LIST OF COVERED DRUGS

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1 LIST OF COVERED DRUGS Community Care Plus FIDA-MMP ICS H4465_ListofCoveredDrugs_2017_82216

2 H4465_ListofCoveredDrugs_2017_82216 ICS Community Care Plus FIDA-MMP 2017 List of Covered Drugs This is a list of drugs that Participants can get in ICS Community Care Plus FIDA-MMP. ICS Community Care Plus FIDA-MMP is a managed care plan that contracts with Medicare and the New York State Department of Health (Medicaid) to provide benefits 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 ICS Community Care Plus FIDA-MMP s up-to-date List of Covered Drugs online at by calling ICS Community Care Plus FIDA-MMP Participant Services at ICS Limitations and restrictions may apply. For more information, call ICS Community Care Plus FIDA-MMP Participant Services or read the ICS Community Care Plus FIDA-MMP Participant Handbook. This means that you need to follow certain rules to have ICS Community Care Plus FIDA-MMP pay for your services. There are no copays for any covered drugs. You can get this information for free in other languages. Call ICS.2525 and TTY: 711 during Monday Friday, 8 a.m. 8 p.m. The call is free. Вы можете бесплатно получить всю эту информацию на других языках. Звоните в ICS по телефону ICS.2525 и телетайпу 711 с понедельника по пятницу с 8:00 до 20:00. Звонок бесплатный. 您可免费获得所有这些信息的其他语言版本 请在周一至周五上午 8 点至晚上 8 点致电 ICS, 电话号码为 ICS.2525, 听障专线 (TTY) 为 711 此为免费电话 Puede obtener toda esta información en otros idiomas de manera gratuita. Llame a ICS al ICS.2525 y a la línea TTY 711, entre las 8 a. m. y las 8 p. m., de lunes a viernes. La llamada es gratuita. Ou kapab jwenn tout enfòmasyon sa a gratis nan lòt lang. Rele ICS nan ICS.2525 ak TTY 711, ant 8 a.m. ak 8 p.m., lendi jiska vandredi. Apèl la gratis. This formulary was updated on 8/1/17. If you have questions, please call ICS Community Care Plus FIDA-MMP at ICS.2525, Monday Friday, 8 a.m. 8 p.m. The call is free. (TTY users call 711.) For more information, visit /? H4465_ListofCoveredDrugs_2017 Approved 8/22/16. HPMS Approved Formulary File Submission ID , Version 14, as of 8/1/2017 1

3 H4465_ListofCoveredDrugs_2017_82216 이모든정보는타언어로무료로제공됩니다. 월요일 ~ 금요일, 오전 8 시 ~ 오후 8 시사이에 ICS.2525 및 TTY( 청각장애인용전화 ) 711 로 ICS 에전화해주십시오. 이전화는무료입니다. Le informazioni in questione sono disponibili gratuitamente anche in altre lingue. Chiamare ICS ai numeri ICS.2525 e TTY 711 tra le 8:00 e le dal lunedì al venerdì. La chiamata è gratuita. You can get this information for free in other formats, such as large print, braille, or audio. Call ICS.2525 and TTY: 711 during Monday Friday, 8 a.m. 8 p.m. The call is free. 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 ICS Community Care Plus FIDA-MMP. ICAN may be reached toll-free at (TTY users call 711, then follow the prompts to dial ) or online at icannys.org. 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 14 are the drugs covered by ICS Community Care Plus FIDA-MMP. 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. ICS Community Care Plus FIDA-MMP will cover all drugs on the Drug List if: your doctor or other 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 ICS Community Care Plus FIDA-MMP network pharmacy. This formulary was updated on 8/1/17. If you have questions, please call ICS Community Care Plus FIDA-MMP at ICS.2525, Monday Friday, 8 a.m. 8 p.m. The call is free. (TTY users call 711.) For more information, visit /? H4465_ListofCoveredDrugs_2017 Approved 8/22/16. HPMS Approved Formulary File Submission ID , Version 14, as of 8/1/2017 2

4 H4465_ListofCoveredDrugs_2017_82216 ICS Community Care Plus FIDA-MMP 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 or call Participant Services at ICS Does the Drug List ever change? Yes. ICS Community Care Plus FIDA-MMP 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. 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 ICS Community Care Plus FIDA-MMP 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 ICS Community Care Plus FIDA-MMP s up to date Drug List online at You can also call Participant Services to check the current Drug List at ICS This formulary was updated on 8/1/17. If you have questions, please call ICS Community Care Plus FIDA-MMP at ICS.2525, Monday Friday, 8 a.m. 8 p.m. The call is free. (TTY users call 711.) For more information, visit /? H4465_ListofCoveredDrugs_2017 Approved 8/22/16. HPMS Approved Formulary File Submission ID , Version 14, as of 8/1/2017 3

5 H4465_ListofCoveredDrugs_2017_ 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. ICS Community Care Plus FIDA-MMP 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. ICS Community Care Plus FIDA-MMP will inform members of these changes by mail, and will include information about how to file a grievance, appeal, or exception request. ICS Community Care Plus FIDA-MMP will also post this information on our website which can be found at and will notify members annually of our up-to-date formulary. This information can be provided in alternate formats. 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. You will be instructed to contact the prescribing physician as soon as possible and get instructions for replacing the discontinued drug. You can also reach out to your care manager for assistance. 5. Are there any restrictions or limits on drug coverage? Or are there any required actions to take in order to get certain drugs? This formulary was updated on 8/1/17. If you have questions, please call ICS Community Care Plus FIDA-MMP at ICS.2525, Monday Friday, 8 a.m. 8 p.m. The call is free. (TTY users call 711.) For more information, visit /? H4465_ListofCoveredDrugs_2017 Approved 8/22/16. HPMS Approved Formulary File Submission ID , Version 14, as of 8/1/2017 4

