2017 FORMULARY. (List of Covered Drugs) Prominence Health Plan (HMO)

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1 Prominence Health Plan (HMO) 2017 FORMULARY (List This formulary was updated on 12/28/2016. For more recent information or other questions, please contact Prominence Health Plan Customer Service, at or, for TTY users, 711, 8 am to 8 pm, 7 days a week from October 1 February 14 and 8 am to 8 pm, Monday Friday from February 15 September 0 or visit prominencemedicare.com. Please read: This document contains information about the drugs we cover in this plan. HPMS Approved Formulary File Submission ID 17120, Version 7 Y0109_PHPFORM_17C_CMS ACCEPTED

2 2017 Prominence Health Plan (HMO) Formulary This information is available for free in other languages. Please contact our Member Services number at for additional information. (TTY users should call 711). Hours are 8 a.m. to 8 p.m. seven days a week from October 1 to February 14. From February 15 through September 0, hours are 8 a.m. to 8 p.m. Monday through Friday. Member Services also has free language interpreter services available for non-english speakers. Esta información está disponible gratis en otros idiomas. Por favor, póngase en contacto con nuestro número de Servicio al Cliente al para obtener información adicional. (Los usuarios de TTY deben llamar 711). Nuestro horario es de 8 a.m. - 8 p.m. los siete días de la semana Desde el 1 de Octubre al 14 de Febrero. Desde el 15 de Febrero al 0 de Septiembre, horas de 8 a.m. - 8 p.m. de Lunes a Viernes. Servicios para Miembros también tienen servicios de intérprete de idiomas gratis disponibles para personas que no hablan inglés. Prominence Health Plan is an HMO Plan with a Medicare contract. Enrollment in Prominence Health Plan depends on contract renewal. This information is not a complete description of benefits. Contact the plan for more information. Limitations, copayments, and restrictions may apply. Benefits, premiums and/or copayments/co-insurance may change on January 1 of each year. The Formulary may change at any time. You will receive notice when necessary.

3 2017 Prominence Health Plan (HMO) Formulary 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 Prominence Health Plan. When it refers to plan or our plan, it means Prominence Plus (HMO) or Prominence Value (HMO). This document includes a list of the drugs (formulary) for our plan which is current as of 08/08/2016. 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, 2018 and from time to time during the year. What is the Prominence Health Plan Formulary? A formulary is a list of covered drugs selected by Prominence Health Plan in consultation with a team of health care providers, which represents the prescription therapies believed to be a necessary part of a quality treatment program. Prominence Health Plan will generally cover the drugs listed in our formulary as long as the drug is medically necessary, the prescription is filled at a Prominence Health Plan network pharmacy, and other plan rules are followed. For more information on how to fill your prescriptions, please review your Evidence of Coverage. Can the Formulary (drug list) change? Generally, if you are taking a drug on our 2017 formulary that was covered at the beginning of the year, we will not discontinue or reduce coverage of the drug during the 2017 coverage year except when a new, less expensive generic drug becomes available or when new adverse information about the safety or effectiveness of a drug is released. Other types of formulary changes, such as removing a drug from our formulary, will not affect members who are currently taking the drug. It will remain available at the same cost-sharing for those members taking it for the remainder of the coverage year. We feel it is important that you have continued access for the remainder of the coverage year to the formulary drugs that were available when you chose our plan, except for cases in which you can save additional money or we can ensure your safety. If we remove drugs from our formulary, add prior authorization, quantity limits and/or step therapy restrictions on a drug or move a drug to a higher cost-sharing tier, we must notify affected members of the change at least 60 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 60-day supply of the drug. 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. The enclosed formulary is current as of 08/08/2016. To get updated information about the drugs covered by Prominence Health Plan, please contact us. Our contact information appears on the front and back cover pages. How do I use the Formulary? There are two ways to find your drug within the formulary:

4 2017 Prominence Health Plan (HMO) Formulary Medical Condition The formulary begins on page. The drugs in this formulary are grouped into categories depending on the type of medical conditions that they are used to treat. For example, drugs used to treat a heart condition are listed under the category, Cardiovascular Agents. If you know what your drug is used for, look for the category name in the list that begins page. Then look under the category name for your drug. Alphabetical Listing If you are not sure what category to look under, you should look for your drug in the Index that begins on page 155. 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? Prominence Health Plan covers both brand name drugs and generic drugs. A generic drug is approved by the FDA as having the same active ingredient as the brand name drug. Generally, generic drugs cost less than brand name drugs. Are there any restrictions on my coverage? Some covered drugs may have additional requirements or limits on coverage. These requirements and limits may include: Prior Authorization: Prominence Health Plan requires you or your physician to get prior authorization for certain drugs. This means that you will need to get approval from Prominence Health Plan before you fill your prescriptions. If you don t get approval, Prominence Health Plan may not cover the drug. Quantity Limits: For certain drugs, Prominence Health Plan limits the amount of the drug that Prominence Health Plan will cover. For example, Prominence Health Plan provides 0 tablets per prescription for Digoxin. This may be in addition to a standard one-month or three-month supply Step Therapy: In some cases, Prominence Health Plan requires you to first try certain drugs to treat your medical condition before we will cover another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, Prominence Health Plan may not cover Drug B unless you try Drug A first. If Drug A does not work for you, Prominence Health Plan 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. 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 Prominence Health Plan to make an exception to these restrictions or limits or for a list of

5 2017 Prominence Health Plan (HMO) Formulary other, similar drugs that may treat your health condition. See the section, How do I request an exception to the Prominence Health Plan formulary? on this page for information about how to request an exception. What if my drug is not on the Formulary? If your drug is not included in this formulary (list of covered drugs), you should first contact Member Services and ask if your drug is covered. For more information, 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 learn that Prominence Health Plan does not cover your drug, you have two options: You can ask Member Services for a list of similar drugs that are covered by Prominence Health Plan. When you receive the list, show it to your doctor and ask him or her to prescribe a similar drug that is covered by Prominence Health Plan. You can ask Prominence Health Plan to make an exception and cover your drug. See below for information about how to request an exception. How do I request an exception to the Prominence Health Plan Formulary? You can ask Prominence Health Plan to make an exception to our coverage rules. There are several types of exceptions that you can ask us to make. You can ask us to cover a drug even if it is not on our formulary. If approved, this drug will be covered at a pre-determined cost-sharing level, and you would not be able to ask us to provide the drug at a lower cost-sharing level. You can ask us to cover a formulary drug at a lower cost-sharing level if this drug is not on the specialty tier. If approved this would lower the amount you must pay for your drug. You can ask us to waive coverage restrictions or limits on your drug. For example, for certain drugs, Prominence Health Plan limits the amount of the drug that we will cover. If your drug has a quantity limit, you can ask us to waive the limit and cover a greater amount Generally, Prominence Health Plan will only approve your request for an exception if the alternative drugs included on the plan s formulary, the lower cost-sharing drug or additional utilization restrictions would not be as effective in treating your condition and/or would cause you to have adverse medical effects. You should contact us to ask us for an initial coverage decision for a formulary, tiering or utilization restriction exception. When you request a formulary, tiering or utilization restriction exception you should submit a statement from your prescriber or physician supporting your request. Generally, we must make our decision within 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.

