Formulary. IEHP DualChoice Cal MediConnect Plan (Medicare-Medicaid Plan) IEHP (4347) TTY

Transcription

1 Formulary IEHP DualChoice Cal MediConnect Plan (Medicare-Medicaid Plan) IEHP (4347) TTY May 2016

2 IEHP DualChoice Cal MediConnect Plan (Medicare-Medicaid Plan) 2016 List of Covered Drugs (Formulary) HPMS Approved Formulary File Submission ID , Version 10 This is a list of drugs that members can get in IEHP DualChoice. IEHP DualChoice Cal MediConnect Plan (Medicare-Medicaid Plan) is a health plan that contracts with both Medicare and Medi-Cal to provide benefits of both programs to enrollees. The List of Covered Drugs and/or pharmacy and provider networks may change throughout the year. We will send you a notice before we make a change that affects you. Benefits and/or co-payments may change on January 1 of each year. You can always check IEHP DualChoice s up-to-date List of Covered Drugs online at or by calling IEHP (4347), 8am-8pm (PST), 7 days week, including holidays. TTY/TDD users should call The call is free. You can get this information for free in other formats, such as large print, braille, or audio. Call IEHP (4347). The call is free. Limitations, copays, and restrictions may apply. For more information, call IEHP DualChoice Member Services or read the IEHP DualChoice Member Handbook. Co-pays for prescription drugs may vary based on the level of Extra Help you receive. Please contact the plan for more details. You can get this information for free in other languages. Call IEHP (4347), 8am-8pm (PST), 7 days a week, including holidays. TTY/TDD users should call The call is free. Usted puede obtener esta información gratis en otros idiomas. Llame al IEHP (4347), 8am-8pm (Hora del Pacifico), los 7 días de la semana, incluidos días festivos. Los usuarios de TTY/TDD deben llamar al La llamada es gratuita.? If you have questions, please call IEHP DualChoice at IEHP (4347), 8am-8pm (PST), 7 days a week, including holidays. TTY/TDD users should call The call is free. For more information, visit 1

3 Frequently Asked Questions (FAQ) Find answers here to questions you have about this List of Covered Drugs. You can read all of the FAQ to learn more, or look for a question and answer. 1. What prescription drugs are on the List of Covered Drugs? (We call the List of Covered Drugs the Drug List for short.) The drugs on the Drug List are the drugs covered by IEHP DualChoice. The drugs are available at pharmacies within our network. A pharmacy is in our network if we have an agreement with them to work with us and provide you services. We refer to these pharmacies as network pharmacies. IEHP DualChoice will cover all medically necessary drugs on the Drug List if: your doctor or other prescriber says you need them to get better or stay healthy, and you fill the prescription at an IEHP DualChoice network pharmacy. In some cases, you have to do something before you can get a drug (see question #5 below). You can also see an up-to-date list of drugs that we cover on our website at or call Member Services at IEHP (4347). 2. Does the Drug List ever change? Yes. IEHP DualChoice may add or remove drugs on the Drug List during the year. Generally, the Drug List will only change if: a cheaper drug comes along that works as well as a drug on the Drug List now, or we learn that a drug is not safe. We may also change our rules about drugs. For example, we could: Decide to require or not require prior approval for a drug. (Prior approval is permission from IEHP DualChoice before you can get a drug.) Add or change the amount of a drug you can get (called quantity limits ). (For more information on these drug rules, see page 4.) We will tell you when a drug you are taking is removed from the Drug List. We will also tell you when we change our rules for covering a drug. Questions 3, 4, and 7 below have more information on what happens when the Drug List changes. You can always check IEHP DualChoice s up to date Drug List online at You can also call Member Services to check the current Drug List at IEHP (4347). 2

4 3. What happens when a cheaper drug comes along that works as well as a drug on the Drug List now? If you are taking a drug that is removed because a cheaper drug that works just as well comes along, we will tell you. We will tell you at least 60 days before we remove it from the Drug List or when you ask for a refill. Then you can get a 60-day supply of the drug before the drug is removed from the drug list. You will receive a letter at least 60-days before the change is effective. This information is also available on our website at 4. What happens when we find out a drug is not safe? If the Food and Drug Administration (FDA) says a drug you are taking is not safe, we will take it off the Drug List right away. We will also send you a letter telling you that. Please contact the prescribing doctor after you receive your letter. 5. Are there any restrictions or limits on drug coverage? Or are there any required actions to take in order to get certain drugs? Yes, some drugs have coverage rules or have limits on the amount you can get. In some cases you or your doctor or other prescriber must do something before you can get the drug. For example: Prior approval (or prior authorization): For some drugs, you or your doctor or other prescriber must get approval from IEHP DualChoice before you fill your prescription. If you don t get approval, IEHP DualChoice may not cover the drug. Quantity limits: Sometimes IEHP DualChoice limits the amount of a drug you can get. You can find out if your drug has any additional requirements or limits by looking in the tables on pages You can also get more information by visiting our web site at We have posted online documents that explain our prior authorization restrictions. You may also ask us to send you a copy. You can ask for an exception from these limits. Please see Question 11 for more information on exceptions. If you are in a nursing home or other long-term care facility and need a drug that is not on the Drug List, or if you cannot easily get the drug you need, we can help. We will cover a 31-day emergency supply of the drug you need (unless you have a prescription for fewer days), whether or not you are a new IEHP DualChoice member. This will give you time to talk to your doctor or other prescriber. He or she can help you decide if there is a similar drug on the Drug List you can take instead or whether to request an exception. Please see Question 11 for more information about exceptions.? If you have questions, please call IEHP DualChoice at IEHP (4347), 8am-8pm (PST), 7 days a week, including holidays. TTY/TDD users should call The call is free. For more information, visit 3

5 6. How will you know if the drug you want has limitations or if there are required actions to take to get the drug? The List of Covered Drugs that begins on page 11 has a column labeled Necessary actions, restrictions, or limits on use. 7. What happens if we change our rules on how we cover some of the drugs? For example, if we add prior authorization (approval) and/or quantity limits restrictions on a drug. We will tell you if we add prior approval and/or quantity limits restrictions on a drug. We will tell you at least 60 days before the restriction is added or when you next ask your pharmacy for a refill. Then, you can get a 60-day supply of the drug before the change to the coverage rules is made. This gives you time to talk to your doctor or other prescriber about what to do next. 8. How can you find a drug on the Drug List? There are two ways to find a drug: You can search alphabetically (if you know how to spell the drug), or You can search by medical condition. To search alphabetically, go to the Alphabetical Listing section. You can find it in the index that begins on page 87. Look in the index and find your drug. Next to your drug, you will see the page number where you can find the coverage information. Turn to the page listed in the index and find the name of your drug in the first column of the list. To search by medical condition, find the section labeled List of drugs by medical condition on page 9. The drugs in this section are grouped into categories depending on the type of medical conditions they are used to treat. For example, if you have a heart condition, you should look in the category, Cardiovascular Agents. That is where you will find drugs that treat heart conditions. 9. What if the drug you want to take is not on the Drug List? If you don t see your drug on the Drug List, call Member Services at IEHP (4347), 8am-8pm (PST), 7 days a week, including holidays. TTY/TDD users should call and ask about it. If you learn that IEHP DualChoice will not cover the drug, you can do one of these things: Ask Member Services for a list of drugs like the one you want to take. Then show the list to your doctor or other prescriber. He or she can prescribe a drug on the Drug List that is like the one you want to take. Or You can ask the health plan to make an exception to cover your drug. Please see question 11 for more information about exceptions. 4

