List of Covered Drugs

Transcription

1 List of Covered Drugs Effective July 1, 2018

2 INTRODUCTION We are pleased to provide the old Coast Health Plan List of Covered Drugs as a useful reference and informational tool. The CHP List of Covered Drugs can assist practitioners in selecting clinically appropriate and cost effective products for their patients. The information contained in the CHP List of Covered Drugs is provided solely for the convenience of medical providers. We do not warrant or assure accuracy of such information nor is it intended to be comprehensive in nature. This List of Covered Drugs is not intended to be a substitute for the knowledge, expertise, skill and judgment of the medical provider in his or her choice of prescription drugs. All the information in this List of Covered Drugs is provided as a reference for drug therapy selection. Specific drug selection for an individual patient rests solely with the prescriber. We assume no responsibility for the actions or omissions of any medical provider based upon reliance, in whole or in part, on the information contained herein. The medical provider should consult the drug manufacturer's product literature or standard references for more detailed information. National guidelines can be found on the National uideline Clearinghouse site at PREFACE The CHP List of Covered Drugs is organized by sections. Each section is divided by therapeutic drug class primarily defined by mechanism of action. Unless exceptions are noted, generally all applicable dosage forms and strengths of the drug cited are included in the CHP List of Covered Drugs. enerics should be considered the first line of prescribing. Drugs represented in the CHP List of Covered Drugs may have varying cost to the plan member based on the plans benefit structure. eneric medications typically are available at the lowest cost, brand-name medications on the CHP List of Covered Drugs will generally cost more than generics, and brand-name medications not on the list will generally cost the most. PHARMACY AND THERAPEUTICS (P&T) COMMITTEE The services of the CHP Pharmacy and Therapeutics Committee ("P&T Committee") are utilized to approve safe and clinically effective drug therapies. The P&T Committee is an external advisory body of experts. The P&T Committee's voting members include physicians and pharmacists, all of whom have a broad background of clinical and academic expertise regarding prescription drugs. Employees with significant clinical expertise are invited to meet with the P&T Committee. Voting members of the P&T Committee must disclose any financial relationship or conflicts of interest with any pharmaceutical manufacturers. ENERIC SUSTITUTION eneric substitution is a pharmacy action whereby a generic version is dispensed rather than a prescribed brand-name product. However, not all strengths or dosage forms of the generic name in may be generically available. The CHP List of Covered Drugs is a mandatory generic drug list. So whenever a generic to a covered agent becomes available, it is added. And if the branded agent was part of the cover drug list, the branded agent will be removed from the covered drug list. eneric drugs are usually priced lower than their brand-name equivalents. eneric drugs are: Approved by the U.S. Food and Drug Administration for safety and effectiveness, and are manufactured under the same strict standards that apply to brand-name drugs. Tested in humans to assure the generic is absorbed into the bloodstream in a similar rate and extent compared to the brand-name drug (bioequivalence). enerics may be different from the brand in size, color, and inactive ingredients, but this does not alter their effectiveness or ability to be absorbed just like the brand-name drug. Manufactured in the same strength and dosage form as the brand-name drugs. When a generic drug is substituted for a brand-name drug, you can expect the generic to produce the same clinical effect and safety profile as the brand-name drug (therapeutic equivalence). i

3 SPECIALTY PLAN DESIN Specialty uideline Management (SM) SM is our utilization management program that helps ensure appropriate utilization for specialty medication based on currently accepted evidence-based medicine guidelines. The utilization management program is available for all therapeutic areas dispensed by our specialty pharmacies. SM is designed to ensure safety and efficacy while preventing off-guideline utilization. Medications which may be included in the SM program are identified in the CHP List of Covered Drugs under the heading of Specialty for your reference. SM may also be combined with Inventory Management/ Dose Optimization and Optimal Drug Mix through High Performance Specialty Design to appropriately manage specialty medications. PLAN DESIN The CHP List of Covered Drugs is a closed drug list plan design. The medications listed on the drug list are covered by the plan as represented. Certain medications on the list are covered if utilization management criteria are met (i.e. Step Therapy, LMN, C, Quantity Limits, etc); requests for use of such medications outside of their listed criteria will be reviewed for medical necessity. Should it become necessary to write a prescription for a drug, which is not on the CHP List of Covered Drugs, one must obtain clinical prior authorization. LEEND Prior Authorization QL Quantity Limit ST Step Therapy SP Specialty - Limited to Specialty Pharmacies ii

4 EXCLUDED THERAPEUTIC CLASSES AND DRUS FROM CHP LIST OF COVERED DRUS These therapeutic classes of drugs are carved out from the CHP List of Covered Drugs. This means that when one of these medications is prescribed, it will be filled by the pharmacist, who in turn will bill the State of California for reimbursement. Acamprosate Calcium uprenorphine HCl uprenorphine HCl-Naloxone HCl DEPENDENCTY TREATMENT uprenorphine Transdermal Patch Naltrexone Naltrexone HCl Naltrexone Microsphere Injectable Suspension Naloxone HCL HIV Abacavir Sulfate Elvitegravir-Cobicistat-Emtricitabine- Lopinavir-Ritonavir Abacavir Sulfate-Lamivudine Tenofovir DF Maraviroc Abacavir Sulfate-Lamivudine-Zidovudine Elvitegravir-Cobicistat-Emtricitabine- Nevirapine Abacavir Sulfate-Dolutegravir-Lamivudine Tenofovir Alafenamide Nelfinavir Mesylate Atazanavir Sulfate Emtricitabine Raltegravir Potassium Atazanavir-Cobisitat Emtricitabine-Rilpivirine-Tenofovir DF Rilpirvirine Hydrochloride Cobicistat Emtricitabine-Rilpivirine-Tenofovir Alafen. Ritonavir Darunavir Ethanolate Emtricitabine-Tenofovir DF Saquinavir Darunavir-Cobicistat Enfuvirtide Saquinavir Mesylate Delavirdine Mesylate Etravirine Stavudine Dolutegravir Fosamprenavir Calcium Tenofovir Disoproxil Fumarate Efavirenz Indinavir Sulfate Tipranavir Efavirenz-Emtricitabine-Tenofovir DF Elvitegravir Lamivudine Lamivudine-Zidovudine ERECTILE DYSFUNCTION COAULATION FACTORS Antihemophilic Factor(Factor VIII) Factor VIIa Factor IX Factor IX Complex Factor XIIIa Factor XIII Antihemophilic Factor/Von Willebrand Complex Anti-inhibitor Coagulant Complex Von Willebrand Factor Complex PSYCHIATRIC Amantadine HCl Iloperidone Phenelzine Sulfate Aripiprazole Isocarboxazid Pimozide Asenapine Maleate Lithium Carbonate Quetiapine enztropine Mesylate Lithium Citrate Risperidone rexpiprazole Loxapine Succinate Selegiline TD Patch Cariprazine (pending) Lurasidone Hydrochloride Thioridazine HCl Chlorpromazine HCl Molindone HCl Thiothixene Clozapine Olanzapine Thiothixene HCl Fluphenazine Decanoate Olanzapine-Fluoxetine HCl Tranylcypromine Sulfate Fluphenazine HCl Olanzapine Pamoate Trifluoperazine HCl Haloperidol Paliperidone Trihexyphenidyl Haloperidol Decanoate Paliperidone Palmitate Ziprasidone HCl Haloperidol Lactate Perphenazine Ziprasidone Mesylate NOTICE The information contained in this document is proprietary. The information may not be copied in whole or in part without written permission. All rights reserved. This document contains references to brand-name prescription drugs that are trademarks or registered trademarks of pharmaceutical manufacturers that are not affiliated with old Coast Health Plan. When viewing the CHP List of Covered Drugs via the Internet, please be advised that the CHP List of Covered Drugs is updated periodically and changes may appear prior to their effective date to allow for client notification. 1

