2019 FORMULARY PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN

Transcription

1 ALOHACARE ADVANTAGE PLUS (HMO SNP) 209 FORMULARY list of covered drugs FORMULARY ID , VERSION 4 PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN This formulary was updated on September, 208. For more recent information or other questions, please contact AlohaCare Advantage Plus (HMO SNP) Member Services Department at or toll free at October to March 3, 8 a.m. to 8 p.m., 7 days a week. April to September 30, 8 a.m. to 8 p.m., Monday through Friday. TTY/TDD users call , or visit AlohaCare Advantage Plus (HMO SNP) is an HMO SNP with a Medicare contract and a contract with the Hawaii Medicaid program. Enrollment in AlohaCare Advantage Plus depends on contract renewal. The formulary may change at any time. You will receive notice when necessary. H5969_CF08590_C

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 AlohaCare. When it refers to plan or our plan, it means AlohaCare Advantage Plus. This document includes a list of the drugs (formulary) for our plan which is current as of September, 208. 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, 2020, and from time to time during the year. What is the AlohaCare Advantage Plus Formulary? A formulary is a list of covered drugs selected by AlohaCare Advantage Plus 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. AlohaCare Advantage Plus will generally cover the drugs listed in our formulary as long as the drug is medically necessary, the prescription is filled at an AlohaCare Advantage Plus 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 209 formulary that was covered at the beginning of the year, we will not discontinue or reduce coverage of the drug during the 209 coverage year except when a new, less expensive generic drug becomes available, when new information about the safety or effectiveness of a drug is released, or the drug is removed from the market. (See bullets below for more information on changes that affect members currently taking the drug.) 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. Below are changes to the drug list that will also affect members currently taking a drug: New generic drugs. We may immediately remove a brand name drug on our List if we are replacing it with a new generic drug that will appear on the same or lower cost sharing tier and with the same or fewer restrictions. Also, when adding the new generic drug, we may decide to keep the brand name drug on our List, but immediately move it to a different cost-sharing tier or add new restrictions. If you are currently taking that brand name drug, we may not tell you in advance before we make that change, but we will later provide you with information about the specific change(s) we have made. o If we make such a change, you or your prescriber can ask us to make an exception and continue to cover the brand name drug for you. The notice we provide you will also page i

3 include information on the steps you may take to request an exception, and you can also find information in the section below entitled How do I request an exception to the AlohaCare Advantage Plus Formulary? s removed from the market. If the Food and 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. Other changes. We may make other changes that affect members currently taking a drug. For instance, we may add a generic drug that is not new to market to replace a brand name drug currently on the formulary or add new restrictions to the brand name drug or move it to a different cost-sharing tier. Or we may make changes based on new clinical guidelines. If we remove drugs from our formulary, or add prior authorization, quantity limits and/or step therapy restrictions on a drug we must notify affected members of the change at least 30 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 30-day supply of the drug. The enclosed formulary is current as of September, 208. To get updated information about the drugs covered by AlohaCare Advantage Plus, please contact us. Our contact information appears on the front and back cover pages. How do I use the Formulary? There are two ways to find your drug within the formulary: Medical Condition The formulary begins on page. 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, Hypertension/ Lipids. If you know what your drug is used for, look for the category name in the list that begins on page. 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 80. 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? AlohaCare Advantage Plus 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: page ii

4 Prior Authorization:AlohaCare Advantage Plus requires you or your physician to get prior authorization for certain drugs. This means that you will need to get approval from AlohaCare Advantage Plus before you fill your prescriptions. If you don t get approval, AlohaCare Advantage Plus may not cover the drug. Quantity Limits: For certain drugs, AlohaCare Advantage Plus limits the amount of the drug that AlohaCare Advantage Plus will cover. For example, AlohaCare Advantage Plus provides 30 capsules per prescription for Januvia. This may be in addition to a standard one-month or three-month supply. Step Therapy: In some cases, AlohaCare Advantage Plus requires you to first try certain drugs to treat your medical condition before we will cover another drug for that condition. For example, if A and B both treat your medical condition, AlohaCare Advantage Plus may not cover B unless you try A first. If A does not work for you, AlohaCare Advantage Plus will then cover B. You can find out if your drug has any additional requirements or limits by looking in the formulary that begins on page 80. 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 AlohaCare Advantage Plus 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 AlohaCare Advantage Plus formulary? on page 3 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 AlohaCare Advantage Plus does not cover your drug, you have two options: You can ask Member Services for a list of similar drugs that are covered by AlohaCare Advantage Plus. When you receive the list, show it to your doctor and ask him or her to prescribe a similar drug that is covered by AlohaCare Advantage Plus. You can ask AlohaCare Advantage Plus 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 AlohaCare Advantage Plus Formulary? You can ask AlohaCare Advantage Plus 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 page iii

5 able to ask us to provide the drug at a lower cost-sharing level. You can ask us to waive coverage restrictions or limits on your drug. For example, for certain drugs, AlohaCare Advantage Plus 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, AlohaCare Advantage Plus will only approve your request for an exception if the alternative drugs included on the plan s formulary, or additional utilization restrictions would not be as effective in treating your condition and/or would cause you to have adverse medical effects. You should contact us to ask us for an initial coverage decision for a formulary, or utilization restriction exception. When you request a formulary or utilization restriction exception you should submit a statement from your prescriber or physician supporting your request. Generally, we must make our decision within 72 hours of getting your prescriber s supporting statement. You can request an expedited (fast) exception if you or your doctor believe that your health could be seriously harmed by waiting up to 72 hours for a decision. If your request to expedite is granted, we must give you a decision no later than 24 hours after we get a supporting statement from your doctor or other prescriber. What do I do before I can talk to my doctor about changing my drugs or requesting an exception? As a new or continuing member in our plan you may be taking drugs that are not on our formulary. Or, you may be taking a drug that is on our formulary but your ability to get it is limited. For example, you may need a prior authorization from us before you can fill your prescription. You should talk to your doctor to decide if you should switch to an appropriate drug that we cover or request a formulary exception so that we will cover the drug you take. While you talk to your doctor to determine the right course of action for you, we may cover your drug in certain cases during the first 90 days you are a member of our plan. 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 30-day supply. If your prescription is written for fewer days, we ll allow refills to provide up to a maximum 30- day supply of medication. After your first 30day 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 and 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 3-day emergency supply of that drug while you pursue a formulary exception. Transition policy for level of care changes Upon notification, AlohaCare Advantage Plus will cover up to a 3-day supply of a prescription drug (unless you have a prescription written for fewer for current members who have a level of care change. A level of care change includes the following situations: If you enter a long-term care facility from a hospital or other setting; page iv

6 If you leave a long-term care facility to return to a community/home setting; If you are discharged from a hospital to a community/home setting; If you end your skilled nursing facility stay covered under Medicare Part A and need to revert to coverage under AlohaCare Advantage Plus; If your hospice status reverts to standard Medicare Part A and B benefits; or If you are discharged from a psychiatric hospital with a drug regimen that is highly individualized. For more information For more detailed information about your AlohaCare Advantage Plus prescription drug coverage, please review your Evidence of Coverage and other plan materials. If you have questions about AlohaCare Advantage Plus, 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 -800-MEDICARE ( ) 24 hours a day/7 days a week. TTY users should call Or, visit AlohaCare Advantage Plus Formulary The formulary that begins on page provides coverage information about the drugs covered by AlohaCare Advantage Plus. If you have trouble finding your drug in the list, turn to the Index that begins on page 80. The first column of the chart lists the drug name. Brand name drugs are capitalized (e.g., ACTOS) and generic drugs are listed in lower-case italics (e.g., pioglitazone). The information in the column tells you if AlohaCare Advantage Plus has any special requirements for coverage of your drug. BvsD = Part B versus Part D: This drug may be covered under Medicare Part B or Part D, depending on the circumstances. MO = Mail Order service available: This service helps you save money on your prescription drug costs and your drugs will be conveniently mailed to your home. PA = Prior Authorization QL = Quantity Limit ST = Step Therapy LA = Limited Access: This prescription may be available only at certain pharmacies. page v

