2017 Comprehensive Formulary

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1 MoDOT/MSHP Medical and Life Insurance Plan 07 Comprehensive Formulary (List of Covered Drugs) PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN This formulary was updated on August, 07. For more recent information on covered drugs or other prescription drug benefit questions, please contact MedImpact Customer Service at (844) , 4 hours/day, 7 days/week. TTY users should call 7. Or visit MoDOT/MSHP Medical and Life Insurance Plan is a Health plan with a Medicare contract MoDOT/MSHP Medical and Life Insurance Plan Effective: August, 07 Formulary ID: Version: 8

2 Note to existing members: This formulary has changed since last year. Please review this document to make sure that it still contains the drugs you take. When this drug list (formulary) refers to we, us, or our, it means MoDOT/MSHP Medical and Life Insurance Plan. When it refers to plan or our plan, it means MoDOT/MSHP Medical and Life Insurance Plan. This document includes a partial list of the drugs (formulary) for our plan which is current as of August, 07. For a complete, updated formulary, please contact us. You must generally use network pharmacies to use your prescription drug benefit. Benefits, formulary, pharmacy network, premium and/or copayments/coinsurance may change on August, 07. This information may be available in a different format, including large print. Please call MoDOT Customer Service at (877) if you need this information in another format. MoDOT/MSHP Medical and Life Insurance Plan Effective: August, 07 Formulary ID: Version: 8

3 What is the MoDOT/MSHP Medical and Life Insurance Plan Formulary? A formulary is a list of covered drugs selected by MoDOT/MSHP Medical and Life Insurance 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. MoDOT/MSHP Medical and Life Insurance Plan will generally cover the drugs listed in our formulary as long as the drug is medically necessary, the prescription is filled at a MoDOT/MSHP Medical and Life Insurance Plan network pharmacy, and other plan rules are followed. For more information on how to fill your prescriptions, please review your Summary Plan Design document. Can the Formulary (drug list) change? Generally, if you are taking a drug on our 07 formulary that was covered at the beginning of the year, we will not discontinue or reduce coverage of the drug during the 07 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 0-day supply of the drug. If you are a resident in a long term care facility or have a level of care change you may be eligible to receive additional refills. 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 August, 07. To get updated information about the drugs covered by MoDOT/MSHP Medical and Life Insurance Plan, please contact MedImpact Customer Service (844) If we make any mid-year non-maintenance formulary changes, we will mail you an errata sheet showing those changes. Non-maintenance formulary changes are when we: Remove a Part D drug from our formulary, Move covered Part D drugs to a less preferred tier status, or Add utilization management requirements. MoDOT/MSHP Medical and Life Insurance Plan Effective: August, 07 Formulary ID: Version: 8

4 How do I use the Formulary? There are two ways to find your drug within the formulary: Medical Condition The formulary begins on page. The drugs in this formulary are grouped into categories depending on the type of medical conditions that they are used to treat. For example, drugs used to treat a heart condition are listed under the category, Cardiovascular Agents. If you know what your drug is used for, look for the category name in the list that begins on 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 I-. 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? MoDOT/MSHP Medical and Life Insurance Plan cover 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 (PA): MoDOT/MSHP Medical and Life Insurance Plan requires you or your physician to get prior authorization for certain drugs. This means that you will need to get approval from MedImpact Health Systems, Inc before you fill your prescriptions. If you don t get approval, MoDOT/MSHP Medical and Life Insurance Plan may not cover the drug. Quantity Limits (QL): For certain drugs, MoDOT/MSHP Medical and Life Insurance Plan limits the amount of the drug that MoDOT/MSHP Medical and Life Insurance Plan will cover.. This may be in addition to a standard one month or three month supply. Step Therapy (ST): In some cases, MoDOT/MSHP Medical and Life Insurance Plan requires you to first try certain drugs to treat your medical condition before we will MoDOT/MSHP Medical and Life Insurance Plan Effective: August, 07 Formulary ID: Version: 8

5 cover another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, MoDOT/MSHP Medical and Life Insurance Plan may not cover Drug B unless you try Drug A first. If Drug A does not work for you, MoDOT/MSHP Medical and Life Insurance 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 website. You can ask MoDOT/MSHP Medical and Life Insurance Plan to make an exception to these restrictions or limits. See the section, How do I request an exception to the MoDOT/MSHP Medical and Life Insurance Plan formulary? below 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 MedImpact Customer Service and ask if your drug is covered. This document includes only a partial list of covered drugs, so MoDOT/MSHP Medical and Life Insurance Plan may cover your drug. For more information, please contact MedImpact Customer Service (844) If you learn that MoDOT/MSHP Medical and Life Insurance Plan does not cover your drug, you have two options: You can ask MedImpact Customer Service (844) for a list of similar drugs that are covered by MoDOT/MSHP Medical and Life Insurance 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 MoDOT/MSHP Medical and Life Insurance Plan. You can ask MoDOT/MSHP Medical and Life Insurance 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 MoDOT/MSHP Medical and Life Insurance Plan Formulary? You can ask MoDOT/MSHP Medical and Life Insurance 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 waive coverage restrictions or limits on your drug. For example, for certain drugs, MoDOT/MSHP Medical and Life Insurance 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 more. You can ask us to cover a formulary drug at a lower cost-sharing level. If approved this would lower the amount you must pay for your drug. MoDOT/MSHP Medical and Life Insurance Plan Effective: August, 07 Formulary ID: Version: 8

6 Generally, MoDOT/MSHP Medical and Life Insurance Plan will only approve your request for an exception if the alternative drugs included on the plan s formulary, the lower-tiered 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 are requesting a formulary, tiering or utilization restriction exception, you should submit a statement from your prescriber or physician supporting your request. Generally, we must make our decision within 7 hours of getting your prescribing physician s supporting statement. You can request an expedited (fast) exception if you or your doctor believe that your health could be seriously harmed by waiting up to 7 hours for a decision. If your request to expedite is granted, we must give you a decision no later than 4 hours after we get your prescriber s or prescribing physician s supporting statement. 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 a 0 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 -day emergency supply of that drug (unless you have a prescription for fewer while you pursue a formulary exception. Members with levels-of-care changes may contact MedImpact Customer Service (844) (or have their doctor or prescriber contact us) to request transitional supplies of medication during their transitions of care. MoDOT/MSHP Medical and Life Insurance Plan will not supply a transition fill for any drugs that are not Part D-approved drugs. For more information MoDOT/MSHP Medical and Life Insurance Plan Effective: August, 07 Formulary ID: Version: 8

7 For more detailed information about your MoDOT/MSHP Medical and Life Insurance Plan prescription drug coverage, please review your Summary Plan Design documentand other plan materials. If you have questions about MoDOT/MSHP Medical and Life Insurance 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 -800-MEDICARE ( ) 4 hours a day/7 days a week. TTY/TDD users should call Or, visit MoDOT/MSHP Medical and Life Insurance Plan's Formulary The formulary below provides coverage information about some of the drugs covered by MoDOT/MSHP Medical and Life Insurance Plan. If you have trouble finding your drug in the list, turn to the Index that begins on page I-. Remember: This is only a partial list of drugs covered by MoDOT/MSHP Medical and Life Insurance Plan. If your prescription is not in this partial formulary, please contact MedImpact Customer Service (844) The first column of the chart lists the drug name. Brand name drugs are capitalized (e.g., LOPRESSOR) and generic drugs are listed in lower-case italics (e.g., metoprolol tartrate). The information in the Requirements/Limits column tells you if MoDOT/MSHP Medical and Life Insurance Plan has any special requirements for coverage of your drug. Formulary Key The first column of the drug list contains the drug name: Brand name drugs are Capitalized (e.g., LOPRESSOR) Generic drugs are listed in lower-case italics (e.g., metoprolol tartrate) The second column shows the drug coverage tier. Each tier is described below. Tier = Generics. These drugs offer the most cost savings. Tier = Brand Name drugs with no generic equivalent. These drugs offer the most cost savings among brand-name drugs. Tier = Brand Name drugs with a generic equivalent. These drugs cost more because less expensive alternatives may exist. MoDOT/MSHP Medical and Life Insurance Plan Effective: August, 07 Formulary ID: Version: 8

