2015 List of Covered Drugs (Formulary)

Transcription

1 L.A. Care Cal MediConnect Plan (Medicare-Medicaid Plan) 05 List of Covered Drugs (Formulary) PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN. This Formulary was updated on September 9, 0. If you have questions, please call L.A. Care Cal MediConnect Plan Member Services at (TTY: ), hours a day, 7 days a week, including holidays. For more information, visit H858_560_05Formulary Accepted Formulary ID 00058, Version 5

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3 This is a list of drugs that members can get in L.A. Care Cal MediConnect Plan. L.A. Care Health Plan is a health plan that contracts with both Medicare and Medi-Cal to provide benefits of both programs to enrollees. Benefits, List of Covered Drugs, and pharmacy and provider networks and/or copayments may change from time to time throughout the year and on January of each year. You can always check L.A. Care Cal MediConnect Plan s up-to-date List of Covered Drugs online at or by calling (TTY: ). You can ask for this information in other formats, such as Braille or large print. Call (TTY: ). The call is free. Limitations and restrictions may apply. For more information, call L.A. Care Cal MediConnect Plan Member Services or read the L.A. Care Cal MediConnect Plan 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 (TTY: ). The call is free. Puede obtener esta información gratis en otros idiomas. Llame al (TTY: ). La llamada es gratis. Այս տեղեկությունները անվճար կարող եք ստանալ այլ լեզուներով: Զանգահարեք հեռախոսահամարով (TTY` ): Զանգն անվճար է: អ នកអ ចទទ លព ត ម នន ជ ភ ស ផ ស ងៗដ យឥតគ តថ ល ស មហ ល ខ (TTY: ) ក រហ ន គ ឥតគ តថ ល ឡ យ 이 정보는 다른 언어로도 무료로 구하실 수 있습니다 (TTY: )로 전화하시면 되며 통화료는 무료입니다. Вы можете бесплатно получить эту информацию на других языках. Позвоните по номеру телефона (TTY: ). Звонок бесплатный. Makukuha ninyo ang impormasyong ito nang libre sa ibang mga wika. Tumawag sa (TTY: ). Ang tawag ay libre. 本 資 訊 備 有 其 他 語 言 版 本 供 您 免 費 索 取 請 致 電 (TTY: ) 這 是 免 費 電 話? If you have questions, please call L.A. Care Cal MediConnect Plan at (TTY: ), hours a day, 7 days a week, including holidays. The call is free. For more information, visit i

4 Quý vị có thể được cấp thông tin này miễn phí bằng nhiều ngôn ngữ. Vui lòng gọi số (TTY: ). Số điện thoại này miễn phí. يمكنك الحصول على هذه المعلومات مجان ا بلغات ا خرٮاتصل على الرقم (رقم الهاتف النصي: ). هذه المكالمة مجانية. ii? If you have questions, please call L.A. Care Cal MediConnect Plan at (TTY: ), hours a day, 7 days a week, including holidays. The call is free. For more information, visit

5 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.. 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 L.A. Care Cal MediConnect Plan. 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. L.A. Care Cal MediConnect Plan 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 L.A. Care Cal MediConnect Plan network pharmacy. In some cases, you have to do something before you can get a drug (see Question 5). You can also see an up-to-date list of drugs that we cover on our website at or call Member Services at (TTY: ).. Does the Drug List ever change? Yes. L.A. Care Cal MediConnect Plan 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 L.A. Care Cal MediConnect Plan before you can get a drug.) Add or change the amount of a drug you can get (called quantity limits ). Add or change step therapy restrictions on a drug. (Step therapy means you must try one drug before we will cover another drug.) (For more information on these drug rules, see page iv.) We will tell you when a drug you are taking is removed from the Drug List. We will also tell? If you have questions, please call L.A. Care Cal MediConnect Plan at (TTY: ), hours a day, 7 days a week, including holidays. The call is free. For more information, visit iii

6 iv? you when we change our rules for covering a drug. Questions 3,, and 7 below have more information on what happens when the Drug List changes. You can always check L.A. Care Cal MediConnect Plan s up-to-date Drug List online at You can also call Member Services to check the current Drug List at (TTY: ). 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. You will be notified of this change in a document called the Explanation of Benefits which shows drugs to be removed from the Drug List in 60 days. The list of drugs to be removed is also posted on L.A. Care Cal MediConnect Plan s website, 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. We will also notify your provider so you can consult him/her to change to a drug on the Drug List that is safe to use. 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 must do something before you can get the drug. For example: Prior approval (or prior authorization): For some drugs, you or your doctor must get approval from L.A. Care Cal MediConnect Plan before you fill your prescription. If you don t get approval, L.A. Care Cal MediConnect Plan may not cover the drug. Quantity limits: Sometimes L.A. Care Cal MediConnect Plan limits the amount of a drug you can get. Step therapy: Sometimes L.A. Care Cal MediConnect Plan requires you to do step therapy. This means you will have to try drugs in a certain order for your medical condition. You might have to try one drug before we will cover another drug. If your doctor thinks the first drug doesn t work for you, then we will cover the second. You can find out if your drug has any additional requirements or limits by looking in the tables on pages -6. You can also get more information by visiting our website at We have posted online a document that explains our prior authorization and step therapy restrictions. You may also ask us to send you a copy. If you have questions, please call L.A. Care Cal MediConnect Plan at (TTY: ), hours a day, 7 days a week, including holidays. The call is free. For more information, visit

7 You can also ask for an exception from these limits. Please see Question 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 3-day emergency supply of the drug you need (unless you have a prescription for fewer days), whether or not you are a new L.A. Care Cal MediConnect Plan 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 for more information about exceptions. 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 on page has a column labeled 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), quantity limits, and/or step therapy restrictions on a drug. We will tell you if we add prior approval, quantity limits, and/or step therapy 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 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 by looking at the index at the end of the list. The medications are listed in alphabetical order. To search by medical condition, find the section labeled List of drugs by medical condition on page. Then find your medical condition. For example, if you have a heart condition, you should look in that category. That is where you will find drugs that treat heart conditions.? If you have questions, please call L.A. Care Cal MediConnect Plan at (TTY: ), hours a day, 7 days a week, including holidays. The call is free. For more information, visit v

8 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 (TTY: ) and ask about it. If you learn that L.A. Care Cal MediConnect Plan 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 for more information about exceptions. 0. What if you are a new L.A. Care Cal MediConnect Plan 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 30-day supply of your drug during the first 90 days you are a member of L.A. Care Cal MediConnectPlan. 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 30-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 L.A. Care Cal MediConnect Plan, or you are taking a drug that is part of a step therapy restriction. 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 the 90 days. This gives your prescriber time to change your drugs to those on the Drug List or ask for an exception. Level of Care Changes We will provide a transition supply of your drugs when you experience a change in level of care. Examples of level of care changes may include the following:. Members who enter long-term care facilities from hospitals. Members who are discharged from a hospital to a home 3. Members who end their skilled nursing facility Medicare Part A stay and who need to revert to their Part D plan formulary. Members who give up hospice status to revert to standard Medicare Part A and B benefits vi? If you have questions, please call L.A. Care Cal MediConnect Plan at (TTY: ), hours a day, 7 days a week, including holidays. The call is free. For more information, visit

