Pharmacy Benefit Guide

Transcription

1 Pharmacy Benefit Guide

2 Together with CCHP PO Box MS 6280 Milwaukee, WI Toll-free: togethercchp.org Pharmacy Program Overview The pharmacy program of Together with Children s Community Health Plan (CCHP) offers a variety of high-quality, effective generic and brand-name prescription drugs. This guide provides information that applies to most members. For information specific to your plan, please read your Schedule of Benefits. When you need a prescription medication, you and your doctor can choose from six different levels, or tiers. Each tier has a different copayment. This gives you and your doctor the freedom to choose the medication that is right for you. At the same time, this will help you to better budget your health care dollars. This guide provides an overview of your pharmacy benefit with Together with CCHP. It explains the copayment structure, the process for getting certain drugs covered, your options for filling prescriptions, important phone numbers, and more. Contact Numbers Current Together with CCHP Members: o Customer Service: o Pharmacy Services (for practitioners and pharmacies): o Hearing-impaired members: Prospective Together with CCHP Members: o Prospective members should direct their questions to Together with CCHP Sales Team at o Online information is available at togethercchp.org/formulary Read your contract carefully to determine which health care services are covered. This Pharmacy Benefit Guide is effective September, 208. For the latest information on the Together with CCHP drug formulary and other pharmacy benefits, go to: togethercchp.org/formulary. You may also call our Customer Service at the number listed above or on the back of your member ID card. Page of 7 Effective

3 Together with CCHP PO Box MS 6280 Milwaukee, WI Toll-free: togethercchp.org Understanding Coverage and Cost Sharing Our formulary is the list of Food and Drug Administration (FDA)-approved drugs that we cover. Our Pharmacy and Therapeutics (P&T) Committee researches and evaluates medications it may cover. Committee members include local doctors and pharmacists who meet regularly during the year to review and update the formulary. Committee members base their decision on the drug s safety, effectiveness, and cost. Together with CCHP prescription drugs are organized into six formulary tiers: Tier is for generic medications, which have the lowest copayment. Generic drugs offer the same level of safety and quality as their brand-name equivalents. They have the same amount of active ingredients as brand-name medications. Together with CCHP requires you to use a generic version of the drug if one is available. This means that if you receive a brand-name drug when a generic is available, you must pay the brand copayment in addition to the retail cost difference between the brand-name and generic forms of the drug. Tier 2 is for preferred-brand medications. Together with CCHP classifies these drugs as preferred because of their value and effectiveness. Tier is for non-preferred medications (brand and generic). Tier 4 is for specialty medications, for which you will have the highest level of cost sharing. Specialty medications usually treat complex and rare conditions. These drugs are created because of advancements in drug development. These drugs can be high-cost medications and biologicals regardless of how they are administered (injectable, oral, transdermal, or inhalant). Specialty drugs require close management by a physician. Physicians need to monitor these drugs due to potential side effects and the need for frequent dosage adjustments. Tier 5 is for select generic medications. Select generic medications are offered at no additional cost share to you. Many of these medications can help you to avoid getting sick and to improve your overall health. Tier 6 is for zero cost share preventive drugs. In accordance with the Patient Protection and Affordable Care Act of 200 (PPACA), many select preventive medications are covered at no cost to you. About Generic Drugs Generic drugs have the same active ingredients as their brand-name equivalents, but cost significantly less. Not all drugs have a generic equivalent. Generally, new drugs receive patent protection. Once the patent expires, other pharmaceutical companies can produce the same drug in a generic formulation. Companies that make generic drugs do not have to invest large amounts of money in research, since the company making the brand-name equivalent has already done this. Also, generic companies do not need to advertise their drugs. As a result, generic drug makers can pass these savings on to you. Generic medications have the same active ingredients as brand-name drugs, but their inactive ingredients can vary. This is why the generic drug might look different from the brand-name drug. Inactive ingredients can be dyes used to color the drug or powders used to shape the tablets. Inactive ingredients do not affect how the generic drug works. Page 2 of 7 Effective

4 Together with CCHP PO Box MS 6280 Milwaukee, WI Toll-free: togethercchp.org The FDA regulates generic drug manufacturers just as it regulates the makers of brand-name medications. The generic drug must pass strict FDA measurements to ensure that it delivers the same amount of the active ingredient in the same time frame as its brand-name counterpart. The manufacturer of the generic drug must prove that it produces its product under the same strict guidelines as the brand-name drug. Formulary Overview The most commonly prescribed Together with CCHP drugs are listed in the formulary section of this guide. Please note there are other drugs that Together with CCHP covers in addition to the ones listed in this guide. For the latest information on the complete Together with CCHP formulary and other pharmacy benefits, visit our website at togethercchp.org/formulary. (Select Together with CCHP to access the searchable drug list.) You may also call our Customer Service at the number listed on your member ID card or on the first page of this guide. If you are a current Together with CCHP member, refer to your Schedule of Benefits for your applicable coinsurance or copayment amounts. If you did not receive a Schedule of Benefits, contact our Customer Service at the number on your member ID card. Your member ID card should also list your applicable coinsurance or copayment amounts. For Prospective Members If you are thinking about joining Together with CCHP and would like information about applicable coinsurance or copayment amounts, go to the Summary of Benefits and Coverage (SBC) on the Together with CCHP website at togethercchp.org or call the Sales Support team at Understanding our symbols Prior Authorization You will see the symbol PA next to certain drugs on the formulary tables in this booklet. PA stands for Prior Authorization. If a drug requires prior authorization, the Together with CCHP Pharmacy Services Department must authorize the use of this drug before it will be covered. Drugs that require prior authorization are often: Newer drugs for which Together with CCHP wants to track usage. Drugs not used as a standard first-line option in treating a medical condition. Drugs with potential side effects that Together with CCHP wants to monitor for patient safety. Drugs categorized as specialty medications. Compounded medications that contain included ingredients require prior authorization. Step Therapy You will see the symbol ST next to certain drugs on the formulary tables in this booklet. ST stands for Step Therapy. Step therapy is the practice of using specific medications first when beginning drug therapy for a medical condition. The preferred first course of treatment may be generic medications or drugs that are considered as the standard first-line treatment. Step therapy is built into the electronic system that checks your medication history. A drug with step therapy will be automatically approved if there is a record that you have already tried the preferred drug(s). If there is no record that you Page of 7 Effective

