2016 LIST OF COVERED DRUGS (FORMULARY) VNSNY CHOICE FIDA Complete (Medicare-Medicaid Plan) TTY: 711

Transcription

1 2016 LIST OF COVERED DRUGS (FORMULARY) VNSNY CHOICE FIDA Complete (Medicare-Medicaid Plan) Formulary ID: , Version: 15 Effective: July 01, 2016 Call CHOICE toll-free: TTY: am - 8 pm, 7 days a week 1250 Broadway, New York, NY vnsnychoice.org H8490_2016 Formulary_16702_E CMS Approved

2 VNSNY CHOICE FIDA Complete 2016 List of Covered Drugs (Formulary) This is a list of drugs that Participants can get in VNSNY CHOICE FIDA Complete. VNSNY CHOICE FIDA Complete is a managed care plan that contracts with both Medicare and the New York State Department of Health (Medicaid) to provide benefits of both programs to Participants through the Fully Integrated Duals Advantage (FIDA) Demonstration. The List of Covered Drugs, and/or pharmacy and provider networks may change throughout the year. We will send you a notice before we make a change that affects you. Benefits may change on January 1 of each year. You can always check VNSNY CHOICE FIDA Complete s up-to-date List of Covered Drugs online at vnsnychoice.org or by calling VNSNY CHOICE FIDA Complete Participant Services at Limitations and restrictions may apply. For more information, call VNSNY CHOICE FIDA Complete Participant Services or read the VNSNY CHOICE FIDA Complete Participant Handbook. There are no copays for any covered drugs. You can get this information for free in other formats, such as large print braille, or audio. Call and TTY is 711 during 8 AM 8 PM, 7 days a week. The call is free. You can get this information for free in other languages. Call and TTY is 711 during 8 AM 8 PM, 7 days a week. The call is free. Puede obtener esta información gratis en otros idiomas. Llame al y (TTY es 711) de 8 a.m. a 8 p.m., 7 días a la semana. La llamada es gratis (TTY 711) If you have questions, please call VNSNY CHOICE FIDA Complete at , 7 days a week from 8 AM - 8PM (TTY is 711). The call is free. For more information, visit vnsnychoice.org I

3 (TTY 711 ).. Вы можете получить эту информацию бесплатно и на других языках. Звоните по телефону (телетайп: 711) ежедневно с 8:00 до 20:00. Звонок бесплатный. Ou kapab jwenn enfòmasyon sa a pou gratis nan lòt lang. Rele ak (TTY se 711) ant 8 di maten jiska 8 di swa, 7 jou pa semèn. Apèl la gratis. È possibile ottenere gratuitamente queste informazioni in altre lingue. Chiamare il numero (il numero TTY è 711) dalle 8:00 alle 20:00, 7 giorni alla settimana. La chiamata è gratuita. The State of New York has created a participant ombudsman program called the Independent Consumer Advocacy Network (ICAN) to provide Participants free, confidential assistance on any services offered by VNSNY CHOICE FIDA Complete. ICAN may be reached toll-free at or online at icannys.org. If you have questions, please call VNSNY CHOICE FIDA Complete at , 7 days a week from 8 AM - 8PM (TTY is 711). The call is free. For more information, visit vnsnychoice.org II

4 Frequently Asked Questions (FAQ) Find answers here to questions you have about this List of Covered Drugs. You can read all of the FAQ to learn more, or look for a question and answer. 1. What prescription drugs are on the List of Covered Drugs? (We call the List of Covered Drugs the Drug List for short.) The drugs on the List of Covered Drugs that starts on page 12 are the drugs covered by VNSNY CHOICE FIDA Complete. These drugs are available at pharmacies within our network. A pharmacy is in our network if we have an agreement with them to work with us and provide you services. We refer to these pharmacies as network pharmacies. VNSNY CHOICE FIDA Complete will cover all drugs on the Drug List if: your doctor or other network prescriber says you need them to get better or stay healthy, the drug is medically necessary for your condition, and you fill the prescription at a VNSNY CHOICE FIDA Complete network pharmacy. VNSNY CHOICE FIDA Complete may have additional steps to access certain drugs (see question #5 below). In some cases, you may have to do something before you can get a drug, like try other drugs first. You can also see an up-to-date list of drugs that we cover on our website at vnsnychoice.org or call Participant Services at Does the Drug List ever change? Yes. VNSNY CHOICE FIDA Complete may add or remove drugs on the Drug List during the year. Generally, the Drug List will only change if: a new drug comes along that works as well as a drug on the Drug List now, or we learn that a drug is not safe. If you have questions, please call VNSNY CHOICE FIDA Complete at , 7 days a week from 8 AM - 8PM (TTY is 711). The call is free. For more information, visit vnsnychoice.org III

5 We may also change our rules about drugs. For example, we could: Decide to require or not require prior approval for a drug. (Prior approval is permission from VNSNY CHOICE FIDA Complete or your Interdisciplinary Team (IDT) before you can get a drug.) Add or change the amount of a drug you can get (called quantity limits ). Add or change step therapy restrictions on a drug. (Step therapy means you must try one drug before we will cover another drug.) (For more information on these drug rules, see page 5.) We will tell you when a drug you are taking is removed from the Drug List. We will also tell you when we change our rules for covering a drug. Questions 3, 4, and 7 below have more information on what happens when the Drug List changes. You can always check VNSNY CHOICE FIDA Complete s up to date Drug List online at vnsnychoice.org You can also call Participant Services to check the current Drug List at What happens when a cheaper drug comes along that works as well as a drug on the Drug List now? If a cheaper drug becomes available that works as well as a drug on the Drug List now: Your pharmacist may give you the cheaper drug the next time you fill your prescription. If you and your provider decide that the cheaper drug is not right for you, your provider can tell the pharmacist to continue to give you the drug you take now. VNSNY CHOICE FIDA Complete may decide to take the more expensive drug off of the Drug List. If you are taking a drug that we remove from the Drug List because a cheaper drug that works just as well comes along, we will tell you at least 60 days before we remove it from the Drug List or when you ask for a refill. Then you can get a 60-day supply of the drug before the change to the Drug List is made. If there is a change to coverage for a drug you are taking, the plan will send you a notice normally 60 days in advance to tell you. If you have questions, please call VNSNY CHOICE FIDA Complete at , 7 days a week from 8 AM - 8PM (TTY is 711). The call is free. For more information, visit vnsnychoice.org IV

