2018 Abridged Advantage Formulary. (Partial List of Covered Drugs)

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1 FirstMedicare Direct HMO Plus FirstMedicare Direct HMO Standard FirstMedicare Direct Healthy State HMO Plus FirstMedicare Direct Healthy State HMO Prime 018 Abridged Advantage Formulary (Partial List of Covered Drugs) PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT SOME OF THE DRUGS WE COVER IN THIS PLAN This abridged formulary was updated on 05/01/018. This is not a complete list of drugs covered by our plan. For a complete listing or other questions, please contact FirstMedicare Direct Member Services at or, for TTY users, 711, 4 hours a day/7 days a week, or visit The Formulary may change at any time. You will receive notice when necessary. FirstCarolinaCare Insurance Company is a HMO and PPO health plan with a Medicare contract. Enrollment in a FirstMedicareDirect plan depends on contract renewal. FirstCarolinaCare complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Formulary ID: 180, Version Number: 1 H606_18_50 Accepted 09/0/017 Effective: 05/01/018

2 Note to existing members: This formulary has changed since last year. Please review this document to make sure that it still contains the drugs you take. When this drug list (formulary) refers to we, us, or our, it means FirstCarolinaCare Insurance Company. When it refers to plan or our plan, it means FirstMedicare Direct. This document includes a partial list of the drugs (formulary) for our plan which is current as of 05/01/018. For a complete, 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, 018, and from time to time during the year. H606_18_50 Effective: 05/01/018

3 What is the FirstMedicare Direct Abridged Formulary? A formulary is a list of covered drugs selected by FirstMedicare Direct 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. FirstMedicare Direct will generally cover the drugs listed in our formulary as long as the drug is medically necessary, the prescription is filled at a FirstMedicare Direct network pharmacy, and other plan rules are followed. For more information on how to fill your prescriptions, please review your Evidence of Coverage. This document is a partial formulary and includes only some of the drugs covered by FirstMedicare Direct. For a complete listing of all prescription drugs covered by FirstMedicare Direct, please visit our website or call us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages. Can the Formulary (drug list) change? Generally, if you are taking a drug on our 018 formulary that was covered at the beginning of the year, we will not discontinue or reduce coverage of the drug during the 018 coverage year except when a new, less expensive generic drug becomes available or when new adverse information about the safety or effectiveness of a drug is released. Other types of formulary changes, such as removing a drug from our formulary, will not affect members who are currently taking the drug. It will remain available at the same cost-sharing for those members taking it for the remainder of the coverage year. We feel it is important that you have continued access for the remainder of the coverage year to the formulary drugs that were available when you chose our plan, except for cases in which you can save additional money or we can ensure your safety. If we remove drugs from our formulary, add prior authorization, quantity limits and/or step therapy restrictions on a drug or move a drug to a higher cost-sharing tier, we must notify affected members of the change at least 60 days before the change becomes effective, or at the time the member requests a refill of the drug, at which time the member will receive a 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 05/01/018. To get updated information about the drugs covered by FirstMedicare Direct, please contact us. Our contact information appears on the front and back cover pages. If non-maintenance formulary changes occur during the plan year, members will be provided notice and the printable formulary will be updated and posted on our website at How do I use the Formulary? There are two ways to find your drug within the formulary: Medical Condition The formulary begins on page. The drugs in this formulary are grouped into categories depending on the type of medical conditions that they are used to treat. For example, drugs used to treat a heart condition are listed under the category, Cardiovascular Agents. If you know what your drug is used for, look for the category name in the list that begins on page 1. Then look under the category name for your drug. Alphabetical Listing If you are not sure what category to look under, you should look for your drug in the Index that begins on page I-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

4 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? FirstMedicare Direct 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: FirstMedicare Direct requires you or your physician to get prior authorization for certain drugs. This means that you will need to get approval from FirstMedicare Direct before you fill your prescriptions. If you don t get approval, FirstMedicare Direct may not cover the drug. Quantity Limits: For certain drugs, FirstMedicare Direct limits the amount of the drug that FirstMedicare Direct will cover. For example, FirstMedicare Direct provides 0 tablets per prescription for pioglitazone. This may be in addition to a standard one-month or three-month supply. Step Therapy: In some cases, FirstMedicare Direct 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, FirstMedicare Direct may not cover Drug B unless you try Drug A first. If Drug A does not work for you, FirstMedicare Direct will then cover Drug B. You can find out if your drug has any additional requirements or limits by looking in the formulary that begins on page. You can also get more information about the restrictions applied to specific covered drugs by visiting our 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 FirstMedicare Direct 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 FirstMedicare Direct formulary? on page 5 for information about how to request an exception. What if my drug is not on the Formulary? If your drug is not included in this formulary (list of covered drugs), you should first contact Member Services and ask if your drug is covered. This document includes only a partial list of covered drugs, so FirstMedicare Direct may cover your drug. For more information, 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 learn that FirstMedicare Direct does not cover your drug, you have two options: You can ask Member Services for a list of similar drugs that are covered by FirstMedicare Direct. When you receive the list, show it to your doctor and ask him or her to prescribe a similar drug that is covered by FirstMedicare Direct.

5 You can ask FirstMedicare Direct 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 FirstMedicare Direct s Formulary? You can ask FirstMedicare Direct 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 cover a formulary drug at a lower cost-sharing level if this drug is not on the specialty tier. If approved, this would lower the amount you must pay for your drug. You can ask us to waive coverage restrictions or limits on your drug. For example, for certain drugs, FirstMedicare Direct 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, FirstMedicare Direct will only approve your request for an exception if the alternative drugs included on the plan s formulary, the lower cost-sharing drug or additional utilization restrictions would not be as effective in treating your condition and/or would cause you to have adverse medical effects. You should contact us to ask us for an initial coverage decision for a formulary, tiering or utilization restriction exception. When you request a formulary, tiering or utilization restriction exception you should submit a statement from your prescriber or physician supporting your request. Generally, we must make our decision within 7 hours of getting your 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 7 hours for a decision. If your request to expedite is granted, we must give you a decision no later than 4 hours after we get 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. For each of your drugs that is not on our formulary or if your ability to get your drugs is limited, we will cover a temporary 0 day supply (unless you have a prescription written for fewer days) when you go to a network pharmacy. After your first 0 day supply, we will not pay for these drugs, even if you have been a member of the plan less than 90 days. If you are a resident of a long-term care facility, we will allow you to refill your prescription until we have provided you with up to 98 day transition supply, consistent with dispensing increment, (unless you have a prescription written for fewer days). We will cover more than one refill of these drugs for the first 90 days you

