(Comprehensive list of covered drugs)

Transcription

1 Standard Plan 015 Prescription Drug Formulary (Comprehensive list of covered drugs) +306$SSURYHG)RUPXODU\)LOH6XEPLVVLRQ,'9HUVLRQ1XPEHU16 This document contains information about the drugs we cover in this plan. )RUPRUHUHFHQWLQIRUPDWLRQRURWKHUTXHVWLRQV SOHDVHFRQWDFW%OXH0HGLFDUH5[&XVWRPHU6HUYLFHV at RUIRU 77<XVHUV DPWRSPGDLO\RU visit 7KLVIRUPXODU\ZDVXSGDWHGRQ 1/01/015 + Note to existing members: This formulary has changed since last year. Please review this document to make sure that it still contains the drugs you take. + + %HQHÀWVIRUPXODU\SKDUPDF\QHWZRUNSUHPLXP DQGRUFRSD\PHQWVFRLQVXUDQFHPD\FKDQJHRQ January 1 of each year. This information may be available in a different format. Please contact Customer Service at the QXPEHUVOLVWHGDERYHLI\RXQHHGSODQLQIRUPDWLRQ in another format or language. Blue Cross Blue Shield of North Carolina is a PDP plan with a Medicare contract. Enrollment in Blue Cross Blue Shield of North Carolina depends on contract renewal. Y0079_6770 CMS Accepted 0801

2 When this drug list (formulary) refers to we, us, or our, it means Blue Cross and Blue Shield of North Carolina. When it refers to plan or our plan, it means Blue Medicare Rx Standard. This document includes a list of the drugs (formulary) for our plan which is current as of 1/01/015. For an updated formulary, please contact us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages. You must generally use network pharmacies to use your prescription drug benefit. Benefits, formulary, pharmacy network, premium and/or copayments/coinsurance may change on January 1, 015 and from time to time during the year. What is the Blue Medicare Rx Standard Formulary? A formulary is a list of covered drugs selected by Blue Medicare Rx Standard in consultation with a team of health care providers, which represents the prescription therapies believed to be a necessary part of a quality treatment program. Blue Medicare Rx Standard will generally cover the drugs listed in our formulary as long as the drug is medically necessary, the prescription is filled at a Blue Medicare Rx Standard network pharmacy, and other plan rules are followed. For more information on how to fill your prescriptions, please review your Evidence of Coverage. Can the Formulary (drug list) change? Generally, if you are taking a drug on our 015 formulary that was covered at the beginning of the year, we will not discontinue or reduce coverage of the drug during the 015 coverage year except when a new, less expensive generic drug becomes available or when new adverse information about the safety or effectiveness of a drug is released. Other types of formulary changes, such as removing a drug from our formulary, will not affect members who are currently taking the drug. It will remain available at the same cost-sharing for those members taking it for the remainder of the coverage year. We feel it is important that you have continued access for the remainder of the coverage year to the formulary drugs that were available when you chose our plan, except for cases in which you can save additional money or we can ensure your safety. If we remove drugs from our formulary, or add prior authorization, quantity limits and/or step therapy restrictions on a drug or move a drug to a higher cost-sharing tier, we must notify affected members of the change at least 60 days before the change becomes effective, or at the time the member requests a refill of the drug, at which time the member will receive a 60-day supply of the drug. If the Food and Drug Administration deems a drug on our formulary to be unsafe or the drug s manufacturer removes the drug from the market, we will immediately remove the drug from our formulary and provide notice to members who take the drug. The enclosed formulary is current as of December 1, 015. To get updated information about the drugs covered by Blue Medicare Rx Standard, please contact us. Our contact information appears on the front and back cover pages. If non-maintenance formulary changes occur during the plan year, members will be provided notice and the printable formulary will updated and posted on our website at How do I use the Formulary? There are two ways to find your drug within the formulary: Medical Condition The formulary begins on page 1. The drugs in this formulary are grouped into categories depending on the type of medical conditions that they are used to treat. For example, drugs used to treat a heart i