6 4. What happens when we find out a drug is not safe? If the Food and Drug Administration (FDA) says a drug you are taking is not safe, we will take it off the Drug List right away. We will also send you a letter and call you to tell you that the unsafe drug was taken off the Drug List. Your provider will also know about this change, and can work with you to find another drug for your condition. 5. Are there any restrictions or limits on drug coverage? Or are there any required actions to take in order to get certain drugs? Yes, some drugs have coverage rules or have limits on the amount you can get. In some cases you must do something before you can get the drug. For example: Prior approval (or prior authorization): For some drugs, you or your doctor or other prescriber must get approval from VNSNY CHOICE FIDA Complete or your Interdisciplinary Team (IDT) before you fill your prescription. If you don t get approval, VNSNY CHOICE FIDA Complete may not cover the drug. Quantity limits: Sometimes VNSNY CHOICE FIDA Complete limits the amount of a drug you can get. Step therapy: Sometimes VNSNY CHOICE FIDA Complete requires you to do step therapy. This means you will have to try drugs in a certain order for your medical condition. You might have to try one drug before we will cover another drug. If your doctor thinks the first drug doesn t work for you, then we will cover the second. You can find out if your drug has any additional requirements or limits by looking in the tables beginning on page 14.You can also get more information by visiting our web site at vnsnychoice.org. We have posted online documents that explain prior authorization and step therapy restrictions. You may also ask us to send you a copy. You can ask for an exception from these limits. Please see question 11 for more information on exceptions. If you are in a nursing facility or other long-term care facility and need a drug that is not on the Drug List, or if you cannot easily get the drug you need, we can help. We will cover a 31-day emergency supply of the drug you need If you have questions, please call VNSNY CHOICE FIDA Complete at , 7 days a week from 8 AM - 8PM (TTY is 711). The call is free. For more information, visit vnsnychoice.org V

7 (unless you have a prescription for fewer days), whether or not you are a new VNSNY CHOICE FIDA Complete Participant. This will give you time to talk to your doctor or other prescriber. He or she can help you decide if there is a similar drug on the Drug List you can take instead or whether to request an exception. Please see question 11 for more information about exceptions. 6. How will you know if the drug you want has limitations or if there are required actions to take to get the drug? The List of Covered Drugs on page 14 has a column labeled Necessary actions, restrictions, or limits on use. 7. What happens if we change our rules on how we cover some drugs? For example, if we add prior authorization (approval), quantity limits, and/or step therapy restrictions on a drug. We will tell you if we add prior approval, quantity limits, and/or step therapy restrictions on a drug. We will tell you at least 60 days before the restriction is added or when you next ask for a refill. Then, you can get a 60-day supply of the drug before the change to the Drug List is made. This gives you time to talk to your doctor or other prescriber about what to do next. 8. How can you find a drug on the Drug List? There are two ways to find a drug: You can search alphabetically (if you know how to spell the drug), or You can search by medical condition. To search alphabetically, go to the Alphabetical Listing section on page I-1. Then look for the name of your drug in the list. To search by medical condition, find the section labeled List of drugs by medical condition on page 14. The drugs in this section are grouped into categories depending on the type of medical conditions they are used to treat. For example, if If you have questions, please call VNSNY CHOICE FIDA Complete at , 7 days a week from 8 AM - 8PM (TTY is 711). The call is free. For more information, visit vnsnychoice.org VI

8 you have a heart condition, you should look in the category, Cardiovascular Agents. That is where you will find drugs that treat heart conditions. 9. What if the drug you want to take is not on the Drug List? If you don t see your drug on the Drug List, call Participant Services at and ask about it. If you learn that VNSNY CHOICE FIDA Complete will not cover the drug, you can do one of these things: Ask Participant Services for a list of drugs like the one you want to take. Then show the list to your doctor or other prescriber. He or she can prescribe a drug on the Drug List that is like the one you want to take. Or You can ask the plan or your Interdisciplinary Team (IDT) to make an exception to cover your drug. Please see question 11 for more information about exceptions. 10. What if you are a new VNSNY CHOICE FIDA Complete Participant and can t find your drug on the Drug List or have a problem getting your drug? We can help. We must cover up to 90 days of temporary supplies of your drug, as needed, during the first 90 days you are a Participant of VNSNY CHOICE FIDA Complete. This will give you time to talk to your doctor or other prescriber. He or she can help you decide if there is a similar drug on the Drug List you can take instead or whether to request an exception. We will cover up to 90 days of temporary supplies of your drug if: you are taking a drug that is not on our Drug List, or health plan rules do not let you get the amount ordered by your prescriber, or the drug requires prior approval by VNSNY CHOICE FIDA Complete or your Interdisciplinary Team (IDT), or you are taking a drug that is part of a step therapy restriction. If you have questions, please call VNSNY CHOICE FIDA Complete at , 7 days a week from 8 AM - 8PM (TTY is 711). The call is free. For more information, visit vnsnychoice.org VII

9 If you live in a nursing facility or other long-term care facility, you may refill your prescription for as long as 98 days. You may refill the drug multiple times during the 98 days. This gives your prescriber time to change your drugs to ones on the Drug List or ask for an exception. If you experience a change in your level of care, such as you move from a hospital to a home setting, and you need a drug that is not on our formulary or if your ability to get your drugs is limited, but you are past the first 90-days of membership in our plan, we will cover a one-time temporary supply for up to 30-days (or 31-days if you are a long-term care resident) when you go to a network pharmacy. During this period, you should use the plan s exception process if you wish to have continued coverage of the drug after the temporary supply is finished. To ask for a temporary supply of a drug, call Participant Services. 11. Can you ask for an exception to cover your drug? Yes. You can ask VNSNY CHOICE FIDA Complete or your Interdisciplinary Team (IDT) to make an exception to cover a drug that is not on the Drug List. You can also ask VNSNY CHOICE FIDA Complete or your IDT to change the rules on your drug. For example, VNSNY CHOICE FIDA Complete may limit the amount of a drug we will cover. If your drug has a limit, you can ask us or your IDT to change the limit and cover more. Other examples: You can ask us or your IDT to drop step therapy restrictions or prior approval requirements. If you have questions, please call VNSNY CHOICE FIDA Complete at , 7 days a week from 8 AM - 8PM (TTY is 711). The call is free. For more information, visit vnsnychoice.org VIII

10 12. How long does it take to get an exception? First, VNSNY CHOICE FIDA Complete or your Interdisciplinary Team (IDT) must receive a statement from your prescriber supporting your request for an exception. After we receive the statement, you will get a decision on your exception request within 72 hours. If you or your prescriber think your health may be harmed if you have to wait 72 hours for a decision, you can ask for an expedited exception. This is a faster decision. If your prescriber supports your request, you will get a decision within 24 hours of receiving your prescriber s supporting statement. 13. How can you ask for an exception? To ask for an exception, call your Care Manager. Your Care Manager will work with you and your provider to help you ask for an exception. 14. What are generic drugs? Generic drugs are made up of the same ingredients as brand name drugs. They usually cost less than the brand name drug and usually don t have well-known names. Generic drugs are approved by the Food and Drug Administration (FDA). VNSNY CHOICE FIDA Complete covers both brand name drugs and generic drugs. 15. What are OTC drugs? OTC stands for over-the-counter. VNSNY CHOICE FIDA Complete covers some OTC drugs when they are written as prescriptions by your provider. You can read the VNSNY CHOICE FIDA Complete Drug List to see what OTC drugs are covered. If you have questions, please call VNSNY CHOICE FIDA Complete at , 7 days a week from 8 AM - 8PM (TTY is 711). The call is free. For more information, visit vnsnychoice.org IX