6 H4465_ListofCoveredDrugs_2017_82216 Yes, some drugs have coverage rules or have limits on the amount you can get. In some cases you or your doctor or other prescriber must do something before you can get the drug. For example: Prior approval (or prior authorization): For some drugs, you or your doctor or other prescriber must get approval from ICS Community Care Plus FIDA-MMP or your Interdisciplinary Team (IDT) before you fill your prescription. If you don t get approval, ICS Community Care Plus FIDA-MMP may not cover the drug. Quantity limits: Sometimes ICS Community Care Plus FIDA-MMP limits the amount of a drug you can get. Step therapy: Sometimes ICS Community Care Plus FIDA-MMP 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 We have posted online documents that explain our prior authorization and step therapy restrictions. You may also ask us to send you a copy. You can ask for an exception from these limits. Please see question 11 for more information on exceptions. If you are in an intermediate care 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 (unless you have a prescription for fewer, whether or not you are a new ICS Community Care Plus FIDA-MMP 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 ask for 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? This formulary was updated on 8/1/17. If you have questions, please call ICS Community Care Plus FIDA-MMP at ICS.2525, Monday Friday, 8 a.m. 8 p.m. The call is free. (TTY users call 711.) For more information, visit /? H4465_ListofCoveredDrugs_2017 Approved 8/22/16. HPMS Approved Formulary File Submission ID , Version 14, as of 8/1/2017 5

7 H4465_ListofCoveredDrugs_2017_82216 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 14. 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 you have a heart condition, you should look in the category. 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 ICS.2525 and ask about it. If you learn that ICS Community Care Plus FIDA-MMP will not cover the drug, you can do one of these things: This formulary was updated on 8/1/17. If you have questions, please call ICS Community Care Plus FIDA-MMP at ICS.2525, Monday Friday, 8 a.m. 8 p.m. The call is free. (TTY users call 711.) For more information, visit /? H4465_ListofCoveredDrugs_2017 Approved 8/22/16. HPMS Approved Formulary File Submission ID , Version 14, as of 8/1/2017 6

8 H4465_ListofCoveredDrugs_2017_82216 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 ICS Community Care Plus FIDA-MMP 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 ICS Community Care Plus FIDA-MMP. This will give you time to talk to your doctor or other prescriber. He or she can help you decide if there is a similar drug on the Drug List you can take instead or whether to ask for an exception. 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 ICS Community Care Plus FIDA-MMP or your Interdisciplinary Team (IDT), or you are taking a drug that is part of a step therapy restriction. If you live in an intermediate care 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 your first 98 days in the plan. This gives your prescriber time to change your drugs to ones on the Drug List or ask for an exception. If you are a current participant experiencing a level-of-care change from one treatment setting to another, you may qualify for up to a 90-day supply of a drug not on the Drug List to give your doctor or prescriber time to locate one on the list or file an exception. You may qualify for a levelof-care transition supply if you: enter a long-term care (LTC) facility from a hospital or other setting leave an LTC facility and return to the community This formulary was updated on 8/1/17. If you have questions, please call ICS Community Care Plus FIDA-MMP at ICS.2525, Monday Friday, 8 a.m. 8 p.m. The call is free. (TTY users call 711.) For more information, visit /? H4465_ListofCoveredDrugs_2017 Approved 8/22/16. HPMS Approved Formulary File Submission ID , Version 14, as of 8/1/2017 7

9 H4465_ListofCoveredDrugs_2017_82216 discharge from a hospital to a home end a skilled nursing facility stay covered under Medicare Part A (including pharmacy charges), and revert to coverage under Part D revert from hospice status to standard Medicare Part A and B benefits or discharge from a psychiatric hospital with medication regimens that are highly individualized. 11. Can you ask for an exception to cover your drug? Yes. You can ask ICS Community Care Plus FIDA-MMP or your Interdisciplinary Team (IDT) to make an exception to cover a drug that is not on the Drug List. You can also ask ICS Community Care Plus FIDA-MMP or your IDT to change the rules on your drug. For example, ICS Community Care Plus FIDA-MMP 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. 12. How long does it take to get an exception? First, ICS Community Care Plus FIDA-MMP or your Interdisciplinary Team (IDT) must get a statement from your prescriber supporting your request for an exception. After we get 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 getting your prescriber s supporting statement. 13. How can you ask for an exception? This formulary was updated on 8/1/17. If you have questions, please call ICS Community Care Plus FIDA-MMP at ICS.2525, Monday Friday, 8 a.m. 8 p.m. The call is free. (TTY users call 711.) For more information, visit /? H4465_ListofCoveredDrugs_2017 Approved 8/22/16. HPMS Approved Formulary File Submission ID , Version 14, as of 8/1/2017 8

10 H4465_ListofCoveredDrugs_2017_82216 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). ICS Community Care Plus FIDA-MMP covers both brand name drugs and generic drugs. 15. What are OTC drugs? OTC stands for over-the-counter. ICS Community Care Plus FIDA-MMP covers some OTC drugs when they are written as prescriptions by your provider. You can read the ICS Community Care Plus FIDA-MMP Drug List to see what OTC drugs are covered. 16. Does ICS Community Care Plus FIDA-MMP cover OTC non-drug products? ICS Community Care Plus FIDA-MMP covers some OTC non-drug products such as gauze bandages, alcohol swabs/pads, insulin syringes and needles, etc., when they are written as prescriptions by your provider. You can read the ICS Community Care Plus FIDA-MMP Drug List to see what OTC non-drug products are covered. 17. What is your copay? As a ICS Community Care Plus FIDA-MMP Participant, you have no copays for prescription and OTC drugs as long as you follow ICS Community Care Plus FIDA-MMP s rules. This formulary was updated on 8/1/17. If you have questions, please call ICS Community Care Plus FIDA-MMP at ICS.2525, Monday Friday, 8 a.m. 8 p.m. The call is free. (TTY users call 711.) For more information, visit /? H4465_ListofCoveredDrugs_2017 Approved 8/22/16. HPMS Approved Formulary File Submission ID , Version 14, as of 8/1/2017 9