3 condition are listed under the category, Cardiovascular Agents. If you know what your drug is used for, look for the category name in the list that begins on page 1. Then look under the category name for your drug. Alphabetical Listing If you are not sure what category to look under, you should look for your drug in the Index that begins on page 101. The Index provides an alphabetical list of all of the drugs included in this document. Both brand name drugs and generic drugs are listed in the Index. Look in the Index and find your drug. Next to your drug, you will see the page number where you can find coverage information. Turn to the page listed in the Index and find the name of your drug in the first column of the list. What are generic drugs? Blue Medicare Rx Standard covers both brand name drugs and generic drugs. A generic drug is approved by the FDA as having the same active ingredient as the brand name drug. Generally, generic drugs cost less than brand name drugs. Are there any restrictions on my coverage? Some covered drugs may have additional requirements or limits on coverage. These requirements and limits may include: x x x : Blue Medicare Rx Standard requires you or your physician to get prior authorization for certain drugs. This means that you will need to get approval from Blue Medicare Rx Standard before you fill your prescriptions. If you don t get approval, Blue Medicare Rx Standard may not cover the drug. Quantity : For certain drugs, Blue Medicare Rx Standard limits the amount of the drug that Blue Medicare Rx Standard will cover. For example, Blue Medicare Rx Standard provides per prescription for alfuzosin ER. This may be in addition to a standard one-month or three-month supply. : In some cases, Blue Medicare Rx Standard requires you to first try certain drugs to treat your medical condition before we will cover another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, Blue Medicare Rx Standard may not cover Drug B unless you try Drug A first. If Drug A does not work for you, Blue Medicare Rx Standard will then cover Drug B. You can find out if your drug has any additional requirements or limits by looking in the formulary that begins on page 1. You can also get more information about the restrictions applied to specific covered drugs by visiting our Web site. We have posted on line documents that explain our prior authorization and step therapy restrictions. You may also ask us to send you a copy. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages. You can ask Blue Medicare Rx Standard to make an exception to these restrictions or limits or for a list of other, similar drugs that may treat your health condition. See the section, How do I request an exception to the Blue Medicare Rx Standard s formulary? on page iii for information about how to request an exception. ii

4 What if my drug is not on the Formulary? If your drug is not included in this formulary (list of covered drugs), you should first contact Customer Services and ask if your drug is covered. If you learn that Blue Medicare Rx Standard does not cover your drug, you have two options: x x You can ask Customer Services for a list of similar drugs that are covered by Blue Medicare Rx Standard. When you receive the list, show it to your doctor and ask him or her to prescribe a similar drug that is covered by Blue Medicare Rx Standard. You can ask Blue Medicare Rx Standard to make an exception and cover your drug. See below for information about how to request an exception. How do I request an exception to the Blue Medicare Rx Standard s Formulary? You can ask Blue Medicare Rx Standard to make an exception to our coverage rules. There are several types of exceptions that you can ask us to make. x You can ask us to cover a drug even if it is not on our formulary. If approved, this drug will be covered at a pre-determined cost-sharing level, and you would not be able to ask us to provide the drug at a lower cost-sharing level. x x You can ask us to cover a formulary drug at a lower cost-sharing level if this drug is not on the specialty tier. If approved this would lower the amount you must pay for your drug. You can ask us to waive coverage restrictions or limits on your drug. For example, for certain drugs, Blue Medicare Rx Standard limits the amount of the drug that we will cover. If your drug has a quantity limit, you can ask us to waive the limit and cover a greater amount. Generally, Blue Medicare Rx Standard will only approve your request for an exception if the alternative drugs included on the plan s formulary, the lower cost-sharing drug or additional utilization restrictions would not be as effective in treating your condition and/or would cause you to have adverse medical effects. You should contact us to ask us for an initial coverage decision for a formulary, tiering or utilization restriction exception. When you request a formulary, tiering or utilization restriction exception you should submit a statement from your prescriber or physician supporting your request. Generally, we must make our decision within 7 hours of getting your prescriber s supporting statement. You can request an expedited (fast) exception if you or your doctor believe that your health could be seriously harmed by waiting up to 7 hours for a decision. If your request to expedite is granted, we must give you a decision no later than hours after we get a supporting statement from your doctor or other prescriber. What do I do before I can talk to my doctor about changing my drugs or requesting an exception? As a new or continuing member in our plan you may be taking drugs that are not on our formulary. Or, you may be taking a drug that is on our formulary but your ability to get it is limited. For example, you may need a prior authorization from us before you can fill your prescription. You should talk to your doctor to decide if you should switch to an appropriate drug that we cover or request a formulary exception so that we will iii