9 5. Members who end a long-term care facility stay and return to the community 6. Members who are discharged from psychiatric hospitals with drug regimens that are highly individualized. Pharmacies may contact L.A. Care Cal MediConnect Plan Pharmacy Services at to process point-of-sale overrides to ensure members receive access to their medications without any delays.. Can you ask for an exception to cover your drug? Yes. You can ask L.A. Care Cal MediConnect Plan 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. For example, L.A. Care Cal MediConnect Plan 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 step therapy restrictions or prior approval requirements.. 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 7 hours. If you or your prescriber think your health may be harmed if you have to wait 7 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 hours of receiving your prescriber s supporting statement. 3. How can you ask for an exception? To ask for an exception, call Member Services or our Pharmacy Department. Your care team will work with you and your provider to help you ask for an exception.. 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). L.A. Care Cal MediConnect Plan covers both brand-name drugs and generic drugs.? If you have questions, please call L.A. Care Cal MediConnect Plan at (TTY: ), hours a day, 7 days a week, including holidays. The call is free. For more information, visit vii

10 5. What are OTC drugs? OTC stands for over-the-counter. You can buy OTC drugs without a prescription. L.A. Care Cal MediConnect Plan covers some OTC drugs. You can read the L.A. Care Cal MediConnect Plan Drug List to see what OTC drugs are covered. 6. Does L.A. Care Cal MediConnect Plan cover OTC non-drug products? L.A. Care Cal MediConnect Plan covers some OTC non-drug products. You can read the L.A. Care Cal MediConnect Plan Drug List to see what OTC non-drug products are covered. 7. What is your co-pay? You can read the L.A. Care Cal MediConnect Plan Drug List to learn about the co-pay for each drug. L.A. Care Cal MediConnect Plan members living in nursing homes or other long-term care facilities will have no co-pays. 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 drugs are generic drugs. The co-pay will be from $0 to $.65, depending on your level of Medicaid eligibility. Tier drugs are brand name drugs. The co-pay will be from $0 to $6.60, depending on your level of Medicaid eligibility. Tier 3 drugs are Non-Medicare Rx Generic drugs. For Tier 3 drugs you pay nothing. Tier drugs are Non-Medicare OTC drugs. For Tier drugs you pay nothing. List of Covered Drugs The list of covered drugs below or that begins on the next page gives you information about the drugs covered by L.A. Care Cal MediConnect Plan. If you have trouble finding your drug in the list, turn to the Index that begins on page. The first column of the chart lists the name of the drug. Brand-name drugs are capitalized (e.g., CYMBALTA) and generic drugs are listed in lowercase italics (e.g., metformin). The information in the column tells you if L.A. Care Cal MediConnect Plan has any rules for covering your drug. viii? If you have questions, please call L.A. Care Cal MediConnect Plan at (TTY: ), hours a day, 7 days a week, including holidays. The call is free. For more information, visit

11 COVERAGE NOTES ABBREVIATIONS ABBREVIATION DESCRIPTION EXPLANATION NSO Prior Authorization Restriction Prior Authorization Restriction for Part B vs Part D Determination Prior Authorization Restriction for New Starts Only Utilization Management Restrictions You (or your physician) are required to get prior authorization from L.A. Care Cal MediConnect Plan before you fill your prescription for this drug. Without prior approval, L.A. Care Cal MediConnect Plan may not cover this drug. This drug may be eligible for payment under Medicare Part B or Part D. You (or your physician) are required to get prior authorization from L.A. Care Cal MediConnect Plan to determine that this drug is covered under Medicare Part D before you fill your prescription for this drug. Without prior approval, L.A. Care Cal MediConnect Plan may not cover this drug. If this is a new prescription for you, i.e., the first time this drug is prescribed for you, you (or your physician) are required to get prior authorization from L.A. Care Cal MediConnect Plan before you fill your prescription for this drug. Without prior approval, L.A. Care Cal MediConnect Plan may not cover this drug. QL Quantity Limit Restriction L.A. Care Cal MediConnect Plan limits the quantity to be covered within a specific time frame for this drug. ST Step Therapy Restriction Before L.A. Care Cal MediConnect Plan will provide coverage for this drug, you must first try another drug(s) on the formulary to treat your medical condition. This drug may only be covered if the other drug(s) does not work for you. Other Special Requirements for Coverage LD Limited Distribution Drug This prescription may be available only at certain pharmacies. For more information, consult your Provider/Pharmacy Directory or call Member Services at (TTY: ), hours a day, 7 days a week, including holidays. Note: The asterisk (*) next to a drug means the drug is not a Part D drug. The amount you pay when you fill a prescription for this drug does not count towards your total drug costs (that is, the amount you pay does not help you qualify for catastrophic coverage). 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 (TTY: ). You can also read the Member Handbook to learn how to appeal a decision.? If you have questions, please call L.A. Care Cal MediConnect Plan at (TTY: ), hours a day, 7 days a week, including holidays. The call is free. For more information, visit ix

12 ADHD/ ANTI-NARCOLEPSY/ ANTI-OBESITY/ ANOREXIANTS AMPHETAMINES ADDERALL XR CAP amphetamine/ dextroamphetamine tab dextroamphetamine ER cap dextroamphetamine tab methamphetamine tab VYVANSE CAP ANOREXIANTS NON-AMPHETAMINE phentermine cap 5mg* 3 phentermine cap 30mg* 3 phentermine tab 37.5mg* 3 QSYMIA CAP* 3 ANTI-OBESITY AGENTS XENICAL CAP 0MG* 3 ATTENTION-DEFICIT/ HYPERACTIVITY DISORDER (ADHD) AGENTS INTUNIV TAB MG, MG ST INTUNIV TAB 3MG, MG NSO ST STRATTERA CAP QL=60 Caps/30 Days STIMULANTS - MISC. dexmethylphenidate ER cap dexmethylphenidate tab metadate ER tab methylphenidate CD cap methylphenidate ER cap methylphenidate ER tab methylphenidate soln. methylphenidate tab NUVIGIL TAB QL=30 Tabs/30 Days AMINOGLYCOSIDES AMINOGLYCOSIDES amikacin inj. gentamicin inj. gentamicin/ nacl inj. gentamicin/ nacl inj..6mg/ ml gentamycin/ nacl inj. isotonic gentamicin neomycin tab paromomycin cap STREPTOMYCIN INJ. TOBI NEB NM TOBI PODHALER NM tobramycin inj TOBRAMYCIN/ NACL INJ.

13 ANALGESICS - ANTI-INFLAMMATORY ANTI-TNF-ALPHA - MONOCLONAL ANTIBODIES HUMIRA KIT NM SIMPONI INJ. NM GOLD COMPOUNDS RIDAURA CAP INTERLEUKIN- BLOCKERS ARCALYST INJ. NM INTERLEUKIN-BETA BLOCKERS ILARIS INJ. NM NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS) CELEBREX CAP QL=60 Caps/30 Days diclofenac ec tab diclofenac potassium tab diclofenac XR tab diclofenac/ misoprostol tab etodolac cap etodolac ER tab etodolac tab fenoprofen tab flurbiprofen tab ibuprofen cap 00mg* ibuprofen chew tab 00mg* ibuprofen susp. ibuprofen tab ibuprofen tab 00mg* ibuprofen tab 00mg* QL=00 Tabs/00 Days INDOCIN SUSP. indomethacin cap indomethacin ER cap ketoprofen cap ketorolac inj. ketorolac tab QL=0 Tabs/5 Days MECLOFENAMATE SODIUM CAP mefenamic acid cap MELOXICAM SUSP meloxicam tab nabumetone tab naproxen dr tab naproxen sodium tab naproxen susp. naproxen tab oxaprozin tab piroxicam cap