11 H4465_ListofCoveredDrugs_2017_ 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: Generic drugs covered by Medicare Tier 2: Brand name and specialty drugs covered by Medicare Tier 3: Non-Part D generic and brand name drugs covered by Medicaid Tier 4: Over-the-Counter (OTC) drugs covered by Medicaid This formulary was updated on 8/1/17. If you have questions, please call ICS Community Care Plus FIDA-MMP at ICS.2525, Monday Friday, 8 a.m. 8 p.m. The call is free. (TTY users call 711.) For more information, visit /? H4465_ListofCoveredDrugs_2017 Approved 8/22/16. HPMS Approved Formulary File Submission ID , Version 14, as of 8/1/

12 H4465_ListofCoveredDrugs_2017_82216 List of Covered Drugs The list of covered drugs on page 14 gives you information about the drugs covered by ICS Community Care Plus FIDA-MMP. 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., AVONEX) and generic drugs are listed in lower-case italics (e.g. amoxicillin). The information in the necessary actions, restrictions, or limits on use column tells you if ICS Community Care Plus FIDA-MMP has any rules for covering your drug. Abbreviations and Symbols The following Utilization Management abbreviations may be found within the body of this document. COVERAGE NOTES ABBREVIATIONS ABBREVIATION DESCRIPTION EXPLANATION PA Utilization Management Restrictions Prior Authorization Restriction You (or your physician) are required to get prior authorization from ICS Community Care Plus FIDA-MMP before you fill your prescription for this drug. Without prior approval, ICS Community Care Plus FIDA-MMP may not cover this drug. PA BvD Prior Authorization Restriction for Part B vs Part D Determination 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 ICS Community Care Plus FIDA-MMP to determine that this drug is covered under Medicare Part D before you fill your prescription for this drug. Without This formulary was updated on 8/1/17. If you have questions, please call ICS Community Care Plus FIDA-MMP at ICS.2525, Monday Friday, 8 a.m. 8 p.m. The call is free. (TTY users call 711.) For more information, visit /? H4465_ListofCoveredDrugs_2017 Approved 8/22/16. HPMS Approved Formulary File Submission ID , Version 14, as of 8/1/

13 H4465_ListofCoveredDrugs_2017_82216 ABBREVIATION DESCRIPTION EXPLANATION prior approval, FIDA Care Complete may not cover this drug. PA NSO QL ST Prior Authorization Restriction for New Starts Only Quantity Limit Restriction Step Therapy Restriction If you are a new member, or you have not taken this drug before, you (or your physician) are required to get prior authorization from ICS Community Care Plus FIDA-MMP before you fill your prescription for this drug. Without prior approval, FIDA Care Complete may not cover this drug. ICS Community Care Plus FIDA-MMP limits the amount of this drug that is covered per prescription, or within a specific time frame. Before ICS Community Care Plus FIDA-MMP will provide coverage for this drug, you must first try 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 abbreviations may not be found within the body of this document OTHER SPECIAL REQUIREMENTS FOR COVERAGE LA Limited Access Drug This prescription may be available only at certain pharmacies. For more information consult your Pharmacy Directory or call Member Services at ICS.2525, 8 a.m. to 8 p.m., Monday through Friday. TTY/TDD users should call 711. NM Non-Mail Order Drug 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 This formulary was updated on 8/1/17. If you have questions, please call ICS Community Care Plus FIDA-MMP at ICS.2525, Monday Friday, 8 a.m. 8 p.m. The call is free. (TTY users call 711.) For more information, visit /? H4465_ListofCoveredDrugs_2017 Approved 8/22/16. HPMS Approved Formulary File Submission ID , Version 14, as of 8/1/

14 H4465_ListofCoveredDrugs_2017_82216 ABBREVIATION DESCRIPTION EXPLANATION * Not a Part D Drug available via your mail order benefit are noted with NM in the Requirements/Limits column of your formulary. This drug is a non-part D drug covered by Medicaid. 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, ICS Community Care Plus FIDA-MMP 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 ICS.2525 or the Independent Consumer Advocacy Network (ICAN). The Participant Ombudsman may be reached toll-free at (TTY users call 711, then follow the prompts to dial ) or online at icannys.org. You can also read the Participant Handbook to learn how to appeal a decision. Here are the meanings of the codes used in the Necessary actions, restrictions, or limits on use column: (g) = Only the generic version of this drug is covered. The brand name version is not covered. M = The brand name version of this drug is in Tier 3. The generic version is in Tier 1. PA = Prior authorization (approval): you must have approval from the plan or your Interdisciplinary Team (IDT) before you can get this drug. ST = Step therapy: you must try another drug before you can get this one. This formulary was updated on 8/1/17. If you have questions, please call ICS Community Care Plus FIDA-MMP at ICS.2525, Monday Friday, 8 a.m. 8 p.m. The call is free. (TTY users call 711.) For more information, visit /? H4465_ListofCoveredDrugs_2017 Approved 8/22/16. HPMS Approved Formulary File Submission ID , Version 14, as of 8/1/

15 Table of Contents Analgesics Anesthetics Anti-Addiction/Substance Abuse Treatment Agents Antianxiety Agents Antibacterials Anticancer Agents Anticholinergic Agents Anticonvulsants Antidementia Agents Antidepressants Antidiabetic Agents Antifungals Antigout Agents 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 Cardiovascular Agents Central Nervous System Agents Contraceptives

