Geisinger Gold $0 Deductible Rx Comprehensive Formulary. (List of Covered Drugs)

Transcription

1 Geisinger Gold $0 Deductible Rx 016 Comprehensive Formulary (List of Covered Drugs) PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN This formulary was updated on 11/9/16. For more recent information or other questions, please contact Geisinger Gold Member Services at (800) or, for TTY users, 711, 8 a.m. to 8 p.m. (7 days a week, Oct. Feb.) or 8 a.m. to 8 p.m. (Mon. Fri., March Sept.), or visit Y00_1509_1_FINAL_ Populated Template 1/9/16 HPMS Approved Formulary File Submission ID 1670, Version Number 1

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 Geisinger Gold. When it refers to plan or our plan, it means Geisinger Gold $0 Deductible Rx. This document includes a list of the drugs (formulary) for our plan which is current as of February 01, 016. For an updated formulary, please contact us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages. You must generally use network pharmacies to use your prescription drug benefit. Benefits, formulary, pharmacy network, and/or copayments/coinsurance may change on January 1, 016, and from time to time during the year. Geisinger Gold Medicare Advantage HMO, PPO, and HMO SNP plans are offered by Geisinger Health Plan/Geisinger Indemnity Insurance Company/Geisinger Quality Options, Inc., health plans with a Medicare contract. Continued enrollment in Geisinger Gold depends on annual contract renewal. What is the Geisinger Gold $0 Deductible Rx Formulary? A formulary is a list of covered drugs selected by Geisinger Gold $0 Deductible Rx 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. Geisinger Gold $0 Deductible Rx will generally cover the drugs listed in our formulary as long as the drug is medically necessary, the prescription is filled at a Geisinger Gold $0 Deductible Rx network pharmacy, and other plan rules are followed. For more information on how to fill your prescriptions, please review your Evidence of Coverage. Can the Formulary (drug list) change? Generally, if you are taking a drug on our 016 formulary that was covered at the beginning of the year, we will not discontinue or reduce coverage of the drug during the 016 coverage year except when a new, less expensive generic drug becomes available or when new adverse information about the safety or effectiveness of a drug is released. Other types of formulary changes, such as removing a drug from our formulary, will not affect members who are currently taking the drug. It will remain available at the same cost-sharing for those members taking it for the remainder of the coverage year. We feel it is important that you have continued access for the remainder of the coverage year to the formulary drugs that were available when you chose our plan, except for cases in which you can save additional money or we can ensure your safety. If we remove drugs from our formulary, or add prior authorization, quantity limits and/or step therapy restrictions on a drug or move a drug to a higher cost-sharing tier, we must notify affected members of the change at least 60 days before the change becomes effective, or at the time the member requests a refill of the drug, at which time the member will receive a 60-day supply of the drug. If the Food and Drug Administration deems a drug on our formulary to be unsafe or the drug s manufacturer removes the drug from the market, we will immediately remove the drug from our formulary and provide notice to members who take the drug. The enclosed formulary is current as of 11/9/16. To get updated information about the drugs covered by Geisinger Gold $0 Deductible Rx, please contact us. Our contact information appears on the front and back cover pages. If non-maintenance changes are made to the formulary during the plan year, Geisinger Gold $0 Deductible Rx communicates these changes in the member newsletter and within the monthly explanation of benefits (EOB).

3 How do I use the Formulary? There are two ways to find your drug within the formulary: Medical Condition The formulary begins on page ten (10). 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 ten (10). 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 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? Geisinger Gold $0 Deductible Rx 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: Geisinger Gold $0 Deductible Rx requires you or your physician to get prior authorization for certain drugs. This means that you will need to get approval from Geisinger Gold $0 Deductible Rx before you fill your prescriptions. If you don t get approval, Geisinger Gold $0 Deductible Rx may not cover the drug. Quantity Limits: For certain drugs, Geisinger Gold $0 Deductible Rx limits the amount of the drug that Geisinger Gold $0 Deductible Rx will cover. For example, Geisinger Gold $0 Deductible Rx provides 16 tablets per prescription for sumatriptan. This may be in addition to a standard one-month or three-month supply. Step Therapy: In some cases, Geisinger Gold $0 Deductible Rx 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, Geisinger Gold $0 Deductible Rx may not

4 cover Drug B unless you try Drug A first. If Drug A does not work for you, Geisinger Gold $0 Deductible Rx 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 ten (10). 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 Geisinger Gold $0 Deductible Rx 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 Geisinger Gold $0 Deductible Rx formulary? on page four () 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. If you learn that Geisinger Gold $0 Deductible Rx does not cover your drug, you have two options: You can ask Member Services for a list of similar drugs that are covered by Geisinger Gold $0 Deductible Rx. When you receive the list, show it to your doctor and ask him or her to prescribe a similar drug that is covered by Geisinger Gold $0 Deductible Rx. You can ask Geisinger Gold $0 Deductible Rx to make an exception and cover your drug. See below for information about how to request an exception. How do I request an exception to the Geisinger Gold $0 Deductible Rx Formulary? You can ask Geisinger Gold $0 Deductible Rx 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.

5 You can ask us to waive coverage restrictions or limits on your drug. For example, for certain drugs, Geisinger Gold $0 Deductible Rx 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, Geisinger Gold $0 Deductible Rx 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 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 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 a 9-day transition supply, consistent with dispensing increment, (unless you have a prescription written for fewer. We will cover more than one refill of these drugs for the first 90 days you are a member of our plan. If you need a drug that is not on our formulary or if your ability to get your drugs is limited, but you are past the first 90 days of membership in our plan, we will cover a 1-day emergency supply of that drug (unless you have a prescription for fewer while you pursue a formulary exception. For members who experience a level of care change such as changing from one treatment setting to another (e.g. hospital to long-term care facility), being admitted to or discharged from a long-term care facility, or reverting from hospice status back to standard Medicare Part A and B benefits, an exception for a one-time temporary fill will be granted even if the member is past the first 90 days of membership in our plan. Early refill edits will not be applied when a level of care change exists. 5

6 For more information For more detailed information about your Geisinger Gold $0 Deductible Rx prescription drug coverage, please review your Evidence of Coverage and other plan materials. If you have questions about Geisinger Gold $0 Deductible Rx, 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 ( ) hours a day/7 days a week. TTY users should call Or, visit Geisinger Gold $0 Deductible Rx Formulary The formulary that begins on page ten (10) provides coverage information about the drugs covered by Geisinger Gold $0 Deductible Rx. If you have trouble finding your drug in the list, turn to the Index that begins on page I-1. The first column of the chart lists the drug name. Brand name drugs are capitalized (e.g., ADVAIR DISKUS) and generic drugs are listed in lower-case italics (e.g., simvastatin). The information in the Requirements/Limits column tells you if Geisinger Gold $0 Deductible Rx has any special requirements for coverage of your drug. 6