7 Below is a list of abbreviations that may appear on the following pages in the column that tells you if there are any special requirements for coverage of your drug. List of Abbreviations B/D PA: This prescription drug may be covered under Medicare Part B or D depending upon the circumstances. Information may need to be submitted describing the use and setting of the drug to make the determination. LA: Limited Availability. This prescription may be available only at certain pharmacies. For more information, please call Customer Service. MO: Mail-Order. This prescription drug is available through our mail-order service, as well as through our retail network pharmacies. Consider using mail order for your long-term (maintenance) medications (such as high blood pressure medications). Retail network pharmacies may be more appropriate for short-term prescriptions (such as antibiotics). PA: Prior Authorization. The Plan requires you or your physician to get prior authorization for certain drugs. This means that you will need to get approval before you fill your prescriptions. If you don t get approval, we may not cover the drug. QL: Quantity Limit. For certain drugs, the Plan limits the amount of the drug that we will cover. ST: Step Therapy. In some cases, the Plan requires you to first try certain drugs to treat your medical condition before we will cover another drug for that condition. For example, if A and B both treat your medical condition, we may not cover B unless you try A first. If A does not work for you, we will then cover B.

8 Name ANTI - INFECTIVES ANTIFUNGAL AGENTS ABELCET B/D PA; MO AMBISOME B/D PA; MO amphotericin b B/D PA; MO caspofungin B/D PA clotrimazole mucous membrane CRESEMBA INTRAVENOUS CRESEMBA ORAL fluconazole fluconazole in dextrose(iso-o) fluconazole in nacl (iso-osm) piggyback 200 mg/00 ml fluconazole in nacl (iso-osm) piggyback 400 mg/200 ml flucytosine griseofulvin microsize griseofulvin ultramicrosize itraconazole ketoconazole oral MYCAMINE NOXAFIL ORAL nystatin oral suspension Name nystatin oral tablet SPORANOX ORAL SOLUTION terbinafine hcl oral voriconazole voriconazole oral ANTIVIRALS abacavir abacavir-lamivudine abacavirlamivudinezidovudine acyclovir oral capsule acyclovir oral suspension 200 mg/5 ml acyclovir oral tablet acyclovir sodium recon soln 500 mg acyclovir sodium solution B/D PA B/D PA; MO adefovir amantadine hcl APTIVUS ORAL CAPSULE APTIVUS ORAL SOLUTION atazanavir oral capsule 50 mg, 200 mg atazanavir oral capsule 300 mg ATRIPLA 2

9 Name BARACLUDE ORAL SOLUTION BIKTARVY cidofovir B/D PA; MO CIMDUO COMPLERA CRIXIVAN ORAL CAPSULE 200 MG, 400 MG DESCOVY didanosine oral capsule,delayed release(dr/ec) 200 mg, 250 mg, 400 mg EDURANT efavirenz oral capsule 200 mg efavirenz oral capsule 50 mg efavirenz oral tablet EMTRIVA entecavir EPCLUSA PA; MO; QL (28 per 28 EPIVIR HBV ORAL SOLUTION EVOTAZ famciclovir fosamprenavir FUZEON SUBCUTANEOUS RECON SOLN ganciclovir sodium B/D PA; MO GENVOYA Name HARVONI PA; MO; QL (28 per 28 INTELENCE ORAL TABLET 00 MG, 200 MG INTELENCE ORAL TABLET 25 MG INVIRASE ISENTRESS HD ISENTRESS ORAL POWDER IN PACKET ISENTRESS ORAL TABLET ISENTRESS ORAL TABLET,CHEWAB LE 00 MG ISENTRESS ORAL TABLET,CHEWAB LE 25 MG JULUCA KALETRA ORAL TABLET MG KALETRA ORAL TABLET MG lamivudine lamivudinezidovudine LEXIVA ORAL SUSPENSION lopinavir-ritonavir moderiba 3

10 Name moderiba oral tablets,dose pack 200 mg (28)- 400 mg (28), mg (28)-mg (28) moderiba dose pack oral tablets,dose pack 400 mg (7)- 400 mg (7) moderiba dose pack oral tablets,dose pack 600 mg (7)- 600 mg (7) moderiba dose pack oral tablets,dose pack mg (28)-mg (28), mg (28)-mg (28) nevirapine oral tablet nevirapine oral tablet extended release 24 hr NORVIR ORAL CAPSULE NORVIR ORAL POWDER IN PACKET NORVIR ORAL SOLUTION ODEFSEY oseltamivir PREVYMIS INTRAVENOUS PREVYMIS ORAL ; QL (30 PREZCOBIX PREZISTA ORAL SUSPENSION Name PREZISTA ORAL TABLET 50 MG, 75 MG PREZISTA ORAL TABLET 600 MG, 800 MG REBETOL ORAL SOLUTION RELENZA DISKHALER RESCRIPTOR RETROVIR INTRAVENOUS REYATAZ ORAL POWDER IN PACKET ribasphere oral capsule ribasphere oral tablet 200 mg, 400 mg ribasphere oral tablet 600 mg ribasphere ribapak oral tablets,dose pack 200 mg (28)- 400 mg (28) ribasphere ribapak oral tablets,dose pack 200 mg (7)- 400 mg (7) ribasphere ribapak oral tablets,dose pack 400 mg (7)- 400 mg (7), 600 mg (7)- 400 mg (7), 600 mg (7)- 600 mg (7) 4

11 Name ribasphere ribapak oral tablets,dose pack mg (28)-mg (28), mg (28)-mg (28), mg (28)-mg (28) ribavirin oral capsule ribavirin oral tablet 200 mg rimantadine ritonavir SELZENTRY stavudine oral capsule STRIBILD SYMFI SYMFI LO SYMTUZA SYNAGIS ; LA tenofovir disoproxil fumarate TIVICAY ORAL TABLET 0 MG TIVICAY ORAL TABLET 25 MG, 50 MG TRIUMEQ TROGARZO ; LA TRUVADA valacyclovir oral tablet gram valacyclovir oral tablet 500 mg ; QL (20 ; QL (60 valganciclovir Name VEMLIDY VIDEX 2 GRAM PEDIATRIC VIDEX 4 GRAM PEDIATRIC VIDEX EC ORAL CAPSULE,DELAY ED RELEASE(DR/EC) 25 MG VIRACEPT ORAL TABLET VIRAMUNE ORAL SUSPENSION VIREAD ORAL POWDER VIREAD ORAL TABLET 50 MG, 200 MG, 250 MG ZERIT ORAL RECON SOLN zidovudine CEPHALOSPORINS cefaclor oral capsule cefaclor oral suspension for reconstitution 25 mg/5 ml, 250 mg/5 ml cefaclor oral suspension for reconstitution 375 mg/5 ml cefaclor oral tablet extended release 2 hr cefadroxil oral capsule 5