11 16. Does VNSNY CHOICE FIDA Complete cover OTC non-drug products? VNSNY CHOICE FIDA Complete covers some OTC non-drug products when they are written as prescriptions by your provider. Examples of non-drug OTC products are alcohol pads. You can read the VNSNY CHOICE FIDA Complete Drug List to see what OTC nondrug products are covered. 17. What is your copay? You will not be charged a copay for drugs on the Drug List. 18. What are drug tiers? Tiers are groups of drugs. Every drug on the plan s Drug List is in one of 4 tiers. There is no cost to you for drugs on any of the tiers. Tier 1 drugs are Generic Drugs. Tier 2 drugs are Brand Name Drugs. Tier 3 drugs are Non-Medicare Rx Drugs. Tier 4 drugs are Non-Medicare OTC Drugs. If you have questions, please call VNSNY CHOICE FIDA Complete at , 7 days a week from 8 AM - 8PM (TTY is 711). The call is free. For more information, visit vnsnychoice.org X

12 List of Covered Drugs The list of covered drugs that begins on the next page gives you information about the drugs covered by VNSNY CHOICE FIDA Complete. If you have trouble finding your drug in the list, turn to the Index that begins on page I-1. The first column of the chart lists the name of the drug. Brand name drugs are capitalized (e.g., ROZEREM) and generic drugs are listed in lower-case italics (e.g., zaleplon). The information in the necessary actions, restrictions, or limits on use column tells you if VNSNY CHOICE FIDA Complete has any rules for covering your drug. Note: The * next to a drug means the drug is not a Part D drug. These drugs have different rules for appeals. An appeal is a formal way of asking for a review of and change to a coverage decision if you think there was a mistake. For example, VNSNY CHOICE FIDA Complete or your Interdisciplinary Team (IDT) might decide that a drug that you want is not covered or is no longer covered by Medicare or Medicaid. If you or your doctor or other prescriber disagrees with the decision, you can appeal. To ask for instructions on how to appeal, call Participant Services at or the Independent Consumer Advocacy Network (ICAN) at You can also read the Participant Handbook to learn how to appeal a decision. If you have questions, please call VNSNY CHOICE FIDA Complete at , 7 days a week from 8 AM - 8PM (TTY is 711). The call is free. For more information, visit vnsnychoice.org XI

13 The following Utilization Management abbreviations may be found within the body of this document COVERAGE NOTES ABBREVIATIONS ABBREVIATION DESCRIPTION EXPLANATION Utilization Management Restrictions PA PA-HRM PA NSO QL Prior Authorization Restriction Prior Authorization Restriction for Part B vs Part D Determination Prior Authorization Restriction for High Risk Medications Prior Authorization Restriction for New Starts Only Quantity Limit Restriction You (or your physician) are required to get prior authorization from VNSNY CHOICE FIDA Complete before you fill your prescription for this drug. Without prior approval, VNSNY CHOICE FIDA Complete may not cover this drug. 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 VNSNY CHOICE FIDA Complete to determine that this drug is covered under Medicare Part D before you fill your prescription for this drug. Without prior approval, VNSNY CHOICE FIDA Complete may not cover this drug. This drug has been deemed by CMS to be potentially harmful and therefore, a High Risk Medication for Medicare beneficiaries 65 years or older. Participants age 65 years or older are required to get prior authorization from VNSNY CHOICE FIDA Complete before you fill your prescription for this drug. Without prior approval, VNSNY CHOICE FIDA Complete may not cover this drug If you are a new participant or if you have not taken this drug before, you (or your physician) are required to get prior authorization from VNSNY CHOICE FIDA Complete before you fill your prescription for this drug. Without prior approval, VNSNY CHOICE FIDA Complete may not cover this drug. VNSNY CHOICE FIDA Complete limits the amount of this drug that is covered per prescription, or within a specific time frame. If you have questions, please call VNSNY CHOICE FIDA Complete at , 7 days a week from 8 AM - 8PM (TTY is 711). The call is free. For more information, visit vnsnychoice.org XII

14 ABBREVIATION DESCRIPTION EXPLANATION ST Step Therapy Restriction another drug(s) to treat your medical condition. This drug may only be covered if the other drug(s) does not work for you. The following additional coverage note abbreviations may be found within the body of this document OTHER SPECIAL REQUIREMENTS FOR COVERAGE ABBREVIATION DESCRIPTION EXPLANATION LA NM Limited Access Drug Non-Mail Order Drug This prescription may be available only at certain pharmacies. For more information consult your Provider and Pharmacy Directory or call Participant Services at , days a week from 8 AM - 8PM. TTY/TDD users should call 711. You may be able to receive greater than a 1-month supply of most of the drugs on your formulary via mail order at a reduced cost share. Drugs not available via your mail order benefit are noted with NM in the Requirements/Limits column of your formulary. * Not a Part D Drug This drug is a non-part D drug, or an OTC drug or product. If you have questions, please call VNSNY CHOICE FIDA Complete at , 7 days a week from 8 AM - 8PM (TTY is 711). The call is free. For more information, visit vnsnychoice.org XIII

15 Table of Contents Analgesics... 3 Anesthetics Anti-Addiction/Substance Abuse Treatment Agents Antianxiety Agents Antibacterials Anticancer Agents Anticholinergic Agents Anticonvulsants Antidementia Agents Antidepressants Antidiabetic Agents Antifungals Antihistamines 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 VNSNY CHOICE FIDA Complete Formulary ID: , Version: 15 Effective: July 01,

16 Cardiovascular Agents Central Nervous System Agents Contraceptives Cough And Cold Products Dental And Oral Agents Dermatological Agents Devices Disinfectants (For Non-Dermatologic Use) 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 Miscellaneous Therapeutic Agents Ophthalmic Agents Replacement Preparations Respiratory Tract Agents Skeletal Muscle Relaxants Sleep Disorder Agents Vasodilating Agents Vitamins And Minerals VNSNY CHOICE FIDA Complete Formulary ID: , Version: 15 Effective: July 01,

17 Analgesics Analgesics, Miscellaneous acephen 120 mg suppository outer 120 mg * acephen 325 mg suppository outer 325 mg * acephen 650 mg suppository outer 650 mg * acetaminophen 120 mg suppos outer 120 mg * acetaminophen 160 mg/5 ml elx 160 mg/5 ml * acetaminophen 650 mg suppos 650 mg * acetaminophen 80 mg rapid tab children's 80 mg * acetaminophen 80 mg/0.8 ml drp infants 80 mg/0.8 ml * acetaminophen-codeine 120 mg-12 mg/5 ml solution mg/5 ml acetaminophen-codeine oral solution 300 mg-30 mg /12.5 ml acetaminophen-codeine oral tablet mg, mg acetaminophen-codeine oral tablet mg ALLZITAL ORAL TABLET MG ascomp with codeine oral capsule mg BELBUCA BUCCAL FILM 150 MCG, 300 MCG, 450 MCG, 600 MCG, 75 MCG, 750 MCG, 900 MCG buprenorphine hcl injection syringe 0.3 mg/ml (Acetaminophen) (Acetaminophen) (Acetaminophen) (Acetaminophen) (Acetaminophen) (Acetaminophen) (Acetaminophen) (Acetaminophen) (Acetaminophen with Codeine) (Acetaminophen with Codeine) (Tylenol-Codeine No.3) (Tylenol-Codeine No.3) (Fiorinal with Codeine #3) (Buprenorphine HCl) QL (360 per 30 days) QL (30 per 30 days) QL (30 per 30 days) QL (30 per 30 days) QL (240 per 30 days) QL (30 per 30 days) QL (30 per 30 days) QL (30 per 30 days) QL (2700 per 30 days) QL (2700 per 30 days) QL (360 per 30 days) QL (180 per 30 days) PA-HRM; QL (180 per 30 days) ST; QL (60 per 30 days) 3