6 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 1 day emergency supply of that drug (unless you have a prescription for fewer days) while you pursue a formulary exception. Transition medications will be provided to members who change treatment settings due to changes in level of care (e.g. individuals who enter long term care facilities from hospitals or enter an ambulatory setting from a hospital). For more information For more detailed information about your FirstMedicare Direct prescription drug coverage, please review your Evidence of Coverage and other plan materials. If you have questions about FirstMedicare Direct, 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 ( ) 4 hours a day/7 days a week. TTY users should call Or, visit FirstMedicare Direct s Formulary The abridged formulary below provides coverage information about some of the drugs covered by FirstMedicare Direct. If you have trouble finding your drug in the list, turn to the Index that begins on page I-1. Remember: This is only a partial list of drugs covered by FirstMedicare Direct. If your prescription is not in this partial formulary, please contact us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages. The first column of the chart lists the drug name. Brand name drugs are capitalized (e.g., JANUVIA) and generic drugs are listed in lower-case italics (e.g., simvastatin). The information in the Requirements/Limits column tells you if FirstMedicare Direct has any special requirements for coverage of your drug. The following abbreviations may be found within the body of this document COVERAGE NOTES ABBREVIATIONS ABBREVIATION DESCRIPTION EXPLANATION GENERAL generic(brand) UTILIZATION MANAGEMENT RESTRICTIONS AGE Restriction for members over 64 years of age The reference brand name in parentheses is provided for information only, to assist in identifying the generic medication and does NOT indicate formulary status or coverage A clinical review may be required for members 65 years of age and older. Without prior approval, FirstMedicare Direct may not cover this drug.

7 ABBREVIATION DESCRIPTION EXPLANATION NDS Non-Extended Days This drug is not available for an extended day supply Supply (example: 90 days supply) You (or your physician) are required to get prior PA Prior Authorization authorization from FirstMedicare Direct before you fill Restriction your prescription for this drug. Without prior approval, FirstMedicare Direct may not cover this drug. This drug may be eligible for payment under Medicare PA B v D Part B or Part D. You (or your physician) are required Prior Authorization to get prior authorization from FirstMedicare Direct to Restriction for determine that this drug is covered under Medicare Part Part B vs Part D D before you fill your prescription for this drug. Determination Without prior approval, FirstMedicare Direct may not cover this drug. This drug has been deemed by CMS to be potentially harmful and therefore, a High Risk Medication for PA HRM Prior Authorization Restriction for High Risk Medication Medicare beneficiaries 65 and older. Members age 65 years and older are required to get prior authorization from FirstMedicare Direct before you fill your prescription for this drug. Without prior approval, FirstMedicare Direct may not cover this drug. PA NSO Prior Authorization Restriction for New Starts Only If you are a new member, you (or your physician) are required to get prior authorization from FirstMedicare Direct before you fill your prescription for this drug. Without prior approval, FirstMedicare Direct may not cover this drug. QL Quantity Limit Restriction FirstMedicare Direct limits the amount of this drug that is covered per prescription, or within a specific time frame. ST Step Therapy Restriction Before FirstMedicare Direct 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. OTHER SPECIAL REQUIREMENTS FOR COVERAGE GC LA Gap Coverage Limited Access Drug We provide coverage of this prescription drug in the coverage gap. Please refer to our Evidence of Coverage for more information about this coverage. This prescription may be available only at certain pharmacies. For more information consult your Pharmacy Directory or call Member Services at , 4 hours a day/7 days a week. TTY users should call 711.

8 STRENGTH AND DOSAGE FORM ABBREVIATIONS ABBREVIATION DESCRIPTION adh. patch adhesive patch aer br act aerosol, breath activated aer pow aerosol, powder aer pow ba aerosol powder, breath activated aer refill aerosol refill aer w/adap aerosol with adapter ampul ampule blkbaginj bulk bag injection cap dr mp capsule, delayed release multiphasic cap ds pk capsule, dose pack cap er 1h capsule, 1 hour extended release cap er 4h capsule, 4 hour extended release cap er deg capsule, extended release degradable cap er pel capsule, extended release pellets cap mphase capsule, multiphasic cap.sa 4h capsule, 4 hour sustained action cap.sr 1h capsule, 1 hour sustained release cap.sr 4h capsule, 4 hour sustained release cap4h pct capsule, 4 hour controlled-onset pellets cap4h pel capsule, 4 hour sustained release pellets cap sprink capsule, sprinkle cap sr pel capsule sustained release pellets cap w/dev capsule with device capsule dr capsule, delayed release capsule er capsule, extended release capsule sa capsule, sustained action cmb cappad combination: capsule, pad cmb ont fm combination: ointment, foam cmb ont lt combination: ointment, lotion cmb tabpad combination: tablet, pad combo. pkg combination package cpmp 1hr capsule, 1 hour multiphasic cpmp 4hr capsule, 4 hour multiphasic cpmp 0-70 capsule, multiphasic, 0%-70% cpmp capsule, multiphasic, 50%-50% cream(g), cream(gm) cream (grams) cream(ml) cream (milliliters) cream/appl cream with applicator cream, er (g) cream, extended release (grams) cream pack cream, package

9 ABBREVIATION dehp fr bg dis needle disk w/dev disp syrin drops susp drps hpvis emul adhes emul packt emulsn(g) foam/appl. froz.piggy G gel/pf app gel (gm) gel (ml) gel md pmp gel w/appl gel w/pump gran pack hfa aer ad infus. btl insuln pen ip soln irrig soln iv soln. Jel jelly/app jel/pf app kit cl&crm kt crm le kt lotn ce kt oint le lotion, er lozenge hd m.ht patch ma buc tab Mcg med. pad med. swab med. tape Mg Ml muc er 1h ndl fr inj DESCRIPTION di(-ethylhexyl)phthalate free bag disposable needle disk with inhalation device disposable syringe drops, suspension drops, hyperviscous emulsion adhesive emulsion packet emulsion (grams) foam with applicator frozen piggyback gram gel with prefilled applicator gel (grams) gel (milliliters) gel in metered dose pump gel with applicator gel with pump granule pack hfa aerosol adapter infusion bottle insulin pen intraperitoneal solution irrigating solution intravenous solution jelly jelly with applicator jelly with pre-filled applicator kit: cleanser and cream kit: cream, lotion emollient kit: lotion, cream emollient kit: ointment, lotion emollient lotion, extended release lozenge handle medicated heated patch mucoadhesive buccal tablet microgram medicated pad medicated swab medicated tape milligram milliliter mucoadhesive system, 1 hour extended release needle for injection