16 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

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 16 ; QL (30 per 30 ; QL (30 per 30 ; QL (30 per 30 (Children's Fever Reducing) ; QL (30 per 30 (Non-Aspirin) ; QL (240 per 30 ml * acetaminophen 325 mg liqui-gel 325 mg * (Pain Relief) ; QL (360 per 30 acetaminophen 500 mg softgel 500 mg * (Tylophen) ; QL (240 per 30 acetaminophen 650 mg suppos 650 mg * (Acephen) ; QL (30 per 30 acetaminophen 80 mg rapid tab children's (Children's ; QL (30 per mg * Acetaminophen) acetaminophen-codeine oral solution mg/5 ml ; QL (2700 per 30 acetaminophen-codeine oral tablet mg ; QL (360 per 30 acetaminophen-codeine oral tablet mg (Tylenol-Codeine #3) ; QL (360 per 30 acetaminophen-codeine oral tablet mg (Tylenol-Codeine #4) ; QL (180 per 30 ALLZITAL ORAL TABLET MG 1 PA-HRM; $0; QL (360 per 30 ; AGE (Max 64 Years) 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 solution 0.3 mg/ml buprenorphine hcl injection syringe 0.3 mg/ml (Buprenex) 1 PA-HRM; $0; QL (180 per 30 ; AGE (Max 64 Years) ; QL (60 per 30

18 buprenorphine transdermal patch weekly 10 mcg/hour, 15 mcg/hour, 20 mcg/hour, 5 mcg/hour, 7.5 mcg/hour 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 (Butrans) ; QL (4 per 28 1 PA-HRM; $0; QL (180 per 30 ; AGE (Max 64 Years) 1 PA-HRM; $0; QL (180 per 30 ; AGE (Max 64 Years) (Marten-Tab) 1 PA-HRM; $0; QL (180 per 30 ; AGE (Max 64 Years) (Zebutal) 1 PA-HRM; $0; QL (180 per 30 ; AGE (Max 64 Years) (Esgic) 1 PA-HRM; $0; QL (180 per 30 ; AGE (Max 64 Years) (Fiorinal) 1 PA-HRM; $0; QL (180 per 30 ; AGE (Max 64 Years) ; QL (4 per 28 capacet oral capsule mg 1 PA-HRM; $0; QL (180 per 30 ; AGE (Max 64 Years) child non-aspirin 160 mg/5 ml children's 160 mg/5 ml * ; QL (240 per 30 child pain-fever 160 mg/5 ml a/f, asa/f, ibu/f 160 mg/5 ml * ; QL (240 per 30 child tactinal 80 mg tab chw 80 mg * ; QL (30 per 30 children's mapap 80 mg rapid 80 mg * ; QL (30 per 30 codeine sulfate oral tablet 15 mg, 30 mg, 60 mg ; QL (180 per 30 cvs acetaminophen 8-hr 650 mg caplet 650 mg * (8 HOUR PAIN RELIEVER) ; QL (180 per 30 cvs child non-asa 80 mg tb chw 80 mg * ; QL (30 per 30 cvs non-aspirin jr tab chew 160 mg * ; QL (30 per 30 17

19 18 cvs pain relief 325 mg liq gel 325 mg * ; QL (360 per 30 cvs pain relief adult liquid 500 mg/15 ml * ; QL (120 per 30 endocet oral tablet mg ; QL (240 per 30 endocet oral tablet mg, mg ; QL (360 per 30 endocet oral tablet mg ; QL (300 per 30 endodan oral tablet mg ; QL (360 per 30 fentanyl citrate buccal lozenge on a handle 1,200 mcg, 1,600 mcg, 200 mcg, 400 mcg, 600 mcg, 800 mcg fentanyl transdermal patch 72 hour 100 mcg/hr, 12 mcg/hr, 25 mcg/hr, 50 mcg/hr, 75 mcg/hr fentanyl transdermal patch 72 hour 37.5 mcg/hour, 62.5 mcg/hour, 87.5 mcg/hour feverall 120 mg suppository children's, outer 120 mg * feverall 325 mg suppository junior str, outer 325 mg * feverall 650 mg suppository adult, inner 650 mg * hydrocodone-acetaminophen oral solution mg/5 ml, mg/7.5ml(7.5ml) hydrocodone-acetaminophen oral solution mg/15 ml hydrocodone-acetaminophen oral tablet mg hydrocodone-acetaminophen oral tablet mg, mg hydrocodone-acetaminophen oral tablet mg hydrocodone-acetaminophen oral tablet mg hydrocodone-acetaminophen oral tablet mg (Actiq) 1 PA; $0; QL (120 per 30 (Duragesic) ; QL (10 per 30 ; QL (10 per 30 ; QL (30 per 30 ; QL (30 per 30 ; QL (30 per 30 ; QL (2700 per 30 (Hycet) ; QL (2700 per 30 (Vicodin HP) ; QL (390 per 30 (Norco) ; QL (360 per 30 (Verdrocet) ; QL (360 per 30 (Xodol 5/300) ; QL (390 per 30 (Lorcet (hydrocodone)) ; QL (360 per 30