8 The Requirements/Limits section of the drug list tells you if MoDOT/MSHP Medical and Life Insurance Plan has restrictions, special requirements, or limitations for coverage of the drug. A drug may display one or more of the following abbreviations: Symbol PA PA BvD PA NSO QL ST LA NM Definition Prior Authorization. There may be restrictions on this medication. See Are there any restrictions on my coverage?. Prior Authorization (PA) is required for Part B versus Part D Determinations (BvD). This drug may be eligible for payment under Medicare Part B or Part D. You (or your physician) are required to get prior authorization from MoDOT/MSHP Medical and Life Insurance Plan to determine that this drug is covered under Medicare Part D before you fill your prescription for this drug. Without prior approval, MoDOT/MSHP Medical and Life Insurance Plan may not cover this drug. Prior Authorization (PA) is required for New Starts Only (NSO). If this medication is new for you, you (or your physician) are required to get prior authorization from MoDOT/MSHP Medical and Life Insurance Plan before you fill your prescription for this drug. Without prior approval, MoDOT/MSHP Medical and Life Insurance Plan may not cover this drug. Quantity Limit Restriction. There may be restrictions on this medication. See Are there any restrictions on my coverage?. Step Therapy Restriction. There may be restrictions on this medication. See Are there any restrictions on my coverage?. Limited Access Drug. Due to limited manufacturers, this medication may be only available through limited pharmacies. See the Pharmacy Directory or call MedImpact Customer Service (844) Non-Mail Order. Drugs marked NM cannot be filled by mail order, though are available at retail/local pharmacies. The right-hand column of the Requirements/Limits section includes information about dosage forms (such as tablet, capsule, or spray) or dosage strengths. If no information is displayed in this column, it means that all dosage forms and strengths are covered on the same drug tier. If information is displayed, it means that only those dosage forms/s Strengths are covered on that tier. MoDOT/MSHP Medical and Life Insurance Plan Effective: August, 07 Formulary ID: Version: 8

9 Table of Contents Analgesics... Anesthetics... 7 Anti-Addiction/Substance Abuse Treatment Agents... 8 Antianxiety Agents...9 Antibacterials... Anticancer Agents... 8 Anticholinergic Agents Anticonvulsants...5 Antidementia Agents...58 Antidepressants Antidiabetic Agents Antifungals...7 Antigout Agents Antihistamines...76 Anti-Infectives (Skin And Mucous Membrane)...77 Antimigraine Agents...78 Antimycobacterials...80 Antinausea Agents...8 Antiparasite Agents...84 Antiparkinsonian Agents...85 Antipsychotic Agents...87 Antivirals (Systemic)...9 Blood Products/Modifiers/Volume Expanders...00 Caloric Agents Cardiovascular Agents...09 Central Nervous System Agents... 0 Contraceptives...5 Dental And Oral Agents Dermatological Agents Devices Enzyme Replacement/Modifiers Eye, Ear, Nose, Throat Agents... 6 Gastrointestinal Agents Genitourinary Agents Heavy Metal Antagonists Hormonal Agents, Stimulant/Replacement/Modifying...79

10 Immunological Agents...9 Inflammatory Bowel Disease Agents... 0 Irrigating Solutions...0 Metabolic Bone Disease Agents...04 Miscellaneous Therapeutic Agents...07 Ophthalmic Agents... Replacement Preparations... Respiratory Tract Agents... 7 Skeletal Muscle Relaxants... 4 Sleep Disorder Agents... 6 Sympathomimetic (Adrenergic) Agents... 8 Vasodilating Agents...8 Vitamins And Minerals...9

11 Analgesics Analgesics, Miscellaneous ABSTRAL SUBLINGUAL TABLET 00 MCG, 00 MCG, 00 MCG, 400 MCG, 600 MCG, 800 MCG acetaminophen-caff-dihydrocod oral capsule mg acetaminophen-caff-dihydrocod oral tablet mg acetaminophen-codeine oral solution 0- mg/5 ml acetaminophen-codeine oral tablet 00-5 mg acetaminophen-codeine oral tablet 00-0 mg acetaminophen-codeine oral tablet mg ACTIQ BUCCAL LOZENGE ON A HANDLE,00 MCG,,600 MCG, 00 MCG, 400 MCG, 600 MCG, 800 MCG ALLZITAL ORAL TABLET 5-5 ascomp with codeine oral capsule mg aspirin-caffeine-dihydrocodein oral capsule mg astramorph-pf injection solution 0.5 mg/ml, mg/ml BELBUCA BUCCAL FILM 50 MCG, 00 MCG, 450 MCG, 600 MCG, 75 MCG, 750 MCG, 900 MCG PA; QL (0 per 0 (Trezix) QL (00 per 0 QL (00 per 0 QL (700 per 0 QL (60 per 0 (Tylenol-Codeine #) QL (60 per 0 (Tylenol-Codeine #4) QL (80 per 0 PA; QL (0 per 0 QL (80 per 0 (Synalgos-DC) QL (60 per 0 BUPAP ORAL TABLET BUPRENEX INJECTION SOLUTION 0. /ML buprenorphine hcl injection solution 0. (Buprenex) mg/ml buprenorphine hcl injection syringe 0. mg/ml PA BvD

12 buprenorphine transdermal patch weekly (Butrans) PA; QL (4 per 8 0 mcg/hour, 5 mcg/hour, 0 mcg/hour, 5 mcg/hour, 7.5 mcg/hour butalbital compound w/codeine oral QL (80 per 0 capsule mg butalbital-acetaminop-caf-cod oral QL (80 per 0 capsule mg, mg butalbital-acetaminophen oral tablet 50- (Bupap) QL (80 per 0 00 mg butalbital-acetaminophen oral tablet 50- (Marten-Tab) QL (80 per 0 5 mg butalbital-acetaminophen-caff oral capsule mg butalbital-acetaminophen-caff oral (Zebutal) QL (80 per 0 capsule mg butalbital-acetaminophen-caff oral tablet (Esgic) QL (80 per mg butalbital-aspirin-caffeine oral capsule (Fiorinal) QL (80 per mg butorphanol tartrate injection solution mg/ml, mg/ml butorphanol tartrate nasal spray,nonaerosol QL (5 per 8 0 mg/ml BUTRANS TRANSDERMAL PA; QL (4 per 8 PATCH WEEKLY 0 MCG/HOUR, 5 MCG/HOUR, 0 MCG/HOUR, 5 MCG/HOUR, 7.5 MCG/HOUR capacet oral capsule mg QL (80 per 0 CAPITAL WITH CODEINE ORAL QL (700 per 0 SUSPENSION 0- /5 ML codeine sulfate oral tablet 5 mg, 0 mg, QL (80 per 0 60 mg CONZIP ORAL CAPSULE,ER QL (0 per 0 BIPHASE 4 HR CONZIP ORAL CAPSULE,ER QL (0 per 0 BIPHASE 4 HR , 00 DEMEROL (PF) INJECTION SOLUTION 00 / ML, 5 /0.5 ML, 50 /ML, 75 /.5 ML 4