7 The following Utilization Management abbreviations may be found within the body of this document COVERAGE NOTES ABBREVIATIONS ABBREVIATION DESCRIPTION EXPLANATION General Generic (BRAND) The reference brand name in parenthesis is provided for information only to assist in identifying the generic medication and does NOT indicate formulary status or coverage. Utilization Management Restrictions PA PA BvD PA-HRM PA NSO QL ST Prior Authorization Restriction Prior Authorization Restriction for Part B vs Part D Determination Prior Authorization Restriction for High Risk Medications Prior Authorization Restriction for New Starts Only Quantity Limit Restriction Step Therapy Restriction You (or your physician) are required to get prior authorization from Geisinger Gold $0 Deductible Rx before you fill your prescription for this drug. Without prior approval, Geisinger Gold $0 Deductible Rx may not cover this drug. This drug may be eligible for payment under Medicare Part B or Part D. You (or your physician) are required to get prior authorization from Geisinger Gold $0 Deductible Rx to determine that this drug is covered under Medicare Part D before you fill your prescription for this drug. Without prior approval, Geisinger Gold $0 Deductible Rx may not cover this drug. This drug has been deemed by CMS to be potentially harmful and therefore, a High Risk Medication for Medicare beneficiaries 65 years or older. Members age 65 yrs or older are required to get prior authorization from Geisinger Gold $0 Deductible Rx before you fill your prescription for this drug. Without prior approval, Geisinger Gold $0 Deductible Rx may not cover this drug If you are a new member or if you have not taken this drug before, you (or your physician) are required to get prior authorization from Geisinger Gold $0 Deductible Rx before you fill your prescription for this drug. Without prior approval, Geisinger Gold $0 Deductible Rx may not cover this drug. Geisinger Gold $0 Deductible Rx limits the amount of this drug that is covered per prescription, or within a specific time frame. Before Geisinger Gold $0 Deductible Rx 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. 7

8 The following additional coverage note abbreviations may be found within the body of this document OTHER SPECIAL REQUIREMENTS FOR COVERAGE ABBREVIATION DESCRIPTION EXPLANATION LA NM GC Limited Access Drug Non-Mail Order Drug Gap Coverage This prescription may be available only at certain pharmacies. For more information consult your Pharmacy Directory or call Member Services at (800) , 8 a.m. to 8 p.m. (7 days a week, Oct. Feb.) or 8 a.m. to 8 p.m. (Mon. Fri., March- Sept.). TTY/TDD users should call 711. Drugs not available via your mail order benefit are noted with NM in the Requirements/Limits column of your formulary. We may provide coverage of this prescription drug in the coverage gap. Please refer to your Evidence of Coverage for more information about this coverage. 8

9 Every medication on the Geisinger Gold $0 Deductible Rx formulary is in one of five (5) cost-sharing tiers. In general, the higher the cost-sharing tier number, the higher your cost for the medication: As shown in the table below, the amount of the copayment or coinsurance depends on which cost-sharing tier your medication is in. Please note: what you pay for your medication depends on which drug payment stage you are in when you get the medication, where you get the medication filled, and if you qualify for any additional payment assistance. Your share of the cost when you get a 0-day supply of a covered Part D prescription drug prior to entering the coverage gap: Tier 1 (preferred generic) $ Tier (generic) $0 Tier (preferred brand) $7 Tier (non-preferred brand) $100 Tier 5 (specialty tier) % coinsurance If you are a member of an employer group, these prices may not apply to you. Please refer to your benefit documents for appropriate cost sharing amounts. 9

10 Table of Contents Analgesics... Anesthetics... 9 Anti-Addiction/Substance Abuse Treatment Agents... 9 Antianxiety Agents Antibacterials... 1 Anticancer Agents... Anticholinergic Agents... Anticonvulsants... Antidementia Agents... 8 Antidepressants... 8 Antidiabetic Agents... Antifungals... 6 Antihistamines... 8 Anti-Infectives (Skin And Mucous Membrane)... 9 Antimigraine Agents... 9 Antimycobacterials Antinausea Agents Antiparasite Agents... 5 Antiparkinsonian Agents... 5 Antipsychotic Agents... 5 Antivirals (Systemic) Blood Products/Modifiers/Volume Expanders... 6 Caloric Agents Cardiovascular Agents Central Nervous System Agents... 8 Contraceptives... 8 Dental And Oral Agents

11 Dermatological Agents Devices Enzyme Replacement/Modifiers Eye, Ear, Nose, Throat Agents Gastrointestinal Agents Genitourinary Agents Heavy Metal Antagonists Hormonal Agents, Stimulant/Replacement/Modifying Immunological Agents Inflammatory Bowel Disease Agents... 1 Irrigating Solutions... 1 Metabolic Bone Disease Agents Miscellaneous Therapeutic Agents Ophthalmic Agents Replacement Preparations... 1 Respiratory Tract Agents Skeletal Muscle Relaxants Sleep Disorder Agents Vasodilating Agents Vitamins And Minerals... 1

12 Analgesics Analgesics, Miscellaneous acetaminophen-codeine 10 mg-1 mg/5 ml solution 10-1 mg/5 ml acetaminophen-codeine oral solution 00 mg-0 mg /1.5 ml acetaminophen-codeine oral tablet mg acetaminophen-codeine oral tablet 00-0 mg acetaminophen-codeine oral tablet mg aspirin-caffeine-dihydrocodein oral capsule mg (Acetaminophen with Codeine) NM; QL (5000 per 0 (Acetaminophen with NM; QL (5000 per 0 Codeine) (Tylenol-Codeine No.) QL (90 per 0 (Tylenol-Codeine No.) NM; QL (60 per 0 (Tylenol-Codeine No.) QL (180 per 0 (Synalgos-Dc) NM; QL (60 per 0 astramorph-pf injection solution 1 mg/ml (Morphine Sulfate/PF) NM buprenorphine hcl injection syringe 0. (Buprenorphine HCl) NM mg/ml butalbital-acetaminophen oral tablet 50- (Tencon) QL (180 per 0 5 mg butalbital-acetaminophen-caff oral (Esgic) QL (180 per 0 capsule mg, mg butalbital-acetaminophen-caff oral tablet (Esgic) QL (180 per mg butalbital-aspirin-caffeine oral capsule (Fiorinal) QL (180 per mg butorphanol tartrate injection solution 1 (Butorphanol Tartrate) NM mg/ml butorphanol tartrate injection solution (Butorphanol Tartrate) mg/ml butorphanol tartrate nasal spray,nonaerosol (Butorphanol Tartrate) NM 10 mg/ml BUTRANS TRANSDERMAL PATCH WEEKLY 10 MCG/HOUR, 15 MCG/HOUR, 0 MCG/HOUR, 5 MCG/HOUR, 7.5 MCG/HOUR PA; NM; QL ( per 8 capacet oral capsule mg (Esgic) QL (180 per 0 codeine sulfate oral tablet 15 mg, 0 mg, (Codeine Sulfate) NM; QL (180 per 0 60 mg