6 2017 Prominence Health Plan (HMO) Formulary 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 0-day supply (unless you have a prescription written for fewer when you go to a network pharmacy. After your first 0-day supply, we will not pay for these drugs, even if you have been a member of the plan less than 90 days. If you are a resident of a long-term care facility, we will allow you to refill your prescription until we have provided you with up to a 91-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 you are a member of our plan. If you need a drug that is not on our formulary or if your ability to get your drugs is limited, but you are past the first 90 days of membership in our plan, we will cover a 1-day emergency supply of that drug (unless you have a prescription for fewer while you pursue a formulary exception. Members who have a change in level of care (setting) will be allowed up to a one-time 0-day transition supply per drug. For example, members who: Enter long-term care (LTC) facilities from hospitals are sometimes accompanied by a discharge list of medications from the hospital formulary, with very short term planning taken into account (often under 8 hours). Are discharged from a hospital to a home. End their skilled nursing facility Medicare Part A stay (where payments include all pharmacy charges) and who need to revert to their Part D plan formulary. End a long-term care facility stay and return to the community. If a member has more than one change in level of care in a month, the pharmacy will have to call us to request an extension of the transition policy. For more information For more detailed information about your Prominence Health Plan prescription drug coverage, please review your Evidence of Coverage and other plan materials. If you have questions about Prominence Health Plan, please contact us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages. If you have general questions about Medicare prescription drug coverage, please call Medicare at MEDICARE ( ) 24 hours a day/7 days a week. TTY users should call Or, visit

7 2017 Prominence Health Plan (HMO) Formulary Prominence Health Plan s Formulary The formulary that begins on page provides coverage information about the drugs covered by Prominence Health Plan. If you have trouble finding your drug in the list, turn to the Index that begins on page 155. The first column of the chart lists the drug name. Brand name drugs are capitalized (e.g., COUMADIN) and generic drugs are listed in lower-case italics (e.g., warfarin). The information in the Requirements/Limits column tells you if Prominence Health Plan has any special requirements for coverage of your drug. List of Abbreviations: B/D: This prescription drug has a Part B versus D administrative prior authorization requirement. This drug may be covered under Medicare Part B or D depending upon the circumstances. Information may need to be submitted describing the use and setting of the drug to make the determination. QL: Quantity Limit. For certain drugs, Prominence Health Plan limits the amount of the drug that we will cover. For example, Prominence Health Plan provides twelve tablets per prescription for Sumatriptan Succinate. This may be in addition to a standard one month or three month supply. ST: Step Therapy. In some cases, Prominence Health Plan requires you to first try certain drugs to treat your medical condition before we will cover another drug for that condition. For example, if 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, we will then cover Drug B. PA: Prior Authorization. Prominence Health Plan requires you or your physician to get prior authorization for certain drugs. This means that you will need to get approval from us before you fill your prescriptions. If you don't get approval, we may not cover the drug. GC: Gap Coverage. We provide coverage of this prescription drug in the coverage gap, if your plan provides gap coverage. Please refer to our Evidence of Coverage for more information about this coverage. LA: Limited Availability. This prescription may be available only at certain pharmacies. For more information consult your Provider and Pharmacy Directory or call Member Services at , 8 am to 8 pm, 7 days a week from October 1- February 14 and 8am to 8pm, Monday-Friday from February 15- September 0. TTY/TDD users should call 711. MO: Mail Order. This prescription may be filled by a Prominence Health Plan network mail order pharmacy. Please review your Pharmacy Directory for more information about which pharmacies offer mail order service. For more information consult your Pharmacy Directory or call Member Services at , 8 am to 8 pm, 7 days a week from October 1- February 14 and 8am to 8pm, Monday - Friday from February 15- September 0. TTY/TDD users should call 711.

8 2017 Prominence Health Plan (HMO) Formulary During the Initial Coverage Stage, your cost for a drug filled at a network pharmacy with standard costsharing: Prominence Value (H ) Northern Nevada Tiers 1 & 2 Covered in the Gap Standard Retail Cost-Sharing Tier Tier 1 (Preferred Generic) Tier 2 (Generic) Tier (Preferred Brand) Tier 4 (Non-Preferred Brand) Tier 5 (Specialty Tier) One-month supply $ copay $12 copay $45 copay $100 copay % of the cost Prominence Plus (H ) Washoe County, Nevada Tiers 1 & 2 Covered in the Gap Standard Retail Cost-Sharing Tier Tier 1 (Preferred Generic) Tier 2 (Generic) Tier (Preferred Brand) Tier 4 (Non-Preferred Brand) Tier 5 (Specialty Tier) One-month supply $ copay $12 copay $45 copay $100 copay % of the cost Prominence Plus (H ) Northern Texas No additional Gap Coverage, $200 Deductible Tiers 4&5 Standard Retail Cost-Sharing Tier Tier 1 (Preferred Generic) Tier 2 (Generic) Tier (Preferred Brand) Tier 4 (Non-Preferred Brand) Tier 5 (Specialty Tier) One-month supply $ copay $14 copay $45 copay $100 copay 29% of the cost Prominence Plus (H ) Southern Texas Tiers 1 & 2 Covered in the Gap Standard Retail Cost-Sharing Tier Tier 1 (Preferred Generic) Tier 2 (Generic) Tier (Preferred Brand) Tier 4 (Non-Preferred Brand) Tier 5 (Specialty Tier) One-month supply $2 copay $8 copay $0 copay $60 copay % of the cost

9 2017 Prominence Health Plan (HMO) Formulary Discrimination is Against the Law Prominence Health Plan complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Prominence Health Plan does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. Prominence Health Plan: Provides free aids and services to people with disabilities to communicate effectively with us, such as: o Qualified sign language interpreters o Written information in other formats (large print, audio, accessible electronic formats, other formats) Provides free language services to people whose primary language is not English, such as: o Qualified interpreters o Information written in other languages If you need these services, contact our Civil Rights Compliance Officer. If you believe that Prominence Health Plan has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Civil Rights Compliance Officer, 1510 Meadow Wood Lane, Reno, NV 89502, , TTY/TDD: 711, or Fax You can file a grievance in person or by mail or fax. If you need help filing a grievance, the Civil Rights Compliance Officer is available to help you. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, electronically through the Office for Civil Rights Complaint Portal, available at: or by mail or phone at: U.S. Department of Health and Human Services 200 Independence Avenue, SW Room 509F, HHH Building Washington, D.C , (TDD) Complaint forms are available at Prominence Health Plan cumple con las leyes federales de derechos civiles aplicables y no discrimina por motivos de raza, color, nacionalidad, edad, discapacidad o sexo. Sumusunod ang Prominence Health Plan sa mga naaangkop na Pederal na batas sa karapatang sibil at hindi nandidiskrimina batay sa lahi, kulay, bansang pinagmulan, edad, kapansanan o kasarian. Prominence Health Plan tuân thủ luật dân quyền hiện hành của Liên bang và không phân biệt đối xử dựa trên chủng tộc, màu da, nguồn gốc quốc gia, độ tuổi, khuyết tật, hoặc giới tính.