18 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 butalbital-acetaminophen-caff oral tablet mg butalbital-aspirin-caffeine oral capsule mg BUTRANS TRANSDERMAL PATCH WEEKLY 10 MCG/HOUR, 15 MCG/HOUR, 20 MCG/HOUR, 5 MCG/HOUR, 7.5 MCG/HOUR (Fiorinal with Codeine #3) (Fioricet with Codeine) (Tencon) (Esgic) (Esgic) (Fiorinal) capacet oral capsule mg (Esgic) child non-aspirin 160 mg/5 ml children's 160 mg/5 ml * child pain & fever 160 mg/5 ml a/f,gluten/f,cherry 160 mg/5 ml * child tactinal 80 mg tab chw 80 mg * children's mapap 80 mg rapid 80 mg * children's silapap elixir 160 mg/5 ml * codeine sulfate oral tablet 15 mg, 30 mg, 60 mg cvs child non-asa 80 mg tb chw 80 mg * cvs non-aspirin jr tab chew 160 mg * (Acetaminophen) (Infants' Tylenol) (Acetaminophen) (Acetaminophen) (Tylenol Sore Throat) (Codeine Sulfate) (Acetaminophen) (Acetaminophen) PA-HRM; QL (180 per 30 days) PA-HRM; QL (180 per 30 days) PA-HRM; QL (180 per 30 days) PA-HRM; QL (180 per 30 days) PA-HRM; QL (180 per 30 days) PA-HRM; QL (180 per 30 days) QL (4 per 28 days) PA-HRM; QL (180 per 30 days) QL (240 per 30 days) QL (240 per 30 days) QL (30 per 30 days) QL (30 per 30 days) QL (240 per 30 days) QL (180 per 30 days) QL (30 per 30 days) QL (30 per 30 days) 4

19 5 cvs pain relief adult liquid 500 (Tylenol Sore QL (120 per 30 days) mg/15 ml * Throat) endocet oral tablet mg, 2.5- QL (360 per 30 days) (Xolox) 325 mg, mg, mg endodan oral tablet mg (Percodan) QL (360 per 30 days) fentanyl citrate buccal lozenge on a handle 1,200 mcg, 1,600 mcg, 200 (Actiq) PA; QL (120 per 30 days) mcg, 400 mcg, 600 mcg, 800 mcg fentanyl transdermal patch 72 hour 100 mcg/hr, 12 mcg/hr, 25 mcg/hr, 37.5 mcg/hour, 50 mcg/hr, 62.5 mcg/hour, 75 mcg/hr, 87.5 mcg/hour (Duragesic) QL (10 per 30 days) feverall 120 mg suppository QL (30 per 30 days) (Acetaminophen) children's, outer 120 mg * feverall 325 mg suppository junior QL (30 per 30 days) (Acetaminophen) str, outer 325 mg * feverall 650 mg suppository adult, QL (30 per 30 days) (Acetaminophen) outer 650 mg * hydrocodone-acetaminophen oral solution mg/15 ml(15 ml), mg/5 ml, mg/15 ml hydrocodone-acetaminophen oral tablet mg, mg, mg hydrocodone-acetaminophen oral tablet mg, mg, mg, mg hydrocodone-ibuprofen oral tablet mg, mg, mg, mg hydromorphone (pf) injection solution 10 mg/ml hydromorphone (pf) injection solution 4 mg/ml hydromorphone injection solution 2 mg/ml (Hycet) (Norco) (Norco) (Ibudone) (Dilaudid-HP) (Dilaudid) (Hydromorphone HCl) QL (2700 per 30 days) (includes Vicodin, Vicodin ES and Vicodin HP); QL (390 per 30 days) QL (360 per 30 days) QL (150 per 30 days)

20 6 hydromorphone injection syringe 2 (Hydromorphone mg/ml HCl) hydromorphone oral liquid 1 mg/ml (Dilaudid) QL (1200 per 30 days) hydromorphone oral tablet 2 mg, 4 QL (180 per 30 days) (Dilaudid) mg hydromorphone oral tablet 8 mg (Dilaudid) QL (240 per 30 days) HYSINGLA ER ORAL TABLET,ORAL ONLY,EXT.REL.24 HR 100 MG, 120 MG, 20 MG, 30 MG, 40 MG, 60 MG, 80 MG QL (30 per 30 days) junior mapap 160 mg rapid tab 160 QL (30 per 30 days) (Acetaminophen) mg * LAZANDA NASAL SPRAY,NON- AEROSOL 100 MCG/SPRAY, 400 MCG/SPRAY PA; QL (30 per 30 days) lorcet (hydrocodone) oral tablet 5- QL (360 per 30 days) (Norco) 325 mg lorcet hd oral tablet mg (Norco) QL (360 per 30 days) lorcet plus oral tablet mg (Norco) QL (360 per 30 days) mapap 160 mg/5 ml liquid 160 mg/5 QL (240 per 30 days) ml * mapap 160 mg/5 ml suspension 160 QL (240 per 30 days) (Infants' Tylenol) mg/5 ml * mapap 325 mg tablet 325 mg * (Tylenol) QL (360 per 30 days) mapap 500 mg capsule 500 mg * (Acetaminophen) QL (240 per 30 days) mapap 500 mg tablet 500 mg * (Tylenol) QL (240 per 30 days) mapap 500 mg/15 ml liquid 500 (Tylenol Sore QL (120 per 30 days) mg/15 ml * Throat) mapap 80 mg tablet chew 80 mg * (Acetaminophen) QL (30 per 30 days) mapap arthritis er 650 mg cplt 650 QL (180 per 30 days) (Acetaminophen) mg * margesic oral capsule mg methadone injection solution 10 mg/ml (Esgic) (Methadone HCl) PA-HRM; QL (180 per 30 days)

21 7 methadone oral solution 10 mg/5 QL (1800 per 30 days) (Methadone HCl) ml, 5 mg/5 ml methadone oral tablet 10 mg, 5 mg (Diskets) QL (360 per 30 days) methadose oral tablet,soluble 40 mg (Diskets) QL (90 per 30 days) morphine (pf) in 0.9 % nacl intravenous pt controlled analgesia (Morphine Sulfate/0.9% syring 50 mg/25 ml (2 mg/ml) Nacl/PF) morphine 10 mg/ml carpuject 10 mg/ml (Morphine Sulfate) morphine 2 mg/ml carpuject 2 mg/ml (Morphine Sulfate) morphine 4 mg/ml carpuject 4 mg/ml (Morphine Sulfate) morphine 8 mg/ml syringe 8 mg/ml (Morphine Sulfate) morphine concentrate oral solution QL (200 per 30 days) (Morphine Sulfate) 100 mg/5 ml (20 mg/ml) morphine concentrate oral syringe 20 mg/ml (Morphine Sulfate) morphine in dextrose 5 % injection pt controlled analgesia syring 100 mg/50 ml (2 mg/ml), 50 mg/25 ml (2 mg/ml) morphine injection solution 15 mg/ml, 8 mg/ml morphine injection syringe 10 mg/ml morphine intramuscular pen injector 10 mg/0.7 ml morphine intravenous cartridge 15 mg/ml morphine intravenous solution 25 mg/ml, 50 mg/ml morphine intravenous syringe 10 mg/ml, 2 mg/ml, 4 mg/ml, 8 mg/ml (Morphine Sulfate/D5W) (Morphine Sulfate) (Morphine Sulfate) (Morphine Sulfate) (Morphine Sulfate) (Morphine Sulfate) (Morphine Sulfate) morphine oral solution 10 mg/5 ml (Morphine Sulfate) QL (700 per 30 days) morphine oral solution 20 mg/5 ml QL (300 per 30 days) (Morphine Sulfate) (4 mg/ml)