12 Name cefadroxil oral suspension for reconstitution 250 mg/5 ml, 500 mg/5 ml cefadroxil oral tablet cefazolin in dextrose (iso-os) piggyback gram/50 ml, 2 gram/50 ml cefazolin injection recon soln gram, 500 mg cefazolin injection recon soln 0 gram, 00 gram, 20 gram, 300 g cefazolin cefdinir cefepime cefepime in dextrose,iso-osm piggyback gram/50 ml cefepime in dextrose,iso-osm piggyback 2 gram/00 ml cefixime cefotaxime injection recon soln gram, 2 gram, 500 mg cefotaxime injection recon soln 0 gram cefotetan Name cefoxitin in dextrose, iso-osm cefoxitin recon soln gram, 2 gram cefoxitin recon soln 0 gram cefpodoxime cefprozil ceftazidime injection recon soln gram, 2 gram ceftazidime injection recon soln 6 gram ceftriaxone in dextrose,iso-os ceftriaxone injection recon soln gram, 2 gram, 250 mg, 500 mg ceftriaxone injection recon soln 0 gram ceftriaxone cefuroxime axetil oral tablet cefuroxime sodium injection recon soln 750 mg cefuroxime sodium recon soln.5 gram cefuroxime sodium recon soln 7.5 gram cephalexin SUPRAX ORAL CAPSULE 6

13 Name SUPRAX ORAL SUSPENSION FOR RECONSTITUTIO N 500 MG/5 ML SUPRAX ORAL TABLET,CHEWAB LE TEFLARO ERYTHROMYCINS / OTHER MACROLIDES azithromycin clarithromycin e.e.s. 400 oral tablet ery-tab oral tablet,delayed release (dr/ec) 250 mg, 333 mg ERY-TAB ORAL TABLET,DELAYE D RELEASE (DR/EC) 500 MG erythrocin (as stearate) oral tablet 250 mg ERYTHROCIN INTRAVENOUS RECON SOLN 500 MG erythromycin ethylsuccinate oral suspension for reconstitution erythromycin ethylsuccinate oral tablet erythromycin oral capsule,delayed release(dr/ec) Name erythromycin oral tablet MISCELLANEOUS ANTIINFECTIVES ALBENZA ALINIA ORAL SUSPENSION FOR RECONSTITUTIO N ALINIA ORAL TABLET amikacin injection solution,000 mg/4 ml, 500 mg/2 ml atovaquone atovaquoneproguanil aztreonam baciim bacitracin intramuscular BENZNIDAZOLE BETHKIS B/D PA; MO; QL (224 per 28 CAPASTAT CAYSTON ; LA; QL (84 per 28 chloramphenicol sod succinate chloroquine phosphate clindamycin hcl clindamycin in 5 % dextrose 7

14 Name clindamycin palmitate hcl clindamycin pediatric clindamycin phosphate injection clindamycin phosphate COARTEM colistin (colistimethate na) dapsone oral daptomycin recon soln 500 mg DARAPRIM PA; MO EMVERM ertapenem ethambutol gentamicin in nacl (iso-osm) piggyback 00 mg/00 ml, 60 mg/50 ml, 80 mg/50 ml gentamicin in nacl (iso-osm) piggyback 80 mg/00 ml gentamicin injection gentamicin sulfate (ped) (pf) hydroxychloroquine imipenem-cilastatin IMPAVIDO Name INVANZ INJECTION INVANZ INTRAVENOUS isoniazid injection isoniazid oral ivermectin lincomycin linezolid linezolid in dextrose 5% linezolid-0.9% sodium chloride mefloquine meropenem metro i.v. metronidazole in nacl (iso-os) metronidazole oral NEBUPENT B/D PA; MO; QL ( per 28 neomycin paromomycin PASER PENTAM polymyxin b sulfate praziquantel PRIFTIN PRIMAQUINE pyrazinamide quinine sulfate rifabutin 8

15 Name rifampin SIRTURO ; LA STREPTOMYCIN SYNERCID tigecycline tinidazole TOBI PODHALER INHALATION CAPSULE TOBI PODHALER INHALATION CAPSULE, W/INHALATION DEVICE tobramycin in % nacl tobramycin sulfate injection recon soln tobramycin sulfate injection solution QL (224 per 28 ; QL (224 per 28 B/D PA; MO; QL (280 per 28 TRECATOR VANCOMYCIN IN 0.9 % SODIUM CHL INTRAVENOUS PIGGYBACK VANCOMYCIN INJECTION vancomycin vancomycin oral capsule 25 mg vancomycin oral capsule 250 mg Name VIBATIV INTRAVENOUS RECON SOLN 750 MG XIFAXAN ORAL TABLET 200 MG XIFAXAN ORAL TABLET 550 MG PENICILLINS amoxicillin oral capsule amoxicillin oral suspension for reconstitution amoxicillin oral tablet amoxicillin oral tablet,chewable 25 mg, 250 mg amoxicillin-pot clavulanate ampicillin oral capsule 500 mg ampicillin sodium injection ampicillin sodium ampicillin-sulbactam injection recon soln.5 gram, 3 gram ampicillin-sulbactam injection recon soln 5 gram ampicillin-sulbactam recon soln.5 gram ; QL (9 per 30 ; QL (60 9

16 Name ampicillin-sulbactam recon soln 3 gram AUGMENTIN ORAL SUSPENSION FOR RECONSTITUTIO N MG/5 ML BICILLIN C-R BICILLIN L-A dicloxacillin nafcillin in dextrose iso-osm piggyback gram/50 ml nafcillin in dextrose iso-osm piggyback 2 gram/00 ml nafcillin injection recon soln gram, 2 gram nafcillin injection recon soln 0 gram nafcillin oxacillin in dextrose(iso-osm) piggyback gram/50 ml oxacillin in dextrose(iso-osm) piggyback 2 gram/50 ml oxacillin injection recon soln gram Name oxacillin injection recon soln 0 gram oxacillin injection recon soln 2 gram PENICILLIN G POT IN DEXTROSE INTRAVENOUS PIGGYBACK MILLION UNIT/50 ML, 2 MILLION UNIT/50 ML PENICILLIN G POT IN DEXTROSE INTRAVENOUS PIGGYBACK 3 MILLION UNIT/50 ML penicillin g potassium penicillin g procaine intramuscular syringe.2 million unit/2 ml penicillin g procaine intramuscular syringe 600,000 unit/ml penicillin g sodium penicillin v potassium pfizerpen-g piperacillintazobactam recon soln 2.25 gram, gram, 4.5 gram, 40.5 gram QUINOLONES 0

17 Name ciprofloxacin ciprofloxacin (mixture) ciprofloxacin hcl oral ciprofloxacin in 5 % dextrose levofloxacin in d5w piggyback 250 mg/50 ml levofloxacin in d5w piggyback 500 mg/00 ml, 750 mg/50 ml levofloxacin levofloxacin oral moxifloxacin in nacl (iso-osm) moxifloxacin oral ofloxacin oral tablet 300 mg ofloxacin oral tablet 400 mg SULFA'S / RELATED AGENTS sulfadiazine sulfamethoxazoletrimethoprim sulfatrim TETRACYCLINES demeclocycline doxy-00 doxycycline hyclate Name doxycycline hyclate oral capsule doxycycline hyclate oral tablet 00 mg, 50 mg, 20 mg, 75 mg doxycycline hyclate oral tablet 50 mg doxycycline monohydrate oral capsule doxycycline monohydrate oral suspension for reconstitution doxycycline monohydrate oral tablet minocycline oral capsule minocycline oral tablet mondoxyne nl morgidox okebo oral capsule 75 mg tetracycline VIBRAMYCIN ORAL SYRUP URINARY TRACT AGENTS methenamine hippurate methenamine mandelate nitrofurantoin nitrofurantoin macrocrystal

