Premier Formulary Medicare Plans. RMHP is a Medicare-approved Cost plan. Enrollment in RMHP depends on contract renewal.

Transcription

1 Premier Formulary 017 Medicare Plans RMHP is a Medicare-approved Cost plan. Enrollment in RMHP depends on contract renewal. H060_PH_PH9_ Approved PH9R07/11/16þ

2 Notice of Nondiscrimination Rocky Mountain Health Plans (RMHP) complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. RMHP does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. RMHP takes reasonable steps to ensure meaningful access and effective communication is provided timely and free of charge: Provides free auxiliary aids and services to people with disabilities to communicate effectively with us, such as: Qualified sign language interpreters (remote interpreting service or on-site appearance) Written information in other formats (large print, audio, accessible electronic formats, other formats) Provides free language assistance services to people whose primary language is not English, such as: Qualified interpreters (remote or on-site) Information written in other languages If you need these services, contact the RMHP Member Concerns Coordinator at , , or TTY , , Relay 711; para asistencia en español llame al If you believe that RMHP has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: the RMHP EEO Officer at , , ext. 788, or TTY , , Relay 711; para asistencia en español llame al , or eeoofficer@rmhp.org. You can file a grievance in person or by mail, fax, or . If you need help filing a grievance, the RMHP EEO Officer is available to help you. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at or by mail or phone at: U.S. Department of Health and Human Services, 00 Independence Avenue SW., Room 509F, HHH Building, Washington, DC 001, , (TDD). Complaint forms are available at RMHP is a Medicare-approved Cost plan. Enrollment in RMHP depends on contract renewal. H060_MC_1557Notice_ Accepted

3 Multi-Language Insert English Spanish Vietnamese Chinese Korean Russian Amharic Arabic German French Nepali Tagalog Japanese Cushite/Oromo Persian Ibo/Igbo Kru-Bassa Yoruba ATTENTION: If you speak English, language assistance services, free of charge, are available to you. Call (TTY: 711). ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al (TTY: 711). CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho bạn. Gọi số (TTY: 711). 注意 : 如果您使用繁體中文, 您可以免費獲得語言援助服務 請致電 (TTY: 711) 주의 : 한국어를사용하시는경우, 언어지원서비스를무료로이용하실수있습니다 (TTY: 711) 번으로전화해주십시오. ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услуги перевода. Звоните (телетайп: 711). ማስታወሻ: የሚናገሩት ቋንቋ ኣማርኛ ከሆነ የትርጉም እርዳታ ድርጅቶች በነጻ ሊያግዝዎት ተዘጋጀተዋል ወደ ሚከተለው ቁጥር ይደውሉ (መስማት ለተሳናቸው: 711). ملحوظة: ا ذا كنت تتحدث اذكر اللغة فا ن خدمات المساعدة اللغوية تتوافر لك بالمجان. اتصل برقم (رقم هاتف الصم والبكم: 117). ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen zur Verfügung. Rufnummer: (TTY: 711). ATTENTION : Si vous parlez français, des services d'aide linguistique vous sont proposés gratuitement. Appelez le (ATS : 711). ध य दन ह स: तप इ ल न प ल ब ल ह न भन तप इ क न म भ ष सह यत स व हर न श ल र पम उपलब छ फ न गन रह स ( ट टव इ: 711) PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng a serbisyo ng tulong sa wika nang walang bayad. Tumawag sa (TTY: 711). 注意事項 : 日本語を話される場合 無料の言語支援をご利用いただけます (TTY:711) まで お電話にてご連絡ください XIYYEEFFANNAA: Afaan dubbattu Oroomiffa, tajaajila gargaarsa afaanii, kanfaltiidhaan ala, ni argama. Bilbilaa (TTY: 711). توجه : اگر به زبان فارسی گفتگو می کنيد تسهيلات زبانی بصورت رايگان برای شما فراهم می باشد. با - (117:YTT) تماس بگيريد. Ige nti: O buru na asu Ibo asusu, enyemaka diri gi site na call (TTY: 711). Dè ɖɛ nìà kɛ dyéɖé gbo: Ɔ jǔ ké m [Ɓàsɔ ɔ -wùɖù-po-nyɔ ] jǔ ní, nìí, à wuɖu kà kò ɖò po-poɔ ɓɛ ìn m gbo kpáa. Ɖá (TTY: 711) AKIYESI: Ti o ba nso ede Yoruba ofe ni iranlowo lori ede wa fun yin o. E pe ero ibanisoro yi (TTY: 711). H060_MC_MLIS_ Accepted

4 Rocky Mountain Health Plans 017 Premier Medicare Formulary (List of Covered Drugs) PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN This formulary was updated on December 1, 017. For more recent information or other questions, please contact Rocky Mountain Health Plans (RMHP) Customer Service at (TTY users should call 711 for Relay Colorado). Hours are 8:00 a.m. to 8:00 p.m., Mountain Time, October 1 - February 14, 7 days/week; February 15-September 0, Monday-Friday, or visit 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 RMHP. When it refers to plan or our plan, it means RMHP. This document includes a list of the drugs (formulary) for our plan which is current as of December 1, 017. 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, 018, and from time to time during the year. RMHP is a Medicare-approved Cost plan. Enrollment in RMHP depends on contract renewal. This information is not a complete description of benefits. Contact the plan for more information. Limitations, copayments, and restrictions may apply. Benefits may change on January 1 of each year. The formulary may change at any time. You will receive notice when necessary. This information is available for free in other languages. Please call our Customer Service at (TTY dial 711). Hours are 8am - 8pm, 7 days/week, Oct.1 Feb.14, and 8am - 8pm, M-F, Feb.15 Sept.0. Esta información está disponible gratuitamente en otros idiomas. Por favor llame a la línea de Atención a Clientes, al (TTY marque 711). Horario de 8am - 8pm, 7 días a la semana, del 1 de octubre al 14 de febrero; y 8am - 8pm, de lunes a viernes, del 15 de febrero al 0 de septiembre. H060_PH_PremierFormulary_ Populated Template Version 18 FORM-Premier