6 10. What if you are a new IEHP DualChoice member and can t find your drug on the Drug List or have a problem getting your drug? We can help. We may cover a temporary 31-day supply of your drug during the first 90 days you are a member of IEHP DualChoice. This will give you time to talk to your doctor or other prescriber. He or she can help you decide if there is a similar drug on the Drug List you can take instead or whether to request an exception. We will cover a 31-day supply of your drug if: you are taking a drug that is not on our Drug List, or health plan rules do not let you get the amount ordered by your prescriber, or the drug requires prior approval by IEHP DualChoice. If you live in a nursing home or other long-term care facility, you may refill your prescription for as long as 98 days. You may refill the drug multiple times during your first 90 days in the plan. This gives your prescriber time to change your drugs to those on the Drug List or ask for an exception. As a new member in our plan or continuing member who was affected by a formulary change from one year the next, you may be taking drugs that are not on our formulary. Or, you may be taking drugs that are on our formulary that are hard for you to get. For example, you may need our approval before you can get your drug. Either way, talk to your doctor. He or she can help you choose the right course of action. This could be changing to a drug we do cover or seeking a formulary exception so that we will cover the drug. 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 is hard for you to get, we will cover a temporary 31-day supply (unless you have a prescription written for fewer days) when you go to a network pharmacy. After your first 31-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 cover your prescription refill until we have provided you with a 98-day transition supply, consistent with dispensing increment, (unless you have a prescription written for fewer days). We will cover more than one refill of these drugs for the first 90 days of your membership. If you need a drug that is not on our formulary or it is hard for you to get, but you are past the first 90 days of membership in our plan, we will cover a 31-day emergency supply of that drug (unless you have a prescription for fewer days) while you ask for a formulary exception. 11. Can you ask for an exception to cover your drug? Yes. You can ask IEHP DualChoice to make an exception to cover a drug that is not on the Drug List. You can also ask us to change the rules on your drug.? If you have questions, please call IEHP DualChoice at IEHP (4347), 8am-8pm (PST), 7 days a week, including holidays. TTY/TDD users should call The call is free. For more information, visit 5

7 For example, IEHP DualChoice may limit the amount of a drug we will cover. If your drug has a limit, you can ask us to change the limit and cover more. Other examples: You can ask us to drop prior approval requirements. 12. How long does it take to get an exception? First, we must receive a statement from your prescriber supporting your request for an exception. After we receive the statement, we will give you a decision on your exception request within 72 hours. If you or your prescriber think your health may be harmed if you have to wait 72 hours for a decision, you can ask for an expedited exception. This is a faster decision. If your prescriber supports your request, we will give you a decision within 24 hours of receiving your prescriber s supporting statement. 13. How can you ask for an exception? To ask for an exception, call IEHP DualChoice Member Services. IEHP DualChoice Member Services will work with you and your provider to help you ask for an exception. 14. What are generic drugs? Generic drugs are made up of the same ingredients as brand name drugs. They usually cost less than the brand name drug and their names are less commonly known. Generic drugs are approved by the Food and Drug Administration (FDA). IEHP DualChoice covers both brand name drugs and generic drugs. 15. What are OTC drugs? OTC stands for over-the-counter. IEHP DualChoice covers some OTC drugs when they are written as prescriptions by your provider. You can read the IEHP DualChoice Drug List to see what OTC drugs are covered. 16. Does IEHP DualChoice cover OTC non-drug products? IEHP DualChoice covers some OTC non-drug products when they are written as prescriptions by your provider. You can read the IEHP DualChoice Drug List to see what OTC non-drug products are covered. 6

8 17. What is your co-pay? You can read the IEHP DualChoice Drug List to learn about the co-pay for each drug. IEHP DualChoice members living in nursing homes or other long-term care facilities will have no copays. Some members getting long-term care in the community will also have no co-pays. Co-pays are listed by tiers. Tiers are groups of drugs with the same co-pay. Tier 1 are generic drugs. The co-pay will be from $0 to $2.95, depending on your level of Medi-Cal eligibility. Tier 2 are brand name drugs. The co-pay will be from $0 to $7.40, depending on your level of Medi-Cal eligibility. Tier 3 drugs have a co-pay of $0. List of Covered Drugs The list of covered drugs that begins on the page 11 gives you information about the drugs covered by IEHP DualChoice. If you have trouble finding your drug in the list, turn to the Index that begins on page 87. The first column of the chart lists the name of the drug. Brand name drugs are capitalized (e.g., NEXIUM) and generic drugs are listed in lower-case italics (e.g., omeprazole). The information in the Necessary actions, restrictions, or limits on use column tells you if IEHP DualChoice has any rules for covering your drug. Below are the meanings of the codes used in the Necessary actions, restrictions, or limits on use column: UPPERCASE BOLD= Brand name drugs lowercase italics= Generic drugs Drug Tier 1= Tier 1; 2= Tier 2; 3= Tier 3 NC= Not Covered NF= Non-Formulary Requirements / Limits PA= Prior Authorization B vs D= Part B vs D Prior Authorization QL= Quantity Limit Tier 1: Drugs in this tier are generic drugs (including brand drugs treated as generic). The copay is a set payment you make for these generic drugs. For example, the copay is from $0 to $2.95. This amount depends on your income. Tier 2: Drugs in this tier are brand name drugs. The copay is from $0 to $7.40. This amount depends on your income.? If you have questions, please call IEHP DualChoice at IEHP (4347), 8am-8pm (PST), 7 days a week, including holidays. TTY/TDD users should call The call is free. For more information, visit 7

9 Tier 3: Drugs in this tier are drugs that are non-medicare drugs/over-the-counter (OTC) drugs. These drugs are covered by Medi-Cal. They have a $0 co-pay. NC: Not covered. These are drugs not covered by IEHP DualChoice. NF: Non-Formulary. Drugs that are not on our prescribed drugs list (known as a Formulary). PA: Prior Authorization. IEHP DualChoice requires you or your physician to get approval from us first before filling a certain drug. This extra step is called prior authorization. If you don't get approval, IEHP DualChoice may not cover the drug. B vs D: Part B vs D Prior Authorization. This is a drug that has a special PA requirement. It may be covered under one or two benefit programs: 1) Medicare Part B, and/or 2) Medicare Part D. This depends on many factors. Your physician may need to give us more details about the use and setting of the drug. QL: Quantity Limit. For certain drugs, IEHP DualChoice limits the amount of the drug that it will cover. This may be in addition to a standard one month or three month supply. Note: A drug in Tier 3 means the drug is not a Part D drug. You will not be required to pay a copay for these drugs. These drugs also have different rules for appeals. An appeal is a formal way of asking us to review a decision we made about your coverage and to change it if you think we made a mistake. For example, we might decide that a drug that you want is not covered or is no longer covered by Medicare or Medi-Cal. If you or your doctor disagrees with our decision, you can appeal. If you ever have a question, call Member Services at IEHP (4347). You can also read the Member Handbook to learn how to appeal a decision. 8

10 IEHP DualChoice Cal MediConnect Plan (Medicare-Medicaid Plan) 2016 Formulary Table of Contents Additional Demonstration Drugs Analgesics Anesthetics Anti-Addiction/ Substance Abuse Treatment Agents Antibacterials Anticonvulsants Antidementia Agents Antidepressants Antiemetics Antifungals Antigout Agents Anti-Inflammatory Agents Antimigraine Agents Antimyasthenic Agents Antimycobacterials Antineoplastics Antiparasitics Antiparkinson Agents Antipsychotics Antispasticity Agents Antivirals Anxiolytics Bipolar Agents Blood Glucose Regulators Blood Products/ Modifiers/ Volume Expanders Cardiovascular Agents Central Nervous System Agents Dental And Oral Agents Dermatological Agents Enzyme Replacement/ Modifiers Gastrointestinal Agents Genitourinary Agents Hormonal Agents, Stimulant/ Replacement/ Modifying (Adrenal)

11 Hormonal Agents, Stimulant/ Replacement/ Modifying (Pituitary) Hormonal Agents, Stimulant/ Replacement/ Modifying (Sex Hormones/ Modifiers) Hormonal Agents, Stimulant/ Replacement/ Modifying (Thyroid) Hormonal Agents, Suppressant (Adrenal) Hormonal Agents, Suppressant (Parathyroid) Hormonal Agents, Suppressant (Pituitary) Hormonal Agents, Suppressant (Thyroid) Immunological Agents Inflammatory Bowel Disease Agents Metabolic Bone Disease Agents Ophthalmic Agents Otic Agents Respiratory Tract/ Pulmonary Agents Skeletal Muscle Relaxants Sleep Disorder Agents Therapeutic Nutrients/ Minerals/ Electrolytes Index

