PERS Moda Health PPORX (PPO) PERS Moda Health Rx (PDP)

Transcription

1 PERS Moda Health PPORX (PPO) PERS Moda Health Rx (PDP) 2017 Comprehensive Formulary (complete list of covered drugs) Please read: this document contains information about the drugs we cover in this plan Note to existing members: This formulary has changed since last year. Please review this document to make sure that it still contains the drugs you take. This formulary was updated on December 1, For more recent information or other questions, please contact Moda Health Plan, Inc. Customer Service at or, for TTY users, 711, from 7 a.m. to 8 p.m. Pacific Time, seven days a week, or visit H S Y0115_CFPERS17A Accepted

2 Next year, you can get plan documents delivered to you online Online documents give you easy access to all your Medicare information. The Centers for Medicare and Medicaid Services (CMS) require that we send you important plan documents every year. These documents contain information specific to your Moda Health plan: > > Combined Annual Notice of Changes (ANOC) and Evidence of Coverage (EOC) > > Comprehensive formulary (if applicable) That s a lot of paper to clutter your home. Luckily, all of these documents are available electronically through your mymoda account. To receive an from Moda Health when new materials are available, simply log in to your mymoda account by visiting The mymoda log in is on the right side of your screen. You can also create an account on this page. Once logged in, select the Account tab. Next, click on Change account settings. From here, you can update your and make your electronic delivery preference. Once you request electronic delivery, you will no longer receive these documents in the mail. Questions? Call us at (8/15) MDCR-1456 Health plans in Oregon, Washington and Alaska provided by Moda Health Plan, Inc. Dental plans in Oregon provided by Oregon Dental Service. Dental plans in Alaska provided by Oregon Dental Service doing business as Delta Dental of Alaska.

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4 Moda Health nondiscrimination notice Moda, Inc. complies with applicable federal civil rights laws. We do not discriminate on the basis of race, color, national origin, age, disability or sex. Moda provides free, timely aids and services to people with disabilities to help them communicate with us effectively. These accommodations include sign language interpreters and written information in other formats. If your primary language is not English, Moda also provides free, timely interpretation services and/or materials written in other languages. If you need any of the services listed above, contact: Medicare Customer Service, (TDD/TTY 711) Medicaid Customer Service, (TDD/TTY 711) Customer Service for all other plans, (TDD/TTY 711) If you believe that Moda has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability or sex, you can file a written grievance by mailing or faxing it to: Moda, Inc. Attention: Appeal Unit 601 SW Second Ave. Portland, OR Fax: If you need assistance filing a grievance, please call the applicable Customer Service department listed above. You can also file a civil rights complaint with the U.S. Department of Health and Human Services Office for Civil Rights at ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone to: U.S. Department of Health and Human Services 200 Independence Ave. SW, Room 509F HHH Building, Washington, DC , (TDD). Office for Civil Rights complaint forms are available at hhs.gov/ocr/office/file/index.html. Moda s efforts to assure nondiscrimination are coordinated by: Tom Bikales, VP Legal Affairs 601 SW Second Ave. Portland, OR compliance@modahealth.com

5 ATENCIÓN: Si habla español, hay disponibles servicios de ayuda con el idioma sin costo alguno para usted. Llame al (TTY: 711). 注意 : 如果您說中文, 可得到免費語言幫助服務 請致電 ( 聾啞人專用 :711) CHÚ Ý: Nếu bạn nói tiếng Việt, có dịch vụ hổ trợ ngôn ngữ miễn phí cho bạn. Gọi (TTY:711) 주의 : 한국어로무료언어지원서비스를이용하시려면다음연락처로연락해주시기바랍니다. 전화 (TTY: 711) PAUNAWA: Kung nagsasalita ka ng Tagalog, ang a serbisyong tulong sa wika, ay walang bayad, at magagamit mo. Tumawag sa numerong (TTY: 711) ВНИМАНИЕ! Если Вы говорите по-русски, воспользуйтесь бесплатной языковой поддержкой. Позвоните по тел (текстовый телефон: 711). تنبيه: إذا كنت تتحدث العربية فهناك خدمات مساعدة لغوية متاحة لك مجان ا. اتصل برقم )الهاتف النصي: 711( ATANSYON: Si ou pale Kreyòl Ayisyen, nou ofri sèvis gratis pou ede w nan lang ou pale a. Rele nan (moun ki itilize sistèm TTY rele : 711) ATTENTION : si vous êtes locuteurs francophones, le service d assistance linguistique gratuit est disponible. Appelez au (TTY : 711) UWAGA: Dla osób mówiących po polsku dostępna jest bezpłatna pomoc językowa. Zadzwoń: (obsługa TTY: 711) ATENÇÃO: Caso fale português, estão disponíveis serviços gratuitos de ajuda linguística. Telefone para (TERMINAL: 711) ATTENZIONE: Se parla italiano, sono disponibili per lei servizi gratuiti di assistenza linguistica. Chiamare il numero (TTY: 711) 注意 : 日本語をご希望の方には 日本語サービスを無料で提供しております (TYY テレタイプライターをご利用の方は 711) までお電話ください Achtung: Falls Sie Deutsch sprechen, stehen Ihnen kostenlos Sprachassistenzdienste zur Verfügung. Rufen sie (TTY: 711) توجه: در صورتی که به فارسی صحبت می کنید خدمات ترجمه به صورت رایگان برای شما موجود است. با 711( )TTY: تماس بگیرید. УВАГА! Якщо ви говорите українською, для вас доступні безкоштовні консультації рідною мовою. Зателефонуйте (TTY: 711) ATENȚIE: Dacă vorbiți limba română, vă punem la dispoziție serviciul de asistență lingvistică în mod gratuit. Sunați la (TTY 711) THOV CEEB TOOM: Yog hais tias koj hais lus Hmoob, muaj cov kev pab cuam txhais lus, pub dawb rau koj. Hu rau (TTY: 711) โปรดทราบ: หากค ณพ ดภาษาไทย ค ณ สามารถใช บร การช วยเหล อด านภาษาได ฟร โทร (TTY: 711) ត រ វចងច ប អ នកន យ យភ ស ខ ម រ ហ យត រ វ ក រស វ កម មជ ន យផ ន កភ ស ដ យឥតគ តថ ល គ ម នផ ដល ជ នល កអ នក ស មទ រស ព ទទ ក ន ល ខ (TTY: 711) HUBACHIISA: Yoo afaan Kshtik kan dubbattan ta e tajaajiloonni gargaarsaa isiniif jira (TTY:711) tiin bilbilaa. Y0115_MLI17A Accepted