5 Table of Contents Analgesics - Drugs for Pain... 4 Analgesics - Drugs for Pain and Inflammation Anesthetics Anti-Addiction / Substance Abuse Treatment Agents Antibacterials Anticoagulants Anticonvulsants - Drugs for Seizures Antidementia Agents - Drugs for Alzheimer's Disease and Dementia Antidepressants Antiemetics - Drugs for Nausea and Vomiting Antifungals Antigout Agents Antimigraine Agents Antimyasthenic Agents Antimycobacterials Antineoplastics - Drugs for Cancer Antiparasitics Antiparkinson Agents Antiplatelets Antivirals Anxiolytics - Drugs for Anxiety lood Products / Modifiers / Volume Expanders - Drugs for leeding Disorders Cardiovascular Agents - Drugs for Heart and Circulation Conditions Central Nervous System Agents - Drugs for Attention Deficit Disorder Central Nervous System Agents - Drugs for Multiple Sclerosis Central Nervous System Agents - Miscellaneous Dental and Oral Agents - Drugs for Mouth and Throat Conditions Dermatological Agents - Drugs for Skin Conditions Diabetes - Antidiabetic Agents Diabetes - lucose Monitoring

6 Diabetes - lycemic Agents Diabetes - Insulins Electrolytes / Minerals / Metals / Vitamins astrointestinal Agents - Drugs for Acid Reflux and Ulcer astrointestinal Agents - Drugs for owel, Intestine and Stomach Conditions enetic or Enzyme Disorder: Drugs for Replacement, Modifiers, Treatment enitourinary Agents - Drugs for ladder, enital and Kidney Conditions enitourinary Agents - Drugs for Prostate Conditions Hormonal Agents - Adrenal Hormonal Agents - Men's Health Hormonal Agents - Osteoporosis Hormonal Agents - Parathyroid Hormonal Agents - Pituitary Hormonal Agents - Sex Hormones and irth Control Hormonal Agents - Thyroid Immunological Agents - Drugs for Immune System Stimulation or Suppression Immunological Agents - Drugs for Vaccination Inflammatory owel Disease Agents Metabolic one Disease Agents - Drugs for Osteoporosis Miscellaneous Therapeutic Agents Ophthalmic Agents - Drugs for Eye Allergy, Infection and Inflammation Ophthalmic Agents - Drugs for laucoma Ophthalmic Agents - Drugs for Miscellaneous Eye Conditions Otic Agents - Drugs for Ear Conditions Respiratory Tract / Pulmonary Agents - Drugs for Allergies, Cough, Cold Respiratory Tract / Pulmonary Agents - Drugs for Asthma and Other Lung Conditions Respiratory Tract / Pulmonary Agents - Drugs for Cystic Fibrosis Respiratory Tract / Pulmonary Agents - Drugs for Pulmonary Hypertension Skeletal Muscle Relaxants - Drugs for Muscle Pain and Spasm Sleep Disorder Agents

7 Drug Name Reference rand-eneric Notes Analgesics - Drugs for Pain acetaminophen-codeine #2 oral tablet acetaminophen-codeine #3 oral tablet acetaminophen-codeine #4 oral tablet acetaminophen-codeine oral solution /5ml acetaminophen-codeine oral tablet acetaminophen-codeine oral tablet alfentanil hcl intravenous solution 1000 mcg/2ml, 2500 mcg/5ml apap-caff-dihydrocodeine oral capsule apap-caff-dihydrocodeine oral tablet ascomp-codeine oral capsule butalbital-acetaminophen oral tablet butalbital-acetaminophen oral tablet Tylenol with Codeine #3 Tylenol with Codeine #4 Tylenol with Codeine #4 Trezix Ascomp-Codeine upap Tencon butalbital-apap oral tablet Tencon butalbital-apap-caff-cod oral capsule butalbital-apap-caff-cod oral capsule butalbital-apap-caffeine oral capsule butalbital-apap-caffeine oral capsule Fioricet/Codeine Fioricet Esgic QL (124 EA per 31 QL (124 EA per 31 QL (124 EA per 31 QL (124 EA per 31 QL (124 EA per 31 QL (124 EA per 31 QL (124 EA per 31 4

8 Drug Name Reference rand-eneric Notes butalbital-apap-caffeine oral tablet butalbital-asa-caff-codeine oral capsule butalbital-asa-caffeine oral capsule butalbital-aspirin-caffeine oral capsule butalbital-aspirin-caffeine oral tablet butorphanol tartrate injection solution 1 /ml, 2 /ml butorphanol tartrate nasal solution 10 /ml Esgic Ascomp-Codeine Fiorinal Fiorinal capacet oral capsule Esgic carisoprodol-aspirin-codeine oral tablet codeine sulfate oral tablet 15, 30, 60 DILAUDID ORAL TALET 2 M, 4 M, 8 M duramorph injection solution 0.5 /ml, 1 /ml duraxin oral capsule endocet oral tablet , , 5-325, Dilaudid Endocet esgic oral capsule Esgic fentanyl citrate (pf) injection solution 100 mcg/2ml, 1000 mcg/20ml, 250 mcg/5ml, 2500 mcg/50ml, 500 mcg/10ml fentanyl citrate (pf) injection solution cartridge 100 mcg/2ml fentanyl citrate buccal lozenge on a handle 1200 mcg, 1600 mcg, 200 mcg, 400 mcg, 600 mcg, 800 mcg fentanyl citrate intravenous solution prefilled syringe 100 mcg/2ml Actiq QL (124 EA per 31 QL (186 EA per 31 QL (124 EA per 31 QL (124 EA per 31 fentanyl citrate-nacl epidural solution /250ml-% 5

9 Drug Name Reference rand-eneric Notes fentanyl citrate-nacl intravenous solution /100ml-%, /250ml-%, /250ml-%, mcg/50ml- %, /250ml-% fentanyl citrate-nacl intravenous solution prefilled syringe mcg/3ml-%, mcg/5ml-%, mcg/50ml-% fentanyl cit-ropivacaine-nacl epidural solution /100ml-%, /100ml-%, /100ml-%, /200ml-%, /100ml-%, /250ml-%, /250ml- % fentanyl cit-ropivacaine-nacl epidural solution prefilled syringe /50ml-%, /50ml-% fentanyl transdermal patch 72 hour 100 mcg/hr fentanyl transdermal patch 72 hour 12 mcg/hr fentanyl transdermal patch 72 hour 25 mcg/hr fentanyl transdermal patch 72 hour 37.5 mcg/hr, 62.5 mcg/hr, 87.5 mcg/hr fentanyl transdermal patch 72 hour 50 mcg/hr fentanyl transdermal patch 72 hour 75 mcg/hr fentanyl-bupivacaine-nacl epidural solution /100ml-%, /100ml-%, /125ml-%, /200ml-%, /100ml-%, /250ml-%, /100ml- %, /200ml-%, /150ml-%, /250ml-%, /250ml- %, /250ml-% FENTORA UCCAL TALET 100 MC, 200 MC, 400 MC, 600 MC, 800 MC hydrocodone-acetaminophen oral solution /15ml, /5ml, /10ml, /15ml hydrocodone-acetaminophen oral tablet Duragesic-100 Duragesic-12 Duragesic-25 Duragesic-50 Duragesic-75 Vicodin HP QL (15 EA per 31 QL (15 EA per 31 QL (15 EA per 31 QL (15 EA per 31 QL (15 EA per 31 QL (15 EA per 31 ; QL (124 EA per 31 QL (124 EA per 31 6