13 DURAMORPH (PF) INJECTION NM SOLUTION 0.5 MG/ML, 1 MG/ML endocet oral tablet 10-5 mg,.5-5 mg, 5-5 mg, mg (Xolox) NM; QL (60 per 0 endodan oral tablet mg (Percodan) NM; QL (60 per 0 fentanyl citrate buccal lozenge on a handle 1,00 mcg, 1,600 mcg, 00 mcg, (Actiq) 5 PA; NM; QL (10 per 0 00 mcg, 600 mcg, 800 mcg fentanyl transdermal patch 7 hour 100 (Duragesic) NM; QL (0 per 0 mcg/hr, 75 mcg/hr fentanyl transdermal patch 7 hour 1 (Duragesic) NM; QL (10 per 0 mcg/hr, 5 mcg/hr, 50 mcg/hr hydrocodone-acetaminophen oral solution 10-5 mg/15 ml(15 ml), mg/5 ml, mg/15 ml hydrocodone-acetaminophen oral tablet mg, 5-00 mg, mg hydrocodone-acetaminophen oral tablet 10-5 mg,.5-5 mg, 5-5 mg, mg (Hycet) NM; QL (700 per 0 (Norco) NM; QL (90 per 0 (Norco) NM; QL (60 per 0 hydrocodone-ibuprofen oral tablet mg,.5-00 mg, 5-00 mg, mg (Ibudone) NM; QL (150 per 0 hydromorphone (pf) injection solution 10 (Dilaudid-HP) mg/ml hydromorphone mg/ml vial outer,latexfree,suv (Hydromorphone HCl) mg/ml hydromorphone injection solution (Hydromorphone HCl) NM mg/ml, mg/ml hydromorphone injection syringe mg/ml (Hydromorphone HCl) NM hydromorphone oral tablet mg, mg (Dilaudid) NM; QL (180 per 0 hydromorphone oral tablet 8 mg (Dilaudid) NM; QL (0 per 0 ibuprofen-oxycodone oral tablet 00-5 mg (Ibuprofen/Oxycodone HCl) LAZANDA NASAL SPRAY,NON- AEROSOL 100 MCG/SPRAY, 00 MCG/SPRAY, 00 MCG/SPRAY NM; QL (8 per 0 5 PA; NM

14 levorphanol tartrate oral tablet mg (Levorphanol Tartrate) NM; QL (180 per 0 margesic oral capsule mg (Esgic) QL (180 per 0 marten-tab oral tablet 50-5 mg (Tencon) QL (180 per 0 methadone injection solution 10 mg/ml (Methadone HCl) NM methadone intensol oral concentrate 10 mg/ml (Methadose) NM; QL (1800 per 0 methadone oral solution 10 mg/5 ml, 5 mg/5 ml (Methadone HCl) NM; QL (1800 per 0 methadone oral tablet 10 mg, 5 mg (Diskets) NM; QL (60 per 0 methadose oral tablet,soluble 0 mg (Diskets) NM; QL (90 per 0 morphine (pf) injection solution 0.5 mg/ml (Morphine Sulfate/PF) NM morphine (pf) injection solution 1 mg/ml (Morphine Sulfate/PF) morphine (pf) intravenous patient (Morphine Sulfate/PF) control.analgesia soln 150 mg/0 ml morphine (pf) intravenous patient (Morphine Sulfate/PF) NM control.analgesia soln 0 mg/0 ml morphine 10 mg/ml carpuject 10 mg/ml (Morphine Sulfate) NM morphine mg/ml carpuject outer, latex-f, (Morphine Sulfate) NM p/f mg/ml morphine mg/ml carpuject outer,latexfree,p/f (Morphine Sulfate) NM mg/ml morphine 8 mg/ml syringe 8 mg/ml (Morphine Sulfate) NM morphine concentrate oral solution 100 (Morphine Sulfate) QL (00 per 0 mg/5 ml (0 mg/ml) morphine in 0.9 % nacl intravenous (Morphine Sulfate In 0.9 solution 1 mg/ml % NaCl) morphine injection solution 15 mg/ml, 8 (Morphine Sulfate) mg/ml morphine injection syringe 10 mg/ml, 5 (Morphine Sulfate) mg/ml morphine intramuscular pen injector 10 (Morphine Sulfate) NM mg/0.7 ml morphine intravenous cartridge 15 mg/ml (Morphine Sulfate) NM morphine intravenous solution 5 mg/ml, (Morphine Sulfate) NM 50 mg/ml morphine intravenous syringe 10 mg/ml, mg/ml, mg/ml, 8 mg/ml (Morphine Sulfate) NM 5

15 morphine oral capsule, er multiphase (Avinza) NM; QL (60 per 0 hr 10 mg, 75 mg, 90 mg morphine oral capsule, er multiphase (Avinza) NM; QL (0 per 0 hr 0 mg, 5 mg, 60 mg morphine oral capsule,extend.release pellets 10 mg, 0 mg, 60 mg, 80 mg (Kadian) NM; QL (10 per 0 morphine oral capsule,extend.release (Kadian) NM; QL (90 per 0 pellets 100 mg, 0 mg, 50 mg morphine oral solution 10 mg/5 ml (Morphine Sulfate) NM; QL (700 per 0 morphine oral solution 0 mg/5 ml ( mg/ml) (Morphine Sulfate) NM; QL (00 per 0 MORPHINE ORAL TABLET 15 MG, 0 MG NM; QL (180 per 0 morphine oral tablet extended release 100 (MS Contin) NM; QL (90 per 0 mg, 15 mg, 0 mg morphine oral tablet extended release 00 mg, 60 mg (MS Contin) NM; QL (10 per 0 morphine rectal suppository 10 mg, 0 mg, 0 mg, 5 mg (Morphine Sulfate) NM nalbuphine injection solution 10 mg/ml, 0 (Nalbuphine HCl) NM mg/ml oxycodone oral capsule 5 mg (Oxycodone HCl) NM; QL (180 per 0 oxycodone oral concentrate 0 mg/ml (Oxycodone HCl) NM; QL (180 per 0 oxycodone oral solution 5 mg/5 ml (Oxycodone HCl) NM; QL (100 per 0 oxycodone oral tablet 10 mg, 15 mg, 0 mg, 0 mg, 5 mg (Roxicodone) NM; QL (180 per 0 oxycodone oral tablet,oral only,ext.rel.1 hr 10 mg, 0 mg, 0 mg (Oxycontin) ST; NM; QL (90 per 0 oxycodone oral tablet,oral only,ext.rel.1 (Oxycontin) ST; QL (90 per 0 hr 15 mg, 0 mg oxycodone oral tablet,oral only,ext.rel.1 hr 60 mg (Oxycontin) ST; QL (10 per 0 oxycodone oral tablet,oral only,ext.rel.1 hr 80 mg (Oxycontin) ST; NM; QL (10 per 0 6