13 DEMEROL (PF) INJECTION SYRINGE 00 /ML, 5 /ML, 50 /ML, 75 /ML DEMEROL INJECTION SOLUTION 50 /ML DEMEROL ORAL TABLET 00, QL (80 per 0 50 DILAUDID INJECTION SYRINGE /ML, 4 /ML DILAUDID ORAL LIQUID QL (00 per 0 /ML DILAUDID ORAL TABLET, 4 QL (80 per 0, 8 DILAUDID-HP (PF) INJECTION SOLUTION 0 /ML DISKETS ORAL TABLET,SOLUBLE QL (90 per 0 40 DOLOPHINE ORAL TABLET 0 QL (60 per 0 DOLOPHINE ORAL TABLET 5 QL (80 per 0 DURAGESIC TRANSDERMAL QL (0 per 0 PATCH 7 HOUR 00 MCG/HR, MCG/HR, 5 MCG/HR, 50 MCG/HR, 75 MCG/HR DURAMORPH (PF) INJECTION PA BvD SOLUTION 0.5 /ML, /ML EMBEDA ORAL CAPSULE,ORAL QL (60 per 0 ONLY,EXT.REL PELL 00-4, 0-0.8, 0-., 50-, 60-.4, 80-. endocet oral tablet 0-5 mg QL (40 per 0 endocet oral tablet.5-5 mg, 5-5 mg QL (60 per 0 endocet oral tablet mg QL (00 per 0 endodan oral tablet mg QL (60 per 0 ESGIC ORAL CAPSULE QL (80 per 0 ESGIC ORAL TABLET QL (80 per 0 EXALGO ER ORAL TABLET EXTENDED RELEASE 4 HR, 6, 8 PA; QL (0 per 0 5

14 EXALGO ER ORAL TABLET EXTENDED RELEASE 4 HR fentanyl citrate buccal lozenge on a handle,00 mcg,,600 mcg, 00 mcg, 400 mcg, 600 mcg, 800 mcg fentanyl transdermal patch 7 hour 00 mcg/hr, mcg/hr, 5 mcg/hr, 50 mcg/hr, 75 mcg/hr fentanyl transdermal patch 7 hour 7.5 mcg/hour, 6.5 mcg/hour, 87.5 mcg/hour FENTORA BUCCAL TABLET, EFFERVESCENT 00 MCG, 00 MCG, 400 MCG, 600 MCG, 800 MCG FIORICET ORAL CAPSULE FIORICET WITH CODEINE ORAL CAPSULE FIORINAL ORAL CAPSULE FIORINAL-CODEINE # ORAL CAPSULE HYCET ORAL SOLUTION /5 ML hydrocodone-acetaminophen oral solution.5-67 mg/5 ml, 5-6 mg/7.5ml(7.5ml) hydrocodone-acetaminophen oral solution mg/5 ml hydrocodone-acetaminophen oral tablet 0-00 mg hydrocodone-acetaminophen oral tablet 0-5 mg, mg hydrocodone-acetaminophen oral tablet.5-5 mg hydrocodone-acetaminophen oral tablet 5-00 mg hydrocodone-acetaminophen oral tablet 5-5 mg hydrocodone-acetaminophen oral tablet mg PA; QL (60 per 0 (Actiq) PA; QL (0 per 0 (Duragesic) QL (0 per 0 QL (0 per 0 PA; QL (0 per 0 QL (80 per 0 QL (80 per 0 QL (80 per 0 QL (700 per 0 QL (700 per 0 (Hycet) QL (700 per 0 (Xodol 0/00) QL (90 per 0 (Norco) QL (60 per 0 (Verdrocet) QL (60 per 0 (Xodol 5/00) QL (90 per 0 (Lorcet (hydrocodone)) QL (60 per 0 (Xodol 7.5/00) QL (90 per 0 6

15 hydrocodone-ibuprofen oral tablet 0-00 (Ibudone) QL (50 per 0 mg, 5-00 mg hydrocodone-ibuprofen oral tablet 7.5- QL (50 per 0 00 mg hydromorphone (pf) injection solution 0 (mg/ml) (5 ml) hydromorphone (pf) injection solution 0 mg/ml hydromorphone 0 mg/ml vial p/f,sdv,latex-f 0 mg/ml hydromorphone injection solution 4 mg/ml hydromorphone injection syringe mg/ml (Dilaudid) hydromorphone oral liquid mg/ml (Dilaudid) QL (00 per 0 hydromorphone oral tablet mg, 4 mg, 8 (Dilaudid) QL (80 per 0 mg hydromorphone oral tablet extended release 4 hr mg, 6 mg, 8 mg (Exalgo ER) PA; QL (0 per 0 hydromorphone oral tablet extended release 4 hr mg (Exalgo ER) PA; QL (60 per 0 HYSINGLA ER ORAL QL (0 per 0 TABLET,ORAL ONLY,EXT.REL.4 HR 00, 0, 0, 0, 40, 60, 80 IBUDONE ORAL TABLET 0-00 QL (50 per 0, 5-00 ibuprofen-oxycodone oral tablet QL (8 per 0 mg INFUMORPH P/F INJECTION PA BvD SOLUTION 0 /ML, 5 /ML KADIAN ORAL QL (60 per 0 CAPSULE,EXTEND.RELEASE PELLETS 0, 0, 0, 50 KADIAN ORAL QL (0 per 0 CAPSULE,EXTEND.RELEASE PELLETS 00, 60, 80 KADIAN ORAL CAPSULE,EXTEND.RELEASE PELLETS 00 QL (0 per 0 7

16 KADIAN ORAL CAPSULE,EXTEND.RELEASE PELLETS 40 LAZANDA NASAL SPRAY,NON- AEROSOL 00 MCG/SPRAY, 00 MCG/SPRAY, 400 MCG/SPRAY QL (60 per 0 PA; QL (0 per 0 levorphanol tartrate oral tablet mg QL (50 per 0 lorcet (hydrocodone) oral tablet 5-5 QL (60 per 0 mg lorcet hd oral tablet 0-5 mg QL (60 per 0 lorcet plus oral tablet mg QL (60 per 0 LORTAB 0-5 ORAL TABLET 0- QL (60 per 0 5 LORTAB 5-5 ORAL TABLET 5-5 QL (60 per 0 LORTAB ORAL TABLET 7.5- QL (60 per 0 5 LORTAB ELIXIR ORAL SOLUTION QL (05 per /5 ML margesic oral capsule mg QL (80 per 0 marten-tab oral tablet 50-5 mg meperidine (pf) injection solution 00 (Demerol (PF)) mg/ml, 50 mg/ml meperidine (pf) injection solution 5 mg/ml meperidine injection cartridge 0 mg/ml meperidine oral solution 50 mg/5 ml QL (900 per 0 meperidine oral tablet 00 mg (Demerol) QL (80 per 0 meperidine oral tablet 50 mg QL (80 per 0 methadone injection solution 0 mg/ml methadone intensol oral concentrate 0 QL (080 per 0 mg/ml methadone oral solution 0 mg/5 ml, 5 QL (800 per 0 mg/5 ml methadone oral tablet 0 mg (Dolophine) QL (60 per 0 methadone oral tablet 5 mg (Dolophine) QL (80 per 0 METHADOSE ORAL QL (080 per 0 CONCENTRATE 0 /ML methadose oral tablet,soluble 40 mg QL (90 per 0 8