5 Together with CCHP PO Box MS 6280 Milwaukee, WI Toll-free: togethercchp.org tried the preferred drug(s) in your medication history, your physician must submit relevant clinical information to the Together with CCHP Pharmacy Services Department before it will be covered. Quantity Limits You will see the symbol QL next to certain drugs on the formulary tables in this booklet. QL stands for Quantity Limits. Quantity limits are drug-specific and limit the amount of certain drugs that can be dispensed during a specified period of time. These limits are based on FDA guidelines, clinical literature, and the manufacturer s instructions. Quantity limits promote appropriate use of the drug, prevent waste, and help control costs. For some drugs, the dosing guidelines may recommend that patients take the drug one time a day in a larger dose instead of several times a day in smaller doses. The quantity limits follow the guidelines and cover one larger dose per day. Your physician can request an exception to the quantity limit through the Together with CCHP Pharmacy Services Department. Prescriptions for controlled substances and specialty medications are limited to a 0-day supply. Affordable Care Act You will see the symbol ACA next to certain drugs on the formulary tables in this booklet. ACA stands for Affordable Care Act. In accordance with the Patient Protection and Affordable Care Act of 200 (PPACA), many select preventive medications are covered at no cost to you. Over the Counter You will see the symbol OTC next to certain drugs on the formulary tables in this booklet. OTC stands for Over the Counter. Even though over the counter drugs can typically be purchased without a prescription, a prescription is required for coverage of these medications on your pharmacy benefit. Limited Availability You will see the symbol LA next to certain drugs on the formulary tables in this booklet. LA stands for Limited Availability. Limited availability drugs must be obtained through our designated specialty pharmacy provider. Getting Your Prescriptions Filled I. Retail The Together with CCHP network of retail pharmacies includes hundreds of locations independent pharmacies as well as multistore chains throughout the region. You can take your prescription to any pharmacy in the network. You must use 75 percent of your medication before you can get a refill. For specific pharmacy names, locations, and telephone numbers, visit togethercchp.org/pharmacy or call our Customer Service Team at II. Mail Order Page 4 of 7 Effective

6 Together with CCHP PO Box MS 6280 Milwaukee, WI Toll-free: togethercchp.org If you take maintenance medications for a chronic condition, you can get them through a mail order pharmacy. Maintenance medications are generally taken on a regular, long-term basis. This may include drugs to treat high blood pressure, diabetes, asthma, high cholesterol, and more. With convenient mail-order service: You receive a 90-day supply of most drugs, plus refills, as prescribed by your doctor. You usually pay a lower out-of-pocket cost for a 90-day supply at a mail-order pharmacy than you would pay at a retail pharmacy. You get these drugs delivered right to your door. Most mail order prescriptions are written for a 90-day supply. If your doctor writes for a 0-day supply with two refills, the mail order facility may combine the prescription to make a 90-day supply. If you do not want a 90-day supply, you should indicate this on the mail-order form. For a new medication, Together with CCHP recommends that you try a 0-day supply of the drug from a retail pharmacy. That way your doctor has a chance to make sure that it is the right dose for you and that it does not cause any side effects. Once you re confident that the medication is appropriate, ask your doctor to write a prescription for a 90-day supply of each maintenance drug that you need (plus refills if appropriate). Then order the supply through the mailorder pharmacy. To avoid running out of your mail-order prescription, reorder your medication while you still have an adequate supply remaining, allowing a few weeks for processing and delivery. To request refills, you may order online or over the telephone. You can request a mail-order form by calling Customer Service at or requesting the form here: togethercchp.org/member-forms III. Specialty Pharmacy Provider Specialty medications that require special handling, provider coordination, or patient education that cannot be provided by a retail pharmacy must be obtained through our designated specialty pharmacy provider. When you are prescribed a specialty medication and use a specialty pharmacy provider, you get mail-order delivery and improved access to drugs, as many retail pharmacies do not carry these types of medications. Specialty pharmacy providers also improve care by providing education for our members and expanded access to health care professionals trained in the proper use of these specialty medications. A specialty pharmacy provider offers cost-effective health care and medication management and compliance programs. Together with CCHP highly recommends the use of a specialty pharmacy provider. Most specialty medications are required to be filled by a specialty pharmacy provider; however, certain specialty medications can be obtained from a retail pharmacy. You may be assessed an increased cost share for your specialty medication if you continue to obtain from a retail pharmacy after the first fill. Page 5 of 7 Effective

7 Together with CCHP PO Box MS 6280 Milwaukee, WI Toll-free: togethercchp.org IV. Filling your prescription when traveling When you travel outside of the Together with CCHP service area, thousands of pharmacies across the country will honor your Together with CCHP member ID card. To locate a participating pharmacy, contact our Customer Service team at the phone number listed on the back of your member ID card or on page of this booklet. To fill a prescription at a participating out-of-area pharmacy, present your Together with CCHP member ID card. Some pharmacies may ask you to pay the full price of the medication. If that happens and your claim is approved, you will be reimbursed the amount that you paid for the medication, less the appropriate copayment. You can request a Pharmacy Program Direct Reimbursement Claim Form by calling the Customer Service team or requesting the form online at togethercchp.org/member-forms If you will be away from home for an extended period of time, or if you will be traveling outside of the country, you may want to use our mail-order service so that you receive a 90-day supply before you leave home. V. Medication Supplies Not Covered No authorizations will be provided for medications that are reported by the member, provider, or pharmacy to be lost, misplaced, stolen, destroyed, or damaged. Medications received at no charge to the member (workers compensation, medications purchased with a manufacturer s coupon, etc.) will not be covered. Prescriptions that are written more than a year ago will not be covered. Your doctor will need to write a new prescription. VI. Medications not covered The following medications are benefit exclusions and will not be covered under the pharmacy benefit: Antimalarial agents when used for prevention Antiobesity medications, including, but not limited to, appetite suppressants and lipase inhibitors Blood or blood plasma products* Compounded products containing excluded ingredients (examples are compounded hormone replacement therapies and compounded narcotic analgesics) Drugs labeled for investigational use Drugs used for cosmetic purposes or hair growth Drugs used to treat sexual dysfunction (examples are Cialis, Levitra, Stendra, Viagra, Caverject, Muse, Intrarosa, and Osphena) Fertility agents Legend vitamins (other than prenatal, fluoride, and certain therapeutic vitamins) Most over the counter medications** Needles/syringes (other than insulin) * Nutrition and dietary supplements* Ostomy supplies* Page 6 of 7 Effective

8 Together with CCHP PO Box MS 6280 Milwaukee, WI Toll-free: togethercchp.org Therapeutic devices/appliances* Urine strips (Because our doctors feel blood glucose strips are more accurate than urine test strips in measuring blood glucose, urine strips are not a covered benefit.) This is not a complete list and there may be other medications that are not covered. For more information, please contact Customer Service at the phone number on the back of your member ID card or on the first page of this guide. *Please note that, under certain circumstances, your medical benefits may cover the items marked with an asterisk (*). For information on these items, you can contact our Customer Service team at the number listed on the back of your member ID card. If you have not yet received an ID card, call our Customer Service team number listed on page of this booklet. **Additional over the counter medications may be covered in accordance with the Patient Protection and Affordable Care Act. The Preventive Service Guide available at togethercchp.org/preventive-guidelines Drug Exceptions Time Frames and Enrollee Responsibilities If the medication you take is not on the list of covered drugs for your benefit plan (also called a formulary ), you can ask us to cover it. This is called a non-formulary exception. A request for a non-formulary exception will only be approved if there is documented evidence that the formulary alternatives are not effective in treating your condition; the formulary alternatives would cause adverse side effects; or a contraindication exists such that you cannot safely try the formulary medication. As a first step, you can contact Customer Service for a list of similar drugs that are covered by your plan or you can go to togethercchp.org/formulary for this information. When you have the list, show it to your doctor and see whether he or she is able to prescribe one of the drugs on this list. If you need to request a non-formulary exception, contact Member Services or access the exception request form through your member portal CCHP Connect (togethercchp.org/cchp-connect). When you make this request, we may contact your prescriber or physician for information to support your request. After Together with CCHP receives your request, we will make our decision within 72 hours. You can request a faster (expedited) decision if you or your doctor believe that waiting up to 72 hours for a decision could seriously harm your health. If your request to expedite is granted, we must give you a decision no later than 24 hours from when we received your request. If we deny your request for a non-formulary exception, you may first request an internal review of that decision by contacting Customer Service. If the denial of the non-formulary exception request is upheld through an internal review, you may then request an external review by an Independent Review Organization (IRO). Requests for an external review can also be made by contacting Customer Service at Page 7 of 7 Effective