14 sulindac tab tolmetin cap tolmetin tab TOLMETIN TAB 00MG PYRIMIDINE SYNTHESIS INHIBITORS leflunomide tab SELECTIVE COSTIMULATION MODULATORS ORENCIA INJ. ORENCIA SUB-Q INJ. SOLUBLE TUMOR NECROSIS FACTOR RECEPTOR AGENTS ENBREL INJ. ANALGESICS - NONNARCOTIC ANALGESIC COMBINATIONS aspirin/ acetaminophen/ caffeine tab mg* ANALGESICS OTHER acetaminophen cap 500mg* acetaminophen chew tab 60mg* acetaminophen CR tab 650mg* acetaminophen elixir 60mg/ 5ml* acetaminophen liquid 60mg/ 5ml* ACETAMINOPHEN LIQUID 500MG/ 5ML* acetaminophen soln. 60mg/ 5ml* acetaminophen suppository 0mg* acetaminophen suppository 35mg* acetaminophen suppository 650mg* acetaminophen suppository 80mg* acetaminophen susp. 60mg/ 5ml* acetaminophen susp. 80mg/ 0.8ml* acetaminophen tab 35mg* acetaminophen tab 500mg* SALICYLATES ASCRIPTIN TAB 35MG* aspirin 8mg tab* aspirin DR tab 35mg* aspirin DR tab 8mg* aspirin tab 35mg* aspirin tab 500mg* diflunisal tab ANALGESICS - OPIOID OPIOID AGONISTS codeine sulfate tab duramorph inj. EXALGO TAB fentanyl lollipop 3 NM QL=00 Tabs/00 Days QL=00 Tabs/00 Days QL=00 Tabs/00 Days QL=00 Tabs/00 Days QL=0 Lozenges/30 Days

15 fentanyl patch hydromorphone ER tab hydromorphone inj. hydromorphone oral liquid hydromorphone tab LAZANDA SPRAY LEVORPHANOL TAB meperitab tab methadone soln. methadone tab morphine sulfate ER cap morphine sulfate ER tab MORPHINE SULFATE PF INJ. MG, MG morphine sulfate soln. morphine sulfate tab NUCYNTA ER TAB oxycodone cap oxycodone soln. oxycodone tab OXYCONTIN TAB OXYCONTIN TAB 80MG oxymorphone ER tab oxymorphone tab tramadol ER tab tramadol hcl tab OPIOID COMBINATIONS acetaminophen/ codeine soln. acetaminophen/ codeine tab endocet tab endodan tab hydrocodone/ acetaminophen soln mg/ 5ml hydrocodone/ acetaminophen tab 5-300mg, mg, 0-300mg hydrocodone/ acetaminophen tab 5-35mg, mg, 0-35mg hydrocodone/ ibuprofen tab oxycodone / aspirin tab oxycodone / ibuprofen tab oxycodone/ acetaminophen tab ROXICET SOLN tramadol/ acetaminophen tab OPIOID RTIAL AGONISTS buprenorphine inj. buprenorphine sl tab butorphanol inj QL=30 Bottles/30 Days QL=60 Caps/30 Days QL=0 Tabs/30 Days QL=60 Tabs/30 Days QL=60 Tabs/30 Days QL=0 Tabs/30 Days QL=60 Tabs/30 Days

16 butorphanol soln. BUTRANS TCH pentazocine/ naloxone tab SUBOXONE SL FILM ANDROGENS-ANABOLIC ANABOLIC STEROIDS ANADROL-50 TAB oxandrolone tab ANDROGENS ANDRODERM TCH MG/ HR ANDRODERM TCH MG/ HR ANDROGEL GEL %(50MG) ANDROGEL PUMP ANDROXY TAB danazol cap testosterone cypionate inj. testosterone enanthate inj. ANORECTAL AGENTS INTRARECTAL STEROIDS colocort enema hydrocortisone enema RECTAL STEROIDS procto-pak proctozone-hc cream ANTACIDS ANTACID COMBINATIONS aluminum hydroxide/ magnesium carbonate chew tab* aluminum/ mag hydroxide/ simethicone susp mg/ 5ml* antacid susp.* GELUSIL CHEW TAB* MAALOX ADVANCED MAXIMUM STRENGTH CHEW TAB* maalox max susp* ANTACIDS - ALUMINUM SALTS ALUMINUM HYDROXIDE GEL SUSP. 30MG/ 5ML* aluminum hydroxide gel susp. 600mg/ 5ml* ANTACIDS - BICARBONATE sodium bicarbonate tab 650mg* ANTACIDS - CALCIUM SALTS calcium carbonate chew tab 000mg* calcium carbonate chew tab 0mg* QL= Bottles/30 Days QL= Patches/8 Days QL=60 Patches/30 Days QL=30 Patches/30 Days QL=60 Patches/30 Days QL= Bottles/30 Days 5

17 calcium carbonate chew tab 500mg* calcium carbonate chew tab 750mg* calcium carbonate tab 68mg* ANTHELMINTICS ANTHELMINTICS ALBENZA TAB STROMECTOL TAB ANTIANGINAL AGENTS ANTIANGINALS-OTHER RANEXA TAB NITRATES isosorbide dinitrate ER tab isosorbide dinitrate tab isosorbide mononitrate ER tab isosorbide mononitrate tab minitran patch NITRO-DUR TCH 0.3MG/ HR, 0.8MG/ HR nitroglycerin inj. nitroglycerin lingual spray nitroglycerin patch NITROSTAT SL TAB ANTIANXIETY AGENTS ANTIANXIETY AGENTS - MISC. buspirone tab hydroxyzine inj. hydroxyzine pamoate cap hydroxyzine syrup hydroxyzine tab meprobamate tab BENZODIAZEPINES alprazolam ER tab alprazolam odt tab alprazolam tab chlordiazepoxide cap clorazepate tab DIAZEM INTENSOL DIAZEM SOLN. diazepam tab lorazepam conc lorazepam tab oxazepam cap ANTIARRHYTHMICS ANTIARRHYTHMICS TYPE I-A 6

18 disopyramide cap NORCE CR PROCAINAMIDE INJ. quinidine gluconate CR tab QUINIDINE GLUCONATE INJ. quinidine sulfate tab ANTIARRHYTHMICS TYPE I-B mexiletine cap ANTIARRHYTHMICS TYPE I-C flecainide tab propafenone ER cap propafenone tab ANTIARRHYTHMICS TYPE III amiodarone inj amiodarone tab MULTAQ TAB NEXTERONE INJ. TIKOSYN CAP ANTIASTHMATIC AND BRONCHODILATOR AGENTS ANTIASTHMATIC - MONOCLONAL ANTIBODIES XOLAIR INJ. NM ANTI-INFLAMMATORY AGENTS cromolyn neb BRONCHODILATORS - ANTICHOLINERGICS ATROVENT HFA INHALER ipratropium neb SPIRIVA CAP HANDIHALER TUDORZA INHALER LEUKOTRIENE MODULATORS montelukast chew tab montelukast granules montelukast tab zafirlukast tab SELECTIVE PHOSPHODIESTERASE (PDE) INHIBITORS DALIRESP TAB STEROID INHALANTS ASMANEX INHALER budesonide neb QL=60 Neb/30 Days FLOVENT DISKUS QL= Inhalers/30 Days FLOVENT HFA INHALER 0MCG QL= Inhalers/30 Days FLOVENT HFA INHALER MCG, 0MCG QL= Inhalers/30 Days PULMICORT NEB MG/ ML QL=60 Neb/30 Days QVAR INHALER QL= Inhalers/30 Days SYMTHOMIMETICS 7