10 2017 Prominence Health Plan (HMO) Formulary This information is available for free in other languages. Español (Spanish) ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al (TTY: 711). Tagalog (Tagalog Filipino) PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng tulong sa wika nang walang bayad. Tumawag sa (TTY: 711). 繁體中文 (Chinese) 注意 如果您使用繁體中文 您可以免費獲得語言援助服務 請致電 TTY 711 한국어 (Korean) 주의: 한국어를 사용하시는 경우, 언어 지원 서비스를 무료로 이용하실 수 있습니다 (TTY: 711)번으로 전화해 주십시오. Tiếng Việt (Vietnamese) CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho bạn. Gọi số (TTY: 711). አማርኛ (Amharic) ማስታወሻ: የሚናገሩት ቋንቋ ኣማርኛ ከሆነ የትርጉም እርዳታ ድርጅቶች በነጻ ሊያግዝዎት ተዘጋጀተዋል ወደ ሚከተለው ቁጥር ይደውሉ (መስማት ለተሳናቸው: 711). ภาษาไทย (Thai) เร ยน: ถ าค ณพ ดภาษาไทยค ณสามารถใช บร การช วยเหล อทางภาษาได ฟร โทร (TTY: 711). 日本語 (Japanese) 注意事項 日本語を話される場合 無料の言語支援をご利用いただけます TTY:711 まで お電話にてご連絡ください )Arabic( العربية (رقم هاتف الصم 711 اتصل برقم. فإن خدمات المساعدة اللغوية تتوافر لك بالمجان إذا كنت تتحدث اذكر اللغة : ملحوظة.) : والبكم Русский (Russian) ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услуги перевода. Звоните (телетайп: 711). Français (French) ATTENTION : Si vous parlez français, des services d'aide linguistique vous sont proposés gratuitement. Appelez le (ATS : 711). )Farsi( فارسی با. تسهیالت زبانی بصورت رايگان برای شما فراهم می باشد اگر به زبان فارسی گفتگو می کنید : وجه. ) تماس بگیريد TTY: 711( 5882 Gagana fa'a Sāmoa (Samoan) MO LOU SILAFIA: Afai e te tautala Gagana fa'a Sāmoa, o loo iai auaunaga fesoasoan, e fai fua e leai se totogi, mo oe, Telefoni mai: (TTY: 711). Deutsch (German) ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen zur Verfügung. Rufnummer: (TTY: 711). Ilokano (Ilocano) PAKDAAR: Nu saritaem ti Ilocano, ti serbisyo para ti baddang ti lengguahe nga awanan bayadna, ket sidadaan para kenyam. Awagan ti (TTY: 711). (Urdu) و د تو آپ کو زبان کی مدد کی خدمات مفت میں دستیاب ہیں کال کريں اگر آپ اردو بولتے ہیں : خبردار 5882TTY:711. ह द (Hindi) ર ત (Gujarati) ગજ ध य न द : यदद आप द द ब लत त आपक ललए मफ त म भ ष स यत स व ए उपलब ध (TTY: 711) पर क ल कर લ ગ પડત સમવ ય ન ગર ક અધ ક ક યદ સ થ સ સગ ત છ અન જ ધત, ગ, ષ ટ ર ય મ ળ, ઉ મ, અશક તત અથવ લલ ગન આ ભ દભ વ ખવ મ આવત નથ. າພາສາ ລາວ, ການບ ເສ ໂປດຊາບ: ຖ າວ າທ ານເວ ລການຊ ວຍເຫ ານພາສາ, ໂດຍບ າ, ອດ ຽຄ ພາສາລາວ (Lao) ແມ ນມ ອມໃຫ ທ ານ. ໂທຣ (TTY: 711). ພ

11 Table of Contents Analgesics... Anesthetics Anti-Addiction/Substance Abuse Treatment Agents Antianxiety Agents Antibacterials Anticancer Agents Anticholinergic Agents... 7 Anticonvulsants... 7 Antidementia Agents Antidepressants Antidiabetic Agents Antifungals Antigout Agents... 5 Antihistamines... 5 Anti-Infectives (Skin And Mucous Membrane) Antimigraine Agents Antimycobacterials Antinausea Agents Antiparasite Agents Antiparkinsonian Agents Antipsychotic Agents Antivirals (Systemic) Blood Products/Modifiers/Volume Expanders Caloric Agents... 7 Cardiovascular Agents Central Nervous System Agents Contraceptives Dental And Oral Agents Dermatological Agents Devices Enzyme Replacement/Modifiers Eye, Ear, Nose, Throat Agents Gastrointestinal Agents Genitourinary Agents Heavy Metal Antagonists Hormonal Agents, Stimulant/Replacement/Modifying Immunological Agents Inflammatory Bowel Disease Agents Irrigating Solutions Metabolic Bone Disease Agents

12 Miscellaneous Therapeutic Agents Ophthalmic Agents Replacement Preparations Respiratory Tract Agents Skeletal Muscle Relaxants Sleep Disorder Agents Vasodilating Agents Vitamins And Minerals

13 Analgesics Analgesics, Miscellaneous acetaminophen-codeine 120 mg-12 mg/5 ml solution mg/5 ml acetaminophen-codeine oral solution 00 mg-0 mg /12.5 ml acetaminophen-codeine oral tablet mg, 00-0 mg acetaminophen-codeine oral tablet mg ALLZITAL ORAL TABLET MG ascomp with codeine oral capsule mg BELBUCA BUCCAL FILM 150 MCG, 00 MCG, 450 MCG, 600 MCG, 75 MCG, 750 MCG, 900 MCG buprenorphine hcl injection solution 0. mg/ml buprenorphine hcl injection syringe 0. mg/ml butalbital compound w/codeine oral capsule mg butalbital-acetaminop-caf-cod oral capsule mg, mg butalbital-acetaminophen oral tablet mg butalbital-acetaminophen-caff oral capsule mg (Acetaminophen with Codeine) (Acetaminophen with Codeine) (Tylenol-Codeine No.) (Tylenol-Codeine No.) (Fiorinal with Codeine #) (Buprenorphine HCl) (Buprenorphine HCl) (Fiorinal with Codeine #) ; QL (2700 per 0 ; QL (2700 per 0 ; QL (60 per 0 ; QL (180 per 0 2 PA-HRM; GC; QL (60 per 0 ; AGE (Max 64 Years) 2 PA-HRM; GC; QL (180 per 0 ; AGE (Max 64 Years) QL (60 per 0 2 PA-HRM; GC; QL (180 per 0 ; AGE (Max 64 Years) (Fioricet with Codeine) 2 PA-HRM; GC; QL (180 per 0 ; AGE (Max 64 Years) (Tencon) 2 PA-HRM; GC; QL (180 per 0 ; AGE (Max 64 Years) (Esgic) 2 PA-HRM; GC; QL (180 per 0 ; AGE (Max 64 Years)