5 cover the drug you take. While you talk to your doctor to determine the right course of action for you, we may cover your drug in certain cases during the first 90 days you are a member of our plan. For each of your drugs that is not on our formulary or if your ability to get your drugs is limited, we will cover a temporary 30-day supply (unless you have a prescription written for fewer days) when you go to a network pharmacy. After your first 30-day supply, we will not pay for these drugs, even if you have been a member of the plan less than 90 days. If you are a resident of a long-term care facility, we will allow you to refill your prescription until we have provided you with a maximum of 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 you are a member of our plan. If you need a drug that is not on our formulary or if your ability to get your drugs is limited, but you are past the first 90 days of membership in our plan, we will cover a 31-day emergency supply of that drug (unless you have a prescription for fewer days) while you pursue a formulary exception. Circumstances exist in which unplanned transitions for current members could arise and in which prescribed drug regimens may not be on the formulary. These circumstances usually involve level of care changes in which a member is changing from one treatment setting to another. For these unplanned transitions, you must use our exceptions and appeals process. Coverage determinations and redeterminations will be processed as expeditiously as your health condition requires. In order to prevent a temporary gap in care when a member is discharged to home, members are permitted to have a full outpatient supply available to continue therapy once their limited supply provided at discharge is exhausted. This outpatient supply is available in advance of discharge from a Part A stay. When a member is admitted to or discharged from an LTC facility, he or she does not have access to the remainder of the previously dispensed prescription. We will ensure you have a refill upon admission or discharge. A one-time override of the refill too soon edits, are provided, for each medication which would be impacted due to a member being admitted to or discharged from an LTC facility. Early refill edits are not used to limit appropriate and necessary access to a member s Part D benefit, and such members are allowed to access a refill upon admission or discharge. For more information For more detailed information about your Blue Medicare Rx Standard prescription drug coverage, please review your Evidence of Coverage and other plan materials. If you have questions about Blue Medicare Rx Standard, please contact us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages. If you have general questions about Medicare prescription drug coverage, please call Medicare at MEDICARE ( ) hours a day/7 days a week. TTY users should call Or, visit iv

6 Blue Medicare Rx Standard s Formulary The formulary below provides coverage information about the drugs covered by Blue Medicare Rx Standard. If you have trouble finding your drug in the list, turn to the Index that begins on page 101. The first column of the chart lists the drug name. Brand name drugs are capitalized (e.g., LANTUS) and generic drugs are listed in lower-case italics (e.g., metformin). The next column tells you whether your drug may be covered by Medicare Part B or Part D, depending on the circumstances of its use. The information in the column tells you if Blue Medicare Rx Standard has any special requirements for coverage of your drug. Most of the drugs on our formulary are also available by mail order. If you have questions about mail order please contact Customer Service. Our contact information appears on the front and back cover pages. The Drug Table includes a column titled,. This column indicates what tier each drug is listed under. The following copayments are associated with the corresponding tiers if you receive the drugs at an in-network pharmacy. These copayments apply during the initial coverage phase. Refer to your Evidence of Coverage for details about your benefits during the coverage gap and catastrophic coverage. After the $30 deductible, the following amounts apply: Preferred Retail Retail Pharmacy for a Preferred Mail Order Long Term Care Pharmacy for a day supply Pharmacy for a 90 Pharmacy for a 31 Tier Number day supply day supply day supply Tier 1 Preferred $ copayment $10 copayment $0 copayment $10 copayment Generic Tier Non- $10 copayment $33 copayment $5 copayment $33 copayment Preferred Generic Tier 3 - Preferred $0 copayment $5 copayment $100 copayment $5 copayment Brand Tier Non- $85 copayment $95 copayment $1.50 copayment $95 copayment Preferred Brand Tier 5 Specialty 5% coinsurance 5% coinsurance 5% coinsurance 5% coinsurance X Drugs that may be covered by Medicare Part B or Medicare Part D depending on the circumstance Utilization Management:, Quantity, * Limited distribution drug. This prescription may be available only at certain pharmacies. For more information consult your Pharmacy Directory or call Customer Services at or, for TTY users, , 8 a.m. to 8 p.m. daily Quantity limit restrictions apply. Restriction amounts are listed beginning on page 79. # High Risk Medication (HRM). Medicine that may be unsafe in patients greater than 65 years of age. Our formulary does include coverage for some of these drugs, but alternatives may be found in lower co-pay tiers. Please discuss with your doctor if there are alternatives to these medications that would be appropriate for you to use. ^ We provide additional coverage of this prescription drug in the coverage gap. Please refer to our Evidence of Coverage for more information about this coverage. v