10 Drug Name Reference rand-eneric Notes hydrocodone-acetaminophen oral tablet hydrocodone-acetaminophen oral tablet hydrocodone-acetaminophen oral tablet hydrocodone-acetaminophen oral tablet hydrocodone-acetaminophen oral tablet hydrocodone-acetaminophen oral tablet hydrocodone-ibuprofen oral tablet , hydrocodone-ibuprofen oral tablet hydromorphone hcl er oral tablet er 24 hour abuse-deterrent 12, 16, 32, 8 hydromorphone hcl injection solution 1 /ml, 2 /ml, 4 /ml Lorcet HD Verdrocet Vicodin Lorcet Vicodin ES Lorcet Plus Ibudone Exalgo Dilaudid hydromorphone hcl oral liquid 1 /ml Dilaudid hydromorphone hcl oral tablet 2, 4, 8 hydromorphone hcl pf injection solution 1 /ml, 10 /ml, 2 /ml, 4 /ml, 50 /5ml, 500 /50ml hydromorphone hcl rectal suppository 3 hydromorphone hcl-nacl intravenous solution /100ml-%, /50ml-%, /30ml-%, /50ml-%, /50ml-%, /100ml-%, /50ml-%, /30ml-% hydromorphone hcl-nacl intravenous solution prefilled syringe /5ml-%, /25ml-%, /50ml-%, /60ml-%, /30ml-%, /50ml-%, /30ml-%, /25ml-% hydromorphone-bupivacaine-nacl epidural solution /250ml-% hydromorphone-ropivacaine-nacl epidural solution /200ml-% Dilaudid QL (124 EA per 31 QL (124 EA per 31 QL (124 EA per 31 QL (186 EA per 31 QL (186 EA per 31 QL (500 ML per 31 QL (186 EA per 31 7

11 Drug Name Reference rand-eneric Notes ibudone oral tablet Ibudone levorphanol tartrate oral tablet 2 lorcet hd oral tablet Lorcet HD lorcet oral tablet Lorcet lorcet plus oral tablet Lorcet Plus mapap oral liquid 160 /5ml Little Remedies for Fever marten-tab oral tablet Tencon meperidine hcl injection solution 10 /ml meperidine hcl injection solution 100 /ml, 25 /ml, 50 /ml meperidine hcl oral solution 50 /5ml Demerol meperidine hcl oral tablet 100, 50 Demerol meperidine hcl-sodium chloride intravenous solution /100ml- %, /50ml-% meperidine-promethazine oral capsule methadone hcl injection solution 10 /ml methadone hcl intensol oral concentrate 10 /ml Methadone HCl Intensol methadone hcl oral concentrate 10 /ml Methadone HCl Intensol methadone hcl oral solution 10 /5ml, 5 /5ml methadone hcl oral tablet 10, 5 Dolophine methadone hcl oral tablet soluble 40 Methadose methadose oral concentrate 10 /ml Methadone HCl Intensol methadose oral tablet soluble 40 Methadose methadose sugar-free oral concentrate 10 /ml morphine sulfate (concentrate) oral solution 100 /5ml, 20 /ml morphine sulfate (pf) injection solution 0.5 /ml, 1 /ml, 10 /ml, 2 /ml, 4 /ml, 5 /ml, 8 /ml Methadone HCl Intensol QL (186 EA per 31 QL (124 EA per 31 QL (124 EA per 31 QL (124 EA per 31 QL (248 EA per 31 ; AL (Max 10 Years) QL (250 ML per 31 QL (250 ML per 31 QL (500 ML per 31 QL (124 EA per 31 QL (250 ML per 31 QL (250 ML per 31 QL (240 ML per 31 8

12 Drug Name Reference rand-eneric Notes morphine sulfate (pf) intravenous solution 10 /ml, 2 /ml, 4 /ml, 8 /ml morphine sulfate er beads oral capsule extended release 24 hour 120, 30, 45, 60, 75, 90 morphine sulfate er oral capsule extended release 24 hour 10 morphine sulfate er oral capsule extended release 24 hour 100, 20, 30, 50, 60, 80 morphine sulfate er oral tablet extended release 100, 15, 200, 30, 60 morphine sulfate injection solution 10 /ml, 15 /ml, 2 /ml, 4 /ml, 5 /ml, 8 /ml morphine sulfate intramuscular device 10 /0.7ml morphine sulfate intravenous solution 1 /ml, 150 /30ml, 25 /ml, 50 /ml morphine sulfate oral solution 10 /5ml, 20 /5ml morphine sulfate oral tablet 15, 30 morphine sulfate rectal suppository 10, 20, 30, 5 morphine sulfate-nacl intravenous solution /50ml-% morphine sulfate-nacl intravenous solution prefilled syringe /ml-%, /50ml-% MS CONTIN ORAL TALET EXTENDED RELEASE 100 M nalbuphine hcl injection solution 10 /ml, 20 /ml NUCYNTA ORAL TALET 50 M ONA ER ORAL TALET ER 12 HOUR AUSE-DETERRENT 10 M, 15 M, 20 M, 30 M, 40 M, 5 M, 7.5 M oxycodone hcl oral capsule 5 oxycodone hcl oral concentrate 100 /5ml oxycodone hcl oral solution 5 /5ml oxycodone hcl oral tablet 10, 20 Kadian Kadian MS Contin MS Contin 9 QL (93 EA per 31 QL (93 EA per 31 QL (93 EA per 31 QL (30 EA per 30 ST; QL (62 EA per 31 QL (186 EA per 31 QL (186 EA per 31

13 Drug Name Reference rand-eneric Notes oxycodone hcl oral tablet 15, 30, 5 oxycodone-acetaminophen oral solution /5ml oxycodone-acetaminophen oral tablet , , 5-325, oxycodone-aspirin oral tablet oxycodone-ibuprofen oral tablet oxymorphone hcl er oral tablet extended release 12 hour 10, 15, 20, 30, 40, 5, 7.5 Roxicodone Endocet oxymorphone hcl oral tablet 10, 5 Opana panlor oral tablet pentazocine-naloxone hcl oral tablet phrenilin forte oral capsule Fioricet remifentanil hcl intravenous solution reconstituted 1, 2, 5 sufentanil citrate intravenous solution 100 mcg/2ml, 250 mcg/5ml, 50 mcg/ml Ultiva tencon oral tablet Tencon tramadol hcl er (biphasic) oral tablet extended release 24 hour 100, 200, 300 tramadol hcl er oral capsule extended release 24 hour 150 tramadol hcl er oral tablet extended release 24 hour 100, 300 tramadol hcl er oral tablet extended release 24 hour 200 tramadol hcl oral tablet 50 Ultram tramadol-acetaminophen oral tablet vanatol lq oral solution /15ml vanatol s oral solution /15ml Ultracet verdrocet oral tablet Verdrocet vicodin es oral tablet Vicodin ES vicodin hp oral tablet Vicodin HP QL (186 EA per 31 QL (124 EA per 31 ST; QL (124 EA per 31 QL (31 EA per 31 QL (31 EA per 31 QL (124 EA per 31 QL (124 EA per 31 QL (124 EA per 31 10