6 PERS Moda Health PPORX (PPO) PERS Moda Health Rx (PDP) 2017 Comprehensive Formulary (Complete List of Covered Drugs) Formulary 17049, Version 19 PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN This formulary was updated on December 1, For more recent information or other questions, please contact Moda Health Plan, Inc. Customer Service at or, for TTY users, 711, from 7 a.m. to 8 p.m., Pacific Time, seven days a week from October 1 through February 14 (After February 15, your call will be handled by our automated phone system Saturdays, Sundays and holidays.), or visit Note to existing members: This formulary has changed since last year. Please review this document to make sure that it still contains the drugs you take. When this drug list (formulary) refers to we, us, or our, it means Moda Health Plan, Inc. When it refers to plan or our plan, it means PERS Moda Health PPORX (PPO) or PERS Moda Health Rx (PDP). This document includes a list of the drugs (formulary) for our plan which is current as of December 1, For an updated formulary, please contact us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages. You must generally use network pharmacies to use your prescription drug benefit. Benefits, formulary, pharmacy network, and/or copayments/coinsurance may change on January 1, 2018, and from time to time during the year. Moda Health Plan, Inc. is a PPO and stand-alone prescription drug plan with Medicare contracts. Enrollment in Moda Health Plan, Inc. depends on contract renewal Formulary ID 17049, Version 19 Y0115_CF_PERS17A Accepted i

7 What is the PERS Moda Health Formulary? A formulary is a list of covered drugs selected by PERS Moda Health in consultation with a team of health care providers, which represents the prescription therapies believed to be a necessary part of a quality treatment program. PERS Moda Health will generally cover the drugs listed in our formulary as long as the drug is medically necessary, the prescription is filled at a PERS Moda Health network pharmacy, and other plan rules are followed. For more information on how to fill your prescriptions, please review your Evidence of Coverage. Can the Formulary (drug list) change? Generally, if you are taking a drug on our 2017 formulary that was covered at the beginning of the year, we will not discontinue or reduce coverage of the drug during the 2017 coverage year except when a new, less expensive generic drug becomes available or when new adverse information about the safety or effectiveness of a drug is released. Other types of formulary changes, such as removing a drug from our formulary, will not affect members who are currently taking the drug. It will remain available at the same cost-sharing for those members taking it for the remainder of the coverage year. We feel it is important that you have continued access for the remainder of the coverage year to the formulary drugs that were available when you chose our plan, except for cases in which you can save additional money or we can ensure your safety. If we remove drugs from our formulary, or add prior authorization, quantity limits and/or step therapy restrictions on a drug or move a drug to a higher cost-sharing tier, we must notify affected members of the change at least 60 days before the change becomes effective, or at the time the member requests a refill of the drug, at which time the member will receive a 60-day supply of the drug. If the Food and Drug Administration deems a drug on our formulary to be unsafe or the drug s manufacturer removes the drug from the market, we will immediately remove the drug from our formulary and provide notice to members who take the drug. The enclosed formulary is current as of December 1, To get updated information about the drugs covered by PERS Moda Health, please contact us. Our contact information appears on the front and back cover pages. How do I use the Formulary? There are two ways to find your drug within the formulary: Medical Condition The formulary begins on page 1. The drugs in this formulary are grouped into categories depending on the type of medical conditions that they are used to treat. For example, drugs used to treat a heart condition are listed under the category, Cardiovascular Agents. If you know what your drug is used for, look for the category name in the list that begins on page 1. Then look under the category name for your drug. ii

8 Alphabetical Listing If you are not sure what category to look under, you should look for your drug in the Index that begins on page I-1. The Index provides an alphabetical list of all of the drugs included in this document. Both brand name drugs and generic drugs are listed in the Index. Look in the Index and find your drug. Next to your drug, you will see the page number where you can find coverage information. Turn to the page listed in the Index and find the name of your drug in the first column of the list. What are generic drugs? PERS Moda Health covers both brand name drugs and generic drugs. A generic drug is approved by the FDA as having the same active ingredient as the brand name drug. Generally, generic drugs cost less than brand name drugs. Are there any restrictions on my coverage? Some covered drugs may have additional requirements or limits on coverage. These requirements and limits may include: Prior Authorization: PERS Moda Health requires you or your physician to get prior authorization for certain drugs. This means that you will need to get approval from PERS Moda Health before you fill your prescriptions. If you don t get approval, PERS Moda Health may not cover the drug. Quantity Limits: For certain drugs, PERS Moda Health limits the amount of the drug that PERS Moda Health will cover. For example, PERS Moda Health provides 18 tablets per 28 days (18/28 per prescription for sumatriptan. This may be in addition to a standard one-month or threemonth supply. Step Therapy: In some cases, PERS Moda Health requires you to first try certain drugs to treat your medical condition before we will cover another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, PERS Moda Health may not cover Drug B unless you try Drug A first. If Drug A does not work for you, PERS Moda Health will then cover Drug B. You can find out if your drug has any additional requirements or limits by looking in the formulary that begins on page 1. You can also get more information about the restrictions applied to specific covered drugs by visiting our Web site. We have posted on line documents that explain our prior authorization and step therapy restrictions. You may also ask us to send you a copy. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages. You can ask PERS Moda Health to make an exception to these restrictions or limits or for a list of other, similar drugs that may treat your health condition. See the section, How do I request an exception to the PERS Moda Health formulary? on page iv for information about how to request an exception. iii