9 Table of Contents ANTI - INFECTIVES... ANTINEOPLASTIC & IMMUNOSUPPRESSANT DRUGS... 5 AUTONOMIC & CNS DRUGS, NEUROLOGY & PSYCH... 2 CARDIOVASCULAR, HYPERTENSION & LIPIDS... 9 DERMATOLOGICALS/TOPICAL THERAPY DIAGNOSTICS & MISCELLANEOUS AGENTS EAR, NOSE & THROAT MEDICATIONS ENDOCRINE/DIABETES GASTROENTEROLOGY IMMUNOLOGY, VACCINES & BIOTECHNOLOGY MUSCULOSKELETAL & RHEUMATOLOGY OBSTETRICS & GYNECOLOGY OPHTHALMOLOGY RESPIRATORY, ALLERGY, COUGH & COLD UROLOGICALS... 0 VITAMINS, HEMATINICS & ELECTROLYTES Index... 4

10 List of Abbreviations ACA: Affordable Care Act. LA: Limited Availability. This prescription may be available only at certain pharmacies. For more information, please call Customer Service. OTC: Over the Counter. An OTC drug is a non-prescription drug. 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 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. 2

11 ANTI - INFECTIVES ANTIFUNGAL AGENTS ABELCET INTRAVENOUS SUSPENSION AMBISOME INTRAVENOUS SUSPENSION FOR RECONSTITUTION amphotericin b injection recon soln caspofungin intravenous recon soln clotrimazole mucous membrane troche CRESEMBA INTRAVENOUS RECON SOLN 4 QL CRESEMBA ORAL CAPSULE 4 QL ERAXIS(WATER DILUENT) INTRAVENOUS RECON SOLN fluconazole in nacl (iso-osm) intravenous piggyback 200 mg/00 ml, 400 mg/200 ml fluconazole oral suspension for reconstitution fluconazole oral tablet QL flucytosine oral capsule 4 griseofulvin microsize oral suspension griseofulvin microsize oral tablet griseofulvin ultramicrosize oral tablet itraconazole oral capsule PA; QL ketoconazole oral tablet MYCAMINE INTRAVENOUS RECON SOLN NOXAFIL ORAL SUSPENSION 4 PA NOXAFIL ORAL TABLET,DELAYED RELEASE (DR/EC) nystatin oral powder 50 million unit, 500 million unit nystatin oral suspension nystatin oral tablet 4 PA; QL ONMEL ORAL TABLET PA; QL ORAVIG BUCCAL MUCO-ADHESIVE BUCCAL TABLET PA; QL

12 SPORANOX ORAL SOLUTION PA terbinafine hcl oral tablet QL voriconazole intravenous solution voriconazole oral suspension for reconstitution 4 QL voriconazole oral tablet 4 QL ANTIVIRALS abacavir oral solution QL abacavir oral tablet QL abacavir-lamivudine oral tablet QL abacavir-lamivudine-zidovudine oral tablet QL acyclovir oral capsule acyclovir oral suspension 200 mg/5 ml acyclovir oral tablet acyclovir sodium intravenous solution adefovir oral tablet 4 PA amantadine hcl oral capsule amantadine hcl oral solution amantadine hcl oral tablet APTIVUS ORAL CAPSULE 4 QL APTIVUS ORAL SOLUTION 4 QL atazanavir oral capsule QL ATRIPLA ORAL TABLET 4 QL BARACLUDE ORAL SOLUTION 4 PA BIKTARVY ORAL TABLET 4 QL cidofovir intravenous solution CIMDUO ORAL TABLET 2 QL COMPLERA ORAL TABLET 4 QL CRIXIVAN ORAL CAPSULE 200 MG, 400 MG 2 QL DAKLINZA ORAL TABLET 4 PA; LA; QL DESCOVY ORAL TABLET 4 QL didanosine oral capsule,delayed release(dr/ec) QL EDURANT ORAL TABLET 4 QL 4

13 efavirenz oral capsule QL efavirenz oral tablet QL EMTRIVA ORAL CAPSULE 2 QL EMTRIVA ORAL SOLUTION 2 QL entecavir oral tablet 4 PA EPCLUSA ORAL TABLET 4 PA; LA; QL EPIVIR HBV ORAL SOLUTION 2 PA EVOTAZ ORAL TABLET 4 QL famciclovir oral tablet QL fosamprenavir oral tablet QL FUZEON SUBCUTANEOUS RECON SOLN 4 QL ganciclovir sodium intravenous recon soln GENVOYA ORAL TABLET 4 QL HARVONI ORAL TABLET 4 PA; LA; QL INTELENCE ORAL TABLET 4 QL INVIRASE ORAL CAPSULE 4 QL INVIRASE ORAL TABLET 4 QL ISENTRESS HD ORAL TABLET 4 QL ISENTRESS ORAL POWDER IN PACKET 4 QL ISENTRESS ORAL TABLET 4 QL ISENTRESS ORAL TABLET,CHEWABLE 4 QL JULUCA ORAL TABLET 4 QL KALETRA ORAL TABLET 4 QL lamivudine oral solution QL lamivudine oral tablet 00 mg lamivudine oral tablet 50 mg, 00 mg QL lamivudine-zidovudine oral tablet QL LEXIVA ORAL SUSPENSION 4 QL lopinavir-ritonavir oral solution QL MAVYRET ORAL TABLET 4 PA; LA; QL nevirapine oral suspension QL nevirapine oral tablet QL 5

14 nevirapine oral tablet extended release 24 hr QL NORVIR ORAL CAPSULE 2 QL NORVIR ORAL POWDER IN PACKET 4 QL NORVIR ORAL SOLUTION 4 QL ODEFSEY ORAL TABLET 4 QL oseltamivir oral capsule QL oseltamivir oral suspension for reconstitution QL PREZCOBIX ORAL TABLET 4 QL PREZISTA ORAL SUSPENSION 4 QL PREZISTA ORAL TABLET 50 MG, 600 MG, 75 MG, 800 MG RELENZA DISKHALER INHALATION BLISTER WITH DEVICE 4 QL QL RESCRIPTOR ORAL TABLET 2 QL RESCRIPTOR ORAL TABLET, DISPERSIBLE 2 QL RETROVIR INTRAVENOUS SOLUTION 4 QL REYATAZ ORAL POWDER IN PACKET 4 QL rimantadine oral tablet ritonavir oral tablet QL SELZENTRY ORAL SOLUTION 4 PA; QL SELZENTRY ORAL TABLET 4 PA; QL SOVALDI ORAL TABLET 4 PA; LA; QL stavudine oral capsule QL STRIBILD ORAL TABLET 4 QL SYMFI LO ORAL TABLET 2 QL SYMFI ORAL TABLET 2 QL SYNAGIS INTRAMUSCULAR SOLUTION 4 PA; LA; QL TECHNIVIE ORAL TABLET 4 PA; LA; QL tenofovir disoproxil fumarate oral tablet QL TIVICAY ORAL TABLET 4 QL TRIUMEQ ORAL TABLET 4 QL TRUVADA ORAL TABLET 4 QL 6