10 ABBREVIATION nl fm susp oint. (g), oint.(gm) oral conc oral susp paste (g) patch td4 patch td7 patch tdsw patch tdwk pca syring pca vial pellet(ea) pen ij kit pen injctr pggybk btl plast. bag powd pack sol md pmp sol w/appl sol/pf app sol-gel soln recon soln(gram) spray susp spray/pump stick(ea) supp.rect supp.vag suppos. sus er 4h sus er rec sus mc rec suspdr pkt susp recon syringekit tab chew tab er 1h tab er 4h tab er prt tab er seq tab disper tab ds pk tab er 4 tab mphase DESCRIPTION nail film suspension ointment (grams) oral concentrate oral suspension paste (grams) patch, 4 hour transdermal patch, 7 hour transdermal patch, biweekly transdermal patch, weekly transdermal patient-controlled analgesic syringe patient-controlled analgesic vial pellet (each) pen injector kit pen injector piggyback bottle plastic bag powder pack solution with multi-dose pump solution with applicator solution with pre-filled applicator solution, gel-forming solution, reconstituted solution (grams) spray, suspension spray with pump stick (each) suppository, rectal suppository, vaginal suppository suspension, 4 hour extended release suspension, extended release reconstituted suspension, microcapsule reconstituted suspension, delayed release packet suspension, reconstituted syringe kit tablet, chewable tablet, 1 hour extended release tablet, 4 hour extended release tablet, extended release particles tablet, extended release sequels tablet, dispersible tablet, dose pack tablet, 4 hour extended release tablet, multiphasic

11 ABBREVIATION tab part tab rap dr tab rapdis tab subl tab.sr 1h tab.sr 4h tabergr4hr tablet dr tablet, er tablet eff tablet sa tablet sol tb er dspk tb mp dspk tb rd dspk tbdspk mo tbmp 1hr tbmp 4hr U vag ring DESCRIPTION tablet, particles tablet, rapid disintegrating delayed release tablet, rapid disintegrating tablet, sublingual tablet, 1 hour sustained release tablet, 4 hour sustained release tablet, 4 hour gradual extended release tablet, delayed release tablet, extended release tablet, effervescent tablet, sustained action tablet, soluble tablet, extended release dose pack tablet, multiphasic dose pack tablet, rapid disintegrating dose pack tablet, -month dose pack tablet, 1 hour multiphasic tablet, 4 hour multiphasic unit vaginal ring

12 Discrimination is Against the Law FirstCarolinaCare Insurance Company complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. FirstCarolinaCare Insurance Company does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. FirstCarolinaCare Insurance Company provides free aids and services to people with disabilities to communicate effectively with us, such as: Qualified sign language interpreters Written information in other formats (large print, audio, accessible electronic formats, other formats). Provides free language services to people whose primary language is not English, such as: Qualified interpreters Information written in other languages. If you need these services, contact the Civil Rights Coordinator for FirstCarolinaCare Insurance Company. If you believe that FirstCarolinaCare Insurance Company 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 grievance with: FCC Civil Rights Coordinator FirstCarolinaCare Insurance Company 4 Memorial Drive Pinehurst, NC 874 Telephone: Fax number: fccfmd@firstcarolinacare.com You can file a grievance in person or by mail, fax, or . If you need help filing a grievance, the FCC Civil Rights Coordinator is available to help you. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at or by mail or phone at: U.S. Department of Health and Human Services, 00 Independence Avenue SW., Room 509F, HHS Building, Washington, DC 001, , (TDD). Complaint forms are available at Y0094_18_07 Accepted 08/15/017

13 MULTI-LANGUAGE INTERPRETER SERVICES English ATTENTION: If you speak any language other than English, language assistance services, free of charge, are available to you. Call (TTY 711). Español (Spanish) ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al (TTY 711). 繁體中文 (Chinese) 注意 : 如果您使用繁體中文, 您可以免費獲得語言援助服務 請致電 (TTY 711) Tiếng Việt (Vietnamese) CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho bạn. Gọi số (TTY 711). 한국어 (Korean) 주의 : 한국어를사용하시는경우, 언어지원서비스를무료로이용하실수있습니다 (TTY 711) 번으로전화해주십시오. Français (French) ATTENTION : Si vous parlez français, des services d'aide linguistique vous sont proposés gratuitement. Appelez le (ATS 711). (Arabic) ةيبرعلا ملحوظة: إذا كنت تتحدث اذكر اللغة فا ن خدمات المساعدة اللغویة تتوافر لك بالمجان. اتصل برقم 1-<< (رقم ھاتف الصم والبكم: 711 W-TTY Y0094_18_07 Accepted 08/15/017

14 Hmoob (Hmong) LUS CEEV: Yog tias koj hais lus Hmoob, cov kev pab txog lus, muaj kev pab dawb rau koj. Hu rau (TTY 711). Русский (Russian) ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услуги перевода. Звоните (телетайп: 711). Tagalog (Tagalog Filipino) PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng a serbisyo ng tulong sa wika nang walang bayad. Tumawag sa (TTY 711). જર ત (Gujarati) ચન : જ તમ જર ત બ લત હ, ત ન: લ ક ભ ષ સહ ય સ વ ઓ તમ ર મ ટ ઉપલબ ધ છ. ફ ન કર (TTY 711). ខ រ (Cambodian) របយ ត ប ស នជ អ កន យ យ ភ ស ខ រ, សវ ជ ន យ ផ កភ ស ដ យម នគ តឈ ល គ ឣ ចម នស រ ប ប រ អ ក ច រ ទ រស ព (TTY 711) Deutsch (German) ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen zur Verfügung. Rufnummer: (TTY 711). ह द (Hindi) ध य न द : य द आप ह द ब लत ह त आपक लए म फ त म भ ष सह यत स व ए उपलब ध ह (TTY 711) पर क ल कर ພາສາລາວ (Lao) ໂປດຊາບ: ຖ າວ າ ທ ານເວ າພາສາ ລາວ, ການບ ລການຊ ວຍເຫ ອດ ານພາສາ, ໂດຍບ ເສ ຽຄ າ, ແ ມ ນ ມ ພ ອມໃຫ ທ ານ. ໂທຣ (TTY 711). 日本語 (Japanese) 注意事項 : 日本語を話される場合 無料の言語支援をご利用いただけます (TTY:711) まで お電話にてご連絡ください Y0094_18_07 Accepted 08/15/017

