Comprehensive Preferred Drug List (List of Covered Drugs)

Transcription

1 2014 Comprehensive referred Drug List (List of Covered Drugs) WellCare Georgia Family lanning 00 9 lease read: This document contains information about the drugs we cover in this plan. ara solicitar este documento en español o para escuchar la traducción, llame al Servicio al Cliente al (TTY/TDD: ). lease note that the Georgia Family lanning referred Drug List is updated quarterly. roviders, please visit our website at to view updates to the preferred drug list. Members, please visit our website at to view updates to the preferred drug list. Last updated (01/01/2014)

2 Vaccines: Vaccines are covered under the Vaccines for Children program for members through 18 years of age. Coverage beyond the age of 18 is evaluated through the A process. UERCASE = Brand name drugs italics = Generic drugs reference Details = referred Dagger ( ) = N/A Asterisk (*) = N/A Asterisk (**) = N/A Asterisk (***) = N/A XX = N/A Coverage Details A = rior Authorization ST = Step Therapy QL = Quantity Limit AL = Age Limit OTC = OTC- Covered w/rx Drug Name reference Details Coverage Details *Anthelmintics* *Anthelmintics** *Anthelmintics*** ALBENZA ORAL TABLET 200 MG A Reeses inworm Medicine ORAL SUSENSION 144 MG/ML OTC STROMECTOL ORAL TABLET 3 MG QL (10 EA per 31 day(s)) *Antiasthmatic And Bronchodilator Agents* *Antiasthmatic - Monoclonal Antibodies** *Anti-Ige Monoclonal Antibodies*** XOLAIR SUBCUTANEOUS* SOLUTION RECONSTITUTED 150 MG *Antifungals* *Antifungals** *Antifungals*** GRIS-EG ORAL TABLET 125 MG, 250 MG Griseofulvin Microsize ORAL SUSENSION 125 MG/5ML Griseofulvin Microsize ORAL TABLET 500 MG A QL (450 ML per 31 day(s)) 1

3 Drug Name reference Details Coverage Details Griseofulvin Ultramicrosize ORAL TABLET 125 MG, 250 MG Nystatin ORAL TABLET UNIT Terbinafine HCl ORAL TABLET 250 MG *Imidazole-Related Antifungals** *Imidazoles*** Ketoconazole ORAL TABLET 200 MG *Triazoles*** Fluconazole ORAL SUSENSION RECONSTITUTED 10 MG/ML, 40 MG/ML Fluconazole ORAL TABLET 100 MG, 150 MG, 200 MG, 50 MG *Anti-Infective Agents - Misc.* *Anti-Infective Agents - Misc.** *Anti-Infective Agents - Misc.*** MetroNIDAZOLE ORAL TABLET 250 MG, 500 MG Trimethoprim ORAL TABLET 100 MG *Anti-Infective Misc. - Combinations** *Anti-Infective Misc. - Combinations*** Erythromycin-Sulfisoxazole ORAL SUSENSION RECONSTITUTED MG/5ML Sulfamethoxazole-TM DS ORAL TABLET MG Sulfamethoxazole-Trimethoprim ORAL SUSENSION MG/5ML Sulfamethoxazole-Trimethoprim ORAL TABLET MG *Antiprotozoal Agents** *Antiprotozoal Agents*** MERON ORAL SUSENSION 750 MG/5ML *Lincosamides** *Lincosamides*** Clindamycin HCl ORAL CASULE 150 MG, 300 MG, 75 MG QL (1200 ML per 31 day(s)) 2

4 Drug Name reference Details Coverage Details Clindamycin almitate HCl ORAL SOLUTION RECONSTITUTED 75 MG/5ML Clindamycin hosphate INJECTION SOLUTION 300 MG/2ML, 600 MG/4ML, 9 GM/60ML, 900 MG/6ML Clindamycin hosphate INTRAVENOUS* SOLUTION 300 MG/2ML *Antimalarials* *Antimalarial Combinations** *Antimalarial Combinations*** Atovaquone-roguanil HCl ORAL TABLET MG, MG *Antimalarials** *Antimalarials*** DARARIM ORAL TABLET 25 MG Hydroxychloroquine Sulfate ORAL TABLET 200 MG Mefloquine HCl ORAL TABLET 250 MG rimaquine hosphate ORAL TABLET 26.3 MG *Antiparkinson Agents* *Antiparkinson Dopaminergics** *Antiparkinson Dopaminergics*** Amantadine HCl ORAL CASULE 100 MG Amantadine HCl ORAL SYRU 50 MG/5ML Amantadine HCl ORAL TABLET 100 MG *Antivirals* *Herpes Agents** *Herpes Agents - urine Analogues*** Acyclovir ORAL CASULE 200 MG QL (2400 ML per 31 day(s)) Acyclovir ORAL SUSENSION 200 MG/5ML QL (3500 ML per 31 day(s)) Acyclovir ORAL TABLET 400 MG, 800 MG ValACYclovir HCl ORAL TABLET 1 GM, 500 MG *Influenza Agents** *Influenza Agents*** Rimantadine HCl ORAL TABLET 100 MG QL (62 EA per 31 day(s)) 3