14 butalbital-acetaminophen-caff oral tablet mg butalbital-aspirin-caffeine oral capsule mg (Esgic) 2 PA-HRM; GC; QL (180 per 0 ; AGE (Max 64 Years) (Fiorinal) 2 PA-HRM; GC; QL (180 per 0 ; AGE (Max 64 Years) (Butorphanol Tartrate) ; QL (5 per 28 butorphanol tartrate nasal spray,non-aerosol 10 mg/ml BUTRANS TRANSDERMAL QL (4 per 28 PATCH WEEKLY 10 MCG/HOUR, 15 MCG/HOUR, 20 MCG/HOUR, 5 MCG/HOUR, 7.5 MCG/HOUR capacet oral capsule mg (Esgic) 2 PA-HRM; GC; QL (180 per 0 ; AGE (Max 64 Years) codeine sulfate oral tablet 15 mg, 0 mg, 60 mg (Codeine Sulfate) ; QL (180 per 0 EMBEDA ORAL CAPSULE,ORAL 4 QL (60 per 0 ONLY,EXT.REL PELL MG, MG, MG, 50-2 MG, MG, MG endocet oral tablet mg (Xolox) ; QL (240 per 0 endocet oral tablet mg, 5-25 mg (Xolox) ; QL (60 per 0 endocet oral tablet mg (Xolox) ; QL (00 per 0 endodan oral tablet mg (Oxycodone HCl/Aspirin) ; QL (60 per 0 fentanyl citrate buccal lozenge on a handle 1,200 mcg, 1,600 mcg, 200 mcg, 400 mcg, 600 mcg, 800 mcg (Actiq) 5 PA; NDS; QL (120 per 0 fentanyl transdermal patch 72 hour 100 mcg/hr, 12 mcg/hr, 25 mcg/hr, 7.5 mcg/hour, 50 mcg/hr, 75 mcg/hr fentanyl transdermal patch 72 hour 62.5 mcg/hour, 87.5 mcg/hour (Duragesic) ; QL (10 per 0 (Duragesic) ; QL (10 per 0 4

15 hydrocodone-acetaminophen oral solution mg/15 ml(15 ml), mg/5 ml, mg/15 ml hydrocodone-acetaminophen oral tablet mg, 5-00 mg, mg hydrocodone-acetaminophen oral tablet mg, mg, 5-25 mg, mg hydrocodone-ibuprofen oral tablet mg, mg, mg hydromorphone (pf) injection solution 10 (mg/ml) (5 ml) hydromorphone (pf) injection solution 10 mg/ml hydromorphone 10 mg/ml vial p/f,sdv,latex-f 10 mg/ml hydromorphone injection solution 2 mg/ml, 4 mg/ml (Hycet) ; QL (2700 per 0 (Norco) ; QL (90 per 0 (Norco) ; QL (60 per 0 (Ibudone) ; QL (150 per 0 (Hydromorphone HCl/PF) (Dilaudid) (Hydromorphone HCl/PF) (Hydromorphone HCl) hydromorphone injection syringe 2 mg/ml (Hydromorphone HCl) hydromorphone oral liquid 1 mg/ml (Dilaudid) ; QL (1200 per 0 hydromorphone oral tablet 2 mg, 4 mg, 8 mg (Dilaudid) ; QL (180 per 0 HYSINGLA ER ORAL TABLET,ORAL ONLY,EXT.REL.24 HR 100 MG, 120 MG, 20 MG, 0 MG, 40 MG, 60 MG, 80 MG QL (0 per 0 LAZANDA NASAL SPRAY,NON-AEROSOL 100 MCG/SPRAY, 00 MCG/SPRAY, 400 MCG/SPRAY lorcet (hydrocodone) oral tablet 5-25 mg 5 PA; NDS; QL (0 per 0 (Norco) ; QL (60 per 0 lorcet hd oral tablet mg (Norco) ; QL (60 per 0 lorcet plus oral tablet mg (Norco) ; QL (60 per 0 5

16 margesic oral capsule mg (Esgic) 2 PA-HRM; GC; QL (180 per 0 ; AGE (Max 64 Years) methadone injection solution 10 mg/ml (Methadone HCl) methadone oral solution 10 mg/5 ml, 5 mg/5 ml (Methadone HCl) ; QL (1800 per 0 methadone oral tablet 10 mg (Diskets) ; QL (60 per 0 methadone oral tablet 5 mg (Diskets) ; QL (180 per 0 methadose oral tablet,soluble 40 mg (Diskets) ; QL (90 per 0 morphine 10 mg/ml carpuject 10 mg/ml (Morphine Sulfate) morphine 2 mg/ml carpuject outer, (Morphine Sulfate) latex-f, p/f 2 mg/ml morphine 4 mg/ml syringe p/f, latex-free (Morphine Sulfate) 4 mg/ml morphine 8 mg/ml syringe 8 mg/ml (Morphine Sulfate) morphine concentrate oral solution 100 mg/5 ml (20 mg/ml) (Morphine Sulfate) ; QL (180 per 0 morphine intramuscular pen injector 10 (Morphine Sulfate) mg/0.7 ml morphine intravenous cartridge 15 mg/ml (Morphine Sulfate) morphine intravenous syringe 10 mg/ml, 2 (Morphine Sulfate) mg/ml, 4 mg/ml, 8 mg/ml morphine oral solution 10 mg/5 ml (Morphine Sulfate) ; QL (700 per 0 morphine oral solution 20 mg/5 ml (4 mg/ml) (Morphine Sulfate) ; QL (00 per 0 MORPHINE ORAL TABLET 15 MG 4 QL (180 per 0 MORPHINE ORAL TABLET 0 MG 4 QL (120 per 0 morphine oral tablet extended release 100 (MS Contin) ; QL (60 per 0 mg, 200 mg, 60 mg morphine oral tablet extended release 15 mg (MS Contin) ; QL (180 per 0 6