7 Dosage Form Abbreviations Key act actuation aer, aero aerosol cap capsules chew tab chewable tablets conc concentrate conj conjugate CR controlled-release crys crystals DR delayed-release deter deterrent ec enteric coated ER, extended, extended rel, XL, XR extended-release g, gm gram hr hour IR immediate-release inh, inhal inhalation inj injection im intramuscular iv intravenous liqd liquid LA long acting mcg microgram meq milliequivalent mg milligram ml milliliter nebu nebules NF non-formulary odt, orally disintegrating tab orally disintegrating tablets oint ointment op, ophth ophthalmic pow, powd powder pf preservative-free sl sublingual soln solution suppos suppositories susp suspension sr sustained-release tab tablets td transdermal tl translingual unt unit vac Vaccine vi

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9 Analgesics acetaminophen w/ codeine soln 10-1 mg/5ml acetaminophen w/ codeine tab mg acetaminophen w/ codeine tab mg acetaminophen w/ codeine tab mg butorphanol tartrate inj 1 mg/ml butorphanol tartrate inj mg/ml diclofenac potassium tab 50 mg diclofenac sodium tab delayed release 5 mg diclofenac sodium tab delayed release 50 mg diclofenac sodium tab delayed release 75 mg diclofenac sodium tab sr hr 100 mg etodolac cap 00 mg etodolac cap 300 mg etodolac tab 00 mg etodolac tab 500 mg fentanyl citrate lozenge on a handle 00 mcg fentanyl citrate lozenge on a handle 00 mcg fentanyl citrate lozenge on a handle 600 mcg fentanyl citrate lozenge on a handle 800 mcg fentanyl citrate lozenge on a handle 100 mcg fentanyl citrate lozenge on a handle 1600 mcg fentanyl td patch 7hr 1 mcg/hr fentanyl td patch 7hr 5 mcg/hr fentanyl td patch 7hr 50 mcg/hr fentanyl td patch 7hr 75 mcg/hr fentanyl td patch 7hr 100 mcg/hr hydrocodone-acetaminophen soln mg/15ml hydrocodone-acetaminophen tab mg hydrocodone-acetaminophen tab mg hydrocodone-acetaminophen tab mg hydrocodone-acetaminophen tab 5-35 mg hydrocodone-acetaminophen tab mg hydrocodone-acetaminophen tab mg hydromorphone hcl liqd 1 mg/ml hydromorphone hcl preservative free (pf) inj 10 mg/ml X hydromorphone hcl tab mg hydromorphone hcl tab mg hydromorphone hcl tab 8 mg ibuprofen tab 00 mg 1 ibuprofen tab 600 mg 1 1 = Preferred Generic Drugs = Non-Preferred Generic Drugs 3 = Preferred Brand Drugs = Non-Preferred Brand Drugs 5 = Specialty Drugs = Utilization Management (UM) * = Limited Distribution Drug # = High Risk Medication (HRM) 1

10 ibuprofen tab 800 mg 1 ketorolac tromethamine tab 10 mg# LAZANDA - fentanyl citrate nasal spray 100 mcg/act LAZANDA - fentanyl citrate nasal spray 00 mcg/act meloxicam tab 7.5 mg 1 meloxicam tab 15 mg 1 methadone hcl tab 5 mg methadone hcl tab 10 mg MORPHINE SULFATE - morphine sulfate tab 15 mg MORPHINE SULFATE - morphine sulfate tab 30 mg morphine sulfate inj pf 0.5 mg/ml X morphine sulfate inj pf 1 mg/ml X morphine sulfate tab cr 15 mg morphine sulfate tab cr 30 mg morphine sulfate tab cr 60 mg morphine sulfate tab cr 100 mg morphine sulfate tab cr 00 mg nabumetone tab 500 mg nabumetone tab 750 mg naproxen tab 50 mg 1 naproxen tab 375 mg 1 naproxen tab 500 mg 1 oxycodone hcl tab 5 mg oxycodone hcl tab 10 mg oxycodone hcl tab 15 mg oxycodone hcl tab 0 mg oxycodone hcl tab 30 mg oxycodone w/ acetaminophen tab.5-35 mg oxycodone w/ acetaminophen tab 5-35 mg oxycodone w/ acetaminophen tab mg oxycodone w/ acetaminophen tab mg sulindac tab 150 mg sulindac tab 00 mg tramadol hcl tab 50 mg VOLTAREN - diclofenac sodium gel 1% ZOHYDRO ER - hydrocodone bitartrate cap sr 1hr abusedeterrent 10 mg ZOHYDRO ER - hydrocodone bitartrate cap sr 1hr abusedeterrent 15 mg ZOHYDRO ER - hydrocodone bitartrate cap sr 1hr abusedeterrent 0 mg ZOHYDRO ER - hydrocodone bitartrate cap sr 1hr abusedeterrent 30 mg ZOHYDRO ER - hydrocodone bitartrate cap sr 1hr abusedeterrent 0 mg 1 = Preferred Generic Drugs = Non-Preferred Generic Drugs 3 = Preferred Brand Drugs = Non-Preferred Brand Drugs 5 = Specialty Drugs = Utilization Management (UM) * = Limited Distribution Drug # = High Risk Medication (HRM)

