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

Transcription

1 Formulary IEHP DualChoice Cal MediConnect Plan (Medicare-Medicaid Plan) IEHP (4347) TTY April 09

2 IEHP DualChoice Cal MediConnect Plan (Medicare-Medicaid Plan) 09 List of Covered Drugs (Formulary) Introduction PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN. Note to existing enrollees: This formulary has changed since last year. Please review this document to make sure that it still contains the drugs you take. This document is called the List of Covered Drugs (also known as the Drug List). It tells you which prescription drugs and over-the-counter drugs are covered by IEHP DualChoice. The Drug List also tells you if there are any special rules or restrictions on any drugs covered by IEHP DualChoice. Key terms and their definitions appear in the last chapter of the Member Handbook. Table of Contents A. Disclaimers... 3 B. Frequently Asked Questions (FAQ)... 4 B. What prescription drugs are on the List of Covered Drugs? (We call the List of Covered Drugs the Drug List for short.)... 4 B. Does the Drug List ever change?... 4 B3. What happens when there is a change to the Drug List?... 5 B4. Are there any restrictions or limits on drug coverage or any required actions to take to get certain drugs?... 6 B5. How will you know if the drug you want has limitations or if there are required actions to take to get the drug?... 6 B6. What happens if we change our rules about some drugs (for example, prior authorization (approval), quantity limits, and/or step therapy restrictions)?...7 B7. How can you find a drug on the Drug List?... 7 B8. What if the drug you want to take is not on the Drug List?...7 B9. What if you are a new IEHP DualChoice member and can t find your drug on the Drug List or have a problem getting your drug?... 7 B0. Can you ask for an exception to cover your drug?... 9? If you have questions, please call IEHP DualChoice at IEHP (4347), 8am-8pm (PST), 7 days a week, including holidays. TTY/TDD users should call The call is free. For more information, visit

3 B. How can you ask for an exception?... 9 B. How long does it take to get an exception?... 9 B3. What are generic drugs?... 9 B4. What are OTC drugs?... 9 B5. Does IEHP DualChoice cover OTC non-drug products?... 0 B6. What is your copay?... 0 C.List of Covered Drugs...0 D.List of Drugs by Medical Condition E.Index...86? If you have questions, please call IEHP DualChoice at IEHP (4347), 8am-8pm (PST), 7 days a week, including holidays. TTY/TDD users should call The call is free. For more information, visit

4 A. Disclaimers HPMS Approved Formulary File Submission ID , Version 0. This is a list of drugs that members can get in IEHP DualChoice. IEHP DualChoice Cal MediConnect Plan (Medicare-Medicaid Plan) is a health plan that contract with both Medicare and Medi-Cal to provide benefits of both programs to enrollees. The List of Covered Drugs and/or pharmacy and provider networks may change throughout the year. We will send you a notice before we make change that affects you. You can always check IEHP DualChoice s up-to-date List of Covered Drugs online at or by calling IEHP (4347), 8am-8pm (PST), 7 days a week, including holidays. TTY/TDD users should call This call is free. ATTENTION: If you speak Spanish, language assistance services, free of charge, are available to you. Call IEHP (4347), 8am-8pm (PST), 7 days a week, including holidays. TTY/TDD users should call The call is free. ATENCIÓN: Si usted prefiere comunicarse en un idioma que no es inglés, sin cargo, a su disposición. Llame a Servicios para Miembros de IEHP DualChoice al IEHP (4347), de 8am a 8pm (Hora del Pacífico), los 7 días de la semana, incluidos los días festivos. Los usuarios de TTY/TDD deben llamar al La llamada es gratuita. You can get this document for free in other formats, such as large print, braille, or audio. Call IEHP (4347), 8am-8pm (PST), 7 days a week, including holidays. TTY/TDD users should call The call is free. To make a standing request to receive materials in a language other than English or in an alternate format, please call IEHP (4347), 8am-8pm (PST), 7 days a week, including holidays. TTY/TDD users should call ? If you have questions, please call IEHP DualChoice at IEHP (4347), 8am-8pm (PST), 7 days a week, including holidays. TTY/TDD users should call The call is free. For more information, visit 3

5 B. Frequently Asked Questions (FAQ) Find answers here to questions you have about this List of Covered Drugs. You can read all of the FAQ to learn more, or look for a question and answer. B. What prescription drugs are on the List of Covered Drugs? (We call the List of Covered Drugs the Drug List for short.) The drugs on the Drug List are the drugs covered by IEHP DualChoice. The drugs are available at pharmacies within our network. A pharmacy is in our network if we have an agreement with them to work with us and provide you services. We refer to these pharmacies as network pharmacies. IEHP DualChoice will cover all medically necessary drugs on the Drug List if: o your doctor or other prescriber says you need them to get better or stay healthy, and o you fill the prescription at a IEHP DualChoice network pharmacy. In some cases, you have to do something before you can get a drug (see question B4 below). You can also see an up-to-date list of drugs that we cover on our website at or call Member Services at IEHP (4347). B. Does the Drug List ever change? Yes. IEHP DualChoice may add or remove drugs on the Drug List during the year. We may also change our rules about drugs. For example, we could: Decide to require or not require prior approval for a drug. (Prior approval is permission from IEHP DualChoice before you can get a drug.) Add or change the amount of a drug you can get (called quantity limits). Add or change step therapy restrictions on a drug. (Step therapy means you must try one drug before we will cover another drug.) For more information on these drug rules, see question B4. If you are taking a drug that was covered at the beginning of the year, we will generally not remove or change coverage of that drug during the rest of the year unless: a new, cheaper drug comes along that works as well as a drug on the Drug List now, or we learn that a drug is not safe, or a drug is removed from the market.? If you have questions, please call IEHP DualChoice at IEHP (4347), 8am-8pm (PST), 7 days a week, including holidays. TTY/TDD users should call The call is free. For more information, visit 4