17 morphine oral tablet extended release 0 mg (MS Contin) ; QL (120 per 0 NUCYNTA ER ORAL TABLET QL (60 per 0 EXTENDED RELEASE 12 HR 100 MG, 150 MG, 200 MG, 250 MG, 50 MG NUCYNTA ORAL TABLET 100 MG, QL (181 per 0 50 MG, 75 MG oxycodone oral capsule 5 mg (Oxycodone HCl) ; QL (180 per 0 oxycodone oral concentrate 20 mg/ml (Oxycodone HCl) ; QL (120 per 0 oxycodone oral solution 5 mg/5 ml (Oxycodone HCl) ; QL (100 per 0 oxycodone oral tablet 10 mg, 5 mg (Roxicodone) ; QL (180 per 0 oxycodone oral tablet 15 mg, 20 mg, 0 mg (Roxicodone) ; QL (120 per 0 oxycodone-acetaminophen oral solution 5-25 mg/5 ml (Oxycodone HCl/Acetaminophen) ; QL (1800 per 0 oxycodone-acetaminophen oral tablet mg (Xolox) ; QL (240 per 0 oxycodone-acetaminophen oral tablet mg, 5-25 mg (Xolox) ; QL (60 per 0 oxycodone-acetaminophen oral tablet mg (Xolox) ; QL (00 per 0 oxycodone-aspirin oral tablet mg (Oxycodone HCl/Aspirin) ; QL (60 per 0 OXYCONTIN ORAL QL (60 per 0 TABLET,ORAL ONLY,EXT.REL.12 HR 10 MG, 15 MG, 20 MG, 0 MG, 40 MG, 60 MG OXYCONTIN ORAL QL (120 per 0 TABLET,ORAL ONLY,EXT.REL.12 HR 80 MG oxymorphone oral tablet 10 mg (Opana) ; QL (120 per 0 7

18 oxymorphone oral tablet 5 mg (Opana) ; QL (180 per 0 oxymorphone oral tablet extended release (Opana ER) ; QL (60 per 0 12 hr 10 mg, 15 mg, 20 mg, 0 mg, 40 mg, 5 mg, 7.5 mg reprexain oral tablet mg, mg, mg (Ibudone) ; QL (150 per 0 tencon oral tablet mg (Tencon) 2 PA-HRM; GC; QL (180 per 0 ; AGE (Max 64 Years) tramadol oral tablet 50 mg (Ultram) ; QL (240 per 0 tramadol-acetaminophen oral tablet mg (Ultracet) ; QL (240 per 0 vicodin es oral tablet mg (Norco) ; QL (90 per 0 vicodin hp oral tablet mg (Norco) ; QL (90 per 0 vicodin oral tablet 5-00 mg (Norco) ; QL (90 per 0 XARTEMIS XR ORAL TAB,ORAL QL (00 per 0 ONLY,IR - ER, BIPHASE MG XTAMPZA ER ORAL QL (60 per 0 CAPSULE,SPRINKLE,ER 12HR TMPRR 1.5 MG, 18 MG, 9 MG XTAMPZA ER ORAL QL (120 per 0 CAPSULE,SPRINKLE,ER 12HR TMPRR 27 MG XTAMPZA ER ORAL QL (240 per 0 CAPSULE,SPRINKLE,ER 12HR TMPRR 6 MG xylon 10 oral tablet mg (Ibudone) ; QL (150 per 0 zebutal oral capsule mg (Esgic) 2 PA-HRM; GC; QL (180 per 0 ; AGE (Max 64 Years) 8

19 ZOHYDRO ER ORAL CAPSULE, ORAL ONLY, ER 12HR 10 MG, 15 MG, 20 MG, 0 MG, 40 MG, 50 MG Nonsteroidal Anti-Inflammatory Agents CALDOLOR INTRAVENOUS RECON SOLN 400 MG/4 ML (100 MG/ML) celecoxib oral capsule 100 mg, 200 mg, 400 mg, 50 mg 4 QL (60 per 0 (Celebrex) ; QL (60 per 0 diclofenac potassium oral tablet 50 mg (Diclofenac Potassium) diclofenac sodium oral tablet extended (Voltaren-XR) release 24 hr 100 mg diclofenac sodium oral tablet,delayed (Diclofenac Sodium) release (dr/ec) 25 mg, 50 mg, 75 mg diclofenac-misoprostol oral (Arthrotec 50) tablet,ir,delayed rel,biphasic mg-mcg, mg-mcg diflunisal oral tablet 500 mg (Diflunisal) etodolac oral capsule 200 mg, 00 mg (Etodolac) etodolac oral tablet 400 mg, 500 mg (Lodine) etodolac oral tablet extended release 24 (Etodolac) hr 400 mg, 500 mg, 600 mg fenoprofen oral tablet 600 mg (Fenoprofen Calcium) FLECTOR TRANSDERMAL PA PATCH 12 HOUR 1. % flurbiprofen oral tablet 100 mg, 50 mg (Flurbiprofen) ibuprofen oral suspension 100 mg/5 ml (Ibuprofen) ibuprofen oral tablet 400 mg, 600 mg, (Ibuprofen) 1 GC 800 mg indomethacin oral capsule 25 mg (Indomethacin) 1 GC; QL (240 per 0 indomethacin oral capsule 50 mg (Indomethacin) 1 GC; QL (120 per 0 indomethacin oral capsule, extended release 75 mg (Indomethacin) ; QL (60 per 0 4 9

20 indomethacin sodium intravenous recon (Indomethacin soln 1 mg Sodium) ketoprofen oral capsule 50 mg, 75 mg (Ketoprofen) ketoprofen oral capsule,ext rel. pellets 24 (Ketoprofen) hr 200 mg ketorolac injection cartridge 15 mg/ml (Ketorolac Tromethamine) ; QL (40 per 0 ketorolac injection cartridge 0 mg/ml (Ketorolac Tromethamine) ; QL (20 per 0 ketorolac injection solution 15 mg/ml (Ketorolac Tromethamine) ; QL (40 per 0 ketorolac injection solution 0 mg/ml (1 ml) (Ketorolac Tromethamine) ; QL (20 per 0 ketorolac injection syringe 0 mg/ml (Ketorolac Tromethamine) ; QL (20 per 0 ketorolac intramuscular solution 60 mg/2 ml (Ketorolac Tromethamine) ; QL (20 per 0 ketorolac oral tablet 10 mg (Ketorolac Tromethamine) ; QL (20 per 0 mefenamic acid oral capsule 250 mg (Ponstel) meloxicam oral suspension 7.5 mg/5 ml (Mobic) meloxicam oral tablet 15 mg, 7.5 mg (Mobic) 1 GC nabumetone oral tablet 500 mg, 750 mg (Nabumetone) naproxen oral suspension 125 mg/5 ml (Naprosyn) naproxen oral tablet 250 mg, 75 mg, 500 (Naprosyn) 1 GC mg naproxen oral tablet,delayed release (Ec-Naprosyn) (dr/ec) 75 mg, 500 mg naproxen sodium oral tablet 275 mg, 550 (Anaprox Ds) mg piroxicam oral capsule 10 mg, 20 mg (Feldene) sulindac oral tablet 150 mg, 200 mg (Sulindac) tolmetin oral capsule 400 mg (Tolmetin Sodium) tolmetin oral tablet 200 mg, 600 mg (Tolmetin Sodium) VOLTAREN TOPICAL GEL 1 % 10