15 Table of Contents Analgesics... Anesthetics... 5 Anti-Addiction/Substance Abuse Treatment Agents... 5 Antianxiety Agents... 6 Antibacterials... 6 Anticancer Agents... 9 Anticholinergic Agents... 1 Anticonvulsants... 1 Antidementia Agents... 1 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)... 0 Blood Products/Modifiers/Volume Expanders... Caloric Agents... Cardiovascular Agents... 4 Central Nervous System Agents... 9 Contraceptives

16 Dental And Oral Agents... Dermatological Agents... Devices... 4 Enzyme Replacement/Modifiers... 5 Eye, Ear, Nose, Throat Agents... 5 Gastrointestinal Agents... 7 Genitourinary Agents... 8 Heavy Metal Antagonists... 8 Hormonal Agents, Stimulant/Replacement/Modifying... 9 Immunological Agents... 4 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... 51

17 Analgesics Analgesics, Miscellaneous acetaminophen-codeine oral solution 10-1 /5 ml acetaminophen-codeine oral tablet acetaminophen-codeine oral tablet 00-0 acetaminophen-codeine oral tablet butalbital-acetaminophen-caff oral capsule butalbital-acetaminophen-caff oral tablet QL (700 per 0 days) QL (60 per 0 days) (Tylenol-Codeine #) QL (60 per 0 days) (Tylenol-Codeine #4) QL (180 per 0 days) (Capacet) 4 PA-HRM; QL (180 per 0 days); AGE (Max 64 Years) (Esgic) PA-HRM; QL (180 per 0 days); AGE (Max 64 Years) endocet oral tablet 10-5 QL (40 per 0 days) endocet oral tablet 5-5 QL (60 per 0 days) endocet oral tablet QL (00 per 0 days) hydrocodone-acetaminophen oral solution (Hycet) 4 QL (700 per 0 days) /15 ml hydrocodone-acetaminophen oral tablet (Lorcet HD) QL (60 per 0 days) 10-5 hydrocodone-acetaminophen oral tablet (Verdrocet) QL (60 per 0 days).5-5 hydrocodone-acetaminophen oral tablet 5- (Lorcet (hydrocodone)) QL (60 per 0 days) 5 hydrocodone-acetaminophen oral tablet (Lorcet Plus) QL (60 per 0 days) lorcet (hydrocodone) oral tablet 5-5 QL (60 per 0 days) lorcet hd oral tablet 10-5 QL (60 per 0 days) lorcet plus oral tablet QL (60 per 0 days) morphine /ml carpuject outer, l/f, p/f, sdv /ml morphine 4 /ml carpuject outer,l/f,p/f, sdv 4 /ml morphine 8 /ml carpuject sdv, l/f, outer 8 /ml morphine concentrate oral solution 100 QL (180 per 0 days) /5 ml (0 /ml) morphine intravenous syringe 10 /ml, /ml, 4 /ml, 8 /ml

18 morphine oral solution 10 /5 ml QL (700 per 0 days) morphine oral solution 0 /5 ml (4 QL (00 per 0 days) /ml) MORPHINE ORAL TABLET 15 MG 4 QL (180 per 0 days) MORPHINE ORAL TABLET 0 MG 4 QL (10 per 0 days) morphine oral tablet extended release 100 (MS Contin) QL (60 per 0 days), 00, 60 morphine oral tablet extended release 15 (MS Contin) QL (90 per 0 days), 0 morphine sulfate 10 /ml vial 10 /ml oxycodone oral concentrate 0 /ml 4 QL (10 per 0 days) oxycodone oral solution 5 /5 ml QL (100 per 0 days) oxycodone oral tablet 10 QL (180 per 0 days) oxycodone oral tablet 15, 0 (Roxicodone) QL (10 per 0 days) oxycodone oral tablet 0 QL (10 per 0 days) oxycodone oral tablet 5 (Roxicodone) QL (180 per 0 days) oxycodone oral tablet,oral only,ext.rel.1 (OxyContin) 4 QL (60 per 0 days) hr 10, 15, 0, 0, 40, 60 oxycodone oral tablet,oral only,ext.rel.1 hr 80 (OxyContin) 5 NDS; QL (10 per 0 days) oxycodone-acetaminophen oral solution 5- QL (1800 per 0 days) 5 /5 ml oxycodone-acetaminophen oral tablet 10- (Endocet) QL (40 per 0 days) 5 oxycodone-acetaminophen oral tablet.5- (Endocet) QL (60 per 0 days) 5, 5-5 oxycodone-acetaminophen oral tablet 7.5- (Endocet) QL (00 per 0 days) 5 OXYCONTIN ORAL TABLET,ORAL QL (60 per 0 days) ONLY,EXT.REL.1 HR 10 MG, 15 MG, 0 MG, 0 MG, 40 MG, 60 MG OXYCONTIN ORAL TABLET,ORAL QL (10 per 0 days) ONLY,EXT.REL.1 HR 80 MG tramadol oral tablet 50 (Ultram) 1 GC; QL (40 per 0 days) zebutal oral capsule PA-HRM; QL (180 per 0 days); AGE (Max 64 Years) Nonsteroidal Anti-Inflammatory Agents diclofenac sodium oral tablet extended release 4 hr 100 (Voltaren-XR) 4

19 diclofenac sodium oral tablet,delayed release (dr/ec) 5, 50, 75 ibuprofen oral suspension 100 /5 ml (Child Ibuprofen) ibuprofen oral tablet 400, 600, 800 (IBU) 1 GC meloxicam oral tablet 15, 7.5 (Mobic) 1 GC nabumetone oral tablet 500, 750 naproxen oral suspension 15 /5 ml (Naprosyn) naproxen oral tablet 50, 75 1 GC naproxen oral tablet 500 (Naprosyn) 1 GC naproxen oral tablet,delayed release (EC-Naprosyn) (dr/ec) 75, 500 Anesthetics Local Anesthetics lidocaine hcl injection solution 0 /ml (Xylocaine) ( %) lidocaine hcl mucous membrane jelly % lidocaine hcl mucous membrane solution 4 % (40 /ml) lidocaine topical adhesive patch,medicated 5 % (Lidoderm) PA; QL (90 per 0 days) lidocaine topical ointment 5 % 4 PA; QL (90 per 0 days) lidocaine viscous mucous membrane solution % Anti-Addiction/Substance Abuse Treatment Agents Anti-Addiction/Substance Abuse Treatment Agents BUNAVAIL BUCCAL FILM.1-0. MG QL (0 per 0 days) BUNAVAIL BUCCAL FILM QL (60 per 0 days) MG, 6.-1 MG buprenorphine hcl sublingual tablet, QL (90 per 0 days) 8 buprenorphine-naloxone sublingual tablet QL (90 per 0 days) -0.5, 8- CHANTIX CONTINUING MONTH QL (168 per 84 days) BOX ORAL TABLET 1 MG CHANTIX ORAL TABLET 0.5 MG, 1 QL (168 per 84 days) MG CHANTIX STARTING MONTH BOX ORAL TABLETS,DOSE PACK 0.5 MG (11)- 1 MG (4) QL (5 per 8 days) 5