6 Questions B3 and B6 below have more information on what happens when the Drug List changes. You can always check IEHP DualChoice s up to date Drug List online at You can also call Member Services to check the current Drug List at IEHP (4347). B3. What happens when there is a change to the Drug List? Some changes to the Drug List will happen immediately. For example: A new generic drug becomes available. Sometimes, a new and cheaper drug comes along that works as well as a drug on the Drug List now. When that happens, we may remove the current drug, but your cost for the new drug will stay the same or will be lower. When we add the new generic drug, we may also decide to keep the current drug on the list but change its coverage rules or limits. o We may not tell you before we make this change, but we will send you information about the specific change or changes we made. o You or your provider can ask for an exception from these changes. We will send you a notice with the steps you can take to ask for an exception. Please see question B0 for more information on exceptions. A drug is taken off the market. If the Food and Drug Administration (FDA) says a drug you are taking is not safe or the drug s manufacturer takes a drug off the market, we will take it off the Drug List. If you are taking the drug, we will let you know. Please contact the prescribing doctor after you receive a letter. We may make other changes that affect the drugs you take. We will tell you in advance about these other changes to the Drug List. These changes might happen if: The FDA provides new guidance or there are new clinical guidelines about a drug. We add a generic drug that is not new to the market and o Replace a brand name drug currently on the Drug List or o Change the coverage rules or limits for the brand name drug. When these changes happen, we will tell you at least 30 days before we make the change to the Drug List or when you ask for a refill. This will give you time to talk to your doctor or other prescriber. He or she can help you decide if there is a similar drug on the Drug List you can take instead or whether to ask for an exception. Then you can: Get a 3-day supply of the drug before the change to the Drug List is made, or Ask for an exception from these changes. Please see question B0 for more information about exceptions.? If you have questions, please call IEHP DualChoice at IEHP (4347), 8am-8pm (PST), 7 days a week, including holidays. TTY/TDD users should call The call is free. For more information, visit 5

7 B4. Are there any restrictions or limits on drug coverage or any required actions to take to get certain drugs? Yes, some drugs have coverage rules or have limits on the amount you can get. In some cases you or your doctor or other prescriber must do something before you can get the drug. For example: Prior approval (or prior authorization): For some drugs, you or your doctor or other prescriber must get approval from IEHP DualChoice before you fill your prescription. IEHP DualChoice may not cover the drug if you do not get approval. Quantity limits: Sometimes IEHP DualChoice limits the amount of a drug you can get. Step therapy: Sometimes IEHP DualChoice requires you to do step therapy. This means you will have to try drugs in a certain order for your medical condition. You might have to try one drug before we will cover another drug. If your doctor thinks the first drug doesn t work for you, then we will cover the second. You can find out if your drug has any additional requirements or limits by looking in the tables on pages 4. You can also get more information by visiting our web site at We have posted online documents that explain our prior authorization and step therapy restrictions. You may also ask us to send you a copy. You can ask for an exception from these limits. This will give you time to talk to your doctor or other prescriber. He or she can help you decide if there is a similar drug on the Drug List you can take instead or whether to ask for an exception. Please see questions B0-B for more information about exceptions. IEHP DualChoice conducts drug use reviews for our members to help make sure that they are getting safe and appropriate care. These reviews are especially important for members who have more than one provider who prescribes their drugs. We do a review each time you fill a prescription. We also review our records on a regular basis. If IEHP DualChoice sees a possible problem in your use of medications, we will work with your Doctor to correct the problem. IEHP DualChoice also provides information to the Centers for Medicare and Medicaid Services (CMS) regarding its quality assurance measures according to the guidelines specified by CMS. B5. How will you know if the drug you want has limitations or if there are required actions to take to get the drug? The List of Covered Drugs on page 4 has a column labeled Necessary actions, restrictions, or limits on use.? If you have questions, please call IEHP DualChoice at IEHP (4347), 8am-8pm (PST), 7 days a week, including holidays. TTY/TDD users should call The call is free. For more information, visit 6

8 B6. What happens if we change our rules about some drugs (for example, prior authorization (approval), quantity limits, and/or step therapy restrictions)? In some cases, we will tell you in advance if we add or change prior approval, quantity limits, and/or step therapy restrictions on a drug. See question B3 for more information about this advance notice and situations where we may not be able to tell you in advance when our rules about drugs on the Drug List change. B7. How can you find a drug on the Drug List? There are two ways to find a drug: You can search alphabetically (if you know how to spell the drug), or You can search by medical condition. To search alphabetically, go to the Index of Covered Drugs section. You can find it You can find it in the index that begins on page 86. Look in the index and find your drug. Next to your drug, you will see the page number where you can find the coverage information. Turn to the page listed in the index and find the name of your drug in the first column of the list. To search by medical condition, find the section labeled List of drugs by medical condition on page 4. The drugs in this section are grouped into categories depending on the type of medical conditions they are used to treat. For example, if you have a heart condition, you should look in the category, Cardiovascular Agents. That is where you will find drugs that treat heart conditions. B8. What if the drug you want to take is not on the Drug List? If you don t see your drug on the Drug List, call Member Services at IEHP (4347), 8am- 8pm (PST), 7 days a week, including holidays. TTY/TDD users should call and ask about it. If you learn that IEHP DualChoice will not cover the drug, you can do one of these things: Ask Member Services for a list of drugs like the one you want to take. Then show the list to your doctor or other prescriber. He or she can prescribe a drug on the Drug List that is like the one you want to take. Or You can ask the health plan to make an exception to cover your drug. Please see questions B0-B for more information about exceptions. B9. What if you are a new IEHP DualChoice member and can t find your drug on the Drug List or have a problem getting your drug? We can help. We may cover a temporary 3-day supply of your drug during the first 90 days you are a member of IEHP DualChoice. This will give you time to talk to your doctor or other prescriber. He or she can help you decide if there is a similar drug on the Drug List you can take instead or whether to ask for an exception.? If your prescription is written for fewer days, we will allow multiple fills to provide up to a maximum of 3-days of medication. If you have questions, please call IEHP DualChoice at IEHP (4347), 8am-8pm (PST), 7 days a week, including holidays. TTY/TDD users should call The call is free. For more information, visit 7