16 oxycodone-acetaminophen oral solution 5- (Oxycodone QL (180 per 0 5 mg/5 ml HCl/Acetaminophen) oxycodone-acetaminophen oral tablet 10-5 mg,.5-5 mg, 5-5 mg, (Xolox) NM; QL (60 per 0 mg oxycodone-aspirin oral tablet mg (Percodan) NM; QL (60 per 0 OXYCONTIN ORAL TABLET,ORAL ONLY,EXT.REL.1 HR 10 MG, 15 MG, ST; NM; QL (90 per 0 0 MG, 0 MG, 0 MG OXYCONTIN ORAL TABLET,ORAL ONLY,EXT.REL.1 HR 60 MG, 80 MG ST; NM; QL (10 per 0 oxymorphone oral tablet 10 mg, 5 mg (Opana) NM; QL (180 per 0 reprexain oral tablet mg,.5-00 mg, 5-00 mg (Ibudone) NM; QL (150 per 0 roxicet oral solution 5-5 mg/5 ml (Oxycodone HCl/Acetaminophen) NM; QL (180 per 0 roxicet oral tablet 5-5 mg (Xolox) NM; QL (60 per 0 tencon oral tablet 50-5 mg (Tencon) QL (180 per 0 tramadol hcl er 00 mg tablet 00 mg (Ultram ER) NM; QL (0 per 0 tramadol oral capsule,er biphase hr (Conzip) NM; QL (0 per mg tramadol oral capsule,er biphase hr (Conzip) NM; QL (60 per mg, 150 mg, 00 mg tramadol oral tablet 50 mg (Ultram) NM; QL (0 per 0 tramadol oral tablet extended release (Ultram ER) NM; QL (90 per 0 hr 100 mg tramadol oral tablet extended release (Ultram ER) NM; QL (0 per 0 hr 00 mg tramadol oral tablet, er multiphase hr (Ultram ER) NM; QL (0 per 0 00 mg tramadol-acetaminophen oral tablet mg (Ultracet) NM; QL (0 per 0 xylon 10 oral tablet mg (Ibudone) NM; QL (150 per 0 zebutal oral capsule mg (Esgic) QL (180 per 0 7

17 Nonsteroidal Anti-Inflammatory Agents celecoxib oral capsule 100 mg, 00 mg, (Celebrex) 00 mg, 50 mg choline,magnesium salicylate oral liquid (Choline Sal/Mag 500 mg/5 ml Salicylate) diclofenac potassium oral tablet 50 mg (Diclofenac Potassium) diclofenac sodium oral tablet extended (Voltaren-XR) release hr 100 mg diclofenac sodium oral tablet,delayed (Diclofenac Sodium) release (dr/ec) 5 mg, 50 mg, 75 mg diclofenac sodium topical gel 1 % (Voltaren) diclofenac sodium topical gel % (Voltaren) 5 NM diclofenac-misoprostol oral (Arthrotec 50) tablet,ir,delayed rel,biphasic mgmcg, mg-mcg diflunisal oral tablet 500 mg (Diflunisal) etodolac oral capsule 00 mg, 00 mg (Etodolac) etodolac oral tablet 00 mg, 500 mg (Etodolac) etodolac oral tablet extended release hr (Etodolac) 00 mg, 500 mg, 600 mg fenoprofen oral capsule 00 mg (Nalfon) fenoprofen oral tablet 600 mg (Fenoprofen Calcium) FLECTOR TRANSDERMAL PATCH 1 HOUR 1. % PA; NM; QL (60 per 0 flurbiprofen oral tablet 100 mg, 50 mg (Flurbiprofen) ibuprofen oral suspension 100 mg/5 ml (Ibuprofen) ibuprofen oral tablet 00 mg, 600 mg, 800 (Ibuprofen) mg ketoprofen oral capsule 50 mg, 75 mg (Ketoprofen) ketoprofen oral capsule,ext rel. pellets (Ketoprofen) hr 00 mg meclofenamate oral capsule 100 mg, 50 (Meclofenamate mg Sodium) mefenamic acid oral capsule 50 mg (Ponstel) meloxicam oral suspension 7.5 mg/5 ml (Mobic) meloxicam oral tablet 15 mg, 7.5 mg (Mobic) nabumetone oral tablet 500 mg, 750 mg (Nabumetone) 8

18 naproxen oral suspension 15 mg/5 ml (Naprosyn) naproxen oral tablet 50 mg, 75 mg, 500 (Naprosyn) mg naproxen oral tablet,delayed release (Ec-Naprosyn) (dr/ec) 75 mg, 500 mg naproxen sodium oral tablet 75 mg, 550 (Anaprox) mg oxaprozin oral tablet 600 mg (Daypro) piroxicam oral capsule 10 mg, 0 mg (Feldene) sulindac oral tablet 150 mg, 00 mg (Sulindac) tolmetin oral capsule 00 mg (Tolmetin Sodium) tolmetin oral tablet 00 mg, 600 mg (Tolmetin Sodium) Anesthetics Local Anesthetics cocaine topical solution % (Cocaine HCl) NM glydo mucous membrane jelly in (Lidocaine HCl) applicator % lidocaine (pf) injection solution 15 mg/ml (1.5 %), 0 mg/ml ( %) (Xylocaine-MPF) PA BvD; NM; (PA for ESRD only) lidocaine (pf) injection solution 5 mg/ml (Xylocaine-MPF) PA BvD (0.5 %) lidocaine (pf) intravenous syringe 100 (Lidocaine HCl/PF) NM mg/5 ml ( %) lidocaine % viscous soln % (Xylocaine) lidocaine hcl injection solution 10 mg/ml (1 %), 0 mg/ml ( %) (Xylocaine) PA BvD; NM; (PA for ESRD only) lidocaine hcl mucous membrane gel % (Lidocaine HCl) lidocaine hcl mucous membrane solution (Xylocaine) %, % (0 mg/ml) lidocaine topical adhesive (Lidoderm) PA patch,medicated 5 % lidocaine topical ointment 5 % (Lidocaine) PA BvD; (PA for ESRD only) lidocaine-prilocaine topical cream.5-.5 % (EMLA) PA BvD; (PA for ESRD only) Anti-Addiction/Substance Abuse Treatment Agents 9

19 Anti-Addiction/Substance Abuse Treatment Agents acamprosate oral tablet,delayed release (Acamprosate Calcium) NM (dr/ec) mg buprenorphine hcl sublingual tablet mg, 8 mg (Buprenorphine HCl) PA; NM; QL (90 per 0 buprenorphine-naloxone sublingual tablet -0.5 mg (Buprenorphine HCl/Naloxone HCl) PA; NM; QL (60 per 0 buprenorphine-naloxone sublingual tablet 8- mg (Buprenorphine HCl/Naloxone HCl) PA; NM; QL (90 per 0 bupropion hcl sr 150 mg tablet f/c 150 mg (Zyban) QL (60 per 0 CHANTIX CONTINUING MONTH QL (60 per 0 BOX ORAL TABLET 1 MG CHANTIX ORAL TABLET 0.5 MG, 1 NM; QL (60 per 0 MG CHANTIX STARTING MONTH BOX NM ORAL TABLETS,DOSE PACK 0.5 MG (11)- 1 MG () disulfiram oral tablet 50 mg (Antabuse) NM disulfiram oral tablet 500 mg (Antabuse) naloxone injection solution 0. mg/ml (Naloxone HCl) naloxone injection syringe 0. mg/ml, 1 (Naloxone HCl) NM mg/ml naltrexone oral tablet 50 mg (Revia) NM NARCAN NASAL SPRAY,NON- QL ( per 8 AEROSOL MG/ACTUATION NICOTROL NS NASAL SPRAY,NON- NM AEROSOL 10 MG/ML SUBOXONE SUBLINGUAL FILM 1- MG PA; NM; QL (60 per 0 SUBOXONE SUBLINGUAL FILM -0.5 MG PA; NM; QL (60 per 0 SUBOXONE SUBLINGUAL FILM -1 MG PA; NM; QL (180 per 0 SUBOXONE SUBLINGUAL FILM 8- MG PA; NM; QL (90 per 0 VIVITROL INTRAMUSCULAR SUSPENSION,EXTENDED REL RECON 80 MG 5 NM 10