15 TYBOST ORAL TABLET 2 valacyclovir oral tablet QL valganciclovir oral recon soln 4 valganciclovir oral tablet 4 VEMLIDY ORAL TABLET 4 PA; QL VIDEX 2 GRAM PEDIATRIC ORAL RECON SOLN 2 QL VIEKIRA PAK ORAL TABLETS,DOSE PACK 4 PA; LA; QL VIEKIRA XR ORAL TABLET, IR - ER, BIPHASIC 24HR 4 PA; LA; QL VIRACEPT ORAL TABLET 4 QL VIREAD ORAL POWDER 4 QL VIREAD ORAL TABLET 50 MG, 200 MG, 250 MG 4 QL VOSEVI ORAL TABLET 4 PA; LA; QL ZEPATIER ORAL TABLET 4 PA; LA; QL zidovudine oral capsule QL zidovudine oral syrup QL zidovudine oral tablet QL CEPHALOSPORINS cefaclor oral capsule cefaclor oral suspension for reconstitution 25 mg/5 ml, 250 mg/5 ml, 75 mg/5 ml cefaclor oral tablet extended release 2 hr cefadroxil oral capsule cefadroxil oral suspension for reconstitution 250 mg/5 ml, 500 mg/5 ml cefadroxil oral tablet CEFAZOLIN IN 0.9% SOD CHLORIDE INTRAVENOUS PIGGYBACK cefazolin in dextrose (iso-os) intravenous piggyback gram/50 ml, 2 gram/50 ml CEFAZOLIN IN DEXTROSE 5 % INTRAVENOUS PIGGYBACK 2 GRAM/50 ML 7

16 cefazolin injection recon soln cefazolin intravenous recon soln cefdinir oral capsule cefdinir oral suspension for reconstitution cefditoren pivoxil oral tablet CEFEPIME IN DEXTROSE 5 % INTRAVENOUS PIGGYBACK cefepime in dextrose,iso-osm intravenous piggyback cefepime injection recon soln cefixime oral suspension for reconstitution cefotaxime injection recon soln cefotetan injection recon soln cefotetan intravenous recon soln cefoxitin in dextrose, iso-osm intravenous piggyback cefoxitin intravenous recon soln cefpodoxime oral suspension for reconstitution cefpodoxime oral tablet cefprozil oral suspension for reconstitution cefprozil oral tablet CEFTAZIDIME IN D5W INTRAVENOUS PIGGYBACK ceftazidime injection recon soln ceftriaxone in dextrose,iso-os intravenous piggyback ceftriaxone injection recon soln gram, 0 gram, 2 gram, 250 mg, 500 mg ceftriaxone intravenous recon soln cefuroxime axetil oral tablet cefuroxime sodium injection recon soln 750 mg cefuroxime sodium intravenous recon soln cephalexin oral capsule 250 mg, 500 mg 5 cephalexin oral capsule 750 mg 8

17 cephalexin oral suspension for reconstitution cephalexin oral tablet MAXIPIME INTRAVENOUS RECON SOLN SUPRAX ORAL CAPSULE SUPRAX ORAL SUSPENSION FOR RECONSTITUTION 00 MG/5 ML, 500 MG/5 ML SUPRAX ORAL TABLET,CHEWABLE TEFLARO INTRAVENOUS RECON SOLN ERYTHROMYCINS & OTHER MACROLIDES azithromycin intravenous recon soln azithromycin oral packet azithromycin oral suspension for reconstitution azithromycin oral tablet clarithromycin oral suspension for reconstitution clarithromycin oral tablet clarithromycin oral tablet extended release 24 hr DIFICID ORAL TABLET 4 ST; QL e.e.s. 400 oral tablet ery-tab oral tablet,delayed release (dr/ec) 250 mg, 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) erythromycin oral tablet MISCELLANEOUS ANTIINFECTIVES ALBENZA ORAL TABLET 2 ALINIA ORAL SUSPENSION FOR RECONSTITUTION 2 9

18 ALINIA ORAL TABLET 2 amikacin injection solution,000 mg/4 ml, 500 mg/2 ml atovaquone oral suspension atovaquone-proguanil oral tablet PA AZACTAM IN DEXTROSE (ISO-OSM) INTRAVENOUS PIGGYBACK aztreonam injection recon soln baciim intramuscular recon soln bacitracin intramuscular recon soln BENZNIDAZOLE ORAL TABLET QL CAPASTAT INJECTION RECON SOLN CAYSTON INHALATION SOLUTION FOR NEBULIZATION chloramphenicol sod succinate intravenous recon soln 0 4 QL chloroquine phosphate oral tablet PA clindamycin hcl oral capsule CLINDAMYCIN IN 0.9 % SOD CHLOR INTRAVENOUS PIGGYBACK clindamycin in 5 % dextrose intravenous piggyback clindamycin palmitate hcl oral recon soln clindamycin pediatric oral recon soln clindamycin phosphate injection solution clindamycin phosphate intravenous solution COARTEM ORAL TABLET 2 colistin (colistimethate na) injection recon soln CYCLOSERINE ORAL CAPSULE dapsone oral tablet daptomycin intravenous recon soln 500 mg DARAPRIM ORAL TABLET PA DORIPENEM INTRAVENOUS RECON SOLN ethambutol oral tablet

19 gentamicin in nacl (iso-osm) intravenous piggyback 00 mg/00 ml, 60 mg/50 ml, 70 mg/50 ml, 80 mg/00 ml, 80 mg/50 ml, 90 mg/00 ml GENTAMICIN IN NACL (ISO-OSM) INTRAVENOUS PIGGYBACK 00 MG/50 ML, 20 MG/00 ML gentamicin injection solution gentamicin sulfate (ped) (pf) injection solution gentamicin sulfate (pf) intravenous solution 00 mg/0 ml GENTAMICIN SULFATE (PF) INTRAVENOUS SOLUTION 60 MG/6 ML hydroxychloroquine oral tablet imipenem-cilastatin intravenous recon soln INVANZ INJECTION RECON SOLN INVANZ INTRAVENOUS RECON SOLN isoniazid injection solution isoniazid oral solution isoniazid oral tablet ivermectin oral tablet LINCOCIN INJECTION SOLUTION lincomycin injection solution linezolid in dextrose 5% intravenous piggyback linezolid oral suspension for reconstitution 4 QL linezolid oral tablet 4 QL linezolid-0.9% sodium chloride intravenous parenteral solution mefloquine oral tablet PA meropenem intravenous recon soln metro i.v. intravenous piggyback metronidazole in nacl (iso-os) intravenous piggyback metronidazole oral capsule metronidazole oral tablet

