions would not be as effective in treating your condition and/or would cause you to have adverse medical effects. You should contact us to ask us for an initial coverage decision for a formulary or utilization restriction exception. When you request a formulary or utilization restriction exception you should submit a statement from your prescriber or physician supporting your request. Generally, we must make our decision within 72 hours of getting your prescriber s supporting statement. You can request an expedited (fast) exception if you or your doctor believe that your health could be seriously harmed by waiting up to 72 hours for a decision. If your request to expedite is granted, we must give you a decision no later than 24 hours after we get a supporting statement from your doctor or other prescriber. 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. 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. We will provide transition supplies to you if you are a current member with a level of care change. We will make coverage determinations and redeterminations as expeditiously as your health condition Formulary ID 19401, Version 10 4

5 requires during the level of care change. You will not be qualified for a level of care transition fill if you fail to submit a coverage determination or exception request unless we determine there was a lifethreatening emergency. For more information For more detailed information about your Optima Community Complete prescription drug coverage, please review your Evidence of Coverage and other plan materials. If you have questions about Optima Community 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 ( ) 24 hours a day/7 days a week. TTY users should call Or, visit Optima Community Complete Formulary The formulary below provides coverage information about the drugs covered by Optima Community Complete. If you have trouble finding your drug in the list, turn to the Index that begins on page 112. The first column of the chart lists the drug name. Brand name drugs are capitalized (e.g., NAMENDA) and generic drugs are listed in lower-case italics (e.g., amoxicillin).the information in the column tells you if Optima Community Complete has any special requirements for coverage of your drug. Optima Community Complete Formulary Mail Order Services The formulary that begins on page 7 provides coverage information about the drugs covered by Optima Community Complete. All formulary drugs beginning on page 7 can be shipped to your home by our mail order delivery program through OptumRx. If you have trouble finding your drug in the list, turn to the Index that begins on page 112. To get order forms and information about filling your prescriptions by mail, please call Member Services at or for TTY users, or 711. You can also print the order form from our website at Abbreviations Used in Formulary QL: Quantity Limit. For certain drugs, Optima Community Complete limits the amount of the drug that Optima Community Complete will cover. For example, Optima Community Complete provides 90 units per prescription for LYRICA CAPS. This may be in addition to a standard one-month or three-month supply. : Prior Authorization. Optima Community Complete requires you or your physician to get prior authorization for certain drugs. This means that you will need to get approval from Optima Community Complete before you fill your prescriptions. If you don't get approval, Optima Community Complete may not cover the drug. : Some medications may not be billable under the Part D benefit. Various medications will need a determination whether it will be considered billable under Medicare Part B or Part D based on the medical use of the drug, situations depending on the drug form (e.g., inhalation, nebulizer, metered dose inhaler), or depending on the location where medication is Formulary ID 19401, Version 10 5

6 administered (e.g. the same drug dispensed by a pharmacy is covered under Part B if provided as part of a service in a provider s office, physician s office or home). ST: Step Therapy. In some cases, Optima Community 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 Drug A and Drug B both treat your medical condition, we may not cover Drug B unless you try Drug A first. If Drug A does not work for you, Optima Community Complete will then cover Drug B. : Non-Extended Day Supply. Some medications are not available for 90- day supplies. This means that these medications can only be filled for 30 days or less. Standard Cost Sharing for Optima Community Complete You will pay between $0 - $8.50 for your Part D Prescription Drugs. Standard retail costsharing (in-network) (up to a 31-day supply) Long-term care (LTC) cost-sharing (up to a 31-day supply) Out-of-network cost-sharing (up to a 31-day supply) (Coverage is limited to certain situations; see Chapter 5 of Evidence of Coverage (EOC) for details.) Cost-Sharing $0, $1.25, $0, $1.25, $0, $1.25, (Generic Drugs) or $3.40 or $3.40 or $3.40 Cost-Sharing $0, $3.80, $0, $3.80, $0, $3.80, (Brand Drugs) or $8.50 or $8.50 or $8.50 Formulary ID 19401, Version 10 6

7 Analgesics Analgesics butalbital-acetaminophen oral capsule butalbital-acetaminophen oral tablet mg butalbital-acetaminophen oral tablet mg butalbital-acetaminophen-caffeine oral capsule mg butalbital-acetaminophen-caffeine oral capsule mg capacet oral capsule mg ESGIC ORAL CAPSULE marten-tab oral tablet mg phrenilin forte oral capsule tencon oral tablet zebutal oral capsule Nonsteroidal Anti-inflammatory Drugs celecoxib oral capsule diclofenac potassium oral tablet diclofenac sodium er oral tablet extended release 24 hour diclofenac sodium oral tablet delayed release diclofenac sodium transdermal gel 1 % diclofenac sodium transdermal gel 3 % diclofenac-misoprostol oral tablet delayed release diflunisal oral tablet etodolac er oral tablet extended release 24 hour etodolac oral capsule etodolac oral tablet fenoprofen calcium oral capsule 400 mg fenoprofen calcium oral tablet flurbiprofen oral tablet ibu oral tablet 600 mg, 800 mg ibuprofen oral suspension ibuprofen oral tablet 400 mg, 600 mg, 800 mg indomethacin er oral capsule extended release indomethacin oral capsule indomethacin sodium intravenous solution reconstituted ketoprofen er oral capsule extended release 24 hour ; QL (180 EA per 30 days) ; QL (360 EA per 30 days) ; QL (360 EA per 30 days) ; QL (360 EA per 30 days) ; QL (360 EA per 30 days) ; QL (360 EA per 30 days) ; QL (360 EA per 30 days) ; QL (360 EA per 30 days) QL (60 EA per 30 days) QL (1000 GM per 30 days) 7