22 8 MORPHINE ORAL TABLET 15 QL (180 per 30 days) MG, 30 MG morphine oral tablet extended QL (120 per 30 days) (MS Contin) release 100 mg, 30 mg, 60 mg morphine oral tablet extended QL (180 per 30 days) (MS Contin) release 15 mg, 200 mg morphine rectal suppository 10 mg, 20 mg, 30 mg, 5 mg (Morphine Sulfate) non-aspirin x-str 167 mg/5 ml 500 (Tylenol Sore QL (120 per 30 days) mg/15 ml * Throat) nortemp 80 mg/0.8 ml drop 80 QL (30 per 30 days) (Acetaminophen) mg/0.8 ml * NUCYNTA ER ORAL TABLET QL (60 per 30 days) EXTENDED RELEASE 12 HR 100 MG, 150 MG, 200 MG, 250 MG, 50 MG NUCYNTA ORAL TABLET 100 QL (181 per 30 days) MG, 50 MG, 75 MG oxycodone oral concentrate 20 QL (180 per 30 days) (Oxycodone HCl) mg/ml oxycodone oral solution 5 mg/5 ml (Oxycodone HCl) QL (1300 per 30 days) oxycodone oral tablet 10 mg, 15 mg, QL (180 per 30 days) (Roxicodone) 20 mg, 30 mg, 5 mg oxycodone oral tablet,oral QL (60 per 30 days) only,ext.rel.12 hr 10 mg, 15 mg, 20 mg, 30 mg, 40 mg, 60 mg (Oxycontin) oxycodone oral tablet,oral QL (120 per 30 days) (Oxycontin) only,ext.rel.12 hr 80 mg oxycodone-acetaminophen oral QL (360 per 30 days) tablet mg, mg, (Xolox) mg, mg oxycodone-acetaminophen oral QL (180 per 30 days) (Xolox) tablet mg oxycodone-acetaminophen oral QL (240 per 30 days) (Xolox) tablet mg oxycodone-aspirin oral tablet QL (360 per 30 days) (Percodan) mg

23 OXYCONTIN ORAL QL (60 per 30 days) TABLET,ORAL ONLY,EXT.REL.12 HR 10 MG, 15 MG, 20 MG, 30 MG, 40 MG, 60 MG OXYCONTIN ORAL QL (120 per 30 days) TABLET,ORAL ONLY,EXT.REL.12 HR 80 MG oxymorphone oral tablet 10 mg, 5 QL (180 per 30 days) (Opana) mg oxymorphone oral tablet extended QL (60 per 30 days) release 12 hr 10 mg, 15 mg, 20 mg, 5 mg, 7.5 mg (Opana ER) oxymorphone oral tablet extended QL (120 per 30 days) (Opana ER) release 12 hr 30 mg, 40 mg pain relief 500 mg capsule 500 mg * (Acetaminophen) QL (240 per 30 days) pain reliever er 650 mg caplet 8 QL (180 per 30 days) (Acetaminophen) hour, caplet 650 mg * pharbetol 325 mg tablet regular QL (360 per 30 days) (Tylenol) strength 325 mg * pharbetol 500 mg caplet extra-str, QL (240 per 30 days) (Tylenol) caplet 500 mg * pv non-aspirin 500 mg softgel exstr,liq filled 500 mg * QL (240 per 30 days) (Acetaminophen) q-pap 160 mg/5 ml solution a/f, (Tylenol Sore QL (240 per 30 days) cherry 160 mg/5 ml * Throat) q-pap 325 mg tablet 325 mg * (Tylenol) QL (360 per 30 days) q-pap 80 mg/0.8 ml drops 80 mg/0.8 QL (30 per 30 days) (Acetaminophen) ml * q-pap ex-str 500 mg tablet aspirin QL (240 per 30 days) (Tylenol) free 500 mg * ra jr acetaminophen 160 mg tab QL (30 per 30 days) (Acetaminophen) rapid melts 160 mg * reprexain oral tablet mg, QL (150 per 30 days) (Ibudone) mg, mg 9

24 10 (Oxycodone QL (1800 per 30 days) roxicet oral solution mg/5 ml HCl/Acetaminophe n) silapap infant's drops infant's 80 QL (30 per 30 days) (Acetaminophen) mg/0.8 ml * sm arthritis pain er 650 mg caplet QL (180 per 30 days) (Acetaminophen) 650 mg * sm pain rel jr str tab chew 160 mg * (Acetaminophen) QL (30 per 30 days) sm pain reliever 80 mg tab QL (30 per 30 days) (Acetaminophen) children's 80 mg * tactinal 325 mg tablet 325 mg * (Tylenol) QL (360 per 30 days) tactinal 500 mg tablet extra-strength QL (240 per 30 days) (Tylenol) 500 mg * tencon oral tablet mg (Tencon) PA-HRM; QL (180 per 30 days) tramadol oral tablet 50 mg (Ultram) QL (240 per 30 days) tramadol-acetaminophen oral tablet QL (240 per 30 days) (Ultracet) mg (includes Vicodin, vicodin es oral tablet mg (Norco) Vicodin ES and Vicodin HP); QL (390 per 30 days) vicodin hp oral tablet mg (Norco) (includes Vicodin, Vicodin ES and Vicodin HP); QL (390 per 30 days) vicodin oral tablet mg (Norco) (includes Vicodin, Vicodin ES and Vicodin HP); QL (390 per 30 days) xylon 10 oral tablet mg (Ibudone) QL (150 per 30 days) zebutal oral capsule mg (Esgic) PA-HRM; QL (180 per 30 days) Nonsteroidal Anti- Inflammatory Agents ADVIL 100 MG TABLET JR STRENGTH,COATED 100 MG *