12 List of Drugs by Medical Condition The drugs in this section are grouped into categories depending on the type of medical conditions they are used to treat. For example, if you have a heart condition, you should look in the category, Cardiovascular Agents. That is where you will find drugs that treat heart conditions. Drug Name Additional Demonstration Drugs Additional Demonstration Drugs 12-HR DECONGEST 120 MG CAPLET NON-DROWSY,CAPLET 120 MG 3 QL (60 EA per 30 days) ABREVA 10% CREAM 10 % 3 QL (2 GM per 15 days) ACEPHEN 120 MG SUPPOSITORY OUTER 120 MG 3 ACEPHEN 325 MG SUPPOSITORY OUTER 325 MG 3 acetaminophen 160 mg/5 ml sol 160 mg/5 ml (5 ml) 3 QL (240 ML per 30 days) ACNE MEDICATION 10% GEL 10 % 3 ACNE MEDICATION 10% LOTION 10 % 3 ACNE MEDICATION 5% GEL 5 % 3 ADULT COUGH FORMULA DM MAX LIQ MG/5 ML 3 QL (240 ML per 30 days) ADULT ROBITUSSIN PEAK COLD LIQ NON-DROWSY MG/5 ML 3 QL (240 ML per 30 days) ALAVERT D-12 ALLERGY-SINUS TAB MG 3 QL (60 EA per 30 days) ALLER-CHLOR 2 MG/5 ML SYRUP 2 MG/5 ML 3 ALLER-CHLOR 4 MG TABLET 4 MG 3 ALLERCLEAR 10 MG TABLET NON-DROWSY, 24HR 10 MG 3 QL (30 EA per 30 days) ALLERGY 25 MG TABLET 25 MG 3 QL (100 EA per 30 days) ALLERGY MULTI-SYMPTOM CAPLET CAPLET MG 3 QL (60 EA per 30 days) ALLERGY RELIEF 10 MG ODT NON-DROWSY, 24HR 10 MG 3 QL (30 EA per 30 days) ALLERGY RELIEF 25 MG CAPSULE 25 MG 3 QL (100 EA per 30 days) AMLACTIN ULTRA BODY CREAM 3 ANTACID-ANTIGAS LIQUID REG STR, FAST ACTING MG/5 ML ANTIBIOTIC + PAIN RELIEF OINT MAX-STRENGTH ,000 MG-UNIT-UNIT/G 3 3 ANTIFUNGAL 2% CREAM 2 % 3 QL (60 GM per 30 days) AQUANIL HC 1% LOTION 1 % 3 QL (120 ML per 30 days) ARTIFICIAL TEARS 1.4 % DROPS 1.4 % 3 ARTIFICIAL TEARS DROPS % 3 11

13 aspirin 325 mg tablet 325 mg 3 QL (100 EA per 30 days) AYR SALINE 0.65% NOSE DROPS 0.65 % 3 bacitracin 500 unit/gm ointment 500 unit/gram 3 bacitracin zn 500 unit/gm oint 500 unit/gram 3 QL (30 GM per 30 days) bacitracin-polymyxin ointment u-d,144x.94gm pkt ,000 unit/gram 3 benzonatate 100 mg capsule softgel 100 mg 3 QL (180 EA per 30 days) benzonatate 200 mg capsule softgel 200 mg 3 QL (90 EA per 30 days) benzoyl peroxide 2.5% gel (otc) 2.5 % 3 benzoyl peroxide 5% lotion 5 % 3 benzoyl peroxide 5% wash (otc) 5 % 3 BIO-B KIDS LIQUID MG/5 ML 3 BIO-S-PRES DX PEDIATRIC DROPS MG/ML 3 bisacodyl ec 5 mg tablet 5 mg 3 QL (60 EA per 30 days) bromphenir-pseudoephed-dm syr (rx) mg/5 ml 3 QL (240 ML per 30 days) BROTAPP DM LIQUID MG/5 ML 3 BROTAPP LIQUID 1-15 MG/5 ML 3 CALCIUM 600 MG TABLET 600 MG (1,500 MG) 3 calcium gluconate 500 mg tab 45 mg (500 mg) 3 calcium lactate 648 mg tablet 84 mg (648 mg) 3 cetirizine hcl 10 mg tablet indoor-outdoor,24hr 10 mg 3 QL (30 EA per 30 days) cetirizine hcl 5 mg chew tab children's, outer, u-d 5 mg 3 QL (30 EA per 30 days) cetirizine hcl 5 mg tablet 5 mg 3 QL (30 EA per 30 days) CHEMSTRIP 10 WITH SG 3 CHILD MUCUS RELIEF COUGH LIQ A/F,CHERRY,CHILD MG/5 ML 3 QL (240 ML per 30 days) CHILD PAIN & FEVER 160 MG/5 ML 160 MG/5 ML 3 QL (240 ML per 30 days) CHILDREN'S BENEFIBER ORAL POWDER 3 GRAM/3.5 GRAM 3 CHILDREN'S COLD & COUGH ELIXIR A/F,RED GRAPE,CHILD MG/5 ML CHILDREN'S IRON 15 MG/ML DROPS 15 MG IRON (75 MG)/ML 3 QL (50 ML per 30 days) CHILDREN'S SILAPAP ELIXIR 160 MG/5 ML 3 QL (240 ML per 30 days) CHILDREN'S SILFEDRINE LIQ 15 MG/5 ML 3 QL (240 ML per 30 days) CHILD'S CLARITIN 5 MG TAB CHEW 5 MG 3 QL (30 EA per 30 days) You can find information on what the symbols and abbreviations in this table mean by going to page

14 CHLD MUCINEX STUFFY NOSE-COLD MG/5 ML 3 chlorpheniramine er 12 mg tab 12 mg 3 COMPLETE LICE TREATMENT KIT STEP % 3 QL (2 EA per 30 days) CONCEPTROL GEL 4 % 3 CONDOMS LUBRICATED 3 QL (24 EA per 30 days) cromolyn sodium nasal solution 200 metered sprays 5.2 mg/spray (4 %) 3 CVS ACNE FOAMING FACE 10% WASH 10 % 3 CVS ALLERGY RELIEF 5 MG/5 ML A/F, S/F. GLUTEN/F 5 MG/5 ML CVS ANTI-DANDRUFF 1% SHAMPOO 1 % 3 3 QL (150 ML per 30 days) cvs aspirin 81 mg chewable tab adult, 3x36 tri-pack 81 mg 3 QL (100 EA per 30 days) cvs aspirin ec 81 mg tablet coated, low dose 81 mg 3 QL (100 EA per 30 days) cvs calcium 500 mg tablet 500mg elemental ca 500 mg calcium (1,250 mg) 3 CVS CHILD ALLERGY 10 MG CHW TB 24 HR,INDOOR/OUTDOOR 10 MG CVS CHILD SUPPOSITORY 3 CVS CORN-CALLUS REMOVER LIQ 3 CVS FIBER LAXATIVE 625 MG CPLT CAPLET 625 MG 3 cvs glucose 4 gram tablet chew grape, s/f 4 gram 3 CVS KETONE CARE TEST STRIPS 3 3 QL (30 EA per 30 days) CVS LICE KILLING SHAMPOO MAXIMUM STRENGTH % 3 QL (472 ML per 30 days) CVS LUBRICANT 0.5% EYE DROPS 0.5 % 3 CVS LUBRICANT EYE OINTMENT % 3 cvs magnesium 500 mg tablet coated 500 mg 3 QL (30 EA per 30 days) cvs miconazole 3 combo pack 3pref applic w/cream 4 % (200 mg)- 2 % (9 gram) CVS MUCUS ER 600 MG TABLET 12 HOUR 600 MG 3 CVS NIACIN FLUSH FREE 500 MG 400 MG NIACIN (500 MG) 3 CVS NON-ASPIRIN JR TAB CHEW 160 MG 3 QL (100 EA per 30 days) cvs permethrin 1% lotion 1 % 3 QL (236 ML per 30 days) CVS PRENATAL VITAMINS TABLET WITH MINERALS 28 MG IRON- 800 MCG CVS STOOL SOFTENER 100 MG CAP 100 MG 3 QL (100 EA per 30 days) CVS STOOL SOFTENER 50 MG SFTGL 50 MG 3 QL (100 EA per 30 days)