20 Antianxiety Agents Benzodiazepines ALPRAZOLAM INTENSOL ORAL CONCENTRATE 1 MG/ML NM; QL (00 per 0 alprazolam oral tablet 0.5 mg, 0.5 mg, 1 mg (Xanax) NM; QL (10 per 0 alprazolam oral tablet mg (Xanax) NM; QL (150 per 0 alprazolam oral tablet extended release (Xanax XR) NM; QL (0 per 0 hr 0.5 mg, 1 mg alprazolam oral tablet extended release (Xanax XR) NM; QL (150 per 0 hr mg alprazolam oral tablet extended release (Xanax XR) NM; QL (90 per 0 hr mg alprazolam oral tablet,disintegrating 0.5 mg, 0.5 mg, 1 mg (Alprazolam) NM; QL (10 per 0 alprazolam oral tablet,disintegrating mg (Alprazolam) NM; QL (150 per 0 clonazepam oral tablet 0.5 mg, 1 mg (Klonopin) NM; QL (90 per 0 clonazepam oral tablet mg (Klonopin) NM; QL (00 per 0 clonazepam oral tablet,disintegrating (Clonazepam) NM; QL (90 per mg, 0.5 mg, 0.5 mg, 1 mg clonazepam oral tablet,disintegrating mg (Clonazepam) NM; QL (00 per 0 clorazepate dipotassium oral tablet 15 mg (Tranxene T-Tab) NM; QL (180 per 0 clorazepate dipotassium oral tablet.75 mg, 7.5 mg (Tranxene T-Tab) NM; QL (10 per 0 diazepam intensol oral concentrate 5 mg/ml (Diazepam) NM; QL (0 per 0 diazepam oral solution 5 mg/5 ml (1 mg/ml) (Diazepam) NM; QL (100 per 0 diazepam oral tablet 10 mg, mg, 5 mg (Valium) NM; QL (10 per 0 diazepam rectal kit mg, (Diastat) NM.5 mg, mg estazolam oral tablet 1 mg, mg (Estazolam) NM; QL (0 per 0 11

21 lorazepam injection solution mg/ml (Ativan) NM; QL (10 per 0 lorazepam injection syringe mg/ml (Lorazepam) NM; QL (10 per 0 lorazepam injection syringe mg/ml (Lorazepam) NM; QL (90 per 0 lorazepam intensol oral concentrate mg/ml (Ativan) NM; QL (150 per 0 lorazepam oral tablet 0.5 mg, 1 mg, mg (Ativan) NM; QL (10 per 0 ONFI ORAL SUSPENSION.5 MG/ML PA NSO oxazepam oral capsule 10 mg, 15 mg, 0 mg (Oxazepam) NM; QL (10 per 0 temazepam oral capsule 15 mg,.5 mg, (Restoril) NM; QL (0 per 0 0 mg, 7.5 mg Antibacterials Aminoglycosides amikacin injection solution 500 mg/ ml (Amikacin Sulfate) NM amikacin sulf 1 gram/ ml vial outer, sdv (Amikacin Sulfate) NM 1,000 mg/ ml BETHKIS INHALATION SOLUTION 5 PA; NM FOR NEBULIZATION 00 MG/ ML gentamicin in nacl (iso-osm) intravenous piggyback 100 mg/100 ml, 60 mg/50 ml (Gentamicin In Nacl, Iso-Osm) gentamicin in nacl (iso-osm) intravenous piggyback 100 mg/50 ml, 70 mg/50 ml, 80 mg/100 ml, 80 mg/50 ml, 90 mg/100 ml (Gentamicin In Nacl, Iso-Osm) NM gentamicin injection solution 0 mg/ml (Gentamicin Sulfate) NM gentamicin ped 0 mg/ ml vial latex-free, (Gentamicin Sulfate/PF) NM sdv 0 mg/ ml gentamicin sulfate (pf) intravenous (Gentamicin Sulfate/PF) NM solution 80 mg/8 ml neomycin oral tablet 500 mg (Neomycin Sulfate) streptomycin intramuscular recon soln 1 (Streptomycin Sulfate) NM gram TOBI PODHALER INHALATION CAPSULE, W/INHALATION DEVICE 8 MG tobramycin in 0.5 % nacl inhalation solution for nebulization 00 mg/5 ml 5 PA; NM; QL ( per 8 (Tobi) 5 PA; NM 1

22 tobramycin in 0.9 % nacl intravenous (Tobramycin/Sodium NM piggyback 60 mg/50 ml, 80 mg/100 ml Chloride) tobramycin sulfate injection solution 10 (Tobramycin Sulfate) NM mg/ml tobramycin sulfate injection solution 0 (Tobramycin Sulfate) mg/ml Antibacterials, Miscellaneous baciim intramuscular recon soln 50,000 (Bacitracin) NM unit bacitracin intramuscular recon soln (Bacitracin) NM 50,000 unit chloramphenicol sod succinate (Chloramphenicol Sod NM intravenous recon soln 1 gram Succ) clindamycin 75 mg/5 ml soln 75 mg/5 ml (Cleocin Palmitate) clindamycin hcl oral capsule 150 mg, 00 (Cleocin HCl) mg, 75 mg clindamycin in 5 % dextrose intravenous (Cleocin Phosphate In NM piggyback 00 mg/50 ml, 600 mg/50 ml, 900 mg/50 ml D5w) clindamycin pediatric oral recon soln 75 (Cleocin Palmitate) mg/5 ml clindamycin phosphate injection solution (Cleocin Phosphate) 150 mg/ml clindamycin phosphate intravenous (Cleocin Phosphate) solution 600 mg/ ml colistin (colistimethate na) injection recon (Coly-Mycin M NM soln 150 mg Parenteral) CUBICIN INTRAVENOUS RECON 5 NM SOLN 500 MG daptomycin intravenous recon soln 500 (Cubicin) 5 NM mg LINCOCIN INJECTION SOLUTION 00 NM MG/ML lincomycin injection solution 00 mg/ml (Lincocin) linezolid intravenous parenteral solution 600 mg/00 ml (Zyvox) 5 PA; NM linezolid oral suspension for reconstitution (Zyvox) 5 PA; NM 100 mg/5 ml linezolid oral tablet 600 mg (Zyvox) PA 1