11 ZOHYDRO ER - hydrocodone bitartrate cap sr 1hr abusedeterrent 50 mg ZOHYDRO ER - hydrocodone bitartrate cap sr 1hr 10 mg ZOHYDRO ER - hydrocodone bitartrate cap sr 1hr 15 mg ZOHYDRO ER - hydrocodone bitartrate cap sr 1hr 0 mg ZOHYDRO ER - hydrocodone bitartrate cap sr 1hr 30 mg ZOHYDRO ER - hydrocodone bitartrate cap sr 1hr 0 mg ZOHYDRO ER - hydrocodone bitartrate cap sr 1hr 50 mg Anesthetics lidocaine hcl gel % lidocaine hcl local inj 1% lidocaine hcl local preservative free (pf) inj 1% lidocaine hcl soln % lidocaine hcl viscous soln % lidocaine patch 5% lidocaine-prilocaine cream.5-.5% Anti-Addiction/Substance Abuse Treatment Agents acamprosate calcium tab delayed release 333 mg buprenorphine hcl sl tab mg buprenorphine hcl sl tab 8 mg buprenorphine hcl-naloxone hcl sl tab -0.5 mg buprenorphine hcl-naloxone hcl sl tab 8- mg bupropion hcl (smoking deterrent) tab sr 1hr 150 mg CHANTIX - varenicline tartrate tab 0.5 mg CHANTIX - varenicline tartrate tab 1 mg CHANTIX CONTINUING MONTH - varenicline tartrate tab 1 mg CHANTIX STARTING MONTH PACK - varenicline tartrate tab 0.5 mg x 11 & tab 1 mg x pack disulfiram tab 50 mg disulfiram tab 500 mg naloxone hcl inj 0. mg/ml naloxone hcl inj 1 mg/ml naltrexone hcl tab 50 mg NICOTROL INHALER - nicotine inhaler system 10 mg ( mg delivered) NICOTROL NS - nicotine nasal spray 10 mg/ml (0.5 mg/spray) SUBOXONE - buprenorphine hclnaloxone hcl sl film -0.5 mg SUBOXONE - buprenorphine hclnaloxone hcl sl film -1 mg SUBOXONE - buprenorphine hclnaloxone hcl sl film 8- mg SUBOXONE - buprenorphine hclnaloxone hcl sl film 1-3 mg 1 = Preferred Generic Drugs = Non-Preferred Generic Drugs 3 = Preferred Brand Drugs = Non-Preferred Brand Drugs 5 = Specialty Drugs = Utilization Management (UM) * = Limited Distribution Drug # = High Risk Medication (HRM) 3

12 Antibacterials amikacin sulfate inj 500 mg/ml (50 mg/ml) amikacin sulfate inj 1 gm/ml (50 mg/ml) amoxicillin (trihydrate) cap 1 50 mg amoxicillin (trihydrate) cap 500 mg amoxicillin (trihydrate) for susp 15 mg/5ml amoxicillin (trihydrate) for susp 00 mg/5ml amoxicillin (trihydrate) for susp 50 mg/5ml amoxicillin (trihydrate) for susp 00 mg/5ml amoxicillin (trihydrate) tab 500 mg amoxicillin (trihydrate) tab 875 mg amoxicillin & k clavulanate chew tab mg amoxicillin & k clavulanate chew tab mg amoxicillin & k clavulanate tab mg amoxicillin & k clavulanate tab mg amoxicillin & k clavulanate tab mg AMPICILLIN - ampicillin for susp 15 mg/5ml AMPICILLIN - ampicillin for susp 50 mg/5ml ampicillin & sulbactam sodium for inj -1 gm ampicillin cap 50 mg 1 ampicillin cap 500 mg ampicillin sodium for inj 50 mg ampicillin sodium for inj 500 mg ampicillin sodium for inj 1 gm ampicillin sodium for inj gm AVELOX - moxifloxacin hcl 00 mg/50ml in sodium chloride 0.8% inj azithromycin for susp 100 mg/5ml azithromycin for susp 00 mg/5ml azithromycin iv for soln 500 mg azithromycin tab 50 mg azithromycin tab 500 mg azithromycin tab 600 mg aztreonam for inj 1 gm aztreonam for inj gm BICILLIN L-A - penicillin g benzathine intramuscular susp unit/ml BICILLIN L-A - penicillin g benzathine intramuscular susp unit/ml BICILLIN L-A - penicillin g benzathine intramuscular susp unit/ml cefaclor cap 50 mg cefaclor cap 500 mg 1 = Preferred Generic Drugs = Non-Preferred Generic Drugs 3 = Preferred Brand Drugs = Non-Preferred Brand Drugs 5 = Specialty Drugs = Utilization Management (UM) * = Limited Distribution Drug # = High Risk Medication (HRM)