5 What is the Rocky Mountain Health Plans Formulary? A formulary is a list of covered drugs which represents the prescription therapies believed to be a necessary part of a quality treatment program. RMHP will generally cover the drugs listed in our formulary as long as the drug is medically necessary, the prescription is filled at a RMHP 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 017 formulary that was covered at the beginning of the year, we will not discontinue or reduce coverage of the drug during the 017 coverage year. If a brand name drug becomes available as a cost saving generic, we may discontinue coverage of the brand name version or move it to a higher tier. We may remove a drug from the formulary for safety reasons if new information is released about the safety or effectiveness of a 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. 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. If we remove drugs from our formulary, add prior authorization, quantity limits and/or step therapy restrictions on a drug, or move a drug to a higher cost-sharing tier, we must notify affected members of the change at least 60 days before the change becomes effective, or at the time the member requests a refill of the drug, at which time the member will receive a 60-day supply of the drug. If the Food and Drug Administration deems a drug on our formulary to be unsafe or the drug s manufacturer removes the drug from the market, we will immediately remove the drug from our formulary and provide notice to members who take the drug. The enclosed formulary is current as of December 1, 017. To get updated information about the drugs covered by RMHP, please contact us. Our contact information appears on the front and back cover pages. The only changes made to the formulary mid-year are maintenance drug changes. This means we may add new drugs to the formulary and we may move a brand name drug to a higher tier if a bioequivalent generic becomes available and is included in the formulary. RMHP does not make non-maintenance formulary changes midyear. How do I use the Formulary? There are two ways to find your drug within the formulary: Medical Condition: The formulary begins on page. The drugs in this formulary are grouped into categories depending on the type of medical conditions that they are used to treat. For example, drugs used to treat a heart condition are listed under the category, Cardiovascular Agents. If you know what your drug is used for, look for the category name in the list that begins on page number. 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. II

6 What are generic drugs? RMHP 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: RMHP requires you or your physician to get prior authorization for certain drugs. This means that you will need to get approval from us before you fill your prescriptions. If you don t get approval, we may not cover the drug. Quantity Limits: For certain drugs, RMHP limits the amount of the drug that can be filled within a given amount of time. For example, RMHP provides 0 nitroglycerin patches for a 0 day supply. If you have a 90 day prescription benefit, you would multiply the quantity by to get the 90 day quantity limit. For example, RMHP covers 90 nitroglycerin patches for a 90 day supply (0 patches multiplied by ). Drugs that are subject to a quantity limit will have a QL symbol next to the drug. Refill Limitations: Prescriptions may be refilled when 75% or more of the day s supply has been used. Step Therapy: In some cases, RMHP 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, we may not cover Drug B unless you try Drug A first. If Drug A does not work for you, we will then cover Drug B. Payment Determination: The Centers for Medicaid and Medicare Services (CMS) limits coverage of medications to medically-accepted uses. These uses are described in FDA approved drug labeling and in CMS approved drug research databases called Compendia. Some drugs are prescribed to treat conditions that are not FDA approved or Compendia supported. For this reason, CMS expects Part D sponsors like RMHP to have review procedures in place to make sure medications are being used for Part D covered conditions. These review procedures are called payment determinations. Medications commonly used for non-part D covered conditions will initially deny at the pharmacy until RMHP can determine if the drug is coverable under Part D. Examples of these drugs include, but are not limited to: Lidoderm patch (lidocaine), growth hormones, fentanyl products that dissolve in the mouth, botulinum toxins (Botox), wake-promoting drugs (Nuvigil, modafinil), drugs for the treatment of Pulmonary Arterial Hypertension (sildenafil, Adcirca), Flector patch and Cialis Daily (.5 and 5). All of these medications can be used for conditions that are covered under Part D; however, if prescribed for a condition that is not covered by Part D the drug will deny and your pharmacy will provide you with the notice: Medicare Prescription Drug Coverage and Your Rights. You can find out if your drug has any additional requirements or limits by looking in the formulary that begins on page. You can also get more information about the restrictions applied to specific covered drugs by visiting our Web site. We have posted on line documents that explain our prior authorization and step therapy restrictions. You may also ask us to send you a copy. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages. You can ask RMHP 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 RMHP formulary? below for information about how to request an exception. III

7 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 Customer Service and ask if your drug is covered. CMS specifically excludes the following categories of medications from Part D coverage: Agents when used for anorexia, weight loss, or weight gain (even if used for a non-cosmetic purpose (i.e., morbid obesity)). Agents when used to promote fertility. Agents when used for cosmetic purposes or hair growth. Agents when used for the symptomatic relief of cough and colds. Prescription vitamins and mineral products, except prenatal vitamins and fluoride preparations. Nonprescription drugs. Agents when used for the treatment of sexual or erectile dysfunction (ED). ED drugs will be covered under Part D when prescribed for conditions approved by the FDA other than sexual or erectile dysfunction (such as pulmonary hypertension). However, ED drugs will not be covered under Part D when used for conditions that are not FDA approved, even when the use is listed in one of the Compendia (e.g. American Hospital Formulary Service Drug Information, DRUGDEX Information System). If you learn that your drug is not excluded from Part D coverage, but RMHP does not cover your drug, you have two options: You can ask Customer Service for a list of similar drugs that are covered by RMHP. When you receive the list, show it to your doctor and ask him or her to prescribe a similar drug that is covered by RMHP. You can ask RMHP to make an exception and cover your drug. See below for information about how to request an exception. IV

8 How do I request an exception to the RMHP Formulary? You can ask RMHP 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 your drug even if it is not on our formulary. If approved, this drug will be covered at a pre-determined cost-sharing level, and you would not be able to ask us to provide the drug at a lower cost-sharing level. You can ask us to cover a formulary drug at a lower cost-sharing level, if this drug is not on the specialty tier. If approved, this would lower the amount you must pay for your drug. You can ask us to waive coverage restrictions or limits on your drug. For example, for certain drugs, RMHP 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, RMHP 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 are requesting a formulary, tiering or utilization restriction exception you should submit a statement from your prescriber or physician supporting your request. Generally, we must make our decision within 7 hours of getting your prescriber s supporting statement. You can request an expedited (fast) exception if you or your doctor believe that your health could be seriously harmed by waiting up to 7 hours for a decision. If your request to expedite is granted, we must give you a decision no later than 4 hours after we get a supporting statement from your doctor or other prescriber. What do I do before I can talk to my doctor about changing my drugs or requesting an exception? As a new or continuing member in our plan you may be taking drugs that are not on our formulary. Or, you may be taking a drug that is on our formulary but your ability to get it is limited. For example, you may need a prior authorization from us before you can fill your prescription. You should talk to your doctor to decide if you should switch to an appropriate drug that we cover or request a formulary exception so that we will cover the drug you take. While you talk to your doctor to determine the right course of action for you, we may cover your drug in certain cases during the first 90 days you are a member of our plan. For each of your drugs that is not on our formulary or if your ability to get your drugs is limited, we will cover a temporary 0-day supply (unless you have a prescription written for fewer 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 day transition supply, consistent with the 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. V