23 methenamine hippurate oral tablet 1 gram (Hiprex) metronidazole in nacl (iso-os) intravenous (Metronidazole/Sodium NM piggyback 500 mg/100 ml Chloride) metronidazole oral capsule 75 mg (Flagyl) metronidazole oral tablet 50 mg, 500 mg (Flagyl) moxifloxacin-sod.ace,sul-water (Moxifloxacin/Sod.Ace, intravenous piggyback 00 mg/50 ml Sul/Water) nitrofurantoin macrocrystal oral capsule (Macrodantin) NM 100 mg, 50 mg nitrofurantoin macrocrystal oral capsule (Macrodantin) 5 mg nitrofurantoin monohyd/m-cryst oral (Macrobid) NM capsule 100 mg nitrofurantoin monohyd/m-cryst oral (Macrobid) NM capsule 100 mg (75/5) polymyxin b sulfate injection recon soln (Polymyxin B Sulfate) NM 500,000 unit SIVEXTRO INTRAVENOUS RECON SOLN 00 MG 5 PA; NM; QL (6 per 0 SIVEXTRO ORAL TABLET 00 MG 5 PA; NM; QL (6 per 0 SYNERCID INTRAVENOUS RECON 5 PA; NM SOLN 500 MG trimethoprim oral tablet 100 mg (Trimethoprim) 1 GC vancomycin hcl 1g/00 ml bag 1 gram/00 ml (Vancomycin Hcl In Dextrose 5 %) NM vancomycin in 0.9% sodium cl intravenous (Vancomycin/0.9 % Sod solution 1.5 gram/500 ml Chloride) vancomycin intravenous recon soln 1,000 (Vancomycin HCl) NM mg, 10 gram, 750 mg vancomycin intravenous recon soln 500 (Vancomycin Hcl In NM mg Dextrose 5 %) vancomycin oral capsule 15 mg, 50 mg (Vancocin HCl) ZYVOX ORAL SUSPENSION FOR 5 PA; NM RECONSTITUTION 100 MG/5 ML Cephalosporins cefaclor oral capsule 50 mg, 500 mg (Cefaclor) cefaclor oral suspension for reconstitution 15 mg/5 ml, 50 mg/5 ml, 75 mg/5 ml (Cefaclor) 1

24 cefaclor oral tablet extended release 1 hr (Cefaclor) 500 mg cefadroxil oral capsule 500 mg (Cefadroxil) cefadroxil oral suspension for (Cefadroxil) reconstitution 50 mg/5 ml, 500 mg/5 ml cefadroxil oral tablet 1 gram (Cefadroxil) cefazolin in dextrose (iso-os) intravenous (Cefazolin piggyback 1 gram/50 ml Sodium/Dextrose, Iso) cefazolin injection recon soln 1 gram (Cefazolin Sodium) cefazolin injection recon soln 10 gram, (Cefazolin Sodium) NM 500 mg cefdinir oral capsule 00 mg (Cefdinir) cefdinir oral suspension for reconstitution (Cefdinir) 15 mg/5 ml, 50 mg/5 ml cefditoren pivoxil oral tablet 00 mg, 00 (Spectracef) mg cefepime injection recon soln 1 gram, (Maxipime) NM gram CEFOTAN INJECTION RECON SOLN GRAM cefotaxime injection recon soln 1 gram (Claforan) cefotaxime injection recon soln 10 gram, (Claforan) NM gram, 500 mg cefotetan injection recon soln 1 gram, (Cefotan) NM gram cefotetan intravenous recon soln 10 gram (Cefotan) NM cefoxitin in dextrose, iso-osm intravenous (Cefoxitin NM piggyback gram/50 ml Sodium/Dextrose, Iso) cefoxitin intravenous recon soln 1 gram, (Cefoxitin Sodium) NM gram cefoxitin intravenous recon soln 10 gram (Cefoxitin Sodium) cefpodoxime oral suspension for (Cefpodoxime Proxetil) reconstitution 100 mg/5 ml, 50 mg/5 ml cefpodoxime oral tablet 100 mg, 00 mg (Cefpodoxime Proxetil) cefprozil oral suspension for (Cefprozil) reconstitution 15 mg/5 ml, 50 mg/5 ml cefprozil oral tablet 50 mg, 500 mg (Cefprozil) CEFTAZIDIME 1 GM PIGGYBACK 1 GRAM/50 ML NM 15

25 ceftazidime 1 gm vial 5's 1 gram (Fortaz) ceftazidime in d5w intravenous piggyback 1 gram/50 ml (Fortaz) CEFTAZIDIME IN D5W NM INTRAVENOUS PIGGYBACK GRAM/50 ML ceftazidime injection recon soln gram, 6 (Fortaz) NM gram ceftibuten oral capsule 00 mg (Cedax) ceftibuten oral suspension for (Cedax) reconstitution 180 mg/5 ml ceftriaxone 1 gm piggyback 50ml (Ceftriaxone NM galaxycontainer 1 gram/50 ml Na/Dextrose, Iso) ceftriaxone 1 gm vial 10's, fliptop,l/f 1 (Ceftriaxone Sodium) NM gram ceftriaxone 500 mg vial suv,10's,latex-free (Ceftriaxone Sodium) 500 mg ceftriaxone injection recon soln 10 gram, 50 mg, 500 mg (Ceftriaxone Sodium) NM ceftriaxone intravenous recon soln 1 gram (Ceftriaxone Na/Dextrose, Iso) NM cefuroxime axetil oral tablet 50 mg, 500 (Ceftin) mg cefuroxime sodium injection recon soln (Zinacef) NM 1.5 gram, 750 mg cefuroxime sodium intravenous recon soln (Zinacef) NM 7.5 gram cephalexin oral capsule 50 mg, 500 mg, (Keflex) 750 mg cephalexin oral suspension for (Cephalexin) reconstitution 15 mg/5 ml, 50 mg/5 ml cephalexin oral tablet 50 mg, 500 mg (Cephalexin) SUPRAX ORAL CAPSULE 00 MG tazicef injection recon soln 1 gram, 6 (Fortaz) NM gram TEFLARO INTRAVENOUS RECON NM SOLN 00 MG, 600 MG ZERBAXA INTRAVENOUS RECON SOLN 1.5 GRAM 5 NM 16

26 Macrolides azithromycin intravenous recon soln 500 (Zithromax) mg azithromycin oral packet 1 gram (Zithromax) PA; (PA only w/ digoxin) azithromycin oral suspension for reconstitution 100 mg/5 ml, 00 mg/5 ml (Zithromax) PA; (PA only w/ digoxin) azithromycin oral tablet 50 mg, 50 mg (6 pack), 600 mg (Zithromax) PA; (PA only w/ digoxin) azithromycin oral tablet 500 mg (Zithromax) PA; (PA only w/ digoxin) clarithromycin oral suspension for reconstitution 15 mg/5 ml, 50 mg/5 ml (Biaxin) PA; (PA only w/ digoxin) clarithromycin oral tablet 50 mg, 500 mg (Biaxin) PA; (PA only w/ digoxin) clarithromycin oral tablet extended release hr 500 mg (Clarithromycin) PA; (PA only w/ digoxin) e.e.s. 00 oral tablet 00 mg (Erythromycin Ethylsuccinate) PA; (PA only w/ digoxin) ery-tab oral tablet,delayed release (dr/ec) 50 mg, 500 mg (Erythromycin Base) PA; (PA only w/ digoxin) ERY-TAB ORAL TABLET,DELAYED RELEASE (DR/EC) MG PA; (PA only w/ digoxin) erythrocin (as stearate) oral tablet 50 mg (Erythromycin Stearate) PA; (PA only w/ digoxin) ERYTHROCIN INTRAVENOUS RECON SOLN 500 MG NM erythromycin ethylsuccinate oral (Eryped 00) PA suspension for reconstitution 00 mg/5 ml erythromycin ethylsuccinate oral tablet 00 mg (Erythromycin Ethylsuccinate) PA; (PA only w/ digoxin) erythromycin oral capsule,delayed release(dr/ec) 50 mg (Erythromycin Base) PA; (PA only w/ digoxin) erythromycin oral tablet 50 mg, 500 mg (Erythromycin Base) PA; (PA only w/ digoxin) KETEK ORAL TABLET 00 MG, 00 MG PA 17