13 cefazolin sodium for inj 500 mg cefazolin sodium for inj 1 gm cefdinir cap 300 mg cefdinir for susp 15 mg/5ml cefdinir for susp 50 mg/5ml cefepime hcl for inj 1 gm cefepime hcl for inj gm cefotaxime sodium for inj 500 mg cefotaxime sodium for inj 1 gm cefotaxime sodium for inj gm cefotaxime sodium for inj 10 gm cefoxitin sodium for iv soln 1 gm cefoxitin sodium for iv soln gm cefprozil tab 50 mg cefprozil tab 500 mg ceftazidime for inj 1 gm ceftazidime for inj gm ceftazidime for inj 6 gm ceftazidime for iv soln 1 gm ceftazidime for iv soln gm ceftriaxone sodium for inj 50 mg ceftriaxone sodium for inj 500 mg ceftriaxone sodium for inj 1 gm ceftriaxone sodium for inj gm ceftriaxone sodium for inj 10 gm ceftriaxone sodium for iv soln 1 gm ceftriaxone sodium for iv soln gm cefuroxime axetil tab 50 mg cefuroxime axetil tab 500 mg cefuroxime sodium for inj 750 mg cefuroxime sodium for inj 1.5 gm cefuroxime sodium for inj 7.5 gm cefuroxime sodium for iv soln 1.5 gm cephalexin cap 50 mg 1 cephalexin cap 500 mg cephalexin for susp 15 mg/5ml cephalexin for susp 50 mg/5ml CHLORAMPHENICOL SODIUM SUCCINATE - chloramphenicol sodium succinate for iv inj 1 gm ciprofloxacin hcl tab 100 mg ciprofloxacin hcl tab 50 mg ciprofloxacin hcl tab 500 mg ciprofloxacin hcl tab 750 mg ciprofloxacin iv soln 00 mg/0ml (1%) ciprofloxacin iv soln 00 mg/0ml (1%) ciprofloxacin 00 mg/100ml in d5w ciprofloxacin 00 mg/00ml in d5w clarithromycin for susp 15 mg/5ml clarithromycin for susp 50 mg/5ml clarithromycin tab 50 mg 1 = Preferred Generic Drugs = Non-Preferred Generic Drugs 3 = Preferred Brand Drugs = Non-Preferred Brand Drugs 5 = Specialty Drugs = Utilization Management (UM) * = Limited Distribution Drug # = High Risk Medication (HRM) 5