20 SUBOXONE SUBLINGUAL FILM 1- MG, 8- MG SUBOXONE SUBLINGUAL FILM -0.5 MG, 4-1 MG ZUBSOLV SUBLINGUAL TABLET MG, MG, MG, MG ZUBSOLV SUBLINGUAL TABLET MG Antianxiety Agents Benzodiazepines alprazolam oral tablet 0.5, 0.5, 1 QL (60 per 0 days) QL (0 per 0 days) QL (0 per 0 days) QL (60 per 0 days) (Xanax) 1 GC; QL (10 per 0 days) alprazolam oral tablet (Xanax) 1 GC; QL (150 per 0 days) clonazepam oral tablet 0.5, 1 (Klonopin) 1 GC; QL (90 per 0 days) clonazepam oral tablet (Klonopin) 1 GC; QL (00 per 0 days) clonazepam oral tablet,disintegrating QL (90 per 0 days) 0.15, 0.5, 0.5, 1 clonazepam oral tablet,disintegrating QL (00 per 0 days) lorazepam oral tablet 0.5, 1 (Ativan) 1 GC; QL (90 per 0 days) lorazepam oral tablet (Ativan) 1 GC; QL (150 per 0 days) Antibacterials Aminoglycosides BETHKIS INHALATION SOLUTION FOR NEBULIZATION 00 MG/4 ML 5 PA BvD; NDS neomycin oral tablet GC TOBI PODHALER INHALATION CAPSULE, W/INHALATION DEVICE 8 MG Antibacterials, Miscellaneous clindamycin hcl oral capsule 150, 00, 75 (Cleocin HCl) metronidazole oral tablet 50, 500 (Flagyl) 5 NDS; QL (4 per 8 days) 6

21 nitrofurantoin macrocrystal oral capsule 100, 50 nitrofurantoin macrocrystal oral capsule 5 nitrofurantoin monohyd/m-cryst oral capsule 100 (Macrodantin) 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); QL (10 per 0 days); AGE (Max 64 Years) (Macrodantin) 4 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); QL (10 per 0 days); AGE (Max 64 Years) (Macrobid) 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); QL (60 per 0 days); AGE (Max 64 Years) XIFAXAN ORAL TABLET 00 MG ; QL (9 per 0 days) XIFAXAN ORAL TABLET 550 MG Cephalosporins cefadroxil oral capsule 500 cefadroxil oral suspension for reconstitution 50 /5 ml, 500 /5 ml cefadroxil oral tablet 1 gram cefdinir oral capsule 00 cefdinir oral suspension for reconstitution 15 /5 ml, 50 /5 ml cefprozil oral suspension for reconstitution 15 /5 ml, 50 /5 ml cefprozil oral tablet 50, 500 cefuroxime axetil oral tablet 50, 500 cephalexin oral capsule 50, 500 (Keflex) 1 GC 7

22 cephalexin oral suspension for reconstitution 15 /5 ml, 50 /5 ml cephalexin oral tablet 50, 500 Macrolides azithromycin intravenous recon soln 500 (Zithromax) azithromycin oral packet 1 gram (Zithromax) azithromycin oral suspension for (Zithromax) reconstitution 100 /5 ml, 00 /5 ml azithromycin oral tablet 50 (6 pack), 500 ( pack) azithromycin oral tablet 50, 500, (Zithromax) 600 clarithromycin oral suspension for reconstitution 15 /5 ml, 50 /5 ml clarithromycin oral tablet 50, 500 clarithromycin oral tablet extended 4 release 4 hr 500 Miscellaneous B-Lactam Antibiotics CAYSTON INHALATION SOLUTION 5 LA; NDS FOR NEBULIZATION 75 MG/ML INVANZ INJECTION RECON SOLN 1 4 GRAM Penicillins amoxicillin oral capsule 50, GC amoxicillin oral suspension for 1 GC reconstitution 15 /5 ml, 00 /5 ml, 50 /5 ml, 400 /5 ml amoxicillin oral tablet 500, GC amoxicillin oral tablet,chewable 15, 1 GC 50 amoxicillin-pot clavulanate oral suspension for reconstitution /5 ml, /5 ml 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

23 amoxicillin-pot clavulanate oral tablet (Augmentin) , amoxicillin-pot clavulanate oral tablet,chewable , dicloxacillin oral capsule 50, 500 penicillin v potassium oral recon soln 15 /5 ml, 50 /5 ml penicillin v potassium oral tablet 50, 500 Quinolones ciprofloxacin hcl oral tablet 100, GC ciprofloxacin hcl oral tablet 50, 500 (Cipro) 1 GC levofloxacin intravenous solution 5 4 /ml levofloxacin oral solution 50 /10 ml levofloxacin oral tablet 50, 500, (Levaquin) 750 ofloxacin oral tablet 00, 400 Sulfonamides sulfadiazine oral tablet sulfamethoxazole-trimethoprim intravenous solution /5 ml sulfamethoxazole-trimethoprim oral (Sulfatrim) suspension /5 ml sulfamethoxazole-trimethoprim oral tablet (Bactrim) 1 GC sulfamethoxazole-trimethoprim oral tablet (Bactrim DS) 1 GC Tetracyclines doxy-100 intravenous recon soln 100 doxycycline hyclate oral capsule 100, (Morgidox) 50 doxycycline hyclate oral tablet 100, 0 minocycline oral capsule 100, 50, (Minocin) 75 minocycline oral tablet 100, 50, 75 4 Anticancer Agents Anticancer Agents 9