5 Drug Name reference Details Coverage Details *Neuraminidase Inhibitors*** RELENZA DISKHALER INHALATION AEROSOL OWDER, BREATH ACTIVATED 5 MG/BLISTER QL (40 EA per 365 day(s)); AL (Min 7 TAMIFLU ORAL CASULE 30 MG QL (40 EA per 365 day(s)) TAMIFLU ORAL CASULE 45 MG, 75 MG QL (20 EA per 365 day(s)) TAMIFLU ORAL SUSENSION RECONSTITUTED 6 MG/ML *Cephalosporins* *Cephalosporins - 1St Generation** *Cephalosporins - 1St Generation*** Cefadroxil ORAL CASULE 500 MG Cefadroxil ORAL SUSENSION RECONSTITUTED 250 MG/5ML, 500 MG/5ML Cefadroxil ORAL TABLET 1 GM Cephalexin ORAL CASULE 250 MG, 500 MG, 750 MG Cephalexin ORAL SUSENSION RECONSTITUTED 125 MG/5ML Cephalexin ORAL SUSENSION RECONSTITUTED 250 MG/5ML *Cephalosporins - 2Nd Generation** *Cephalosporins - 2Nd Generation*** Cefaclor ORAL CASULE 250 MG, 500 MG Cefprozil ORAL SUSENSION RECONSTITUTED 125 MG/5ML, 250 MG/5ML Cefprozil ORAL TABLET 250 MG, 500 MG Cefuroxime Axetil ORAL SUSENSION RECONSTITUTED 125 MG/5ML Cefuroxime Axetil ORAL TABLET 250 MG, 500 MG *Cephalosporins - 3Rd Generation** *Cephalosporins - 3Rd Generation*** Cefdinir ORAL CASULE 300 MG Cefdinir ORAL SUSENSION RECONSTITUTED 125 MG/5ML, 250 MG/5ML QL (360 ML per 365 day(s)); AL (Max 18 QL (300 ML per 31 day(s)) 4

6 Drug Name reference Details Coverage Details Cefpodoxime roxetil ORAL SUSENSION RECONSTITUTED 100 MG/5ML, 50 MG/5ML Cefpodoxime roxetil ORAL TABLET 100 MG, 200 MG *Contraceptives* *Combination Contraceptives - Oral** *Biphasic Contraceptives - Oral*** KARIVA ORAL TABLET /0.01 MG (21/5) *Combination Contraceptives - Oral*** ALTAVERA ORAL TABLET Alyacen 1/35 ORAL TABLET 1-35 ARI ORAL TABLET AVIANE ORAL TABLET BALZIVA ORAL TABLET Briellyn ORAL TABLET CRYSELLE-28 ORAL TABLET CYCLAFEM 1/35 ORAL TABLET 1-35 DASETTA 1/35 ORAL TABLET 1-35 ELINEST ORAL TABLET EMOQUETTE ORAL TABLET ESTARYLLA ORAL TABLET FALMINA ORAL TABLET GIANVI ORAL TABLET MG GILDESS 1.5/30 ORAL TABLET GILDESS 1/20 ORAL TABLET 1-20 GILDESS FE 1.5/30 ORAL TABLET

7 Drug Name reference Details Coverage Details GILDESS FE 1/20 ORAL TABLET 1-20 JUNEL 1.5/30 ORAL TABLET JUNEL 1/20 ORAL TABLET 1-20 JUNEL FE 1.5/30 ORAL TABLET JUNEL FE 1/20 ORAL TABLET 1-20 KELNOR 1/35 ORAL TABLET 1-35 LESSINA ORAL TABLET LEVORA 0.15/30 (28) ORAL TABLET LORYNA ORAL TABLET MG LOW-OGESTREL ORAL TABLET LUTERA ORAL TABLET Marlissa ORAL TABLET MICROGESTIN 1.5/30 ORAL TABLET MICROGESTIN 1/20 ORAL TABLET 1-20 MICROGESTIN FE 1.5/30 ORAL TABLET MICROGESTIN FE 1/20 ORAL TABLET 1-20 MONONESSA ORAL TABLET NECON 0.5/35 (28) ORAL TABLET NECON 1/35 (28) ORAL TABLET 1-35 NECON 1/50 (28) ORAL TABLET 1-50 NORTREL 0.5/35 (28) ORAL TABLET NORTREL 1/35 (21) ORAL TABLET

8 Drug Name reference Details Coverage Details NORTREL 1/35 (28) ORAL TABLET 1-35 OCELLA ORAL TABLET MG ORSYTHIA ORAL TABLET HILITH ORAL TABLET ORTIA-28 ORAL TABLET REVIFEM ORAL TABLET RECLISEN ORAL TABLET SOLIA ORAL TABLET SRINTEC 28 ORAL TABLET SRONYX ORAL TABLET SYEDA ORAL TABLET MG ZENCHENT ORAL TABLET ZENCHENT FE ORAL TABLET CHEWABLE ZOVIA 1/35E (28) ORAL TABLET 1-35 ZOVIA 1/50E (28) ORAL TABLET 1-50 *Extended-Cycle Contraceptives - Oral*** QUASENSE ORAL TABLET MG QL (91 EA per 91 day(s)) *Triphasic Contraceptives - Oral*** CAZIANT ORAL TABLET 0.1/0.125/ MG ENRESSE-28 ORAL TABLET MYZILRA ORAL TABLET NECON 7/7/7 ORAL TABLET 0.5/0.75/1-35 NORTREL 7/7/7 ORAL TABLET 0.5/0.75/1-35 TRI-ESTARYLLA ORAL TABLET 0.18/0.215/0.25 MG-35 MCG 7

9 Drug Name reference Details Coverage Details TRI-REVIFEM ORAL TABLET 0.18/0.215/0.25 MG-35 MCG TRI-SRINTEC ORAL TABLET 0.18/0.215/0.25 MG-35 MCG TRINESSA (28) ORAL TABLET 0.18/0.215/0.25 MG-35 MCG TRIVORA (28) ORAL TABLET VELIVET ORAL TABLET 0.1/0.125/ MG *Combination Contraceptives - Vaginal** *Combination Contraceptives - Vaginal*** NUVARING VAGINAL RING MG/24HR *Emergency Contraceptives** *Emergency Contraceptives*** Levonorgestrel ORAL TABLET 0.75 MG QL (4 EA per 31 day(s)) LAN B ONE-STE ORAL TABLET 1.5 MG *rogestin Contraceptives - Injectable** *rogestin Contraceptives - Injectable*** MedroxyROGESTERone Acetate SUSENSION 150 MG/ML *rogestin Contraceptives - Oral** *rogestin Contraceptives - Oral*** CAMILA ORAL TABLET 0.35 MG ERRIN ORAL TABLET 0.35 MG HEATHER ORAL TABLET 0.35 MG JOLIVETTE ORAL TABLET 0.35 MG NOR-QD ORAL TABLET 0.35 MG NORA-BE ORAL TABLET 0.35 MG *Dermatologicals* *Antibiotics - Topical** *Antibiotic Mixtures Topical*** oly Bacitracin EXTERNAL OINTMENT UNIT/GM *Antibiotics - Topical*** OTC QL (1 ML per 93 day(s)) OTC 8