8 ketoprofen oral capsule ketorolac tromethamine injection solution ketorolac tromethamine intramuscular solution ketorolac tromethamine oral tablet meclofenamate sodium oral capsule mefenamic acid oral capsule meloxicam oral tablet nabumetone oral tablet naproxen dr oral tablet delayed release naproxen oral suspension naproxen oral tablet naproxen sodium er oral tablet extended release 24 hour 375 mg naproxen sodium oral tablet 275 mg, 550 mg oxaprozin oral tablet piroxicam oral capsule profeno oral tablet 600 mg SPRIX NASAL SOLUTION sulindac oral tablet tolmetin sodium oral capsule tolmetin sodium oral tablet Opioid Analgesics, Long-acting ARYMO ER ORAL TABLET EXTENDED RELEASE ABUSE- DETERRENT 15 MG ARYMO ER ORAL TABLET EXTENDED RELEASE ABUSE- DETERRENT 30 MG, 60 MG buprenorphine hcl injection solution buprenorphine transdermal patch weekly BUTRANS TRANSDERMAL TCH WEEKLY EMBEDA ORAL CAPSULE EXTENDED RELEASE fentanyl transdermal patch 72 hour 100 mcg/hr, 12 mcg/hr, 25 mcg/hr, 37.5 mcg/hr, 50 mcg/hr, 62.5 mcg/hr, 75 mcg/hr fentanyl transdermal patch 72 hour 87.5 mcg/hr hydromorphone hcl er oral tablet er 24 hour abuse-deterrent 12 mg, 8 mg hydromorphone hcl er oral tablet er 24 hour abuse-deterrent 16 mg, 32 mg ; QL (20 EA per 30 days) QL (5 EA per 30 days) ST; ST; QL (4 EA per 28 days); QL (4 EA per 28 days); 8

9 INFUMORPH 200 INJECTION SOLUTION INFUMORPH 500 INJECTION SOLUTION levorphanol tartrate oral tablet 2 mg levorphanol tartrate oral tablet 3 mg methadone hcl injection solution methadone hcl intensol oral concentrate methadone hcl oral concentrate methadone hcl oral solution methadone hcl oral tablet methadose oral concentrate 10 mg/ml methadose sugar-free oral concentrate mitigo injection solution morphine sulfate er beads oral capsule extended release 24 hour morphine sulfate er oral capsule extended release 24 hour 10 mg, 20 mg, 30 mg, 50 mg, 60 mg, 80 mg morphine sulfate er oral capsule extended release 24 hour 100 mg morphine sulfate er oral capsule extended release 24 hour 40 mg morphine sulfate er oral tablet extended release oxymorphone hcl er oral tablet extended release 12 hour tramadol hcl er (biphasic) oral tablet extended release 24 hour tramadol hcl er oral tablet extended release 24 hour QL (180 EA per 30 days); XTAMPZA ER ORAL CAPSULE ER 12 HOUR ABUSE-DETERRENT ST; Opioid Analgesics, Short-acting ABSTRAL SUBLINGUAL TABLET SUBLINGUAL acetaminophen-codeine oral solution acetaminophen-codeine oral tablet ascomp-codeine oral capsule butalbital-apap-caff-cod oral capsule butalbital-asa-caff-codeine oral capsule butorphanol tartrate injection solution butorphanol tartrate nasal solution codeine sulfate oral tablet DURAMORPH INJECTION SOLUTION endocet oral tablet fentanyl citrate (pf) injection solution fentanyl citrate (pf) injection solution cartridge ; ; ; ; ; ; 9

10 fentanyl citrate buccal lozenge on a handle FENTORA BUCCAL TABLET hydrocodone-acetaminophen oral solution mg/15ml hydrocodone-acetaminophen oral solution mg/15ml hydrocodone-acetaminophen oral tablet hydrocodone-ibuprofen oral tablet hydromorphone hcl injection solution 1 mg/ml, 4 mg/ml HYDROMORPHONE HCL INJECTION SOLUTION 2 MG/ML hydromorphone hcl oral liquid 1 mg/ml hydromorphone hcl oral tablet 2 mg, 4 mg, 8 mg hydromorphone hcl pf injection solution 1 mg/ml, 2 mg/ml, 4 mg/ml hydromorphone hcl pf injection solution 10 mg/ml, 50 mg/5ml ibudone oral tablet mg LAZANDA NASAL SOLUTION lorcet hd oral tablet lorcet oral tablet lorcet plus oral tablet morphine sulfate (concentrate) oral solution 100 mg/5ml morphine sulfate (pf) injection solution morphine sulfate (pf) intravenous solution morphine sulfate injection solution 10 mg/ml, 4 mg/ml, 8 mg/ml MORPHINE SULFATE INJECTION SOLUTION 2 MG/ML, 5 MG/ML morphine sulfate intravenous solution 1 mg/ml, 150 mg/30ml morphine sulfate oral solution MORPHINE SULFATE ORAL TABLET nalbuphine hcl injection solution OXAYDO ORAL TABLET ABUSE-DETERRENT oxycodone hcl oral capsule 5 mg oxycodone hcl oral concentrate 100 mg/5ml oxycodone hcl oral solution 5 mg/5ml oxycodone hcl oral tablet 10 mg, 15 mg, 20 mg, 30 mg, 5 mg oxycodone-acetaminophen oral solution mg/5ml oxycodone-acetaminophen oral tablet oxycodone-aspirin oral tablet oxycodone-ibuprofen oral tablet oxymorphone hcl oral tablet ; ; ; ; 10