20 19 hydrocodone-acetaminophen oral tablet mg (Xodol 7.5/300) ; QL (390 per 30 hydrocodone-ibuprofen oral tablet mg, mg (Ibudone) ; QL (150 per 30 hydrocodone-ibuprofen oral tablet mg ; QL (150 per 30 hydromorphone (pf) injection solution 10 (mg/ml) (5 ml) hydromorphone (pf) injection solution 10 mg/ml hydromorphone 10 mg/ml vial p/f,sdv,latexf 10 mg/ml hydromorphone injection solution 2 mg/ml, 4 mg/ml hydromorphone injection syringe 2 mg/ml, (Dilaudid) 4 mg/ml hydromorphone oral liquid 1 mg/ml (Dilaudid) ; QL (1200 per 30 hydromorphone oral tablet 2 mg, 4 mg, 8 mg (Dilaudid) ; QL (180 per 30 HYSINGLA ER ORAL TABLET,ORAL ; QL (30 per 30 ONLY,EXT.REL.24 HR 100 MG, 120 MG, 20 MG, 30 MG, 40 MG, 60 MG, 80 MG infant pain relv 80 mg/0.8 ml a/f, glutenfree ; QL (30 per mg/0.8 ml * jr pain-fever 160 mg rapid tab ; QL (30 per 30 junior,bubblegum 160 mg * junior mapap 160 mg rapid tab 160 mg * ; QL (30 per 30 LAZANDA NASAL SPRAY,NON- AEROSOL 100 MCG/SPRAY, PA; $0; QL (30 per 30 MCG/SPRAY, 400 MCG/SPRAY lorcet (hydrocodone) oral tablet mg ; QL (360 per 30 lorcet hd oral tablet mg ; QL (360 per 30 lorcet plus oral tablet mg ; QL (360 per 30 mapap 160 mg/5 ml liquid 160 mg/5 ml * ; QL (240 per 30

21 20 mapap 160 mg/5 ml suspension 160 mg/5 ml * ; QL (240 per 30 mapap 325 mg tablet 325 mg * ; QL (360 per 30 mapap 500 mg capsule 500 mg * ; QL (240 per 30 mapap 500 mg tablet 500 mg * ; QL (240 per 30 mapap 500 mg/15 ml liquid 500 mg/15 ml * ; QL (120 per 30 mapap 80 mg tablet chew 80 mg * ; QL (30 per 30 mapap arthritis er 650 mg cplt 650 mg * ; QL (180 per 30 margesic oral capsule mg 1 PA-HRM; $0; QL (180 per 30 ; AGE (Max 64 Years) methadone injection solution 10 mg/ml methadone oral solution 10 mg/5 ml, 5 mg/5 ml ; QL (1800 per 30 methadone oral tablet 10 mg (Dolophine) ; QL (360 per 30 methadone oral tablet 5 mg (Dolophine) ; QL (180 per 30 methadose oral tablet,soluble 40 mg ; QL (90 per 30 morphine 10 mg/ml carpuject outer, p/f, l/f, suv 10 mg/ml morphine 2 mg/ml carpuject outer, l/f, p/f, sdv 2 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 100 mg/5 ml (20 mg/ml) ; QL (180 per 30 morphine intramuscular pen injector 10 mg/0.7 ml morphine intravenous cartridge 15 mg/ml morphine intravenous syringe 10 mg/ml, 2 mg/ml, 4 mg/ml, 8 mg/ml morphine oral solution 10 mg/5 ml ; QL (700 per 30

22 21 morphine oral solution 20 mg/5 ml (4 ; QL (300 per 30 mg/ml) MORPHINE ORAL TABLET 15 MG ; QL (180 per 30 MORPHINE ORAL TABLET 30 MG ; QL (120 per 30 morphine oral tablet extended release 100 (MS Contin) ; QL (60 per 30 mg, 200 mg, 60 mg morphine oral tablet extended release 15 (MS Contin) ; QL (180 per 30 mg morphine oral tablet extended release 30 (MS Contin) ; QL (120 per 30 mg non-aspirin x-str 167 mg/5 ml 500 mg/15 ; QL (120 per 30 ml * nortemp 80 mg/0.8 ml drop 80 mg/0.8 ml * ; QL (30 per 30 NUCYNTA ER ORAL TABLET ; QL (60 per 30 EXTENDED RELEASE 12 HR 100 MG, 150 MG, 200 MG, 250 MG, 50 MG NUCYNTA ORAL TABLET 100 MG, 50 ; QL (181 per 30 MG, 75 MG oxycodone oral concentrate 20 mg/ml ; QL (120 per 30 oxycodone oral solution 5 mg/5 ml ; QL (1300 per 30 oxycodone oral tablet 10 mg ; QL (180 per 30 oxycodone oral tablet 15 mg, 30 mg (Roxicodone) ; QL (120 per 30 oxycodone oral tablet 20 mg ; QL (120 per 30 oxycodone oral tablet 5 mg (Roxicodone) ; QL (180 per 30 oxycodone oral tablet,oral only,ext.rel.12 (OxyContin) ; QL (60 per 30 hr 10 mg, 15 mg, 20 mg, 30 mg, 40 mg, 60 mg oxycodone oral tablet,oral only,ext.rel.12 (OxyContin) ; QL (120 per 30 hr 80 mg oxycodone-acetaminophen oral solution 5- ; QL (1800 per mg/5 ml oxycodone-acetaminophen oral tablet 10- (Percocet) ; QL (240 per mg