15 CVS SUPER PAIN RELIEF TAB MG 3 QL (100 EA per 30 days) CVS TRIPLE ANTIBIOTIC OINTMENT 3.5MG-400 UNIT- 5,000 UNIT/GRAM CVS VITAMIN B-6 50 MG TAB 50 MG 3 cvs vitamin d 400 unit/ml drop infant's, w/dropper 400 unit/ml 3 cvs vitamin d3 1,000 unit sfgl softgel 1,000 unit 3 cvs vitamin d3 400 unit sftgl 400 unit 3 cyanocobalamin 1,000 mcg/ml mdv,5's 1,000 mcg/ml 3 d ,000 units capsule s/f,d/f,p/f 50,000 unit 3 DESITIN 13% CREAM HYPOALLERGENIC 13 % 3 DIABETIC TUSSIN EX LIQUID A/F,D/F,NA/F,S/F 100 MG/5 ML 3 DIAPER RASH 40% OINTMENT MAXIMUM STRENGTH 40 % 3 DIMAPHEN ELIXIR A/F MG/5 ML 3 DIOCTO 60 MG/15 ML SYRUP 60 MG/15 ML 3 QL (480 ML per 30 days) diphenhydramine 50 mg tablet 50 mg 3 QL (100 EA per 30 days) DOCU LIQUID 100 MG/10 ML OUTER 50 MG/5 ML 3 QL (480 ML per 30 days) DOK 100 MG TABLET 100 MG 3 QL (100 EA per 30 days) ELLA 30 MG TABLET 30 MG 3 QL (1 EA per 30 days) EQ ARTIFICIAL TEARS DROPS STERILE % 3 eql natural zinc 50 mg tablet 50 mg 3 EYE ALLERGY RELIEF DROPS % 3 EYE ITCH RELIEF 0.025% DROPS UP TO 12HRS, STERILE % (0.035 %) EYE WASH-IRRIGATING SOLN 3 famotidine 10 mg tablet 10 mg 3 QL (120 EA per 30 days) ferrous sulf 220 mg/5 ml elix 220 mg (44 mg iron)/5 ml 3 QL (480 ML per 30 days) ferrous sulf 300 mg/5 ml liq 300 mg (60 mg iron)/5 ml 3 QL (450 ML per 30 days) ferrous sulf ec 324 mg tablet 324 mg (65 mg iron) 3 QL (90 EA per 30 days) ferrous sulf ec 325 mg tablet 325 mg (65 mg iron) 3 QL (90 EA per 30 days) ferrous sulfate 325 mg tablet u-d,10x10, film coat 325 mg (65 mg iron) 3 QL (90 EA per 30 days) FEVERALL 80 MG SUPPOSITORY INFANT'S, OUTER 80 MG 3 FLANDERS BUTTOCKS OINTMENT 3 FLEET GLYCERIN 2 GM ADULT SUPP 3 You can find information on what the symbols and abbreviations in this table mean by going to page

16 FLEET PEDIA-LAX ENEMA GRAM/59 ML 3 FLEET PEDIA-LAX STOOL SOFTENER 50 MG/15 ML 3 folic acid 1,000 mcg tablet p/f,s/f (otc) 1 mg 3 FOR STY RELIEF EYE OINTMENT 3 FORA BLOOD GLUCOSE TEST STRIP 3 QL (100 EA per 90 days) FORACARE 30G LANCETS 30 GAUGE 3 QL (150 EA per 30 days) FULL SPECTRUM B WITH VIT C TAB 0.8 MG 3 QL (30 EA per 30 days) GAS RELIEF DROPS INFANTS, A/F 40 MG/0.6 ML 3 QL (30 ML per 30 days) GENTEAL MILD 0.2% EYE DROPS 0.2 % 3 GENTEAL MILD-MODERATE EYE DROP P/F, STRL 0.3 % 3 GENTLE LAXATIVE 5 MG TABLET 5 MG 3 QL (60 EA per 30 days) gnp calamine suspension 8-8 % 3 GNP PINK BISMUTH MAX-STR SUSP MAXIMUM STRENGTH 525 MG/15 ML gnp terbinafine 1% cream antifungal 1 % 3 gnp vit d3 400 unit tab chew 400 unit 3 GRX DYNE 10% SWAB 10 % 3 guaifenesin dm syrup 100's, u-d (otc) mg/5 ml 3 QL (240 ML per 30 days) GYNOL II 3% GEL 3 % 3 HIBICLENS 4% LIQUID 4 % 3 hm magnesium citrate solution pasteurized, cherry 3 HM STOOL SOFTENER 250 MG SFTGL SOFTGEL,MAX STRENGTH 250 MG 3 3 QL (100 EA per 30 days) hydrocortisone 0.5% cream 0.5 % 3 QL (30 GM per 30 days) hydrocortisone 0.5% ointment 0.5 % 3 QL (30 GM per 30 days) HYDROMET SYRUP MG/5 ML 3 ibuprofen 200 mg tablet 200 mg 3 QL (100 EA per 30 days) INTENSE COUGH RELIEVER LIQUID S/F, A/F, DOUBLE STR MG/5 ML 3 QL (240 ML per 30 days) IOPHEN-C NR LIQUID MG/5 ML 3 QL (240 ML per 30 days) ISOPTO TEARS 0.5% EYE DROPS 0.5 % 3 KETO-DIASTIX REAGENT STRIPS 3 KONSYL PSYLLIUM FIBER PACKET ORANGE, GLUTEN FREE 3.4 GRAM 3 15

17 levonorgestrel 0.75 mg tablet 0.75 mg 3 QL (2 EA per 30 days) LIQUID WART REMOVER 17% LIQUID W/APPLICATOR 17 % 3 LOHIST-D LIQUID 2-30 MG/5 ML 3 loperamide 2 mg caplet caplet 2 mg 3 LORATADINE-D 24HR TABLET MG 3 QL (30 EA per 30 days) LUBRICANT PM EYE OINTMENT P/F % 3 magnesium oxide 250 mg caplet p/f, s/f, gluten/f 250 mg 3 QL (30 EA per 30 days) magnesium oxide 400 mg tablet 400 mg 3 QL (30 EA per 30 days) magnesium oxide 420 mg tablet 253mg elem magnesium 420 mg 3 QL (30 EA per 30 days) MEDI-CORTISONE 1% CREAM 1 % 3 QL (30 GM per 30 days) MEDI-FIRST ANTI-FUNGAL CRM 1 % 3 MEPHYTON 5 MG TABLET 5 MG 3 METAMUCIL POWDER GLUTEN-FREE, ORANGE 3.4 GRAM/12 GRAM miconazole 100 mg vag supp 100 mg 3 QL (7 EA per 30 days) MICONAZOLE 3 COMBO PACK 3 SUPP W/9GM CREAM 200 MG- 2 % (9 GRAM) You can find information on what the symbols and abbreviations in this table mean by going to page QL (1 EA per 30 days) MICONAZOLE 7 CREAM W/7 DISP APPLICATORS 2 % 3 QL (45 GM per 30 days) MILK OF MAGNESIA CONCENTRATED 2,400 MG/10 ML 3 MILK OF MAGNESIA SUSPENSION 400 MG/5 ML 3 MINTOX PLUS TABLET CHEWABLE MG 3 MOTION SICKNESS RELIEF TB CHEW CHEWABLE TABLET 25 MG MUCINEX COUGH MINI-MELT PACK MG 3 3 QL (60 EA per 30 days) MUCINEX D ER 1, MG TAB 120-1,200 MG 3 QL (60 EA per 30 days) MUCINEX D ER MG TABLET MG 3 QL (36 EA per 30 days) MUCINEX DM ER 1, MG TAB BI-LAYER, MAX-STR 60-1,200 MG MUCINEX DM ER MG TABLET MG 3 MUCINEX ER 1,200 MG TABLET MAX STR, BI-LAYER 1,200 MG 3 MURO-128 2% EYE DROPS 2 % 3 NASAL DECONGESTANT 0.05% SPRAY 12-HOUR 0.05 % 3 NASAL DECONGESTANT 30 MG TAB MAX-STR,NON-DROWSY 30 MG 3 3 QL (60 EA per 30 days)