11 pentazocine-naloxone hcl oral tablet primlev oral tablet mg primlev oral tablet mg, mg ROXYBOND ORAL TABLET ABUSE-DETERRENT tramadol hcl oral tablet tramadol hcl-acetaminophen oral tablet verdrocet oral tablet vicodin es oral tablet vicodin hp oral tablet vicodin oral tablet xylon oral tablet mg Anesthetics Local Anesthetics 7T LIDO EXTERNAL GEL chloroprocaine hcl (pf) injection solution glydo external gel lidocaine external ointment lidocaine external patch lidocaine hcl (pf) injection solution lidocaine hcl external gel lidocaine hcl external solution lidocaine hcl injection solution LIDOCAINE IN DEXTROSE SOLUTION lidocaine-epinephrine injection solution lidocaine-prilocaine external cream LIDOCAINE-TETRACAINE EXTERNAL CREAM PLIAGLIS EXTERNAL CREAM polocaine injection solution polocaine-mpf injection solution xylocaine dental injection solution Anti-Addiction/Substance Abuse Treatment Agents Alcohol Deterrents/Anti-craving acamprosate calcium oral tablet delayed release disulfiram oral tablet VIVITROL INTRAMUSCULAR SUSPENSION RECONSTITUTED ; ; QL (30 GM per 30 days) ; QL (30 ML per 30 days) ; QL (150 GM per 30 days) ; QL (30 ML per 30 days) ; QL (50 ML per 30 days) ; QL (30 GM per 30 days) ; QL (30 GM per 30 days) ; QL (30 GM per 30 days) 11

12 Opioid Dependence Treatments buprenorphine hcl sublingual tablet sublingual buprenorphine hcl-naloxone hcl sublingual film 12-3 mg buprenorphine hcl-naloxone hcl sublingual film mg buprenorphine hcl-naloxone hcl sublingual film 4-1 mg buprenorphine hcl-naloxone hcl sublingual film 8-2 mg buprenorphine hcl-naloxone hcl sublingual tablet sublingual mg buprenorphine hcl-naloxone hcl sublingual tablet sublingual 8-2 mg LUCEMYRA ORAL TABLET naltrexone hcl oral tablet SUBOXONE SUBLINGUAL FILM 12-3 MG SUBOXONE SUBLINGUAL FILM MG SUBOXONE SUBLINGUAL FILM 4-1 MG SUBOXONE SUBLINGUAL FILM 8-2 MG Opioid Reversal Agents naloxone hcl injection solution naloxone hcl injection solution cartridge naloxone hcl injection solution prefilled syringe NARCAN NASAL LIQUID Smoking Cessation Agents bupropion hcl er (smoking det) oral tablet extended release 12 hour CHANTIX CONTINUING MONTH K ORAL TABLET CHANTIX ORAL TABLET CHANTIX STARTING MONTH K ORAL TABLET NICOTROL INHALATION INHALER NICOTROL NS NASAL SOLUTION Antibacterials Aminoglycosides amikacin sulfate injection solution gentak ophthalmic ointment gentamicin in saline intravenous solution mg/ml-%, mg/ml-%, mg/ml-%, mg/ml-% GENTAMICIN IN SALINE INTRAVENOUS SOLUTION MG/ML-%, MG/ML-%, MG/ML-% gentamicin sulfate external cream gentamicin sulfate external ointment QL (60 EA per 30 days) QL (360 EA per 30 days) QL (180 EA per 30 days) QL (90 EA per 30 days) QL (360 EA per 30 days) QL (90 EA per 30 days) QL (480 EA per 30 days) QL (60 EA per 30 days) QL (360 EA per 30 days) QL (180 EA per 30 days) QL (90 EA per 30 days) QL (60 EA per 30 days) QL (504 EA per 365 days) QL (504 EA per 365 days) QL (504 EA per 365 days) QL (2688 EA per 365 days) QL (360 ML per 365 days) 12

13 gentamicin sulfate injection solution gentamicin sulfate intravenous solution 10 mg/ml gentamicin sulfate ophthalmic solution neomycin sulfate oral tablet neomycin-polymyxin b gu irrigation solution paromomycin sulfate oral capsule streptomycin sulfate intramuscular solution reconstituted tobramycin ophthalmic solution tobramycin sulfate injection solution tobramycin sulfate injection solution reconstituted TOBREX OPHTHALMIC OINTMENT Antibacterials, Other ALTABAX EXTERNAL OINTMENT baciim intramuscular solution reconstituted bacitracin intramuscular solution reconstituted bacitracin ophthalmic ointment BACTROBAN NASAL NASAL OINTMENT 2 % chloramphenicol sod succinate intravenous solution reconstituted CLEOCIN VAGINAL SUPPOSITORY clindacin etz external swab clindacin-p external swab clindamycin hcl oral capsule clindamycin palmitate hcl oral solution reconstituted clindamycin phosphate external foam clindamycin phosphate external gel clindamycin phosphate external lotion clindamycin phosphate external solution clindamycin phosphate external swab clindamycin phosphate in d5w intravenous solution CLINDAMYCIN PHOSPHATE IN NACL INTRAVENOUS SOLUTION clindamycin phosphate injection solution clindamycin phosphate intravenous solution clindamycin phosphate vaginal cream CLINDESSE VAGINAL CREAM 13

14 colistimethate sodium (cba) injection solution reconstituted CORTISPORIN EXTERNAL CREAM CORTISPORIN EXTERNAL OINTMENT DALVANCE INTRAVENOUS SOLUTION RECONSTITUTED DAPTOMYCIN INTRAVENOUS SOLUTION RECONSTITUTED 350 MG daptomycin intravenous solution reconstituted 500 mg IMVIDO ORAL CAPSULE lincomycin hcl injection solution linezolid in sodium chloride intravenous solution linezolid intravenous solution linezolid oral suspension reconstituted linezolid oral tablet mafenide acetate external packet methenamine hippurate oral tablet METRONIDAZOLE IN NACL INTRAVENOUS SOLUTION MG/100ML-% metronidazole in nacl intravenous solution mg/100ml-% METRONIDAZOLE INTRAVENOUS SOLUTION 5 MG/ML metronidazole oral capsule 375 mg metronidazole oral tablet 250 mg metronidazole oral tablet 500 mg metronidazole vaginal gel 0.75 % MONUROL ORAL CKET mupirocin external cream mupirocin external ointment nitrofurantoin macrocrystal oral capsule 100 mg nitrofurantoin macrocrystal oral capsule 25 mg nitrofurantoin macrocrystal oral capsule 50 mg nitrofurantoin monohydrate macrocrystals oral capsule nitrofurantoin oral suspension ORBACTIV INTRAVENOUS SOLUTION RECONSTITUTED polymyxin b sulfate injection solution reconstituted PRIMSOL ORAL SOLUTION silver sulfadiazine external cream QL (1800 ML per 28 days) QL (56 EA per 28 days) QL (360 EA per 365 days) QL (1440 EA per 365 days) QL (720 EA per 365 days) QL (180 EA per 365 days) QL (7200 ML per 365 days) 14