23 22 oxycodone-acetaminophen oral tablet mg, mg (Percocet) ; QL (360 per 30 oxycodone-acetaminophen oral tablet mg (Endocet) ; QL (300 per 30 oxycodone-aspirin oral tablet mg ; QL (360 per 30 OXYCONTIN ORAL TABLET,ORAL ; QL (60 per 30 ONLY,EXT.REL.12 HR 10 MG, 15 MG, 20 MG, 30 MG, 40 MG, 60 MG OXYCONTIN ORAL TABLET,ORAL ONLY,EXT.REL.12 HR 80 MG ; QL (120 per 30 oxymorphone oral tablet 10 mg (Opana) ; QL (120 per 30 oxymorphone oral tablet 5 mg (Opana) ; QL (180 per 30 oxymorphone oral tablet extended release ; QL (60 per hr 10 mg, 15 mg, 20 mg, 30 mg, 40 mg, 5 mg, 7.5 mg pain relief 500 mg capsule 500 mg * ; QL (240 per 30 pharbetol 325 mg tablet regular strength 325 mg * ; QL (360 per 30 pharbetol 500 mg caplet extra-str, caplet 500 mg * ; QL (240 per 30 pv non-aspirin 500 mg softgel ex-str,liq filled 500 mg * ; QL (240 per 30 q-pap 160 mg/5 ml solution a/f, cherry 160 mg/5 ml * ; QL (240 per 30 q-pap 325 mg tablet 325 mg * ; QL (360 per 30 q-pap 80 mg/0.8 ml drops 80 mg/0.8 ml * ; QL (30 per 30 q-pap ex-str 500 mg tablet aspirin free 500 mg * ; QL (240 per 30 reprexain oral tablet mg, mg, mg ; QL (150 per 30 sm pain rel jr str tab chew 160 mg * ; QL (30 per 30 sm pain reliever 80 mg tab children's 80 mg ; QL (30 per 30 * tactinal 325 mg tablet 325 mg * ; QL (360 per 30

24 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 325 mg tablet 325 mg * (Bayer Aspirin) aspirin 600 mg suppository 600 mg * aspirin 81 mg chewable tablet 81 mg * (St Joseph Aspirin) aspirin buffered 325 mg tab 325 mg * (Bufferin) aspirin ec 325 mg tablet 325 mg * (E.C. Prin) 23 tactinal 500 mg tablet extra-strength 500 mg * ; QL (240 per 30 tencon oral tablet mg 1 PA-HRM; $0; QL (180 per 30 ; AGE (Max 64 Years) tramadol oral tablet 50 mg (Ultram) ; QL (240 per 30 tramadol-acetaminophen oral tablet mg (Ultracet) ; QL (240 per 30 vicodin es oral tablet mg ; QL (390 per 30 vicodin hp oral tablet mg ; QL (390 per 30 vicodin oral tablet mg ; QL (390 per 30 XTAMPZA ER ORAL CAPSULE,SPRINKLE,ER 12HR TMPRR ; QL (60 per MG, 18 MG, 9 MG XTAMPZA ER ORAL CAPSULE,SPRINKLE,ER 12HR TMPRR 27 MG XTAMPZA ER ORAL CAPSULE,SPRINKLE,ER 12HR TMPRR 36 MG ; QL (120 per 30 ; QL (240 per 30 xylon 10 oral tablet mg ; QL (150 per 30 zebutal oral capsule mg 1 PA-HRM; $0; QL (180 per 30 ; AGE (Max 64 Years) Nonsteroidal Anti-Inflammatory Agents ADVIL 100 MG TABLET JR STRENGTH,COATED 100 MG *

25 24 aspirin ec 500 mg tablet 500 mg * aspirin ec 81 mg tablet low dose 81 mg * (Ecotrin Low Strength) aspir-low ec 81 mg tablet 81 mg * bufferin 325 mg tablet coated 325 mg * CALDOLOR INTRAVENOUS RECON SOLN 400 MG/4 ML (100 MG/ML) celecoxib oral capsule 100 mg, 200 mg, (Celebrex) ; QL (60 per mg, 50 mg CHILDREN'S ADVIL 100 MG/5 ML (OTC) 100 MG/5 ML * cvs ibuprofen 200 mg softgel liquid (Wal-Profen) filled,softge 200 mg * diclofenac potassium oral tablet 50 mg diclofenac sodium oral tablet extended (Voltaren-XR) release 24 hr 100 mg diclofenac sodium oral tablet,delayed release (dr/ec) 25 mg, 50 mg, 75 mg diclofenac-misoprostol oral (Arthrotec 50) tablet,ir,delayed rel,biphasic mgmcg diclofenac-misoprostol oral (Arthrotec 75) tablet,ir,delayed rel,biphasic mgmcg diflunisal oral tablet 500 mg ecotrin ec 325 mg tablet saftey coated 325 mg * ecpirin ec 325 mg tablet 325 mg * etodolac oral capsule 200 mg, 300 mg etodolac oral tablet 400 mg (Lodine) etodolac oral tablet 500 mg etodolac oral tablet extended release 24 hr 400 mg, 500 mg, 600 mg fenoprofen oral tablet 600 mg FLECTOR TRANSDERMAL PATCH 12 2 PA; $0 HOUR 1.3 % flurbiprofen oral tablet 100 mg, 50 mg gnp ibuprofen jr str 100 mg tb 100 mg * ibuprofen 100 mg/5 ml susp children's (otc) (Children's Motrin) 100 mg/5 ml * ibuprofen 200 mg tablet 200 mg * (I-Prin)

26 25 ibuprofen oral suspension 100 mg/5 ml (Children's Motrin) ibuprofen oral tablet 400 mg, 600 mg, 800 mg indomethacin oral capsule 25 mg ; QL (240 per 30 indomethacin oral capsule 50 mg ; QL (120 per 30 indomethacin oral capsule, extended ; QL (60 per 30 release 75 mg indomethacin sodium intravenous recon soln 1 mg infant ibuprofen 50 mg/1.25 ml d/f,a/f,nonstaining 50 mg/1.25 ml * infants' advil 50 mg/1.25 ml 50 mg/1.25 ml * ketoprofen oral capsule 50 mg, 75 mg ketoprofen oral capsule,ext rel. pellets 24 hr 200 mg ketorolac oral tablet 10 mg ; QL (20 per 30 mefenamic acid oral capsule 250 mg (Ponstel) meloxicam oral suspension 7.5 mg/5 ml meloxicam oral tablet 15 mg, 7.5 mg (Mobic) nabumetone oral tablet 500 mg, 750 mg naproxen oral suspension 125 mg/5 ml (Naprosyn) naproxen oral tablet 250 mg, 375 mg naproxen oral tablet 500 mg (Naprosyn) naproxen oral tablet,delayed release (EC-Naprosyn) (dr/ec) 375 mg, 500 mg naproxen sodium oral tablet 275 mg naproxen sodium oral tablet 550 mg (Anaprox DS) piroxicam oral capsule 10 mg, 20 mg (Feldene) 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 * sulindac oral tablet 150 mg, 200 mg tolmetin oral capsule 400 mg tolmetin oral tablet 200 mg, 600 mg