18 Name nitrofurantoin monohyd/m-cryst trimethoprim ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS ADJUNCTIVE AGENTS dexrazoxane hcl recon soln 250 mg dexrazoxane hcl recon soln 500 mg B/D PA B/D PA; MO ELITEK KEPIVANCE leucovorin calcium injection recon soln 00 mg, 200 mg, 350 mg, 50 mg leucovorin calcium injection recon soln 500 mg leucovorin calcium oral LEVOLEUCOVORI N INTRAVENOUS RECON SOLN 75 MG levoleucovorin recon soln 50 mg levoleucovorin solution B/D PA; MO B/D PA B/D PA B/D PA B/D PA mesna B/D PA; MO MESNEX ORAL VISTOGARD XGEVA B/D PA; MO Name 2 ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS ABRAXANE B/D PA; MO adriamycin solution adrucil solution 2.5 gram/50 ml adrucil solution 5 gram/00 ml, 500 mg/0 ml B/D PA B/D PA B/D PA; MO AFINITOR PA; MO; QL (30 per 30 AFINITOR DISPERZ PA; MO ALECENSA PA; MO; QL (240 per 30 ALIMTA B/D PA; MO ALIQOPA B/D PA; MO; LA ALUNBRIG ORAL TABLET 80 MG, 90 MG ALUNBRIG ORAL TABLET 30 MG ALUNBRIG ORAL TABLETS,DOSE PACK PA; MO; QL (30 per 30 PA; MO; QL (60 per 30 PA; MO; QL (30 per 30 anastrozole ARRANON B/D PA ARZERRA B/D PA; MO AVASTIN B/D PA; MO azacitidine B/D PA; MO azathioprine B/D PA; MO

19 Name azathioprine sodium B/D PA BAVENCIO B/D PA; MO; LA BELEODAQ B/D PA; MO BENDEKA B/D PA; MO BESPONSA B/D PA; MO; LA bexarotene PA; MO bicalutamide BICNU B/D PA; MO bleomycin B/D PA; MO BLINCYTO INTRAVENOUS KIT B/D PA; MO BORTEZOMIB B/D PA; MO BOSULIF ORAL TABLET 00 MG BOSULIF ORAL TABLET 400 MG, 500 MG BRAFTOVI ORAL CAPSULE 50 MG BRAFTOVI ORAL CAPSULE 75 MG PA; MO; QL (90 per 30 PA; MO; QL (30 per 30 PA; MO; LA; QL (20 per 30 PA; MO; LA; QL (80 per 30 busulfan B/D PA CABOMETYX PA; MO; LA CALQUENCE PA; MO; LA; QL (60 per 30 CAPRELSA ORAL TABLET 00 MG PA; MO; LA; QL (60 per 30 Name CAPRELSA ORAL TABLET 300 MG carboplatin solution 3 PA; MO; LA; QL (30 per 30 B/D PA; MO cisplatin B/D PA; MO cladribine B/D PA; MO clofarabine B/D PA COMETRIQ PA; MO COSMEGEN B/D PA; MO COTELLIC PA; MO; LA; QL (63 per 28 cyclophosphamide cyclophosphamide oral capsule cyclosporine cyclosporine modified cyclosporine oral capsule B/D PA; MO B/D PA; MO B/D PA B/D PA; MO B/D PA; MO CYRAMZA B/D PA; MO cytarabine B/D PA; MO cytarabine (pf) injection solution 00 mg/5 ml (20 mg/ml), 2 gram/20 ml (00 mg/ml) cytarabine (pf) injection solution 20 mg/ml B/D PA; MO B/D PA dacarbazine B/D PA; MO dactinomycin B/D PA DARZALEX B/D PA; MO; LA

20 Name daunorubicin solution B/D PA decitabine B/D PA; MO docetaxel solution 60 mg/6 ml (0 mg/ml), 20 mg/2 ml (0 mg/ml) docetaxel solution 60 mg/8 ml (20 mg/ml), 20 mg/ml ( ml), 80 mg/4 ml (20 mg/ml), 80 mg/8 ml (0 mg/ml) DOCETAXEL INTRAVENOUS SOLUTION 20 MG/ML doxorubicin recon soln 0 mg doxorubicin recon soln 50 mg doxorubicin solution doxorubicin, pegliposomal B/D PA B/D PA; MO B/D PA B/D PA B/D PA; MO B/D PA; MO B/D PA; MO DROXIA EMCYT EMPLICITI B/D PA; MO epirubicin solution B/D PA; MO ERBITUX B/D PA; MO ERIVEDGE PA; MO; QL (30 per 30 ERLEADA PA; MO Name 4 ERWINAZE B/D PA; MO ETOPOPHOS B/D PA; MO etoposide B/D PA; MO exemestane FARESTON FARYDAK ORAL CAPSULE 0 MG FARYDAK ORAL CAPSULE 5 MG, 20 MG PA; MO; QL (2 per 2 PA; MO; QL (6 per 2 FASLODEX B/D PA; MO FIRMAGON KIT W DILUENT SYRINGE SUBCUTANEOUS RECON SOLN 20 MG FIRMAGON KIT W DILUENT SYRINGE SUBCUTANEOUS RECON SOLN 80 MG B/D PA; MO B/D PA; MO floxuridine B/D PA fludarabine recon soln fludarabine solution fluorouracil B/D PA; MO B/D PA B/D PA; MO flutamide FOLOTYN B/D PA; MO GAZYVA B/D PA; MO

21 Name gemcitabine recon soln gram, 200 mg gemcitabine recon soln 2 gram gemcitabine solution gram/26.3 ml (38 mg/ml), 200 mg/5.26 ml (38 mg/ml) GEMCITABINE INTRAVENOUS SOLUTION 00 MG/ML gemcitabine solution 2 gram/52.6 ml (38 mg/ml) gengraf oral capsule 00 mg, 25 mg B/D PA; MO B/D PA B/D PA; MO B/D PA B/D PA B/D PA; MO gengraf oral solution B/D PA; MO GILOTRIF PA; MO; QL (30 per 30 GLEOSTINE HALAVEN B/D PA; MO HERCEPTIN B/D PA; MO HEXALEN hydroxyurea IBRANCE PA; MO; QL (2 per 28 ICLUSIG ORAL TABLET 5 MG ICLUSIG ORAL TABLET 45 MG PA; MO; QL (60 per 30 PA; MO; QL (30 per 30 Name 5 idarubicin B/D PA IDHIFA PA; MO; LA; QL (30 per 30 ifosfamide recon soln ifosfamide solution imatinib oral tablet 00 mg imatinib oral tablet 400 mg IMBRUVICA ORAL CAPSULE 40 MG IMBRUVICA ORAL CAPSULE 70 MG IMBRUVICA ORAL TABLET B/D PA; MO B/D PA PA; MO; QL (80 per 30 PA; MO; QL (60 per 30 PA; MO; QL (20 per 30 PA; MO; QL (30 per 30 PA; MO; QL (30 per 30 IMFINZI B/D PA; MO; LA INLYTA ORAL TABLET MG INLYTA ORAL TABLET 5 MG PA; MO; QL (80 per 30 PA; MO; QL (20 per 30 IRESSA PA; MO; QL (30 per 30 irinotecan solution 00 mg/5 ml B/D PA; MO