15 SIVEXTRO INTRAVENOUS SOLUTION RECONSTITUTED SIVEXTRO ORAL TABLET SSD EXTERNAL CREAM SULFAMYLON EXTERNAL CREAM SYNERCID INTRAVENOUS SOLUTION RECONSTITUTED tigecycline intravenous solution reconstituted trimethoprim oral tablet TRIMPEX ORAL SOLUTION 50 MG/5ML vancomycin hcl in dextrose intravenous solution 1-5 gm/200ml-%, mg/100ml-% vancomycin hcl in dextrose solution mg/150ml-% intravenous VANCOMYCIN HCL IN DEXTROSE SOLUTION MG/150ML-% INTRAVENOUS vancomycin hcl intravenous solution reconstituted 1 gm, 1.25 gm, 1.5 gm, 10 gm, 100 gm, 5 gm, 500 mg, 5000 mg, 750 mg VANCOMYCIN HCL INTRAVENOUS SOLUTION RECONSTITUTED 250 MG vancomycin hcl oral capsule 125 mg vancomycin hcl oral capsule 250 mg VANDAZOLE VAGINAL GEL VIBATIV INTRAVENOUS SOLUTION RECONSTITUTED XIFAXAN ORAL TABLET Beta-lactam, Cephalosporins AVYCAZ INTRAVENOUS SOLUTION RECONSTITUTED cefaclor er oral tablet extended release 12 hour cefaclor oral capsule cefaclor oral suspension reconstituted cefadroxil oral capsule cefadroxil oral suspension reconstituted cefadroxil oral tablet cefazolin sodium injection solution reconstituted cefazolin sodium intravenous solution reconstituted cefazolin sodium-dextrose intravenous solution 1-4 gm/50ml-%, 2-4 gm/100ml-% cefazolin sodium-dextrose intravenous solution reconstituted cefdinir oral capsule QL (6 EA per 30 days) QL (6 EA per 30 days) 15

16 cefdinir oral suspension reconstituted cefditoren pivoxil oral tablet cefepime hcl injection solution reconstituted cefepime hcl intravenous solution cefepime-dextrose intravenous solution reconstituted cefixime oral suspension reconstituted cefotaxime sodium injection solution reconstituted cefotetan -dextrose intravenous solution reconstituted cefotetan injection solution reconstituted cefoxitin sodium injection solution reconstituted cefoxitin sodium intravenous solution reconstituted CEFOXITIN SODIUM-DEXTROSE INTRAVENOUS SOLUTION RECONSTITUTED cefpodoxime proxetil oral suspension reconstituted cefpodoxime proxetil oral tablet cefprozil oral suspension reconstituted cefprozil oral tablet ceftazidime and dextrose intravenous solution reconstituted ceftazidime injection solution reconstituted ceftibuten oral capsule 400 mg ceftibuten oral suspension reconstituted 180 mg/5ml ceftriaxone sodium in dextrose intravenous solution ceftriaxone sodium injection solution reconstituted ceftriaxone sodium intravenous solution reconstituted ceftriaxone sodium-dextrose intravenous solution reconstituted cefuroxime axetil oral tablet cefuroxime sodium injection solution reconstituted cefuroxime sodium intravenous solution reconstituted cephalexin oral capsule cephalexin oral suspension reconstituted cephalexin oral tablet SUPRAX ORAL CAPSULE SUPRAX ORAL SUSPENSION RECONSTITUTED 500 MG/5ML suprax oral tablet chewable 16

17 tazicef injection solution reconstituted tazicef intravenous solution reconstituted TEFLARO INTRAVENOUS SOLUTION RECONSTITUTED ZINACEF IN STERILE WATER INTRAVENOUS SOLUTION 1.5 GM ZINACEF INTRAVENOUS SOLUTION RECONSTITUTED 750 MG Beta-lactam, Other AZACTAM IN DEXTROSE INTRAVENOUS SOLUTION aztreonam injection solution reconstituted 1 gm aztreonam injection solution reconstituted 2 gm DORIPENEM INTRAVENOUS SOLUTION RECONSTITUTED ertapenem sodium injection solution reconstituted imipenem-cilastatin intravenous solution reconstituted INVANZ INJECTION SOLUTION RECONSTITUTED INVANZ INTRAVENOUS SOLUTION RECONSTITUTED 1 GM meropenem intravenous solution reconstituted MEROPENEM-SODIUM CHLORIDE INTRAVENOUS SOLUTION RECONSTITUTED 1 GM/50ML MEROPENEM-SODIUM CHLORIDE INTRAVENOUS SOLUTION RECONSTITUTED 500 MG/50ML VABOMERE INTRAVENOUS SOLUTION RECONSTITUTED Beta-lactam, Penicillins amoxicillin oral capsule amoxicillin oral suspension reconstituted amoxicillin oral tablet amoxicillin oral tablet chewable amoxicillin-potassium clavulanate er oral tablet extended release 12 hour amoxicillin-potassium clavulanate oral suspension reconstituted mg/5ml, mg/5ml, mg/5ml, mg/5ml amoxicillin-potassium clavulanate oral tablet mg amoxicillin-potassium clavulanate oral tablet mg, mg amoxicillin-potassium clavulanate oral tablet chewable mg, mg ampicillin oral capsule ampicillin sodium injection solution reconstituted ampicillin sodium intravenous solution reconstituted 17