10 Drug Name reference Details Coverage Details Bacitracin Zinc EXTERNAL OINTMENT 500 UNIT/GM *Antifungals - Topical** *Antifungals - Topical*** Ciclopirox EXTERNAL SOLUTION 8 % Ciclopirox Olamine EXTERNAL CREAM 0.77 % Ciclopirox Olamine EXTERNAL SUSENSION 0.77 % Nystatin EXTERNAL CREAM UNIT/GM Nystatin EXTERNAL OINTMENT UNIT/GM Nystatin EXTERNAL OWDER UNIT/GM OTC Terbinafine HCl EXTERNAL CREAM 1 % OTC *Imidazole-Related Antifungals - Topical*** Baza Antifungal EXTERNAL CREAM 2 % OTC Clotrimazole EXTERNAL CREAM 1 % OTC Clotrimazole EXTERNAL SOLUTION 1 % OTC Econazole Nitrate EXTERNAL CREAM 1 % Ketoconazole EXTERNAL CREAM 2 % Ketoconazole EXTERNAL SHAMOO 2 % *Antivirals - Topical** *Antivirals - Topical*** DENAVIR EXTERNAL CREAM 1 % ST ZOVIRAX EXTERNAL CREAM 5 % ST *Emollient/Keratolytic Agents** *Emollient/Keratolytic Agents*** REMEVEN EXTERNAL CREAM 50 % *Rosacea Agents** *Rosacea Agents*** MetroNIDAZOLE EXTERNAL CREAM 0.75 % MetroNIDAZOLE EXTERNAL GEL 1 % *Estrogens* *Estrogen Combinations** 9

11 Drug Name reference Details Coverage Details *Estrogen & rogestin*** Estradiol-Norethindrone Acet ORAL TABLET MG, MG *Fluoroquinolones* *Fluoroquinolones** *Fluoroquinolones*** Ciprofloxacin HCl ORAL TABLET 250 MG, 500 MG, 750 MG Levofloxacin ORAL TABLET 250 MG, 500 MG, 750 MG *Hematopoietic Agents* *Folic Acid/Folates** *Folic Acid/Folates*** Folic Acid ORAL TABLET 1 MG, 400 MCG, 800 MCG *Macrolides* *Azithromycin** *Azithromycin*** Azithromycin INTRAVENOUS* SOLUTION RECONSTITUTED 500 MG Azithromycin ORAL SUSENSION RECONSTITUTED 100 MG/5ML, 200 MG/5ML QL (14 EA per 31 day(s)) OTC Azithromycin ORAL TABLET 250 MG QL (6 EA per 31 day(s)) Azithromycin ORAL TABLET 500 MG, 600 MG Azithromycin Hydrogencitrate INTRAVENOUS* SOLUTION RECONSTITUTED 2.5 GM *Clarithromycin** *Clarithromycin*** Clarithromycin ORAL SUSENSION RECONSTITUTED 125 MG/5ML, 250 MG/5ML Clarithromycin ORAL TABLET 250 MG, 500 MG *Erythromycins** *Erythromycins*** 10

12 Drug Name reference Details Coverage Details E.E.S. GRANULES ORAL SUSENSION RECONSTITUTED 200 MG/5ML ERY-TAB ORAL TABLET DELAYED RELEASE 250 MG, 333 MG, 500 MG ERYED 200 ORAL SUSENSION RECONSTITUTED 200 MG/5ML ERYED 400 ORAL SUSENSION RECONSTITUTED 400 MG/5ML ERYTHROCIN STEARATE ORAL TABLET 250 MG Erythromycin Base ORAL CASULE DELAYED RELEASE ARTICLES 250 MG Erythromycin Base ORAL TABLET 250 MG, 500 MG Erythromycin Ethylsuccinate ORAL TABLET 400 MG *Medical Devices* *Contraceptives** *Diaphragms*** ORTHO DIAHRAGM ALL-FLEX VAGINAL DIAHRAGM 65 MM, 70 MM, 75 MM, 80 MM *Mouth/Throat/Dental Agents* *Anti-Infectives - Throat** *Anti-Infectives - Throat*** Clotrimazole MOUTH/THROAT LOZENGE 10 MG Clotrimazole MOUTH/THROAT TROCHE 10 MG Nystatin MOUTH/THROAT SUSENSION UNIT/ML *Multivitamins* *B-Complex W/ Folic Acid** *B-Complex W/ Folic Acid*** B Complex lus ORAL TABLET OTC *B-Complex W/Biotin & Folic Acid*** B-50 Complex ORAL TABLET EXTENDEDRELEASE* *Multiple Vitamins W/ Minerals** OTC 11