21 Anesthetics Local Anesthetics glydo mucous membrane jelly in applicator 2 % (Lidocaine HCl) lidocaine (pf) injection solution 15 mg/ml (Xylocaine-MPF) (1.5 %), 40 mg/ml (4 %), 5 mg/ml (0.5 %) lidocaine 2% viscous soln 2 % (Pre-Attached Lta Kit) lidocaine hcl injection solution 10 mg/ml (Xylocaine) (1 %), 20 mg/ml (2 %), 5 mg/ml (0.5 %) lidocaine hcl mucous membrane jelly 2 % (Lidocaine HCl) lidocaine hcl mucous membrane solution (Pre-Attached Lta Kit) 2 %, 4 % (40 mg/ml) lidocaine topical adhesive (Lidoderm) 2 PA; GC patch,medicated 5 % lidocaine topical ointment 5 % (Lidocaine) lidocaine-prilocaine topical cream % Anti-Addiction/Substance Abuse Treatment Agents Anti-Addiction/Substance Abuse Treatment Agents acamprosate oral tablet,delayed release (dr/ec) mg BUNAVAIL BUCCAL FILM MG BUNAVAIL BUCCAL FILM MG, 6.-1 MG buprenorphine hcl sublingual tablet 2 mg, 8 mg buprenorphine-naloxone sublingual tablet mg, 8-2 mg buproban oral tablet extended release 150 mg bupropion hcl (smoking deter) oral tablet extended release 150 mg (EMLA) (Acamprosate Calcium) PA; QL (0 per 0 PA; QL (60 per 0 (Buprenorphine HCl) 2 PA; GC; QL (90 per 0 (Buprenorphine 2 PA; GC; QL (90 per 0 HCl/Naloxone HCl) (Zyban) (Zyban) 11

22 CHANTIX CONTINUING MONTH QL (168 per 84 BOX ORAL TABLET 1 MG CHANTIX ORAL TABLET 0.5 MG, 1 QL (168 per 84 MG CHANTIX STARTING MONTH QL (5 per 28 BOX ORAL TABLETS,DOSE PACK 0.5 MG (11)- 1 MG (42) disulfiram oral tablet 250 mg, 500 mg (Antabuse) naloxone injection solution 0.4 mg/ml (Naloxone HCl) naloxone injection syringe 0.4 mg/ml, 1 (Naloxone HCl) mg/ml naltrexone oral tablet 50 mg (Revia) NARCAN NASAL 4 QL (4 per 0 SPRAY,NON-AEROSOL 4 MG/ACTUATION NICOTROL INHALATION 4 QL (1008 per 90 CARTRIDGE 10 MG SUBOXONE SUBLINGUAL FILM 12- MG, 8-2 MG 4 PA; QL (60 per 0 SUBOXONE SUBLINGUAL FILM MG, 4-1 MG 4 PA; QL (0 per 0 ZUBSOLV SUBLINGUAL TABLET MG, MG, MG, MG PA; QL (0 per 0 ZUBSOLV SUBLINGUAL TABLET MG Antianxiety Agents Benzodiazepines alprazolam oral tablet 0.25 mg, 0.5 mg, 1 mg PA; QL (60 per 0 (Xanax) 1 GC; QL (120 per 0 alprazolam oral tablet 2 mg (Xanax) 1 GC; QL (150 per 0 alprazolam oral tablet extended release 24 hr 0.5 mg, 1 mg, 2 mg alprazolam oral tablet extended release 24 hr mg (Xanax XR) ; QL (120 per 0 (Xanax XR) ; QL (90 per 0 12

23 chlordiazepoxide hcl oral capsule 10 mg, 25 mg, 5 mg (Chlordiazepoxide HCl) 1 GC; QL (120 per 0 clonazepam oral tablet 0.5 mg, 1 mg (Klonopin) 1 GC; QL (90 per 0 clonazepam oral tablet 2 mg (Klonopin) 1 GC; QL (00 per 0 clonazepam oral tablet,disintegrating mg, 0.25 mg, 0.5 mg, 1 mg (Clonazepam) ; QL (90 per 0 clonazepam oral tablet,disintegrating 2 mg (Clonazepam) ; QL (00 per 0 clorazepate dipotassium oral tablet 15 mg,.75 mg, 7.5 mg (Tranxene T-Tab) ; QL (180 per 0 diazepam injection solution 5 mg/ml (Diazepam) ; QL (10 per 28 diazepam intensol oral concentrate 5 mg/ml (Diazepam) ; QL (1200 per 0 diazepam oral solution 5 mg/5 ml (1 mg/ml) (Diazepam) ; QL (1200 per 0 diazepam oral tablet 10 mg, 2 mg, 5 mg (Valium) 1 GC; QL (120 per 0 diazepam rectal kit mg, (Diastat) 2.5 mg, mg estazolam oral tablet 1 mg (Estazolam) 2 PA-HRM; GC; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use with any benzodiazepine hypnotic drug); QL (60 per 0 ; AGE (Max 64 Years) 1

24 estazolam oral tablet 2 mg (Estazolam) 2 PA-HRM; GC; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use with any benzodiazepine hypnotic drug); QL (0 per 0 ; AGE (Max 64 Years) flurazepam oral capsule 15 mg (Flurazepam HCl) 2 PA-HRM; GC; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use with any benzodiazepine hypnotic drug); QL (60 per 0 ; AGE (Max 64 Years) flurazepam oral capsule 0 mg (Flurazepam HCl) 2 PA-HRM; GC; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use with any non-benzodiazepine hypnotic drug); QL (0 per 0 ; AGE (Max 64 Years) lorazepam 2 mg/ml oral concent 2 mg/ml (Lorazepam) ; QL (150 per 0 lorazepam injection solution 2 mg/ml (Ativan) ; QL (2 per 0 lorazepam intensol oral concentrate 2 mg/ml (Lorazepam) ; QL (150 per 0 14