17 MORPHABOND ER ORAL QL (60 per 0 TABLET,ORAL ONLY,EXT.REL. HR 00, 60 MORPHABOND ER ORAL QL (80 per 0 TABLET,ORAL ONLY,EXT.REL. HR 5 MORPHABOND ER ORAL QL (0 per 0 TABLET,ORAL ONLY,EXT.REL. HR 0 morphine (pf) injection solution 0.5 (Duramorph (PF)) PA BvD mg/ml, mg/ml morphine (pf) intravenous patient PA BvD control.analgesia soln 50 mg/0 ml, 0 mg/0 ml morphine 0 mg/ml carpuject outer, p/f, l/f, suv 0 mg/ml morphine mg/ml carpuject outer, l/f, p/f, sdv mg/ml morphine 4 mg/ml syringe p/f, latexfree,suv 4 mg/ml morphine 8 mg/ml syringe 8 mg/ml morphine concentrate oral solution 00 QL (80 per 0 mg/5 ml (0 mg/ml) morphine in 0.9 % nacl intravenous PA BvD solution mg/ml morphine injection solution 5 mg/ml, 8 mg/ml morphine injection syringe 0 mg/ml morphine injection syringe 5 mg/ml PA BvD morphine intramuscular pen injector 0 mg/0.7 ml morphine intravenous cartridge 5 mg/ml morphine intravenous solution 5 mg/ml, 50 mg/ml morphine intravenous syringe 0 mg/ml, mg/ml, 4 mg/ml, 8 mg/ml morphine oral capsule, er multiphase 4 QL (0 per 0 hr 0 mg, 0 mg, 45 mg, 60 mg, 75 mg, 90 mg morphine oral capsule,extend.release pellets 0 mg, 0 mg, 0 mg, 50 mg (Kadian) QL (60 per 0 9

18 morphine oral capsule,extend.release (Kadian) QL (0 per 0 pellets 00 mg, 60 mg, 80 mg morphine oral solution 0 mg/5 ml QL (700 per 0 morphine oral solution 0 mg/5 ml (4 QL (00 per 0 mg/ml) MORPHINE ORAL TABLET 5 QL (80 per 0 MORPHINE ORAL TABLET 0 QL (0 per 0 morphine oral tablet extended release 00 (MS Contin) QL (60 per 0 mg, 00 mg, 60 mg morphine oral tablet extended release 5 (MS Contin) QL (80 per 0 mg morphine oral tablet extended release 0 (MS Contin) QL (0 per 0 mg morphine rectal suppository 0 mg, 5 mg QL (60 per 0 morphine rectal suppository 0 mg QL (80 per 0 morphine rectal suppository 0 mg QL (0 per 0 MS CONTIN ORAL TABLET QL (60 per 0 EXTENDED RELEASE 00, 00, 60 MS CONTIN ORAL TABLET QL (80 per 0 EXTENDED RELEASE 5 MS CONTIN ORAL TABLET QL (0 per 0 EXTENDED RELEASE 0 nalbuphine injection solution 0 mg/ml, 0 mg/ml NORCO ORAL TABLET 0-5, QL (60 per 0 5-5, NUCYNTA ER ORAL TABLET QL (60 per 0 EXTENDED RELEASE HR 00, 50, 00, 50, 50 NUCYNTA ORAL TABLET 00, QL (8 per 0 50, 75 OPANA ER ORAL TABLET,ORAL QL (60 per 0 ONLY,EXT.REL. HR 0, 5, 0, 0, 40, 5, 7.5 OPANA ORAL TABLET 0 QL (0 per 0 OPANA ORAL TABLET 5 QL (80 per 0 oxycodone oral capsule 5 mg QL (80 per 0 oxycodone oral concentrate 0 mg/ml QL (0 per 0 0

19 oxycodone oral solution 5 mg/5 ml QL (00 per 0 oxycodone oral tablet 0 mg QL (80 per 0 oxycodone oral tablet 5 mg, 0 mg (Roxicodone) QL (0 per 0 oxycodone oral tablet 0 mg QL (0 per 0 oxycodone oral tablet 5 mg (Roxicodone) QL (80 per 0 oxycodone oral tablet,oral only,ext.rel. (OxyContin) QL (60 per 0 hr 0 mg, 5 mg, 0 mg, 0 mg, 40 mg, 60 mg oxycodone oral tablet,oral only,ext.rel. (OxyContin) QL (0 per 0 hr 80 mg oxycodone-acetaminophen oral solution QL (800 per mg/5 ml oxycodone-acetaminophen oral tablet 0- (Endocet) QL (40 per 0 5 mg oxycodone-acetaminophen oral tablet (Endocet) QL (60 per mg oxycodone-acetaminophen oral tablet 5- (Percocet) QL (60 per 0 5 mg oxycodone-acetaminophen oral tablet (Percocet) QL (00 per mg oxycodone-aspirin oral tablet QL (60 per 0 mg OXYCONTIN ORAL QL (60 per 0 TABLET,ORAL ONLY,EXT.REL. HR 0, 0, 40 OXYCONTIN ORAL QL (60 per 0 TABLET,ORAL ONLY,EXT.REL. HR 5, 0, 60 OXYCONTIN ORAL QL (0 per 0 TABLET,ORAL ONLY,EXT.REL. HR 80 oxymorphone oral tablet 0 mg (Opana) QL (0 per 0 oxymorphone oral tablet 5 mg (Opana) QL (80 per 0 oxymorphone oral tablet extended release QL (60 per 0 hr 0 mg, 5 mg, 0 mg, 0 mg, 40 mg, 5 mg, 7.5 mg pentazocine-naloxone oral tablet QL (60 per 0 mg PERCOCET ORAL TABLET 0-5 QL (40 per 0

20 PERCOCET ORAL TABLET.5-5 QL (60 per 0, 5-5 PERCOCET ORAL TABLET QL (00 per 0 PRIALT INTRATHECAL SOLUTION 00 MCG/ML, 5 MCG/ML PRIMLEV ORAL TABLET 0-00 QL (40 per 0 PRIMLEV ORAL TABLET 5-00 QL (90 per 0 PRIMLEV ORAL TABLET QL (00 per 0 reprexain oral tablet 0-00 mg,.5-00 QL (50 per 0 mg, 5-00 mg ROXICODONE ORAL TABLET 5 QL (0 per 0, 0 ROXICODONE ORAL TABLET 5 QL (80 per 0 SUBSYS SUBLINGUAL SPRAY,NON-AEROSOL,00 MCG PA; QL (0 per 0 (600 MCG/SPRAY X ),,600 MCG (800 MCG/SPRAY X ), 00 MCG/SPRAY, 00 MCG/SPRAY, 400 MCG/SPRAY, 600 MCG/SPRAY, 800 MCG/SPRAY SYNALGOS-DC ORAL CAPSULE QL (60 per TALWIN INJECTION SOLUTION 0 /ML tencon oral tablet 50-5 mg QL (80 per 0 tramadol hcl er 00 mg tablet 00 mg QL (0 per 0 tramadol oral capsule,er biphase 4 hr (ConZip) QL (0 per mg tramadol oral capsule,er biphase 4 hr (ConZip) QL (0 per mg, 00 mg tramadol oral capsule,er biphase 4 hr QL (0 per mg tramadol oral tablet 50 mg (Ultram) QL (40 per 0 tramadol oral tablet extended release 4 hr 00 mg QL (90 per 0