9 When you have a level of care change (e.g. you are admitted to a Long Term Care facility), you may need additional supplies of your medications. When this occurs, the pharmacy can call the RMHP Pharmacy Help Desk to receive a transition supply of each affected drug. RMHP will not limit appropriate and necessary access to Part D benefits when you are being admitted to, or discharged from a Long Term Care facility. For more information For more detailed information about your RMHP prescription drug coverage, please review your Evidence of Coverage and other plan materials. If you have questions about RMHP, please contact us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages. If you have general questions about Medicare prescription drug coverage, please call Medicare at MEDICARE ( ) 4 hours a day/7 days a week. TTY users should call Or, visit RMHP Formulary The formulary that begins on page provides coverage information about the drugs covered by RMHP. 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., ALLEGRA) and generic drugs are listed in lower-case italics (e.g., amoxicillin). The information in the Requirements/Limits column tells you if RMHP has any special requirements for coverage of your drug. The RMHP formulary key for the Requirements/Limits column is as follows: Drug Tier 1 Preferred Generic Drugs (lowest cost generic drugs) Drug Tier Generic Drugs Drug Tier Preferred Brand Drugs Drug Tier 4 Non-Preferred Brand Drugs Drug Tier 5 Specialty Drugs See the Summary of Benefits or Evidence of Coverage to determine how much you will pay for prescription drugs in each tier. The Evidence of Coverage will help you determine when drugs listed in the Part D Formulary may be covered under Part B. Drugs that appear with: italics = Generic drugs CAPITALIZATION = Brand name drugs VI

10 The following Utilization Management abbreviations may be found within the body of this document COVERAGE NOTES ABBREVIATIONS ABBREVIATION DESCRIPTION EXPLANATION Utilization Management Restrictions Non-Extended This drug is not eligible for a long-term supply. NDS Day Supply 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 RMHP before you fill your prescription for this drug. Without prior approval, RMHP 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 RMHP to determine that this drug is covered under Medicare Part D before you fill your prescription for this drug. Without prior approval, RMHP 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 RMHP before you fill your prescription for this drug. Without prior approval, RMHP 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 RMHP before you fill your prescription for this drug. Without prior approval, RMHP may not cover this drug. RMHP limits the amount of this drug that is covered per prescription, or within a specific time frame. Before RMHP 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. The following additional coverage note abbreviations may be found within the body of this document OTHER SPECIAL REQUIREMENTS FOR COVERAGE ABBREVIATION DESCRIPTION EXPLANATION LA Limited Access Drug This prescription may be available only at certain pharmacies. For more information consult your Provider Directory or call Customer Service at or (TTY users call 711.) We are available for phone calls 8:00 a.m. to 8:00 p.m., Mountain Time, (from October 1-February 14, 7 days/week and from February 15 - September 0, Monday - Friday). VII

11 Table of Contents Analgesics... Anesthetics Anti-Addiction/Substance Abuse Treatment Agents Antianxiety Agents Antibacterials Anticancer Agents... 4 Anticholinergic Agents... 5 Anticonvulsants... 5 Antidementia Agents... 9 Antidepressants Antidiabetic Agents... 4 Antifungals Antigout Agents Antihistamines Anti-Infectives (Skin And Mucous Membrane) Antimigraine Agents Antimycobacterials Antinausea Agents Antiparasite Agents... 5 Antiparkinsonian Agents Antipsychotic Agents Antivirals (Systemic) Blood Products/Modifiers/Volume Expanders Caloric Agents Cardiovascular Agents Central Nervous System Agents Contraceptives Dental And Oral Agents Dermatological Agents Devices Enzyme Replacement/Modifiers

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

13 Analgesics Analgesics, Miscellaneous acetaminophen-codeine oral solution 10- QL (700 per 0 1 /5 ml, 60-6 /15 ml (15 ml) acetaminophen-codeine oral tablet QL (60 per 0 acetaminophen-codeine oral tablet 00-0 (Tylenol-Codeine #) QL (60 per 0 acetaminophen-codeine oral tablet (Tylenol-Codeine #4) QL (180 per 0 ALLZITAL ORAL TABLET 5-5 MG PA-HRM; QL (60 per 0 ; AGE (Max 64 Years) ascomp with codeine oral capsule BELBUCA BUCCAL FILM 150 MCG, 00 MCG, 450 MCG, 600 MCG, 75 MCG, 750 MCG, 900 MCG buprenorphine hcl injection solution 0. /ml buprenorphine hcl injection syringe 0. /ml buprenorphine transdermal patch weekly 10 mcg/hour, 15 mcg/hour, 0 mcg/hour, 5 mcg/hour, 7.5 mcg/hour butalbital compound w/codeine oral capsule butalbital-acetaminop-caf-cod oral capsule , butalbital-acetaminophen oral tablet 50-5 butalbital-acetaminophen-caff oral capsule (Buprenex) PA-HRM; QL (180 per 0 ; AGE (Max 64 Years) QL (60 per 0 (Butrans) QL (4 per 8 PA-HRM; QL (180 per 0 ; AGE (Max 64 Years) PA-HRM; QL (180 per 0 ; AGE (Max 64 Years) (Marten-Tab) PA-HRM; QL (180 per 0 ; AGE (Max 64 Years) (Capacet) PA-HRM; QL (180 per 0 ; AGE (Max 64 Years)