13 Drug Name reference Details Coverage Details *Multiple Vitamins W/ Minerals*** AQUADEKS ORAL CASULE OTC *Multivitamins** *Multivitamins*** Multi-Vitamins ORAL TABLET OTC *ed Mv W/ Fluoride** *ed Mv W/ Fluoride*** Multi-Vitamin/Fluoride ORAL TABLET CHEWABLE 0.25 MG, 0.5 MG, 1 MG Multivitamin/Fluoride ORAL TABLET CHEWABLE 0.25 MG, 0.5 MG, 1 MG *ed Vitamins Acd W/ Fluoride*** Vitamins ACD-Fluoride ORAL SOLUTION 0.25 MG/ML *ediatric Multiple Vitamins** *ediatric Multiple Vitamins W/ C*** olyvitamin ORAL SOLUTION 35 MG/ML OTC *ediatric Vitamins** *ediatric Vitamins A & D W/ C*** Tri-Vitamin ORAL SOLUTION OTC *renatal Vitamins** *renatal Mv & Min W/Fe-Fa*** ELITE-OB ORAL TABLET MG MYNATAL ADVANCE ORAL TABLET Mynatal-Z ORAL TABLET Mynate 90 lus ORAL TABLET EXTENDEDRELEASE* renatabs OBN ORAL TABLET 29-1 MG RENATABS RX ORAL TABLET 29-1 MG renatal ORAL TABLET MG OTC renatal 19 ORAL TABLET CHEWABLE renatal Low Iron ORAL TABLET MG OTC renatal lus ORAL TABLET 27-1 MG renatal lus Iron ORAL TABLET 29-1 MG Trinatal Rx 1 ORAL TABLET 60-1 MG TRINATE ORAL TABLET AL (Max 20 AL (Max 20 AL (Max 20 12

14 Drug Name reference Details Coverage Details TRIVEEN-U ORAL CASULE MG UltimateCare Combo ORAL MISC 30-1 MG VINATE AZ ORAL TABLET 27-1 MG VINATE AZ EXTRA ORAL TABLET 29-1 MG VINATE GT ORAL TABLET 90-1 MG VINATE II ORAL TABLET 29-1 MG VINATE M ORAL TABLET 27-1 MG *renatal Mv & Min W/Fe-Fa-Ca-Omega 3 Fish Oil*** R NATAL 400 EC ORAL MISC & 400 MG (DR) *Vitamins W/ Lipotropics** *Vitamins W/ Lipotropics*** B-100 Complex ORAL TABLET OTC B-100 CR ORAL TABLET EXTENDEDRELEASE* *Ophthalmic Agents* *Ophthalmic Anti-Infectives** *Ophthalmic Antibiotics*** Ciprofloxacin HCl OHTHALMIC SOLUTION 0.3 % Erythromycin OHTHALMIC OINTMENT 5 MG/GM Gentamicin Sulfate OHTHALMIC OINTMENT 0.3 % Gentamicin Sulfate OHTHALMIC SOLUTION 0.3 % Ofloxacin OHTHALMIC SOLUTION 0.3 % *Ophthalmic Anti-Infective Combinations*** AK-oly-Bac OHTHALMIC OINTMENT UNIT/GM Neomycin-Bacitracin Zn-olymyx OHTHALMIC OINTMENT Neomycin-olymyxin-Gramicidin OHTHALMIC SOLUTION olymyxin B-Trimethoprim OHTHALMIC SOLUTION UNIT/ML-% OTC 13

15 Drug Name reference Details Coverage Details *Ophthalmic Antivirals*** Trifluridine OHTHALMIC SOLUTION 1 % *Ophthalmic Steroids** *Ophthalmic Steroid Combinations*** Neomycin-olymyxin-Dexameth OHTHALMIC OINTMENT Neomycin-olymyxin-Dexameth OHTHALMIC SUSENSION Neomycin-olymyxin-HC OHTHALMIC SUSENSION *Otic Agents* *Otic Anti-Infectives** *Otic Anti-Infectives*** Ofloxacin OTIC SOLUTION 0.3 % *assive Immunizing Agents* *Immune Serums** *Immune Serums*** HEAGAM B INJECTION SOLUTION HYERHE B S/D SOLUTION NABI-HB SOLUTION *enicillins* *Aminopenicillins** *Aminopenicillins*** Amoxicillin ORAL CASULE 250 MG, 500 MG Amoxicillin ORAL SUSENSION RECONSTITUTED 125 MG/5ML, 200 MG/5ML, 250 MG/5ML, 400 MG/5ML Amoxicillin ORAL TABLET 500 MG, 875 MG Amoxicillin ORAL TABLET CHEWABLE 125 MG, 250 MG Ampicillin ORAL CASULE 250 MG, 500 MG Ampicillin ORAL SUSENSION RECONSTITUTED 125 MG/5ML, 250 MG/5ML QL (300 ML per 31 day(s)) 14

16 Drug Name reference Details Coverage Details *Natural enicillins** *Natural enicillins*** BICILLIN L-A SUSENSION UNIT/2ML, UNIT/4ML, UNIT/ML enicillin G rocaine SUSENSION UNIT/ML enicillin V otassium ORAL SOLUTION RECONSTITUTED 125 MG/5ML, 250 MG/5ML enicillin V otassium ORAL TABLET 250 MG, 500 MG FIZEREN-G INJECTION SOLUTION RECONSTITUTED UNIT, UNIT *enicillin Combinations** *enicillin Combinations*** Amoxicillin-ot Clavulanate ORAL SUSENSION RECONSTITUTED MG/5ML, MG/5ML, MG/5ML, MG/5ML Amoxicillin-ot Clavulanate ORAL TABLET MG, MG, MG Amoxicillin-ot Clavulanate ORAL TABLET CHEWABLE MG, MG BICILLIN C-R SUSENSION UNIT/2ML BICILLIN C-R 900/300 SUSENSION UNIT/2ML *enicillinase-resistant enicillins** *enicillinase-resistant enicillins*** Dicloxacillin Sodium ORAL CASULE 250 MG, 500 MG Oxacillin Sodium INJECTION SOLUTION RECONSTITUTED 1 GM, 10 GM, 2 GM *rogestins* *rogestins** *rogestins*** QL (300 ML per 31 day(s)) QL (300 ML per 31 day(s)) 15