21 tramadol oral tablet extended release 4 QL (0 per 0 hr 00 mg tramadol oral tablet, er multiphase 4 hr QL (0 per 0 00 mg tramadol-acetaminophen oral tablet 7.5- (Ultracet) QL (40 per 0 5 mg TREZIX ORAL CAPSULE QL (00 per 0 6 TYLENOL-CODEINE # ORAL QL (60 per 0 TABLET 00-0 TYLENOL-CODEINE #4 ORAL QL (80 per 0 TABLET ULTRACET ORAL TABLET QL (40 per 0 ULTRAM ER ORAL TABLET QL (90 per 0 EXTENDED RELEASE 4 HR 00 ULTRAM ER ORAL TABLET QL (0 per 0 EXTENDED RELEASE 4 HR 00, 00 ULTRAM ORAL TABLET 50 QL (40 per 0 VANATOL LQ ORAL SOLUTION /5 ML VERDROCET ORAL TABLET.5- QL (60 per 0 5 vicodin es oral tablet mg QL (90 per 0 vicodin hp oral tablet 0-00 mg QL (90 per 0 vicodin oral tablet 5-00 mg QL (90 per 0 VICOPROFEN ORAL TABLET 7.5- QL (50 per 0 00 XARTEMIS XR ORAL TAB,ORAL QL (00 per 0 ONLY,IR - ER, BIPHASE XODOL 0/00 ORAL TABLET 0- QL (90 per 0 00 XODOL 5/00 ORAL TABLET 5-00 QL (90 per 0 XODOL 7.5/00 ORAL TABLET 7.5- QL (90 per 0 00 XTAMPZA ER ORAL CAPSULE,SPRINKLE,ER HR TMPRR.5, 8, 9 QL (60 per 0

22 XTAMPZA ER ORAL QL (0 per 0 CAPSULE,SPRINKLE,ER HR TMPRR 7 XTAMPZA ER ORAL QL (40 per 0 CAPSULE,SPRINKLE,ER HR TMPRR 6 xylon 0 oral tablet 0-00 mg QL (50 per 0 ZAMICET ORAL SOLUTION 0-5 QL (700 per 0 /5 ML zebutal oral capsule mg QL (80 per 0 ZOHYDRO ER ORAL CAPSULE, QL (60 per 0 ORAL ONLY, ER HR 0, 5, 0, 0, 40, 50 Nonsteroidal Anti-Inflammatory Agents ANAPROX DS ORAL TABLET 550 ARTHROTEC 50 ORAL TABLET,IR,DELAYED REL,BIPHASIC MCG ARTHROTEC 75 ORAL TABLET,IR,DELAYED REL,BIPHASIC MCG CAMBIA ORAL POWDER IN PACKET 50 CELEBREX ORAL CAPSULE 00 QL (60 per 0, 00, 400, 50 celecoxib oral capsule 00 mg, 00 mg, (Celebrex) QL (60 per mg, 50 mg choline,magnesium salicylate oral liquid 500 mg/5 ml DAYPRO ORAL TABLET 600 diclofenac potassium oral tablet 50 mg diclofenac sodium oral tablet extended (Voltaren-XR) release 4 hr 00 mg diclofenac sodium oral tablet,delayed release (dr/ec) 5 mg, 50 mg, 75 mg diclofenac sodium topical drops.5 % diclofenac sodium topical gel % (Voltaren) diclofenac-misoprostol oral tablet,ir,delayed rel,biphasic mgmcg (Arthrotec 50) 4

23 diclofenac-misoprostol oral (Arthrotec 75) tablet,ir,delayed rel,biphasic mgmcg diflunisal oral tablet 500 mg DUEXIS ORAL TABLET QL (90 per 0 EC-NAPROSYN ORAL TABLET,DELAYED RELEASE (DR/EC) 75, 500 etodolac oral capsule 00 mg, 00 mg etodolac oral tablet 400 mg (Lodine) etodolac oral tablet 500 mg etodolac oral tablet extended release 4 hr 400 mg, 500 mg, 600 mg FELDENE ORAL CAPSULE 0, 0 fenoprofen oral capsule 00 mg, 400 mg (Fenortho) fenoprofen oral tablet 600 mg FLECTOR TRANSDERMAL PA PATCH HOUR. % flurbiprofen oral tablet 00 mg, 50 mg ibuprofen oral suspension 00 mg/5 ml (Children's Profen IB) ibuprofen oral tablet 400 mg, 600 mg, 800 mg INDOCIN ORAL SUSPENSION 5 /5 ML INDOCIN RECTAL SUPPOSITORY 50 indomethacin oral capsule 5 mg QL (40 per 0 indomethacin oral capsule 50 mg QL (0 per 0 indomethacin oral capsule, extended QL (60 per 0 release 75 mg ketoprofen oral capsule 50 mg, 75 mg ketoprofen oral capsule,ext rel. pellets 4 hr 00 mg ketorolac injection cartridge 5 mg/ml QL (40 per 0 ketorolac injection cartridge 0 mg/ml QL (0 per 0 ketorolac injection solution 5 mg/ml QL (40 per 0 ketorolac injection solution 0 mg/ml ( ml) QL (0 per 0 5

24 ketorolac injection syringe 0 mg/ml QL (0 per 0 ketorolac intramuscular solution 60 mg/ QL (0 per 0 ml ketorolac oral tablet 0 mg QL (0 per 0 LODINE ORAL TABLET 400 meclofenamate oral capsule 00 mg, 50 mg mefenamic acid oral capsule 50 mg (Ponstel) meloxicam oral suspension 7.5 mg/5 ml meloxicam oral tablet 5 mg, 7.5 mg (Mobic) MOBIC ORAL SUSPENSION 7.5 /5 ML MOBIC ORAL TABLET 5, 7.5 nabumetone oral tablet 500 mg, 750 mg NALFON ORAL CAPSULE 400 NAPRELAN CR ORAL TABLET, ER MULTIPHASE 4 HR 75, 500 NAPRELAN CR ORAL TABLET, ER MULTIPHASE 4 HR 750 NAPROSYN ORAL SUSPENSION 5 /5 ML NAPROSYN ORAL TABLET 500 naproxen oral suspension 5 mg/5 ml (Naprosyn) naproxen oral tablet 50 mg, 75 mg naproxen oral tablet 500 mg (Naprosyn) naproxen oral tablet,delayed release (EC-Naprosyn) (dr/ec) 75 mg, 500 mg naproxen sodium oral tablet 75 mg naproxen sodium oral tablet 550 mg (Anaprox DS) naproxen sodium oral tablet, er (Naprelan CR) multiphase 4 hr 75 mg, 500 mg oxaprozin oral tablet 600 mg (Daypro) PENNSAID TOPICAL SOLUTION IN METERED-DOSE PUMP 0 /GRAM /ACTUATION( %) piroxicam oral capsule 0 mg, 0 mg (Feldene) PONSTEL ORAL CAPSULE 50 6

25 SPRIX NASAL SPRAY,NON- QL (5 per 0 AEROSOL 5.75 /SPRAY sulindac oral tablet 50 mg, 00 mg TIVORBEX ORAL CAPSULE 0 QL (90 per 0, 40 tolmetin oral capsule 400 mg tolmetin oral tablet 00 mg, 600 mg VIMOVO ORAL TABLET,IR,DELAYED REL,BIPHASIC 75-0, VIVLODEX ORAL CAPSULE 0, 5 VOLTAREN TOPICAL GEL % VOLTAREN-XR ORAL TABLET EXTENDED RELEASE 4 HR 00 ZIPSOR ORAL CAPSULE 5 ZORVOLEX ORAL CAPSULE 8, 5 Anesthetics Local Anesthetics cocaine topical solution 4 % EMLA TOPICAL CREAM.5-.5 % glydo mucous membrane jelly in applicator % lidocaine (pf) injection solution 5 mg/ml (Xylocaine-MPF) (.5 %), 0 mg/ml ( %), 5 mg/ml (0.5 %) lidocaine (pf) injection solution 40 mg/ml (4 %) lidocaine hcl injection solution 0 mg/ml (Xylocaine) ( %), 0 mg/ml ( %), 5 mg/ml (0.5 %) lidocaine hcl mucous membrane jelly % lidocaine hcl mucous membrane solution 4 % (40 mg/ml) lidocaine topical adhesive (Lidoderm) PA patch,medicated 5 % lidocaine topical ointment 5 % PA BvD lidocaine viscous mucous membrane solution % 7