19 ADVAIR DISKUS ADVAIR HFA INHALER albuterol neb albuterol sulfate ER tab albuterol syrup albuterol tab COMBIVENT RESPIMAT DULERA INHALER EPHEDRINE SULFATE CAP 5MG* FORADIL CAP ipratropium/ albuterol neb. levalbuterol neb METAPROTERENOL SYRUP SEREVENT INHALER SYMBICORT INHALER terbutaline inj. terbutaline tab VENTOLIN HFA INHALER XANTHINES aminophylline inj. ELIXOPHYLLIN SOLN. theophylline ER tab theophylline soln. ANTICOAGULANTS COUMARIN ANTICOAGULANTS COUMADIN INJ. jantoven tab warfarin tab DIRECT FACTOR XA INHIBITORS ELIQUIS TAB XARELTO TAB HERINS AND HERINOID-LIKE AGENTS enoxaparin inj. fondaparinux inj. FRAGMIN INJ. heparin inj. heparin/ d5w inj. heparin/ nacl inj. THROMBIN INHIBITORS argatroban inj. 00mg/ ml ARGATROBAN INJ. 5MG/ 5ML PRADAXA CAP ANTICONVULSANTS AM GLUTAMATE RECEPTOR ANTAGONISTS 8 QL= Inhalers/30 Days QL= Inhalers/30 Days QL= Inhalers/30 Days QL= Inhalers/30 Days QL= Inhalers/30 Days QL=35 Syringes/7 Days NM NM

20 FYCOM TAB ANTICONVULSANTS - BENZODIAZEPINES clonazepam odt tab clonazepam tab DIASTAT RECTAL GEL DIAZEM RECTAL GEL ONFI SUSPENSION ONFI TAB ANTICONVULSANTS - MISC. APTIOM TAB BANZEL SUSP. BANZEL TAB carbamazepine chew tab carbamazepine ER cap carbamazepine ER tab carbamazepine susp. carbamazepine tab epitol tab gabapentin cap gabapentin soln. gabapentin tab LAMICTAL ODT LAMICTAL STARTER KIT LAMICTAL XR KIT lamotrigine chew tab lamotrigine ER tab lamotrigine tab levetiracetam ER tab levetiracetam inj levetiracetam soln. levetiracetam tab LYRICA CAP LYRICA SOLN. oxcarbazepine oral susp. oxcarbazepine tab OXTELLAR XR TAB POTIGA TAB primidone tab TEGRETOL-XR TAB topiramate sprinkle cap topiramate tab TROKENDI XR CAP VIMT INJ. VIMT SOLN. VIMT TAB 9 NSO NSO NSO NSO NSO QL=90 Tabs/30 Days NSO QL=60 Tabs/30 Days

21 zonisamide cap CARBAMATES felbamate susp. felbamate tab GABA MODULATORS GABITRIL TAB SABRIL POWDER SABRIL TAB tiagabine tab HYDANTOINS DILANTIN CAP fosphenytoin inj. PEGANONE TAB phenytoin cap phenytoin chew tab phenytoin inj. phenytoin susp. SUCCINIMIDES CELONTIN CAP ethosuximide cap ethosuximide soln. VALPROIC ACID divalproex dr tab divalproex ER tab divalproex sprinkle cap valproate sodium inj. valproic acid cap valproic acid syrup ANTIDEPRESSANTS ALPHA- RECEPTOR ANTAGONISTS (TETRACYCLICS) mirtazapine odt tab mirtazapine tab ANTIDEPRESSANTS - MISC. APLENZIN TAB bupropion SR tab bupropion tab bupropion XL tab maprotiline tab MODIFIED CYCLICS BRINTELLIX TAB NEFAZODONE TAB trazodone tab VIIBRYD STARTER CK VIIBRYD TAB 0 NM NM ST ST NSO ST

22 MONOAMINE OXIDASE INHIBITORS (MAOIS) EMSAM TCH MARPLAN TAB phenelzine tab tranylcypromine tab SELECTIVE SEROTONIN REUPTAKE INHIBITORS (SSRIS) citalopram soln. citalopram tab escitalopram soln. escitalopram tab fluoxetine cap fluoxetine soln. fluoxetine tab fluvoxamine ER cap fluvoxamine tab paroxetine ER tab paroxetine tab XIL SUSP. PEXEVA TAB sertraline conc. sertraline tab SEROTONIN-NOREPINEPHRINE REUPTAKE INHIBITORS (SNRIS) DESVENLAFAXINE ER TAB duloxetine cap FETZIMA CAP FETZIMA CK KHEDEZYLA TAB PRISTIQ TAB venlafaxine ER cap venlafaxine ER tab VENLAFAXINE ER TAB 5MG venlafaxine tab TRICYCLIC AGENTS amitriptyline tab amoxapine tab clomipramine cap desipramine tab doxepin conc. doxepine cap imipramine pamoate imipramine tab nortriptyline cap nortriptyline soln. protriptyline tab SURMONTIL CAP ST ST ST QL=60 Caps/30 Days ST ST ST ST NSO NSO NSO NSO NSO NSO NSO

23 ANTIDIABETICS ALPHA-GLUCOSIDASE INHIBITORS acarbose tab GLYSET TAB ANTIDIABETIC - AMYLIN ANALOGS SYMLINPEN ANTIDIABETIC COMBINATIONS AVANDAMET TAB AVANDARYL TAB glipizide/ metformin tab glyburide/ metformin tab JANUMET TAB JANUMET XR TAB pioglitazone/ glimepiride tab pioglitazone/ metformin tab BIGUANIDES metformin ER osmotic tab 000mg metformin ER tab metformin tab DIABETIC OTHER GLUCAGEN HYPOKIT GLUCAGON KIT KORLYM TAB PROGLYCEM SUSP. DIPEPTIDYL PEPTIDASE- (DPP-) INHIBITORS JANUVIA TAB ONGLYZA TAB TRADJENTA TAB INCRETIN MIMETIC AGENTS (GLP- RECEPTOR AGONISTS) BYDUREON INJ. VICTOZA INJ. INSULIN HUMALOG PEN HUMALOG VIAL HUMULIN 70/ 30 PEN HUMULIN N PEN HUMULIN R U-500 VIAL LANTUS SOLOSTAR LANTUS VIAL LEVEMIR FLEXPEN LEVEMIR INJ. NOVOLIN 70/ 30 VIAL NOVOLIN N VIAL NOVOLIN R VIAL NM QL=30 Tabs/30 Days QL=30 Tabs/30 Days QL=30 Tabs/30 Days ST ST