9 We will cover a 3-day supply of your drug if: you are taking a drug that is not on our Drug List, or health plan rules do not let you get the amount ordered by your prescriber, or the drug requires prior approval by IEHP DualChoice, or you are taking a drug that is part of a step therapy restriction. If you are in a nursing home or other long-term care facility and need a drug that is not on the Drug List or if you cannot easily get the drug you need, we can help. If you have been in the plan for more than 98 days, live in a long-term care facility, and need a supply right away: We will cover one 3-day supply of the drug you need (unless you have a prescription for fewer, whether or not you are a new IEHP DualChoice member. This is in addition to the temporary supply during the first 90 days you are a member of IEHP DualChoice. As a new member in our plan or continuing member who was affected by a formulary change from one year to the next, you may be taking drugs that are not on our formulary. Or, you may be taking drugs that are on our formulary that are hard for you to get. For example, you may need our approval before you can get your drug. Either way, talk to your doctor. He or she can help you choose the right course of action. This could be changing to a drug we do cover or seeking a formulary exception so that we will cover the drug. While you talk to your doctor to determine the right course of action for you, we may cover your drug in certain cases during the first 90 days you are a member of our plan. For each of your drugs that is not on our formulary or is hard for you to get, we will cover a temporary 3-day supply (unless you have a prescription written for fewer when you go to a network pharmacy. After your first 3-day supply, we will not pay for these drugs, even if you have been a member of the plan less than 90 days. If you are a resident of a long-term care facility, we will cover your prescription refill until we have provided you with a 98-day transition supply, consistent with dispensing increment, (unless you have a prescription written for fewer. We will cover more than one refill of these drugs for the first 90 days of your membership. If you need a drug that is not on our formulary or it is hard for you to get, but you are past the first 90 days of membership in our plan, we will cover a 3-day emergency supply of that drug (unless you have a prescription for fewer while you ask for a formulary exception.? If you have questions, please call IEHP DualChoice at IEHP (4347), 8am-8pm (PST), 7 days a week, including holidays. TTY/TDD users should call The call is free. For more information, visit 8

10 B0. Can you ask for an exception to cover your drug? Yes. You can ask IEHP DualChoice to make an exception to cover a drug that is not on the Drug List. You can also ask us to change the rules on your drug. For example, IEHP DualChoice may limit the amount of a drug we will cover. If your drug has a limit, you can ask us to change the limit and cover more. Other examples: You can ask us to drop step therapy restrictions or prior approval requirements. B. How can you ask for an exception? To ask for an exception, call IEHP DualChoice Member Services. IEHP DualChoice Member Services will work with you and your provider to help you ask for an exception. You can also read Chapter 9, (What to do if you have a problem or complaint [coverage decisions, appeals, complaints]), of the Member Handbook to learn more about exceptions. B. How long does it take to get an exception? First, we must get a statement from your prescriber supporting your request for an exception. After we get the statement, we will give you a decision on your exception request within 7 hours. If you or your prescriber think your health may be harmed if you have to wait 7 hours for a decision, you can ask for an expedited exception. This is a faster decision. If your prescriber supports your request, we will give you a decision within 4 hours of getting your prescriber s supporting statement. B3. What are generic drugs? Generic drugs are made up of the same ingredients as brand name drugs. They usually cost less than the brand name drug and their names are less commonly known. Generic drugs are approved by the Food and Drug Administration (FDA). IEHP DualChoice covers both brand name drugs and generic drugs. 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. B4. What are OTC drugs? OTC stands for over-the-counter. IEHP DualChoice covers some OTC drugs when they are written as prescriptions by your provider. You can read the IEHP DualChoice Drug List to see what OTC drugs are covered.? If you have questions, please call IEHP DualChoice at IEHP (4347), 8am-8pm (PST), 7 days a week, including holidays. TTY/TDD users should call The call is free. For more information, visit 9

11 B5. Does IEHP DualChoice cover OTC non-drug products? IEHP DualChoice covers some OTC non-drug products when they are written as prescriptions by your provider. Examples of OTC non-drug products include alcohol pads. You can read the IEHP DualChoice Drug List to see what OTC non-drug products are covered. B6. What is your copay? IEHP DualChoice members living in nursing homes or other long-term care facilities will have no copays. Some members getting long-term care in the community will also have no copays. Copays are listed by tiers. Tiers are groups of drugs with the same copay. Tier drugs may be generic drugs or non-medicare drugs that are covered by Medi- Cal. The copay is from $0 to $3.40, depending on your level of Medi-Cal eligibility. Tier drugs are brand name drugs. The copay is from $0 to $8.50, depending on your level of Medi-Cal eligibility. Tier 3 drugs have a copay of $0. C. List of Covered Drugs The following list of covered drugs gives you information about the drugs covered by IEHP DualChoice. If you have trouble finding your drug in the list, turn to the Index of Covered Drugs that begins on page 86. The Index alphabetically lists all drugs covered by IEHP DualChoice. The first column of the chart lists the name of the drug. Brand name drugs are capitalized (e.g., NEXIUM) and generic drugs are listed in lower-case italics (e.g., omeprazole). The information in the Necessary actions, restrictions, or limits on use column tells you if IEHP DualChoice has any rules for covering your drug. UPPERCASE BOLD= Brand name drugs lowercase italics= Generic drugs Drug Tier = Tier = Tier 3= Tier 3 NC= Not Covered NF= Non-Formulary Requirements / Limits PA= Prior Authorization PA NSO= Prior Authorization for New Starts Only B vs D= Part B vs D Prior Authorization QL= Quantity Limit ST= Step Therapy Tier : Drugs in this tier are generic drugs (including brand drugs treated as generic). The copay is a set payment you make for these generic drugs. For example, the copay is from $0 to $3.40. This amount depends on your income.? If you have questions, please call IEHP DualChoice at IEHP (4347), 8am-8pm (PST), 7 days a week, including holidays. TTY/TDD users should call The call is free. For more information, visit 0

12 Tier : Drugs in this tier are brand name drugs. The copay is from $0 to $8.50. This amount depends on your income. Tier 3: Drugs in this tier are drugs that are non-medicare drugs/over-the-counter (OTC) drugs. These drugs are covered by Medi-Cal. They have a $0 co-pay. NC: Not covered. These are drugs not covered by IEHP DualChoice. NF: Non-Formulary. Drugs that are not on our prescribed drugs list (known as a Formulary). PA: Prior Authorization. IEHP DualChoice requires you or your physician to get approval from us first before filling a certain drug. This extra step is called prior authorization. If you don't get approval, IEHP DualChoice may not cover the drug. PA NSO: Prior Authorization for New Starts Only. IEHP DualChoice requires you or your physician to get approval from us first before filling a certain drug if you have not taken this drug before. If you don t get approval, IEHP DualChoice may not cover the drug. B vs D: Part B vs D Prior Authorization. This is a drug that has a special PA requirement. It may be covered under one or two benefit programs: ) Medicare Part B, and/or ) Medicare Part D. This depends on many factors. Your physician may need to give us more details about the use and setting of the drug. QL: Quantity Limit. For certain drugs, IEHP DualChoice limits the amount of the drug that it will cover. This may be in addition to a standard one month or three-month supply. ST: Step Therapy. In some cases, IEHP DualChoice requires you to first try certain drugs to treat your medical condition. This is the process before we will cover another drug for that condition. For example, either Drug A or Drug B may treat your medical condition. IEHP DualChoice may not cover Drug B unless you try Drug A first. If Drug A does not work for you, IEHP DualChoice will then cover Drug B. Note: A drug in Tier 3 means the drug is not a Part D drug. You will not be required to pay a copay for these drugs. These drugs also have different rules for appeals. An appeal is a formal way of asking us to review a decision we made about your coverage and to change it if you think we made a mistake. For example, we might decide that a drug that you want is not covered or is no longer covered by Medicare or Medi-Cal. If you or your doctor disagrees with our decision, you can appeal. If you ever have a question, call Member Services at IEHP (4347). You can also read Chapter 9, (What to do if you have a problem or complaint [coverage decisions, appeals, complaints]), of the Member Handbook to learn how to appeal a decision.? If you have questions, please call IEHP DualChoice at IEHP (4347), 8am-8pm (PST), 7 days a week, including holidays. TTY/TDD users should call The call is free. For more information, visit