20 NEBUPENT INHALATION RECON SOLN 2 neomycin oral tablet paromomycin oral capsule PASER ORAL GRANULES DR FOR SUSP IN PACKET PENTAM INJECTION RECON SOLN polymyxin b sulfate injection recon soln praziquantel oral tablet PRIFTIN ORAL TABLET PRIMAQUINE ORAL TABLET PA pyrazinamide oral tablet quinine sulfate oral capsule PA rifabutin oral capsule rifampin intravenous recon soln rifampin oral capsule RIFATER ORAL TABLET SIRTURO ORAL TABLET 4 PA SIVEXTRO INTRAVENOUS RECON SOLN 4 QL SIVEXTRO ORAL TABLET 4 QL STREPTOMYCIN INTRAMUSCULAR RECON SOLN SYNERCID INTRAVENOUS RECON SOLN tigecycline intravenous recon soln tinidazole oral tablet TOBI PODHALER INHALATION CAPSULE 4 QL TOBI PODHALER INHALATION CAPSULE, W/INHALATION DEVICE tobramycin in % nacl inhalation solution for nebulization tobramycin in 0.9 % nacl intravenous piggyback 60 mg/50 ml tobramycin sulfate injection recon soln tobramycin sulfate injection solution QL 4 QL

21 TRECATOR ORAL TABLET VABOMERE INTRAVENOUS RECON SOLN XIFAXAN ORAL TABLET 200 MG QL XIFAXAN ORAL TABLET 550 MG 4 PA; QL ZYVOX INTRAVENOUS PIGGYBACK 200 MG/00 ML PENICILLINS amoxicillin oral capsule 5 amoxicillin oral suspension for reconstitution amoxicillin oral tablet amoxicillin oral tablet,chewable 25 mg, 250 mg amoxicillin-pot clavulanate oral suspension for reconstitution amoxicillin-pot clavulanate oral tablet amoxicillin-pot clavulanate oral tablet extended release 2 hr amoxicillin-pot clavulanate oral tablet,chewable ampicillin oral capsule 5 ampicillin sodium injection recon soln ampicillin sodium intravenous recon soln ampicillin-sulbactam injection recon soln AUGMENTIN ORAL SUSPENSION FOR RECONSTITUTION MG/5 ML BICILLIN C-R INTRAMUSCULAR SYRINGE BICILLIN L-A INTRAMUSCULAR SYRINGE dicloxacillin oral capsule nafcillin in dextrose iso-osm intravenous piggyback nafcillin injection recon soln nafcillin intravenous recon soln oxacillin in dextrose(iso-osm) intravenous piggyback oxacillin injection recon soln oxacillin intravenous recon soln 2 gram

22 PENICILLIN G POT IN DEXTROSE INTRAVENOUS PIGGYBACK penicillin g potassium injection recon soln penicillin g procaine intramuscular syringe penicillin g sodium injection recon soln penicillin v potassium oral recon soln penicillin v potassium oral tablet 250 mg 5 penicillin v potassium oral tablet 500 mg pfizerpen-g injection recon soln piperacillin-tazobactam intravenous recon soln 2.25 gram,.75 gram, 4.5 gram, 40.5 gram QUINOLONES ciprofloxacin (mixture) oral tablet, er multiphase 24 hr ciprofloxacin hcl oral tablet 00 mg, 750 mg ciprofloxacin hcl oral tablet 250 mg, 500 mg 5 ciprofloxacin in 5 % dextrose intravenous piggyback ciprofloxacin oral suspension,microcapsule recon 4 QL FACTIVE ORAL TABLET QL levofloxacin in d5w intravenous piggyback levofloxacin intravenous solution levofloxacin oral solution levofloxacin oral tablet moxifloxacin in nacl (iso-osm) intravenous piggyback moxifloxacin oral tablet MOXIFLOXACIN-SOD.ACE,SUL-WATER INTRAVENOUS PIGGYBACK ofloxacin oral tablet 00 mg, 400 mg SULFA'S & RELATED AGENTS sulfadiazine oral tablet sulfamethoxazole-trimethoprim intravenous solution

23 sulfamethoxazole-trimethoprim oral suspension sulfamethoxazole-trimethoprim oral tablet sulfatrim oral suspension TETRACYCLINES demeclocycline oral tablet doxy-00 intravenous recon soln doxycycline hyclate oral capsule doxycycline hyclate oral tablet 00 mg, 20 mg doxycycline monohydrate oral capsule 00 mg, 50 mg doxycycline monohydrate oral suspension for reconstitution doxycycline monohydrate oral tablet MINOCIN INTRAVENOUS RECON SOLN minocycline oral capsule morgidox oral capsule 00 mg tetracycline oral capsule URINARY TRACT AGENTS methenamine hippurate oral tablet methenamine mandelate oral tablet nitrofurantoin macrocrystal oral capsule nitrofurantoin monohyd/m-cryst oral capsule trimethoprim oral tablet VANCOMYCIN VANCOMYCIN IN DEXTROSE 5 % INTRAVENOUS PIGGYBACK 500 MG/00 ML VANCOMYCIN IN DEXTROSE 5 % INTRAVENOUS PIGGYBACK 750 MG/50 ML vancomycin intravenous recon soln vancomycin oral capsule 4 VIBATIV INTRAVENOUS RECON SOLN 750 MG ANTINEOPLASTIC & IMMUNOSUPPRESSANT DRUGS 5 2

24 ADJUNCTIVE AGENTS amifostine crystalline intravenous recon soln 4 dexrazoxane hcl intravenous recon soln 4 LA ELITEK INTRAVENOUS RECON SOLN 4 LA KEPIVANCE INTRAVENOUS RECON SOLN 4 leucovorin calcium oral tablet mesna intravenous solution 4 LA MESNEX ORAL TABLET 4 XGEVA SUBCUTANEOUS SOLUTION 4 PA; QL ANTINEOPLASTIC & IMMUNOSUPPRESSANT DRUGS ABRAXANE INTRAVENOUS SUSPENSION FOR RECONSTITUTION 4 LA adriamycin intravenous solution 4 LA adrucil intravenous solution 4 LA AFINITOR DISPERZ ORAL TABLET FOR SUSPENSION 4 PA; QL AFINITOR ORAL TABLET 4 PA; QL ALECENSA ORAL CAPSULE 4 PA; LA; QL ALIMTA INTRAVENOUS RECON SOLN 4 LA ALUNBRIG ORAL TABLET 4 PA; LA; QL ALUNBRIG ORAL TABLETS,DOSE PACK 4 PA; LA; QL anastrozole oral tablet ARRANON INTRAVENOUS SOLUTION 4 LA AVASTIN INTRAVENOUS SOLUTION 4 LA azathioprine oral tablet azathioprine sodium injection recon soln bexarotene oral capsule 4 PA bicalutamide oral tablet BICNU INTRAVENOUS RECON SOLN 4 LA bleomycin injection recon soln 4 LA BOSULIF ORAL TABLET 4 PA; LA; QL busulfan intravenous solution 4 LA 6