14 butalbital-acetaminophen-caff oral tablet butalbital-aspirin-caffeine oral capsule butalbital-aspirin-caffeine oral tablet (Esgic) PA-HRM; QL (180 per 0 ; AGE (Max 64 Years) (Fiorinal) PA-HRM; QL (180 per 0 ; AGE (Max 64 Years) PA-HRM; QL (180 per 0 ; AGE (Max 64 Years) QL (5 per 8 butorphanol tartrate nasal spray,nonaerosol 10 /ml BUTRANS TRANSDERMAL PATCH QL (4 per 8 WEEKLY 7.5 MCG/HOUR capacet oral capsule PA-HRM; QL (180 per 0 ; AGE (Max 64 Years) codeine sulfate oral tablet 15, 0, QL (180 per 0 60 EMBEDA ORAL CAPSULE,ORAL 4 QL (60 per 0 ONLY,EXT.REL PELL MG, MG, 0-1. MG, 50- MG, MG, 80-. MG endocet oral tablet 10-5 QL (40 per 0 endocet oral tablet.5-5, 5-5 QL (60 per 0 endocet oral tablet QL (00 per 0 endodan oral tablet QL (60 per 0 fentanyl citrate buccal lozenge on a handle 1,00 mcg, 1,600 mcg, 00 mcg, 400 mcg, 600 mcg, 800 mcg (Actiq) 5 PA; NDS; QL (10 per 0 fentanyl transdermal patch 7 hour 100 mcg/hr, 1 mcg/hr, 5 mcg/hr, 50 mcg/hr, 75 mcg/hr fentanyl transdermal patch 7 hour 7.5 mcg/hour fentanyl transdermal patch 7 hour 6.5 mcg/hour, 87.5 mcg/hour hydrocodone-acetaminophen oral solution /5 ml, 5-16 /7.5ml(7.5ml) hydrocodone-acetaminophen oral solution /15 ml (Duragesic) QL (10 per 0 4 QL (10 per 0 ; QL (10 per 0 QL (700 per 0 (Hycet) QL (700 per 0

15 hydrocodone-acetaminophen oral tablet (Vicodin HP) QL (90 per hydrocodone-acetaminophen oral tablet (Lorcet HD) QL (60 per hydrocodone-acetaminophen oral tablet (Verdrocet) QL (60 per hydrocodone-acetaminophen oral tablet 5- (Vicodin) QL (90 per 0 00 hydrocodone-acetaminophen oral tablet 5- (Lorcet (hydrocodone)) QL (60 per 0 5 hydrocodone-acetaminophen oral tablet (Vicodin ES) QL (90 per hydrocodone-acetaminophen oral tablet (Lorcet Plus) QL (60 per hydrocodone-ibuprofen oral tablet (Ibudone) QL (150 per 0, 5-00 hydrocodone-ibuprofen oral tablet QL (150 per 0 hydromorphone (pf) injection solution 10 (/ml) (5 ml) hydromorphone (pf) injection solution 10 /ml hydromorphone 10 /ml vial p/f,sdv,latex-f 10 /ml hydromorphone injection solution /ml, 4 /ml hydromorphone injection syringe /ml, (Dilaudid) 4 /ml hydromorphone oral liquid 1 /ml (Dilaudid) QL (100 per 0 hydromorphone oral tablet, 4, 8 (Dilaudid) QL (180 per 0 HYSINGLA ER ORAL TABLET,ORAL QL (0 per 0 ONLY,EXT.REL.4 HR 100 MG, 10 MG, 0 MG, 0 MG, 40 MG, 60 MG, 80 MG LAZANDA NASAL SPRAY,NON- 5 PA; NDS; QL (0 per 0 AEROSOL 100 MCG/SPRAY, 00 MCG/SPRAY, 400 MCG/SPRAY lorcet (hydrocodone) oral tablet 5-5 QL (60 per 0 lorcet hd oral tablet 10-5 QL (60 per 0 5

16 lorcet plus oral tablet QL (60 per 0 margesic oral capsule PA-HRM; QL (180 per 0 ; AGE (Max 64 Years) methadone injection solution 10 /ml methadone oral solution 10 /5 ml, 5 QL (1800 per 0 /5 ml methadone oral tablet 10 (Dolophine) QL (60 per 0 methadone oral tablet 5 (Dolophine) QL (180 per 0 methadose oral tablet,soluble 40 QL (90 per 0 morphine 10 /ml carpuject outer, p/f, l/f, suv 10 /ml morphine /ml carpuject outer, l/f, p/f, sdv /ml morphine 4 /ml syringe p/f, latexfree,suv 4 /ml morphine 8 /ml syringe 8 /ml morphine concentrate oral solution 100 QL (180 per 0 /5 ml (0 /ml) morphine intramuscular pen injector 10 /0.7 ml morphine intravenous cartridge 15 /ml morphine intravenous syringe 10 /ml, /ml, 4 /ml, 8 /ml morphine oral solution 10 /5 ml QL (700 per 0 morphine oral solution 0 /5 ml (4 QL (00 per 0 /ml) MORPHINE ORAL TABLET 15 MG 4 QL (180 per 0 MORPHINE ORAL TABLET 0 MG 4 QL (10 per 0 morphine oral tablet extended release 100 (MS Contin) QL (60 per 0, 00, 60 morphine oral tablet extended release 15 (MS Contin) QL (180 per 0 morphine oral tablet extended release 0 (MS Contin) QL (10 per 0 NUCYNTA ER ORAL TABLET QL (60 per 0 EXTENDED RELEASE 1 HR 100 MG, 150 MG, 00 MG, 50 MG, 50 MG NUCYNTA ORAL TABLET 100 MG, 50 MG, 75 MG QL (181 per 0 6