13 IEHP DualChoice Cal MediConnect Plan (Medicare-Medicaid Plan) 09 Formulary Table of Contents Additional Demonstration Drugs... 4 Analgesics... 0 Anesthetics... Anti-Addiction/ Substance Abuse Treatment Agents... Antibacterials... Anticonvulsants... 8 Antidementia Agents... 3 Antidepressants... 3 Antiemetics Antifungals Antigout Agents Anti-Inflammatory Agents Antimigraine Agents Antimyasthenic Agents Antimycobacterials Antineoplastics Antiparasitics... 4 Antiparkinson Agents... 4 Antipsychotics Antispasticity Agents Antivirals Anxiolytics Bipolar Agents Blood Glucose Regulators Blood Products/ Modifiers/ Volume Expanders... 5 Cardiovascular Agents Central Nervous System Agents Dental And Oral Agents... 6 Dermatological Agents... 6 Electrolytes/Minerals/Metals/Vitamins... 6 Gastrointestinal Agents Genetic Or Enzyme Disorder: Replacement, Modifiers, Treatment Genitourinary Agents... 67

14 Hormonal Agents, Stimulant/ Replacement/ Modifying (Adrenal) Hormonal Agents, Stimulant/ Replacement/ Modifying (Pituitary) Hormonal Agents, Stimulant/ Replacement/ Modifying (Sex Hormones/ Modifiers)...69 Hormonal Agents, Stimulant/ Replacement/ Modifying (Thyroid)... 7 Hormonal Agents, Suppressant (Adrenal) Hormonal Agents, Suppressant (Pituitary) Hormonal Agents, Suppressant (Thyroid) Immunological Agents Inflammatory Bowel Disease Agents Metabolic Bone Disease Agents Ophthalmic Agents Otic Agents Respiratory Tract/ Pulmonary Agents Skeletal Muscle Relaxants Sleep Disorder Agents Index

15 List of Drugs by Medical Condition The drugs in this section are grouped into categories depending on the type of medical conditions they are used to treat. For example, if you have a heart condition, you should look in the category, Cardiovascular Agents. That is where you will find drugs that treat heart conditions. Drug Name Additional Demonstration Drugs Additional Demonstration Drugs Tier Requirements / Limits ABREVA 0% CREAM 0 % ACID REDUCER 0 MG TABLET MAX STRENGTH 0 MG ACNE MEDICATION 0% LOTION 0 % ACNE MEDICATION 5% LOTION 5 % ALL DAY ALLERGY 0 MG TABLET INDOOR/OUTDOOR 0 MG ALLERGY 4 MG TABLET 4 MG ALLERGY MULTI-SYMPTOM CAPLET CAPLET MG ALLERGY RELIEF 0 MG ODT NON-DROWSY 0 MG ALLERGY RELIEF 0 MG TABLET 0 MG ALLI 60 MG CAPSULE STARTER PACK 60 MG ANTACID-SIMETHICONE LIQUID MG/5 ML ANTI-DANDRUFF % SHAMPOO % ANTI-DIARRHEAL MG SOFTGEL SOFTGEL MG ANTIFUNGAL % CREAM % ARTIFICIAL TEARS DROPS % aspirin ec 35 mg tablet orange 35 mg aspirin ec 8 mg tablet 8 mg AYR SALINE 0.65% NOSE DROPS 0.65 % bacitracin 500 unit/gm ointmnt 500 unit/gram bacitracin zn 500 unit/gm oint 500 unit/gram benzonatate 00 mg capsule 00 mg benzonatate 00 mg capsule 00 mg benzoyl peroxide 0% gel aqueous (otc) 0 % benzoyl peroxide.5% gel (otc).5 % benzoyl peroxide 5% gel aqueous (otc) 5 % benzoyl peroxide 5% wash (otc) 5 % bisacodyl ec 5 mg tablet 5 mg bromphenir-pseudoephed-dm syr (rx) mg/5 ml calamine lotion 8-8 % QL ( GM per 5 QL (60 EA per 30 QL (30 EA per 30 PA; QL (90 EA per 30 QL (60 GM per 30 QL (00 EA per 30 QL (00 EA per 30 QL (80 EA per 30 QL (90 EA per 30 QL (60 EA per 30 4