9 What if my drug is not on the Formulary? If your drug is not included in this formulary (list of covered drugs), you should first contact Customer Service and ask if your drug is covered. If you learn that PERS Moda Health does not cover your drug, you have two options: You can ask Customer Service for a list of similar drugs that are covered by PERS Moda Health. When you receive the list, show it to your doctor and ask him or her to prescribe a similar drug that is covered by PERS Moda Health. You can ask PERS Moda Health to make an exception and cover your drug. See below for information about how to request an exception. How do I request an exception to the PERS Moda Health Formulary? You can ask PERS Moda Health to make an exception to our coverage rules. There are several types of exceptions that you can ask us to make. You can ask us to cover a drug even if it is not on our formulary. If approved, this drug will be covered at a pre-determined cost-sharing level, and you would not be able to ask us to provide the drug at a lower cost-sharing level. You can ask us to waive coverage restrictions or limits on your drug. For example, for certain drugs, PERS Moda Health limits the amount of the drug that we will cover. If your drug has a quantity limit, you can ask us to waive the limit and cover a greater amount. Generally, PERS Moda Health will only approve your request for an exception if the alternative drugs included on the plan s formulary or additional utilization restrictions would not be as effective in treating your condition and/or would cause you to have adverse medical effects. You should contact us to ask us for an initial coverage decision for a formulary, or utilization restriction exception. When you request a formulary or utilization restriction exception you should submit a statement from your prescriber or physician supporting your request. Generally, we must make our decision within 72 hours of getting your prescriber s supporting statement. You can request an expedited (fast) exception if you or your doctor believe that your health could be seriously harmed by waiting up to 72 hours for a decision. If your request to expedite is granted, we must give you a decision no later than 24 hours after we get a supporting statement from your doctor or other prescriber. What do I do before I can talk to my doctor about changing my drugs or requesting an exception? As a new or continuing member in our plan you may be taking drugs that are not on our formulary. Or, you may be taking a drug that is on our formulary but your ability to get it is limited. For example, you may need a prior authorization from us before you can fill your prescription. You should talk to your doctor to decide if you should switch to an appropriate drug that we cover or request a formulary exception so that we will cover the drug you take. While you talk to your doctor to determine the right course of action for you, we may cover your drug in certain cases during the first 90 days you are a member of our plan. iv

10 For each of your drugs that is not on our formulary or if your ability to get your drugs is limited, we will cover a 31-day supply (unless you have a prescription written for fewer when you go to a network pharmacy. After your first 31-day supply, we will not pay for these drugs, even if you have been a member of the plan less than 90 days. If you are a resident of a long-term care facility, we will allow you to refill your prescription until we have provided you with 93-day transition supply, consistent with dispensing increment, (unless you have a prescription written for fewer. We will cover more than one refill of these drugs for the first 90 days you are a member of our plan. If you need a drug that is not on our formulary or if your ability to get your drugs is limited, but you are past the first 90 days of membership in our plan, we will cover a 31-day emergency supply of that drug (unless you have a prescription for fewer while you pursue a formulary exception. If you have a level of care change (such as going into or coming out of a skilled nursing facility or long term care home) we will cover a temporary 31-day transition supply (unless you have a prescription written for fewer. If you need a drug that is not on our formulary or if your ability to get your drugs is limited, but you are past the first 90 days of membership in our plan, we will cover a 31-day emergency supply of that drug (unless you have a prescription for fewer while you pursue a formulary exception. For more information For more detailed information about your PERS Moda Health prescription drug coverage, please review your Evidence of Coverage and other plan materials. If you have questions about PERS Moda Health, please contact us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages. If you have general questions about Medicare prescription drug coverage, please call Medicare at MEDICARE ( ) 24 hours a day/7 days a week. TTY users should call Or, visit PERS Moda Health Formulary The formulary that begins on page 1 provides coverage information about the drugs covered by PERS Moda Health. 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 drug name. Brand name drugs are capitalized (e.g., LYRICA) and generic drugs are listed in lower-case italics (e.g., valsartan). The information in the Requirements/Limits column tells you if PERS Moda Health has any special requirements for coverage of your drug. v

11 ABBREVIATION DESCRIPTION EXPLANATION Utilization Management Restrictions This drug is covered at the same tiering GC Gap Coverage level through the coverage gap. Please refer to our Evidence of Coverage for more information about this coverage. LA Limited Access Drug This prescription may be available only at certain pharmacies. For more information call Customer Service at from 7 a.m. to 8 p.m., Pacific time, seven days a week, from October 1st to February 14 (after February 15, your call will be handled by our automated phone system Saturdays, Sundays and holi. TTY users, call 711. NDS Non-Extended Days Supply This prescription is limited to a 31-day supply. For more information call Customer Service at from 7 a.m. to 8 p.m., Pacific time, seven days a week, from October 1st to February 14 (after February 15, your call will be handled by our automated phone system Saturdays, Sundays and holi. TTY users, call 711. You (or your physician) are required to get prior authorization from PERS Moda Health before you fill your prescription for this drug. Without prior approval, Moda Health may not cover the drug. To request a PA coverage determination, please call Prior Authorization Customer Service at from Restriction 7 a.m. to 8 p.m., Pacific time, seven days a week, from October 1st to February 14 (after February 15, your call will be handled by our automated phone system Saturdays, Sundays and holi. TTY users, call 711. PA for ESRD Only Prior Authorization Restriction for ESRD Members These drugs are also prescribed for members who have End-Stage Renal Disease (ESRD). If you have ESRD then you may need to receive these drugs from your dialysis facility. If you don t have ESRD, see page iv to learn how to request an exception. If you need help requesting an exception please call Customer Service at from 7 a.m. to 8 p.m., vi

12 ABBREVIATION DESCRIPTION EXPLANATION Pacific time, seven days a week, from October 1st to February 14 (after February 15, your call will be handled by our automated phone system Saturdays, Sundays and holi. TTY users, call 711. PA BvD PA-HRM Prior Authorization Restriction for Part B vs Part D Determination Prior Authorization Restriction for High Risk Medications 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 PERS Moda Health to determine that this drug is covered under Medicare Part D before you fill your prescription for this drug. Without prior approval, Moda Health may not cover the drug. To request a coverage determination, please call Customer Service at from 7 a.m. to 8 p.m., Pacific time, seven days a week, from October 1st to February 14 (after February 15, your call will be handled by our automated phone system Saturdays, Sundays and holi. TTY users, call 711. This drug has been deemed by CMS to be potentially harmful and therefore, a High Risk Medication for Medicare beneficiaries 65 years or older. Members age 65 years or older are required to get prior authorization from PERS Moda Health before you fill your prescription for this drug. Without prior approval, Moda Health may not cover the drug. To request a coverage determination, please call Customer Service at from 7 a.m. to 8 p.m., Pacific time, seven days a week, from October 1st to February 14 (after February 15, your call will be handled by our automated phone system Saturdays, Sundays and holi. TTY users, call 711. vii