27 26 tri buffered asa 325 mg tab 325 mg * VOLTAREN TOPICAL GEL 1 % wal-profen 200 mg softgel softgel 200 mg * Anesthetics Local Anesthetics glydo mucous membrane jelly in applicator 2 % lidocaine (pf) injection solution 15 mg/ml (Xylocaine-MPF) (1.5 %), 20 mg/ml (2 %), 5 mg/ml (0.5 %) lidocaine (pf) injection solution 40 mg/ml (4 %) lidocaine hcl injection solution 10 mg/ml (1 (Xylocaine) %), 20 mg/ml (2 %), 5 mg/ml (0.5 %) lidocaine hcl mucous membrane jelly 2 % lidocaine hcl mucous membrane solution 4 % (40 mg/ml) lidocaine topical adhesive patch,medicated (Lidoderm) 1 PA; $0 5 % lidocaine topical ointment 5 % lidocaine viscous mucous membrane solution 2 % lidocaine-prilocaine topical cream % Anti-Addiction/Substance Abuse Treatment Agents Anti-Addiction/Substance Abuse Treatment Agents acamprosate oral tablet,delayed release (dr/ec) 333 mg BUNAVAIL BUCCAL FILM MG ; QL (30 per 30 BUNAVAIL BUCCAL FILM MG, ; QL (60 per MG buprenorphine hcl sublingual tablet 2 mg, 8 ; QL (90 per 30 mg buprenorphine-naloxone sublingual tablet ; QL (90 per mg, 8-2 mg buproban oral tablet extended release 12 hr 150 mg bupropion hcl (smoking deter) oral tablet extended release 12 hr 150 mg (Zyban)

28 27 CHANTIX CONTINUING MONTH BOX ORAL TABLET 1 MG ; QL (168 per 84 CHANTIX ORAL TABLET 0.5 MG, 1 MG ; QL (168 per 84 CHANTIX STARTING MONTH BOX ; QL (53 per 28 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 injection syringe 0.4 mg/ml, 1 mg/ml naltrexone oral tablet 50 mg (Revia) NARCAN NASAL SPRAY,NON- ; QL (4 per 30 AEROSOL 2 MG/ACTUATION, 4 MG/ACTUATION nicorelief 2 mg gum 2 mg * nicorelief 4 mg gum 4 mg * NICORETTE 2 MG CHEWING GUM WHITE ICE MINT 2 MG * nicotine 14 mg/24hr patch step 2 (otc) 14 mg/24 hr * (Nicoderm CQ) ; QL (180 per 365 nicotine 2 mg chewing gum sugar free 2 mg (Nicorelief) * nicotine 2 mg lozenge mint, 3 quittube 2 mg * (Nicorette) nicotine 21 mg/24hr patch outer, clear, step (NTS Step 1) ; QL (168 per (otc) 21 mg/24 hr * nicotine 22 mg/24hr patch 1 week starter kit 22 mg/24 hr * ; QL (168 per 365 nicotine 4 mg chewing gum 4 mg * (Nicorelief) nicotine 4 mg lozenge mint, 3 quittube 4 mg (Nicorette) * nicotine 7 mg/24hr patch step 3 (otc) 7 mg/24 hr * (Nicoderm CQ) ; QL (180 per 365 NICOTROL INHALATION CARTRIDGE 10 MG ; QL (1008 per 90 SUBOXONE SUBLINGUAL FILM 12-3 ; QL (60 per 30 MG, 8-2 MG SUBOXONE SUBLINGUAL FILM MG, 4-1 MG ; QL (30 per 30

29 ZUBSOLV SUBLINGUAL TABLET MG, MG, MG, MG, MG ZUBSOLV SUBLINGUAL TABLET MG Antianxiety Agents Benzodiazepines alprazolam oral tablet 0.25 mg, 0.5 mg, 1 28 ; QL (30 per 30 ; QL (60 per 30 (Xanax) ; QL (120 per 30 mg alprazolam oral tablet 2 mg (Xanax) ; QL (150 per 30 chlordiazepoxide hcl oral capsule 10 mg, 25 mg, 5 mg ; QL (120 per 30 clonazepam oral tablet 0.5 mg, 1 mg (Klonopin) ; QL (90 per 30 clonazepam oral tablet 2 mg (Klonopin) ; QL (300 per 30 clonazepam oral tablet,disintegrating ; QL (90 per 30 mg, 0.25 mg, 0.5 mg, 1 mg clonazepam oral tablet,disintegrating 2 mg ; QL (300 per 30 clorazepate dipotassium oral tablet 15 mg, 3.75 mg ; QL (180 per 30 clorazepate dipotassium oral tablet 7.5 mg (Tranxene T-Tab) ; QL (180 per 30 diazepam injection solution 5 mg/ml ; QL (10 per 28 diazepam intensol oral concentrate 5 mg/ml ; QL (1200 per 30 diazepam oral solution 5 mg/5 ml (1 mg/ml) ; QL (1200 per 30 diazepam oral tablet 10 mg, 2 mg, 5 mg (Valium) ; QL (120 per 30 diazepam rectal kit mg, 5- (Diastat AcuDial) mg diazepam rectal kit 2.5 mg (Diastat) lorazepam injection solution 2 mg/ml (Ativan) ; QL (2 per 30 lorazepam oral tablet 0.5 mg, 1 mg (Ativan) ; QL (90 per 30 lorazepam oral tablet 2 mg (Ativan) ; QL (150 per 30 ONFI ORAL SUSPENSION 2.5 MG/ML 2 PA NSO; $0; QL (480 per 30