14 clarithromycin tab 500 mg clindamycin hcl cap 75 mg clindamycin hcl cap 150 mg clindamycin hcl cap 300 mg clindamycin phosphate inj 300 mg/ml clindamycin phosphate inj 600 mg/ml clindamycin phosphate inj 900 mg/6ml clindamycin phosphate inj 9 gm/60ml clindamycin phosphate iv soln 600 mg/ml clindamycin phosphate iv soln 900 mg/6ml clindamycin phosphate vaginal cream % colistimethate sodium for inj 150 mg DALVANCE - dalbavancin hcl for 5 iv soln 500 mg dicloxacillin sodium cap 50 mg dicloxacillin sodium cap 500 mg doxycycline hyclate cap 50 mg doxycycline hyclate cap 100 mg doxycycline hyclate for inj 100 mg doxycycline hyclate tab 100 mg ERY-TAB - erythromycin tab delayed release 50 mg ERY-TAB - erythromycin tab delayed release 333 mg ERY-TAB - erythromycin tab delayed release 500 mg ERYTHROCIN LACTOBIONATE - erythromycin lactobionate for inj 500 mg ERYTHROCIN LACTOBIONATE - erythromycin lactobionate for inj 1000 mg ERYTHROMYCIN BASE - erythromycin tab 50 mg ERYTHROMYCIN BASE - erythromycin tab 500 mg gentamicin sulfate inj 10 mg/ml gentamicin sulfate inj 0 mg/ml gentamicin sulfate iv soln 10 mg/ ml imipenem-cilastatin intravenous for soln 50 mg imipenem-cilastatin intravenous for soln 500 mg levofloxacin in d5w iv soln 50 mg/50ml levofloxacin in d5w iv soln 500 mg/100ml levofloxacin in d5w iv soln 750 mg/150ml levofloxacin iv soln 5 mg/ml levofloxacin oral soln 5 mg/ml levofloxacin tab 50 mg levofloxacin tab 500 mg 1 = Preferred Generic Drugs = Non-Preferred Generic Drugs 3 = Preferred Brand Drugs = Non-Preferred Brand Drugs 5 = Specialty Drugs = Utilization Management (UM) * = Limited Distribution Drug # = High Risk Medication (HRM) 6

15 levofloxacin tab 750 mg linezolid iv soln mg/ml 5 linezolid tab 600 mg meropenem iv for soln 500 mg meropenem iv for soln 1 gm metronidazole in nacl 0.79% iv soln 500 mg/100ml metronidazole tab 50 mg metronidazole tab 500 mg metronidazole vaginal gel 0.75% minocycline hcl cap 50 mg 1 minocycline hcl cap 75 mg minocycline hcl cap 100 mg NAFCILLIN SODIUM - nafcillin sodium for iv soln 1 gm NAFCILLIN SODIUM - nafcillin sodium for iv soln gm nafcillin sodium for inj 1 gm nafcillin sodium for inj gm nafcillin sodium for inj 10 gm neomycin sulfate tab 500 mg nitrofurantoin macrocrystalline cap 50 mg# nitrofurantoin macrocrystalline cap 100 mg# nitrofurantoin monohydrate macrocrystalline cap 100 mg# paromomycin sulfate cap 50 mg penicillin g potassium for inj unit PENICILLIN G POTASSIUM IN DEXTROSE - penicillin g potassium inj 0000 unit/ml in dextrose PENICILLIN G POTASSIUM IN DEXTROSE - penicillin g potassium inj 0000 unit/ml in dextrose PENICILLIN G POTASSIUM IN DEXTROSE - penicillin g potassium inj unit/ml in dextrose penicillin v potassium for soln 15 mg/5ml penicillin v potassium for soln 50 mg/5ml penicillin v potassium tab 50 mg penicillin v potassium tab 500 mg piperacillin sodium-tazobactam sodium for inj -0.5 gm piperacillin sodium-tazobactam sodium for inj gm piperacillin sodium-tazobactam sodium for inj -0.5 gm SIVEXTRO - tedizolid phosphate tab 00 mg SIVEXTRO - tedizolid phosphate for iv soln 00 mg STREPTOMYCIN SULFATE - streptomycin sulfate for inj 1 gm SULFADIAZINE - sulfadiazine tab 500 mg 5 1 = Preferred Generic Drugs = Non-Preferred Generic Drugs 3 = Preferred Brand Drugs = Non-Preferred Brand Drugs 5 = Specialty Drugs = Utilization Management (UM) * = Limited Distribution Drug # = High Risk Medication (HRM) 7