13 ABBREVIATION DESCRIPTION EXPLANATION PA NSO QL Rx Product Only Prior Authorization Restriction for New Starts Only Quantity Limit Restriction Prescription Strength Covered If you are a new member or if you have not taken this drug before, you (or your physician) are required to get prior authorization from PERS Moda Health before you fill your prescription for this drug. Without prior approval, Moda Health may not cover the drug. To request a coverage determination, please call Customer Service at from 7 a.m. to 8 p.m., Pacific time, seven days a week, from October 1st to February 14 (after February 15, your call will be handled by our automated phone system Saturdays, Sundays and holi. TTY users, call 711. PERS Moda Health limits the amount of this drug that is covered per prescription, or within a specific time frame. Without prior approval, Moda Health may not cover the drug. To request a coverage determination, please call Customer Service at from 7 a.m. to 8 p.m., Pacific time, seven days a week, from October 1st to February 14 (after February 15, your call will be handled by our automated phone system Saturdays, Sundays and holi. TTY users, call 711. This drug is now available as a generic over-the-counter (OTC) medication. OTC products are not covered under your Part D benefit. The prescription strength is only covered under your Part D benefit. If you have questions please call Customer Service at from 7 a.m. to 8 p.m., Pacific time, seven days a week, from October 1st to February 14 (After February 15, your call will be handled by our automated phone system Saturdays, Sundays and holidays.). TTY users, call 711. viii

14 ABBREVIATION DESCRIPTION EXPLANATION ST Step Therapy Restriction Before PERS Moda Health 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. To request a coverage determination, please call Customer Service at from 7 a.m. to 8 p.m., Pacific time, seven days a week, from October 1st to February 14 (after February 15, your call will be handled by our automated phone system Saturdays, Sundays and holi. TTY users, call 711. Below is your cost sharing in the plan by drug tier: Drug Tier 1: You pay 40% of the total cost up to a maximum $250 for up to a 93-day supply of preferred generic drugs Drug Tier 2: You pay 40% of the total cost up to a maximum $250 for up to a 93-day supply of generic drugs Drug Tier 3: You pay 40% of the total cost up to a maximum $250 for up to a 31-day supply of preferred brand drugs. You pay 40% of the total cost up to a maximum $750 for up to a 93-day supply of preferred brand drugs Drug Tier 4: You pay 40% of the total cost up to a maximum $250 for up to a 31-day supply of nonpreferred brand drugs. You pay 40% of the total cost up to a maximum $750 for up to a 93-day supply of non-preferred brand drugs Drug Tier 5: You pay 40% of the total cost up to a maximum $250 for up to a 31-day supply of specialty drugs. ix

15 Table of Contents Analgesics...3 Anesthetics Anti-Addiction/Substance Abuse Treatment Agents Antianxiety Agents...12 Antibacterials Anticancer Agents Anticholinergic Agents Anticonvulsants...31 Antidementia Agents...35 Antidepressants Antidiabetic Agents Antifungals...42 Antigout Agents Antihistamines...44 Anti-Infectives (Skin And Mucous Membrane)...45 Antimigraine Agents...45 Antimycobacterials...46 Antinausea Agents...46 Antiparasite Agents...48 Antiparkinsonian Agents...49 Antipsychotic Agents...50 Antivirals (Systemic)...55 Blood Products/Modifiers/Volume Expanders Caloric Agents...63 Cardiovascular Agents Central Nervous System Agents Contraceptives...83 Dental And Oral Agents...89 Dermatological Agents...90 Devices Enzyme Replacement/Modifiers...96 Eye, Ear, Nose, Throat Agents...97 Gastrointestinal Agents Genitourinary Agents Heavy Metal Antagonists Hormonal Agents, Stimulant/Replacement/Modifying

16 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 acetaminophen-codeine oral solution /5 ml, /15 ml (15 ml) acetaminophen-codeine oral tablet acetaminophen-codeine oral tablet acetaminophen-codeine oral tablet ALLZITAL ORAL TABLET MG ascomp with codeine oral capsule BELBUCA BUCCAL FILM 150 MCG, 300 MCG, 450 MCG, 600 MCG, 75 MCG, 750 MCG, 900 MCG buprenorphine hcl injection solution 0.3 /ml buprenorphine hcl injection syringe 0.3 /ml 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 butalbital-acetaminop-caf-cod oral capsule , butalbital-acetaminophen oral tablet butalbital-acetaminophen-caff oral capsule ; QL (2700 per 30 ; QL (360 per 30 (Tylenol-Codeine #3) ; QL (360 per 30 (Tylenol-Codeine #4) ; QL (180 per 30 2 PA-HRM; GC; QL (360 per 30 ; AGE (Max 64 Years) 2 PA-HRM; GC; QL (180 per 30 ; AGE (Max 64 Years) ; QL (60 per 30 (Buprenex) (Butrans) ; QL (4 per 28 2 PA-HRM; GC; QL (180 per 30 ; AGE (Max 64 Years) 2 PA-HRM; GC; QL (180 per 30 ; AGE (Max 64 Years) (Marten-Tab) 2 PA-HRM; GC; QL (180 per 30 ; AGE (Max 64 Years) (Capacet) 2 PA-HRM; GC; QL (180 per 30 ; AGE (Max 64 Years) 3

18 butalbital-acetaminophen-caff oral tablet butalbital-aspirin-caffeine oral capsule butalbital-aspirin-caffeine oral tablet (Esgic) 2 PA-HRM; GC; QL (180 per 30 ; AGE (Max 64 Years) (Fiorinal) 2 PA-HRM; GC; QL (180 per 30 ; AGE (Max 64 Years) 2 PA-HRM; GC; QL (180 per 30 ; AGE (Max 64 Years) ; QL (4 per 28 BUTRANS TRANSDERMAL PATCH WEEKLY 7.5 MCG/HOUR capacet oral capsule PA-HRM; GC; QL (180 per 30 ; AGE (Max 64 Years) codeine sulfate oral tablet 15, 30, 60 ; QL (180 per 30 endocet oral tablet ; QL (240 per 30 endocet oral tablet , ; QL (360 per 30 endocet oral tablet ; QL (300 per 30 endodan oral tablet ; 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 fentanyl transdermal patch 72 hour 62.5 mcg/hour, 87.5 mcg/hour hydrocodone-acetaminophen oral solution /5 ml, /7.5ml(7.5ml) hydrocodone-acetaminophen oral solution /15 ml hydrocodone-acetaminophen oral tablet (Actiq) 5 PA; GC; NDS; QL (120 per 30 (Duragesic) ; QL (10 per 30 ; QL (10 per 30 ; QL (10 per 30 ; QL (2700 per 30 (Hycet) ; QL (2700 per 30 (Vicodin HP) ; QL (390 per 30 4