18 ampicillin-sulbactam sodium injection solution reconstituted ampicillin-sulbactam sodium intravenous solution reconstituted 1.5 (1-0.5) gm, 15 (10-5) gm AUGMENTIN ORAL SUSPENSION RECONSTITUTED MG/5ML BACTOCILL IN DEXTROSE INTRAVENOUS SOLUTION BICILLIN C-R INTRAMUSCULAR SUSPENSION BICILLIN L-A INTRAMUSCULAR SUSPENSION dicloxacillin sodium oral capsule NAFCILLIN SODIUM IN DEXTROSE INTRAVENOUS SOLUTION nafcillin sodium injection solution reconstituted 1 gm, 2 gm nafcillin sodium intravenous solution reconstituted 1 gm nafcillin sodium intravenous solution reconstituted 10 gm, 2 gm oxacillin sodium injection solution reconstituted PENICILLIN G POT IN DEXTROSE INTRAVENOUS SOLUTION penicillin g potassium injection solution reconstituted penicillin g sodium injection solution reconstituted penicillin v potassium oral solution reconstituted penicillin v potassium oral tablet PFIZERPEN INJECTION SOLUTION RECONSTITUTED UNIT piperacillin-tazobactam intravenous solution reconstituted ZOSYN INTRAVENOUS SOLUTION Macrolides AZASITE OPHTHALMIC SOLUTION azithromycin intravenous solution reconstituted AZITHROMYCIN ORAL CKET azithromycin oral suspension reconstituted azithromycin oral tablet clarithromycin er oral tablet extended release 24 hour clarithromycin oral suspension reconstituted clarithromycin oral tablet DIFICID ORAL TABLET ery external pad ERYPED 400 ORAL SUSPENSION RECONSTITUTED 18

19 ery-tab oral tablet delayed release erythrocin lactobionate intravenous solution reconstituted erythrocin stearate oral tablet erythromycin ethylsuccinate oral suspension reconstituted erythromycin ethylsuccinate oral tablet erythromycin external gel erythromycin external pad erythromycin external solution erythromycin ophthalmic ointment erythromycin oral capsule delayed release particles erythromycin oral tablet erythromycin stearate oral tablet PCE ORAL TABLET DELAYED RELEASE 333 MG, 500 MG ZMAX ORAL SUSPENSION RECONSTITUTED 2 GM Quinolones BAXDELA INTRAVENOUS SOLUTION RECONSTITUTED BAXDELA ORAL TABLET BESIVANCE OPHTHALMIC SUSPENSION CILOXAN OPHTHALMIC OINTMENT ciprofloxacin er oral tablet extended release 24 hour ciprofloxacin hcl ophthalmic solution ciprofloxacin hcl oral tablet CIPROFLOXACIN HCL OTIC SOLUTION ciprofloxacin in d5w intravenous solution ciprofloxacin intravenous solution 200 mg/20ml, 400 mg/40ml ciprofloxacin oral suspension reconstituted gatifloxacin ophthalmic solution levofloxacin in d5w intravenous solution levofloxacin intravenous solution levofloxacin ophthalmic solution levofloxacin oral solution levofloxacin oral tablet moxifloxacin hcl in nacl intravenous solution MOXIFLOXACIN HCL INTRAVENOUS SOLUTION 19

20 moxifloxacin hcl ophthalmic solution moxifloxacin hcl oral tablet ofloxacin ophthalmic solution ofloxacin oral tablet ofloxacin otic solution Sulfonamides sulfacetamide sodium (acne) external lotion sulfacetamide sodium ophthalmic ointment sulfacetamide sodium ophthalmic solution sulfadiazine oral tablet sulfamethoxazole-trimethoprim intravenous solution sulfamethoxazole-trimethoprim oral suspension sulfamethoxazole-trimethoprim oral tablet sulfatrim pediatric oral suspension Tetracyclines coremino oral tablet extended release 24 hour demeclocycline hcl oral tablet DORYX MPC ORAL TABLET DELAYED RELEASE doxy 100 intravenous solution reconstituted doxycycline hyclate intravenous solution reconstituted doxycycline hyclate oral capsule doxycycline hyclate oral tablet 100 mg, 20 mg, 75 mg doxycycline hyclate oral tablet 150 mg doxycycline hyclate oral tablet delayed release doxycycline monohydrate oral capsule doxycycline monohydrate oral suspension reconstituted doxycycline monohydrate oral tablet minocycline hcl er oral tablet extended release 24 hour 115 mg, 55 mg, 65 mg minocycline hcl er oral tablet extended release 24 hour 135 mg, 45 mg, 90 mg minocycline hcl oral capsule minocycline hcl oral tablet mondoxyne nl oral capsule 20

21 morgidox oral capsule NUZYRA INTRAVENOUS SOLUTION RECONSTITUTED NUZYRA ORAL TABLET okebo oral capsule SEYSARA ORAL TABLET soloxide oral tablet delayed release tetracycline hcl oral capsule VIBRAMYCIN ORAL SYRUP Anticonvulsants Anticonvulsants, Other APTIOM ORAL TABLET BRIVIACT INTRAVENOUS SOLUTION BRIVIACT ORAL SOLUTION BRIVIACT ORAL TABLET EPIDIOLEX ORAL SOLUTION FYCOM ORAL SUSPENSION FYCOM ORAL TABLET levetiracetam er oral tablet extended release 24 hour levetiracetam in nacl intravenous solution levetiracetam intravenous solution 500 mg/5ml levetiracetam oral solution 100 mg/ml levetiracetam oral tablet 1000 mg, 250 mg, 500 mg, 750 mg roweepra oral tablet roweepra xr oral tablet extended release 24 hour SPRITAM ORAL TABLET DISINTEGRATING SOLUBLE 1000 MG, 250 MG, 500 MG, 750 MG Calcium Channel Modifying Agents CELONTIN ORAL CAPSULE ethosuximide oral capsule ethosuximide oral solution LYRICA ORAL CAPSULE 100 MG, 150 MG, 200 MG, 225 MG, 25 MG, 50 MG, 75 MG LYRICA ORAL CAPSULE 300 MG LYRICA ORAL SOLUTION zonisamide oral capsule QL (90 EA per 30 days) QL (60 EA per 30 days) QL (900 ML per 30 days) 21