26 lidocaine-prilocaine topical cream.5-.5 % lidocaine-tetracaine topical cream 7-7 % (Pliaglis) LIDODERM TOPICAL ADHESIVE PA PATCH,MEDICATED 5 % PLIAGLIS TOPICAL CREAM 7-7 % PONTOCAINE TOPICAL SOLUTION % SYNERA TOPICAL PATCH, MEDICATED SELF-HEATING XYLOCAINE INJECTION SOLUTION 0 /ML ( %) XYLOCAINE INJECTION SOLUTION 5 /ML (0.5 %) XYLOCAINE-MPF INJECTION SOLUTION 0 /ML ( %) XYLOCAINE-MPF INJECTION SOLUTION 5 /ML (.5 %) xylocaine-mpf injection solution 5 mg/ml (0.5 %) Anti-Addiction/Substance Abuse Treatment Agents Anti-Addiction/Substance Abuse Treatment Agents acamprosate oral tablet,delayed release (dr/ec) mg ANTABUSE ORAL TABLET 50, 500 BUNAVAIL BUCCAL FILM.-0. PA; QL (90 per 0 BUNAVAIL BUCCAL FILM , 6.- PA; QL (60 per 0 buprenorphine hcl sublingual tablet mg, 8 mg PA; QL (90 per 0 buprenorphine-naloxone sublingual tablet -0.5 mg, 8- mg PA; QL (90 per 0 buproban oral tablet extended release hr 50 mg bupropion hcl (smoking deter) oral tablet (Zyban) extended release hr 50 mg 8

27 CHANTIX CONTINUING MONTH QL (68 per 84 BOX ORAL TABLET CHANTIX ORAL TABLET 0.5, QL (68 per 84 CHANTIX STARTING MONTH BOX ORAL TABLETS,DOSE PACK 0.5 ()- (4) QL (5 per 8 disulfiram oral tablet 50 mg, 500 mg (Antabuse) EVZIO INJECTION AUTO- INJECTOR 0.4 /0.4 ML, /0.4 ML naloxone injection solution 0.4 mg/ml naloxone injection syringe 0.4 mg/ml, mg/ml naltrexone oral tablet 50 mg (Revia) NARCAN NASAL SPRAY,NON- QL (4 per 0 AEROSOL /ACTUATION, 4 /ACTUATION NICOTROL INHALATION QL (008 per 90 CARTRIDGE 0 NICOTROL NS NASAL QL (40 per 80 SPRAY,NON-AEROSOL 0 /ML REVIA ORAL TABLET 50 SUBOXONE SUBLINGUAL FILM - PA; QL (60 per 0 SUBOXONE SUBLINGUAL FILM - 0.5, 4-, 8- PA; QL (90 per 0 VIVITROL INTRAMUSCULAR SUSPENSION,EXTENDED REL RECON 80 ZUBSOLV SUBLINGUAL TABLET ,.4-0.6,.4-.9 PA; QL (90 per 0,.9-0.7, , ZYBAN ORAL TABLET EXTENDED RELEASE HR 50 Antianxiety Agents Benzodiazepines ALPRAZOLAM INTENSOL ORAL CONCENTRATE /ML QL (00 per 0 9

28 alprazolam oral tablet 0.5 mg, 0.5 mg, (Xanax) QL (50 per 0 mg, mg alprazolam oral tablet extended release (Xanax XR) QL (0 per 0 4 hr 0.5 mg, mg, mg alprazolam oral tablet extended release (Xanax XR) QL (90 per 0 4 hr mg alprazolam oral tablet,disintegrating 0.5 QL (50 per 0 mg, 0.5 mg, mg, mg ATIVAN INJECTION SOLUTION QL ( per 0 /ML, 4 /ML ATIVAN ORAL TABLET 0.5, QL (50 per 0, chlordiazepoxide hcl oral capsule 0 mg, QL (0 per 0 5 mg, 5 mg clonazepam oral tablet 0.5 mg, mg (Klonopin) QL (90 per 0 clonazepam oral tablet mg (Klonopin) QL (00 per 0 clonazepam oral tablet,disintegrating QL (90 per mg, 0.5 mg, 0.5 mg, mg clonazepam oral tablet,disintegrating QL (00 per 0 mg clorazepate dipotassium oral tablet 5 QL (80 per 0 mg,.75 mg clorazepate dipotassium oral tablet 7.5 (Tranxene T-Tab) QL (80 per 0 mg DIASTAT ACUDIAL RECTAL KIT , DIASTAT RECTAL KIT.5 diazepam injection solution 5 mg/ml QL (0 per 8 diazepam intensol oral concentrate 5 QL (00 per 0 mg/ml diazepam oral solution 5 mg/5 ml ( QL (00 per 0 mg/ml) diazepam oral tablet 0 mg, mg, 5 mg (Valium) QL (0 per 0 diazepam rectal kit mg, (Diastat AcuDial) mg diazepam rectal kit.5 mg (Diastat) DORAL ORAL TABLET 5 estazolam oral tablet mg PA NSO; QL (60 per 0 ; AGE (Max 64 Years) 0

29 estazolam oral tablet mg PA NSO; QL (0 per 0 ; AGE (Max 64 Years) flurazepam oral capsule 5 mg PA NSO; QL (60 per 0 ; AGE (Max 64 Years) flurazepam oral capsule 0 mg PA NSO; QL (0 per 0 ; AGE (Max 64 Years) HALCION ORAL TABLET 0.5 PA NSO; QL (60 per 0 ; AGE (Max 64 Years) KLONOPIN ORAL TABLET 0.5, QL (90 per 0 KLONOPIN ORAL TABLET QL (00 per 0 lorazepam mg/ml oral concent mg/ml (Lorazepam Intensol) QL (50 per 0 lorazepam injection solution mg/ml (Ativan) QL ( per 0 lorazepam injection syringe mg/ml, 4 QL ( per 0 mg/ml lorazepam intensol oral concentrate QL (50 per 0 mg/ml lorazepam oral tablet 0.5 mg, mg, mg (Ativan) QL (50 per 0 midazolam (pf) injection syringe mg/ QL ( per 0 ml ( mg/ml) midazolam injection solution mg/ml, 5 QL ( per 0 mg/ml midazolam oral syrup mg/ml QL (0 per 0 ONFI ORAL SUSPENSION.5 QL (480 per 0 /ML ONFI ORAL TABLET 0, 0 QL (60 per 0 oxazepam oral capsule 0 mg, 5 mg, 0 QL (0 per 0 mg quazepam oral tablet 5 mg (Doral) RESTORIL ORAL CAPSULE 5,.5, 0 PA NSO; QL (0 per 0 ; AGE (Max 64 Years) RESTORIL ORAL CAPSULE 7.5 PA NSO; QL (0 per 0 ; AGE (Max 64 Years)