14 Drug Name Reference rand-eneric Notes vicodin oral tablet Vicodin xylon oral tablet Ibudone zebutal oral capsule Esgic ZOHYDRO ER ORAL CAPSULE ER 12 HOUR AUSE-DETERRENT 10 M, 15 M, 20 M, 30 M, 40 M, 50 M Analgesics - Drugs for Pain and Inflammation aspirin ec low dose oral tablet delayed release 81 aspirin ec oral tablet delayed release 325 aspirin low dose oral tablet delayed release 81 aspirin oral tablet 325 Aspir-Low ayer Aspirin Regimen Aspir-Low ayer Advanced Aspirin Reg St aspirin oral tablet delayed release 325 ayer Aspirin Regimen bayer aspirin ec low dose oral tablet delayed release 81 bayer aspirin oral tablet 325 celecoxib oral capsule 100, 200, 400, 50 choline-mag trisalicylate oral liquid 500 /5ml diclofenac potassium oral tablet 50 diclofenac sodium er oral tablet extended release 24 hour 100 diclofenac sodium oral tablet delayed release 25, 50, 75 Aspir-Low ayer Advanced Aspirin Reg St QL (186 EA per 31 QL (124 EA per 31 CeleREX ST diclofenac sodium transdermal gel 1 % Voltaren diclofenac sodium transdermal solution 1.5 % diclofenac-misoprostol oral tablet delayed release , diclofex dc combination therapy pack 1.5 & % diclopak combination therapy pack 1.5 & % diclosaicin combination therapy pack 1.5 & % Klofensaid II Arthrotec DermacinRx Lexitral PharmaPak DermacinRx Lexitral PharmaPak DermacinRx Lexitral PharmaPak QL (122 EA per 31 QL (122 EA per 31 QL (122 EA per 31 QL (120 EA per 30 QL (122 EA per 31 QL (122 EA per 31 QL (120 EA per 30 ; QL (500 M per 30 11

15 Drug Name Reference rand-eneric Notes diclotral combination therapy pack 1.5 & % diflunisal oral tablet 500 etodolac er oral tablet extended release 24 hour 400, 500, 600 etodolac oral capsule 200, 300 DermacinRx Lexitral PharmaPak etodolac oral tablet 400 Lodine etodolac oral tablet 500 fenoprofen calcium oral capsule 200 Fenortho fenoprofen calcium oral capsule 400 Nalfon fenoprofen calcium oral tablet 600 ProFeno fenortho oral capsule 200 Fenortho flurbiprofen oral tablet 100, 50 gnp all day pain relief oral tablet 220 Aleve ibuprofen childrens oral suspension 100 /5ml ibuprofen lysine intravenous solution 10 /ml Childrens Advil NeoProfen ibuprofen oral suspension 100 /5ml Childrens Advil ibuprofen oral tablet 200 Advil ibuprofen oral tablet 400, 600, 800 indomethacin er oral capsule extended release 75 indomethacin oral capsule 25, 50 indomethacin sodium intravenous solution reconstituted 1 inflammacin combination therapy pack 75 & % isometheptene-caffeine-apap oral tablet isometheptene-dichloral-apap oral capsule ketoprofen er oral capsule extended release 24 hour 200 ketoprofen oral capsule 25, 50, 75 IU Derma SilkRX DicloPak QL (106 EA per 31 QL (248 ML per 30 ; AL (Max 11 Years) QL (248 ML per 30 ; AL (Max 11 Years) QL (160 EA per 30 12

16 Drug Name Reference rand-eneric Notes ketorolac tromethamine injection solution 15 /ml, 30 /ml ketorolac tromethamine intramuscular solution 60 /2ml ketorolac tromethamine oral tablet 10 klofensaid ii transdermal solution 1.5 % Klofensaid II meclofenamate sodium oral capsule 100, 50 mefenamic acid oral capsule 250 Ponstel meloxicam oral tablet 15, 7.5 Mobic nabumetone oral tablet 500, 750 naproxen dr oral tablet delayed release 375, 500 EC-Naprosyn naproxen oral suspension 125 /5ml Naprosyn naproxen oral tablet 250, 500 Naprosyn naproxen oral tablet 375 naproxen sodium er oral tablet extended release 24 hour 375, 500 Naprelan naproxen sodium oral capsule 220 Aleve naproxen sodium oral tablet 220 Aleve naproxen sodium oral tablet 275 naproxen sodium oral tablet 550 Anaprox DS nodolor oral capsule nudiclo solupak combination therapy pack 1.5 & % nudiclo tabpak combination therapy pack 75 & % DermacinRx Lexitral PharmaPak Derma SilkRX DicloPak oxaprozin oral tablet 600 Daypro piroxicam oral capsule 10, 20 Feldene previdolrx plus analgesic combination therapy pack 75 & % Derma SilkRX DicloPak profeno oral tablet 600 ProFeno salsalate oral tablet 500, 750 sulindac oral tablet 150, 200 sure result dss premium pack combination therapy pack 1.5 & % tolmetin sodium oral capsule 400 tolmetin sodium oral tablet 200, 600 DermacinRx Lexitral PharmaPak QL (106 EA per 31 QL (106 EA per 31 13

17 Drug Name Reference rand-eneric Notes xelitral combination therapy pack 1.5 & % xenaflamm combination therapy pack 75 & % Anesthetics DermacinRx Lexitral PharmaPak Derma SilkRX DicloPak agoneaze external kit % DermacinRx Empricaine anodyne lpt external kit % DermacinRx Empricaine bd pudendal/local tray/1% lido injection kit 1 % bupivacaine hcl (pf) injection solution 0.25 %, 0.5 % bupivacaine hcl (pf) injection solution 0.75 % bupivacaine hcl injection solution 0.25 %, 0.5 % bupivacaine hcl-nacl injection solution % bupivacaine in dextrose intrathecal solution % bupivacaine spinal intrathecal solution % bupivacaine-epinephrine (pf) injection solution 0.25% -1:200000, 0.5% - 1: bupivacaine-epinephrine injection solution 0.25% -1:200000, 0.5% -1: chloroprocaine hcl (pf) injection solution 2 %, 3 % cocaine hcl external solution 4 % dermacinrx empricaine external kit % Marcaine Preservative Free Marcaine Marcaine Marcaine Spinal Marcaine Spinal Marcaine/Epinephrine PF Marcaine/Epinephrine Nesacaine-MPF DermacinRx Empricaine dermacinrx prizopak external kit % DermacinRx Empricaine ethyl chloride external aerosol glydo external gel 2 % lydo leva set/occlusive dressing external kit % DermacinRx Empricaine lidenza external patch 4-1 % Endoxcin lido bdk external kit % DermacinRx Empricaine lidocaine external ointment 5 % lidocaine external patch 5 % Lidoderm lidocaine hcl (cardiac) intravenous solution 10 /ml, 20 /ml ST; QL (3 EA per 1 day) 14