22 Name irinotecan solution 40 mg/2 ml irinotecan solution 500 mg/25 ml B/D PA; MO B/D PA ISTODAX B/D PA; MO IXEMPRA B/D PA; MO JAKAFI PA; MO; QL (60 per 30 JEVTANA B/D PA; MO KADCYLA PA; MO KEYTRUDA INTRAVENOUS SOLUTION PA; MO KISQALI PA; MO KISQALI FEMARA CO-PACK KYPROLIS INTRAVENOUS RECON SOLN 30 MG, 60 MG PA; MO B/D PA; MO LARTRUVO B/D PA; MO; LA LENVIMA ORAL CAPSULE 0 MG/DAY (0 MG X ), 4 MG/DAY(0 MG X -4 MG X ), 8 MG/DAY (0 MG X -4 MG X2), 20 MG/DAY (0 MG X 2), 24 MG/DAY(0 MG X 2-4 MG X ), 8 MG/DAY (4 MG X 2) PA; MO letrozole Name LEUKERAN leuprolide subcutaneous kit LONSURF PA; MO LUPRON DEPOT PA; MO LUPRON DEPOT (3 MONTH) LUPRON DEPOT (4 MONTH) LUPRON DEPOT (6 MONTH) LUPRON DEPOT- PED LUPRON DEPOT- PED (3 MONTH) LYNPARZA ORAL CAPSULE LYNPARZA ORAL TABLET PA; MO PA; MO PA; MO PA; MO PA; MO PA; MO; QL (480 per 30 PA; MO; QL (20 per 30 LYSODREN MARQIBO B/D PA; MO MATULANE megestrol oral suspension 400 mg/0 ml (0 ml) megestrol oral suspension 400 mg/0 ml (40 mg/ml), 625 mg/5 ml PA PA; MO megestrol oral tablet PA; MO MEKINIST ORAL TABLET 0.5 MG PA; MO; QL (90 per 30 6

23 Name MEKINIST ORAL TABLET 2 MG PA; MO; QL (30 per 30 MEKTOVI PA; MO; LA; QL (80 per 30 melphalan B/D PA; MO melphalan hcl B/D PA mercaptopurine methotrexate sodium B/D PA; MO methotrexate sodium (pf) injection recon soln methotrexate sodium (pf) injection solution mitomycin recon soln 20 mg, 5 mg mitomycin recon soln 40 mg B/D PA B/D PA; MO B/D PA; MO B/D PA; MO mitoxantrone B/D PA; MO MUSTARGEN B/D PA; MO mycophenolate mofetil hcl mycophenolate mofetil oral capsule mycophenolate mofetil oral suspension for reconstitution mycophenolate mofetil oral tablet mycophenolate sodium B/D PA B/D PA; MO B/D PA; MO B/D PA; MO B/D PA; MO MYLOTARG B/D PA; MO; LA Name 7 NERLYNX PA; MO; LA NEXAVAR PA; MO; LA; QL (20 per 30 nilutamide NINLARO ORAL CAPSULE 2.3 MG NINLARO ORAL CAPSULE 3 MG NINLARO ORAL CAPSULE 4 MG PA; MO; QL (6 per 28 PA; MO; QL (4 per 28 PA; MO; QL (3 per 28 NULOJIX B/D PA; MO octreotide acetate injection solution,000 mcg/ml, 500 mcg/ml octreotide acetate injection solution 00 mcg/ml, 200 mcg/ml, 50 mcg/ml octreotide acetate injection syringe 00 mcg/ml ( ml), 50 mcg/ml ( ml) octreotide acetate injection syringe 500 mcg/ml ( ml) ODOMZO PA; MO; LA; QL (30 per 30 ONCASPAR B/D PA; MO ONIVYDE B/D PA; MO OPDIVO PA; MO oxaliplatin recon soln 00 mg B/D PA; MO

24 Name oxaliplatin recon soln 50 mg oxaliplatin solution B/D PA B/D PA; MO paclitaxel B/D PA; MO PERJETA B/D PA; MO POMALYST PA; MO; LA PORTRAZZA B/D PA; MO PROGRAF INTRAVENOUS B/D PA; MO PURIXAN RAPAMUNE ORAL SOLUTION B/D PA; MO REVLIMID PA; MO; LA; QL (28 per 28 RITUXAN PA; MO RITUXAN HYCELA PA; MO ROMIDEPSIN B/D PA RUBRACA PA; MO; LA; QL (20 per 30 RYDAPT PA; MO SANDIMMUNE ORAL SOLUTION SANDOSTATIN LAR DEPOT INTRAMUSCULA R SUSPENSION,EXT ENDED REL RECON B/D PA; MO SIGNIFOR Name SIMULECT INTRAVENOUS RECON SOLN 0 MG SIMULECT INTRAVENOUS RECON SOLN 20 MG sirolimus oral tablet 0.5 mg, mg sirolimus oral tablet 2 mg B/D PA B/D PA; MO B/D PA; MO B/D PA; MO SOLTAMOX SOMATULINE DEPOT SPRYCEL ORAL TABLET 00 MG, 40 MG, 50 MG, 80 MG SPRYCEL ORAL TABLET 20 MG SPRYCEL ORAL TABLET 70 MG PA; MO; QL (30 per 30 PA; MO; QL (90 per 30 PA; MO; QL (60 per 30 STIVARGA PA; MO; QL (84 per 28 SUTENT PA; MO; QL (30 per 30 SYLVANT B/D PA; MO SYNRIBO B/D PA; MO TABLOID tacrolimus oral B/D PA; MO TAFINLAR PA; MO; QL (20 per 30 8

25 Name TAGRISSO PA; MO; LA; QL (30 per 30 tamoxifen TARCEVA ORAL TABLET 00 MG, 50 MG TARCEVA ORAL TABLET 25 MG TARGRETIN TOPICAL TASIGNA ORAL CAPSULE 50 MG, 200 MG TASIGNA ORAL CAPSULE 50 MG PA; MO; QL (30 per 30 PA; MO; QL (60 per 30 PA; MO PA; MO; QL (2 per 28 PA; MO; QL (20 per 30 TECENTRIQ B/D PA; MO; LA TEMODAR INTRAVENOUS B/D PA; MO THALOMID PA; MO thiotepa B/D PA; MO TIBSOVO PA; MO toposar B/D PA; MO topotecan recon soln topotecan solution B/D PA B/D PA; MO TORISEL B/D PA; MO TREANDA INTRAVENOUS RECON SOLN B/D PA; MO TRELSTAR B/D PA; MO Name tretinoin (chemotherapy) TRISENOX INTRAVENOUS SOLUTION 2 MG/ML B/D PA; MO TYKERB PA; MO; LA; QL (80 per 30 UNITUXIN B/D PA; MO VALSTAR B/D PA; MO VANTAS B/D PA; MO VECTIBIX B/D PA; MO VELCADE B/D PA; MO VENCLEXTA ORAL TABLET 0 MG, 50 MG VENCLEXTA ORAL TABLET 00 MG VENCLEXTA STARTING PACK PA; MO; LA PA; MO; LA PA; MO; LA; QL (42 per 80 VERZENIO PA; MO; LA; QL (60 per 30 vinblastine solution vincasar pfs solution mg/ml vincasar pfs solution 2 mg/2 ml B/D PA; MO B/D PA B/D PA; MO vincristine B/D PA; MO vinorelbine B/D PA; MO 9