18 NATURAL BALANCE TEARS DROPS 0.4 % 3 NEXT CHOICE ONE DOSE 1.5 MG TB (OTC) 1.5 MG 3 QL (1 EA per 30 days) niacin 250 mg tablet 250 mg 3 niacin 50 mg tablet 50 mg 3 niacin 500 mg capsule sa 500 mg 3 niacin 500 mg tablet 500 mg 3 niacin er 500 mg tablet 500 mg 3 niacin sa 250 mg capsule (otc) 250 mg 3 NICODERM CQ 14 MG/24HR PATCH 14 MG/24 HR 3 QL (180 EA per 365 days) nicotine 4 mg chewing gum coated, cinnamon 4 mg 3 QL (4320 EA per 365 days) nicotine 7 mg/24hr patch clear, step 3 (otc) 7 mg/24 hr 3 QL (180 EA per 365 days) nicotine transdermal system 24 hour patch kit mg/24 hr 3 QL (112 EA per 365 days) NON-ASA PAIN RELIEF TB CHEW 80 MG 3 QL (100 EA per 30 days) NON-ASPIRIN 100 MG/ML DROPS 100 MG/ML 3 QL (15 ML per 30 days) NUTRISOURCE FIBER POWDER 3 OCEAN 0.65% NASAL SPRAY 0.65 % 3 PAIN RELIEVER 500 MG TABLET EXTRA STRENGTH 500 MG 3 QL (240 EA per 30 days) PANDA MASK MEDIUM 3 QL (1 EA per 365 days) PEAK-AIR PEAK FLOW METER 3 QL (1 EA per 365 days) PEDIATRIC COUGH-COLD LIQUID MG/5 ML 3 PEDIATRIC ELECTROLYTE SOLUTION 8'S, A/F, GRAPE 3 QL (2000 ML per 30 days) PEDIATRIC MEDIUM MASK 3 QL (1 EA per 365 days) PHARBEDRYL 50 MG CAPSULE 50 MG 3 QL (100 EA per 30 days) phentermine 37.5 mg tablet 37.5 mg 3 PA; QL (31 EA per 31 days) PINK BISMUTH CAPLET CAPLET 262 MG 3 POLYSPORIN OINTMENT (OTC) ,000 UNIT/GRAM 3 POLY-VI-SOL DROPS UNIT-MG-UNIT/ML 3 POLYVITAMIN W-IRON DROPS 1,500 UNIT-400 UNIT-10 MG/ML 3 povidone-iodine 10% solution 10 % 3 PRENATAL CAPLET S/F,P/F,GLUTEN/FREE 28 MG IRON- 800 MCG PRENATAL TABLET (OTC) MG 3 PRILOSEC OTC 20.6 MG TABLET OTC 20 MG

19 PROMETHAZINE VC-CODEINE SYRUP MG/5 ML 3 QL (480 ML per 30 days) promethazine-codeine syrup mg/5 ml 3 QL (480 ML per 30 days) promethazine-dm syrup mg/5 ml 3 psyllium fiber 0.52 g capsule 0.52 gram 3 pv calamine lotion 3 PV LICE TREATMENT KIT W/ NIT COMB % 3 PYRETHRIN LICE TREATMENT % 3 pyridoxine 25 mg tablet 25 mg 3 QC 3 DAY VAGINAL 4% CREAM 200 MG/5 GRAM (4 %) 3 QL (25 GM per 30 days) QC NATURAL VEGETABLE POWDER 3.4 GRAM/12 GRAM 3 Q-PAP 325 MG TABLET 325 MG 3 RA ACNE TREATMENT 10% CREAM 10 % 3 RA ANTI-DIARRHEAL 1 MG/5 ML 1 MG/5 ML 3 ra aspirin ec 325 mg tablet regular strength 325 mg 3 QL (100 EA per 30 days) RA CETIRI-D ER TABLET MG 3 QL (60 EA per 30 days) ra folic acid 0.4 mg tablet p/f 400 mcg 3 ra ibuprofen 200 mg capsule softgel, mg 3 QL (100 EA per 30 days) ra naproxen sod 220 mg tablet 220 mg 3 ra niacin 100 mg tablet p/f 100 mg 3 ra nicotine 2 mg chewing gum mint 2 mg 3 QL (4320 EA per 365 days) ra nicotine 4 mg mini lozenge mini,mint,4 quittube 4 mg 3 QL (3600 EA per 365 days) ra omeprazole dr 20 mg tablet delayed release 20 mg 3 QL (60 EA per 30 days) RA SALINE ENEMA LATEX FREE 19-7 GRAM/118 ML 3 RA SLEEP TABLET 25 MG 3 QL (100 EA per 30 days) ra sodium chloride 5% eye drop 5 % 3 RA SOLUBLE FIBER 500 MG CPLT 500 MG 3 RA STOMACH RELIEF 262 MG/15 ML REG STRENGTH 262 MG/15 ML RA TUSSIN CF LIQUID A/F, MG/5 ML 3 QL (240 ML per 30 days) RA VITAMIN D3 2,000 UNIT SFGL 2,000 UNIT 3 ra vitamin d3 5,000 unit sftgl softgel 5,000 unit 3 RA WART REMOVER 17% GEL MAXIMUM STRENGTH 17 % 3 RA WART REMOVER LIQUID 3 You can find information on what the symbols and abbreviations in this table mean by going to page

20 ra zinc 50 mg tablet p/f 50 mg 3 ra zinc oxide ointment 3 ranitidine 75 mg tablet 75 mg 3 REESE'S PINWORM 144 MG/ML SUSP 50 MG/ML 3 REFRESH LACRI-LUBE OINTMENT % 3 ROBITUSSIN PEDIATRIC COUGH SYP A/F,LONG-ACTING 7.5 MG/5 ML SCALPICIN 1% ANTI-ITCH LIQUID 1 % 3 QL (74 ML per 30 days) SCOT-TUSSIN DM S-F LIQUID 2-15 MG/5 ML 3 SCOT-TUSSIN SENIOR LIQUID MG/5 ML 3 QL (240 ML per 30 days) SENNA 8.6 MG TABLET 8.6 MG 3 SENNA 8.8 MG/5 ML SYRUP 8.8 MG/5 ML 3 SENNA PLUS TABLET MG 3 QL (60 EA per 30 days) SILAPAP INFANT'S DROPS INFANT 80 MG/0.8 ML 3 QL (15 ML per 30 days) simethicone 80 mg tab chew 80 mg 3 QL (60 EA per 30 days) SM ANTACID ANTI-GAS LIQUID ORIGINAL, MAX STR MG/5 ML SM CHILD'S PAIN RELIEVER SUSP 160 MG/5 ML 3 QL (240 ML per 30 days) sm clotrimazole 1% cream 1 % 3 QL (45 GM per 30 days) SM EAR DROPS 6.5% 6.5 % 3 QL (15 ML per 30 days) SM INF PAIN RELV 80 MG/0.8 ML 80 MG/0.8 ML 3 QL (15 ML per 30 days) sm nicotine 2 mg lozenge 2 mg 3 QL (3600 EA per 365 days) sm nicotine 21 mg/24hr patch step 1 (otc) 21 mg/24 hr 3 QL (180 EA per 365 days) SM VITAMIN D3 4,000 UNIT SFTGL SOFTGEL, GLUTEN-FREE 4,000 UNIT sodium bicarb 325 mg tablet 325 mg 3 sodium bicarb 650 mg tablet 10 gr 650 mg 3 sodium chloride 0.9% inhal vl u-d, suv, p/f (rx) 0.9 % 3 sodium chloride 5% eye oint 5 % 3 SOOTHE 262 MG CHEWABLE TABLET 262 MG 3 SUDOGEST 60 MG TABLET 60 MG 3 QL (60 EA per 30 days) SYSTANE NIGHTTIME EYE OINT 94-3 % 3 TEARS NATURALE FORTE DROPS % 3 TEARS NATURALE-II EYE DROPS