30 ONFI ORAL TABLET 10 MG, 20 MG 2 PA NSO; $0; QL (60 per 30 Antibacterials Aminoglycosides BETHKIS INHALATION SOLUTION 2 PA BvD; $0 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 latex-free, sdv 20 mg/2 ml gentamicin sulfate (pf) intravenous solution 100 mg/10 ml neomycin oral tablet 500 mg streptomycin intramuscular recon soln 1 gram TOBI PODHALER INHALATION CAPSULE, W/INHALATION DEVICE 28 MG tobramycin in % nacl inhalation solution for nebulization 300 mg/5 ml tobramycin in 0.9 % nacl intravenous piggyback 60 mg/50 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 ; QL (224 per 28 (Tobi) 1 PA BvD; $0 (BACiiM) (Clindamycin Pediatric) (Cleocin HCl) (Cleocin in 5 % dextrose) 29

31 clindamycin pediatric oral recon soln 75 mg/5 ml clindamycin phosphate injection solution 150 (mg/ml) (6 ml) clindamycin phosphate injection solution (Cleocin) 150 mg/ml clindamycin phosphate intravenous (Cleocin) solution 600 mg/4 ml colistin (colistimethate na) injection recon (Coly-Mycin M soln 150 mg Parenteral) daptomycin intravenous recon soln 500 mg (Cubicin) linezolid intravenous parenteral solution (Zyvox) 600 mg/300 ml linezolid oral suspension for reconstitution (Zyvox) 100 mg/5 ml linezolid oral tablet 600 mg (Zyvox) methenamine hippurate oral tablet 1 gram (Hiprex) metronidazole in nacl (iso-os) intravenous (Metro I.V.) piggyback 500 mg/100 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) 1 PA-HRM; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use of nitrofurantoin drugs); $0; QL (120 per 30 ; AGE (Max 64 nitrofurantoin monohyd/m-cryst oral capsule 100 mg Years) (Macrobid) 1 PA-HRM; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use of nitrofurantoin drugs); $0; QL (60 per 30 ; AGE (Max 64 Years) 30

32 31 polymyxin b sulfate injection recon soln 500,000 unit SYNERCID INTRAVENOUS RECON SOLN 500 MG trimethoprim oral tablet 100 mg vancomycin hcl 1g/200 ml bag 1 gram/200 ml vancomycin intravenous recon soln 1,000 mg, 10 gram, 750 mg vancomycin intravenous recon soln 500 mg vancomycin oral capsule 125 mg, 250 mg (Vancocin) XIFAXAN ORAL TABLET 200 MG 2 PA; $0; QL (9 per 30 XIFAXAN ORAL TABLET 550 MG 2 PA; $0 Cephalosporins cefaclor oral capsule 250 mg, 500 mg cefaclor oral suspension for reconstitution 125 mg/5 ml, 250 mg/5 ml, 375 mg/5 ml cefadroxil oral capsule 500 mg cefadroxil oral suspension for reconstitution 250 mg/5 ml, 500 mg/5 ml cefadroxil oral tablet 1 gram cefazolin in dextrose (iso-os) intravenous piggyback 1 gram/50 ml, 2 gram/50 ml cefazolin injection recon soln 1 gram, 10 gram, 500 mg cefdinir oral capsule 300 mg cefdinir oral suspension for reconstitution 125 mg/5 ml, 250 mg/5 ml cefditoren pivoxil oral tablet 200 mg cefditoren pivoxil oral tablet 400 mg (Spectracef) CEFEPIME 1 GM INJECTION 1 GRAM/50 ML cefepime hcl 1 gm vial 10's, sdv 1 gram (Maxipime) cefepime hcl 2 gram vial latex/f, sdv, outer (Maxipime) 2 gram CEFEPIME INJECTION RECON SOLN 1 (Maxipime) GRAM, 2 GRAM CEFEPIME-DEXTROSE 2 GM/50 ML 2 GRAM/50 ML

33 cefotaxime injection recon soln 1 gram, 10 (Claforan) gram, 2 gram cefotaxime injection recon soln 500 mg cefoxitin 2 gm piggyback bag 2 gram/50 ml cefoxitin 2 gm vial l/f, outer, sdv 2 gram cefoxitin intravenous recon soln 1 gram, 10 gram cefoxitin intravenous recon soln 2 gram 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 cefprozil oral tablet 250 mg, 500 mg ceftazidime injection recon soln 2 gram (Fortaz) ceftazidime injection recon soln 6 gram (TAZICEF) ceftibuten oral capsule 400 mg (Cedax) ceftibuten oral suspension for (Cedax) reconstitution 180 mg/5 ml ceftriaxone 1 gm piggyback l/g, single use 1 gram/50 ml ceftriaxone 2 gm piggyback l/f, single use 2 gram/50 ml ceftriaxone injection recon soln 1 gram, 10 gram, 250 mg, 500 mg ceftriaxone intravenous recon soln 1 gram, 2 gram cefuroxime axetil oral tablet 250 mg, 500 mg cefuroxime sodium injection recon soln 750 (Zinacef) mg cefuroxime sodium intravenous recon soln (Zinacef) 1.5 gram, 7.5 gram cephalexin oral capsule 250 mg, 500 mg, (Keflex) 750 mg cephalexin oral suspension for reconstitution 125 mg/5 ml, 250 mg/5 ml cephalexin oral tablet 250 mg, 500 mg 32

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