17 oxycodone oral capsule 5 QL (180 per 0 oxycodone oral concentrate 0 /ml QL (10 per 0 oxycodone oral solution 5 /5 ml QL (100 per 0 oxycodone oral tablet 10 QL (180 per 0 oxycodone oral tablet 15, 0 (Roxicodone) QL (10 per 0 oxycodone oral tablet 0 QL (10 per 0 oxycodone oral tablet 5 (Roxicodone) QL (180 per 0 oxycodone oral tablet,oral only,ext.rel.1 (OxyContin) QL (60 per 0 hr 10, 15, 0, 0, 40, 60 oxycodone oral tablet,oral only,ext.rel.1 hr 80 (OxyContin) ; QL (10 per 0 oxycodone-acetaminophen oral solution 5- QL (1800 per 0 5 /5 ml oxycodone-acetaminophen oral tablet 10- (Endocet) QL (40 per 0 5 oxycodone-acetaminophen oral tablet.5- (Endocet) QL (60 per 0 5, 5-5 oxycodone-acetaminophen oral tablet 7.5- (Endocet) QL (00 per 0 5 oxycodone-aspirin oral tablet QL (60 per 0 OXYCONTIN ORAL TABLET,ORAL QL (60 per 0 ONLY,EXT.REL.1 HR 10 MG, 15 MG, 0 MG, 0 MG, 40 MG, 60 MG OXYCONTIN ORAL TABLET,ORAL QL (10 per 0 ONLY,EXT.REL.1 HR 80 MG oxymorphone oral tablet 10 (Opana) QL (10 per 0 oxymorphone oral tablet 5 (Opana) QL (180 per 0 oxymorphone oral tablet extended release QL (60 per 0 1 hr 10, 15, 0, 0, 40, 5, 7.5 reprexain oral tablet 10-00,.5-00 QL (150 per 0, 5-00 tencon oral tablet 50-5 PA-HRM; QL (180 per 0 ; AGE (Max 64 Years) tramadol oral tablet 50 (Ultram) QL (40 per 0 7

18 tramadol-acetaminophen oral tablet 7.5- (Ultracet) QL (40 per 0 5 vicodin es oral tablet QL (90 per 0 vicodin hp oral tablet QL (90 per 0 vicodin oral tablet 5-00 QL (90 per 0 XARTEMIS XR ORAL TAB,ORAL QL (00 per 0 ONLY,IR - ER, BIPHASE MG XTAMPZA ER ORAL QL (60 per 0 CAPSULE,SPRINKLE,ER 1HR TMPRR 1.5 MG, 18 MG, 9 MG XTAMPZA ER ORAL QL (10 per 0 CAPSULE,SPRINKLE,ER 1HR TMPRR 7 MG XTAMPZA ER ORAL QL (40 per 0 CAPSULE,SPRINKLE,ER 1HR TMPRR 6 MG xylon 10 oral tablet QL (150 per 0 zebutal oral capsule PA-HRM; QL (180 per 0 ; AGE (Max 64 Years) ZOHYDRO ER ORAL CAPSULE, 4 QL (60 per 0 ORAL ONLY, ER 1HR 10 MG, 15 MG, 0 MG, 0 MG, 40 MG, 50 MG Nonsteroidal Anti-Inflammatory Agents CALDOLOR INTRAVENOUS RECON 4 SOLN 400 MG/4 ML (100 MG/ML), 800 MG/8 ML (100 MG/ML) celecoxib oral capsule 100, 00, (Celebrex) QL (60 per 0 400, 50 diclofenac potassium oral tablet 50 diclofenac sodium oral tablet extended (Voltaren-XR) release 4 hr 100 diclofenac sodium oral tablet,delayed release (dr/ec) 5, 50, 75 diclofenac sodium topical gel 1 % (Voltaren) diclofenac-misoprostol oral (Arthrotec 50) tablet,ir,delayed rel,biphasic mcg diclofenac-misoprostol oral (Arthrotec 75) tablet,ir,delayed rel,biphasic mcg 8

19 diflunisal oral tablet 500 etodolac oral capsule 00, 00 etodolac oral tablet 400 (Lodine) etodolac oral tablet 500 etodolac oral tablet extended release 4 hr 400, 500, 600 fenoprofen oral tablet 600 FLECTOR TRANSDERMAL PATCH 1 PA HOUR 1. % flurbiprofen oral tablet 100, 50 ibuprofen oral suspension 100 /5 ml (Child Ibuprofen) ibuprofen oral tablet 400, 600, indomethacin oral capsule 5 1 QL (40 per 0 indomethacin oral capsule 50 1 QL (10 per 0 indomethacin oral capsule, extended QL (60 per 0 release 75 indomethacin sodium intravenous recon soln 1 ketoprofen oral capsule 50, 75 ketoprofen oral capsule,ext rel. pellets 4 hr 00 ketorolac injection cartridge 15 /ml QL (40 per 0 ketorolac injection cartridge 0 /ml QL (0 per 0 ketorolac injection solution 15 /ml QL (40 per 0 ketorolac injection solution 0 /ml (1 QL (0 per 0 ml) ketorolac injection syringe 0 /ml QL (0 per 0 ketorolac intramuscular solution 60 / QL (0 per 0 ml ketorolac oral tablet 10 QL (0 per 0 mefenamic acid oral capsule 50 (Ponstel) meloxicam oral suspension 7.5 /5 ml meloxicam oral tablet 15, 7.5 (Mobic) 1 nabumetone oral tablet 500, 750 naproxen oral suspension 15 /5 ml (Naprosyn) naproxen oral tablet 50, 75 1 naproxen oral tablet 500 (Naprosyn) 1 9

20 naproxen oral tablet,delayed release (EC-Naprosyn) (dr/ec) 75, 500 naproxen sodium oral tablet 75 naproxen sodium oral tablet 550 (Anaprox DS) piroxicam oral capsule 10, 0 (Feldene) sulindac oral tablet 150, 00 tolmetin oral capsule 400 tolmetin oral tablet 00, 600 VOLTAREN TOPICAL GEL 1 % Anesthetics Local Anesthetics glydo mucous membrane jelly in applicator % lidocaine (pf) injection solution 10 /ml (Xylocaine-MPF) (1 %), 15 /ml (1.5 %), 0 /ml ( %), 5 /ml (0.5 %) lidocaine (pf) injection solution 40 /ml (4 %) lidocaine hcl injection solution 10 /ml (Xylocaine) (1 %), 0 /ml ( %), 5 /ml (0.5 %) lidocaine hcl injection syringe 10 /ml (1 %) lidocaine hcl mucous membrane jelly % lidocaine hcl mucous membrane solution 4 % (40 /ml) lidocaine hcl(pf) in 0.9% nacl injection syringe 100 /10 ml (1 %) lidocaine topical adhesive (Lidoderm) PA; patch,medicated 5 % lidocaine topical ointment 5 % PA NSO; QL (90 per 0 lidocaine viscous mucous membrane solution % lidocaine-prilocaine topical cream.5-.5 % Anti-Addiction/Substance Abuse Treatment Agents acamprosate oral tablet,delayed release (dr/ec) BUNAVAIL BUCCAL FILM.1-0. MG QL (0 per 0 10