17 Drug Name reference Details Coverage Details MedroxyROGESTERone Acetate ORAL TABLET 10 MG, 2.5 MG, 5 MG Norethindrone Acetate ORAL TABLET 5 MG *Tetracyclines* *Tetracyclines** *Tetracyclines*** DOXY 100 INTRAVENOUS* SOLUTION RECONSTITUTED 100 MG Doxycycline Hyclate ORAL CASULE 100 MG, 50 MG Doxycycline Hyclate ORAL TABLET 100 MG A Doxycycline Hyclate ORAL TABLET 20 MG Minocycline HCl ORAL CASULE 100 MG, 50 MG, 75 MG Tetracycline HCl ORAL CASULE 250 MG, 500 MG *Toxoids* *Toxoid Combinations** *Toxoid Combinations*** ADACEL SUSENSION BOOSTRIX SUSENSION DATACEL SUSENSION INFANRIX SUSENSION TENIVAC INJECTABLE 5-2 LFU Tetanus-Diphtheria Toxoids Td SUSENSION 2-2 LF/0.5ML *Toxoids** *Toxoids*** Tetanus Toxoid Adsorbed SOLUTION 5 LFU *Urinary Anti-Infectives* *Urinary Anti-Infective Combinations** A 16

18 Drug Name reference Details Coverage Details *Urinary Antiseptic-Antispasmodic &/Or Analgesics*** URETRON D/S ORAL TABLET Uticap ORAL CASULE 120 MG *Urinary Anti-Infectives** *Urinary Anti-Infectives*** MACRODANTIN ORAL CASULE 25 MG AL (Max 8 Nitrofurantoin Macrocrystal ORAL CASULE 100 MG, 50 MG Nitrofurantoin Monohyd Macro ORAL CASULE 100 MG *Vaccines* *Viral Vaccines** *Viral Vaccines*** ENGERIX-B INJECTION SUSENSION 10 MCG/0.5ML, 20 MCG/ML ENGERIX-B INJECTABLE 10 MCG/0.5ML, 20 MCG/ML RECOMBIVAX HB INJECTION SUSENSION 10 MCG/ML, 40 MCG/ML, 5 MCG/0.5ML *Vaginal roducts* *Vaginal Anti-Infectives** *Imidazole-Related Antifungals*** 3 Day Vaginal VAGINAL CREAM 2 % OTC Clotrimazole VAGINAL CREAM 1 % OTC Miconazole 3 VAGINAL SUOSITORY 200 MG Miconazole 3 Combo ack VAGINAL KIT MG-% (9GM) OTC Miconazole Nitrate VAGINAL CREAM 2 % OTC Miconazole Nitrate VAGINAL SUOSITORY 100 MG MONISTAT 1 COMBO ACK VAGINAL KIT MG-% OTC OTC MONISTAT 3 VAGINAL CREAM 4 % OTC Terconazole VAGINAL CREAM 0.4 %, 0.8 % 17

19 Drug Name reference Details Coverage Details Terconazole VAGINAL SUOSITORY 80 MG *Vaginal Anti-Infectives*** Clindamycin hosphate VAGINAL CREAM 2 % MetroNIDAZOLE VAGINAL GEL 0.75 % VANDAZOLE VAGINAL GEL 0.75 % *Vaginal rogestins** *Vaginal rogestins*** ENDOMETRIN VAGINAL INSERT 100 MG FIRST-ROGESTERONE VGS 100 VAGINAL SUOSITORY 100 MG FIRST-ROGESTERONE VGS 200 VAGINAL SUOSITORY 200 MG FIRST-ROGESTERONE VGS 25 VAGINAL SUOSITORY 25 MG FIRST-ROGESTERONE VGS 400 VAGINAL SUOSITORY 400 MG FIRST-ROGESTERONE VGS 50 VAGINAL SUOSITORY 50 MG 18

20 Index 3 Day Vaginal VAGINAL CREAM 2 % Acyclovir ORAL CASULE 200 MG... 3 Acyclovir ORAL SUSENSION 200 MG/5ML... 3 Acyclovir ORAL TABLET 400 MG, 800 MG... 3 ADACEL SUSENSION AK-oly-Bac OHTHALMIC OINTMENT UNIT/GM ALBENZA ORAL TABLET 200 MG... 1 ALTAVERA ORAL TABLET Alyacen 1/35 ORAL TABLET Amantadine HCl ORAL CASULE 100 MG... 3 Amantadine HCl ORAL SYRU 50 MG/5ML... 3 Amantadine HCl ORAL TABLET 100 MG... 3 Amoxicillin ORAL CASULE 250 MG, 500 MG Amoxicillin ORAL SUSENSION RECONSTITUTED 125 MG/5ML, 200 MG/5ML, 250 MG/5ML, 400 MG/5ML Amoxicillin ORAL TABLET 500 MG, 875 MG Amoxicillin ORAL TABLET CHEWABLE 125 MG, 250 MG Amoxicillin-ot Clavulanate ORAL SUSENSION RECONSTITUTED MG/5ML, MG/5ML, MG/5ML, MG/5ML Amoxicillin-ot Clavulanate ORAL TABLET MG, MG, MG Amoxicillin-ot Clavulanate ORAL TABLET CHEWABLE MG, MG Ampicillin ORAL CASULE 250 MG, 500 MG Ampicillin ORAL SUSENSION RECONSTITUTED 125 MG/5ML, 250 MG/5ML ARI ORAL TABLET AQUADEKS ORAL CASULE Atovaquone-roguanil HCl ORAL TABLET MG, MG... 3 AVIANE ORAL TABLET Azithromycin Hydrogencitrate INTRAVENOUS* SOLUTION RECONSTITUTED 2.5 GM Azithromycin INTRAVENOUS* SOLUTION RECONSTITUTED 500 MG Azithromycin ORAL SUSENSION RECONSTITUTED 100 MG/5ML, 200 MG/5ML Azithromycin ORAL TABLET 250 MG Azithromycin ORAL TABLET 500 MG, 600 MG B Complex lus ORAL TABLET B-100 Complex ORAL TABLET B-100 CR ORAL TABLET EXTENDEDRELEASE* B-50 Complex ORAL TABLET EXTENDEDRELEASE* Bacitracin Zinc EXTERNAL OINTMENT 500 UNIT/GM... 9 BALZIVA ORAL TABLET Baza Antifungal EXTERNAL CREAM 2 %... 9 BICILLIN C-R 900/300 SUSENSION UNIT/2ML BICILLIN C-R SUSENSION UNIT/2ML BICILLIN L-A SUSENSION UNIT/2ML, UNIT/4ML, UNIT/ML BOOSTRIX SUSENSION Briellyn ORAL TABLET CAMILA ORAL TABLET 0.35 MG... 8 CAZIANT ORAL TABLET 0.1/0.125/ MG... 7 Cefaclor ORAL CASULE 250 MG, 500 MG... 4 Cefadroxil ORAL CASULE 500 MG... 4 Cefadroxil ORAL SUSENSION RECONSTITUTED 250 MG/5ML, 500 MG/5ML... 4 Cefadroxil ORAL TABLET 1 GM... 4 Cefdinir ORAL CASULE 300 MG... 4 Cefdinir ORAL SUSENSION RECONSTITUTED 125 MG/5ML, 250 MG/5ML... 4 Cefpodoxime roxetil ORAL SUSENSION RECONSTITUTED 100 MG/5ML, 50 MG/5ML... 5 Cefpodoxime roxetil ORAL TABLET 100 MG, 200 MG... 5 Cefprozil ORAL SUSENSION RECONSTITUTED 125 MG/5ML, 250 MG/5ML... 4 Cefprozil ORAL TABLET 250 MG, 500 MG... 4 Cefuroxime Axetil ORAL SUSENSION RECONSTITUTED 125 MG/5ML... 4 Cefuroxime Axetil ORAL TABLET 250 MG, 500 MG... 4 Cephalexin ORAL CASULE 250 MG, 500 MG, 750 MG