22 Gamma-aminobutyric Acid (GABA) Augmenting Agents clobazam oral suspension clobazam oral tablet clonazepam oral tablet 0.5 mg, 1 mg clonazepam oral tablet 2 mg clonazepam oral tablet dispersible mg, 0.25 mg, 0.5 mg, 1 mg clonazepam oral tablet dispersible 2 mg DIASTAT ACUDIAL RECTAL GEL DIASTAT PEDIATRIC RECTAL GEL diazepam rectal gel 10 mg, 2.5 mg, 20 mg divalproex sodium er oral tablet extended release 24 hour divalproex sodium oral capsule delayed release sprinkle divalproex sodium oral tablet delayed release gabapentin oral capsule 100 mg, 300 mg gabapentin oral capsule 400 mg gabapentin oral solution 250 mg/5ml gabapentin oral tablet 600 mg gabapentin oral tablet 800 mg GABITRIL ORAL TABLET 12 MG, 16 MG ONFI ORAL SUSPENSION ONFI ORAL TABLET phenobarbital oral elixir phenobarbital oral tablet phenobarbital sodium injection solution primidone oral tablet SABRIL ORAL TABLET SYMZAN ORAL FILM 10 MG, 20 MG SYMZAN ORAL FILM 5 MG tiagabine hcl oral tablet valproate sodium intravenous solution 100 mg/ml valproate sodium oral solution valproic acid oral capsule vigabatrin oral packet vigabatrin oral tablet vigadrone oral packet QL (90 EA per 30 days) QL (300 EA per 30 days) QL (90 EA per 30 days) QL (300 EA per 30 days) QL (360 EA per 30 days) QL (270 EA per 30 days) QL (2160 ML per 30 days) QL (180 EA per 30 days) QL (150 EA per 30 days) 22

23 Glutamate Reducing Agents felbamate oral suspension felbamate oral tablet lamotrigine er oral tablet extended release 24 hour lamotrigine oral kit 25 & 50 & 100 mg, 25 (21)-50 (7) mg lamotrigine oral kit 50 (42)-100(14) mg lamotrigine oral tablet 100 mg, 150 mg, 200 mg, 25 mg lamotrigine oral tablet chewable 25 mg, 5 mg lamotrigine oral tablet dispersible 100 mg, 200 mg, 25 mg, 50 mg lamotrigine starter kit-blue oral kit lamotrigine starter kit-green oral kit lamotrigine starter kit-orange oral kit subvenite oral tablet subvenite starter kit-blue oral kit subvenite starter kit-green oral kit subvenite starter kit-orange oral kit topiramate er oral capsule er 24 hour sprinkle topiramate oral capsule sprinkle topiramate oral tablet Sodium Channel Agents BANZEL ORAL SUSPENSION BANZEL ORAL TABLET carbamazepine er oral capsule extended release 12 hour carbamazepine er oral tablet extended release 12 hour carbamazepine oral suspension 100 mg/5ml carbamazepine oral tablet 200 mg carbamazepine oral tablet chewable 100 mg CARBATROL ORAL CAPSULE EXTENDED RELEASE 12 HOUR dilantin infatabs oral tablet chewable dilantin oral capsule DILANTIN ORAL SUSPENSION epitol oral tablet fosphenytoin sodium injection solution oxcarbazepine oral suspension 300 mg/5ml 23

24 oxcarbazepine oral tablet 150 mg, 300 mg, 600 mg PEGANONE ORAL TABLET phenytek oral capsule phenytoin oral suspension phenytoin oral tablet chewable phenytoin sodium extended oral capsule phenytoin sodium injection solution TEGRETOL ORAL SUSPENSION TEGRETOL ORAL TABLET TEGRETOL XR ORAL TABLET EXTENDED RELEASE 12 HOUR VIMT INTRAVENOUS SOLUTION VIMT ORAL SOLUTION VIMT ORAL TABLET 100 MG, 150 MG, 200 MG VIMT ORAL TABLET 50 MG Antidementia Agents Antidementia Agents, Other ergoloid mesylates oral tablet Cholinesterase Inhibitors donepezil hcl oral tablet 10 mg, 5 mg donepezil hcl oral tablet 23 mg donepezil hcl oral tablet dispersible galantamine hbr er oral capsule extended release 24 hour galantamine hbr oral solution 4 mg/ml galantamine hbr oral tablet 12 mg, 4 mg, 8 mg rivastigmine tartrate oral capsule rivastigmine transdermal patch 24 hour N-methyl-D-aspartate (NMDA) Receptor Antagonist memantine hcl er oral capsule extended release 24 hour memantine hcl oral solution memantine hcl oral tablet 10 mg, 5 mg MEMANTINE HCL ORAL TABLET 5 (28)-10 (21) MG Antidepressants Antidepressants, Other APLENZIN ORAL TABLET EXTENDED RELEASE 24 HOUR QL (30 EA per 30 days) ST; QL (30 EA per 30 days) 24