25 CABOMETYX ORAL TABLET 4 PA; LA; QL CALQUENCE ORAL CAPSULE 4 PA; QL capecitabine oral tablet 4 PA CAPRELSA ORAL TABLET 4 PA; QL carboplatin intravenous solution 4 LA cisplatin intravenous solution 4 LA cladribine intravenous solution 4 LA COMETRIQ ORAL CAPSULE 4 PA; QL COTELLIC ORAL TABLET 4 PA; LA; QL cyclophosphamide intravenous recon soln 4 LA cyclophosphamide oral capsule 4 cyclosporine intravenous solution 4 cyclosporine modified oral capsule cyclosporine modified oral solution cyclosporine oral capsule cytarabine (pf) injection solution 4 LA cytarabine injection solution 4 LA dacarbazine intravenous recon soln 4 LA daunorubicin intravenous recon soln 4 LA daunorubicin intravenous solution 4 LA doxorubicin intravenous recon soln 4 LA doxorubicin intravenous solution 4 LA doxorubicin, peg-liposomal intravenous suspension ELIGARD ( MONTH) SUBCUTANEOUS SYRINGE ELIGARD (4 MONTH) SUBCUTANEOUS SYRINGE ELIGARD (6 MONTH) SUBCUTANEOUS SYRINGE LA 4 PA; QL 4 PA; QL 4 PA; QL ELIGARD SUBCUTANEOUS SYRINGE 4 PA; QL EMCYT ORAL CAPSULE 4 PA epirubicin intravenous recon soln 200 mg 4 LA 7

26 epirubicin intravenous solution 50 mg/25 ml 4 LA ERBITUX INTRAVENOUS SOLUTION 4 LA ERIVEDGE ORAL CAPSULE 4 PA; LA; QL ERLEADA ORAL TABLET 4 PA; QL ETOPOPHOS INTRAVENOUS RECON SOLN 4 LA etoposide intravenous solution 4 PA; LA etoposide oral capsule 4 PA exemestane oral tablet FARESTON ORAL TABLET 4 FARYDAK ORAL CAPSULE 4 PA; LA; QL FASLODEX INTRAMUSCULAR SYRINGE 4 LA FIRMAGON KIT W DILUENT SYRINGE SUBCUTANEOUS RECON SOLN 4 PA; LA; QL floxuridine injection recon soln 4 LA fludarabine intravenous recon soln 4 LA fludarabine intravenous solution 4 LA fluorouracil intravenous solution 4 LA flutamide oral capsule gemcitabine intravenous recon soln 4 LA gemcitabine intravenous solution gram/26. ml (8 mg/ml), 2 gram/52.6 ml (8 mg/ml), 200 mg/5.26 ml (8 mg/ml) gengraf oral capsule 00 mg, 25 mg gengraf oral solution 4 LA GILOTRIF ORAL TABLET 4 PA; LA; QL GLEEVEC ORAL TABLET 4 PA; QL GLEOSTINE ORAL CAPSULE 4 PA HEXALEN ORAL CAPSULE 4 HYCAMTIN ORAL CAPSULE 4 PA hydroxyurea oral capsule IBRANCE ORAL CAPSULE 4 PA; LA; QL ICLUSIG ORAL TABLET 4 PA; QL idarubicin intravenous solution 4 LA 8

27 IDHIFA ORAL TABLET 4 PA; LA; QL ifosfamide intravenous recon soln 4 LA ifosfamide intravenous solution 4 LA ifosfamide-mesna intravenous kit 4 LA IMBRUVICA ORAL CAPSULE 4 PA; QL IMBRUVICA ORAL TABLET 4 PA; QL INLYTA ORAL TABLET 4 PA; LA; QL IODOPEN INTRAVENOUS SOLUTION IRESSA ORAL TABLET 4 PA; LA; QL irinotecan intravenous solution 4 LA IXEMPRA INTRAVENOUS RECON SOLN 4 LA JAKAFI ORAL TABLET 4 PA; LA; QL KISQALI FEMARA CO-PACK ORAL TABLET 4 PA; LA; QL KISQALI ORAL TABLET 4 PA; LA; QL LENVIMA ORAL CAPSULE 4 PA; LA; QL letrozole oral tablet QL LEUKERAN ORAL TABLET 4 leuprolide subcutaneous kit 4 PA; LA lipodox 50 intravenous suspension 4 LA lipodox intravenous suspension 4 LA LONSURF ORAL TABLET 4 PA; LA LUPRON DEPOT ( MONTH) INTRAMUSCULAR SYRINGE KIT LUPRON DEPOT (4 MONTH) INTRAMUSCULAR SYRINGE KIT LUPRON DEPOT (6 MONTH) INTRAMUSCULAR SYRINGE KIT LUPRON DEPOT INTRAMUSCULAR SYRINGE KIT LUPRON DEPOT-PED ( MONTH) INTRAMUSCULAR SYRINGE KIT 4 PA; LA; QL 4 PA; LA; QL 4 PA; LA; QL 4 PA; LA; QL 4 PA; LA; QL LUPRON DEPOT-PED INTRAMUSCULAR KIT 4 PA; LA; QL LYNPARZA ORAL CAPSULE 4 PA; QL 9

28 LYNPARZA ORAL TABLET 4 PA; LA; QL LYSODREN ORAL TABLET 4 PA; LA MATULANE ORAL CAPSULE 4 megestrol oral suspension 400 mg/0 ml (40 mg/ml) megestrol oral tablet MEKINIST ORAL TABLET 4 PA; LA; QL melphalan oral tablet 4 mercaptopurine oral tablet methotrexate sodium (pf) injection recon soln 4 methotrexate sodium (pf) injection solution 4 methotrexate sodium injection solution 4 methotrexate sodium oral tablet mitomycin intravenous recon soln 4 LA mitoxantrone intravenous concentrate 4 LA MUSTARGEN INJECTION RECON SOLN 4 LA mycophenolate mofetil hcl intravenous recon soln 4 mycophenolate mofetil oral capsule mycophenolate mofetil oral suspension for reconstitution mycophenolate mofetil oral tablet mycophenolate sodium oral tablet,delayed release (dr/ec) MYLERAN ORAL TABLET 4 LA NERLYNX ORAL TABLET 4 PA; LA; QL NEXAVAR ORAL TABLET 4 PA; LA; QL nilutamide oral tablet 4 PA; LA NINLARO ORAL CAPSULE 4 PA; LA; QL NULOJIX INTRAVENOUS RECON SOLN 4 PA; LA octreotide acetate injection solution 4 LA octreotide acetate injection syringe 4 LA ODOMZO ORAL CAPSULE 4 PA; LA; QL ONCASPAR INJECTION SOLUTION 4 LA 20 4