21 Cephalexin ORAL SUSENSION RECONSTITUTED 125 MG/5ML... 4 Cephalexin ORAL SUSENSION RECONSTITUTED 250 MG/5ML... 4 Ciclopirox EXTERNAL SOLUTION 8 %... 9 Ciclopirox Olamine EXTERNAL CREAM 0.77 %... 9 Ciclopirox Olamine EXTERNAL SUSENSION 0.77 %... 9 Ciprofloxacin HCl OHTHALMIC SOLUTION 0.3 % Ciprofloxacin HCl ORAL TABLET 250 MG, 500 MG, 750 MG Clarithromycin ORAL SUSENSION RECONSTITUTED 125 MG/5ML, 250 MG/5ML Clarithromycin ORAL TABLET 250 MG, 500 MG Clindamycin HCl ORAL CASULE 150 MG, 300 MG, 75 MG... 2 Clindamycin almitate HCl ORAL SOLUTION RECONSTITUTED 75 MG/5ML... 3 Clindamycin hosphate INJECTION SOLUTION 300 MG/2ML, 600 MG/4ML, 9 GM/60ML, 900 MG/6ML... 3 Clindamycin hosphate INTRAVENOUS* SOLUTION 300 MG/2ML... 3 Clindamycin hosphate VAGINAL CREAM 2 % Clotrimazole EXTERNAL CREAM 1 %... 9 Clotrimazole EXTERNAL SOLUTION 1 %... 9 Clotrimazole MOUTH/THROAT LOZENGE 10 MG Clotrimazole MOUTH/THROAT TROCHE 10 MG Clotrimazole VAGINAL CREAM 1 % CRYSELLE-28 ORAL TABLET CYCLAFEM 1/35 ORAL TABLET DATACEL SUSENSION DARARIM ORAL TABLET 25 MG... 3 DASETTA 1/35 ORAL TABLET DENAVIR EXTERNAL CREAM 1 %... 9 Dicloxacillin Sodium ORAL CASULE 250 MG, 500 MG DOXY 100 INTRAVENOUS* SOLUTION RECONSTITUTED 100 MG Doxycycline Hyclate ORAL CASULE 100 MG, 50 MG Doxycycline Hyclate ORAL TABLET 100 MG Doxycycline Hyclate ORAL TABLET 20 MG E.E.S. GRANULES ORAL SUSENSION RECONSTITUTED 200 MG/5ML Econazole Nitrate EXTERNAL CREAM 1 %... 9 ELINEST ORAL TABLET ELITE-OB ORAL TABLET MG EMOQUETTE ORAL TABLET ENDOMETRIN VAGINAL INSERT 100 MG ENGERIX-B INJECTION SUSENSION 10 MCG/0.5ML, 20 MCG/ML ENGERIX-B INJECTABLE 10 MCG/0.5ML, 20 MCG/ML ENRESSE-28 ORAL TABLET... 7 ERRIN ORAL TABLET 0.35 MG... 8 ERYED 200 ORAL SUSENSION RECONSTITUTED 200 MG/5ML ERYED 400 ORAL SUSENSION RECONSTITUTED 400 MG/5ML ERY-TAB ORAL TABLET DELAYED RELEASE 250 MG, 333 MG, 500 MG ERYTHROCIN STEARATE ORAL TABLET 250 MG Erythromycin Base ORAL CASULE DELAYED RELEASE ARTICLES 250 MG Erythromycin Base ORAL TABLET 250 MG, 500 MG Erythromycin Ethylsuccinate ORAL TABLET 400 MG Erythromycin OHTHALMIC OINTMENT 5 MG/GM Erythromycin-Sulfisoxazole ORAL SUSENSION RECONSTITUTED MG/5ML... 2 ESTARYLLA ORAL TABLET Estradiol-Norethindrone Acet ORAL TABLET MG, MG FALMINA ORAL TABLET FIRST-ROGESTERONE VGS 100 VAGINAL SUOSITORY 100 MG FIRST-ROGESTERONE VGS 200 VAGINAL SUOSITORY 200 MG FIRST-ROGESTERONE VGS 25 VAGINAL SUOSITORY 25 MG FIRST-ROGESTERONE VGS 400 VAGINAL SUOSITORY 400 MG FIRST-ROGESTERONE VGS 50 VAGINAL SUOSITORY 50 MG Fluconazole ORAL SUSENSION RECONSTITUTED 10 MG/ML, 40 MG/ML