25 ADVIL 200 MG TABLET 200 MG * ADVIL JR STR 100 MG TAB CHEW TB CHEW,8 HOUR,GRAPE 100 MG * aspirin 300 mg suppository 300 mg (Aspirin) * aspirin 325 mg tablet 325 mg * (Ecotrin) aspirin 600 mg suppository 600 mg (Aspirin) * aspirin 81 mg chewable tablet 81 (Bayer Chewable mg * Aspirin) aspirin buffered 325 mg tab 325 mg (Aspirin/Calcium * Carbonate/Mag) aspirin ec 325 mg tablet 325 mg * (Ecotrin) aspirin ec 500 mg tablet 500 mg * (Ecotrin) aspirin ec 81 mg tablet low dose 81 (Ecotrin) mg * aspir-low ec 81 mg tablet 81 mg * (Ecotrin) CALDOLOR INTRAVENOUS RECON SOLN 400 MG/4 ML (100 MG/ML) celecoxib oral capsule 100 mg, 200 (Celebrex) mg, 400 mg, 50 mg CHILDREN'S ADVIL 100 MG/5 ML A/F (OTC) 100 MG/5 ML * cvs ibuprofen 200 mg softgel liquid (Advil) filled,softge 200 mg * diclofenac sodium oral tablet (Voltaren-XR) extended release 24 hr 100 mg bufferin 325 mg tablet coated 325 choline,magnesium salicylate oral diclofenac potassium oral tablet 50 (Aspirin/Calcium (Choline Sal/Mag (Diclofenac mg * liquid 500 mg/5 ml mg Carbonate/Mag) Salicylate) Potassium) QL (60 per 30 days) 11

26 diclofenac sodium oral tablet,delayed release (dr/ec) 25 mg, 50 mg, 75 mg (Diclofenac Sodium) diclofenac sodium topical gel 3 % (Voltaren) diclofenac-misoprostol oral tablet,ir,delayed rel,biphasic mg-mcg, mg-mcg (Arthrotec 50) diflunisal oral tablet 500 mg (Diflunisal) ecpirin ec 325 mg tablet 325 mg * (Ecotrin) etodolac oral capsule 200 mg, 300 mg (Etodolac) etodolac oral tablet 400 mg, 500 mg (Etodolac) etodolac oral tablet extended release 24 hr 400 mg, 500 mg, 600 mg (Etodolac) fenoprofen oral tablet 600 mg (Fenoprofen Calcium) FLECTOR TRANSDERMAL PATCH 12 HOUR 1.3 % flurbiprofen oral tablet 100 mg, 50 mg (Flurbiprofen) gnp ibuprofen jr str 100 mg tb 100 mg * (Advil) ibuprofen 100 mg/5 ml susp children's (otc) 100 mg/5 ml * (Children'S Advil) ibuprofen 200 mg tablet 200 mg * (Advil) ibuprofen oral suspension 100 mg/5 ml (Ibuprofen) ibuprofen oral tablet 400 mg, 600 mg, 800 mg (Ibuprofen) indomethacin oral capsule 25 mg (Indomethacin) indomethacin oral capsule 50 mg (Indomethacin) indomethacin oral capsule, extended release 75 mg (Indomethacin) PA PA-HRM; QL (240 per 30 days) PA-HRM; QL (120 per 30 days) PA-HRM; QL (60 per 30 days) 12

27 13 indomethacin sodium intravenous (Indomethacin recon soln 1 mg Sodium) infant ibuprofen 50 mg/1.25 ml d/f,a/f,non-staining 50 mg/1.25 ml * (Infants' Motrin) INFANTS' MOTRIN 50 MG/1.25 ML D/F, BERRY FLAVOR 50 3 $0 MG/1.25 ML * ketoprofen oral capsule 50 mg, 75 mg (Ketoprofen) ketoprofen oral capsule,ext rel. pellets 24 hr 200 mg (Ketoprofen) ketorolac oral tablet 10 mg (Ketorolac Tromethamine) 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) nabumetone oral tablet 500 mg, 750 mg (Nabumetone) naproxen oral suspension 125 mg/5 ml (Naprosyn) naproxen oral tablet 250 mg, 375 mg, 500 mg (Naprosyn) naproxen oral tablet,delayed release (Ec-Naprosyn) (dr/ec) 375 mg, 500 mg naproxen sodium oral tablet 275 mg, 550 mg (Anaprox) piroxicam oral capsule 10 mg, 20 mg (Feldene) ra aspirin tri-buffered tb 325 mg * (Aspirin/Calcium Carbonate/Mag) sm ibuprofen ib 100 mg tablet junior (Advil) strength 100 mg * st. joseph aspirin 81 mg chew orange 81 mg * st. joseph aspirin ec 81 mg tb enteric coated 81 mg * (Bayer Chewable Aspirin) (Ecotrin) PA-HRM QL (20 per 30 days)

28 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 % wal-profen 200 mg softgel softgel 200 mg * (Advil) Anesthetics Local Anesthetics glydo mucous membrane jelly in applicator 2 % (Lidocaine HCl) lidocaine (pf) injection solution 15 mg/ml (1.5 %), 40 mg/ml (4 %), 5 (Xylocaine-MPF) mg/ml (0.5 %) lidocaine 2% viscous soln 2 % (Xylocaine) lidocaine hcl injection solution 10 mg/ml (1 %), 20 mg/ml (2 %) (Xylocaine) lidocaine hcl laryngotracheal solution 4 % (Xylocaine) lidocaine hcl mucous membrane gel 2 % (Lidocaine HCl) lidocaine hcl mucous membrane jelly in applicator 2 % (Lidocaine HCl) lidocaine hcl mucous membrane solution 2 %, 4 % (40 mg/ml) (Xylocaine) lidocaine hcl urethral gel 2 % (Lidocaine HCl) lidocaine topical adhesive patch,medicated 5 % (Lidoderm) lidocaine topical ointment 5 % (Lidocaine) lidocaine-prilocaine topical cream % (EMLA) Anti-Addiction/Substance Abuse Treatment Agents Anti-Addiction/Substance Abuse Treatment Agents acamprosate oral tablet,delayed release (dr/ec) 333 mg (Acamprosate Calcium) PA 14

29 buprenorphine hcl sublingual tablet (Buprenorphine 2 mg, 8 mg HCl) (Buprenorphine buprenorphine-naloxone sublingual HCl/Naloxone tablet mg, 8-2 mg HCl) bupropion hcl sr 150 mg tablet f/c 150 mg (Zyban) CHANTIX CONTINUING MONTH BOX ORAL TABLET 1 MG CHANTIX ORAL TABLET 0.5 MG, 1 MG CHANTIX STARTING MONTH 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 mg/ml (Naloxone HCl) naltrexone oral tablet 50 mg (Revia) NARCAN NASAL SPRAY,NON- AEROSOL 4 MG/ACTUATION NICODERM CQ 14 MG/24HR PATCH 14 MG/24 HR * NICODERM CQ 21 MG/24HR PATCH 21 MG/24 HR * NICODERM CQ 7 MG/24HR PATCH 7 MG/24 HR * nicorelief 2 mg gum 2 mg * (Nicorette) nicorelief 4 mg gum 4 mg * (Nicorette) nicorette 2 mg chewing gum white ice mint 2 mg * (Nicorette) nicotine 14 mg/24hr patch outer (otc) 14 mg/24 hr * (Nicoderm Cq) PA; QL (90 per 30 days) PA; QL (90 per 30 days) QL (168 per 84 days) QL (168 per 84 days) QL (53 per 28 days) QL (4 per 30 days) QL (168 per 365 days) QL (168 per 365 days) QL (180 per 365 days) 15