21 thiamine 250 mg tablet 250 mg 3 tolnaftate 1% solution 1 % 3 TRI-VITA DROPS 1, UNIT-MG-UNIT/ML 3 TRYMINE D LIQUID MG/5 ML 3 urea 10% lotion 10 % 3 VCF CONTRACEPTIVE FILM 28 % 3 VCF CONTRACEPTIVE FOAM 12.5 % 3 VISINE-A EYE DROPS % 3 vit d mg (50,000 unit) softgel 50,000 unit 3 QL (4 EA per 28 days) vitamin a 10,000 units softgel 10,000 unit 3 VITAMIN B MG TABLET 100 MG 3 VITAMIN B MG TABLET S/F,P/F,GLUTEN-FREE 100 MG 3 VITAMIN B-1 50 MG TABLET 50 MG 3 VITAMIN B MG TABLET GLUTEN-FREE 100 MG 3 VITAMIN B MG TABLET 100 MG 3 VITAMIN C-500 MG TABLET P/F, S/F, GLUTEN/F 500 MG 3 vitamin d 10,000 unit softgel softgel, p/f,s/f 10,000 unit 3 vitamin d2 400 unit tablet s/f,l/f,y/f, gluten/f 400 unit 3 VITAMIN D3 1,000 UNIT TABLET S/F,Y/F,P/F 1,000 UNIT 3 VITAMIN D3 2,000 UNIT TABLET W/ CALCIUM CARBONATE 2,000 UNIT VITAMIN D3 400 UNIT TABLET S/F,P/F 400 UNIT 3 vitamin d3 5,000 unit tablet p/f,s/f, gluten-free 5,000 unit 3 vitamin e 400 unit capsule 400 unit 3 WAL-ACT D COLD & ALLERGY TAB MG 3 WAL-FINATE-D TABLET 4-60 MG 3 QL (60 EA per 30 days) WAL-MUCIL 100% NATURAL FIBER S/F,180 DOSES,ORANGE 3.4 GRAM/5.8 GRAM zinc oxide paste 25 % 3 Analgesics Analgesics acetaminophen-codeine oral solution 300 mg-30 mg /12.5 ml 1 QL (4650 ML per 31 days) acetaminophen-codeine oral tablet mg 1 QL (413 EA per 31 days) You can find information on what the symbols and abbreviations in this table mean by going to page

22 acetaminophen-codeine oral tablet mg 1 QL (372 EA per 31 days) acetaminophen-codeine oral tablet mg 1 QL (186 EA per 31 days) hydrocodone-acetaminophen oral tablet mg, mg, mg 1 QL (372 EA per 31 days) hydrocodone-ibuprofen oral tablet mg 1 QL (155 EA per 31 days) oxycodone-acetaminophen oral tablet mg 1 QL (372 EA per 31 days) tramadol-acetaminophen oral tablet mg 1 QL (248 EA per 31 days) Nonsteroidal Anti-Inflammatory Drugs celecoxib oral capsule 100 mg, 200 mg, 400 mg 1 QL (62 EA per 31 days) diclofenac sodium oral tablet, delayed release (dr/ec) 25 mg, 75 mg 1 diclofenac sodium topical drops 1.5 % 1 ibuprofen oral tablet 800 mg 1 indomethacin oral capsule 25 mg 1 PA; QL (124 EA per 31 days) meloxicam oral tablet 15 mg, 7.5 mg 1 QL (31 EA per 31 days) nabumetone oral tablet 500 mg, 750 mg 1 naproxen oral tablet 375 mg, 500 mg 1 Opioid Analgesics, Long-Acting DURAMORPH (PF) INJECTION SOLUTION 0.5 MG/ML, 1 MG/ML 2 fentanyl transdermal patch 72 hour 100 mcg/hr, 12 mcg/hr, 25 mcg/hr, 50 mcg/hr, 75 mcg/hr morphine oral capsule, extend. release pellets 10 mg, 100 mg, 20 mg, 30 mg, 50 mg, 60 mg, 80 mg 1 QL (10 EA per 30 days) 1 QL (62 EA per 31 days) morphine oral solution 10 mg/5 ml 1 QL (3100 ML per 31 days) morphine oral tablet 15 mg, 30 mg 1 QL (186 EA per 31 days) morphine oral tablet extended release 100 mg, 15 mg, 30 mg, 60 mg 1 QL (93 EA per 31 days) morphine oral tablet extended release 200 mg 1 QL (62 EA per 31 days) tramadol oral tablet extended release 24 hr 100 mg 1 QL (93 EA per 31 days) tramadol oral tablet extended release 24 hr 200 mg 1 QL (31 EA per 31 days) Opioid Analgesics, Short-Acting butorphanol tartrate nasal spray, non-aerosol 10 mg/ml 1 QL (22.5 ML per 31 days) fentanyl citrate buccal lozenge on a handle 1,200 mcg, 1,600 mcg, 200 mcg, 400 mcg, 600 mcg, 800 mcg hydromorphone (pf) injection solution 10 mg/ml 1 1 PA; QL (124 EA per 31 days) hydromorphone oral tablet 2 mg, 4 mg, 8 mg 1 QL (279 EA per 31 days) 21

23 LAZANDA NASAL SPRAY,NON-AEROSOL 100 MCG/SPRAY, 400 MCG/SPRAY ; QL (31 EA per 31 days) oxycodone oral tablet 10 mg, 15 mg, 20 mg, 30 mg, 5 mg 1 QL (186 EA per 31 days) tramadol oral tablet 50 mg 1 QL (248 EA per 31 days) Anesthetics Local Anesthetics lidocaine (pf) injection solution 5 mg/ml (0.5 %) 1 lidocaine hcl injection solution 20 mg/ml (2 %) 1 lidocaine hcl mucous membrane gel 2 % 1 lidocaine hcl mucous membrane solution 2 %, 4 % (40 mg/ml) 1 lidocaine topical adhesive patch, medicated 5 % 1 PA; QL (93 EA per 31 days) lidocaine topical ointment 5 % 1 lidocaine-prilocaine topical cream % 1 Anti-Addiction/ Substance Abuse Treatment Agents Alcohol Deterrents/ Anti-Craving acamprosate oral tablet, delayed release (dr/ec) 333 mg 1 disulfiram oral tablet 250 mg, 500 mg 1 Opioid Dependence Treatments buprenorphine hcl injection syringe 0.3 mg/ml 1 buprenorphine hcl sublingual tablet 2 mg, 8 mg 1 QL (93 EA per 31 days) buprenorphine-naloxone sublingual tablet mg 1 QL (372 EA per 31 days) buprenorphine-naloxone sublingual tablet 8-2 mg 1 QL (93 EA per 31 days) naltrexone oral tablet 50 mg 1 Opioid Reversal Agents naloxone injection syringe 1 mg/ml 1 NARCAN NASAL SPRAY,NON-AEROSOL 4 MG/ACTUATION Smoking Cessation Agents CHANTIX CONTINUING MONTH BOX ORAL TABLET 1 MG ; QL (336 EA per 168 days) CHANTIX ORAL TABLET 0.5 MG, 1 MG ; QL (336 EA per 168 days) NICOTROL INHALATION CARTRIDGE 10 MG 2 NICOTROL NS NASAL SPRAY,NON-AEROSOL 10 MG/ML 2 You can find information on what the symbols and abbreviations in this table mean by going to page 7. 22