25 bupropion hcl er (sr) oral tablet extended release 12 hour bupropion hcl er (xl) oral tablet extended release 24 hour 150 mg bupropion hcl er (xl) oral tablet extended release 24 hour 300 mg bupropion hcl oral tablet mirtazapine oral tablet 15 mg mirtazapine oral tablet 30 mg, 45 mg, 7.5 mg mirtazapine oral tablet dispersible Monoamine Oxidase Inhibitors EMSAM TRANSDERMAL TCH 24 HOUR MARPLAN ORAL TABLET phenelzine sulfate oral tablet tranylcypromine sulfate oral tablet SSRI/SNRI (Selective Serotonin Reuptake Inhibitors/Serotonin and Norepinephrine Reuptake Inhibitors) citalopram hbr oral solution 10 mg/5ml citalopram hbr oral tablet 10 mg, 20 mg, 40 mg desvenlafaxine er oral tablet extended release 24 hour 100 mg desvenlafaxine er oral tablet extended release 24 hour 50 mg DESVENLAFAXINE FUMARATE ER ORAL TABLET EXTENDED RELEASE 24 HOUR 100 MG DESVENLAFAXINE FUMARATE ER ORAL TABLET EXTENDED RELEASE 24 HOUR 50 MG desvenlafaxine succinate er oral tablet extended release 24 hour 100 mg desvenlafaxine succinate er oral tablet extended release 24 hour 25 mg, 50 mg duloxetine hcl oral capsule delayed release particles 20 mg, 60 mg duloxetine hcl oral capsule delayed release particles 30 mg, 40 mg escitalopram oxalate oral solution escitalopram oxalate oral tablet FETZIMA ORAL CAPSULE EXTENDED RELEASE 24 HOUR FETZIMA TITRATION ORAL CAPSULE ER 24 HOUR THERAPY CK fluoxetine hcl (pmdd) oral capsule fluoxetine hcl oral capsule 10 mg, 20 mg, 40 mg fluoxetine hcl oral capsule delayed release 90 mg fluoxetine hcl oral solution 20 mg/5ml QL (90 EA per 30 days) QL (90 EA per 30 days) QL (30 EA per 30 days) ST; QL (30 EA per 30 days) ST; QL (120 EA per 30 days) ST; QL (30 EA per 30 days) ST; QL (120 EA per 30 days) ST; QL (30 EA per 30 days) QL (120 EA per 30 days) QL (30 EA per 30 days) QL (60 EA per 30 days) QL (90 EA per 30 days) ST; QL (30 EA per 30 days) ST; QL (56 EA per 365 days) QL (4 EA per 28 days) 25

26 fluoxetine hcl oral tablet 10 mg, 20 mg, 60 mg fluvoxamine maleate er oral capsule extended release 24 hour fluvoxamine maleate oral tablet maprotiline hcl oral tablet nefazodone hcl oral tablet olanzapine-fluoxetine hcl oral capsule mg, mg, 6-50 mg olanzapine-fluoxetine hcl oral capsule 3-25 mg, 6-25 mg paroxetine hcl er oral tablet extended release 24 hour paroxetine hcl oral tablet paroxetine mesylate oral capsule XIL ORAL SUSPENSION PEXEVA ORAL TABLET 10 MG, 20 MG, 40 MG PEXEVA ORAL TABLET 30 MG sertraline hcl oral concentrate sertraline hcl oral tablet trazodone hcl oral tablet TRINTELLIX ORAL TABLET venlafaxine hcl er oral capsule extended release 24 hour venlafaxine hcl er oral tablet extended release 24 hour venlafaxine hcl oral tablet VIIBRYD ORAL TABLET VIIBRYD STARTER CK ORAL KIT Tricyclics amitriptyline hcl oral tablet amoxapine oral tablet chlordiazepoxide-amitriptyline oral tablet clomipramine hcl oral capsule desipramine hcl oral tablet doxepin hcl oral capsule doxepin hcl oral concentrate imipramine hcl oral tablet imipramine pamoate oral capsule nortriptyline hcl oral capsule nortriptyline hcl oral solution perphenazine-amitriptyline oral tablet QL (60 EA per 30 days) QL (30 EA per 30 days) QL (90 EA per 30 days) QL (30 EA per 30 days) ; QL (30 EA per 30 days) ; QL (60 EA per 30 days) QL (30 EA per 30 days) QL (30 EA per 30 days) QL (60 EA per 365 days) 26

27 protriptyline hcl oral tablet trimipramine maleate oral capsule Antiemetics Antiemetics, Other AKYNZEO ORAL CAPSULE compro rectal suppository droperidol injection solution meclizine hcl oral tablet phenadoz rectal suppository phenergan rectal suppository 12.5 mg, 25 mg, 50 mg prochlorperazine edisylate injection solution prochlorperazine maleate oral tablet prochlorperazine rectal suppository promethazine hcl injection solution promethazine hcl oral syrup promethazine hcl oral tablet promethazine hcl rectal suppository promethegan rectal suppository scopolamine transdermal patch 72 hour 1 mg/3days trimethobenzamide hcl oral capsule Emetogenic Therapy Adjuncts ANZEMET ORAL TABLET 100 MG ANZEMET ORAL TABLET 50 MG aprepitant oral capsule 125 mg aprepitant oral capsule 40 mg aprepitant oral capsule 80 & 125 mg aprepitant oral capsule 80 mg CINVANTI INTRAVENOUS EMULSION dronabinol oral capsule 10 mg dronabinol oral capsule 2.5 mg, 5 mg EMEND ORAL SUSPENSION RECONSTITUTED granisetron hcl intravenous solution granisetron hcl oral tablet ondansetron hcl injection solution 4 mg/2ml ondansetron hcl injection solution 40 mg/20ml ; QL (2 EA per 30 days) ; QL (5 EA per 30 days) ; QL (5 EA per 30 days) ; QL (2 EA per 30 days) ; QL (1 EA per 30 days) ; QL (6 EA per 30 days) ; QL (8 EA per 30 days) ; QL (60 EA per 30 days) ; QL (60 EA per 30 days) ; QL (6 EA per 30 days) ; QL (30 EA per 30 days) QL (240 ML per 30 days) QL (120 ML per 30 days) 27