26 Name VOTRIENT PA; MO; QL (20 per 30 VYXEOS B/D PA; MO XALKORI PA; MO; QL (60 per 30 XATMEP B/D PA; MO XERMELO PA; MO; LA; QL (90 per 30 XTANDI PA; MO; QL (20 per 30 YERVOY B/D PA; MO YONDELIS B/D PA; MO YONSA PA; QL (20 ZALTRAP B/D PA; MO ZANOSAR B/D PA; MO ZEJULA PA; MO; LA; QL (90 per 30 ZELBORAF PA; MO; QL (240 per 30 ZOLADEX B/D PA; MO ZOLINZA ZORTRESS B/D PA; MO ZYDELIG PA; MO; QL (60 per 30 ZYKADIA PA; MO; QL (50 per 30 Name ZYTIGA ORAL TABLET 250 MG ZYTIGA ORAL TABLET 500 MG PA; MO; QL (20 per 30 PA; MO; QL (60 per 30 AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH ANTICONVULSANTS APTIOM ORAL TABLET 200 MG, 400 MG, 800 MG APTIOM ORAL TABLET 600 MG BANZEL BRIVIACT INTRAVENOUS BRIVIACT ORAL carbamazepine oral capsule, er multiphase 2 hr carbamazepine oral suspension 00 mg/5 ml carbamazepine oral tablet carbamazepine oral tablet extended release 2 hr carbamazepine oral tablet,chewable CELONTIN ORAL CAPSULE 300 MG clonazepam oral tablet 0.5 mg, mg PA; MO; QL (90 per 30 20

27 Name clonazepam oral tablet 2 mg clonazepam oral tablet,disintegrating 0.25 mg, 0.25 mg, 0.5 mg, mg clonazepam oral tablet,disintegrating 2 mg PA; MO; QL (300 per 30 PA; MO; QL (90 per 30 PA; MO; QL (300 per 30 DIASTAT DIASTAT ACUDIAL diazepam rectal DILANTIN 30 MG divalproex oral capsule, delayed rel sprinkle divalproex oral tablet extended release 24 hr divalproex oral tablet,delayed release (dr/ec) epitol ethosuximide felbamate oral suspension felbamate oral tablet fosphenytoin FYCOMPA ORAL SUSPENSION FYCOMPA ORAL TABLET gabapentin oral capsule 00 mg PA; MO; QL (080 per 30 Name gabapentin oral capsule 300 mg gabapentin oral capsule 400 mg gabapentin oral solution 250 mg/5 ml gabapentin oral solution 250 mg/5 ml (5 ml), 300 mg/6 ml (6 ml) gabapentin oral tablet 600 mg gabapentin oral tablet 800 mg GRALISE 30-DAY STARTER PACK GRALISE ORAL TABLET EXTENDED RELEASE 24 HR 300 MG GRALISE ORAL TABLET EXTENDED RELEASE 24 HR 600 MG lamotrigine oral tablet lamotrigine oral tablet extended release 24hr lamotrigine oral tablet, chewable dispersible PA; MO; QL (360 per 30 PA; MO; QL (270 per 30 PA; MO; QL (260 per 30 PA; QL (260 PA; MO; QL (80 per 30 PA; MO; QL (20 per 30 PA; MO; QL (78 per 80 PA; MO; QL (30 per 30 PA; MO; QL (90 per 30 2

28 Name lamotrigine oral tablet,disintegrating lamotrigine oral tablets,dose pack levetiracetam in nacl (iso-os) piggyback,000 mg/00 ml,,500 mg/00 ml levetiracetam in nacl (iso-os) piggyback 500 mg/00 ml levetiracetam levetiracetam oral solution 00 mg/ml levetiracetam oral solution 500 mg/5 ml (5 ml) levetiracetam oral tablet levetiracetam oral tablet extended release 24 hr LYRICA ORAL CAPSULE 00 MG, 50 MG, 200 MG, 25 MG, 50 MG, 75 MG LYRICA ORAL CAPSULE 225 MG, 300 MG LYRICA ORAL SOLUTION ONFI ORAL SUSPENSION PA; MO; QL (90 per 30 PA; MO; QL (60 per 30 PA; MO; QL (900 per 30 PA; MO; QL (480 per 30 Name ONFI ORAL TABLET 0 MG, 20 MG 22 PA; MO; QL (60 per 30 oxcarbazepine PEGANONE phenobarbital PA; MO phenobarbital sodium injection solution 30 mg/ml phenobarbital sodium injection solution 65 mg/ml phenytoin oral suspension 00 mg/4 ml phenytoin oral suspension 25 mg/5 ml phenytoin oral tablet,chewable phenytoin sodium extended phenytoin sodium solution primidone roweepra roweepra xr SABRIL ORAL TABLET ; LA SPRITAM subvenite subvenite starter (blue) kit subvenite starter (green) kit subvenite starter (orange) kit

29 Name tiagabine topiramate oral capsule, sprinkle topiramate oral tablet PA; MO PA; MO valproate sodium valproic acid valproic acid (as sodium salt) oral solution 250 mg/5 ml valproic acid (as sodium salt) oral solution 250 mg/5 ml (5 ml), 500 mg/0 ml (0 ml) vigabatrin ; LA vigadrone ; LA VIMPAT INTRAVENOUS VIMPAT ORAL SOLUTION VIMPAT ORAL TABLET zonisamide PA; MO ANTIPARKINSONISM AGENTS APOKYN ; LA benztropine injection benztropine oral PA; MO bromocriptine carbidopa carbidopa-levodopa carbidopa-levodopaentacapone entacapone NEUPRO Name pramipexole rasagiline ropinirole selegiline hcl tolcapone MIGRAINE / CLUSTER HEADACHE THERAPY dihydroergotamine injection dihydroergotamine nasal ; QL (8 per 28 eletriptan ; QL (8 per 28 ergotamine-caffeine migergot naratriptan ; QL (8 per 28 rizatriptan ; QL (36 per 28 sumatriptan nasal spray,non-aerosol 20 mg/actuation sumatriptan nasal spray,non-aerosol 5 mg/actuation sumatriptan succinate oral sumatriptan succinate subcutaneous cartridge sumatriptan succinate subcutaneous pen injector ; QL (8 per 28 ; QL (36 per 28 ; QL (8 per 28 ; QL (8 per 28 ; QL (8 per 28 23