24 NOVOLOG FLEXPEN NOVOLOG MIX 70/ 30 PEN NOVOLOG MIX 70/ 30 VIAL NOVOLOG VIAL INSULIN SENSITIZING AGENTS AVANDIA TAB pioglitazone tab MEGLITINIDE ANALOGUES nateglinide tab repaglinide tab SODIUM-GLUCOSE CO-TRANSPORTER (SGLT) INHIBITORS FARXIGA TAB INVOKANA TAB SULFONYLUREAS chlorpropamide tab glimepiride tab glipizide ER tab glipizide tab glyburide micronized tab glyburide tab tolazamide tab TOLBUTAMIDE TAB ANTIDIARRHEALS ANTIDIARRHEAL AGENTS - MISC. bismuth subsalicylate chew tab 6mg* bismuth subsalicylate susp 6mg/ 5ml* bismuth subsalicylate susp 55mg/ 5ml* bismuth subsalicylate tab 6mg* ANTIPERISTALTIC AGENTS diphenoxylate/ atropine liquid diphenoxylate/ atropine tab loperamide cap loperamide tab mg* ANTIDOTES ANTIDOTES fomepizole inj. ANTIDOTES - CHELATING AGENTS CHEMET CAP EXJADE ORAL SUSP. FERRIPROX OPIOID ANTAGONISTS naloxone inj. naltrexone tab ST QL=30 Tabs/30 Days NM LD 3

25 ANTIEMETICS 5-HT3 RECEPTOR ANTAGONISTS granisetron inj. granisetron tab QL=9 Tabs/ Days ondansetron inj. ondansetron odt tab ondansetron soln. ondansetron tab ANTIEMETICS - ANTICHOLINERGIC BONINE CHEW TAB 5MG* dimenhydrinate tab 50mg* meclizine tab TRANSDERM SCOP trimethobenzamide cap ANTIEMETICS - MISCELLANEOUS CESAMET CAP dronabinol cap SUBSTANCE P/ NEUROKININ (NK) RECEPTOR ANTAGONISTS EMEND CAP QL=3 Caps/ Days EMEND CK QL=3 Caps/ Days ANTIFUNGALS ANTIFUNGAL - GLUCAN SYNTHESIS INHIBITORS (ECHINOCANDINS) CANCIDAS INJ. NM ERAXIS INJ. MYCAMINE INJ. ANTIFUNGALS ABELCET INJ. AMBISOME INJ. AMPHOTERICIN B INJ. flucytosine cap griseofulvin microsize susp. griseofulvin tab nystatin tab terbinafine tab IMIDAZOLE-RELATED ANTIFUNGALS fluconazole susp. fluconazole tab fluconazole/ dextrose inj. itraconazole cap ketoconazole tab NOXAFIL SUSP NOXAFIL TAB NM voriconazole inj. voriconazole susp.

26 voriconazole tab ANTIHISTAMINES ANTIHISTAMINES - ALKYLAMINES chlorpheniramine syrup mg/ 5ml* chlorpheniramine tab mg* ANTIHISTAMINES - ETHANOLAMINES BENADRYL CHEW TAB.5MG* carbinoxamine soln. carbinoxamine tab CLEMASTINE SYRUP clemastine tab clemastine tab.3mg* diphenhydramine cap 5mg* diphenhydramine cap 50mg* diphenhydramine elixir.5mg/ 5ml* diphenhydramine inj. diphenhydramine liquid.5mg/ 5ml* diphenhydramine oral soln (Rx only) diphenhydramine tab 5mg* ANTIHISTAMINES - NON-SEDATING ALLEGRA TAB 30MG* 3 cetirizine chew tab 0mg* cetirizine chew tab 5mg* cetirizine oral soln (Rx only) cetirizine soln mg/ ml* cetirizine tab 0mg* cetirizine tab 5mg* desloratadine ODT tab desloratatine tab fexofenadine tab 80mg* 3 fexofenadine tab 60mg* 3 levocetirizine soln. levocetirizine tab loratadine ODT tab 0mg* loratadine syrup 5mg/ 5ml* loratadine tab 0mg* ANTIHISTAMINES - PHENOTHIAZINES phenadoz supp. promethazine inj. promethazine supp. promethazine syrup promethazine tab PROMETHAZINE VC CODEINE promethegan supp. NM QL=300 ml/30 Days QL=30 Tabs/30 Days QL=30 Tabs/30 Days QL=30 Tabs/30 Days QL=300 ml/30 Days QL=30 Tabs/30 Days 5

27 PROMETHEGAN SUPP. 50MG ANTIHISTAMINES - PIPERIDINES cyproheptadine syrup cyproheptadine tab ANTIHYPERLIPIDEMICS ANTIHYPERLIPIDEMICS - COMBINATIONS LIPTRUZET TAB ANTIHYPERLIPIDEMICS - MISC. LOVAZA CAP omega-3 acid cap VASCE BILE ACID SEQUESTRANTS cholestyramine light powder cholestyramine lite powder packet colestipol granule colestipol tab WELCHOL TAB FIBRIC ACID DERIVATIVES fenofibrate micronized cap fenofibrate tab gemfibrozil tab LOFIBRA CAP LOFIBRA TAB TRIGLIDE TAB TRILIPIX CAP HMG COA REDUCTASE INHIBITORS atorvastatin tab CRESTOR TAB CRESTOR TAB 0MG fluvastatin cap LESCOL XL TAB lovastatin tab pravastatin tab SIMCOR TAB simvastatin tab INTESTINAL CHOLESTEROL ABSORPTION INHIBITORS ZETIA TAB NICOTINIC ACID DERIVATIVES NIACOR TAB NIASN ER TAB ANTIHYPERTENSIVES ACE INHIBITORS benazepril tab QL=30 Tabs/30 Days QL=5 Tabs/30 Days QL=30 Tabs/30 Days 6

28 captopril tab enalapril tab fosinopril tab lisinopril tab moexipril tab perindopril tab quinapril tab ramipril cap trandolapril tab AGENTS FOR PHEOCHROMOCYTOMA DEMSER CAP DIBENZYLINE CAP ANGIOTENSIN II RECEPTOR ANTAGONISTS candesartan tab DIOVAN TAB eprosartan mesylate tab irbesartan tab losartan tab telmisartan tab ANTIADRENERGIC ANTIHYPERTENSIVES clonidine patch clonidine tab doxazosin tab guanfacine IR tab methyldopa tab prazosin cap terazosin cap ANTIHYPERTENSIVE COMBINATIONS amlodipine/ benazepril cap atenolol/ chlorthalidone tab benazepril/ hctz tab bisoprolol/ hctz tab candesartan/ hctz tab captopril/ hctz tab DUTOPROL TAB enalapril/ hctz tab EXFORGE HCT TAB EXFORGE TAB fosinopril/ hctz tab irbesartan/ hctz tab lisinopril/ hctz tab losartan/ hctz tab methyldopa/ hctz tab metoprolol/ hctz tab moexipril/ hctz tab 7

29 nadolol/ bendroflumethiazide tab propranolol/ hctz tab quinapril/ hctz tab telmisartan/ amlodipine tab telmisartan/ hctz tab valsartan/ hctz tab SELECTIVE ALDOSTERONE RECEPTOR ANTAGONISTS (SARAS) eplerenone tab VASODILATORS hydralazine inj hydralazine tab minoxidil tab ANTI-INFECTIVE AGENTS - MISC. ANTI-INFECTIVE AGENTS - MISC. AZACTAM/ DEXTROSE INJ. aztreonam inj. baciim inj colistimethate inj. metronidazole cap metronidazole tab metronidazole/ nacl inj. NEBUPENT NEB PENTAM INJ. tinidazole tab trimethoprim tab vancomycin cap vancomycin inj. ANTI-INFECTIVE MISC. - COMBINATIONS e.s.p susp. sulfamethoxazole/ trimethoprim DS tab SULFAMETHOXAZOLE/ TRIMETHOPRIM INJ. sulfamethoxazole/ trimethoprim susp. sulfamethoxazole/ trimethoprim tab ANTIPROTOZOAL AGENTS ALINIA SUSP. ALINIA TAB atovaquone susp CARBAPENEMS DORIBAX INJ. imipenem/ cilastatin inj. INVANZ INJ. meropenem inj. CHLORAMPHENICOLS CHLORAMPHENICAL INJ. 8 ST QL=56 Caps/0 Days