29 oxaliplatin intravenous recon soln 4 LA oxaliplatin intravenous solution 4 LA paclitaxel intravenous concentrate 4 LA PHOTOFRIN INTRAVENOUS RECON SOLN 4 LA PROGRAF INTRAVENOUS SOLUTION 4 RAPAMUNE ORAL SOLUTION 4 PA RITUXAN HYCELA SUBCUTANEOUS SOLUTION 4 PA; LA RITUXAN INTRAVENOUS CONCENTRATE 4 PA; LA RUBRACA ORAL TABLET 4 PA; QL RYDAPT ORAL CAPSULE 4 PA; LA; QL SANDOSTATIN LAR DEPOT INTRAMUSCULAR SUSPENSION,EXTENDED REL RECON SIGNIFOR LAR INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION 4 PA; LA; QL 4 PA; LA; QL SIGNIFOR SUBCUTANEOUS SOLUTION 4 PA; LA; QL SIMULECT INTRAVENOUS RECON SOLN 4 LA sirolimus oral tablet SOMATULINE DEPOT SUBCUTANEOUS SYRINGE 4 PA; LA; QL SPRYCEL ORAL TABLET 4 PA; QL STIVARGA ORAL TABLET 4 PA; LA; QL SUPPRELIN LA IMPLANT KIT 4 PA; LA; QL SUTENT ORAL CAPSULE 4 PA; LA; QL SYLVANT INTRAVENOUS RECON SOLN 4 PA; LA TABLOID ORAL TABLET 4 PA tacrolimus oral capsule TAFINLAR ORAL CAPSULE 4 PA; LA; QL TAGRISSO ORAL TABLET 4 PA; LA; QL tamoxifen oral tablet TARCEVA ORAL TABLET 00 MG, 50 MG 4 PA; LA; QL TARCEVA ORAL TABLET 25 MG 4 PA; LA 2

30 TARGRETIN TOPICAL GEL 4 PA TASIGNA ORAL CAPSULE 4 PA; QL TEMODAR INTRAVENOUS RECON SOLN 4 temozolomide oral capsule 4 PA; LA THALOMID ORAL CAPSULE 4 PA; LA; QL toposar intravenous solution 4 LA topotecan intravenous recon soln 4 LA topotecan intravenous solution 4 LA TORISEL INTRAVENOUS RECON SOLN 4 LA TRELSTAR INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION 4 PA; QL TRELSTAR INTRAMUSCULAR SYRINGE 4 PA; LA; QL tretinoin (chemotherapy) oral capsule 4 TYKERB ORAL TABLET 4 PA; LA; QL VANTAS IMPLANT KIT 4 PA; LA; QL VENCLEXTA ORAL TABLET 00 MG 4 PA; QL VERZENIO ORAL TABLET 4 PA; LA; QL vinblastine intravenous solution 4 LA vincasar pfs intravenous solution 4 LA vincristine intravenous solution 4 LA vinorelbine intravenous solution 4 LA VOTRIENT ORAL TABLET 4 PA; LA; QL XALKORI ORAL CAPSULE 4 PA; LA; QL XERMELO ORAL TABLET 4 PA; QL XTANDI ORAL CAPSULE 4 PA; LA; QL ZANOSAR INTRAVENOUS RECON SOLN 4 LA ZEJULA ORAL CAPSULE 4 PA; QL ZELBORAF ORAL TABLET 4 PA; LA; QL ZOLADEX SUBCUTANEOUS IMPLANT 4 PA; LA; QL ZOLINZA ORAL CAPSULE 4 PA; LA; QL ZORTRESS ORAL TABLET 4 ZYDELIG ORAL TABLET 4 PA; QL 22

31 ZYKADIA ORAL CAPSULE 4 PA; LA; QL ZYTIGA ORAL TABLET 4 PA; LA; QL AUTONOMIC & CNS DRUGS, NEUROLOGY & PSYCH ANTICONVULSANTS APTIOM ORAL TABLET PA; QL BANZEL ORAL SUSPENSION PA; QL BANZEL ORAL TABLET PA; QL BRIVIACT INTRAVENOUS SOLUTION PA; QL BRIVIACT ORAL SOLUTION PA; QL BRIVIACT ORAL TABLET PA; QL 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 00 MG 2 clonazepam oral tablet clonazepam oral tablet,disintegrating ST diazepam rectal kit DILANTIN ORAL CAPSULE 0 MG 2 divalproex oral capsule, delayed rel sprinkle divalproex oral tablet extended release 24 hr divalproex oral tablet,delayed release (dr/ec) epitol oral tablet ethosuximide oral capsule ethosuximide oral solution felbamate oral suspension felbamate oral tablet fosphenytoin injection solution FYCOMPA ORAL SUSPENSION PA; QL FYCOMPA ORAL TABLET PA; QL 2

32 gabapentin oral capsule QL gabapentin oral solution 250 mg/5 ml QL gabapentin oral tablet 600 mg, 800 mg QL GRALISE 0-DAY STARTER PACK ORAL TABLET EXTENDED RELEASE 24 HR GRALISE ORAL TABLET EXTENDED RELEASE 24 HR lamotrigine oral tablet PA; QL PA; QL lamotrigine oral tablet, chewable dispersible QL levetiracetam in nacl (iso-os) intravenous piggyback levetiracetam intravenous solution levetiracetam oral solution levetiracetam oral tablet levetiracetam oral tablet extended release 24 hr QL LYRICA ORAL CAPSULE PA; QL LYRICA ORAL SOLUTION PA; QL ONFI ORAL SUSPENSION PA; QL ONFI ORAL TABLET 0 MG, 20 MG PA; QL oxcarbazepine oral suspension oxcarbazepine oral tablet PEGANONE ORAL TABLET QL phenobarbital oral elixir phenobarbital oral tablet phenytoin oral suspension 25 mg/5 ml phenytoin oral tablet,chewable phenytoin sodium extended oral capsule phenytoin sodium intravenous solution phenytoin sodium intravenous syringe primidone oral tablet roweepra oral tablet roweepra xr oral tablet extended release 24 hr QL SABRIL ORAL TABLET 4 PA; LA; QL 24

33 subvenite oral tablet tiagabine oral tablet topiramate oral capsule, sprinkle QL topiramate oral tablet valproate sodium intravenous solution valproic acid (as sodium salt) oral solution 250 mg/5 ml valproic acid oral capsule vigabatrin oral powder in packet 4 PA; LA; QL vigadrone oral powder in packet 4 PA; LA; QL VIMPAT INTRAVENOUS SOLUTION PA; QL VIMPAT ORAL SOLUTION PA; QL VIMPAT ORAL TABLET PA; QL zonisamide oral capsule ANTIPARKINSONISM AGENTS APOKYN SUBCUTANEOUS CARTRIDGE 4 PA; QL benztropine injection solution benztropine oral tablet bromocriptine oral capsule bromocriptine oral tablet carbidopa oral tablet ST carbidopa-levodopa oral tablet carbidopa-levodopa oral tablet extended release carbidopa-levodopa oral tablet,disintegrating carbidopa-levodopa-entacapone oral tablet DUOPA J-TUBE INTESTINAL PUMP SUSPENSION entacapone oral tablet pramipexole oral tablet rasagiline oral tablet ropinirole oral tablet 25 4 PA; LA ropinirole oral tablet extended release 24 hr ST