24 Antibacterials Aminoglycosides amikacin injection solution 500 mg/2 ml 1 gentak ophthalmic ointment 0.3 % (3 mg/gram) 1 gentamicin in nacl (iso-osm) intravenous piggyback 100 mg/100 ml, 60 mg/50 ml, 70 mg/50 ml, 80 mg/100 ml, 80 mg/50 ml, 90 mg/100 ml gentamicin injection solution 40 mg/ml 1 gentamicin ophthalmic drops 0.3 % 1 gentamicin topical cream 0.1 % 1 gentamicin topical ointment 0.1 % 1 neomycin oral tablet 500 mg 1 neomycin-polymyxin b gu irrigation solution 40 mg-200,000 unit/ml 1 paromomycin oral capsule 250 mg 1 streptomycin intramuscular recon soln 1 gram 1 TOBI PODHALER INHALATION CAPSULE, W/INHALATION DEVICE 28 MG TOBRADEX OPHTHALMIC OINTMENT % 2 tobramycin in % nacl inhalation solution for nebulization 300 mg/5 ml tobramycin ophthalmic drops 0.3 % 1 tobramycin sulfate injection solution 10 mg/ml, 40 mg/ml 1 TOBREX OPHTHALMIC OINTMENT 0.3 % 2 ZANOSAR INTRAVENOUS RECON SOLN 1 GRAM Antibacterials colistin (colistimethate na) injection recon soln 150 mg 1 B vs D SYNERCID INTRAVENOUS RECON SOLN 500 MG Antibacterials, Other acetic acid otic solution 2 % 1 alcohol pads topical pads, medicated 1 bacitracin ophthalmic ointment 500 unit/gram 1 chloramphenicol sod succinate intravenous recon soln 1 gram 1 clindamycin hcl oral capsule 150 mg, 300 mg, 75 mg 1 clindamycin in 5 % dextrose intravenous piggyback 300 mg/50 ml, 600 mg/50 ml, 900 mg/50 ml 1 ; QL (224 EA per 28 days) 1 PA; QL (10 ML per 1 day) 1 23

25 clindamycin phosphate intravenous solution 600 mg/4 ml 1 clindamycin phosphate topical foam 1 % 1 clindamycin phosphate topical gel 1 % 1 clindamycin phosphate topical lotion 1 % 1 clindamycin phosphate topical solution 1 % 1 clindamycin phosphate topical swab 1 % 1 clindamycin phosphate vaginal cream 2 % 1 CUBICIN INTRAVENOUS RECON SOLN 500 MG LINCOCIN INJECTION SOLUTION 300 MG/ML 2 lincomycin injection solution 300 mg/ml 1 linezolid intravenous parenteral solution 600 mg/300 ml 1 PA linezolid oral suspension for reconstitution 100 mg/5 ml 1 PA; QL (1680 ML per 28 days) linezolid oral tablet 600 mg 1 PA; QL (28 EA per 14 days) metronidazole in nacl (iso-os) intravenous piggyback 500 mg/100 ml 1 metronidazole oral tablet 250 mg, 500 mg 1 metronidazole topical cream 0.75 % 1 metronidazole topical gel 0.75 %, 1 % 1 metronidazole topical lotion 0.75 % 1 metronidazole vaginal gel 0.75 % 1 mupirocin calcium topical cream 2 % 1 mupirocin topical ointment 2 % 1 nitrofurantoin macrocrystal oral capsule 100 mg, 25 mg, 50 mg 1 PA nitrofurantoin monohyd/m-cryst oral capsule 100 mg, 100 mg (75/25) 1 PA nitrofurantoin oral suspension 25 mg/5 ml 1 PA PRIMSOL ORAL SOLUTION 50 MG/5 ML 2 trimethoprim oral tablet 100 mg 1 TYGACIL INTRAVENOUS RECON SOLN 50 MG vancomycin intravenous recon soln 1,000 mg, 10 gram, 500 mg 1 B vs D vancomycin oral capsule 125 mg 1 PA; QL (56 EA per 14 days) vancomycin oral capsule 250 mg 1 PA; QL (40 EA per 10 days) Beta-Lactam, Cephalosporins cefaclor oral capsule 250 mg, 500 mg 1 You can find information on what the symbols and abbreviations in this table mean by going to page 7. 24

26 cefaclor oral tablet extended release 12 hr 500 mg 1 cefadroxil oral capsule 500 mg 1 cefadroxil oral suspension for reconstitution 250 mg/5 ml, 500 mg/5 ml 1 cefadroxil oral tablet 1 gram 1 cefazolin in dextrose (iso-os) intravenous piggyback 1 gram/50 ml 1 cefazolin injection recon soln 1 gram, 10 gram, 500 mg 1 cefdinir oral capsule 300 mg 1 cefdinir oral suspension for reconstitution 125 mg/5 ml, 250 mg/5 ml 1 cefepime injection recon soln 1 gram, 2 gram 1 cefotaxime injection recon soln 1 gram, 2 gram, 500 mg 1 cefoxitin in dextrose, iso-osm intravenous piggyback 1 gram/50 ml, 2 gram/50 ml cefoxitin intravenous recon soln 1 gram, 10 gram, 2 gram 1 cefpodoxime oral suspension for reconstitution 100 mg/5 ml, 50 mg/5 ml 1 cefpodoxime oral tablet 100 mg, 200 mg 1 cefprozil oral suspension for reconstitution 125 mg/5 ml, 250 mg/5 ml 1 cefprozil oral tablet 250 mg, 500 mg 1 ceftazidime in d5w intravenous piggyback 1 gram/50 ml, 2 gram/50 ml 1 ceftazidime injection recon soln 1 gram, 2 gram, 6 gram 1 ceftriaxone injection recon soln 10 gram, 250 mg, 500 mg 1 ceftriaxone intravenous recon soln 1 gram, 2 gram 1 cefuroxime axetil oral tablet 250 mg, 500 mg 1 cefuroxime sodium injection recon soln 1.5 gram, 750 mg 1 cefuroxime sodium intravenous recon soln 7.5 gram 1 cephalexin oral capsule 250 mg, 500 mg 1 cephalexin oral suspension for reconstitution 125 mg/5 ml, 250 mg/5 ml 1 cephalexin oral tablet 250 mg, 500 mg 1 SUPRAX ORAL CAPSULE 400 MG 2 SUPRAX ORAL TABLET,CHEWABLE 100 MG, 200 MG 2 TEFLARO INTRAVENOUS RECON SOLN 400 MG, 600 MG 2 Beta-Lactam, Other aztreonam injection recon soln 1 gram 1 CAYSTON INHALATION SOLUTION FOR NEBULIZATION 75 MG/ML 1 ; QL (84 ML per 28 days) 25

27 imipenem-cilastatin intravenous recon soln 250 mg, 500 mg 1 INVANZ INJECTION RECON SOLN 1 GRAM meropenem intravenous recon soln 500 mg 1 Beta-Lactam, Penicillins amoxicillin oral capsule 250 mg, 500 mg 1 amoxicillin oral suspension for reconstitution 125 mg/5 ml, 200 mg/5 ml, 250 mg/5 ml, 400 mg/5 ml amoxicillin oral tablet 500 mg, 875 mg 1 amoxicillin oral tablet, chewable 125 mg, 250 mg 1 amoxicillin-pot clavulanate oral suspension for reconstitution mg/5 ml, mg/5 ml, mg/5 ml, mg/5 ml amoxicillin-pot clavulanate oral tablet mg, mg, mg amoxicillin-pot clavulanate oral tablet extended release 12 hr 1, mg amoxicillin-pot clavulanate oral tablet, chewable mg, mg 1 ampicillin oral capsule 250 mg, 500 mg 1 ampicillin oral suspension for reconstitution 125 mg/5 ml, 250 mg/5 ml 1 ampicillin sodium injection recon soln 1 gram, 10 gram, 125 mg 1 ampicillin-sulbactam injection recon soln 15 gram, 3 gram 1 BICILLIN C-R INTRAMUSCULAR SYRINGE 1,200,000 UNIT/ 2 ML(600K/600K), 1,200,000 UNIT/ 2 ML(900K/300K) BICILLIN L-A INTRAMUSCULAR SYRINGE 1,200,000 UNIT/2 ML, 2,400,000 UNIT/4 ML, 600,000 UNIT/ML dicloxacillin oral capsule 250 mg, 500 mg 1 nafcillin injection recon soln 1 gram, 10 gram 1 oxacillin in dextrose(iso-osm) intravenous piggyback 1 gram/50 ml, 2 gram/50 ml oxacillin injection recon soln 10 gram 1 oxacillin intravenous recon soln 2 gram 1 penicillin g pot in dextrose intravenous piggyback 2 million unit/50 ml, 3 million unit/50 ml penicillin g potassium injection recon soln 5 million unit 1 penicillin g procaine intramuscular syringe 1.2 million unit/2 ml 1 penicillin g sodium injection recon soln 5 million unit 1 You can find information on what the symbols and abbreviations in this table mean by going to page