16 CALCIUM 600 MG TABLET 600 MG CALCIUM (,500 MG) 3 calcium carb 500 (,50) mg tb 500 mg calcium (,50 mg) 3 calcium carbonate 648 mg tab 60 mg calcium (648 mg) 3 calcium gluconate 500 mg tab 45 mg (500 mg) 3 calcium gluconate 650 mg tab 60 mg calcium (650 mg) 3 CALPHRON 667 MG TABLET 667 MG 3 cetirizine hcl 0 mg chew tab children's,outer,u-d 0 mg 3 QL (30 EA per 30 cetirizine hcl 5 mg chew tab children's,outer,u-d 5 mg 3 QL (30 EA per 30 cetirizine hcl 5 mg tablet 5 mg 3 CHILD ALL DAY ALLERGY MG/ML D/F,GLUTEN/F,GRAPE MG/ML 3 CHILD SALINE 0.65% NASAL SPRAY 0.65 % 3 CHILD TRIAMINIC COLD-ALLERGY -.5 MG/5 ML 3 CHILDREN IBUPROFEN 00 MG/5 ML A/F,BUBBLE GUM 00 MG/5 ML CHILDREN'S IRON 5 MG/ML DROPS 5 MG IRON (75 MG)/ML 3 3 QL (50 ML per 30 CHILDREN'S SILFEDRINE LIQ 5 MG/5 ML 3 QL (40 ML per 30 chlorpheniramine er mg tab mg 3 cimetidine 00 mg tablet blister pack (otc) 00 mg 3 CITRUCEL 500 MG CAPLET 500 MG 3 clotrimazole % cream (otc) % 3 QL (60 GM per 30 clotrimazole % cream w/7 applicators % 3 QL (90 GM per 30 clotrimazole % solution (otc) % 3 QL (60 ML per 30 COLACE CLEAR 50 MG SOFTGEL 50 MG 3 QL (00 EA per 30 CONDOMS LUBRICATED 3 QL (4 EA per 30 cyanocobalamin 30,000 mcg/30 outer,latex-free,mdv,000 mcg/ml 3 diphenhydramine 50 mg capsule (otc) 50 mg 3 QL (00 EA per 30 docusate sodium 50 mg/5 ml liq 00's, u-d 50 mg/5 ml 3 QL (480 ML per 30 DOK 00 MG TABLET 00 MG 3 QL (00 EA per 30 ED CHLORPED JR SYRUP MG/5 ML 3 ED-A-HIST PSE TABLET.5-60 MG 3 esomeprazole mag dr 0 mg cap outer (otc) 0 mg 3 QL (30 EA per 30 EYE ALLERGY RELIEF DROPS % 3 EYE ITCH RELIEF 0.05% DROPS 0.05 % (0.035 %) 3 You can find information on what the symbols and abbreviations in this table mean by going to page 0. 5

17 famotidine 0 mg tablet 0 mg 3 FC FEMALE CONDOM 3 QL (6 EA per 30 ferrous sulf 0 mg/5 ml elix 0 mg (44 mg iron)/5 ml 3 QL (480 ML per 30 ferrous sulf 300 mg/5 ml liq 300 mg (60 mg iron)/5 ml 3 QL (50 ML per 30 ferrous sulf ec 34 mg tablet 34 mg (65 mg iron) 3 QL (90 EA per 30 ferrous sulf ec 35 mg tablet u-d, outer 35 mg (65 mg iron) 3 QL (90 EA per 30 ferrous sulfate 35 mg tablet 35 mg (65 mg iron) 3 QL (90 EA per 30 FIBER LAXATIVE 65 MG CAPLET CAPLET 65 MG 3 FLEET GLYCERIN ADULT SUPPOS 3 FLEET PEDIA-LAX STOOL SOFTENER 50 MG/5 ML 3 FLEET PEDIA-LAX SUPPOSITORIES 3 folic acid,000 mcg tablet (otc) mg 3 folic acid 400 mcg tablet s/f,p/f,lactose-free 400 mcg 3 FORACARE 30G LANCETS 30 GAUGE 3 FUNGOID-D % CREAM % 3 GAVISCON MG TAB CHEW MG 3 GENTEAL TEARS 0.%-0.%-0.3% % 3 glucose 4 gram tablet chew na/f, caffeine free 4 gram 3 GS ALLERGY RELIEF 5 MG CAP 5 MG 3 QL (00 EA per 30 GS ALLERGY RELIEF 5 MG TABLET 5 MG 3 QL (00 EA per 30 GS ANTACID PLUS ANTI-GAS LIQ MG/5 ML 3 GS ANTI-DIARRHEAL MG CAPLET MG 3 GS ANTI-ITCH % CREAM % 3 gs aspirin 35 mg tablet 35 mg 3 QL (00 EA per 30 gs aspirin 8 mg chewable tab 8 mg 3 QL (00 EA per 30 GS CHILD ALLERGY.5 MG/5 ML.5 MG/5 ML 3 QL (40 ML per 30 gs ibuprofen 00 mg tablet 00 mg 3 QL (00 EA per 30 GS LICE KILLING SHAMPOO W/NIT COMB % 3 QL (47 ML per 30 GS MILK OF MAGNESIA SUSPENSION 400 MG/5 ML 3 gs naproxen sod 0 mg caplet 0 mg 3 gs simethicone 0 mg/0.3 ml 40 mg/0.6 ml 3 QL (30 ML per 30 GS STOMACH RLF 6 MG CHEW TAB GLUTEN-FREE 6 3 MG guaifen-codeine 00-0 mg/5 ml (otc) 0-00 mg/5 ml 3 QL (480 ML per 30 GYNOL II 3% GEL 3 % 3 6

18 HM DOUBLE ANTIBIOTIC OINTMENT 500-0,000 3 UNIT/GRAM hm vitamin e 400 unit softgel gluten-free 400 unit 3 HYDRO SKIN % LOTION % 3 QL (0 ML per 30 hydrocortisone 0.5% cream (otc) 0.5 % 3 QL (30 GM per 30 hydrocortisone 0.5% cream 0.5 % 3 QL (30 GM per 30 hydrocortisone 0.5% ointment 0.5 % 3 QL (30 GM per 30 hydrocortisone % cream % 3 QL (30 GM per 30 hydrocortisone % ointment (otc) % 3 HYDROMET SYRUP 5-.5 MG/5 ML 3 QL (480 ML per 30 ibuprofen 00 mg softgel liquid filled caps 00 mg 3 QL (00 EA per 30 KAOPECTATE 6 MG/5 ML SUSP 6 MG/5 ML 3 KONSYL PSYLLIUM FIBER PACKET GLUTN- F,ORANGE,OUTER 3.4 GRAM KONSYL PSYLLIUM FIBER POWDER GLUTEN FREE, ORANGE 3.4 GRAM/ GRAM KPN TABLET 3 lansoprazole dr 5 mg capsule -4 day treatment (otc) 5 mg 3 QL (30 EA per 30 LICE TREATMENT % CREME RINSE % 3 QL (36 ML per 30 LIQUITEARS.4% DROPS.4 % 3 LOHIST-D LIQUID -30 MG/5 ML 3 loperamide mg/5 ml liquid mg/5 ml 3 loratadine 5 mg/5 ml soln child's,a/f,s/f,d/f 5 mg/5 ml 3 magnesium citrate solution saline laxative 3 magnesium oxide 50 mg caplet p/f, s/f, gluten/f 50 mg magnesium 3 QL (30 EA per 30 magnesium oxide 400 mg tablet 400 mg (4.3 mg magnesium) 3 QL (30 EA per 30 magnesium oxide 40 mg tablet 40 mg 3 QL (30 EA per 30 magnesium oxide 500 mg tablet p/f,s/f,lactose-free 500 mg 3 QL (30 EA per 30 mag-oxide magnesium 00 mg tab 00 mg magnesium 3 QL (30 EA per 30 meclizine.5 mg caplet caplet (otc).5 mg 3 meclizine 5 mg tablet chew raspberry 5 mg 3 QL (60 EA per 30 MEPHYTON 5 MG TABLET 5 MG 3 MICONAZOLE 3 COMBO PACK 3 SUP,9GM CRM W/APP 00 MG- % (9 GRAM) QL ( EA per 30 MICONAZOLE 7 00 MG VAG SUPP 00 MG 3 QL (7 EA per 30 You can find information on what the symbols and abbreviations in this table mean by going to page 0. 7