21 BUNAVAIL BUCCAL FILM QL (60 per 0 MG, 6.-1 MG buprenorphine hcl sublingual tablet, PA; QL (90 per 0 8 buprenorphine-naloxone sublingual tablet QL (90 per 0-0.5, 8- buproban oral tablet extended release 1 hr 150 bupropion hcl (smoking deter) oral tablet extended release 1 hr 150 (Zyban) CHANTIX CONTINUING MONTH QL (168 per 84 BOX ORAL TABLET 1 MG CHANTIX ORAL TABLET 0.5 MG, 1 MG QL (168 per 84 CHANTIX STARTING MONTH BOX ORAL TABLETS,DOSE PACK 0.5 MG (11)- 1 MG (4) QL (5 per 8 disulfiram oral tablet 50, 500 (Antabuse) naloxone injection solution 0.4 /ml naloxone injection syringe 0.4 /ml, 1 /ml naltrexone oral tablet 50 NARCAN NASAL SPRAY,NON- QL (4 per 0 AEROSOL MG/ACTUATION, 4 MG/ACTUATION NICOTROL INHALATION 4 QL (1008 per 90 CARTRIDGE 10 MG SUBOXONE SUBLINGUAL FILM 1- QL (60 per 0 MG, 8- MG SUBOXONE SUBLINGUAL FILM -0.5 QL (0 per 0 MG, 4-1 MG ZUBSOLV SUBLINGUAL TABLET 0.7- QL (0 per MG, MG, MG, MG, MG ZUBSOLV SUBLINGUAL TABLET 8.6- QL (60 per 0.1 MG Antianxiety Agents Benzodiazepines alprazolam oral tablet 0.5, 0.5, 1 (Xanax) 1 QL (10 per 0 11

22 alprazolam oral tablet (Xanax) 1 QL (150 per 0 alprazolam oral tablet extended release 4 (Xanax XR) QL (10 per 0 hr 0.5, 1, alprazolam oral tablet extended release 4 (Xanax XR) QL (90 per 0 hr chlordiazepoxide hcl oral capsule 10, 5, 5 1 QL (10 per 0 clonazepam oral tablet 0.5, 1 (Klonopin) 1 QL (90 per 0 clonazepam oral tablet (Klonopin) 1 QL (00 per 0 clonazepam oral tablet,disintegrating QL (90 per , 0.5, 0.5, 1 clonazepam oral tablet,disintegrating QL (00 per 0 clorazepate dipotassium oral tablet 15,.75 QL (180 per 0 clorazepate dipotassium oral tablet 7.5 (Tranxene T-Tab) QL (180 per 0 DIASTAT ACUDIAL RECTAL KIT MG, MG DIASTAT RECTAL KIT.5 MG 4 diazepam injection solution 5 /ml QL (10 per 8 diazepam intensol oral concentrate 5 QL (100 per 0 /ml diazepam oral solution 5 /5 ml (1 /ml) QL (100 per 0 diazepam oral tablet 10,, 5 (Valium) 1 QL (10 per 0 diazepam rectal kit , 5- (Diastat AcuDial) diazepam rectal kit.5 (Diastat) estazolam oral tablet 1 PA-HRM; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use with any benzodiazepine hypnotic drug); QL (60 per 0 ; AGE (Max 64 Years) 1

23 estazolam oral tablet PA-HRM; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use with any benzodiazepine hypnotic drug); QL (0 per 0 ; AGE (Max 64 Years) flurazepam oral capsule 15 PA-HRM; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use with any benzodiazepine hypnotic drug); QL (60 per 0 ; AGE (Max 64 Years) flurazepam oral capsule 0 PA-HRM; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use with any benzodiazepine hypnotic drug); QL (0 per 0 ; AGE (Max 64 Years) lorazepam /ml oral concent /ml (Lorazepam Intensol) QL (150 per 0 lorazepam injection solution /ml (Ativan) QL ( per 0 lorazepam intensol oral concentrate QL (150 per 0 /ml lorazepam oral tablet 0.5, 1 (Ativan) 1 QL (90 per 0 lorazepam oral tablet (Ativan) 1 QL (150 per 0 midazolam oral syrup /ml QL (10 per 0 ONFI ORAL SUSPENSION.5 MG/ML 5 PA NSO; NDS; QL (480 per 0 ONFI ORAL TABLET 10 MG, 0 MG 5 PA NSO; NDS; QL (60 per 0 1

24 temazepam oral capsule 15,.5, 0 (Restoril) PA-HRM; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use with any benzodiazepine hypnotic drug); QL (0 per 0 ; AGE (Max 64 Years) temazepam oral capsule 7.5 (Restoril) PA-HRM; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use with any benzodiazepine hypnotic drug); QL (10 per 0 ; AGE (Max 64 Years) triazolam oral tablet 0.15 PA-HRM; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use with any benzodiazepine hypnotic drug); QL (10 per 0 ; AGE (Max 64 Years) triazolam oral tablet 0.5 (Halcion) PA-HRM; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use with any benzodiazepine hypnotic drug); QL (60 per 0 ; AGE (Max 64 Years) 14