25 lorazepam oral tablet 0.5 mg, 1 mg (Ativan) 1 GC; QL (90 per 0 lorazepam oral tablet 2 mg (Ativan) 1 GC; QL (150 per 0 midazolam oral syrup 2 mg/ml (Midazolam HCl) ; QL (10 per 0 ONFI ORAL SUSPENSION 2.5 MG/ML 5 PA NSO; NDS; QL (480 per 0 ONFI ORAL TABLET 10 MG, 20 MG 5 PA NSO; NDS; QL (60 per 0 temazepam oral capsule 15 mg, 22.5 mg, 0 mg (Restoril) 2 PA-HRM; GC; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use with any benzodiazepine hypnotic drug); QL (0 per 0 ; AGE (Max 64 Years) temazepam oral capsule 7.5 mg (Restoril) 2 PA-HRM; GC; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use with any benzodiazepine hypnotic drug); QL (120 per 0 ; AGE (Max 64 Years) 15

26 triazolam oral tablet mg (Halcion) 2 PA-HRM; GC; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use with any benzodiazepine hypnotic drug); QL (120 per 0 ; AGE (Max 64 Years) triazolam oral tablet 0.25 mg (Halcion) 2 PA-HRM; GC; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use with any benzodiazepine hypnotic drug); QL (60 per 0 ; AGE (Max 64 Years) Antibacterials Aminoglycosides BETHKIS INHALATION SOLUTION FOR NEBULIZATION 00 MG/4 ML 5 PA BvD; NDS gentamicin in nacl (iso-osm) intravenous piggyback 100 mg/100 ml, 100 mg/50 ml, 60 mg/50 ml, 70 mg/50 ml, 80 mg/100 ml, 80 mg/50 ml, 90 mg/100 ml (Gentamicin In Nacl, Iso-Osm) gentamicin injection solution 40 mg/ml (Gentamicin Sulfate) gentamicin ped 20 mg/2 ml vial (Gentamicin latex-free, sdv 20 mg/2 ml Sulfate/PF) gentamicin sulfate (pf) intravenous (Gentamicin solution 80 mg/8 ml Sulfate/PF) neomycin oral tablet 500 mg (Neomycin Sulfate) 16

27 streptomycin intramuscular recon soln 1 (Streptomycin Sulfate) gram TOBI PODHALER INHALATION CAPSULE, W/INHALATION ; QL (224 per 28 DEVICE 28 MG tobramycin in % nacl inhalation (Tobi) 5 PA BvD; NDS solution for nebulization 00 mg/5 ml tobramycin in 0.9 % nacl intravenous (Tobramycin/Sodium piggyback 60 mg/50 ml Chloride) tobramycin sulfate injection solution 10 (Tobramycin Sulfate) mg/ml, 40 mg/ml Antibacterials, Miscellaneous baciim intramuscular recon soln 50,000 (Bacitracin) unit bacitracin intramuscular recon soln (Bacitracin) 50,000 unit chloramphenicol sod succinate (Chloramphenicol Sod intravenous recon soln 1 gram Succ) clindamycin 75 mg/5 ml soln 75 mg/5 ml (Cleocin Palmitate) clindamycin hcl oral capsule 150 mg, 00 (Cleocin HCl) mg, 75 mg clindamycin in 5 % dextrose intravenous (Cleocin Phosphate In piggyback 00 mg/50 ml, 600 mg/50 ml, 900 mg/50 ml D5w) clindamycin pediatric oral recon soln 75 (Cleocin Palmitate) mg/5 ml clindamycin phosphate injection solution (Cleocin Phosphate) 150 (mg/ml) (6 ml), 150 mg/ml clindamycin phosphate intravenous (Cleocin Phosphate) solution 600 mg/4 ml colistin (colistimethate na) injection (Coly-Mycin M recon soln 150 mg Parenteral) CUBICIN INTRAVENOUS RECON SOLN 500 MG daptomycin intravenous recon soln 500 mg (Cubicin) 17

28 linezolid intravenous parenteral solution (Zyvox) 600 mg/00 ml linezolid oral suspension for (Zyvox) reconstitution 100 mg/5 ml linezolid oral tablet 600 mg (Zyvox) methenamine hippurate oral tablet 1 (Hiprex) gram metronidazole in nacl (iso-os) (Metronidazole/Sodiu intravenous piggyback 500 mg/100 ml m Chloride) metronidazole oral capsule 75 mg (Flagyl) metronidazole oral tablet 250 mg, 500 mg (Flagyl) nitrofurantoin macrocrystal oral capsule 100 mg, 25 mg, 50 mg (Macrodantin/Macrobi d) 2 PA-HRM; GC; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use of nitrofurantoin drugs); QL (120 per 0 ; AGE (Max 64 Years) nitrofurantoin monohyd/m-cryst oral capsule 100 mg (Macrobid) 2 PA-HRM; GC; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use of nitrofurantoin drugs); QL (60 per 0 ; AGE (Max 64 Years) 18

29 nitrofurantoin oral suspension 25 mg/5 ml (Furadantin) 2 PA-HRM; GC; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use of nitrofurantoin drugs); QL (2400 per 0 ; AGE (Max 64 Years) polymyxin b sulfate injection recon soln (Polymyxin B Sulfate) 500,000 unit SYNERCID INTRAVENOUS RECON SOLN 500 MG trimethoprim oral tablet 100 mg (Trimethoprim) vancomycin hcl 1g/200 ml bag 1 (Vancomycin Hcl In gram/200 ml Dextrose 5 %) vancomycin intravenous recon soln 1,000 (Vancomycin HCl) mg, 10 gram, 750 mg vancomycin intravenous recon soln 500 (Vancomycin Hcl In mg Dextrose 5 %) vancomycin oral capsule 125 mg, 250 mg (Vancocin HCl) XIFAXAN ORAL TABLET 200 MG 5 PA; NDS; QL (9 per 0 XIFAXAN ORAL TABLET 550 MG 5 PA; NDS Cephalosporins cefaclor oral capsule 250 mg, 500 mg (Cefaclor) cefaclor oral suspension for reconstitution (Cefaclor) 125 mg/5 ml, 250 mg/5 ml, 75 mg/5 ml cefaclor oral tablet extended release 12 (Cefaclor) hr 500 mg cefadroxil oral capsule 500 mg (Cefadroxil) cefadroxil oral suspension for (Cefadroxil) reconstitution 250 mg/5 ml, 500 mg/5 ml cefadroxil oral tablet 1 gram (Cefadroxil) cefazolin in dextrose (iso-os) intravenous piggyback 1 gram/50 ml, 2 gram/50 ml (Cefazolin Sodium/Dextrose, Iso) 19