27 PCE ORAL TABLET, PARTICLES/CRYSTALS MG, 500 MG Miscellaneous B-Lactam Antibiotics PA; (PA only w/ digoxin) aztreonam injection recon soln 1 gram (Azactam) NM CAYSTON INHALATION SOLUTION FOR NEBULIZATION 75 MG/ML 5 PA; NM; QL (8 per 8 imipenem-cilastatin intravenous recon (Primaxin) NM soln 50 mg, 500 mg INVANZ INJECTION RECON SOLN 1 NM GRAM meropenem intravenous recon soln 500 (Merrem) NM mg meropenem iv 1 gm vial outer, latex-free 1 (Merrem) NM gram Penicillins amoxicillin oral capsule 50 mg, 500 mg (Amoxicillin) amoxicillin oral suspension for reconstitution 15 mg/5 ml, 00 mg/5 ml, 50 mg/5 ml, 00 mg/5 ml (Amoxicillin) amoxicillin oral tablet 500 mg, 875 mg (Amoxicillin) amoxicillin oral tablet, er multiphase (Moxatag) hr 775 mg amoxicillin oral tablet,chewable 15 mg, (Amoxicillin) 50 mg amoxicillin-pot clavulanate oral suspension for reconstitution mg/5 ml, mg/5 ml, mg/5 ml, mg/5 ml (Augmentin) amoxicillin-pot clavulanate oral tablet (Augmentin) mg, mg, mg amoxicillin-pot clavulanate oral tablet (Augmentin XR) extended release 1 hr 1, mg amoxicillin-pot clavulanate oral (Amoxicillin/Potassium tablet,chewable mg, mg Clav) ampicillin gm vial 10's, latex-free (Ampicillin Sodium) NM gram ampicillin oral capsule 50 mg, 500 mg (Ampicillin Trihydrate) 18

28 ampicillin oral suspension for (Ampicillin Trihydrate) reconstitution 15 mg/5 ml, 50 mg/5 ml ampicillin sodium injection recon soln 1 (Ampicillin Sodium) NM gram, 10 gram, 15 mg ampicillin sodium intravenous recon soln (Ampicillin Sodium) NM gram ampicillin-sulbactam injection recon soln (Unasyn) 1.5 gram, gram ampicillin-sulbactam injection recon soln (Unasyn) NM 15 gram BICILLIN L-A INTRAMUSCULAR NM SYRINGE 1,00,000 UNIT/ ML,,00,000 UNIT/ ML, 600,000 UNIT/ML dicloxacillin oral capsule 50 mg, 500 mg (Dicloxacillin Sodium) nafcillin gm vial sterile, latex-free (Nafcillin Sodium) NM gram nafcillin injection recon soln 1 gram, 10 (Nafcillin Sodium) NM gram nafcillin intravenous recon soln gram (Nafcillin Sodium) NM oxacillin 1 gm add-vantage vl addvantage, (Oxacillin Sodium) NM inner 1 gram oxacillin in dextrose(iso-osm) intravenous (Oxacillin NM piggyback 1 gram/50 ml, gram/50 ml Sodium/Dextrose, Iso) oxacillin injection recon soln 10 gram (Oxacillin Sodium) NM oxacillin intravenous recon soln gram (Oxacillin Sodium) NM penicillin g pot in dextrose intravenous (Pen G Pot/Dextrose- NM piggyback 1 million unit/50 ml, million unit/50 ml, million unit/50 ml Water) penicillin g potassium injection recon soln (Penicillin G Potassium) NM 5 million unit penicillin g procaine intramuscular syringe 1. million unit/ ml, 600,000 unit/ml (Penicillin G Procaine) NM penicillin gk 0 million unit 0 million unit (Penicillin G Potassium) NM penicillin v potassium oral recon soln 15 (Penicillin V Potassium) mg/5 ml, 50 mg/5 ml penicillin v potassium oral tablet 50 mg, 500 mg (Penicillin V Potassium) 19

29 pfizerpen-g injection recon soln 0 million (Penicillin G Potassium) NM unit piperacillin-tazobactam intravenous recon (Zosyn) soln.5 gram piperacillin-tazobactam intravenous recon (Zosyn) NM soln.75 gram,.5 gram piperacil-tazobact.75 gm vl suv, p/f, (Zosyn) latex-free.75 gram piperacil-tazobact.5 gm vial 10's, p/f, (Zosyn) sdv.5 gram piperacil-tazobact 0.5 gram p/f, latexfree (Zosyn) NM 0.5 gram TIMENTIN INTRAVENOUS PIGGYBACK.1 GRAM/100 ML TIMENTIN INTRAVENOUS RECON SOLN.1 GRAM TIMENTIN INTRAVENOUS RECON NM SOLN 1 GRAM Quinolones ciprofloxacin (mixture) oral tablet, er (Cipro XR) NM; QL (0 per 0 multiphase hr 1,000 mg, 500 mg ciprofloxacin hcl oral tablet 100 mg, 50 (Cipro) mg, 500 mg, 750 mg ciprofloxacin in 5 % dextrose intravenous (Cipro I.V.) NM piggyback 00 mg/100 ml ciprofloxacin oral (Cipro) suspension,microcapsule recon 50 mg/5 ml, 500 mg/5 ml ciprofloxacn-d5w 00 mg/00 ml (Cipro I.V.) NM p/f,latex/f, in d5w 00 mg/00 ml levofloxacin in d5w intravenous piggyback (Levaquin) 500 mg/100 ml levofloxacin in d5w intravenous piggyback (Levaquin) NM 750 mg/150 ml levofloxacin intravenous solution 5 (Levofloxacin) mg/ml levofloxacin oral solution 50 mg/10 ml (Levaquin) levofloxacin oral tablet 50 mg, 500 mg, 750 mg (Levaquin) 0