19 MICONAZOLE 7 CREAM W/APPLICATOR % 3 QL (45 GM per 30 MILK OF MAGNESIA CONCENTRATED,400 MG/0 ML 3 MINTOX PLUS TABLET CHEWABLE MG 3 MOTION SICKNESS 5 MG TABLET 5 MG 3 MURO-8 % EYE DROPS % 3 NAPHCON-A EYE DROPS % 3 NASAL DECONGESTANT 30 MG TAB MAXIMUM STRENGTH 30 MG 3 QL (60 EA per 30 niacin 00 mg tablet 00 mg 3 niacin 50 mg tablet 50 mg 3 niacin 500 mg tablet 500 mg 3 NIACIN FLUSH FREE 500 MG CAP GLUTEN-FREE,P/F,S/F 400 MG NIACIN (500 MG) niacin sa 50 mg capsule (otc) 50 mg 3 niacin tr 500 mg capsule 500 mg 3 NICODERM CQ 4 MG/4HR PATCH 4 MG/4 HR 3 QL (80 EA per 365 NICODERM CQ MG/4HR PATCH MG/4 HR 3 QL (80 EA per 365 NICODERM CQ 7 MG/4HR PATCH 7 MG/4 HR 3 QL (80 EA per 365 nicotine mg chewing gum original mg 3 QL (430 EA per 365 nicotine mg lozenge inner mg 3 QL (3600 EA per 365 nicotine mg mini lozenge mini,mint,3 quittube mg 3 QL (3600 EA per 365 nicotine 4 mg chewing gum original 4 mg 3 QL (430 EA per 365 nicotine 4 mg lozenge outer 4 mg 3 QL (3600 EA per 365 nicotine 4 mg mini lozenge mini,mint,3 quittube 4 mg 3 QL (3600 EA per 365 nicotine transdermal system step,,3-4-7 mg/4 hr 3 QL ( EA per 365 omega-3,000 mg softgel softgel,000 mg 3 omeprazole dr 0 mg tablet 0 mg 3 QL (60 EA per 30 ONETOUCH VERIO TEST STRIP 4 VIALS OF 5 3 OPTION.5 MG TABLET.5 MG 3 QL ( EA per 30 PANOXYL 0% ACNE FOAMING WASH 0 % 3 pediatric electrolyte solution 3 QL (08 ML per 30 PEDIATRIC ENEMA GRAM/59 ML 3 PERSONAL BEST PEAK FLOW MTR 3 QL ( EA per 80 phentermine 5 mg capsule 5 mg 3 PA; QL (30 EA per 30 phentermine 30 mg capsule 30 mg 3 PA; QL (30 EA per

20 phentermine 37.5 mg tablet 37.5 mg 3 PA; QL (30 EA per 30 plain niacin 50 mg tablet 50 mg 3 polyethylene glycol 3350 powd (otc) 7 gram/dose 3 QL (57 GM per 30 PRENATAL TABLET (OTC) 7 MG IRON- 0.8 MG 3 PRENATAL VITAMIN TABLET (OTC) 7 MG IRON- 0.8 MG 3 PRENATAL VITAMINS TABLET PHOSPHORUS FREE 8 MG IRON- 800 MCG 3 PROMETHAZINE VC SYRUP MG/5 ML 3 PROMETHAZINE VC-CODEINE SYRUP MG/5 ML 3 QL (480 ML per 30 promethazine-codeine syrup mg/5 ml 3 QL (480 ML per 30 promethazine-dm solution mg/5 ml 3 pyridoxine 00 mg/ml vial 5's, mdv 00 mg/ml 3 pyridoxine 5 mg tablet 5 mg 3 QC 3 DAY VAGINAL 4% CREAM 00 MG/5 GRAM (4 %) 3 QL (5 GM per 30 RA NASAL ALLERGY 4HR SPRAY 55 MCG 3 ranitidine 75 mg tablet s/f, sodium-free 75 mg 3 ranitidine 50 mg tablet maximum strength (otc) 50 mg 3 REESE'S PINWORM 44 MG/ML SUSP 50 MG/ML 3 REFRESH TEARS 0.5% EYE DROP 0.5 % 3 REGULOID POWDER 3 RID COMPLETE --3 LICE KIT % 3 QL ( EA per 30 RYNEX PSE LIQUID -5 MG/5 ML 3 QL (0 ML per 30 SB EAR WAX REMOVAL 6.5% DROP 6.5 % 3 QL (30 ML per 30 SCALPICIN % ANTI-ITCH LIQUID % 3 QL (74 ML per 30 SENNA 8.6 MG TABLET 8.6 MG 3 SENNA 8.8 MG/5 ML SYRUP 8.8 MG/5 ML 3 SILACE 60 MG/5 ML SYRUP 60 MG/5 ML 3 QL (480 ML per 30 simethicone 80 mg tab chew 80 mg 3 QL (60 EA per 30 SLO-NIACIN 500 MG TABLET 500 MG 3 SM DOUBLE ANTIBIOTIC OINT 500-0,000 UNIT/GRAM 3 QL (30 GM per 30 SM ENEMA READY TO USE 9-7 GRAM/8 ML 3 SM EYE WASH SOLUTION 3 SM FOAMING ANTACID TABLET CHEW 80-0 MG 3 sodium bicarb 35 mg tablet 35 mg 3 You can find information on what the symbols and abbreviations in this table mean by going to page 0. 9