30 CYCLIC LIPOPEPTIDES CUBICIN INJ. GLYCYLCYCLINES TYGACIL INJ. LEPROSTATICS dapsone tab LINCOSAMIDES clindamycin cap clindamycin inj clindamycin soln. LINCOCIN OXAZOLIDINONES ZYVOX INJ. ZYVOX SUSP. ZYVOX TAB POLYMYXINS polymyxin b inj. STREPTOGRAMINS SYNERCID INJ ANTIMALARIALS ANTIMALARIAL COMBINATIONS atovaquone/ proguanil tab COARTEM TAB ANTIMALARIALS chloroquine tab DARAPRIM TAB hydroxychloroquine tab mefloquine tab PRIMAQUINE TAB quinine sulfate cap ANTIMYASTHENIC AGENTS ANTIMYASTHENIC AGENTS GUANIDINE TAB MESTINON TIMESN TAB pyridostigmine tab ANTIMYCOBACTERIAL AGENTS ANTI TB COMBINATIONS RIFAMATE CAP RIFATER TAB ANTIMYCOBACTERIAL AGENTS CASTAT INJ. ethambutol tab isoniazid inj. 9 NM NM NM NM

31 isoniazid syrup isoniazid tab SER GRANULE PRIFTIN TAB pyrazinamide tab rifabutin cap rifampin cap rifampin inj. TRECATOR TAB ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES ALKYLATING AGENTS BICNU INJ. BUSULFEX INJ. carboplatin inj. cisplatin inj CYCLOPHOSPHAMIDE CAP cyclophosphamide tab HEXALEN CAP NM IFEX INJ. ifosfamide inj. LEUKERAN TAB LOMUSTINE CAP melphalan inj. MYSTARGEN INJ. oxaliplatin inj TREANDA INJ. NM NSO ZANOSAR INJ ANTIMETABOLITES ALIMTA INJ. ARRANON INJ azacitidine inj. cladribine inj. CLOLAR INJ. cytarabine inj. decitabine inj. fludarabine inj. fluorouracil inj. FOLOTYN INJ. NM NSO gemcitabine inj. mercaptopurine tab methotrexate inj. methotrexate PF inj. methotrexate tab TABLOID TAB TREXALL TAB 0

32 ANTINEOPLASTIC - ANGIOGENESIS INHIBITORS AVASTIN INJ ZALTRAP INJ. ANTINEOPLASTIC - ANTIBODIES ARZERRA INJ. ERBITUX SOLN HERCEPTIN INJ. KADCYLA INJ. PERJETA INJ. RITUXAN INJ. VECTIBIX INJ YERVOY INJ. ANTINEOPLASTIC - HEDGEHOG THWAY INHIBITORS ERIVEDGE CAP ANTINEOPLASTIC - HORMONAL AND RELATED AGENTS anastrozole tab bicalutamide tab ELIGARD INJ. EMCYT CAP exemestane tab FARESTON TAB FASLODEX INJ FIRMAGON INJ. flutamide cap letrozole tab leuprolide inj. LUPRON DEPOT (3 MONTH) KIT.5MG,.5MG LUPRON DEPOT ( MONTH) KIT 30MG LUPRON DEPOT (6 MONTH) KIT 5MG LUPRON DEPOT INJ. LYSODREN TAB megestrol acetate susp. megestrol acetate tab NILANDRON TAB SOLTAMOX ORAL SOLN. tamoxifen citrate tab TRELSTAR DEPOT MIXJECT INJ. TRELSTAR LA MIXJECT INJ. TRELSTAR MIXJECT INJ. XTANDI CAP ZYTIGA TAB ANTINEOPLASTIC - IMMUNOMODULATORS POMALYST CAP ANTINEOPLASTIC ANTIBIOTICS NM NM NSO NM NM NSO NM NSO NSO NM NSO NM NM NM NSO NM NM NM NSO NSO NSO NM NSO QL=0 Caps/30 Days NM NSO NM NSO

33 bleomycin sulfate inj. COSMEGEN INJ. 0.5MG daunorubicin inj doxorubicin inj. edirubicin inj idarubicin inj mitomycin inj. mitoxantrone inj ANTINEOPLASTIC ENZYME INHIBITORS AFINITOR DISPERZ AFINITOR TAB BOSULIF TAB CAPRELSA TAB COMETRIQ CK GILOTRIF TAB GLEEVEC TAB IMBRUVICA CAP INLYTA TAB ISTODAX INJ. JAKAFI TAB MEKINIST TAB NEXAVAR TAB SPRYCEL TAB STIVARGA TAB SUTENT CAP TAFINLAR CAP TARCEVA TAB TASIGNA CAP TORISEL SOLN TYKERB TAB VELCADE INJ. VOTRIENT TAB XALKORI CAP ZELBORAF TAB ZOLINZA CAP ZYKADIA CAP ANTINEOPLASTIC ENZYMES ERWINAZE INJ. ONCASR INJ. ANTINEOPLASTICS MISC. ACTIMMUNE INJ. dacarbazine inj. hydroxyurea cap INTRON-A INJ. MATULANE CAP NM NSO NM NSO QL=30 Tabs/30 Days NM NSO NM NSO NM NSO NM NSO QL=30 Tabs/30 Days NM NSO NM NSO NM NSO NM NSO NM NSO QL=60 Tabs/30 Days NM NSO LD NM NSO NM NSO NM NSO QL=0 Tabs/30 Days NM NSO NM NSO NM NSO NM NSO LD NM NSO NM NM NSO NM NSO NM NSO NM NSO NM NSO NM NSO

34 PROLEUKINE IV SOLN. SYLATRON INJ. SYNRIBO INJ. TARGRETIN CAP tretinoin cap TRISENOX INJ. UVADEX SOLN CHEMOTHERAPY ADJUNCTS ELITEK INJ. KEPIVANCE INJ CHEMOTHERAPY RESCUE/ ANTIDOTE AGENTS amifostine inj. dexrazoxane inj. FUSILEV INJ. leucovorin inj. leucovorin tab mesna inj. MESNEX TAB MITOTIC INHIBITORS ABRAXANE SUSP DOCEFREZ INJ. DOCETAXEL INJ. ETOPOPHOS INJ. etoposide inj. HALAVEN INJ. IXEMPRA INJ JEVTANA INJ. paclitaxel inj TAXOTERE INJ toposar inj. vinblastine inj. vincasar pfs inj. vincristine inj. vinorelbine inj TOPOISOMERASE I INHIBITORS irinotecan inj. topotecan inj. ANTIRKINSON AGENTS ANTIRKINSON ADJUVANTS carbidopa tab ANTIRKINSON ANTICHOLINERGICS benztropine inj. benztropine tab trihexyphenidyl soln 3 NM NM NSO NM NM NSO NM NM NM NM NM NM