19 hydrocodone-acetaminophen oral tablet (Lorcet HD) ; QL (360 per 30 hydrocodone-acetaminophen oral tablet (Verdrocet) ; QL (360 per 30 hydrocodone-acetaminophen oral tablet (Vicodin) ; QL (390 per 30 hydrocodone-acetaminophen oral tablet (Lorcet (hydrocodone)) ; QL (360 per 30 hydrocodone-acetaminophen oral tablet (Vicodin ES) ; QL (390 per 30 hydrocodone-acetaminophen oral tablet (Lorcet Plus) ; QL (360 per 30 hydrocodone-ibuprofen oral tablet , (Ibudone) ; QL (150 per 30 hydrocodone-ibuprofen oral tablet ; QL (150 per 30 hydromorphone (pf) injection solution 10 (/ml) (5 ml) hydromorphone (pf) injection solution 10 /ml hydromorphone 10 /ml vial p/f,sdv,latex-f 10 /ml hydromorphone injection solution 2 /ml, 4 /ml hydromorphone injection syringe 2 (Dilaudid) /ml, 4 /ml hydromorphone oral liquid 1 /ml (Dilaudid) ; QL (1200 per 30 hydromorphone oral tablet 2, 4, 8 (Dilaudid) ; QL (180 per 30 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 LAZANDA NASAL SPRAY,NON- AEROSOL 100 MCG/SPRAY, 300 MCG/SPRAY, 400 MCG/SPRAY lorcet (hydrocodone) oral tablet PA; GC; NDS; QL (30 per 30 ; QL (360 per 30 lorcet hd oral tablet ; QL (360 per 30 5

20 lorcet plus oral tablet ; QL (360 per 30 margesic oral capsule PA-HRM; GC; QL (180 per 30 ; AGE (Max 64 Years) methadone injection solution 10 /ml methadone oral solution 10 /5 ml, 5 /5 ml ; QL (1800 per 30 methadone oral tablet 10 (Dolophine) ; QL (360 per 30 methadone oral tablet 5 (Dolophine) ; QL (180 per 30 methadose oral tablet,soluble 40 ; QL (90 per 30 morphine 10 /ml carpuject outer, p/f, l/f, suv 10 /ml morphine 2 /ml carpuject outer, l/f, p/f, sdv 2 /ml morphine 4 /ml syringe p/f, latexfree,suv 4 /ml morphine 8 /ml syringe 8 /ml morphine concentrate oral solution 100 /5 ml (20 /ml) ; QL (180 per 30 morphine intramuscular pen injector 10 /0.7 ml morphine intravenous cartridge 15 /ml morphine intravenous syringe 10 /ml, 2 /ml, 4 /ml, 8 /ml morphine oral solution 10 /5 ml ; QL (700 per 30 morphine oral solution 20 /5 ml (4 /ml) ; QL (300 per 30 MORPHINE ORAL TABLET 15 MG 4 GC; QL (180 per 30 MORPHINE ORAL TABLET 30 MG 4 GC; QL (120 per 30 morphine oral tablet extended release 100 (MS Contin) ; QL (60 per 30, 200, 60 morphine oral tablet extended release 15 (MS Contin) ; QL (180 per 30 6

21 morphine oral tablet extended release 30 (MS Contin) ; QL (120 per 30 NUCYNTA ER ORAL TABLET EXTENDED RELEASE 12 HR 100 ; QL (60 per 30 MG, 150 MG, 200 MG, 250 MG, 50 MG NUCYNTA ORAL TABLET 100 MG, 50 MG, 75 MG ; QL (181 per 30 oxycodone oral concentrate 20 /ml ; QL (120 per 30 oxycodone oral solution 5 /5 ml ; QL (1300 per 30 oxycodone oral tablet 10 ; QL (180 per 30 oxycodone oral tablet 15, 30 (Roxicodone) ; QL (120 per 30 oxycodone oral tablet 20 ; QL (120 per 30 oxycodone oral tablet 5 (Roxicodone) ; QL (180 per 30 oxycodone oral tablet,oral only,ext.rel.12 hr 10, 15, 20, 30, 40, 60 oxycodone oral tablet,oral only,ext.rel.12 hr 80 oxycodone-acetaminophen oral solution /5 ml oxycodone-acetaminophen oral tablet oxycodone-acetaminophen oral tablet , oxycodone-acetaminophen oral tablet oxycodone-aspirin oral tablet OXYCONTIN ORAL TABLET,ORAL ONLY,EXT.REL.12 HR 10 MG, 15 MG, 20 MG, 30 MG, 40 MG, 60 MG (OxyContin) ; QL (60 per 30 (OxyContin) ; QL (120 per 30 ; QL (1800 per 30 (Endocet) ; QL (240 per 30 (Endocet) ; QL (360 per 30 (Endocet) ; QL (300 per 30 ; QL (360 per 30 ; QL (60 per 30 7

22 OXYCONTIN ORAL TABLET,ORAL ONLY,EXT.REL.12 HR 80 MG ; QL (120 per 30 oxymorphone oral tablet 10 (Opana) ; QL (120 per 30 oxymorphone oral tablet 5 (Opana) ; QL (180 per 30 oxymorphone oral tablet extended release 12 hr 10, 15, 20, 30, 40, 5, 7.5 reprexain oral tablet , , ; QL (60 per 30 ; QL (150 per 30 tencon oral tablet PA-HRM; GC; QL (180 per 30 ; AGE (Max 64 Years) tramadol oral tablet 50 (Ultram) ; QL (240 per 30 tramadol-acetaminophen oral tablet (Ultracet) ; QL (240 per 30 vicodin es oral tablet ; QL (390 per 30 vicodin hp oral tablet ; QL (390 per 30 vicodin oral tablet ; QL (390 per 30 XTAMPZA ER ORAL CAPSULE,SPRINKLE,ER 12HR TMPRR 13.5 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 (60 per 30 ; QL (120 per 30 ; QL (240 per 30 xylon 10 oral tablet ; QL (150 per 30 zebutal oral capsule PA-HRM; GC; QL (180 per 30 ; AGE (Max 64 Years) 8