30 temazepam oral capsule 5 mg,.5 mg, 0 mg (Restoril) PA NSO; QL (0 per 0 ; AGE (Max 64 Years) temazepam oral capsule 7.5 mg (Restoril) PA NSO; QL (0 per 0 ; AGE (Max 64 Years) TRANXENE T-TAB ORAL TABLET.75, 7.5 triazolam oral tablet 0.5 mg PA NSO; QL (0 per 0 ; AGE (Max 64 Years) triazolam oral tablet 0.5 mg (Halcion) PA NSO; QL (60 per 0 ; AGE (Max 64 Years) VALIUM ORAL TABLET 0, QL (0 per 0, 5 XANAX ORAL TABLET 0.5, QL (50 per 0 0.5,, XANAX XR ORAL TABLET QL (0 per 0 EXTENDED RELEASE 4 HR 0.5,, XANAX XR ORAL TABLET QL (90 per 0 EXTENDED RELEASE 4 HR Antibacterials Aminoglycosides amikacin injection solution,000 mg/4 ml, 500 mg/ ml BETHKIS INHALATION PA BvD SOLUTION FOR NEBULIZATION 00 /4 ML gentamicin in nacl (iso-osm) intravenous piggyback 00 mg/00 ml, 00 mg/50 ml, 60 mg/50 ml, 70 mg/50 ml, 80 mg/00 ml, 80 mg/50 ml, 90 mg/00 ml gentamicin injection solution 40 mg/ml PA BvD gentamicin ped 0 mg/ ml vial latexfree, PA BvD sdv 0 mg/ ml gentamicin sulfate (pf) intravenous PA BvD solution 00 mg/0 ml neomycin oral tablet 500 mg

31 streptomycin intramuscular recon soln gram TOBI INHALATION SOLUTION PA BvD FOR NEBULIZATION 00 /5 ML TOBI PODHALER INHALATION CAPSULE, W/INHALATION PA; QL (4 per 8 DEVICE 8 tobramycin in 0.5 % nacl inhalation (Tobi) PA BvD solution for nebulization 00 mg/5 ml tobramycin in 0.9 % nacl intravenous piggyback 60 mg/50 ml tobramycin sulfate injection solution 0 PA BvD mg/ml, 40 mg/ml Antibacterials, Miscellaneous baciim intramuscular recon soln 50,000 PA BvD unit bacitracin intramuscular recon soln (BACiiM) 50,000 unit chloramphenicol sod succinate PA BvD intravenous recon soln gram CLEOCIN HCL ORAL CAPSULE 50, 00, 75 CLEOCIN IN 5 % DEXTROSE PA BvD INTRAVENOUS PIGGYBACK 00 /50 ML, 600 /50 ML CLEOCIN IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK 900 /50 ML CLEOCIN INJECTION SOLUTION 50 /ML CLEOCIN INTRAVENOUS PA BvD SOLUTION 00 / ML CLEOCIN INTRAVENOUS SOLUTION 600 /4 ML CLEOCIN PEDIATRIC ORAL RECON SOLN 75 /5 ML CLEOCIN PHOS 50 /ML VIAL 900 /6 ML clindamycin 75 mg/5 ml soln 75 mg/5 ml (Cleocin Pediatric) clindamycin hcl oral capsule 50 mg, 00 mg, 75 mg (Cleocin HCl)

32 clindamycin in 5 % dextrose intravenous piggyback 00 mg/50 ml, 600 mg/50 ml, 900 mg/50 ml clindamycin pediatric oral recon soln 75 mg/5 ml clindamycin phosphate injection solution 50 (mg/ml) (6 ml) clindamycin phosphate injection solution 50 mg/ml clindamycin phosphate intravenous solution 600 mg/4 ml colistin (colistimethate na) injection recon soln 50 mg COLY-MYCIN M PARENTERAL INJECTION RECON SOLN 50 CUBICIN INTRAVENOUS RECON SOLN 500 DALVANCE INTRAVENOUS SOLUTION 500 daptomycin intravenous recon soln 500 mg FLAGYL ER ORAL TABLET EXTENDED RELEASE 750 (Cleocin in 5 % dextrose) PA BvD (Cleocin) PA BvD (Cleocin) PA BvD (Coly-Mycin M Parenteral) PA BvD PA BvD PA BvD PA BvD (Cubicin) PA BvD FLAGYL ORAL CAPSULE 75 FLAGYL ORAL TABLET 50, 500 FURADANTIN ORAL QL (400 per 0 SUSPENSION 5 /5 ML HIPREX ORAL TABLET GRAM LINCOCIN INJECTION SOLUTION 00 /ML lincomycin injection solution 00 mg/ml (Lincocin) PA BvD linezolid intravenous parenteral solution (Zyvox) PA BvD 600 mg/00 ml linezolid oral suspension for (Zyvox) reconstitution 00 mg/5 ml linezolid oral tablet 600 mg (Zyvox) MACROBID ORAL CAPSULE 00 QL (0 per 0 MACRODANTIN ORAL CAPSULE 00, 5, 50 QL (0 per 0 4

33 methenamine hippurate oral tablet (Hiprex) gram metronidazole in nacl (iso-os) (Metro I.V.) PA BvD intravenous piggyback 500 mg/00 ml metronidazole oral capsule 75 mg (Flagyl) metronidazole oral tablet 50 mg, 500 mg (Flagyl) MONUROL ORAL PACKET GRAM moxifloxacin-sod.ace,sul-water intravenous piggyback 400 mg/50 ml nitrofurantoin macrocrystal oral capsule (Macrodantin) QL (0 per 0 00 mg, 5 mg, 50 mg nitrofurantoin monohyd/m-cryst oral capsule 00 mg (Macrobid) QL (0 per 0 nitrofurantoin oral suspension 5 mg/5 ml (Furadantin) QL (400 per 0 ORBACTIV INTRAVENOUS RECON SOLN 400 polymyxin b sulfate injection recon soln 500,000 unit PRIMSOL ORAL SOLUTION 50 /5 ML SIVEXTRO INTRAVENOUS RECON SOLN 00 SIVEXTRO ORAL TABLET 00 SYNERCID INTRAVENOUS PA BvD RECON SOLN 500 trimethoprim oral tablet 00 mg VANCOCIN ORAL CAPSULE 5, 50 vancomycin hcl g/00 ml bag PA BvD gram/00 ml vancomycin in 0.9% sodium cl PA BvD intravenous solution.5 gram/500 ml vancomycin intravenous recon soln,000 PA BvD mg, 0 gram, 750 mg vancomycin intravenous recon soln 500 mg PA BvD vancomycin oral capsule 5 mg, 50 mg (Vancocin) VIBATIV INTRAVENOUS RECON PA BvD SOLN 50, 750 XIFAXAN ORAL TABLET 00 PA; QL (9 per 0 5

34 XIFAXAN ORAL TABLET 550 PA ZYVOX INTRAVENOUS PA BvD PARENTERAL SOLUTION 00 /00 ML, 600 /00 ML ZYVOX ORAL SUSPENSION FOR RECONSTITUTION 00 /5 ML ZYVOX ORAL TABLET 600 Cephalosporins AVYCAZ INTRAVENOUS RECON SOLN.5 GRAM CEDAX ORAL CAPSULE 400 CEDAX ORAL SUSPENSION FOR RECONSTITUTION 80 /5 ML cefaclor oral capsule 50 mg, 500 mg cefaclor oral suspension for reconstitution 5 mg/5 ml, 50 mg/5 ml, 75 mg/5 ml 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 in dextrose (iso-os) intravenous PA BvD piggyback gram/50 ml, gram/50 ml cefazolin injection recon soln gram, 0 PA BvD gram, 500 mg cefdinir oral capsule 00 mg cefdinir oral suspension for reconstitution 5 mg/5 ml, 50 mg/5 ml cefditoren pivoxil oral tablet 00 mg cefditoren pivoxil oral tablet 400 mg (Spectracef) cefepime injection recon soln gram, (Maxipime) gram cefixime oral suspension for (Suprax) reconstitution 00 mg/5 ml, 00 mg/5 ml CEFOTAN INJECTION RECON SOLN GRAM, GRAM cefotaxime injection recon soln gram, (Claforan) 0 gram, gram cefotaxime injection recon soln 500 mg 6