30 Name sumatriptan succinate subcutaneous solution sumatriptannaproxen ; QL (8 per 28 ; QL (8 per 28 zolmitriptan ; QL (8 per 28 MISCELLANEOUS NEUROLOGICAL THERAPY AMPYRA PA; MO; LA AUBAGIO PA; MO COPAXONE SUBCUTANEOUS SYRINGE 40 MG/ML donepezil oral tablet 0 mg, 5 mg donepezil oral tablet 23 mg donepezil oral tablet,disintegrating PA; MO; QL (2 per 28 galantamine GILENYA ORAL CAPSULE 0.5 MG glatiramer subcutaneous syringe 20 mg/ml glatiramer subcutaneous syringe 40 mg/ml glatopa subcutaneous syringe 20 mg/ml glatopa subcutaneous syringe 40 mg/ml PA; MO PA; MO; QL (30 per 30 PA; MO; QL (2 per 28 PA; MO; QL (30 per 30 PA; MO; QL (2 per 28 LEMTRADA PA; MO Name memantine oral capsule,sprinkle,er 24hr memantine oral solution memantine oral tablet 24 PA; MO PA; MO PA; MO NAMZARIC PA; MO NUEDEXTA PA; MO OCREVUS PA; MO; LA RADICAVA PA; MO rivastigmine rivastigmine tartrate TECFIDERA PA; MO; LA tetrabenazine oral tablet 2.5 mg tetrabenazine oral tablet 25 mg PA; MO; QL (240 per 30 PA; MO; QL (20 per 30 TYSABRI PA; MO; LA MUSCLE RELAXANTS / ANTISPASMODIC THERAPY baclofen oral tablet 0 mg, 20 mg cyclobenzaprine oral tablet PA; MO dantrolene LIORESAL INTRATHECAL SOLUTION 2,000 MCG/ML, 500 MCG/ML LIORESAL INTRATHECAL SOLUTION 50 MCG/ML B/D PA; MO B/D PA

31 Name MESTINON ORAL SYRUP neostigmine methylsulfate solution 0.5 mg/ml neostigmine methylsulfate solution mg/ml pyridostigmine bromide regonol revonto tizanidine NARCOTIC ANALGESICS acetaminophen-caffdihydrocod oral capsule acetaminophencodeine oral solution 20 mg-2 mg /5 ml (5 ml), 300 mg-30 mg /2.5 ml acetaminophencodeine oral solution 20-2 mg/5 ml acetaminophencodeine oral tablet mg, mg acetaminophencodeine oral tablet mg buprenorphine hcl injection solution buprenorphine hcl injection syringe ; QL (300 QL (4500 per 30 ; QL (4500 ; QL (360 ; QL (80 ; QL (266 QL (266 per 30 Name buprenorphine hcl sublingual duramorph (pf) injection solution 0.5 mg/ml duramorph (pf) injection solution mg/ml endocet oral tablet mg, mg, mg, mg ; QL (4000 QL (2000 per 30 ; QL (360 fentanyl citrate PA; MO; QL (20 per 30 fentanyl citrate (pf) injection fentanyl citrate (pf) syringe 00 mcg/2 ml (50 mcg/ml) fentanyl transdermal patch 72 hour 00 mcg/hr, 2 mcg/hr, 25 mcg/hr, 37.5 mcg/hour, 50 mcg/hr, 62.5 mcg/hour, 75 mcg/hr fentanyl transdermal patch 72 hour 87.5 mcg/hour hydrocodoneacetaminophen oral solution mg/5 ml hydrocodoneacetaminophen oral tablet mg, mg, mg ; QL (400 QL (400 per 30 PA; MO; QL (0 per 30 PA; MO; QL (0 per 30 ; QL (5550 ; QL (390 25

32 Name hydrocodoneacetaminophen oral tablet mg, mg, mg, mg hydrocodoneibuprofen oral tablet mg, mg, mg hydromorphone (pf) injection solution 0 (mg/ml) (5 ml), 0 mg/ml hydromorphone (pf) injection solution 2 mg/ml hydromorphone injection solution mg/ml hydromorphone injection solution 2 mg/ml hydromorphone injection solution 4 mg/ml hydromorphone injection syringe mg/ml hydromorphone injection syringe 2 mg/ml hydromorphone injection syringe 4 mg/ml hydromorphone oral liquid hydromorphone oral tablet ; QL (360 ; QL (50 ; QL (240 QL (200 per 30 QL (2400 per 30 ; QL (200 ; QL (600 QL (2400 per 30 QL (200 per 30 ; QL (600 ; QL (2400 ; QL (80 Name hydromorphone oral tablet extended release 24 hr 2 mg, 8 mg hydromorphone oral tablet extended release 24 hr 6 mg, 32 mg PA; MO; QL (60 per 30 PA; MO; QL (60 per 30 ibuprofen-oxycodone ; QL (28 levorphanol tartrate ; QL (20 lorcet (hydrocodone) ; QL (360 lorcet hd ; QL (360 lorcet plus oral tablet mg methadone injection solution ; QL (360 QL (50 per 30 methadone intensol PA; MO; QL (90 per 30 methadone oral concentrate methadone oral solution 0 mg/5 ml methadone oral solution 5 mg/5 ml methadone oral tablet 0 mg methadone oral tablet 5 mg PA; MO; QL (90 per 30 PA; MO; QL (600 per 30 PA; MO; QL (200 per 30 PA; MO; QL (20 per 30 PA; MO; QL (240 per 30 26

33 Name methadose oral concentrate morphine (pf) injection solution 0.5 mg/ml morphine (pf) injection solution mg/ml morphine (pf) patient control.analgesia soln 50 mg/30 ml morphine (pf) patient control.analgesia soln 30 mg/30 ml morphine concentrate oral solution morphine injection solution 8 mg/ml morphine injection syringe 0 mg/ml morphine injection syringe 2 mg/ml morphine injection syringe 4 mg/ml morphine injection syringe 5 mg/ml morphine injection syringe 8 mg/ml morphine cartridge 0 mg/ml morphine cartridge 2 mg/ml PA; MO; QL (90 per 30 QL (4000 per 30 ; QL (2000 B/D PA; MO; QL (400 per 30 B/D PA; QL (2000 per 30 ; QL (900 QL (250 per 30 ; QL (200 ; QL (000 ; QL (500 QL (400 per 30 QL (250 per 30 QL (200 per 30 QL (000 per 30 Name morphine cartridge 4 mg/ml morphine solution 0 mg/ml morphine syringe 2 mg/ml morphine syringe 4 mg/ml morphine oral capsule, er multiphase 24 hr morphine oral capsule,extend.relea se pellets morphine oral solution QL (500 per 30 ; QL (200 QL (000 per 30 QL (500 per 30 PA; MO; QL (60 per 30 PA; MO; QL (90 per 30 ; QL (900 morphine oral tablet ; QL (80 morphine oral tablet extended release 00 mg morphine oral tablet extended release 5 mg, 200 mg, 30 mg, 60 mg oxycodone oral capsule oxycodone oral concentrate oxycodone oral solution oxycodone oral tablet 0 mg, 5 mg, 20 mg, 30 mg PA; MO; QL (60 per 30 PA; MO; QL (20 per 30 ; QL (360 ; QL (80 ; QL (200 ; QL (80 27