35 trihexyphenidyl tab ANTIRKINSON COMT INHIBITORS entacapone tab TASMAR ANTIRKINSON DOMINERGICS amantadine cap amantadine syrup APOKYN INJ. bromocriptine cap bromocriptine tab CARBIDO/ ENTACAPONE/ LEVODO TAB carbidopa/ levodopa ER tab carbidopa/ levodopa ODT tab carbidopa/ levodopa tab NEUPRO TCH pramipexole tab ropinirole ER tab ropinirole tab STALEVO TAB ANTIRKINSON MONOAMINE OXIDASE INHIBITORS AZILECT TAB selegiline cap selegiline tab ANTIPSYCHOTICS/ ANTIMANIC AGENTS ANTIMANIC AGENTS lithium carbonate cap lithium carbonate ER tab lithium carbonate tab lithium citrate soln. ANTIPSYCHOTICS - MISC. EQUETRO CAP GEODON INJ. LATUDA TAB NSO QL=30 Tabs/30 Days ziprasidone cap BENZISOXAZOLES FANAPT TAB NSO FANAPT TITRATION CK NSO INVEGA SUSTENNA INJ. NSO INVEGA TAB NSO RISPERDAL CONSTA INJ. risperidone odt risperidone soln. risperidone tab BUTYROPHENONES

36 haloperidol decanoate inj. haloperidol inj. haloperidol oral conc. haloperidol tab DIBENZAPINES clozapine tab FAZACLO TAB loxapine cap olanzapine inj. olanzapine ODT tab olanzapine tab quetiapine tab SAPHRIS SL TAB NSO QL=60 Tabs/30 Days SEROQUEL XR TAB VERSACLOZ SUSP PHENOTHIAZINES chlorpromazine inj. chlorpromazine tab compro suppository FLUPHENAZINE DECANOATE INJ. fluphenazine elixir FLUPHENAZINE INJ. fluphenazine oral conc. fluphenazine tab perphenazine tab prochlorperazine edisylate inj. prochlorperazine suppository prochlorperazine tab thioridazine tab NSO trifluoperazine tab QUINOLINONE DERIVATIVES ABILIFY DISC TAB NM QL=60 Tabs/30 Days ABILIFY INJ. ABILIFY MAINTENANCE INJ. ABILIFY SOLN. ABILIFY TAB QL=60 Tabs/30 Days THIOXANTHENES thiothixene cap ANTISEPTICS & DISINFECTANTS CHLORINE ANTISEPTICS CHLORHEXIDINE GLUCONATE LIQUID %* QL=0 ml/365 Days chlorhexidine gluconate liquid %* QL=0 ml/30 Days CHLORHEXIDINE GLUCONATE DS %* chlorhexidine gluconate soln. 0%* 3 QL=0 ml/30 Days 5

37 ANTIRETROVIRALS abacavir tab abacavir/ lamivudine/ zidovudine tab APTIVUS CAP APTIVUS SOLN. ATRIPLA TAB COMPLERA TAB CRIXIVAN CAP didanosine cap EDURANT TAB EMTRIVA CAP EMTRIVA SOLN. EPIVIR HBV SOLN. EPIVIR SOLN. EPZICOM TAB FUZEON INJ. INTELENCE TAB INVIRASE CAP INVIRASE TAB ISENTRESS CHEW TAB ISENTRESS POWDER CK ISENTRESS TAB KALETRA SOLN. KALETRA TAB lamivudine tab lamivudine/ zidovudine tab LEXIVA SUSP. LEXIVA TAB nevirapine er tab nevirapine tab NORVIR CAP NORVIR SOLN. NORVIR TAB PREZISTA SUSP. PREZISTA TAB RESCRIPTOR TAB RETROVIR INJ. REYATAZ CAP SELZENTRY TAB stavudine cap stavudine soln. STRIBILD TAB SUSTIVA CAP SUSTIVA TAB ANTIVIRALS 6 NM NM NM NM NM NM NM NM NM NM NM NM NM NM NM NM NM NM NM QL=30 Tabs/30 Days

38 TIVICAY TAB TRUVADA TAB VIDEX SOLN. VIRACEPT TAB VIRAMUNE SUSP. VIRAMUNE XR TAB VIREAD POWDER VIREAD TAB ZIAGEN SOLN. zidovudine cap zidovudine syrup zidovudine tab CMV AGENTS cidofovir inj. FOSCARNET INJ. ganciclovir inj. VALCYTE SOLN. VALCYTE TAB HETITIS AGENTS adefovir tab BARACLUDE SOLN. BARACLUDE TAB moderiba tab 00mg MODERIBA TAB 00MG, 600MG OLYSIO TAB PEG-INTRON INJ. PEGASYS INJ. PEGASYS PROCLICK INJ. ribasphere cap ribasphere tab ribavirin cap ribavirin tab SOVALDI TAB TYZEKA TAB HERPES AGENTS acyclovir cap acyclovir inj. acyclovir inj. acyclovir susp. acyclovir tab famciclovir tab valacyclovir tab INFLUENZA AGENTS RELENZA DISKHALER rimantadine tab 7 NM QL=60 Tabs/30 Days NM NM NM NM NM NM NM NM NM NM NM QL=30 Tabs/30 Days QL=56 Blisters/80 Days

39 TAMIFLU CAP 30MG TAMIFLU CAP 5MG, 75MG TAMIFLU SUSP. RESPIRATORY SYNCYTIAL VIRUS (RSV) AGENTS VIRAZOLE INH. ASSORTED CLASSES CHELATING AGENTS CUPRIMINE CAP DEPEN TITRATABS SYPRINE CAP IMMUNOMODULATORS REVLIMID CAP REVLIMID CAP.5MG, 0MG THALOMID CAP IMMUNOSUPPRESSIVE AGENTS ASTAGRAF XL CAP ATGAM INJ AZASAN TAB azathioprine tab CELLCEPT IV INJ CELLCEPT SUSP. cyclosporine cap cyclosporine inj. cyclosporine modified cap CYCLOSPORINE MODIFIED CAP 50MG cyclosporine modified soln. gengraf cap gengraf soln. mycophenolate cap mycophenolate sodium tab mycophenolate tab NULOJIX INJ. PROGRAF INJ RAMUNE SOLN. RAMUNE TAB SANDIMMUNE SOLN. SIMULECT INJ sirolimus cap tacrolimus cap THYMOGLOBULIN INJ. ZORTRESS TAB IRRIGATION SOLUTIONS lactated ringers irrigation physiolyte irrigation soln. QL=8 Caps/80 Days QL=8 Caps/80 Days QL=6 Bottles/80 Days ST LD NM NSO QL=30 Caps/30 Days NM NSO QL=30 Caps/30 Days NM NSO NM NM NM NSO 8

40 physiosol irrigation soln. ringers irrigation sterile water irrigation LYMPHATIC AGENTS SYLVANT INJ. POTASSIUM REMOVING RESINS kionex powder sodium polystyrene sulfonate susp. BETA BLOCKERS ALPHA-BETA BLOCKERS carvedilol tab labetalol inj. labetalol tab BETA BLOCKERS CARDIO-SELECTIVE acebutolol cap atenolol tab betaxolol tab bisoprolol tab BYSTOLIC TAB metoprolol ER tab metoprolol inj. metoprolol tab BETA BLOCKERS NON-SELECTIVE INNOPRAN XL CAP nadolol tab pindolol tab propranolol ER cap propranolol inj. propranolol oral soln. propranolol tab sorine tab sotalol tab timolol maleate tab BIOLOGICALS MISC BIOLOGICALS MISC ADAGEN INJ. CALCIUM CHANNEL BLOCKERS CALCIUM CHANNEL BLOCKERS afeditab CR tab amlodipine tab CARDENE INJ. cartia xt cap dilt-xr cap diltiazem CD cap 9 NM NM