35 cefotetan injection recon soln gram, (Cefotan) gram cefotetan intravenous recon soln 0 gram cefotetan-dextr g duplex bag gram/50 ml cefotetan-dextr g duplex bag gram/50 ml cefoxitin gm piggyback bag gram/50 PA BvD ml cefoxitin gm vial l/f, outer, sdv gram PA BvD cefoxitin intravenous recon soln gram, PA BvD 0 gram cefoxitin intravenous recon soln gram PA BvD 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 IN D5W INTRAVENOUS PIGGYBACK GRAM/50 ML, GRAM/50 ML ceftazidime injection recon soln gram (TAZICEF) ceftazidime injection recon soln gram (Fortaz) ceftazidime injection recon soln 6 gram (TAZICEF) ceftibuten oral capsule 400 mg (Cedax) ceftibuten oral suspension for (Cedax) reconstitution 80 mg/5 ml CEFTIN ORAL SUSPENSION FOR RECONSTITUTION 5 /5 ML, 50 /5 ML CEFTIN ORAL TABLET 50, 500 ceftriaxone gm piggyback l/g, single use gram/50 ml ceftriaxone gm piggyback l/f, single use PA BvD gram/50 ml ceftriaxone injection recon soln gram, PA BvD 50 mg, 500 mg ceftriaxone injection recon soln 0 gram 7

36 ceftriaxone intravenous recon soln gram ceftriaxone intravenous recon soln PA BvD gram cefuroxime axetil oral tablet 50 mg, 500 mg cefuroxime sodium injection recon soln (Zinacef) PA BvD 750 mg cefuroxime sodium intravenous recon soln (Zinacef) PA BvD.5 gram, 7.5 gram cephalexin oral capsule 50 mg, 500 mg, (Keflex) 750 mg cephalexin oral suspension for reconstitution 5 mg/5 ml, 50 mg/5 ml cephalexin oral tablet 50 mg, 500 mg CLAFORAN IN DEXTROSE(ISO- OSM) INTRAVENOUS PIGGYBACK GRAM/50 ML, GRAM/50 ML CLAFORAN INJECTION RECON SOLN GRAM, 0 GRAM, GRAM CLAFORAN INTRAVENOUS RECON SOLN GRAM DAXBIA ORAL CAPSULE FORTAZ GM VIAL GRAM FORTAZ INJECTION RECON SOLN 500 FORTAZ INJECTION RECON SOLN 6 GRAM FORTAZ INTRAVENOUS RECON SOLN GRAM KEFLEX ORAL CAPSULE 50, 500, 750 MAXIPIME GM ADD-VANTAGE VL OUTER, LATEX-FREE GRAM MAXIPIME GM ADD-VANTAGE VL OUTER, LATEX-FREE GRAM MAXIPIME INJECTION RECON SOLN GRAM, GRAM 8

37 MEFOXIN IN DEXTROSE (ISO- PA BvD OSM) INTRAVENOUS PIGGYBACK GRAM/50 ML, GRAM/50 ML SPECTRACEF ORAL TABLET 400 SUPRAX ORAL CAPSULE 400 SUPRAX ORAL SUSPENSION FOR RECONSTITUTION 00 /5 ML, 00 /5 ML SUPRAX ORAL SUSPENSION FOR RECONSTITUTION 500 /5 ML SUPRAX ORAL TABLET,CHEWABLE 00, 00 tazicef injection recon soln gram, gram, 6 gram TEFLARO INTRAVENOUS RECON PA BvD SOLN 400, 600 ZERBAXA INTRAVENOUS RECON SOLN.5 GRAM ZINACEF INJECTION RECON PA BvD SOLN 750 ZINACEF INTRAVENOUS RECON PA BvD SOLN.5 GRAM ZINACEF INTRAVENOUS RECON SOLN 7.5 GRAM Macrolides azithromycin intravenous recon soln 500 (Zithromax) mg azithromycin oral packet gram (Zithromax) azithromycin oral suspension for (Zithromax) reconstitution 00 mg/5 ml, 00 mg/5 ml azithromycin oral tablet 50 mg (6 pack), 500 mg ( pack) azithromycin oral tablet 50 mg, 500 mg, (Zithromax) 600 mg BIAXIN ORAL SUSPENSION FOR RECONSTITUTION 50 /5 ML BIAXIN ORAL TABLET 50, 500 9

38 clarithromycin oral suspension for reconstitution 5 mg/5 ml, 50 mg/5 ml clarithromycin oral tablet 50 mg clarithromycin oral tablet 500 mg (Biaxin) clarithromycin oral tablet extended release 4 hr 500 mg DIFICID ORAL TABLET 00 ST; QL (0 per 0 e.e.s. 400 oral tablet 400 mg e.e.s. granules oral suspension for reconstitution 00 mg/5 ml ERYPED 00 ORAL SUSPENSION FOR RECONSTITUTION 00 /5 ML ERYPED 400 ORAL SUSPENSION FOR RECONSTITUTION 400 /5 ML ery-tab oral tablet,delayed release (dr/ec) 50 mg, 500 mg ERY-TAB ORAL TABLET,DELAYED RELEASE (DR/EC) erythrocin (as stearate) oral tablet 50 mg ERYTHROCIN INTRAVENOUS RECON SOLN,000, 500 PA BvD erythromycin ethylsuccinate oral (EryPed 00) suspension for reconstitution 00 mg/5 ml erythromycin ethylsuccinate oral tablet (E.E.S. 400) 400 mg erythromycin oral capsule,delayed release(dr/ec) 50 mg erythromycin oral tablet 50 mg, 500 mg KETEK ORAL TABLET 00, 400 PA PCE ORAL TABLET, PARTICLES/CRYSTALS, 500 ZITHROMAX INTRAVENOUS RECON SOLN 500 ZITHROMAX ORAL PACKET GRAM 0

39 ZITHROMAX ORAL SUSPENSION FOR RECONSTITUTION 00 /5 ML, 00 /5 ML ZITHROMAX ORAL TABLET 50, 500, 600 ZITHROMAX TRI-PAK ORAL TABLET 500 ZITHROMAX Z-PAK ORAL TABLET 50 ZMAX ORAL SUSPENSION,EXTENDED REL RECON GRAM/60 ML Miscellaneous B-Lactam Antibiotics AZACTAM GM VIAL 5ML, SDV GRAM AZACTAM IN DEXTROSE (ISO- OSM) INTRAVENOUS PIGGYBACK GRAM/50 ML AZACTAM IN DEXTROSE (ISO- OSM) INTRAVENOUS PIGGYBACK GRAM/50 ML AZACTAM-ISO-OSMOT GM/50 ML 4'S,SINGLE USE GRAM/50 ML aztreonam injection recon soln gram, gram CAYSTON INHALATION SOLUTION FOR NEBULIZATION 75 /ML DORIBAX INTRAVENOUS RECON SOLN 50, 500 doripenem intravenous recon soln 50 mg, 500 mg imipenem-cilastatin intravenous recon soln 50 mg, 500 mg INVANZ INJECTION RECON SOLN GRAM meropenem intravenous recon soln gram, 500 mg MERREM INTRAVENOUS RECON SOLN GRAM, 500 (Azactam) PA BvD PA BvD PA PA BvD (Doribax) PA BvD (Primaxin IV) PA BvD PA BvD (Merrem) PA BvD PA BvD

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