30 16 nicotine 2 mg chewing gum sugar free 2 mg * (Nicorette) nicotine 2 mg lozenge mint, 3 quittube 2 mg * (Nicorette) nicotine 21 mg/24hr patch step 1 (otc) 21 mg/24 hr * (Nicoderm Cq) nicotine 22 mg/24hr patch 1 week starter kit 22 mg/24 hr * (Nicoderm Cq) nicotine 4 mg chewing gum 4 mg * (Nicorette) nicotine 4 mg lozenge mint, 3 quittube 4 mg * (Nicorette) nicotine 7 mg/24hr patch (otc) 7 mg/24 hr * (Nicoderm Cq) NICOTROL INHALATION CARTRIDGE 10 MG ZUBSOLV SUBLINGUAL TABLET MG, MG, MG, MG, MG Antianxiety Agents Benzodiazepines alprazolam oral tablet 0.25 mg, 0.5 QL (168 per 365 days) QL (168 per 365 days) QL (180 per 365 days) QL (1008 per 90 days) PA; QL (90 per 30 days) QL (120 per 30 days) (Xanax) mg, 1 mg, 2 mg chlordiazepoxide hcl oral capsule (Chlordiazepoxide QL (120 per 30 days) 10 mg, 25 mg, 5 mg HCl) clonazepam oral tablet 0.5 mg, 1 mg (Klonopin) QL (90 per 30 days) clonazepam oral tablet 2 mg (Klonopin) QL (300 per 30 days) clonazepam oral tablet,disintegrating mg, 0.25 mg, 0.5 mg, 1 mg (Clonazepam) QL (90 per 30 days) clonazepam oral QL (300 per 30 days) (Clonazepam) tablet,disintegrating 2 mg clorazepate dipotassium oral tablet QL (120 per 30 days) (Tranxene T-Tab) 15 mg clorazepate dipotassium oral tablet QL (60 per 30 days) (Tranxene T-Tab) 3.75 mg, 7.5 mg

31 diazepam injection syringe 5 mg/ml (Diazepam) QL (10 per 28 days) diazepam intensol oral concentrate QL (1200 per 30 days) (Diazepam) 5 mg/ml diazepam oral solution 5 mg/5 ml (1 QL (1200 per 30 days) (Diazepam) mg/ml) diazepam oral tablet 10 mg, 2 mg, 5 QL (120 per 30 days) (Valium) mg diazepam rectal kit mg, 2.5 mg, mg (Diastat) lorazepam oral tablet 0.5 mg, 1 mg, QL (90 per 30 days) (Ativan) 2 mg ONFI ORAL SUSPENSION 2.5 PA NSO; QL (480 per MG/ML 30 days) Antibacterials Aminoglycosides BETHKIS INHALATION SOLUTION FOR NEBULIZATION 300 MG/4 ML 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 injection solution 40 mg/ml gentamicin ped 20 mg/2 ml vial 25's,pedi,latex-free 20 mg/2 ml gentamicin sulfate (pf) intravenous solution 80 mg/8 ml (Gentamicin In Nacl, Iso-Osm) (Gentamicin Sulfate) (Gentamicin Sulfate/PF) (Gentamicin Sulfate/PF) neomycin oral tablet 500 mg (Neomycin Sulfate) streptomycin intramuscular recon (Streptomycin soln 1 gram Sulfate) TOBI PODHALER INHALATION CAPSULE, W/INHALATION DEVICE 28 MG QL (224 per 28 days) 17

32 tobramycin in % nacl inhalation solution for nebulization 300 mg/5 ml tobramycin in 0.9 % nacl intravenous piggyback 60 mg/50 ml, 80 mg/100 ml tobramycin sulfate injection solution 10 mg/ml, 40 mg/ml Antibacterials, Miscellaneous bacitracin intramuscular recon soln 50,000 unit chloramphenicol sod succinate intravenous recon soln 1 gram clindamycin 75 mg/5 ml soln 75 mg/5 ml clindamycin hcl oral capsule 150 mg, 300 mg, 75 mg clindamycin in 5 % dextrose intravenous piggyback 300 mg/50 ml, 600 mg/50 ml, 900 mg/50 ml (Tobi) (Tobramycin/Sodiu m Chloride) (Tobramycin Sulfate) (Bacitracin) (Chloramphenicol Sod Succ) (Cleocin Palmitate) (Cleocin HCl) (Cleocin Phosphate In D5w) clindamycin pediatric oral recon soln 75 mg/5 ml (Cleocin Palmitate) clindamycin phosphate injection (Cleocin solution 150 mg/ml Phosphate) clindamycin phosphate intravenous (Cleocin solution 600 mg/4 ml Phosphate) colistin (colistimethate na) injection (Coly-Mycin M recon soln 150 mg Parenteral) CUBICIN INTRAVENOUS RECON SOLN 500 MG linezolid intravenous parenteral solution 600 mg/300 ml (Zyvox) linezolid oral suspension for reconstitution 100 mg/5 ml (Zyvox) linezolid oral tablet 600 mg (Zyvox) 18

33 19 methenamine hippurate oral tablet 1 gram (Hiprex) metronidazole in nacl (iso-os) (Metronidazole/So intravenous piggyback 500 mg/100 dium Chloride) ml metronidazole oral capsule 375 mg (Flagyl) metronidazole oral tablet 250 mg, 500 mg (Flagyl) nitrofurantoin macrocrystal oral capsule 100 mg, 25 mg, 50 mg (Macrodantin) nitrofurantoin monohyd/m-cryst oral capsule 100 mg (Macrobid) nitrofurantoin monohyd/m-cryst oral capsule 100 mg (75/25) (Macrobid) polymyxin b sulfate injection recon (Polymyxin B soln 500,000 unit Sulfate) SYNERCID INTRAVENOUS RECON SOLN 500 MG trimethoprim oral tablet 100 mg (Trimethoprim) vancomycin hcl 1g/200 ml bag 1 (Vancomycin gram/200 ml HCl/D5W) vancomycin intravenous recon soln 1,000 mg, 10 gram, 750 mg (Vancomycin HCl) vancomycin intravenous recon soln (Vancomycin 500 mg HCl/D5W) vancomycin oral capsule 125 mg, 250 mg (Vancocin HCl) XIFAXAN ORAL TABLET 200 MG XIFAXAN ORAL TABLET 550 MG ZYVOX ORAL SUSPENSION FOR RECONSTITUTION 100 MG/5 ML Cephalosporins cefaclor oral capsule 250 mg, 500 mg (Cefaclor) PA-HRM; QL (120 per 30 days) PA-HRM; QL (120 per 30 days) PA-HRM; QL (120 per 30 days) PA; QL (9 per 30 days) PA