41 diltiazem ER cap diltiazem inj diltiazem tab felodipine ER tab isradipine cap matzim la tab nicardipine cap nicardipine inj. nifedical XL tab nifedipine cap nifedipine ER tab nimodipine cap nisoldipine ER tab taztia-xt cap verapamil ER cap verapamil ER tab verapamil inj. verapamil tab CARDIOTONICS CARDIAC GLYCOSIDES digoxin inj. digoxin oral soln digoxin tab 0.5mg QL=30 Tabs/30 Days digoxin tab 0.5mg CARDIOVASCULAR AGENTS - MISC. CARDIOVASCULAR AGENTS MISC. - COMBINATIONS amlodipine/ atorvastatin tab BIDIL TAB PROSTAGLANDIN VASODILATORS REMODULIN INJ. NM TYVASO INH. NM VENTAVIS INH. NM PULMONARY HYPERTENSION - ENDOTHELIN RECEPTOR ANTAGONISTS LETAIRIS TAB NM TRACLEER TAB LD NM PULMONARY HYPERTENSION - PHOSPHODIESTERASE INHIBITORS ADCIRCA TAB NM sildenafil tab CEPHALOSPORINS CEPHALOSPORINS - ST GENERATION cefadroxil cap cefadroxil susp. cefadroxil tab cefazolin inj. 30

42 CEFAZOLIN/ D5W INJ. cephalexin cap cephalexin susp cephalexin tab CEPHALOSPORINS - ND GENERATION cefaclor cap CEFOTETAN INJ. cefoxitin inj. CEFOXITIN/ DEXTROSE INJ. cefprozil susp. cefprozil tab cefuroxime inj. cefuroxime tab CEPHALOSPORINS - 3RD GENERATION CEDAX SUSP. cefdinir cap cefdinir susp. cefotaxime inj. cefpodoxime susp. cefpodoxime tab ceftazidime inj. CEFTAZIDIME/ DEXTROSE INJ. ceftriaxone inj. SUPRAX CAP CEPHALOSPORINS - TH GENERATION cefepime inj. CEPHALOSPORINS - 5TH GENERATION TEFLARO INJ. CONTRACEPTIVES COMBINATION CONTRACEPTIVES - ORAL amethia tab apri tab aranelle tab aviane tab balziva tab BEYAZ TAB briellyn tab cryselle-8 tab cyclafem tab emoquette tab enpresse-8 tab gildagia tab introvale tab junel fe tab 3

43 junel tab kariva tab kelnor tab larin fe tab larin tab leena tab lessina levonest tab levonorgestrel/ ethinyl estradiol tab levora-8 tab LO MINASTRIN FE TAB low-ogestrel tab lutera tab marlissa tab microgestin tab mononessa tab NATAZIA TAB necon tab nortrel tab orsythia tab ORTHO-TRI CYCLEN LO pimtrea tab pirmella tab portia-8 tab previfem tab QUARTETTE TAB quasense tab reclipsen tab sprintec-8 tab sronyx tab tri-legest fe tab tri-previfem tab tri-sprintec tab trinessa tab trivora-8 tab velivet tab vyfemla tab YASMIN TAB zenchent fe tab zenchent tab zovia tab COMBINATION CONTRACEPTIVES - TRANSDERMAL xulane patch COMBINATION CONTRACEPTIVES - VAGINAL NUVARING 3

44 EMERGENCY CONTRACEPTIVES ELLA PROGESTIN CONTRACEPTIVES - INJECTABLE medroxyprogesterone inj. PROGESTIN CONTRACEPTIVES - ORAL camila tab errin tab jolivette tab lyza tab nora-be tab norethindrone tab CORTICOSTEROIDS GLUCOCORTICOSTEROIDS A-HYDROCORT INJ. budesonide EC cap CORTEF TAB cortisone tab dexamethasone conc. dexamethasone elixir dexamethasone inj. dexamethasone tab hydrocortisone tab MEDROL TAB MG methylprednisolone acetate inj. methylprednisolone dose pak methylprednisolone sodium succinate inj. methylprednisolone tab ORAPRED ODT prednisolone sodium phosphate soln. PREDNISONE INTENSOL prednisone soln. prednisone tab SOLU-CORTEF INJ. triamcinolone acetonide inj. UCERIS TAB MINERALOCORTICOIDS fludrocortisone tab COUGH/ COLD/ ALLERGY ANTITUSSIVES benzonatate cap 00mg, 00mg* dextromethorphan liquid 5mg/ 5ml* dextromethorphan syrup 0mg/ 5ml* dextromethorphan syrup 5mg/ 5ml* dextromethorphan syrup 7.5mg/ 5ml* 33 NM QL=30 Tabs/30 Days QL=90 Caps/30 Days

45 hydrocodone/ homatropine syrup 5-.5mg/ 5ml* ZONATUSS CAP 50MG* COUGH/ COLD/ ALLERGY COMBINATIONS brompheniramine/ pseudoephedrine elixir -5mg/ 5ml* chlorpheniramine DM liquid -5mg/ 5ml* chlorpheniramine/ pseudoephedrine tab -60mg* dextromethorphan/ guaifensen syrup 0-00mg/ 5ml* dextromethorphan/ guaifensin liquid 0-00mg/ 5ml* dextromethorphan/ guaifensin liquid 0-00mg/ 5ml* dextromethorphan/ guaifensin liquid 5-00mg/ 5ml* dextromethorphan/ guaifensin liquid 30-00mg/ 5ml* dextromethorphan/ guaifensin liquid 5-00mg/ 5ml* ED A-HIST LIQUID -0MG/ 5ML* guaifensin/ codeine soln 00-0mg/ 5ml* LOHIST-D LIQUID -30MG* loratadine-d tab 0-0mg* loratadine-d tab 5-0mg* phenylephrine chlorpheniramine soln 0--5mg/ 5ml* phenylephrine chlorpheniramine soln 0--5mg/ 5ml* phenylephrine DM/ guaifenesin liquid mg/ 5ml* phenylephrine/ guaifenesin liquid 5-00mg/ 5ml* promethazine DM syrup 6.5-5mg/ 5ml* promethazine/ codeine syrup 6.5-0mg/ 5ml* pseudoephedrine DM/ guaifenesin liquid mg/ 5ml* pseudoephedrine/ brompheniramine DM elixir 5--5mg/ 5ml* pseudoephedrine/ chlorpheniramine DM liquid 5--5mg/ 5ml* pseudoephedrine/ chlorpheniramine DM syrup 30--0mg/ 5ml* pseudoephedrine/ doxylamine/ DM/ acetaminophen liquid mg/ 30ml* pseudoephedrine/ guaifensen liquid mg/ ml* pseudoephedrine/ guaifensin syrup 30-00mg/ 5ml* triprolidine/ pseudoephedrine syrup.5-30mg/ 5ml* triprolidine/ pseudoephedrine tab.5-60mg* EXPECTORANTS guaifenesin liquid 00mg/ 5ml* guaifenesin liquid 00mg/ 5ml* guaifenesin tab 00mg* MUCOLYTICS acetylcysteine soln. DERMATOLOGICALS QL=90 Caps/30 Days QL=60 Tabs/30 Days QL=60 Tabs/30 Days 3