23 Nonsteroidal Anti-Inflammatory Agents CALDOLOR INTRAVENOUS RECON SOLN 400 MG/4 ML (100 MG/ML), 800 MG/8 ML (100 MG/ML) celecoxib oral capsule 100, 200, 400, 50 4 GC (Celebrex) ; QL (60 per 30 diclofenac potassium oral tablet 50 diclofenac sodium oral tablet extended (Voltaren-XR) release 24 hr 100 diclofenac sodium oral tablet,delayed release (dr/ec) 25, 50, 75 diclofenac sodium topical gel 1 % (Voltaren) diclofenac-misoprostol oral (Arthrotec 50) tablet,ir,delayed rel,biphasic mcg diclofenac-misoprostol oral (Arthrotec 75) tablet,ir,delayed rel,biphasic mcg diflunisal oral tablet 500 etodolac oral capsule 200, 300 etodolac oral tablet 400 (Lodine) etodolac oral tablet 500 etodolac oral tablet extended release 24 hr 400, 500, 600 fenoprofen oral tablet 600 FLECTOR TRANSDERMAL 3 PA; GC PATCH 12 HOUR 1.3 % flurbiprofen oral tablet 100, 50 ibuprofen oral suspension 100 /5 ml (Child Ibuprofen) ibuprofen oral tablet 400, 600, 1 GC 800 indomethacin oral capsule 25 1 GC; QL (240 per 30 indomethacin oral capsule 50 1 GC; QL (120 per 30 indomethacin oral capsule, extended release 75 ; QL (60 per 30 indomethacin sodium intravenous recon soln 1 ketoprofen oral capsule 50, 75 9

24 ketoprofen oral capsule,ext rel. pellets 24 hr 200 ketorolac oral tablet 10 ; QL (20 per 30 mefenamic acid oral capsule 250 (Ponstel) meloxicam oral suspension 7.5 /5 ml meloxicam oral tablet 15, 7.5 (Mobic) 1 GC nabumetone oral tablet 500, 750 naproxen oral suspension 125 /5 ml (Naprosyn) naproxen oral tablet 250, GC naproxen oral tablet 500 (Naprosyn) 1 GC naproxen oral tablet,delayed release (EC-Naprosyn) (dr/ec) 375, 500 naproxen sodium oral tablet 275 naproxen sodium oral tablet 550 (Anaprox DS) piroxicam oral capsule 10, 20 (Feldene) sulindac oral tablet 150, 200 tolmetin oral capsule 400 tolmetin oral tablet 200, 600 VOLTAREN TOPICAL GEL 1 % Anesthetics Local Anesthetics glydo mucous membrane jelly in applicator 2 % lidocaine (pf) injection solution 10 /ml (Xylocaine-MPF) (1 %), 15 /ml (1.5 %), 20 /ml (2 %), 5 /ml (0.5 %) lidocaine (pf) injection solution 40 /ml (4 %) lidocaine hcl injection solution 10 /ml (Xylocaine) (1 %), 20 /ml (2 %), 5 /ml (0.5 %) lidocaine hcl injection syringe 10 /ml (1 %) lidocaine hcl mucous membrane jelly 2 % lidocaine hcl mucous membrane solution 4 % (40 /ml) lidocaine hcl(pf) in 0.9% nacl injection syringe 100 /10 ml (1 %) lidocaine topical adhesive patch,medicated 5 % (Lidoderm) 2 PA; GC 10

25 lidocaine topical ointment 5 % 2 PA NSO; GC; QL (90 per 30 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 BUNAVAIL BUCCAL FILM MG ; QL (30 per 30 BUNAVAIL BUCCAL FILM MG, MG ; QL (60 per 30 buprenorphine hcl sublingual tablet 2, 8 2 PA; GC; QL (90 per 30 buprenorphine-naloxone sublingual tablet 2-0.5, 8-2 ; QL (90 per 30 buproban oral tablet extended release 12 hr 150 bupropion hcl (smoking deter) oral tablet (Zyban) extended release 12 hr 150 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 ORAL TABLETS,DOSE PACK 0.5 MG (11)- 1 MG (42) ; QL (53 per 28 disulfiram oral tablet 250, 500 (Antabuse) naloxone injection solution 0.4 /ml naloxone injection syringe 0.4 /ml, 1 /ml naltrexone oral tablet 50 NARCAN NASAL SPRAY,NON- ; QL (4 per 30 AEROSOL 2 MG/ACTUATION, 4 MG/ACTUATION NICOTROL INHALATION CARTRIDGE 10 MG 4 GC; QL (1008 per 90 11

26 SUBOXONE SUBLINGUAL FILM 12-3 MG, 8-2 MG SUBOXONE SUBLINGUAL FILM MG, 4-1 MG ZUBSOLV SUBLINGUAL TABLET MG, MG, MG, MG, MG ZUBSOLV SUBLINGUAL TABLET MG Antianxiety Agents Benzodiazepines alprazolam oral tablet 0.25, 0.5, 1 ; QL (60 per 30 ; QL (30 per 30 ; QL (30 per 30 ; QL (60 per 30 (Xanax) 1 GC; QL (120 per 30 alprazolam oral tablet 2 (Xanax) 1 GC; QL (150 per 30 1 GC; QL (120 per 30 chlordiazepoxide hcl oral capsule 10, 25, 5 clonazepam oral tablet 0.5, 1 (Klonopin) 1 GC; QL (90 per 30 clonazepam oral tablet 2 (Klonopin) 1 GC; QL (300 per 30 clonazepam oral tablet,disintegrating 0.125, 0.25, 0.5, 1 ; QL (90 per 30 clonazepam oral tablet,disintegrating 2 ; QL (300 per 30 clorazepate dipotassium oral tablet 15, 3.75 ; QL (180 per 30 clorazepate dipotassium oral tablet 7.5 (Tranxene T-Tab) ; QL (180 per 30 DIASTAT ACUDIAL RECTAL KIT 4 GC MG, MG DIASTAT RECTAL KIT 2.5 MG 4 GC diazepam injection solution 5 /ml ; QL (10 per 28 diazepam intensol oral concentrate 5 /ml ; QL (1200 per 30 diazepam oral solution 5 /5 ml (1 /ml) ; QL (1200 per 30 diazepam oral tablet 10, 2, 5 (Valium) 1 GC; QL (120 per 30 12