18 Drug Name Reference rand-eneric Notes lidocaine hcl (pf) injection solution 0.5 %, 1 %, 1.5 %, 2 % lidocaine hcl (pf) injection solution 4 % lidocaine hcl external cream 3 % Xylocaine-MPF lidocaine hcl external cream 3.88 % Lidotral lidocaine hcl external gel 2 % lydo lidocaine hcl external lotion 3 % Lidozion lidocaine hcl external solution 4 % lidocaine hcl injection solution 0.5 %, 1 %, 2 % lidocaine in d5w intravenous solution 4-5 /ml-%, 8-5 /ml-% lidocaine pak external ointment 5 % lidocaine-epinephrine injection solution 0.5 %-1:200000, 1 %-1: lidocaine-epinephrine injection solution 1.5 %-1:200000, 2 %-1: lidocaine-epinephrine injection solution 2 %-1:100000, 2 %-1:50000 lidocaine-prilocaine external cream % Xylocaine Xylocaine/Epinephrine Xylocaine- MPF/Epinephrine Xylocaine Dental lidocaine-prilocaine external kit % DermacinRx Empricaine lido-k external lotion 3 % Lidozion lidopin external cream 3 % lidopril external kit % DermacinRx Empricaine lidopril xr external kit % DermacinRx Empricaine lido-prilo caine pack external kit % DermacinRx Empricaine liprozonepak external kit % DermacinRx Empricaine livixil pak external kit % DermacinRx Empricaine lorenza external patch 4-1 % Endoxcin lp lite pak external kit % DermacinRx Empricaine medolor pak external kit % DermacinRx Empricaine polocaine injection solution 1 %, 2 % polocaine-mpf injection solution 1 %, 1.5 %, 2 % port-prep external kit % DermacinRx Empricaine premium lidocaine external ointment 5 % prikaan external kit % DermacinRx Empricaine prikaan lite external kit % DermacinRx Empricaine prilolid external kit % DermacinRx Empricaine 15

19 Drug Name Reference rand-eneric Notes priloxx lp external kit % DermacinRx Empricaine relador pak external kit % DermacinRx Empricaine relador pak plus external kit % DermacinRx Empricaine releevia ml external patch 4-1 % Endoxcin ropivacaine hcl injection solution 10 /ml, 2 /ml, 5 /ml, 7.5 /ml ropivacaine hcl-nacl epidural solution prefilled syringe % sensorcaine injection solution 0.25 %, 0.5 % sensorcaine/epinephrine injection solution 0.25% -1:200000, 0.5% -1: sensorcaine-mpf injection solution 0.25 %, 0.5 % Naropin Marcaine sensorcaine-mpf injection solution 0.75 % Marcaine sensorcaine-mpf spinal intrathecal solution % sensorcaine-mpf/epinephrine injection solution 0.25% -1:200000, 0.5% - 1: Marcaine/Epinephrine Marcaine Preservative Free Marcaine Spinal Marcaine/Epinephrine PF soluline external kit % DermacinRx Empricaine solupicc external kit % DermacinRx Empricaine synvexia external patch 4-1 % Endoxcin tetracaine hcl injection solution 1 % xylocaine dental injection solution 2 %- 1:100000, 2 %-1:50000 Xylocaine Dental zeruvia external patch 4-1 % Endoxcin Anti-Addiction / Substance Abuse Treatment Agents bupropion hcl er (smoking det) oral tablet extended release 12 hour 150 CHANTIX CONTINUIN MONTH K ORAL TALET 1 M Zyban CHANTIX ORAL TALET 0.5 M, 1 M CHANTIX STARTIN MONTH K ORAL TALET 0.5 M X 11 & 1 M X 42 disulfiram oral tablet 250, 500 Antabuse NICORETTE MOUTH/THROAT UM 2 M KLS Quit2 nicotine polacrilex mouth/throat gum 2 KLS Quit2 nicotine polacrilex mouth/throat gum 4 KLS Quit4 16

20 Drug Name Reference rand-eneric Notes nicotine polacrilex mouth/throat lozenge 2, 4 nicotine step 1 transdermal patch 24 hour 21 /24hr nicotine step 2 transdermal patch 24 hour 14 /24hr nicotine step 3 transdermal patch 24 hour 7 /24hr NICOTROL INHALATION INHALER 10 M NICOTROL NS NASAL SOLUTION 10 M/ML Antibacterials amikacin sulfate injection solution 1 gm/4ml, 500 /2ml amoxicillin oral capsule 250, 500 amoxicillin oral suspension reconstituted 125 /5ml, 200 /5ml, 250 /5ml, 400 /5ml amoxicillin oral tablet 500, 875 amoxicillin oral tablet chewable 125, 250 amoxicillin-potassium clavulanate er oral tablet extended release 12 hour amoxicillin-potassium clavulanate oral suspension reconstituted /5ml, /5ml amoxicillin-potassium clavulanate oral suspension reconstituted /5ml amoxicillin-potassium clavulanate oral suspension reconstituted /5ml amoxicillin-potassium clavulanate oral tablet amoxicillin-potassium clavulanate oral tablet , amoxicillin-potassium clavulanate oral tablet chewable , ampicillin oral capsule 500 ampicillin sodium injection solution reconstituted 1 gm, 10 gm, 125, 2 gm, 250, 500 Commit Nicoderm CQ Nicoderm CQ Nicoderm CQ Augmentin XR Augmentin Augmentin ES-600 Augmentin ST ST 17

21 Drug Name Reference rand-eneric Notes ampicillin sodium intravenous solution reconstituted 1 gm, 10 gm, 2 gm ampicillin-sulbactam sodium injection solution reconstituted 1.5 (1-0.5) gm, 15 (10-5) gm, 3 (2-1) gm ampicillin-sulbactam sodium intravenous solution reconstituted 1.5 (1-0.5) gm, 15 (10-5) gm avidoxy oral tablet 100 azithromycin intravenous solution reconstituted 500 Unasyn Zithromax azithromycin oral packet 1 gm Zithromax azithromycin oral suspension reconstituted 100 /5ml, 200 /5ml Zithromax azithromycin oral tablet 250, 600 Zithromax azithromycin oral tablet 500 Zithromax QL (4 EA per 10 aztreonam injection solution reconstituted 1 gm, 2 gm baciim intramuscular solution reconstituted unit bacitracin intramuscular solution reconstituted unit ACTROAN NASAL NASAL OINTMENT 2 % benzalkonium chloride external solution, 50 % ICILLIN L-A INTRAMUSCULAR SUSPENSION UNIT/2ML, UNIT/4ML, UNIT/ML cefaclor er oral tablet extended release 12 hour 500 cefaclor oral capsule 250, 500 cefaclor oral suspension reconstituted 125 /5ml, 250 /5ml, 375 /5ml cefadroxil oral capsule 500 cefadroxil oral suspension reconstituted 250 /5ml, 500 /5ml cefadroxil oral tablet 1 gm cefazolin in d5w intravenous solution 3 gm/100ml cefazolin in sodium chloride intravenous solution gm/50ml-% Azactam 18