34 Name oxycodone oral tablet 5 mg oxycodoneacetaminophen oral tablet mg, mg, mg, mg ; QL (360 ; QL (360 oxycodone-aspirin ; QL (360 OXYCONTIN ORAL TABLET,ORAL ONLY,EXT.REL.2 HR 0 MG, 5 MG, 20 MG, 30 MG, 40 MG, 60 MG OXYCONTIN ORAL TABLET,ORAL ONLY,EXT.REL.2 HR 80 MG oxymorphone oral tablet 0 mg oxymorphone oral tablet 5 mg PA; MO; QL (90 per 30 PA; MO; QL (60 per 30 ; QL (360 ; QL (80 vicodin ; QL (390 vicodin es ; QL (390 vicodin hp ; QL (390 NON-NARCOTIC ANALGESICS buprenorphinenaloxone sublingual tablet mg buprenorphinenaloxone sublingual tablet 8-2 mg ; QL (360 ; QL (90 Name butorphanol tartrate injection solution mg/ml butorphanol tartrate injection solution 2 mg/ml butorphanol tartrate nasal ; QL (857 ; QL (428 ; QL (0 per 28 celecoxib clonidine (pf) epidural solution 5,000 mcg/0 ml diclofenac potassium diclofenac sodium oral diclofenac sodium topical drops diclofenac sodium topical gel % diclofenacmisoprostol ; QL (300 per 28 ; QL (000 per 28 diflunisal etodolac fenoprofen oral tablet FLECTOR PA; MO; QL (60 per 30 flurbiprofen ibu ibuprofen oral suspension ibuprofen oral tablet 400 mg, 600 mg, 800 mg ketoprofen oral capsule 25 mg 28

35 Name ketoprofen oral capsule 50 mg, 75 mg ketoprofen oral capsule,ext rel. pellets 24 hr 200 mg meclofenamate mefenamic acid meloxicam oral tablet 5 mg meloxicam oral tablet 7.5 mg ; QL (30 nabumetone nalbuphine injection solution 0 mg/ml nalbuphine injection solution 20 mg/ml ; QL (200 ; QL (00 naloxone naltrexone naproxen oral suspension naproxen oral tablet naproxen oral tablet,delayed release (dr/ec) naproxen sodium oral tablet 275 mg, 550 mg naproxen sodium oral tablet, er multiphase 24 hr NARCAN NASAL SPRAY,NON- AEROSOL 4 MG/ACTUATION oxaprozin piroxicam ; QL (2 per 28 Name profeno salsalate SUBOXONE SUBLINGUAL FILM 2-3 MG SUBOXONE SUBLINGUAL FILM MG SUBOXONE SUBLINGUAL FILM 4- MG, 8-2 MG ; QL (60 ; QL (360 ; QL (90 sulindac tolmetin tramadol oral tablet ; QL (240 tramadolacetaminophen ; QL (240 VIVITROL PSYCHOTHERAPEUTIC DRUGS ABILIFY MAINTENA ADASUVE LA amitriptyline PA; MO amoxapine PA; MO aripiprazole oral solution aripiprazole oral tablet aripiprazole oral tablet,disintegrating ; QL (30 ; QL (60 ARISTADA ARISTADA INITIO armodafinil PA; MO atomoxetine 29

36 Name bupropion hcl oral tablet bupropion hcl oral tablet extended release 2 hr bupropion hcl oral tablet extended release 24 hr 50 mg bupropion hcl oral tablet extended release 24 hr 300 mg ; QL (60 ; QL (90 ; QL (30 buspirone chlorpromazine citalopram oral solution citalopram oral tablet ; QL (30 clomipramine PA; MO clonidine hcl oral tablet extended release 2 hr clorazepate dipotassium oral tablet 5 mg clorazepate dipotassium oral tablet 3.75 mg, 7.5 mg PA; MO; QL (80 per 30 PA; MO; QL (90 per 30 clozapine oral tablet clozapine oral tablet,disintegrating 00 mg, 2.5 mg, 25 mg desipramine PA; MO desvenlafaxine succinate dextroamphetamine oral solution ; QL (30 Name dextroamphetamineamphetamine diazepam injection solution diazepam injection syringe PA PA; MO diazepam intensol PA; MO; QL (240 per 30 diazepam oral concentrate diazepam oral solution 5 mg/5 ml ( mg/ml) PA; MO; QL (240 per 30 PA; MO; QL (200 per 30 diazepam oral tablet PA; MO; QL (20 per 30 doxepin oral PA; MO duloxetine oral capsule,delayed release(dr/ec) 20 mg, 30 mg, 60 mg duloxetine oral capsule,delayed release(dr/ec) 40 mg ; QL (60 ; QL (90 EMSAM ergoloid escitalopram oxalate oral solution escitalopram oxalate oral tablet ; QL (30 eszopiclone ST; MO; QL (30 per 30 FANAPT ORAL TABLET MG, 2 MG, 4 MG ; QL (60 30

37 Name FANAPT ORAL TABLET 0 MG, 2 MG, 6 MG, 8 MG FANAPT ORAL TABLETS,DOSE PACK FAZACLO ORAL TABLET,DISINTE GRATING 50 MG, 200 MG FETZIMA ORAL CAPSULE,EXT REL 24HR DOSE PACK FETZIMA ORAL CAPSULE,EXTEN DED RELEASE 24 HR ; QL (60 ; QL (8 per 28 ; QL (28 per 28 ; QL (30 flumazenil fluoxetine oral capsule 0 mg fluoxetine oral capsule 20 mg fluoxetine oral capsule 40 mg fluoxetine oral capsule,delayed release(dr/ec) fluoxetine oral solution fluoxetine oral tablet 0 mg fluoxetine oral tablet 20 mg, 60 mg fluphenazine decanoate ; QL (30 ; QL (60 ; QL (4 per 28 ; QL (30 fluphenazine hcl Name fluvoxamine oral capsule,extended release 24hr fluvoxamine oral tablet 00 mg fluvoxamine oral tablet 25 mg fluvoxamine oral tablet 50 mg ; QL (60 ; QL (90 ; QL (30 ; QL (60 FORFIVO XL ; QL (30 GEODON INTRAMUSCULA R guanidine haloperidol haloperidol decanoate haloperidol lactate injection haloperidol lactate intramuscular haloperidol lactate oral HETLIOZ PA; MO; QL (30 per 30 imipramine hcl PA; MO imipramine pamoate PA; MO INVEGA SUSTENNA INTRAMUSCULA R SYRINGE 7 MG/0.75 ML, 56 MG/ML, 234 MG/.5 ML, 78 MG/0.5 ML 3

38 Name INVEGA SUSTENNA INTRAMUSCULA R SYRINGE 39 MG/0.25 ML INVEGA TRINZA LATUDA ORAL TABLET 20 MG, 20 MG, 40 MG, 60 MG LATUDA ORAL TABLET 80 MG ; QL (30 ; QL (60 lithium carbonate lithium citrate oral solution 8 meq/5 ml lorazepam injection solution lorazepam injection syringe PA; MO PA lorazepam intensol PA; MO; QL (50 per 30 lorazepam oral concentrate lorazepam oral tablet 0.5 mg, mg lorazepam oral tablet 2 mg PA; MO; QL (50 per 30 PA; MO; QL (90 per 30 PA; MO; QL (50 per 30 loxapine succinate maprotiline MARPLAN metadate er methylphenidate hcl oral capsule,er biphasic Name methylphenidate hcl oral solution methylphenidate hcl oral tablet methylphenidate hcl oral tablet extended release methylphenidate hcl oral tablet,chewable mirtazapine oral tablet mirtazapine oral tablet,disintegrating 32 modafinil PA; MO nefazodone nortriptyline PA; MO NUPLAZID PA; MO olanzapine intramuscular olanzapine oral ; QL (30 olanzapinefluoxetine paliperidone oral tablet extended release 24hr.5 mg, 3 mg paliperidone oral tablet extended release 24hr 6 mg paliperidone oral tablet extended release 24hr 9 mg paroxetine hcl oral tablet 0 mg, 20 mg, 40 mg paroxetine hcl oral tablet 30 mg ; QL (30 ; QL (60 ; QL (30 ; QL (30 ; QL (60