28 penicillin v potassium oral recon soln 125 mg/5 ml, 250 mg/5 ml 1 penicillin v potassium oral tablet 250 mg, 500 mg 1 piperacillin-tazobactam intravenous recon soln gram, 4.5 gram 1 Macrolides azithromycin intravenous recon soln 500 mg, 500 mg (2 mg/ml) 1 azithromycin oral suspension for reconstitution 100 mg/5 ml, 200 mg/5 ml 1 azithromycin oral tablet 250 mg, 250 mg (6 pack), 500 mg, 600 mg 1 clarithromycin oral suspension for reconstitution 125 mg/5 ml, 250 mg/5 ml clarithromycin oral tablet 250 mg, 500 mg 1 clarithromycin oral tablet extended release 24 hr 500 mg 1 ery pads topical swab 2 % 1 ERY-TAB ORAL TABLET,DELAYED RELEASE (DR/EC) 250 MG, 333 MG, 500 MG erythrocin (as stearate) oral tablet 250 mg 1 erythrocin intravenous recon soln 500 mg 1 erythromycin ophthalmic ointment 5 mg/gram (0.5 %) 1 erythromycin oral capsule, delayed release(dr/ec) 250 mg 1 erythromycin oral tablet 250 mg, 500 mg 1 erythromycin with ethanol topical gel 2 % 1 erythromycin with ethanol topical solution 2 % 1 Quinolones ciprofloxacin (mixture) oral tablet, er multiphase 24 hr 1,000 mg, 500 mg 1 ciprofloxacin hcl ophthalmic drops 0.3 % 1 ciprofloxacin hcl oral tablet 100 mg, 250 mg, 500 mg, 750 mg 1 ciprofloxacin in 5 % dextrose intravenous piggyback 200 mg/100 ml 1 ciprofloxacin lactate intravenous solution 400 mg/40 ml 1 levofloxacin in d5w intravenous piggyback 500 mg/100 ml, 750 mg/150 ml 1 levofloxacin intravenous solution 25 mg/ml 1 levofloxacin ophthalmic drops 0.5 % 1 levofloxacin oral solution 250 mg/10 ml 1 levofloxacin oral tablet 250 mg, 500 mg, 750 mg 1 ofloxacin ophthalmic drops 0.3 % 1 ofloxacin oral tablet 400 mg

29 ofloxacin otic drops 0.3 % 1 VIGAMOX OPHTHALMIC DROPS 0.5 % 2 Sulfonamides silver sulfadiazine topical cream 1 % 1 SSD TOPICAL CREAM 1 % 2 sulfacetamide sodium (acne) topical suspension 10 % 1 sulfacetamide sodium ophthalmic drops 10 % 1 sulfadiazine oral tablet 500 mg 1 sulfamethoxazole-trimethoprim intravenous solution mg/5 ml 1 sulfamethoxazole-trimethoprim oral suspension mg/5 ml 1 sulfamethoxazole-trimethoprim oral tablet mg, mg 1 Tetracyclines doxycycline hyclate intravenous recon soln 100 mg 1 doxycycline hyclate oral capsule 100 mg, 50 mg 1 doxycycline hyclate oral tablet 100 mg, 20 mg, 50 mg 1 doxycycline monohydrate oral suspension for reconstitution 25 mg/5 ml 1 doxycycline monohydrate oral tablet 150 mg, 75 mg 1 minocycline oral capsule 100 mg, 50 mg, 75 mg 1 minocycline oral tablet 100 mg, 50 mg, 75 mg 1 tetracycline oral capsule 250 mg, 500 mg 1 Anticonvulsants Anticonvulsants, Other DIAZEPAM RECTAL KIT MG, 2.5 MG, MG 2 levetiracetam intravenous solution 500 mg/5 ml 1 levetiracetam oral solution 100 mg/ml 1 levetiracetam oral tablet 1,000 mg, 250 mg, 500 mg, 750 mg 1 levetiracetam oral tablet extended release 24 hr 500 mg 1 QL (155 EA per 31 days) levetiracetam oral tablet extended release 24 hr 750 mg 1 QL (124 EA per 31 days) POTIGA ORAL TABLET 200 MG, 300 MG, 400 MG, 50 MG ; QL (93 EA per 31 days) Calcium Channel Modifying Agents CELONTIN ORAL CAPSULE 300 MG 2 ethosuximide oral capsule 250 mg 1 You can find information on what the symbols and abbreviations in this table mean by going to page 7. 28

30 ethosuximide oral solution 250 mg/5 ml 1 LYRICA ORAL CAPSULE 100 MG 2 QL (186 EA per 31 days) LYRICA ORAL CAPSULE 150 MG, 200 MG, 25 MG, 50 MG, 75 MG 2 QL (93 EA per 31 days) LYRICA ORAL CAPSULE 225 MG, 300 MG 2 QL (62 EA per 31 days) LYRICA ORAL SOLUTION 20 MG/ML 2 QL (930 ML per 31 days) zonisamide oral capsule 100 mg, 25 mg, 50 mg 1 Gamma-Aminobutyric Acid (GABA) Augmenting Agents clonazepam oral tablet 0.5 mg, 1 mg, 2 mg 1 QL (310 EA per 31 days) clonazepam oral tablet, disintegrating mg, 0.25 mg, 0.5 mg, 1 mg, 2 mg 1 QL (310 EA per 31 days) clorazepate dipotassium oral tablet 15 mg, 3.75 mg, 7.5 mg 1 QL (186 EA per 31 days) diazepam intensol oral concentrate 5 mg/ml 1 QL (248 ML per 31 days) diazepam oral solution 5 mg/5 ml (1 mg/ml) 1 QL (1240 ML per 31 days) diazepam oral tablet 10 mg, 2 mg, 5 mg 1 QL (124 EA per 31 days) divalproex oral capsule, sprinkle 125 mg 1 divalproex oral tablet extended release 24 hr 250 mg, 500 mg 1 divalproex oral tablet, delayed release (dr/ec) 125 mg, 250 mg, 500 mg 1 gabapentin oral capsule 100 mg, 300 mg, 400 mg 1 QL (279 EA per 31 days) gabapentin oral solution 250 mg/5 ml 1 QL (2232 ML per 31 days) gabapentin oral tablet 600 mg 1 QL (186 EA per 31 days) gabapentin oral tablet 800 mg 1 QL (124 EA per 31 days) GABITRIL ORAL TABLET 12 MG, 16 MG 2 lorazepam oral tablet 0.5 mg, 1 mg, 2 mg 1 QL (155 EA per 31 days) ONFI ORAL SUSPENSION 2.5 MG/ML ; QL (496 ML per 31 days) ONFI ORAL TABLET 10 MG, 20 MG ; QL (62 EA per 31 days) phenobarbital oral elixir 20 mg/5 ml 1 PA phenobarbital oral tablet 100 mg, 15 mg, 16.2 mg, 30 mg, 32.4 mg, 60 mg, 64.8 mg, 97.2 mg primidone oral tablet 250 mg, 50 mg 1 1 PA SABRIL ORAL POWDER IN PACKET 500 MG ; QL (1860 EA per 31 days) SABRIL ORAL TABLET 500 MG ; QL (186 EA per 31 days) tiagabine oral tablet 2 mg, 4 mg 1 valproate sodium intravenous solution 500 mg/5 ml (100 mg/ml) 1 29