22 Drug Name Reference rand-eneric Notes cefazolin sodium injection solution reconstituted 1 gm, 10 gm, 100 gm, 20 gm, 300 gm, 500 cefazolin sodium intravenous solution reconstituted 1 gm cefazolin sodium-dextrose intravenous solution 1-4 gm/50ml-%, 2-4 gm/100ml-% cefazolin sodium-dextrose intravenous solution reconstituted 1-4 gm-%, 2-3 gm- % cefdinir oral capsule 300 cefdinir oral suspension reconstituted 125 /5ml, 250 /5ml cefditoren pivoxil oral tablet 200 cefditoren pivoxil oral tablet 400 Spectracef cefepime hcl injection solution reconstituted 1 gm, 2 gm cefepime hcl intravenous solution 1 gm/50ml, 2 gm/100ml cefepime-dextrose intravenous solution reconstituted 1 gm/50ml, 2 gm/50ml cefixime oral suspension reconstituted 100 /5ml cefixime oral suspension reconstituted 200 /5ml CEFOTAN INJECTION SOLUTION RECONSTITUTED 1 M, 2 M cefotaxime sodium injection solution reconstituted 1 gm, 10 gm, 2 gm, 500 cefotetan disodium injection solution reconstituted 1 gm, 2 gm cefotetan disodium injection solution reconstituted 10 gm cefotetan disodium-dextrose intravenous solution reconstituted gm-%, gm-% cefoxitin sodium injection solution reconstituted 10 gm cefoxitin sodium intravenous solution reconstituted 1 gm, 2 gm cefoxitin sodium-dextrose intravenous solution reconstituted 1-4 gm-%, gm-% cefpodoxime proxetil oral suspension reconstituted 100 /5ml, 50 /5ml Maxipime Suprax Suprax Cefotan ; QL (150 ML per 31 Cefotan 19

23 Drug Name Reference rand-eneric Notes cefpodoxime proxetil oral tablet 100, 200 cefprozil oral suspension reconstituted 125 /5ml, 250 /5ml cefprozil oral tablet 250, 500 ceftazidime injection solution reconstituted 1 gm, 2 gm, 6 gm ceftibuten oral capsule 400 ceftibuten oral suspension reconstituted 180 /5ml ceftriaxone sodium in dextrose intravenous solution 20 /ml, 40 /ml ceftriaxone sodium injection solution reconstituted 1 gm ceftriaxone sodium injection solution reconstituted 100 gm, 2 gm, 250, 500 ceftriaxone sodium intravenous solution reconstituted 1 gm, 10 gm, 2 gm ceftriaxone sodium-dextrose intravenous solution reconstituted gm-%, gm-% cefuroxime axetil oral tablet 250, 500 cefuroxime sodium injection solution reconstituted 7.5 gm, 750 cefuroxime sodium intravenous solution reconstituted 1.5 gm cephalexin oral capsule 250, 500, 750 cephalexin oral suspension reconstituted 125 /5ml, 250 /5ml cephalexin oral tablet 250, 500 chloramphenicol sod succinate intravenous solution reconstituted 1 gm CIPRO ORAL SUSPENSION RECONSTITUTED 250 M/5ML (5%) ciprofloxacin hcl oral tablet 100, 750 ciprofloxacin hcl oral tablet 250, 500 ciprofloxacin in d5w intravenous solution 200 /100ml ciprofloxacin in d5w intravenous solution 400 /200ml Tazicef Rocephin Keflex Cipro Cipro Cipro in D5W QL (20 EA per 10 20

24 Drug Name Reference rand-eneric Notes ciprofloxacin intravenous solution 200 /20ml, 400 /40ml ciprofloxacin oral suspension reconstituted 250 /5ml (5%), 500 /5ml (10%) ciprofloxacin-ciproflox hcl er oral tablet extended release 24 hour 1000, 500 CLAFORAN INJECTION SOLUTION RECONSTITUTED 10 M, 2 M, 500 M CLAFORAN INTRAVENOUS SOLUTION RECONSTITUTED 1 M, 2 M clarithromycin er oral tablet extended release 24 hour 500 clarithromycin oral suspension reconstituted 125 /5ml, 250 /5ml clarithromycin oral tablet 250 Cipro Cipro XR clarithromycin oral tablet 500 iaxin clindamycin hcl oral capsule 150, 300, 75 clindamycin palmitate hcl oral solution reconstituted 75 /5ml clindamycin phosphate in d5w intravenous solution 300 /50ml, 600 /50ml, 900 /50ml clindamycin phosphate injection solution 300 /2ml, 600 /4ml, 9 gm/60ml, 900 /6ml, 9000 /60ml clindamycin phosphate intravenous solution 150 /ml, 300 /2ml, 600 /4ml, 900 /6ml Cleocin Cleocin clindamycin phosphate vaginal cream 2 % Cleocin colistimethate sodium (cba) injection solution reconstituted 150 COLY-MYCIN M INJECTION SOLUTION RECONSTITUTED 150 M coremino oral tablet extended release 24 hour 135, 45, 90 CUICIN INTRAVENOUS SOLUTION RECONSTITUTED 500 M CUICIN RF INTRAVENOUS SOLUTION RECONSTITUTED 500 M Cleocin in D5W Cleocin Phosphate Cleocin Phosphate Coly-Mycin M Coly-Mycin M CoreMino Cubicin Cubicin QL (280 ML per 14 QL (28 EA per 14 QL (28 EA per 14 21

25 Drug Name Reference rand-eneric Notes DALVANCE INTRAVENOUS SOLUTION RECONSTITUTED 500 M daptomycin intravenous solution reconstituted 500 demeclocycline hcl oral tablet 150, 300 dicloxacillin sodium oral capsule 250, 500 doxy 100 intravenous solution reconstituted 100 doxycycline hyclate intravenous solution reconstituted 100 doxycycline hyclate oral capsule 100, 50 doxycycline hyclate oral tablet 100, 20 doxycycline hyclate oral tablet 150, 75 Cubicin Doxy 100 Doxy 100 Morgidox Acticlate doxycycline hyclate oral tablet 50 TargaDOX doxycycline hyclate oral tablet delayed release 100, 75 doxycycline hyclate oral tablet delayed release 150 doxycycline hyclate oral tablet delayed release 200, 50 doxycycline monohydrate oral capsule 100, 50, 75 doxycycline monohydrate oral capsule 150 doxycycline monohydrate oral suspension reconstituted 25 /5ml doxycycline monohydrate oral tablet 100, 150, 50, 75 Soloxide Doryx Mondoxyne NL Vibramycin e.e.s. 400 oral tablet 400 E.E.S. 400 ertapenem sodium injection solution reconstituted 1 gm erythrocin lactobionate intravenous solution reconstituted 500 erythromycin base oral capsule delayed release particles 250 erythromycin base oral tablet 250, 500 erythromycin ethylsuccinate oral suspension reconstituted 200 /5ml INVanz E.E.S. ranules 22

26 Drug Name Reference rand-eneric Notes erythromycin ethylsuccinate oral tablet 400 FIRVANQ ORAL SOLUTION RECONSTITUTED 25 M/ML, 50 M/ML gentamicin in saline intravenous solution /ml-%, /ml-%, /ml-%, /ml-%, /ml-%, /ml-%, /ml- % gentamicin sulfate external cream 0.1 % gentamicin sulfate external ointment 0.1 % gentamicin sulfate injection solution 10 /ml, 40 /ml hydrogen peroxide solution 30 % imipenem-cilastatin intravenous solution reconstituted 250 imipenem-cilastatin intravenous solution reconstituted 500 INVANZ INJECTION SOLUTION RECONSTITUTED 1 M INVANZ INTRAVENOUS SOLUTION RECONSTITUTED 1 M iodine tincture external tincture 2 % iodoquinol-hc-aloe polysacch external gel % levofloxacin in d5w intravenous solution 250 /50ml, 500 /100ml, 750 /150ml levofloxacin intravenous solution 25 /ml levofloxacin oral solution 25 /ml levofloxacin oral tablet 250, 500, 750 lincomycin hcl injection solution 300 /ml linezolid in sodium chloride intravenous solution /300ml-% linezolid intravenous solution 600 /300ml linezolid oral suspension reconstituted 100 /5ml E.E.S. 400 AL (Max 11 Years) Primaxin IV INVanz Alcortin A Levaquin Lincocin Zyvox Zyvox linezolid oral tablet 600 Zyvox lugols external solution 23