25 Antibacterials Aminoglycosides BETHKIS INHALATION SOLUTION 5 PA BvD; NDS FOR NEBULIZATION 00 MG/4 ML gentamicin in nacl (iso-osm) intravenous piggyback 100 /100 ml, 100 /50 ml, 60 /50 ml, 70 /50 ml, 80 /100 ml, 80 /50 ml, 90 /100 ml gentamicin injection solution 40 /ml gentamicin ped 0 / ml vial latex-free, sdv 0 / ml gentamicin sulfate (pf) intravenous solution 100 /10 ml neomycin oral tablet 500 streptomycin intramuscular recon soln 1 gram TOBI PODHALER INHALATION CAPSULE, W/INHALATION DEVICE 8 MG ; QL (4 per 8 tobramycin in 0.5 % nacl inhalation (Tobi) 5 PA BvD; NDS solution for nebulization 00 /5 ml tobramycin in 0.9 % nacl intravenous piggyback 60 /50 ml tobramycin sulfate injection solution 10 /ml, 40 /ml Antibacterials, Miscellaneous baciim intramuscular recon soln 50,000 unit bacitracin intramuscular recon soln (BACiiM) 50,000 unit chloramphenicol sod succinate intravenous recon soln 1 gram clindamycin 75 /5 ml soln 75 /5 ml (Cleocin Pediatric) clindamycin hcl oral capsule 150, 00 (Cleocin HCl), 75 clindamycin in 5 % dextrose intravenous piggyback 00 /50 ml, 600 /50 ml, 900 /50 ml (Cleocin in 5 % dextrose) 15

26 clindamycin pediatric oral recon soln 75 /5 ml clindamycin phosphate injection solution 150 (/ml) (6 ml) clindamycin phosphate injection solution (Cleocin) 150 /ml clindamycin phosphate intravenous (Cleocin) solution 600 /4 ml colistin (colistimethate na) injection recon (Coly-Mycin M soln 150 Parenteral) daptomycin intravenous recon soln 500 (Cubicin) linezolid intravenous parenteral solution 600 /00 ml (Zyvox) linezolid oral suspension for reconstitution (Zyvox) 100 /5 ml linezolid oral tablet 600 (Zyvox) methenamine hippurate oral tablet 1 gram (Hiprex) metronidazole in nacl (iso-os) intravenous (Metro I.V.) piggyback 500 /100 ml metronidazole oral capsule 75 (Flagyl) metronidazole oral tablet 50, 500 (Flagyl) nitrofurantoin macrocrystal oral capsule 100, 5, 50 (Macrodantin) PA-HRM; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use of nitrofurantoin drugs); QL (10 per 0 ; AGE nitrofurantoin monohyd/m-cryst oral capsule 100 (Max 64 Years) (Macrobid) PA-HRM; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use of nitrofurantoin drugs); QL (60 per 0 ; AGE (Max 64 Years) 16

27 nitrofurantoin oral suspension 5 /5 ml (Furadantin) PA-HRM; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use of nitrofurantoin drugs); QL (400 per 0 ; AGE (Max 64 Years) polymyxin b sulfate injection recon soln 500,000 unit SYNERCID INTRAVENOUS RECON SOLN 500 MG trimethoprim oral tablet 100 vancomycin hcl 1g/00 ml bag 1 gram/00 ml vancomycin intravenous recon soln 1,000, 10 gram, 750 vancomycin intravenous recon soln 500 vancomycin oral capsule 15, 50 (Vancocin) XIFAXAN ORAL TABLET 00 MG 5 PA; NDS; QL (9 per 0 XIFAXAN ORAL TABLET 550 MG 5 PA; NDS Cephalosporins cefaclor oral capsule 50, 500 cefaclor oral suspension for reconstitution 15 /5 ml, 50 /5 ml, 75 /5 ml cefaclor oral tablet extended release 1 hr 500 cefadroxil oral capsule 500 cefadroxil oral suspension for reconstitution 50 /5 ml, 500 /5 ml cefadroxil oral tablet 1 gram cefazolin in dextrose (iso-os) intravenous piggyback 1 gram/50 ml, gram/50 ml cefazolin injection recon soln 1 gram, 10 gram, 500 cefdinir oral capsule 00 17

28 cefdinir oral suspension for reconstitution 15 /5 ml, 50 /5 ml cefditoren pivoxil oral tablet 00 cefditoren pivoxil oral tablet 400 (Spectracef) CEFEPIME 1 GM INJECTION 1 GRAM/50 ML CEFEPIME INJECTION RECON SOLN (Maxipime) 1 GRAM, GRAM CEFEPIME-DEXTROSE GM/50 ML GRAM/50 ML cefixime oral suspension for reconstitution (Suprax) 100 /5 ml, 00 /5 ml cefotaxime injection recon soln 1 gram, 500 cefotaxime injection recon soln 10 gram, (Claforan) gram cefoxitin gm piggyback bag gram/50 ml cefoxitin intravenous recon soln 1 gram, 10 gram cefoxitin intravenous recon soln gram cefpodoxime oral suspension for reconstitution 100 /5 ml, 50 /5 ml cefpodoxime oral tablet 100, 00 cefprozil oral suspension for reconstitution 15 /5 ml, 50 /5 ml cefprozil oral tablet 50, 500 ceftazidime injection recon soln gram, 6 (Fortaz) gram ceftibuten oral capsule 400 (Cedax) ceftibuten oral suspension for (Cedax) reconstitution 180 /5 ml ceftriaxone 1 gm piggyback l/g, single use 1 gram/50 ml ceftriaxone gm piggyback l/f, single use gram/50 ml ceftriaxone injection recon soln 10 gram, 50, 500 ceftriaxone intravenous recon soln 1 gram, gram 18

29 cefuroxime axetil oral tablet 50, 500 cefuroxime sodium injection recon soln (Zinacef) 750 cefuroxime sodium intravenous recon soln (Zinacef) 1.5 gram, 7.5 gram cefuroxime-dextrose (iso-osm) intravenous piggyback 750 /50 ml cephalexin oral capsule 50, 500 (Keflex) 1 cephalexin oral capsule 750 (Keflex) cephalexin oral suspension for 1 reconstitution 15 /5 ml, 50 /5 ml cephalexin oral tablet 50, MEFOXIN IN DEXTROSE (ISO-OSM) 4 INTRAVENOUS PIGGYBACK 1 GRAM/50 ML, GRAM/50 ML SUPRAX ORAL CAPSULE 400 MG 4 SUPRAX ORAL SUSPENSION FOR 4 RECONSTITUTION 500 MG/5 ML SUPRAX ORAL TABLET,CHEWABLE MG, 00 MG tazicef injection recon soln gram, 6 gram TEFLARO INTRAVENOUS RECON 4 SOLN 400 MG, 600 MG Macrolides azithromycin intravenous recon soln 500 (Zithromax) azithromycin oral packet 1 gram (Zithromax) azithromycin oral suspension for (Zithromax) reconstitution 100 /5 ml, 00 /5 ml azithromycin oral tablet 50 (6 pack), 500 ( pack) azithromycin oral tablet 50, 500, (Zithromax) 600 clarithromycin oral suspension for reconstitution 15 /5 ml, 50 /5 ml clarithromycin oral tablet 50,