24 AFINITOR DISPERZ ORAL TABLET 5 PA NSO; NDS; QL (11 FOR SUSPENSION MG, MG, 5 MG per 8 days) AFINITOR ORAL TABLET 10 MG 5 PA NSO; NDS; QL (56 per 8 days) AFINITOR ORAL TABLET.5 MG, 5 5 PA NSO; NDS; QL (8 MG, 7.5 MG per 8 days) anastrozole oral tablet 1 (Arimidex) 1 GC bicalutamide oral tablet 50 (Casodex) DROXIA ORAL CAPSULE 00 MG, 00 MG, 400 MG ELIGARD ( MONTH) 4 SUBCUTANEOUS SYRINGE.5 MG ELIGARD (4 MONTH) 4 SUBCUTANEOUS SYRINGE 0 MG ELIGARD (6 MONTH) 4 SUBCUTANEOUS SYRINGE 45 MG ELIGARD SUBCUTANEOUS SYRINGE MG (1 MONTH) exemestane oral tablet 5 (Aromasin) 4 hydroxyurea oral capsule 500 (Hydrea) INLYTA ORAL TABLET 1 MG 5 PA NSO; NDS; QL (180 per 0 days) INLYTA ORAL TABLET 5 MG 5 PA NSO; NDS; QL (60 per 0 days) JAKAFI ORAL TABLET 10 MG, 15 MG, 5 PA NSO; NDS; QL (60 0 MG, 5 MG, 5 MG per 0 days) letrozole oral tablet.5 (Femara) LEUKERAN ORAL TABLET MG 4 leuprolide subcutaneous kit 1 /0. ml LUPRON DEPOT ( MONTH) 5 NDS INTRAMUSCULAR SYRINGE KIT 11.5 MG,.5 MG LUPRON DEPOT (4 MONTH) 5 NDS INTRAMUSCULAR SYRINGE KIT 0 MG LUPRON DEPOT (6 MONTH) 5 NDS INTRAMUSCULAR SYRINGE KIT 45 MG LUPRON DEPOT INTRAMUSCULAR 5 NDS SYRINGE KIT.75 MG, 7.5 MG LYSODREN ORAL TABLET 500 MG 5 NDS megestrol oral tablet 0, 40 PA NSO-HRM; AGE (Max 64 Years) 10

25 mercaptopurine oral tablet 50 methotrexate sodium injection solution 5 PA BvD /ml methotrexate sodium injection solution 5 PA BvD /ml methotrexate sodium oral tablet.5 PA BvD; ST NEXAVAR ORAL TABLET 00 MG 5 PA NSO; NDS; QL (10 per 0 days) POMALYST ORAL CAPSULE 1 MG, MG, MG, 4 MG 5 PA NSO; NDS; QL (1 per 8 days) PURIXAN ORAL SUSPENSION 0 5 NDS MG/ML REVLIMID ORAL CAPSULE 10 MG, 15 5 PA NSO; LA; NDS MG,.5 MG, 0 MG, 5 MG, 5 MG SOLTAMOX ORAL SOLUTION 10 4 MG/5 ML SPRYCEL ORAL TABLET 100 MG, 140 MG, 50 MG, 70 MG, 80 MG 5 PA NSO; NDS; QL (0 per 0 days) SPRYCEL ORAL TABLET 0 MG 5 PA NSO; NDS; QL (60 per 0 days) STIVARGA ORAL TABLET 40 MG 5 PA NSO; NDS; QL (84 per 8 days) SUTENT ORAL CAPSULE 1.5 MG, 5 MG, 7.5 MG, 50 MG 5 PA NSO; NDS; QL (0 per 0 days) tamoxifen oral tablet 10, 0 TARCEVA ORAL TABLET 100 MG, 5 MG 5 PA NSO; NDS; QL (60 per 0 days) TARCEVA ORAL TABLET 150 MG 5 PA NSO; NDS; QL (90 per 0 days) TASIGNA ORAL CAPSULE 150 MG, 00 MG 5 PA NSO; NDS; QL (11 per 8 days) tretinoin (chemotherapy) oral capsule 10 5 NDS TREXALL ORAL TABLET 10 MG, 15 4 PA BvD; ST MG, 5 MG, 7.5 MG TYKERB ORAL TABLET 50 MG 5 NDS VOTRIENT ORAL TABLET 00 MG 5 PA NSO; NDS; QL (10 per 0 days) XALKORI ORAL CAPSULE 00 MG, 50 MG 5 PA NSO; NDS; QL (60 per 0 days) XTANDI ORAL CAPSULE 40 MG 5 PA NSO; NDS; QL (10 per 0 days) 11

26 ZELBORAF ORAL TABLET 40 MG 5 PA NSO; NDS; QL (40 per 0 days) ZYTIGA ORAL TABLET 50 MG 5 PA NSO; NDS; QL (10 per 0 days) Anticholinergic Agents Antimuscarinics/Antispasmodics atropine injection syringe 0.05 /ml propantheline oral tablet 15 4 Anticonvulsants Anticonvulsants carbamazepine oral capsule, er (Carbatrol) multiphase 1 hr 100, 00, 00 carbamazepine oral suspension 100 /5 (Tegretol) ml carbamazepine oral tablet 00 (Epitol) carbamazepine oral tablet extended (Tegretol XR) release 1 hr 100, 00, 400 carbamazepine oral tablet,chewable 100 DILANTIN ORAL CAPSULE 0 MG divalproex oral capsule, delayed rel (Depakote Sprinkles) sprinkle 15 divalproex oral tablet extended release 4 (Depakote ER) hr 50, 500 divalproex oral tablet,delayed release (Depakote) (dr/ec) 15, 50, 500 epitol oral tablet 00 gabapentin oral capsule 100, 00, (Neurontin) 400 gabapentin oral solution 50 /5 ml (Neurontin) gabapentin oral tablet 600, 800 (Neurontin) lamotrigine oral tablet 100, 150, (Lamictal) 00, 5 lamotrigine oral tablet extended release (Lamictal XR) 4 4hr 100, 00, 5, 50, 00, 50 lamotrigine oral tablet, chewable (Lamictal) dispersible 5, 5 levetiracetam intravenous solution 500 (Keppra) /5 ml levetiracetam oral solution 100 /ml (Keppra) 1