34 selegiline hcl oral capsule selegiline hcl oral tablet tolcapone oral tablet ST trihexyphenidyl oral elixir trihexyphenidyl oral tablet MIGRAINE & CLUSTER HEADACHE THERAPY almotriptan malate oral tablet ST; QL dihydroergotamine injection solution 4 dihydroergotamine nasal spray,non-aerosol 4 QL eletriptan oral tablet ST; QL ERGOMAR SUBLINGUAL TABLET PA; QL frovatriptan oral tablet ST; QL isometh-dichloral-acetaminophn oral capsule naratriptan oral tablet QL rizatriptan oral tablet QL rizatriptan oral tablet,disintegrating QL sumatriptan nasal spray,non-aerosol QL sumatriptan succinate oral tablet QL sumatriptan succinate subcutaneous cartridge 2 QL sumatriptan succinate subcutaneous pen injector 2 QL sumatriptan succinate subcutaneous solution 2 QL zolmitriptan oral tablet QL zolmitriptan oral tablet,disintegrating QL ZOMIG NASAL SPRAY,NON-AEROSOL QL MISCELLANEOUS NEUROLOGICAL THERAPY AMPYRA ORAL TABLET EXTENDED RELEASE 2 HR 4 PA; LA; QL AUSTEDO ORAL TABLET 4 PA; QL donepezil oral tablet 0 mg, 5 mg PA donepezil oral tablet,disintegrating PA galantamine oral capsule,ext rel. pellets 24 hr PA galantamine oral solution PA 26

35 galantamine oral tablet PA HORIZANT ORAL TABLET EXTENDED RELEASE PA; QL INGREZZA ORAL CAPSULE 4 PA; QL KEVEYIS ORAL TABLET 4 PA; QL memantine oral solution PA memantine oral tablet PA MEMANTINE ORAL TABLETS,DOSE PACK PA; QL NUEDEXTA ORAL CAPSULE 4 PA; QL rivastigmine tartrate oral capsule PA rivastigmine transdermal patch 24 hour PA tetrabenazine oral tablet 4 PA; LA; QL TYSABRI INTRAVENOUS SOLUTION 4 PA; LA; QL MUSCLE RELAXANTS & ANTISPASMODIC THERAPY baclofen oral tablet 0 mg, 20 mg carisoprodol oral tablet 50 mg carisoprodol-aspirin oral tablet chlorzoxazone oral tablet 500 mg cyclobenzaprine oral tablet 0 mg, 5 mg dantrolene oral capsule meprobamate oral tablet metaxall oral tablet PA; QL metaxalone oral tablet 800 mg PA; QL methocarbamol oral tablet orphenadrine citrate injection solution orphenadrine citrate oral tablet extended release pyridostigmine bromide oral tablet pyridostigmine bromide oral tablet extended release regonol injection solution tizanidine oral tablet NARCOTIC ANALGESICS 4 PA 27

36 ABSTRAL SUBLINGUAL TABLET 4 PA; QL acetaminophen-codeine oral solution 20-2 mg/5 ml PA; QL acetaminophen-codeine oral tablet PA; QL ascomp with codeine oral capsule PA; QL astramorph-pf injection solution mg/ml PA; QL BUPRENEX INJECTION SOLUTION PA; QL buprenorphine hcl injection solution PA; QL buprenorphine hcl injection syringe PA; QL buprenorphine hcl sublingual tablet PA; QL BUPRENORPHINE TRANSDERMAL PATCH WEEKLY PA; QL butalbital compound w/codeine oral capsule PA; QL butalbital-acetaminop-caf-cod oral capsule PA; QL butalbital-acetaminophen oral tablet mg butalbital-acetaminophen-caff oral capsule mg butalbital-acetaminophen-caff oral tablet mg butalbital-aspirin-caffeine oral capsule butalbital-aspirin-caffeine oral tablet capacet oral capsule codeine sulfate oral tablet PA; QL DEMEROL INJECTION SOLUTION PA; QL duramorph (pf) injection solution PA; QL EMBEDA ORAL CAPSULE,ORAL ONLY,EXT.REL PELL endocet oral tablet 0-25 mg, mg, 5-25 mg, mg fentanyl citrate (pf) intravenous syringe 00 mcg/2 ml (50 mcg/ml) 28 PA; QL PA; QL PA; QL fentanyl citrate buccal lozenge on a handle 4 PA; QL fentanyl transdermal patch 72 hour 00 mcg/hr, 2 mcg/hr, 25 mcg/hr, 50 mcg/hr, 75 mcg/hr PA; QL

37 FENTORA BUCCAL TABLET, EFFERVESCENT hydrocodone-acetaminophen oral solution mg/5 ml hydrocodone-acetaminophen oral tablet 0-25 mg, mg, 5-25 mg, mg hydrocodone-ibuprofen oral tablet mg, mg, mg 4 PA; QL PA; QL PA; QL PA; QL hydromorphone (pf) injection solution 0 mg/ml PA; QL hydromorphone in 0.9 % nacl intravenous pt controlled analgesia syring 5 mg/0 ml (0.5 mg/ml) PA; QL hydromorphone injection solution PA; QL HYDROMORPHONE INJECTION SYRINGE 0.5 MG/0.5 ML hydromorphone injection syringe mg/ml, 2 mg/ml, 4 mg/ml PA; QL PA; QL hydromorphone oral tablet PA; QL hydromorphone oral tablet extended release 24 hr PA; QL hydromorphone rectal suppository PA; QL ibuprofen-oxycodone oral tablet PA; QL LAZANDA NASAL SPRAY,NON-AEROSOL 4 PA; QL levorphanol tartrate oral tablet PA; QL lorcet (hydrocodone) oral tablet PA; QL lorcet hd oral tablet PA; QL lorcet plus oral tablet mg PA; QL meperidine (pf) injection solution 00 mg/ml, 25 mg/ml, 50 mg/ml PA; QL meperidine injection cartridge PA; QL meperidine oral solution PA; QL meperidine oral tablet PA; QL methadone injection solution PA; QL methadone oral concentrate PA; QL methadone oral solution PA; QL methadone oral tablet PA; QL 29

38 methadose oral concentrate PA; QL morphine (pf) injection solution 0.5 mg/ml, mg/ml morphine (pf) intravenous patient control.analgesia soln PA; QL PA; QL morphine concentrate oral solution PA; QL morphine injection solution 5 mg/ml, 8 mg/ml PA; QL morphine injection syringe 0 mg/ml, 2 mg/ml, 4 mg/ml, 5 mg/ml, 8 mg/ml MORPHINE INTRAMUSCULAR PEN INJECTOR morphine intravenous cartridge 0 mg/ml, 2 mg/ml, 4 mg/ml MORPHINE INTRAVENOUS CARTRIDGE 8 MG/ML morphine intravenous pt controlled analgesia syring morphine intravenous solution 0 mg/ml, 00 mg/4 ml, 25 mg/ml, 250 mg/0 ml, 50 mg/ml PA; QL PA; QL PA; QL PA; QL PA; QL PA; QL morphine intravenous syringe 2 mg/ml, 4 mg/ml PA; QL morphine oral solution PA; QL morphine oral tablet PA; QL morphine oral tablet extended release PA; QL morphine rectal suppository PA; QL oxycodone oral capsule PA; QL oxycodone oral concentrate PA; QL oxycodone oral solution PA; QL oxycodone oral tablet PA; QL OXYCODONE ORAL TABLET,ORAL ONLY,EXT.REL.2 HR oxycodone-acetaminophen oral tablet 0-25 mg, mg, 5-25 mg, mg PA; QL PA; QL oxycodone-aspirin oral tablet PA; QL oxymorphone oral tablet PA; QL oxymorphone oral tablet extended release 2 hr 2 PA; QL 0