30 clarithromycin oral tablet extended release 4 hr 500 DIFICID ORAL TABLET 00 MG ; QL (0 per 10 e.e.s. 400 oral tablet 400 e.e.s. granules oral suspension for reconstitution 00 /5 ml ery-tab oral tablet,delayed release (dr/ec) 50, 500 ERY-TAB ORAL TABLET,DELAYED RELEASE (DR/EC) MG 4 erythrocin (as stearate) oral tablet 50 ERYTHROCIN INTRAVENOUS 4 RECON SOLN 1,000 MG, 500 MG erythromycin ethylsuccinate oral (E.E.S. Granules) suspension for reconstitution 00 /5 ml erythromycin ethylsuccinate oral tablet (E.E.S. 400) 400 erythromycin oral capsule,delayed release(dr/ec) 50 erythromycin oral tablet 50, 500 Miscellaneous B-Lactam Antibiotics aztreonam injection recon soln 1 gram, gram (Azactam) CAYSTON INHALATION SOLUTION 5 LA; NDS FOR NEBULIZATION 75 MG/ML imipenem-cilastatin intravenous recon soln 50 imipenem-cilastatin intravenous recon (Primaxin IV) soln 500 INVANZ INJECTION RECON SOLN 1 4 GRAM meropenem intravenous recon soln 1 (Merrem) gram, 500 Penicillins amoxicillin oral capsule 50, amoxicillin oral suspension for 1 reconstitution 15 /5 ml, 00 /5 ml, 50 /5 ml, 400 /5 ml amoxicillin oral tablet 500,

31 amoxicillin oral tablet,chewable 15, 1 50 amoxicillin-pot clavulanate oral suspension for reconstitution /5 ml, /5 ml amoxicillin-pot clavulanate oral (Augmentin) suspension for reconstitution /5 ml amoxicillin-pot clavulanate oral (Augmentin ES-600) suspension for reconstitution /5 ml amoxicillin-pot clavulanate oral tablet amoxicillin-pot clavulanate oral tablet (Augmentin) , amoxicillin-pot clavulanate oral tablet (Augmentin XR) extended release 1 hr 1, amoxicillin-pot clavulanate oral tablet,chewable , ampicillin oral capsule 50, ampicillin oral suspension for 1 reconstitution 15 /5 ml, 50 /5 ml ampicillin sodium injection recon soln 1 gram, 10 gram, 15, gram, 50, 500 ampicillin sodium intravenous recon soln gram ampicillin-sulbactam injection recon soln (Unasyn) 1.5 gram, 15 gram, gram BICILLIN C-R INTRAMUSCULAR 4 SYRINGE 1,00,000 UNIT/ ML(600K/600K), 1,00,000 UNIT/ ML(900K/00K) BICILLIN L-A INTRAMUSCULAR 4 SYRINGE 1,00,000 UNIT/ ML,,400,000 UNIT/4 ML, 600,000 UNIT/ML dicloxacillin oral capsule 50, 500 nafcillin gm vial 10's, latex-free gram 1

32 nafcillin injection recon soln 1 gram, 10 gram nafcillin intravenous recon soln gram oxacillin in dextrose(iso-osm) intravenous piggyback 1 gram/50 ml, gram/50 ml oxacillin injection recon soln 10 gram, gram oxacillin intravenous recon soln 1 gram penicillin g pot in dextrose intravenous piggyback 1 million unit/50 ml, million unit/50 ml, million unit/50 ml penicillin g potassium injection recon soln (Pfizerpen-G) 5 million unit penicillin g procaine intramuscular syringe 1. million unit/ ml, 600,000 unit/ml penicillin gk 0 million unit 0 million unit (Pfizerpen-G) penicillin v potassium oral recon soln 15 /5 ml, 50 /5 ml penicillin v potassium oral tablet 50, 500 pfizerpen-g injection recon soln 0 million unit piperacillin-tazobactam intravenous recon (Zosyn) soln.5 gram,.75 gram, 4.5 gram, 40.5 gram Quinolones ciprofloxacin (mixture) oral tablet, er (Cipro XR) multiphase 4 hr 1,000, 500 ciprofloxacin hcl oral tablet 100, ciprofloxacin hcl oral tablet 50, 500 (Cipro) 1 ciprofloxacin in 5 % dextrose intravenous piggyback 00 /100 ml ciprofloxacin in 5 % dextrose intravenous (Cipro in D5W) piggyback 400 /00 ml ciprofloxacin lactate intravenous solution 00 /0 ml, 400 /40 ml

33 ciprofloxacin oral (Cipro) suspension,microcapsule recon 50 /5 ml, 500 /5 ml levofloxacin in d5w intravenous piggyback 50 /50 ml, 500 /100 ml, 750 /150 ml levofloxacin intravenous solution 5 /ml levofloxacin oral solution 50 /10 ml levofloxacin oral tablet 50, 500, (Levaquin) moxifloxacin oral tablet 400 (Avelox) ofloxacin oral tablet 00, 400 Sulfonamides sulfadiazine oral tablet 500 sulfamethoxazole-trimethoprim intravenous solution /5 ml sulfamethoxazole-trimethoprim oral (Sulfatrim) suspension /5 ml sulfamethoxazole-trimethoprim oral tablet (Bactrim) sulfamethoxazole-trimethoprim oral tablet (Bactrim DS) sulfasalazine oral tablet 500 (Azulfidine) sulfasalazine oral tablet,delayed release (Azulfidine EN-tabs) (dr/ec) 500 sulfatrim oral suspension /5 ml Tetracyclines demeclocycline oral tablet 150, 00 doxy-100 intravenous recon soln 100 doxycycline hyclate intravenous recon (Doxy-100) soln 100 doxycycline hyclate oral capsule 100, (Morgidox) 50 doxycycline hyclate oral tablet 100, 0 doxycycline hyclate oral tablet,delayed release (dr/ec) 100, 150, 75