27 diazepam rectal kit , (Diastat AcuDial) diazepam rectal kit 2.5 (Diastat) lorazepam injection solution 2 /ml (Ativan) ; QL (2 per 30 lorazepam oral tablet 0.5, 1 (Ativan) 1 GC; QL (90 per 30 lorazepam oral tablet 2 (Ativan) 1 GC; QL (150 per 30 ONFI ORAL SUSPENSION 2.5 MG/ML 5 PA NSO; GC; NDS; QL (480 per 30 ONFI ORAL TABLET 10 MG, 20 MG 5 PA NSO; GC; NDS; QL (60 per 30 Antibacterials Aminoglycosides BETHKIS INHALATION 5 PA BvD; GC; NDS SOLUTION FOR NEBULIZATION 300 MG/4 ML gentamicin in nacl (iso-osm) intravenous piggyback 100 /100 ml, 100 /50 ml, 60 /50 ml, 70 /50 ml, 80 /100 ml, 80 /50 ml, 90 /100 ml gentamicin injection solution 40 /ml gentamicin ped 20 /2 ml vial latexfree, sdv 20 /2 ml gentamicin sulfate (pf) intravenous solution 100 /10 ml neomycin oral tablet 500 streptomycin intramuscular recon soln 1 gram TOBI PODHALER INHALATION CAPSULE, W/INHALATION ; QL (224 per 28 DEVICE 28 MG tobramycin in % nacl inhalation (Tobi) 5 PA BvD; GC; NDS solution for nebulization 300 /5 ml tobramycin in 0.9 % nacl intravenous piggyback 60 /50 ml tobramycin sulfate injection solution 10 /ml, 40 /ml Antibacterials, Miscellaneous bacitracin intramuscular recon soln 50,000 unit (BACiiM) 13

28 chloramphenicol sod succinate intravenous recon soln 1 gram clindamycin 75 /5 ml soln 75 /5 ml (Cleocin Pediatric) clindamycin hcl oral capsule 150, 300 (Cleocin HCl), 75 clindamycin in 5 % dextrose intravenous (Cleocin in 5 % piggyback 300 /50 ml, 600 /50 ml, 900 /50 ml dextrose) clindamycin pediatric oral recon soln 75 /5 ml clindamycin phosphate injection solution 150 (/ml) (6 ml) clindamycin phosphate injection solution (Cleocin) 150 /ml clindamycin phosphate intravenous (Cleocin) solution 600 /4 ml colistin (colistimethate na) injection (Coly-Mycin M recon soln 150 Parenteral) daptomycin intravenous recon soln 500 (Cubicin) linezolid intravenous parenteral solution (Zyvox) 600 /300 ml linezolid oral suspension for (Zyvox) reconstitution 100 /5 ml linezolid oral tablet 600 (Zyvox) methenamine hippurate oral tablet 1 (Hiprex) gram metronidazole in nacl (iso-os) (Metro I.V.) intravenous piggyback 500 /100 ml metronidazole oral capsule 375 (Flagyl) metronidazole oral tablet 250, 500 (Flagyl) nitrofurantoin macrocrystal oral capsule 100, 25, 50 (Macrodantin) 2 PA-HRM; GC; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use of nitrofurantoin drugs); QL (120 per 30 ; AGE (Max 64 Years) 14

29 nitrofurantoin monohyd/m-cryst oral capsule 100 (Macrobid) 2 PA-HRM; GC; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use of nitrofurantoin drugs); QL (60 per 30 ; AGE (Max 64 Years) polymyxin b sulfate injection recon soln 500,000 unit SYNERCID INTRAVENOUS RECON SOLN 500 MG trimethoprim oral tablet 100 vancomycin hcl 1g/200 ml bag 1 gram/200 ml vancomycin intravenous recon soln 1,000, 10 gram, 750 vancomycin intravenous recon soln 500 vancomycin oral capsule 125, 250 (Vancocin) XIFAXAN ORAL TABLET 200 MG 5 PA; GC; NDS; QL (9 per 30 XIFAXAN ORAL TABLET 550 MG 5 PA; GC; NDS Cephalosporins cefaclor oral capsule 250, 500 cefaclor oral suspension for reconstitution 125 /5 ml, 250 /5 ml, 375 /5 ml cefadroxil oral capsule 500 cefadroxil oral suspension for reconstitution 250 /5 ml, 500 /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 cefdinir oral capsule 300 cefdinir oral suspension for reconstitution 125 /5 ml, 250 /5 ml cefditoren pivoxil oral tablet 200 cefditoren pivoxil oral tablet 400 (Spectracef) 15

30 CEFEPIME 1 GM INJECTION 1 GRAM/50 ML CEFEPIME INJECTION RECON (Maxipime) SOLN 1 GRAM, 2 GRAM CEFEPIME-DEXTROSE 2 GM/50 ML 2 GRAM/50 ML cefotaxime injection recon soln 1 gram, 500 cefotaxime injection recon soln 10 gram, (Claforan) 2 gram cefoxitin 2 gm piggyback bag 2 gram/50 ml cefoxitin intravenous recon soln 1 gram, 10 gram cefoxitin intravenous recon soln 2 gram cefpodoxime oral suspension for reconstitution 100 /5 ml, 50 /5 ml cefpodoxime oral tablet 100, 200 cefprozil oral suspension for reconstitution 125 /5 ml, 250 /5 ml cefprozil oral tablet 250, 500 ceftazidime injection recon soln 2 gram, 6 (Fortaz) gram ceftibuten oral capsule 400 (Cedax) ceftibuten oral suspension for (Cedax) reconstitution 180 /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 10 gram, 250, 500 ceftriaxone intravenous recon soln 1 gram, 2 gram cefuroxime axetil oral tablet 250, 500 cefuroxime sodium injection recon soln (Zinacef) 750 cefuroxime sodium intravenous recon soln 1.5 gram, 7.5 gram (Zinacef) 16

31 cefuroxime-dextrose (iso-osm) intravenous piggyback 750 /50 ml cephalexin oral capsule 250, 500 (Keflex) 1 GC cephalexin oral capsule 750 (Keflex) cephalexin oral suspension for 1 GC reconstitution 125 /5 ml, 250 /5 ml cephalexin oral tablet 250, GC MEFOXIN IN DEXTROSE (ISO- 4 GC OSM) INTRAVENOUS PIGGYBACK 1 GRAM/50 ML, 2 GRAM/50 ML SUPRAX ORAL CAPSULE 400 MG 4 GC SUPRAX ORAL 4 GC TABLET,CHEWABLE 100 MG, 200 MG tazicef injection recon soln 2 gram, 6 gram TEFLARO INTRAVENOUS RECON 4 GC SOLN 400 MG, 600 MG Macrolides azithromycin intravenous recon soln 500 (Zithromax) azithromycin oral packet 1 gram (Zithromax) azithromycin oral suspension for (Zithromax) reconstitution 100 /5 ml, 200 /5 ml azithromycin oral tablet 250 (6 pack), 500 (3 pack) azithromycin oral tablet 250, 500, (Zithromax) 600 clarithromycin oral suspension for reconstitution 125 /5 ml, 250 /5 ml clarithromycin oral tablet 250, 500 clarithromycin oral tablet extended release 24 hr 500 DIFICID ORAL TABLET 200 MG ; QL (20 per 10 e.e.s. 400 oral tablet 400 e.e.s. granules oral suspension for reconstitution 200 /5 ml 17