22 Fluconazole ORAL TABLET 100 MG, 150 MG, 200 MG, 50 MG... 2 Folic Acid ORAL TABLET 1 MG, 400 MCG, 800 MCG Gentamicin Sulfate OHTHALMIC OINTMENT 0.3 % Gentamicin Sulfate OHTHALMIC SOLUTION 0.3 % GIANVI ORAL TABLET MG... 5 GILDESS 1.5/30 ORAL TABLET GILDESS 1/20 ORAL TABLET GILDESS FE 1.5/30 ORAL TABLET GILDESS FE 1/20 ORAL TABLET Griseofulvin Microsize ORAL SUSENSION 125 MG/5ML... 1 Griseofulvin Microsize ORAL TABLET 500 MG... 1 Griseofulvin Ultramicrosize ORAL TABLET 125 MG, 250 MG... 2 GRIS-EG ORAL TABLET 125 MG, 250 MG... 1 HEATHER ORAL TABLET 0.35 MG... 8 HEAGAM B INJECTION SOLUTION Hydroxychloroquine Sulfate ORAL TABLET 200 MG... 3 HYERHE B S/D SOLUTION INFANRIX SUSENSION JOLIVETTE ORAL TABLET 0.35 MG... 8 JUNEL 1.5/30 ORAL TABLET JUNEL 1/20 ORAL TABLET JUNEL FE 1.5/30 ORAL TABLET JUNEL FE 1/20 ORAL TABLET KARIVA ORAL TABLET /0.01 MG (21/5)... 5 KELNOR 1/35 ORAL TABLET Ketoconazole EXTERNAL CREAM 2 %... 9 Ketoconazole EXTERNAL SHAMOO 2 %... 9 Ketoconazole ORAL TABLET 200 MG... 2 LESSINA ORAL TABLET Levofloxacin ORAL TABLET 250 MG, 500 MG, 750 MG Levonorgestrel ORAL TABLET 0.75 MG... 8 LEVORA 0.15/30 (28) ORAL TABLET LORYNA ORAL TABLET MG... 6 LOW-OGESTREL ORAL TABLET LUTERA ORAL TABLET MACRODANTIN ORAL CASULE 25 MG Marlissa ORAL TABLET MedroxyROGESTERone Acetate SUSENSION 150 MG/ML... 8 MedroxyROGESTERone Acetate ORAL TABLET 10 MG, 2.5 MG, 5 MG Mefloquine HCl ORAL TABLET 250 MG... 3 MERON ORAL SUSENSION 750 MG/5ML... 2 MetroNIDAZOLE EXTERNAL CREAM 0.75 %... 9 MetroNIDAZOLE EXTERNAL GEL 1 %... 9 MetroNIDAZOLE ORAL TABLET 250 MG, 500 MG... 2 MetroNIDAZOLE VAGINAL GEL 0.75 % Miconazole 3 Combo ack VAGINAL KIT MG-% (9GM) Miconazole 3 VAGINAL SUOSITORY 200 MG Miconazole Nitrate VAGINAL CREAM 2 % Miconazole Nitrate VAGINAL SUOSITORY 100 MG MICROGESTIN 1.5/30 ORAL TABLET MICROGESTIN 1/20 ORAL TABLET MICROGESTIN FE 1.5/30 ORAL TABLET MICROGESTIN FE 1/20 ORAL TABLET Minocycline HCl ORAL CASULE 100 MG, 50 MG, 75 MG MONISTAT 1 COMBO ACK VAGINAL KIT MG-% MONISTAT 3 VAGINAL CREAM 4 % MONONESSA ORAL TABLET Multivitamin/Fluoride ORAL TABLET CHEWABLE 0.25 MG, 0.5 MG, 1 MG Multi-Vitamin/Fluoride ORAL TABLET CHEWABLE 0.25 MG, 0.5 MG, 1 MG Multi-Vitamins ORAL TABLET MYNATAL ADVANCE ORAL TABLET Mynatal-Z ORAL TABLET Mynate 90 lus ORAL TABLET EXTENDEDRELEASE* MYZILRA ORAL TABLET... 7 NABI-HB SOLUTION NECON 0.5/35 (28) ORAL TABLET NECON 1/35 (28) ORAL TABLET