27 levetiracetam oral tablet 1,000, 50 (Keppra), 500, 750 levetiracetam oral tablet extended release 4 hr 500, 750 (Keppra XR) LYRICA ORAL CAPSULE 100 MG, 150 QL (90 per 0 days) MG, 00 MG, 5 MG, 5 MG, 00 MG, 50 MG, 75 MG LYRICA ORAL SOLUTION 0 MG/ML QL (900 per 0 days) phenytoin sodium extended oral capsule (Dilantin Extended) 100 phenytoin sodium extended oral capsule (Phenytek) 00, 00 ROWEEPRA ORAL TABLET 1,000 MG, 500 MG, 750 MG SPRITAM ORAL TABLET FOR 4 ST; QL (60 per 0 days) SUSPENSION 1,000 MG SPRITAM ORAL TABLET FOR SUSPENSION 50 MG, 500 MG, 750 MG 4 ST; QL (10 per 0 days) topiramate oral capsule, sprinkle 15, (Topamax) 5 topiramate oral capsule,sprinkle,er 4hr (Qudexy XR) 4 100, 150, 00, 5, 50 topiramate oral tablet 100, 00, 50 (Topamax) topiramate oral tablet 5 (Topamax) 1 GC TROKENDI XR ORAL 4 ST; QL (0 per 0 days) CAPSULE,EXTENDED RELEASE 4HR 100 MG, 5 MG, 50 MG TROKENDI XR ORAL CAPSULE,EXTENDED RELEASE 4HR 00 MG 5 ST; NDS; QL (60 per 0 days) Antidementia Agents Antidementia Agents donepezil oral tablet 10, 5 (Aricept) QL (0 per 0 days) donepezil oral tablet,disintegrating 10, QL (0 per 0 days) 5 memantine oral capsule,sprinkle,er 4hr (Namenda XR) QL (0 per 0 days) 14, 1, 8, 7 memantine oral solution /ml 4 QL (60 per 0 days) memantine oral tablet 10, 5 (Namenda) QL (60 per 0 days) memantine oral tablets,dose pack 5-10 (Namenda Titration Pak) QL (49 per 8 days) 1

28 NAMENDA XR ORAL CAP,SPRINKLE,ER 4HR DOSE PACK MG NAMENDA XR ORAL CAPSULE,SPRINKLE,ER 4HR 14 MG, 1 MG, 8 MG, 7 MG Antidepressants Antidepressants bupropion hcl oral tablet 100, 75 QL (8 per 8 days) QL (0 per 0 days) bupropion hcl oral tablet extended release (Wellbutrin SR) 1 hr 100, 150, 00 bupropion hcl oral tablet extended release 4 hr 150, 00 (Wellbutrin XL) citalopram oral solution 10 /5 ml QL (600 per 0 days) citalopram oral tablet 10, 0, 40 (Celexa) 1 GC; QL (0 per 0 days) escitalopram oxalate oral solution 5 /5 ml escitalopram oxalate oral tablet 10, 0 (Lexapro) 1 GC, 5 fluoxetine oral capsule 10, 0, 40 (Prozac) 1 GC fluoxetine oral capsule,delayed 4 QL (4 per 8 days) release(dr/ec) 90 fluoxetine oral solution 0 /5 ml (4 /ml) fluoxetine oral tablet 10, 0 (Sarafem) 4 paroxetine hcl oral tablet 10, 0, 0, 40 (Paxil) 1 PA NSO-HRM; GC; AGE (Max 64 Years) paroxetine hcl oral tablet extended release 4 hr 1.5, 5, 7.5 (Paxil CR) 4 PA NSO-HRM; AGE (Max 64 Years) PAXIL ORAL SUSPENSION 10 MG/5 ML 4 PA NSO-HRM; AGE (Max 64 Years) sertraline oral concentrate 0 /ml (Zoloft) sertraline oral tablet 100, 5, 50 (Zoloft) 1 GC trazodone oral tablet 100, 50 1 GC trazodone oral tablet 150 trazodone oral tablet 00 4 venlafaxine oral capsule,extended release 4hr 150 (Effexor XR) QL (0 per 0 days) 14

29 venlafaxine oral capsule,extended release 4hr 7.5, 75 venlafaxine oral tablet 100, 5, 7.5, 50, 75 Antidiabetic Agents Antidiabetic Agents, Miscellaneous JANUMET ORAL TABLET 50-1,000 MG, MG JANUMET XR ORAL TABLET, ER MULTIPHASE 4 HR 100-1,000 MG JANUMET XR ORAL TABLET, ER MULTIPHASE 4 HR 50-1,000 MG, MG (Effexor XR) QL (90 per 0 days) QL (60 per 0 days) QL (0 per 0 days) QL (60 per 0 days) JANUVIA ORAL TABLET 100 MG, 5 QL (0 per 0 days) MG, 50 MG metformin oral tablet 1,000 (Glucophage) 6 GC; QL (75 per 0 days) metformin oral tablet 500 (Glucophage) 6 GC; QL (150 per 0 days) metformin oral tablet 850 (Glucophage) 6 GC; QL (90 per 0 days) metformin oral tablet extended release 4 hr 500 (Glucophage XR) 6 GC; QL (10 per 0 days) metformin oral tablet extended release 4 (Glucophage XR) 6 GC; QL (90 per 0 days) hr 750 pioglitazone oral tablet 15, 0, 45 (Actos) 6 GC; QL (0 per 0 days) TRADJENTA ORAL TABLET 5 MG QL (0 per 0 days) VICTOZA SUBCUTANEOUS PEN QL (9 per 0 days) INJECTOR 0.6 MG/0.1 ML (18 MG/ ML) Insulins LANTUS SOLOSTAR U-100 INSULIN QL (0 per 8 days) SUBCUTANEOUS INSULIN PEN 100 UNIT/ML ( ML) LANTUS U-100 INSULIN QL (40 per 8 days) SUBCUTANEOUS SOLUTION 100 UNIT/ML NOVOLOG FLEXPEN U-100 INSULIN QL (0 per 8 days) SUBCUTANEOUS INSULIN PEN 100 UNIT/ML NOVOLOG PENFILL U-100 INSULIN SUBCUTANEOUS CARTRIDGE 100 UNIT/ML QL (0 per 8 days) 15

30 NOVOLOG U-100 INSULIN ASPART QL (40 per 8 days) SUBCUTANEOUS SOLUTION 100 UNIT/ML TOUJEO SOLOSTAR U-00 INSULIN QL (1.5 per 8 days) SUBCUTANEOUS INSULIN PEN 00 UNIT/ML (1.5 ML) Sulfonylureas glimepiride oral tablet 1, (Amaryl) 6 GC; QL (0 per 0 days) glimepiride oral tablet 4 (Amaryl) 6 GC; QL (60 per 0 days) glipizide oral tablet 10 (Glucotrol) 6 GC; QL (10 per 0 days) glipizide oral tablet 5 (Glucotrol) 6 GC; QL (60 per 0 days) glipizide oral tablet extended release 4hr (Glucotrol XL) 6 GC; QL (60 per 0 days) 10 glipizide oral tablet extended release 4hr.5, 5 Antifungals Antifungals clotrimazole mucous membrane troche 10 (Glucotrol XL) 6 GC; QL (0 per 0 days) clotrimazole topical cream 1 % (Antifungal (clotrimazole)) clotrimazole topical solution 1 % clotrimazole-betamethasone topical cream (Lotrisone) % clotrimazole-betamethasone topical lotion % fluconazole oral suspension for (Diflucan) reconstitution 10 /ml, 40 /ml fluconazole oral tablet 100, 150, (Diflucan) 00, 50 ketoconazole oral tablet 00 ketoconazole topical cream % ketoconazole topical shampoo % (Nizoral) nyamyc topical powder 100,000 unit/gram nystatin oral suspension 100,000 unit/ml nystatin oral tablet 500,000 unit nystatin topical cream 100,000 unit/gram nystatin topical ointment 100,000 unit/gram nystatin topical powder 100,000 unit/gram (Nyamyc) nystop topical powder 100,000 unit/gram 16