30 moxifloxacin oral tablet 00 mg (Avelox) ofloxacin oral tablet 00 mg (Ofloxacin) Sulfonamides sulfadiazine oral tablet 500 mg (Sulfadiazine) sulfamethoxazole-trimethoprim (Sulfamethoxazole/Trim NM intravenous solution mg/5 ml ethoprim) sulfamethoxazole-trimethoprim oral (Sulfamethoxazole/Trim suspension 00-0 mg/5 ml ethoprim) sulfamethoxazole-trimethoprim oral tablet (Bactrim) 1 GC mg, mg sulfasalazine oral tablet 500 mg (Azulfidine) sulfasalazine oral tablet,delayed release (Azulfidine) (dr/ec) 500 mg sulfatrim oral suspension 00-0 mg/5 ml Tetracyclines demeclocycline oral tablet 150 mg, 00 mg (Sulfamethoxazole/Trim ethoprim) (Demeclocycline HCl) doxy-100 intravenous recon soln 100 mg (Doxycycline Hyclate) NM doxycycline hyclate 100 mg cap 100 mg (Morgidox) doxycycline hyclate 100 mg tab 100 mg (Doryx) doxycycline hyclate intravenous recon (Doxycycline Hyclate) soln 100 mg doxycycline hyclate oral capsule 100 mg (Adoxa) doxycycline hyclate oral capsule 50 mg (Morgidox) doxycycline hyclate oral tablet 100 mg, 50 (Avidoxy) mg doxycycline hyclate oral tablet 0 mg (Doryx) doxycycline hyclate oral tablet,delayed release (dr/ec) 100 mg, 150 mg, 00 mg, 50 mg, 75 mg (Doryx) doxycycline mono 100 mg cap 100 mg (Adoxa) doxycycline mono 100 mg tablet f/c 100 (Avidoxy) mg doxycycline mono 50 mg tablet 50 mg (Avidoxy) doxycycline monohydrate oral capsule 150 (Adoxa) mg, 50 mg, 75 mg doxycycline monohydrate oral suspension for reconstitution 5 mg/5 ml (Vibramycin) 1

31 doxycycline monohydrate oral tablet 150 (Avidoxy) mg, 75 mg minocycline oral capsule 100 mg, 50 mg, (Minocin) 75 mg minocycline oral tablet 100 mg, 50 mg, 75 (Minocycline HCl) mg minocycline oral tablet extended release (Minocycline HCl) NM; QL (0 per 0 hr 15 mg, 5 mg, 90 mg tetracycline oral capsule 50 mg, 500 mg (Tetracycline HCl) TYGACIL INTRAVENOUS RECON NM SOLN 50 MG Anticancer Agents Anticancer Agents ABRAXANE INTRAVENOUS 5 PA NSO; NM SUSPENSION FOR RECONSTITUTION 100 MG ADCETRIS INTRAVENOUS RECON 5 PA NSO; NM SOLN 50 MG adrucil,500 mg/50 ml vial outer, latexfree (Fluorouracil) PA BvD; NM.5 gram/50 ml adrucil 500 mg/10 ml vial sdv,latexfree,inner 500 mg/10 ml (Fluorouracil) PA BvD adrucil intravenous solution 500 mg/10 ml (Fluorouracil) PA BvD; NM AFINITOR DISPERZ ORAL TABLET 5 PA NSO; NM FOR SUSPENSION MG, MG, 5 MG AFINITOR ORAL TABLET 10 MG,.5 5 PA NSO; NM MG, 5 MG, 7.5 MG ALECENSA ORAL CAPSULE 150 MG 5 PA NSO; NM; QL (0 per 0 ALIMTA INTRAVENOUS RECON SOLN 500 MG 5 NM anastrozole oral tablet 1 mg (Arimidex) NM ARRANON INTRAVENOUS 5 PA NSO; NM SOLUTION 50 MG/50 ML ARZERRA INTRAVENOUS 5 PA NSO; NM SOLUTION 1,000 MG/50 ML, 100 MG/5 ML AVASTIN INTRAVENOUS SOLUTION 5 MG/ML, 5 MG/ML (16 ML) 5 NM

32 azacitidine injection recon soln 100 mg (Vidaza) 5 NM BELEODAQ INTRAVENOUS RECON 5 PA NSO; NM SOLN 500 MG BENDEKA INTRAVENOUS 5 NM SOLUTION 5 MG/ML bexarotene oral capsule 75 mg (Targretin) 5 NM bicalutamide oral tablet 50 mg (Casodex) NM BICNU INTRAVENOUS RECON SOLN NM 100 MG bleomycin injection recon soln 0 unit (Bleomycin Sulfate) PA BvD; NM bleomycin sulfate 15 unit vial latex-free 15 (Bleomycin Sulfate) PA BvD; NM unit BLINCYTO INTRAVENOUS KIT 5 5 PA NSO; NM MCG BOSULIF ORAL TABLET 100 MG 5 PA NSO; NM BOSULIF ORAL TABLET 500 MG 5 PA NSO; NM; QL (0 per 0 BUSULFEX INTRAVENOUS SOLUTION 60 MG/10 ML CABOMETYX ORAL TABLET 0 MG, 60 MG 5 PA NSO; NM; QL (0 per 0 CABOMETYX ORAL TABLET 0 MG 5 PA NSO; NM; QL (60 per 0 CAPRELSA ORAL TABLET 100 MG, 00 MG 5 PA NSO; NM; LA carboplatin intravenous solution 10 mg/ml (Carboplatin) NM CERUBIDINE INTRAVENOUS RECON SOLN 0 MG cisplatin intravenous solution 1 mg/ml (Cisplatin) NM cladribine intravenous solution 10 mg/10 (Cladribine) PA BvD; NM ml CLOLAR INTRAVENOUS SOLUTION 5 PA NSO; NM 0 MG/0 ML COMETRIQ ORAL CAPSULE PA NSO; NM MG/DAY(80 MG X1-0 MG X1), 10 MG/DAY(80 MG X1-0 MG X), 60 MG/DAY (0 MG X /DAY) COSMEGEN INTRAVENOUS RECON SOLN 0.5 MG NM

33 COTELLIC ORAL TABLET 0 MG 5 PA NSO; NM; LA; QL (90 per 0 cyclophosphamide intravenous recon soln (Cyclophosphamide) 1 gram, 500 mg cyclophosphamide intravenous recon soln (Cyclophosphamide) NM gram CYCLOPHOSPHAMIDE ORAL PA BvD; NM CAPSULE 5 MG, 50 MG CYRAMZA INTRAVENOUS 5 PA NSO; NM SOLUTION 10 MG/ML, 10 MG/ML (50 ML) cytarabine (pf) injection solution (Cytarabine/PF) PA BvD; NM gram/0 ml (100 mg/ml) cytarabine injection solution 0 mg/ml (Cytarabine) PA BvD; NM dacarbazine intravenous recon soln 00 (Dacarbazine) NM mg DARZALEX 00 MG/0 ML VIAL 0 5 PA NSO; NM MG/ML DARZALEX INTRAVENOUS 5 PA NSO; NM; LA SOLUTION 0 MG/ML daunorubicin intravenous solution 5 (Cerubidine) NM mg/ml DAUNOXOME INTRAVENOUS NM SOLUTION MG/ML decitabine intravenous recon soln 50 mg (Dacogen) 5 PA NSO; NM DEPOCYT (PF) INTRATHECAL PA BvD; NM SUSPENSION 50 MG/5 ML (10 MG/ML) DOCEFREZ INTRAVENOUS RECON 5 NM SOLN 0 MG, 80 MG docetaxel 160 mg/16 ml vial mdv 160 (Taxotere) 5 NM mg/16 ml (10 mg/ml) docetaxel intravenous solution 0 mg/ ml (Taxotere) 5 NM (final), 80 mg/ ml (0 mg/ml), 80 mg/8 ml (10 mg/ml) doxorubicin 00 mg/100 ml vial mdv, p/f (Doxorubicin HCl) PA BvD; NM mg/ml doxorubicin hcl liposome 50 mg/5 ml vial mg/ml (Doxil) PA BvD; NM