34 cefaclor oral suspension for reconstitution 125 mg/5 ml, 250 (Cefaclor) mg/5 ml, 375 mg/5 ml cefadroxil oral capsule 500 mg (Cefadroxil) cefadroxil oral suspension for reconstitution 250 mg/5 ml, 500 (Cefadroxil) mg/5 ml cefadroxil oral tablet 1 gram (Cefadroxil) CEFAZOLIN IN DEXTROSE (ISO-OS) INTRAVENOUS PIGGYBACK 1 GRAM/50 ML cefazolin in dextrose (iso-os) intravenous piggyback 2 gram/50 ml (Cefazolin Sodium/Dextrose, Iso) cefazolin injection recon soln 1 gram, 10 gram, 500 mg (Cefazolin Sodium) cefdinir oral capsule 300 mg (Cefdinir) cefdinir oral suspension for reconstitution 125 mg/5 ml, 250 (Cefdinir) mg/5 ml cefditoren pivoxil oral tablet 200 mg, 400 mg (Spectracef) CEFEPIME 2 GM INJECTION 2 GRAM/100 ML CEFEPIME IN DEXTROSE 5 % INTRAVENOUS PIGGYBACK 1 GRAM/50 ML, 2 GRAM/50 ML cefepime injection recon soln 1 gram, 2 gram (Maxipime) cefotaxime injection recon soln 1 gram, 10 gram, 2 gram, 500 mg (Claforan) (Cefoxitin cefoxitin in dextrose, iso-osm Sodium/Dextrose, intravenous piggyback 2 gram/50 ml Iso) cefoxitin intravenous recon soln 1 gram, 10 gram, 2 gram (Cefoxitin Sodium) 20

35 cefpodoxime oral suspension for reconstitution 100 mg/5 ml, 50 mg/5 ml cefpodoxime oral tablet 100 mg, 200 mg cefprozil oral suspension for reconstitution 125 mg/5 ml, 250 mg/5 ml (Cefpodoxime Proxetil) (Cefpodoxime Proxetil) 21 (Cefprozil) cefprozil oral tablet 250 mg, 500 mg (Cefprozil) ceftazidime injection recon soln 2 gram, 6 gram (Fortaz) ceftibuten oral capsule 400 mg (Cedax) ceftibuten oral suspension for reconstitution 180 mg/5 ml (Cedax) ceftriaxone 1 gm piggyback 50ml (Ceftriaxone galaxycontainer 1 gram/50 ml Na/Dextrose, Iso) ceftriaxone 1 gm vial 10's, fliptop,l/f 1 gram (Rocephin) ceftriaxone 2 gm piggyback 50ml (Ceftriaxone galaxycontainer 2 gram/50 ml Na/Dextrose, Iso) ceftriaxone injection recon soln 10 gram, 250 mg, 500 mg (Rocephin) ceftriaxone intravenous recon soln 1 (Ceftriaxone gram, 2 gram Na/Dextrose, Iso) cefuroxime axetil oral tablet 250 mg, 500 mg (Ceftin) cefuroxime sodium injection recon soln 1.5 gram, 750 mg (Zinacef) cefuroxime sodium intravenous recon soln 7.5 gram (Zinacef) cephalexin oral capsule 250 mg, 500 mg, 750 mg (Keflex) cephalexin oral suspension for reconstitution 125 mg/5 ml, 250 mg/5 ml (Cephalexin) cephalexin oral tablet 250 mg, 500 mg (Cephalexin)

36 MEFOXIN IN DEXTROSE (ISO- OSM) INTRAVENOUS PIGGYBACK 1 GRAM/50 ML, 2 GRAM/50 ML SUPRAX ORAL TABLET,CHEWABLE 100 MG, 200 MG tazicef injection recon soln 2 gram, 6 gram (Fortaz) TEFLARO INTRAVENOUS RECON SOLN 400 MG, 600 MG Macrolides azithromycin intravenous recon soln 500 mg (Zithromax) azithromycin oral packet 1 gram (Zithromax) azithromycin oral suspension for reconstitution 100 mg/5 ml, 200 (Zithromax) mg/5 ml azithromycin oral tablet 250 mg, 250 mg (6 pack), 600 mg (Zithromax) azithromycin oral tablet 500 mg (Zithromax) clarithromycin oral suspension for reconstitution 125 mg/5 ml, 250 (Biaxin) mg/5 ml clarithromycin oral tablet 250 mg, 500 mg (Biaxin) clarithromycin oral tablet extended release 24 hr 500 mg (Clarithromycin) DIFICID ORAL TABLET 200 MG QL (20 per 10 days) e.e.s. 400 oral tablet 400 mg (Erythromycin Ethylsuccinate) e.e.s. granules oral suspension for reconstitution 200 mg/5 ml (Eryped 200) ery-tab oral tablet,delayed release (Erythromycin (dr/ec) 250 mg, 500 mg Base) 22

37 ERY-TAB ORAL TABLET,DELAYED RELEASE (DR/EC) 333 MG erythrocin (as stearate) oral tablet 250 mg ERYTHROCIN INTRAVENOUS RECON SOLN 1,000 MG, 500 MG erythromycin ethylsuccinate oral tablet 400 mg erythromycin oral capsule,delayed release(dr/ec) 250 mg erythromycin oral tablet 250 mg, 500 mg Miscellaneous B-Lactam Antibiotics aztreonam injection recon soln 1 gram CAYSTON INHALATION SOLUTION FOR NEBULIZATION 75 MG/ML imipenem-cilastatin intravenous recon soln 250 mg, 500 mg INVANZ INJECTION RECON SOLN 1 GRAM meropenem intravenous recon soln 500 mg meropenem iv 1 gm vial outer, latexfree 1 gram Penicillins amoxicillin oral capsule 250 mg, 500 mg amoxicillin oral suspension for reconstitution 125 mg/5 ml, 200 mg/5 ml, 250 mg/5 ml, 400 mg/5 ml amoxicillin oral tablet 500 mg, 875 mg (Erythromycin Stearate) (Erythromycin Ethylsuccinate) (Erythromycin Base) (Erythromycin Base) (Azactam) (Primaxin) (Merrem) (Merrem) (Amoxicillin) (Amoxicillin) (Amoxicillin) LA 23

38 amoxicillin oral tablet,chewable 125 mg, 250 mg amoxicillin-pot clavulanate oral suspension for reconstitution mg/5 ml, mg/5 ml, mg/5 ml, mg/5 ml amoxicillin-pot clavulanate oral tablet mg, mg, mg amoxicillin-pot clavulanate oral tablet extended release 12 hr 1, mg amoxicillin-pot clavulanate oral tablet,chewable mg, mg ampicillin 2 gm vial 10's, latex-free 2 gram ampicillin oral capsule 250 mg, 500 mg ampicillin oral suspension for reconstitution 125 mg/5 ml, 250 mg/5 ml ampicillin sodium injection recon soln 1 gram, 10 gram, 125 mg ampicillin sodium intravenous recon soln 2 gram ampicillin-sulbactam 1.5 gm vl p/f, latex-free 1.5 gram ampicillin-sulbactam injection recon soln 15 gram, 3 gram ampicillin-sulbactam intravenous recon soln 1.5 gram BICILLIN C-R INTRAMUSCULAR SYRINGE 1,200,000 UNIT/ 2 ML(600K/600K), 1,200,000 UNIT/ 2 ML(900K/300K) (Amoxicillin) (Augmentin) (Augmentin) (Augmentin XR) (Amoxicillin/Potas sium Clav) (Ampicillin Sodium) (Ampicillin Trihydrate) (Ampicillin Trihydrate) (Ampicillin Sodium) (Ampicillin Sodium) (Unasyn) (Unasyn) (Unasyn) 24