27 Drug Name Reference rand-eneric Notes MACRODANTIN ORAL CAPSULE 25 M Macrodantin mafenide acetate external packet 5 % Sulfamylon meropenem intravenous solution reconstituted 1 gm, 500 meropenem-sodium chloride intravenous solution reconstituted 1 gm/50ml, 500 /50ml Merrem methenamine hippurate oral tablet 1 gm Hiprex methenamine mandelate oral tablet 0.5 gm, 1 gm metronidazole in nacl intravenous solution /ml-%, /100ml-% metronidazole oral capsule 375 Flagyl metronidazole oral tablet 250, 500 Flagyl metronidazole vaginal gel 0.75 % Metroel-Vaginal minocycline hcl er oral tablet extended release 24 hour 115, 65 minocycline hcl er oral tablet extended release 24 hour 135, 45, 90 minocycline hcl oral capsule 100, 50 minocycline hcl oral capsule 75 minocycline hcl oral tablet 100, 50, 75 mondoxyne nl oral capsule 100, 50, 75 Solodyn CoreMino Minocin Mondoxyne NL morgidox oral capsule 100, 50 Morgidox moxifloxacin hcl in nacl intravenous solution 400 /250ml moxifloxacin hcl intravenous solution 400 /250ml Avelox moxifloxacin hcl oral tablet 400 Avelox mupirocin calcium external cream 2 % actroban mupirocin external ointment 2 % Centany nafcillin sodium in dextrose intravenous solution 1 gm/50ml, 2 gm/100ml nafcillin sodium injection solution reconstituted 1 gm, 2 gm nafcillin sodium intravenous solution reconstituted 1 gm, 10 gm, 2 gm neomycin sulfate oral tablet 500 QL (2 EA per 31 neomycin-polymyxin b gu irrigation solution

28 Drug Name Reference rand-eneric Notes nitrofurantoin macrocrystal oral capsule 100, 25, 50 nitrofurantoin monohydrate macrocrystals oral capsule 100 Macrodantin Macrobid nitrofurantoin oral suspension 25 /5ml Furadantin ofloxacin oral tablet 300, 400 okebo oral capsule 75 Mondoxyne NL oxacillin sodium injection solution reconstituted 1 gm, 10 gm, 2 gm paromomycin sulfate oral capsule 250 penicillin g potassium injection solution Pfizerpen reconstituted unit, unit penicillin g procaine intramuscular suspension unit/ml penicillin g sodium injection solution reconstituted unit penicillin v potassium oral solution reconstituted 125 /5ml, 250 /5ml penicillin v potassium oral tablet 250, 500 pfizerpen injection solution reconstituted unit piperacillin sod-tazobactam so intravenous solution reconstituted 13.5 (12-1.5) gm piperacillin sod-tazobactam so intravenous solution reconstituted 2.25 (2-0.25) gm, ( ) gm, 4.5 (4-0.5) gm, 40.5 (36-4.5) gm polymyxin b sulfate injection solution reconstituted unit silver nitrate external ointment 10 % silver nitrate external solution 0.5 %, 10 %, 25 %, 50 % Pfizerpen Zosyn silver sulfadiazine external cream 1 % Silvadene soloxide oral tablet delayed release 150 Soloxide ssd external cream 1 % Silvadene streptomycin sulfate intramuscular solution reconstituted 1 gm sulfadiazine oral tablet 500 sulfamethoxazole-trimethoprim intravenous solution /5ml 25

29 Drug Name Reference rand-eneric Notes sulfamethoxazole-trimethoprim oral suspension /5ml sulfamethoxazole-trimethoprim oral tablet sulfamethoxazole-trimethoprim oral tablet sulfatrim pediatric oral suspension /5ml SUPRAX ORAL CAPSULE 400 M SUPRAX ORAL SUSPENSION RECONSTITUTED 100 M/5ML tazicef injection solution reconstituted 1 gm, 2 gm, 6 gm tazicef intravenous solution reconstituted 1 gm, 2 gm tetracycline hcl oral capsule 250, 500 tigecycline intravenous solution reconstituted 50 tinidazole oral tablet 250 Sulfatrim Pediatric actrim actrim DS Sulfatrim Pediatric Suprax Tazicef ; QL (2 EA per 31 ; QL (150 ML per 31 Tygacil tinidazole oral tablet 500 Tindamax tobramycin sulfate injection solution 1.2 gm/30ml, 10 /ml, 2 gm/50ml, 80 /2ml tobramycin sulfate injection solution reconstituted 1.2 gm trimethoprim oral tablet 100 triple dye external liquid TYACIL INTRAVENOUS SOLUTION RECONSTITUTED 50 M UNASYN INJECTION SOLUTION RECONSTITUTED 1.5 (1-0.5) M, 15 (10-5) M, 3 (2-1) M VANCOCIN HCL ORAL CAPSULE 125 M, 250 M vancomycin hcl in dextrose intravenous solution 1-5 gm/100ml-%, 1-5 gm/200ml- %, 1-5 gm/250ml-%, gm/250ml-%, 2-5 gm/500ml-%, /100ml-%, /150ml-% Tygacil Unasyn Vancocin HCl 26

30 Drug Name Reference rand-eneric Notes vancomycin hcl in nacl intravenous solution gm/150ml-%, gm/200ml-%, gm/250ml-%, gm/150ml-%, gm/250ml-%, gm/500ml-%, gm/250ml-%, gm/300ml-%, gm/250ml-%, /100ml-%, /150ml- % vancomycin hcl intravenous solution reconstituted 10 gm, 100 gm, 1000, 500, 5000, 750 vancomycin hcl oral capsule 125, 250 VANCOMYCIN+SYRSPEND SF PH4 ORAL SUSPENSION 50 M/ML Vancocin HCl vandazole vaginal gel 0.75 % Metroel-Vaginal VIATIV INTRAVENOUS SOLUTION RECONSTITUTED 750 M XIFAXAN ORAL TALET 200 M, 550 M Anticoagulants acd formula a in vitro solution gm/100ml acd formula b in vitro solution acd-a noclot-50 in vitro solution gm/100ml anticoagulant cit dext soln a in vitro solution gm/100ml anticoagulant sodium citrate in vitro solution 4 gm/100ml argatroban in sodium chloride intravenous solution 250 /250ml argatroban intravenous solution 125 /125ml, 250 /2.5ml, 50 /50ml bivalirudin trifluoroacetate intravenous solution reconstituted 250 CATHFLO ACTIVASE INJECTION SOLUTION RECONSTITUTED 2 M ELIQUIS ORAL TALET 2.5 M, 5 M ELIQUIS STARTER CK ORAL TALET 5 M enoxaparin sodium injection solution 300 /3ml ACD-A noclot-50 ACD-A noclot-50 ACD-A noclot-50 Angiomax Lovenox ST QL (2 EA per 31 27