30 cefazolin injection recon soln 1 gram, 10 (Cefazolin Sodium) gram, 500 mg cefdinir oral capsule 00 mg (Cefdinir) cefdinir oral suspension for reconstitution (Cefdinir) 125 mg/5 ml, 250 mg/5 ml cefditoren pivoxil oral tablet 200 mg, 400 (Spectracef) mg CEFEPIME 1 GM INJECTION 1 4 GRAM/50 ML cefepime hcl 1 gm vial 10's, sdv 1 gram (Cefepime HCl) cefepime hcl 2 gram vial latex/f, sdv, (Cefepime HCl) outer 2 gram CEFEPIME INJECTION RECON 4 SOLN 1 GRAM, 2 GRAM CEFEPIME-DEXTROSE 2 GM/50 4 ML 2 GRAM/50 ML cefixime oral suspension for (Suprax) reconstitution 100 mg/5 ml, 200 mg/5 ml cefotaxime injection recon soln 1 gram, (Claforan) 10 gram, 2 gram, 500 mg cefoxitin 2 gm piggyback bag 2 gram/50 (Cefoxitin ml Sodium/Dextrose, Iso) cefoxitin 2 gm vial latex/f, outer 2 gram (Cefoxitin Sodium) cefoxitin intravenous recon soln 1 gram, (Cefoxitin Sodium) 10 gram cefoxitin intravenous recon soln 2 gram (Cefoxitin Sodium/Dextrose, Iso) cefpodoxime oral suspension for (Cefpodoxime Proxetil) reconstitution 100 mg/5 ml, 50 mg/5 ml cefpodoxime oral tablet 100 mg, 200 mg (Cefpodoxime Proxetil) cefprozil oral suspension for (Cefprozil) reconstitution 125 mg/5 ml, 250 mg/5 ml cefprozil oral tablet 250 mg, 500 mg (Cefprozil) ceftazidime injection recon soln 2 gram, 6 (Fortaz) gram ceftibuten oral capsule 400 mg (Cedax) 20

31 ceftibuten oral suspension for (Cedax) reconstitution 180 mg/5 ml ceftriaxone 1 gm piggyback latex-free 1 (Ceftriaxone gram/50 ml Na/Dextrose, Iso) ceftriaxone 2 gm piggyback latex-free 2 (Ceftriaxone gram/50 ml Na/Dextrose, Iso) ceftriaxone injection recon soln 1 gram, (Ceftriaxone Sodium) 10 gram, 250 mg, 500 mg ceftriaxone intravenous recon soln 1 (Ceftriaxone gram, 2 gram Na/Dextrose, Iso) cefuroxime axetil oral tablet 250 mg, 500 (Ceftin) mg cefuroxime sodium injection recon soln (Zinacef) 1.5 gram, 750 mg cefuroxime sodium intravenous recon soln (Zinacef) 7.5 gram cephalexin oral capsule 250 mg, 500 mg (Keflex) 1 GC cephalexin oral capsule 750 mg (Keflex) cephalexin oral suspension for (Cephalexin) 1 GC reconstitution 125 mg/5 ml, 250 mg/5 ml cephalexin oral tablet 250 mg, 500 mg (Cephalexin) 1 GC MEFOXIN IN DEXTROSE 4 (ISO-OSM) INTRAVENOUS PIGGYBACK 1 GRAM/50 ML, 2 GRAM/50 ML SUPRAX ORAL CAPSULE 400 MG 4 SUPRAX ORAL SUSPENSION FOR 4 RECONSTITUTION 500 MG/5 ML SUPRAX ORAL 4 TABLET,CHEWABLE 100 MG, 200 MG tazicef injection recon soln 2 gram, 6 (Fortaz) gram TEFLARO INTRAVENOUS RECON SOLN 400 MG, 600 MG 4 21

32 Macrolides azithromycin intravenous recon soln 500 (Zithromax) mg azithromycin oral packet 1 gram (Zithromax) azithromycin oral suspension for (Zithromax) reconstitution 100 mg/5 ml, 200 mg/5 ml azithromycin oral tablet 250 mg, 250 mg (Zithromax) (6 pack), 600 mg azithromycin oral tablet 500 mg (Zithromax) clarithromycin oral suspension for (Biaxin) reconstitution 125 mg/5 ml, 250 mg/5 ml clarithromycin oral tablet 250 mg, 500 (Biaxin) mg clarithromycin oral tablet extended (Clarithromycin) release 24 hr 500 mg DIFICID ORAL TABLET 200 MG ; QL (20 per 10 e.e.s. 400 oral tablet 400 mg (Erythromycin Ethylsuccinate) e.e.s. granules oral suspension for (Eryped 200) reconstitution 200 mg/5 ml ery-tab oral tablet,delayed release (Erythromycin Base) (dr/ec) 250 mg, 500 mg ERY-TAB ORAL 4 TABLET,DELAYED RELEASE (DR/EC) MG erythrocin (as stearate) oral tablet 250 (Erythromycin mg Stearate) ERYTHROCIN INTRAVENOUS 4 RECON SOLN 1,000 MG, 500 MG erythromycin ethylsuccinate oral (Eryped 200) suspension for reconstitution 200 mg/5 ml erythromycin ethylsuccinate oral tablet (Erythromycin 400 mg Ethylsuccinate) erythromycin oral capsule,delayed (Erythromycin Base) release(dr/ec) 250 mg erythromycin oral tablet 250 mg, 500 mg (Erythromycin Base) 22

33 Miscellaneous B-Lactam Antibiotics aztreonam injection recon soln 1 gram, 2 (Azactam) gram CAYSTON INHALATION 5 LA; NDS SOLUTION FOR NEBULIZATION 75 MG/ML imipenem-cilastatin intravenous recon (Primaxin) soln 250 mg, 500 mg INVANZ INJECTION RECON SOLN 4 1 GRAM meropenem intravenous recon soln 1 (Merrem) gram, 500 mg Penicillins amoxicillin oral capsule 250 mg, 500 mg (Amoxicillin) 1 GC amoxicillin oral suspension for (Amoxicillin) 1 GC reconstitution 125 mg/5 ml, 200 mg/5 ml, 250 mg/5 ml, 400 mg/5 ml amoxicillin oral tablet 500 mg, 875 mg (Amoxicillin) 1 GC amoxicillin oral tablet,chewable 125 mg, (Amoxicillin) 1 GC 250 mg amoxicillin-pot clavulanate oral (Augmentin) suspension for reconstitution mg/5 ml, mg/5 ml, mg/5 ml, mg/5 ml amoxicillin-pot clavulanate oral tablet (Augmentin) mg, mg, mg amoxicillin-pot clavulanate oral tablet (Augmentin XR) extended release 12 hr 1, mg amoxicillin-pot clavulanate oral (Amoxicillin/Potassium tablet,chewable mg, mg Clav) ampicillin oral capsule 250 mg, 500 mg (Ampicillin Trihydrate) 1 GC ampicillin oral suspension for (Ampicillin Trihydrate) 1 GC reconstitution 125 mg/5 ml, 250 mg/5 ml ampicillin sodium injection recon soln 1 gram, 10 gram, 125 mg, 2 gram, 250 mg, 500 mg (Ampicillin Sodium) 2

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