32 ery-tab oral tablet,delayed release (dr/ec) 250, 500 ERY-TAB ORAL 4 GC TABLET,DELAYED RELEASE (DR/EC) 333 MG erythrocin (as stearate) oral tablet 250 ERYTHROCIN INTRAVENOUS 4 GC RECON SOLN 1,000 MG, 500 MG erythromycin ethylsuccinate oral (E.E.S. Granules) suspension for reconstitution 200 /5 ml erythromycin ethylsuccinate oral tablet (E.E.S. 400) 400 erythromycin oral capsule,delayed release(dr/ec) 250 erythromycin oral tablet 250, 500 Miscellaneous B-Lactam Antibiotics aztreonam injection recon soln 1 gram, 2 (Azactam) gram CAYSTON INHALATION 5 GC; LA; NDS SOLUTION FOR NEBULIZATION 75 MG/ML imipenem-cilastatin intravenous recon soln 250 imipenem-cilastatin intravenous recon (Primaxin IV) soln 500 INVANZ INJECTION RECON SOLN 4 GC 1 GRAM meropenem intravenous recon soln 1 (Merrem) gram, 500 Penicillins amoxicillin oral capsule 250, GC amoxicillin oral suspension for 1 GC reconstitution 125 /5 ml, 200 /5 ml, 250 /5 ml, 400 /5 ml amoxicillin oral tablet 500, GC amoxicillin oral tablet,chewable 125, 1 GC 250 amoxicillin-pot clavulanate oral suspension for reconstitution /5 ml, /5 ml 18

33 amoxicillin-pot clavulanate oral (Augmentin) suspension for reconstitution /5 ml amoxicillin-pot clavulanate oral (Augmentin ES-600) suspension for reconstitution /5 ml amoxicillin-pot clavulanate oral tablet amoxicillin-pot clavulanate oral tablet (Augmentin) , amoxicillin-pot clavulanate oral tablet (Augmentin XR) extended release 12 hr 1, amoxicillin-pot clavulanate oral tablet,chewable , ampicillin oral capsule 250, GC ampicillin oral suspension for 1 GC reconstitution 125 /5 ml, 250 /5 ml ampicillin sodium injection recon soln 1 gram, 10 gram, 125, 2 gram, 250, 500 ampicillin sodium intravenous recon soln 2 gram ampicillin-sulbactam injection recon soln (Unasyn) 1.5 gram, 15 gram, 3 gram BICILLIN C-R INTRAMUSCULAR 4 GC SYRINGE 1,200,000 UNIT/ 2 ML(600K/600K), 1,200,000 UNIT/ 2 ML(900K/300K) BICILLIN L-A INTRAMUSCULAR 4 GC SYRINGE 1,200,000 UNIT/2 ML, 2,400,000 UNIT/4 ML, 600,000 UNIT/ML dicloxacillin oral capsule 250, 500 nafcillin 2 gm vial 10's, latex-free 2 gram nafcillin injection recon soln 1 gram, 10 gram nafcillin intravenous recon soln 2 gram oxacillin in dextrose(iso-osm) intravenous piggyback 1 gram/50 ml, 2 gram/50 ml 19

34 oxacillin injection recon soln 10 gram, 2 gram oxacillin intravenous recon soln 1 gram penicillin g pot in dextrose intravenous piggyback 1 million unit/50 ml, 2 million unit/50 ml, 3 million unit/50 ml penicillin g potassium injection recon soln (Pfizerpen-G) 5 million unit penicillin g procaine intramuscular syringe 1.2 million unit/2 ml, 600,000 unit/ml penicillin gk 20 million unit 20 million (Pfizerpen-G) unit penicillin v potassium oral recon soln 125 /5 ml, 250 /5 ml penicillin v potassium oral tablet 250, 500 pfizerpen-g injection recon soln 20 million unit piperacillin-tazobactam intravenous (Zosyn) recon soln 2.25 gram, gram, 4.5 gram, 40.5 gram Quinolones ciprofloxacin hcl oral tablet 100, GC ciprofloxacin hcl oral tablet 250, 500 (Cipro) 1 GC ciprofloxacin in 5 % dextrose intravenous piggyback 200 /100 ml ciprofloxacin in 5 % dextrose intravenous (Cipro in D5W) piggyback 400 /200 ml ciprofloxacin lactate intravenous solution 200 /20 ml, 400 /40 ml ciprofloxacin oral (Cipro) suspension,microcapsule recon 250 /5 ml, 500 /5 ml levofloxacin in d5w intravenous piggyback 250 /50 ml, 500 /100 ml, 750 /150 ml levofloxacin intravenous solution 25 /ml 20

35 levofloxacin oral solution 250 /10 ml levofloxacin oral tablet 250, 500, (Levaquin) 1 GC 750 moxifloxacin oral tablet 400 (Avelox) ofloxacin oral tablet 300, 400 Sulfonamides sulfadiazine oral tablet 500 sulfamethoxazole-trimethoprim intravenous solution /5 ml sulfamethoxazole-trimethoprim oral (Sulfatrim) suspension /5 ml sulfamethoxazole-trimethoprim oral (Bactrim) 1 GC tablet sulfamethoxazole-trimethoprim oral (Bactrim DS) 1 GC tablet sulfasalazine oral tablet 500 (Azulfidine) sulfasalazine oral tablet,delayed release (Azulfidine EN-tabs) (dr/ec) 500 sulfatrim oral suspension /5 ml Tetracyclines doxy-100 intravenous recon soln 100 doxycycline hyclate intravenous recon (Doxy-100) soln 100 doxycycline hyclate oral capsule 100, (Morgidox) 50 doxycycline hyclate oral tablet 100, 20 doxycycline monohydrate oral capsule (Mondoxyne NL) 100, 50, 75 doxycycline monohydrate oral capsule 150 doxycycline monohydrate oral suspension (Vibramycin) for reconstitution 25 /5 ml doxycycline monohydrate oral tablet 100 (Avidoxy) doxycycline monohydrate oral tablet 150, 50, 75 minocycline oral capsule 100, 50, (Minocin) 75 minocycline oral tablet 100, 50, 75 21