31 Drug Name Reference rand-eneric Notes enoxaparin sodium subcutaneous solution 100 /ml, 120 /0.8ml, 150 /ml, 40 /0.4ml, 60 /0.6ml, 80 /0.8ml enoxaparin sodium subcutaneous solution 30 /0.3ml fondaparinux sodium subcutaneous solution 10 /0.8ml, 2.5 /0.5ml, 5 /0.4ml, 7.5 /0.6ml FRAMIN SUCUTANEOUS SOLUTION UNIT/ML, UNIT/0.5ML, UNIT/0.6ML, UNT/0.72ML, 2500 UNIT/0.2ML, 5000 UNIT/0.2ML, 7500 UNIT/0.3ML FRAMIN SUCUTANEOUS SOLUTION UNIT/3.8ML heparin (porcine) in d5w intravenous solution 40-5 unit/ml-%, 50-5 unit/ml-% heparin (porcine) in nacl injection solution unit/ml-%, unit/ml-%, unit/ml-% heparin (porcine) in nacl intravenous solution ut/500ml-%, ut/500ml-%, unit/l-%, unit/l-%, ut/250ml-% heparin (porcine) in nacl intravenous solution prefilled syringe unt/20ml- %, unt/50ml-% heparin sod (porcine) in d5w intravenous solution 100 unit/ml heparin sodium (porcine) injection solution 1000 unit/ml, unit/ml, unit/ml, 5000 unit/ml heparin sodium (porcine) intravenous solution prefilled syringe unit/10ml, 3000 unit/3ml, 5000 unit/5ml heparin sodium (porcine) pf injection solution 5000 unit/0.5ml heparin sodium/d5w intravenous solution 50-5 unit/ml-% jantoven oral tablet 1, 10, 2, 2.5, 3, 4, 5, 6, 7.5 PRADAXA ORAL CAPSULE 110 M, 150 M, 75 M SAVAYSA ORAL TALET 15 M, 30 M, 60 M Lovenox QL (2 ML per 1 day) Lovenox QL (1 ML per 1 day) Arixtra QL (1 ML per 1 day) Coumadin ; QL (1 ML per 1 day) ; QL (10 ML per 30 ST 28

32 Drug Name Reference rand-eneric Notes THROMATE III INTRAVENOUS SOLUTION RECONSTITUTED 1000 UNIT, 500 UNIT warfarin sodium oral tablet 1, 10, 2, 2.5, 3, 4, 5, 6, 7.5 XARELTO ORAL TALET 10 M, 15 M, 20 M XARELTO STARTER CK ORAL TALET THERAPY CK 15 & 20 M Anticonvulsants - Drugs for Seizures Coumadin ANZEL ORAL SUSPENSION 40 M/ML ANZEL ORAL TALET 200 M, 400 M RIVIACT INTRAVENOUS SOLUTION 50 M/5ML RIVIACT ORAL SOLUTION 10 M/ML ST RIVIACT ORAL TALET 10 M, 100 M, 25 M, 50 M, 75 M carbamazepine er oral capsule extended release 12 hour 100, 200, 300 Carbatrol carbamazepine er oral tablet extended release 12 hour 100, 200, 400 TEretol-XR carbamazepine oral suspension 100 /5ml TEretol carbamazepine oral tablet 200 Epitol carbamazepine oral tablet chewable 100 CARATROL ORAL CAPSULE EXTENDED RELEASE 12 HOUR 100 M, 200 M, 300 M Carbatrol diazepam rectal gel 10, 20 Diastat AcuDial diazepam rectal gel 2.5 Diastat Pediatric divalproex sodium er oral tablet extended release 24 hour 250, 500 divalproex sodium oral capsule delayed release sprinkle 125 divalproex sodium oral tablet delayed release 125, 250, 500 Depakote ER Depakote Sprinkles Depakote epitol oral tablet 200 Epitol ethosuximide oral capsule 250 Zarontin ethosuximide oral solution 250 /5ml Zarontin felbamate oral suspension 600 /5ml Felbatol ST ST 29

33 Drug Name Reference rand-eneric Notes felbamate oral tablet 400, 600 Felbatol fosphenytoin sodium injection solution 100 pe/2ml, 500 pe/10ml gabapentin oral capsule 100, 300, 400 gabapentin oral solution 250 /5ml, 300 /6ml Cerebyx Neurontin Neurontin gabapentin oral tablet 600, 800 Neurontin KEPPRA XR ORAL TALET EXTENDED RELEASE 24 HOUR 500 M, 750 M lamotrigine er oral tablet extended release 24 hour 100, 200, 25, 250, 300, 50 lamotrigine oral kit 25 & 50 & 100, 25 (21)-50 (7), 50 (42)-100(14) lamotrigine oral tablet 100, 150, 200, 25 lamotrigine oral tablet chewable 25, 5 lamotrigine oral tablet dispersible 100, 200, 25, 50 lamotrigine starter kit-blue oral kit 25 (35) lamotrigine starter kit-green oral kit 25 (84)-100(14) lamotrigine starter kit-orange oral kit 25 (42)-100 (7) levetiracetam er oral tablet extended release 24 hour 500, 750 levetiracetam in nacl intravenous solution 1000 /100ml, 1500 /100ml, 500 /100ml levetiracetam intravenous solution 500 /5ml Keppra XR LaMICtal XR LaMICtal ODT LaMICtal LaMICtal LaMICtal ODT LaMICtal Starter LaMICtal Starter LaMICtal Starter Keppra XR Keppra levetiracetam oral solution 100 /ml Keppra levetiracetam oral tablet 1000, 250, 500, 750 oxcarbazepine oral suspension 300 /5ml oxcarbazepine oral tablet 150, 300, 600 pentobarbital sodium injection solution 50 /ml phenobarbital oral elixir 20 /5ml Keppra Trileptal Trileptal Nembutal 30

34 Drug Name Reference rand-eneric Notes phenobarbital oral solution 20 /5ml phenobarbital oral tablet 100, 15, 16.2, 30, 32.4, 60, 64.8, 97.2 phenobarbital sodium injection solution 130 /ml, 65 /ml phenytoin infatabs oral tablet chewable 50 Dilantin Infatabs phenytoin oral suspension 125 /5ml Dilantin phenytoin oral tablet chewable 50 Dilantin Infatabs phenytoin sodium extended oral capsule 100 phenytoin sodium extended oral capsule 200, 300 phenytoin sodium injection solution 50 /ml Dilantin Phenytek primidone oral tablet 250, 50 Mysoline roweepra oral tablet 1000, 500, 750 roweepra xr oral tablet extended release 24 hour 500, 750 subvenite oral tablet 100, 150, 200, 25 subvenite starter kit-blue oral kit 25 (35) subvenite starter kit-green oral kit 25 (84)- 100(14) subvenite starter kit-orange oral kit 25 (42)-100 (7) tiagabine hcl oral tablet 12, 16, 2, 4 topiramate er oral capsule er 24 hour sprinkle 100, 150, 200, 25, 50 topiramate oral capsule sprinkle 15, 25 topiramate oral tablet 100, 200, 25, 50 valproate sodium intravenous solution 100 /ml, 500 /5ml valproate sodium oral solution 250 /5ml Keppra Keppra XR LaMICtal LaMICtal Starter LaMICtal Starter LaMICtal Starter abitril Qudexy XR Topamax Sprinkle Topamax Depacon Depakene valproic acid oral capsule 250 Depakene valproic acid oral solution 250 /5ml Depakene 31