31 terbinafine hcl oral tablet 50 (Lamisil) 1 GC Antigout Agents Antigout Agents, Other allopurinol oral tablet 100, 00 (Zyloprim) 1 GC COLCRYS ORAL TABLET 0.6 MG Antihistamines Antihistamines hydroxyzine hcl intramuscular solution 5 /ml, 50 /ml PA-HRM; AGE (Max 64 Years) hydroxyzine hcl oral solution 10 /5 ml PA-HRM; AGE (Max 64 Years) hydroxyzine hcl oral tablet 10, 5, 50 levocetirizine oral solution.5 /5 ml (Xyzal) 4 levocetirizine oral tablet 5 (Xyzal) 1 GC Anti-Infectives (Skin And Mucous Membrane) Anti-Infectives (Skin And Mucous Membrane) metronidazole vaginal gel 0.75 % (Metrogel Vaginal) terconazole vaginal cream 0.4 % (Terazol 7) terconazole vaginal cream 0.8 % terconazole vaginal suppository 80 Antimigraine Agents Antimigraine Agents PA-HRM; AGE (Max 64 Years) rizatriptan oral tablet 10, 5 (Maxalt) QL (18 per 8 days) rizatriptan oral tablet,disintegrating 10 (Maxalt-MLT) QL (18 per 8 days), 5 sumatriptan succinate oral tablet 100, (Imitrex) QL (18 per 8 days) 5, 50 sumatriptan succinate subcutaneous (Imitrex STATdose Kit 4 QL (4 per 8 days) cartridge 4 /0.5 ml, 6 /0.5 ml Refill) sumatriptan succinate subcutaneous pen (Imitrex STATdose Pen) QL (4 per 8 days) injector 4 /0.5 ml sumatriptan succinate subcutaneous pen (Imitrex STATdose Pen) 4 QL (4 per 8 days) injector 6 /0.5 ml sumatriptan succinate subcutaneous solution 6 /0.5 ml (Imitrex) 4 QL (4 per 8 days) Antimycobacterials Antimycobacterials dapsone oral tablet 100, 5 17

32 isoniazid oral solution 50 /5 ml isoniazid oral tablet 100, 00 1 GC rifampin intravenous recon soln 600 (Rifadin) 4 rifampin oral capsule 150, 00 (Rifadin) Antinausea Agents Antinausea Agents meclizine oral tablet 1.5 PA-HRM; AGE (Max 64 Years) meclizine oral tablet 5 (Dramamine Less Drowsy) PA-HRM; AGE (Max 64 Years) ondansetron oral tablet,disintegrating 4 (Zofran ODT) PA BvD, 8 phenadoz rectal suppository 1.5 PA-HRM; AGE (Max 64 Years) prochlorperazine maleate oral tablet 10 (Compazine) 1 GC, 5 promethazine injection solution 5 /ml, 50 /ml (Phenergan) 4 PA-HRM; AGE (Max 64 Years) promethazine oral tablet 1.5, 5, 50 PA-HRM; AGE (Max 64 Years) promethazine rectal suppository 1.5, 5 (Phenadoz) PA-HRM; AGE (Max 64 Years) promethazine rectal suppository 50 (Phenergan) PA-HRM; AGE (Max 64 Years) promethegan rectal suppository 5, 50 PA-HRM; AGE (Max 64 Years) Antiparasite Agents Antiparasite Agents ALBENZA ORAL TABLET 00 MG 5 NDS atovaquone-proguanil oral tablet (Malarone) atovaquone-proguanil oral tablet (Malarone Pediatric) hydroxychloroquine oral tablet 00 (Plaquenil) mefloquine oral tablet 50 Antiparkinsonian Agents Antiparkinsonian Agents benztropine oral tablet 0.5, 1, PA-HRM; AGE (Max 64 carbidopa-levodopa oral tablet , 5-100, 5-50 (Sinemet) Years) 18

33 carbidopa-levodopa oral tablet extended (Sinemet CR) release 5-100, pramipexole oral tablet 0.15, 0.5 (Mirapex), 0.75, 1, 1.5 pramipexole oral tablet 0.5 (Mirapex) 1 GC ropinirole oral tablet 0.5, 0.5, 1 (Requip),,, 4, 5 ropinirole oral tablet extended release 4 hr 1,, 4, 6, 8 (Requip XL) 4 Antipsychotic Agents Antipsychotic Agents chlorpromazine injection solution 5 /ml chlorpromazine oral tablet 10, 100, 4 00, 5, 50 clozapine oral tablet 100 (Clozaril) QL (70 per 0 days) clozapine oral tablet 00 QL (15 per 0 days) clozapine oral tablet 5 (Clozaril) QL (90 per 0 days) clozapine oral tablet 50 QL (90 per 0 days) clozapine oral tablet,disintegrating 100 (FazaClo) 4 ST; QL (90 per 0 days), 1.5, 5 clozapine oral tablet,disintegrating 150 (FazaClo) 4 ST; QL (180 per 0 days) clozapine oral tablet,disintegrating 00 (FazaClo) 4 ST; QL (10 per 0 days) haloperidol oral tablet 0.5, 1, 10,, 0, 5 LATUDA ORAL TABLET 10 MG, 0 QL (0 per 0 days) MG, 40 MG, 60 MG, 80 MG olanzapine intramuscular recon soln 10 (Zyprexa) QL (0 per 0 days) olanzapine oral tablet 10, 15,.5 (Zyprexa) QL (0 per 0 days), 0, 5, 7.5 olanzapine oral tablet,disintegrating 10 (Zyprexa Zydis) 4 QL (0 per 0 days), 15, 0, 5 quetiapine oral tablet 100, 00, 5 (Seroquel) QL (90 per 0 days), 00, 400, 50 quetiapine oral tablet extended release 4 (Seroquel XR) 4 QL (0 per 0 days) hr 150, 00, 50 quetiapine oral tablet extended release 4 (Seroquel XR) 4 QL (60 per 0 days) hr 00, 400 risperidone oral solution 1 /ml (Risperdal) QL (480 per 0 days) 19

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