23 NECON 1/50 (28) ORAL TABLET NECON 7/7/7 ORAL TABLET 0.5/0.75/ Neomycin-Bacitracin Zn-olymyx OHTHALMIC OINTMENT Neomycin-olymyxin-Dexameth OHTHALMIC OINTMENT Neomycin-olymyxin-Dexameth OHTHALMIC SUSENSION Neomycin-olymyxin-Gramicidin OHTHALMIC SOLUTION Neomycin-olymyxin-HC OHTHALMIC SUSENSION Nitrofurantoin Macrocrystal ORAL CASULE 100 MG, 50 MG Nitrofurantoin Monohyd Macro ORAL CASULE 100 MG NORA-BE ORAL TABLET 0.35 MG... 8 Norethindrone Acetate ORAL TABLET 5 MG NOR-QD ORAL TABLET 0.35 MG... 8 NORTREL 0.5/35 (28) ORAL TABLET NORTREL 1/35 (21) ORAL TABLET NORTREL 1/35 (28) ORAL TABLET NORTREL 7/7/7 ORAL TABLET 0.5/0.75/ NUVARING VAGINAL RING MG/24HR... 8 Nystatin EXTERNAL CREAM UNIT/GM... 9 Nystatin EXTERNAL OINTMENT UNIT/GM... 9 Nystatin EXTERNAL OWDER UNIT/GM... 9 Nystatin MOUTH/THROAT SUSENSION UNIT/ML Nystatin ORAL TABLET UNIT... 2 OCELLA ORAL TABLET MG... 7 Ofloxacin OHTHALMIC SOLUTION 0.3 % Ofloxacin OTIC SOLUTION 0.3 % ORSYTHIA ORAL TABLET ORTHO DIAHRAGM ALL-FLEX VAGINAL DIAHRAGM 65 MM, 70 MM, 75 MM, 80 MM Oxacillin Sodium INJECTION SOLUTION RECONSTITUTED 1 GM, 10 GM, 2 GM enicillin G rocaine SUSENSION UNIT/ML enicillin V otassium ORAL SOLUTION RECONSTITUTED 125 MG/5ML, 250 MG/5ML enicillin V otassium ORAL TABLET 250 MG, 500 MG FIZEREN-G INJECTION SOLUTION RECONSTITUTED UNIT, UNIT HILITH ORAL TABLET LAN B ONE-STE ORAL TABLET 1.5 MG... 8 oly Bacitracin EXTERNAL OINTMENT UNIT/GM... 8 olymyxin B-Trimethoprim OHTHALMIC SOLUTION UNIT/ML-% olyvitamin ORAL SOLUTION 35 MG/ML ORTIA-28 ORAL TABLET R NATAL 400 EC ORAL MISC & 400 MG (DR) renatabs OBN ORAL TABLET 29-1 MG RENATABS RX ORAL TABLET 29-1 MG renatal 19 ORAL TABLET CHEWABLE renatal Low Iron ORAL TABLET MG renatal ORAL TABLET MG renatal lus Iron ORAL TABLET 29-1 MG renatal lus ORAL TABLET 27-1 MG REVIFEM ORAL TABLET rimaquine hosphate ORAL TABLET 26.3 MG... 3 QUASENSE ORAL TABLET MG... 7 RECLISEN ORAL TABLET RECOMBIVAX HB INJECTION SUSENSION 10 MCG/ML, 40 MCG/ML, 5 MCG/0.5ML Reeses inworm Medicine ORAL SUSENSION 144 MG/ML... 1 RELENZA DISKHALER INHALATION AEROSOL OWDER, BREATH ACTIVATED 5 MG/BLISTER... 4 REMEVEN EXTERNAL CREAM 50 %... 9 Rimantadine HCl ORAL TABLET 100 MG... 3 SOLIA ORAL TABLET SRINTEC 28 ORAL TABLET SRONYX ORAL TABLET STROMECTOL ORAL TABLET 3 MG... 1 Sulfamethoxazole-TM DS ORAL TABLET MG... 2 Sulfamethoxazole-Trimethoprim ORAL SUSENSION MG/5ML... 2 Sulfamethoxazole-Trimethoprim ORAL TABLET MG... 2 SYEDA ORAL TABLET MG

24 TAMIFLU ORAL CASULE 30 MG... 4 TAMIFLU ORAL CASULE 45 MG, 75 MG... 4 TAMIFLU ORAL SUSENSION RECONSTITUTED 6 MG/ML... 4 TENIVAC INJECTABLE 5-2 LFU Terbinafine HCl EXTERNAL CREAM 1 %... 9 Terbinafine HCl ORAL TABLET 250 MG... 2 Terconazole VAGINAL CREAM 0.4 %, 0.8 % Terconazole VAGINAL SUOSITORY 80 MG Tetanus Toxoid Adsorbed SOLUTION 5 LFU Tetanus-Diphtheria Toxoids Td SUSENSION 2-2 LF/0.5ML Tetracycline HCl ORAL CASULE 250 MG, 500 MG TRI-ESTARYLLA ORAL TABLET 0.18/0.215/0.25 MG-35 MCG... 7 Trifluridine OHTHALMIC SOLUTION 1 % Trimethoprim ORAL TABLET 100 MG... 2 Trinatal Rx 1 ORAL TABLET 60-1 MG TRINATE ORAL TABLET TRINESSA (28) ORAL TABLET 0.18/0.215/0.25 MG-35 MCG... 8 TRI-REVIFEM ORAL TABLET 0.18/0.215/0.25 MG-35 MCG... 8 TRI-SRINTEC ORAL TABLET 0.18/0.215/0.25 MG-35 MCG... 8 TRIVEEN-U ORAL CASULE MG Tri-Vitamin ORAL SOLUTION TRIVORA (28) ORAL TABLET... 8 UltimateCare Combo ORAL MISC 30-1 MG URETRON D/S ORAL TABLET Uticap ORAL CASULE 120 MG ValACYclovir HCl ORAL TABLET 1 GM, 500 MG... 3 VANDAZOLE VAGINAL GEL 0.75 % VELIVET ORAL TABLET 0.1/0.125/ MG... 8 VINATE AZ EXTRA ORAL TABLET 29-1 MG VINATE AZ ORAL TABLET 27-1 MG VINATE GT ORAL TABLET 90-1 MG VINATE II ORAL TABLET 29-1 MG VINATE M ORAL TABLET 27-1 MG Vitamins ACD-Fluoride ORAL SOLUTION 0.25 MG/ML XOLAIR SUBCUTANEOUS* SOLUTION RECONSTITUTED 150 MG... 1 ZENCHENT FE ORAL TABLET CHEWABLE ZENCHENT ORAL TABLET ZOVIA 1/35E (28) ORAL TABLET ZOVIA 1/50E (28) ORAL TABLET ZOVIRAX EXTERNAL CREAM 5 %