21 sodium bicarb 650 mg tablet 0 gr 650 mg 3 sodium chloride 5% eye drop 5 % 3 sodium chloride 5% eye oint sterile 5 % 3 SOOTHE 6 MG CAPLET CAPLET 6 MG 3 STOMACH RELIEF MAX STR LIQUID MAX. STRENGTH 55 MG/5 ML 3 STOOL SOFTENER 00 MG CAPSULE 00 MG 3 QL (00 EA per 30 STOOL SOFTENER 50 MG SOFTGEL EX-STR, SOFTGEL 50 MG 3 QL (00 EA per 30 SUDOGEST 60 MG TABLET 60 MG 3 QL (60 EA per 30 SUDOGEST COLD AND ALLERGY TAB 4-60 MG 3 QL (60 EA per 30 terbinafine % cream % 3 thiamine 00 mg tablet coated 00 mg 3 thiamine 50 mg tablet 50 mg 3 thiamine hcl 50 mg tablet 50 mg 3 TRIPLE ANTIBIOTIC OINTMENT ORIGINAL STRENGTH 3.5MG-400 UNIT- 5,000 UNIT/GRAM VCF CONTRACEPTIVE FOAM.5 % 3 VCF CONTRACEPTIVE GEL 4 % 3 vitamin a 0,000 unit capsule soluble 0,000 unit 3 vitamin b- 00 mg tablet 00 mg 3 vitamin b-,000 mcg tablet,000 mcg 3 VITAMIN B- 00 MG TABLET GLUTEN-FREE 00 MG 3 VITAMIN B-6 00 MG TABLET 00 MG 3 VITAMIN B-6 50 MG TABLET 50 MG 3 VITAMIN C 500 MG TABLET S/F, P/F,GLUTEN-FREE 500 MG VITAMIN D.5 MG(50,000 UNIT) 50,000 UNIT 3 vitamin d 400 unit tablet s/f,l/f,y/f,gluten/f 400 unit 3 V-R NASAL ALLERGY SYM SPRAY 5. MG/SPRAY (4 %) 3 WAL-MUCIL 00% NATURAL FIBER 3.4 GRAM/7 GRAM 3 WAL-MUCIL 00% NATURAL FIBER S/F,4 DOSES,ORANGE 3.4 GRAM/5.8 GRAM WOMEN'S LAXATIVE 5 MG TABLET 5 MG Analgesics Analgesics QL (60 EA per 30 0

22 acetaminophen-codeine oral solution 0- mg/5 ml QL (790 ML per 3 acetaminophen-codeine oral tablet mg, mg QL (37 EA per 3 acetaminophen-codeine oral tablet mg QL (86 EA per 3 endocet oral tablet 0-35 mg hydrocodone-acetaminophen oral tablet 0-35 mg, 5-35 mg, 7.5- QL (48 EA per 3 35 mg hydrocodone-ibuprofen oral tablet mg QL (55 EA per 3 oxycodone-acetaminophen oral tablet 0-35 mg, 5-35 mg Nonsteroidal Anti-Inflammatory Drugs celecoxib oral capsule 00 mg, 00 mg, 400 mg, 50 mg ST; QL (6 EA per 3 diclofenac sodium oral tablet,delayed release (dr/ec) 5 mg, 75 mg ibuprofen oral tablet 800 mg indomethacin oral capsule 5 mg PA; QL (4 EA per 3 meloxicam oral tablet 5 mg, 7.5 mg QL (3 EA per 3 nabumetone oral tablet 500 mg, 750 mg naproxen oral tablet 375 mg, 500 mg Opioid Analgesics, Long-Acting DURAMORPH (PF) INJECTION SOLUTION 0.5 MG/ML, B vs D MG/ML fentanyl transdermal patch 7 hour 00 mcg/hr, mcg/hr, 5 mcg/hr, 50 mcg/hr, 75 mcg/hr morphine concentrate oral solution 00 mg/5 ml (0 mg/ml) morphine oral capsule,extend.release pellets 0 mg, 0 mg, 30 mg, 40 QL (6 EA per 3 mg morphine oral capsule,extend.release pellets 00 mg, 50 mg, 60 mg, 80 mg morphine oral solution 0 mg/5 ml, 0 mg/5 ml (4 mg/ml) morphine oral tablet 5 mg, 30 mg morphine oral tablet extended release 00 mg, 00 mg, 30 mg, 60 mg morphine oral tablet extended release 5 mg QL (93 EA per 3 tramadol oral tablet extended release 4 hr 00 mg QL (93 EA per 3 tramadol oral tablet extended release 4 hr 00 mg QL (3 EA per 3 Opioid Analgesics, Short-Acting fentanyl citrate buccal lozenge on a handle,00 mcg,,600 mcg, PA 00 mcg, 400 mcg, 600 mcg, 800 mcg hydromorphone oral tablet mg, 4 mg, 8 mg You can find information on what the symbols and abbreviations in this table mean by going to page 0.

23 Drug Name LAZANDA NASAL SPRAY,NON-AEROSOL 00 MCG/SPRAY, 300 MCG/SPRAY, 400 MCG/SPRAY oxycodone oral tablet 0 mg, 5 mg, 0 mg, 30 mg oxycodone oral tablet 5 mg tramadol oral tablet 50 mg Anesthetics Local Anesthetics lidocaine hcl mucous membrane jelly % lidocaine hcl mucous membrane solution 4 % (40 mg/ml) lidocaine topical adhesive patch,medicated 5 % lidocaine topical ointment 5 % lidocaine viscous mucous membrane solution % lidocaine-prilocaine topical cream.5-.5 % Anti-Addiction/ Substance Abuse Treatment Agents Alcohol Deterrents/Anti-Craving acamprosate oral tablet,delayed release (dr/ec) 333 mg disulfiram oral tablet 50 mg, 500 mg Opioid Dependence Treatments buprenorphine hcl sublingual tablet mg, 8 mg buprenorphine-naloxone sublingual tablet -0.5 mg, 8- mg naltrexone oral tablet 50 mg Opioid Reversal Agents naloxone injection solution 0.4 mg/ml naloxone injection syringe 0.4 mg/ml, mg/ml NARCAN NASAL SPRAY,NON-AEROSOL 4 MG/ACTUATION Smoking Cessation Agents bupropion hcl (smoking deter) oral tablet extended release hr 50 mg CHANTIX CONTINUING MONTH BOX ORAL TABLET MG Tier CHANTIX ORAL TABLET 0.5 MG, MG CHANTIX STARTING MONTH BOX ORAL TABLETS,DOSE PACK 0.5 MG ()- MG (4) NICOTROL INHALATION CARTRIDGE 0 MG NICOTROL NS NASAL SPRAY,NON-AEROSOL 0 MG/ML Antibacterials Requirements / Limits PA QL (86 EA per 3 QL (48 EA per 3 PA; QL (93 EA per 3 QL (60 GM per 3 QL (93 EA per 3 QL (93 EA per 3