28 ondansetron hcl oral solution ondansetron hcl oral tablet 24 mg ondansetron hcl oral tablet 4 mg, 8 mg ondansetron odt oral tablet dispersible palonosetron hcl intravenous solution palonosetron hcl intravenous solution prefilled syringe SANCUSO TRANSDERMAL TCH SYNDROS ORAL SOLUTION Antifungals Antifungals ABELCET INTRAVENOUS SUSPENSION AMBISOME INTRAVENOUS SUSPENSION RECONSTITUTED AMPHOTEC INTRAVENOUS SUSPENSION RECONSTITUTED 100 MG, 50 MG amphotericin b injection solution reconstituted caspofungin acetate intravenous solution reconstituted ciclodan external cream 0.77 % ciclodan external solution ciclopirox external gel ciclopirox external shampoo ciclopirox external solution ciclopirox olamine external cream ciclopirox olamine external suspension clotrimazole external cream clotrimazole external solution clotrimazole mouth/throat lozenge clotrimazole-betamethasone external cream clotrimazole-betamethasone external lotion CRESEMBA INTRAVENOUS SOLUTION RECONSTITUTED CRESEMBA ORAL CAPSULE econazole nitrate external cream ERAXIS INTRAVENOUS SOLUTION RECONSTITUTED EXELDERM EXTERNAL CREAM EXELDERM EXTERNAL SOLUTION ; QL (450 ML per 30 days) ; QL (14 EA per 28 days) QL (2 EA per 30 days) ; QL (120 ML per 30 days) 28

29 fluconazole in dextrose intravenous solution 200 mg/100ml, 400 mg/200ml fluconazole in sodium chloride intravenous solution fluconazole oral suspension reconstituted fluconazole oral tablet flucytosine oral capsule griseofulvin microsize oral suspension griseofulvin microsize oral tablet griseofulvin ultramicrosize oral tablet gynazole-1 vaginal cream itraconazole oral capsule itraconazole oral solution JUBLIA EXTERNAL SOLUTION ketoconazole external cream ketoconazole external foam ketoconazole external shampoo ketoconazole oral tablet MENTAX EXTERNAL CREAM miconazole 3 vaginal suppository MYCAMINE INTRAVENOUS SOLUTION RECONSTITUTED naftifine hcl external cream NAFTIN EXTERNAL GEL NATACYN OPHTHALMIC SUSPENSION NOXAFIL INTRAVENOUS SOLUTION NOXAFIL ORAL SUSPENSION NOXAFIL ORAL TABLET DELAYED RELEASE nyamyc external powder nyata external powder unit/gm nystatin external cream nystatin external ointment nystatin external powder nystatin mouth/throat suspension nystatin oral tablet nystatin-triamcinolone external cream 29

30 nystatin-triamcinolone external ointment nystop external powder ONMEL ORAL TABLET 200 MG oxiconazole nitrate external cream OXISTAT EXTERNAL LOTION SPORANOX ORAL SOLUTION terbinafine hcl oral tablet terconazole vaginal cream terconazole vaginal suppository TOLSURA ORAL CAPSULE voriconazole intravenous solution reconstituted voriconazole oral suspension reconstituted voriconazole oral tablet Antigout Agents Antigout Agents allopurinol oral tablet allopurinol sodium intravenous solution reconstituted COLCHICINE ORAL CAPSULE colchicine oral tablet colchicine-probenecid oral tablet COLCRYS ORAL TABLET KRYSTEXXA INTRAVENOUS SOLUTION probenecid oral tablet ULORIC ORAL TABLET Anti-inflammatory Agents Glucocorticoids hydrocortisone rectal cream procto-med hc rectal cream procto-pak rectal cream proctosol hc rectal cream proctozone-hc rectal cream triamcinolone acetonide external aerosol solution Antimigraine Agents Ergot Alkaloids QL (84 EA per 180 days) ST 30

31 dihydroergotamine mesylate injection solution dihydroergotamine mesylate nasal solution ERGOMAR SUBLINGUAL TABLET SUBLINGUAL ergotamine-caffeine oral tablet migergot rectal suppository Prophylactic AIMOVIG 140 DOSE SUBCUTANEOUS SOLUTION AUTO- INJECTOR Serotonin (5-HT) 1b/1d Receptor Agonists almotriptan malate oral tablet eletriptan hbr oral tablet frovatriptan succinate oral tablet naratriptan hcl oral tablet rizatriptan benzoate oral tablet rizatriptan benzoate oral tablet dispersible sumatriptan nasal solution sumatriptan succinate oral tablet 100 mg, 25 mg, 50 mg SUMATRIPTAN SUCCINATE REFILL SUBCUTANEOUS SOLUTION CARTRIDGE 4 MG/0.5ML SUMATRIPTAN SUCCINATE REFILL SUBCUTANEOUS SOLUTION CARTRIDGE 6 MG/0.5ML sumatriptan succinate subcutaneous solution 6 mg/0.5ml QL (8 ML per 30 days) ; QL (2 ML per 30 days) QL (12 EA per 30 days) QL (12 EA per 30 days) QL (12 EA per 30 days) QL (9 EA per 30 days) QL (18 EA per 30 days) QL (18 EA per 30 days) QL (12 EA per 30 days) QL (9 EA per 30 days) QL (8 ML per 30 days) QL (5 ML per 30 days) QL (5 ML per 30 days) sumatriptan succinate subcutaneous solution auto-injector 4 mg/0.5ml QL (8 ML per 30 days) sumatriptan succinate subcutaneous solution auto-injector 6 mg/0.5ml QL (5 ML per 30 days) sumatriptan succinate subcutaneous solution prefilled syringe 6 mg/0.5ml sumatriptan-naproxen sodium oral tablet zolmitriptan oral tablet 2.5 mg, 5 mg zolmitriptan oral tablet dispersible 2.5 mg zolmitriptan oral tablet dispersible 5 mg Antimyasthenic Agents Parasympathomimetics GUANIDINE HCL ORAL TABLET MESTINON ORAL SYRUP pyridostigmine bromide er oral tablet extended release pyridostigmine bromide oral tablet QL (5 ML per 30 days) QL (9 EA per 30 days) QL (12 EA per 30 days) QL (12 EA per 30 days) QL (9 EA per 30 days) 31