24 Aminoglycosides amikacin injection solution 500 mg/ ml ARIKAYCE INHALATION SUSPENSION FOR PA NSO; QL (60.4 ML per 3 NEBULIZATION 590 MG/8.4 ML gentak ophthalmic (eye) ointment 0.3 % (3 mg/gram) gentamicin in nacl (iso-osm) intravenous piggyback 00 mg/00 ml, 60 mg/50 ml, 80 mg/00 ml, 80 mg/50 ml gentamicin injection solution 40 mg/ml gentamicin ophthalmic (eye) drops 0.3 % gentamicin topical cream 0. % gentamicin topical ointment 0. % neomycin oral tablet 500 mg paromomycin oral capsule 50 mg streptomycin intramuscular recon soln gram TOBI PODHALER INHALATION CAPSULE, PA; QL (4 EA per 8 W/INHALATION DEVICE 8 MG TOBRADEX OPHTHALMIC (EYE) OINTMENT % tobramycin in 0.5 % nacl inhalation solution for nebulization 300 PA; QL (0 ML per day) mg/5 ml tobramycin ophthalmic (eye) drops 0.3 % tobramycin sulfate injection solution 0 mg/ml, 40 mg/ml Antibacterials, Other acetic acid otic (ear) solution % alcohol pads topical pads, medicated bacitracin ophthalmic (eye) ointment 500 unit/gram clindamycin hcl oral capsule 50 mg, 300 mg, 75 mg clindamycin in 5 % dextrose intravenous piggyback 300 mg/50 ml, 600 mg/50 ml, 900 mg/50 ml clindamycin phosphate injection solution 50 (mg/ml) (6 ml), 50 mg/ml clindamycin phosphate intravenous solution 600 mg/4 ml clindamycin phosphate topical gel % clindamycin phosphate topical lotion % clindamycin phosphate topical solution % clindamycin phosphate topical swab % clindamycin phosphate vaginal cream % You can find information on what the symbols and abbreviations in this table mean by going to page 0. 3

25 colistin (colistimethate na) injection recon soln 50 mg B vs D daptomycin intravenous recon soln 500 mg PA FIRVANQ ORAL RECON SOLN 5 MG/ML PA; QL (385 ML per 8 FIRVANQ ORAL RECON SOLN 50 MG/ML PA; QL (9.5 ML per 8 linezolid in dextrose 5% intravenous piggyback 600 mg/300 ml PA linezolid oral suspension for reconstitution 00 mg/5 ml PA; QL (680 ML per 8 linezolid oral tablet 600 mg PA; QL (8 EA per 4 metronidazole in nacl (iso-os) intravenous piggyback 500 mg/00 ml metronidazole oral tablet 50 mg, 500 mg metronidazole topical cream 0.75 % metronidazole topical gel 0.75 %, % metronidazole topical lotion 0.75 % metronidazole vaginal gel 0.75 % mupirocin topical ointment % nitrofurantoin macrocrystal oral capsule 00 mg, 5 mg, 50 mg PA nitrofurantoin monohyd/m-cryst oral capsule 00 mg PA nitrofurantoin oral suspension 5 mg/5 ml PA tigecycline intravenous recon soln 50 mg PA trimethoprim oral tablet 00 mg vancomycin intravenous recon soln,000 mg, 0 gram, 50 mg, 500 B vs D mg, 750 mg vancomycin oral capsule 5 mg PA; QL (77 EA per 8 vancomycin oral capsule 50 mg PA; QL (56 EA per 4 XIFAXAN ORAL TABLET 00 MG, 550 MG Beta-Lactam, Cephalosporins cefaclor oral capsule 50 mg, 500 mg PA cefaclor oral tablet extended release hr 500 mg cefadroxil oral capsule 500 mg cefadroxil oral suspension for reconstitution 50 mg/5 ml, 500 mg/5 ml cefadroxil oral tablet gram cefazolin injection recon soln gram, 0 gram, 500 mg cefdinir oral capsule 300 mg cefdinir oral suspension for reconstitution 5 mg/5 ml, 50 mg/5 ml cefepime injection recon soln gram, gram 4

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

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

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

29 doxy-00 intravenous recon soln 00 mg doxycycline hyclate oral capsule 00 mg doxycycline hyclate oral tablet 00 mg doxycycline monohydrate oral suspension for reconstitution 5 mg/5 ml doxycycline monohydrate oral tablet 50 mg, 75 mg minocycline oral capsule 00 mg, 50 mg, 75 mg minocycline oral tablet 00 mg, 50 mg, 75 mg ORACEA ORAL CAPSULE,IR - DELAY REL,BIPHASE 40 MG QL (3 EA per 3 tetracycline oral capsule 50 mg, 500 mg Anticonvulsants Anticonvulsants, Other BRIVIACT ORAL SOLUTION 0 MG/ML PA NSO; QL (60 ML per 3 BRIVIACT ORAL TABLET 0 MG PA NSO; QL (48 EA per 3 BRIVIACT ORAL TABLET 00 MG, 5 MG, 50 MG, 75 MG PA NSO; QL (6 EA per 3 DIASTAT ACUDIAL RECTAL KIT MG, MG DIASTAT RECTAL KIT.5 MG levetiracetam oral solution 00 mg/ml levetiracetam oral tablet,000 mg, 50 mg, 500 mg, 750 mg levetiracetam oral tablet extended release 4 hr 500 mg QL (55 EA per 3 levetiracetam oral tablet extended release 4 hr 750 mg QL (4 EA per 3 roweepra oral tablet,000 mg, 500 mg, 750 mg roweepra xr oral tablet extended release 4 hr 500 mg, 750 mg SPRITAM ORAL TABLET FOR SUSPENSION,000 MG, 50 MG, 500 MG, 750 MG Calcium Channel Modifying Agents CELONTIN ORAL CAPSULE 300 MG ethosuximide oral capsule 50 mg ethosuximide oral solution 50 mg/5 ml LYRICA ORAL CAPSULE 00 MG, 50 MG, 00 MG, 5 MG, 50 MG, 75 MG PA NSO PA NSO; QL (93 EA per 3 LYRICA ORAL CAPSULE 5 MG, 300 MG PA NSO; QL (6 EA per 3 8