16 sulfamethoxazole-trimethoprim susp 00-0 mg/5ml sulfamethoxazole-trimethoprim 1 tab mg sulfamethoxazole-trimethoprim 1 tab mg SULFAMETHOXAZOLE/ TRIMETHOPRIM - sulfamethoxazole-trimethoprim iv soln mg/5ml SUPRAX - cefixime cap 00 mg SUPRAX - cefixime chew tab 100 mg SUPRAX - cefixime chew tab 00 mg SYNERCID - quinupristindalfopristin for inj 500 mg 5 ( mg) TEFLARO - ceftaroline fosamil for iv soln 00 mg TEFLARO - ceftaroline fosamil for iv soln 600 mg TETRACYCLINE HCL - tetracycline hcl cap 50 mg TETRACYCLINE HCL - tetracycline hcl cap 500 mg tobramycin sulfate inj 10 mg/ml tobramycin sulfate inj 80 mg/ml (0 mg/ml) tobramycin sulfate inj 1. gm/30ml (0 mg/ml) tobramycin sulfate inj gm/50ml (0 mg/ml) trimethoprim tab 100 mg TYGACIL - tigecycline for iv soln 50 mg vancomycin hcl cap 15 mg 5 vancomycin hcl cap 50 mg 5 vancomycin hcl for inj 500 mg vancomycin hcl for inj 1000 mg vancomycin hcl for inj 5000 mg vancomycin hcl for inj 10 gm XIFAXAN - rifaximin tab 550 mg 5 ZYVOX - linezolid tab 600 mg ZYVOX - linezolid for susp 100 mg/5ml ZYVOX - linezolid iv soln mg/ml 5 Anticonvulsants APTIOM - eslicarbazepine acetate tab 00 mg APTIOM - eslicarbazepine acetate tab 00 mg APTIOM - eslicarbazepine acetate tab 600 mg APTIOM - eslicarbazepine acetate tab 800 mg BANZEL - rufinamide susp 5 0 mg/ml BANZEL - rufinamide tab 00 mg BANZEL - rufinamide tab 00 mg 5 carbamazepine cap sr 1hr 100 mg carbamazepine cap sr 1hr 00 mg 1 = Preferred Generic Drugs = Non-Preferred Generic Drugs 3 = Preferred Brand Drugs = Non-Preferred Brand Drugs 5 = Specialty Drugs = Utilization Management (UM) * = Limited Distribution Drug # = High Risk Medication (HRM) 8

17 carbamazepine cap sr 1hr 300 mg carbamazepine chew tab 100 mg 1 carbamazepine susp 100 mg/5ml carbamazepine tab sr 1hr 00 mg carbamazepine tab sr 1hr 00 mg carbamazepine tab 00 mg 1 CELONTIN - methsuximide cap 300 mg clonazepam orally disintegrating tab 0.15 mg clonazepam orally disintegrating tab 0.5 mg clonazepam orally disintegrating tab 0.5 mg clonazepam orally disintegrating tab 1 mg clonazepam orally disintegrating tab mg clonazepam tab 0.5 mg clonazepam tab 1 mg clonazepam tab mg clorazepate dipotassium tab 3.75 mg clorazepate dipotassium tab 7.5 mg clorazepate dipotassium tab 15 mg DIAZEPAM - diazepam soln 1 mg/ml DIAZEPAM - diazepam rectal gel delivery system.5 mg DIAZEPAM - diazepam rectal gel delivery system 10 mg DIAZEPAM - diazepam rectal gel delivery system 0 mg diazepam tab mg diazepam tab 5 mg diazepam tab 10 mg DILANTIN - phenytoin sodium extended cap 30 mg divalproex sodium cap sprinkle 15 mg divalproex sodium tab delayed release 15 mg divalproex sodium tab delayed release 50 mg divalproex sodium tab delayed release 500 mg divalproex sodium tab sr hr 50 mg divalproex sodium tab sr hr 500 mg ethosuximide cap 50 mg ethosuximide soln 50 mg/5ml felbamate susp 600 mg/5ml felbamate tab 00 mg felbamate tab 600 mg fosphenytoin sodium inj 100 mg/ml 1 = Preferred Generic Drugs = Non-Preferred Generic Drugs 3 = Preferred Brand Drugs = Non-Preferred Brand Drugs 5 = Specialty Drugs = Utilization Management (UM) * = Limited Distribution Drug # = High Risk Medication (HRM) 9

18 fosphenytoin sodium inj 500 mg/10ml FYCOMPA - perampanel tab mg FYCOMPA - perampanel tab mg FYCOMPA - perampanel tab 6 mg FYCOMPA - perampanel tab 8 mg FYCOMPA - perampanel tab 10 mg FYCOMPA - perampanel tab 1 mg gabapentin cap 100 mg 1 gabapentin cap 300 mg gabapentin cap 00 mg gabapentin oral soln 50 mg/5ml gabapentin tab 600 mg gabapentin tab 800 mg LAMICTAL ODT - lamotrigine orally disintegrating tab 5 mg LAMICTAL ODT - lamotrigine orally disintegrating tab 50 mg LAMICTAL ODT - lamotrigine orally disintegrating tab 100 mg LAMICTAL ODT - lamotrigine orally disintegrating tab 00 mg lamotrigine orally disintegrating tab 5 mg lamotrigine orally disintegrating tab 50 mg lamotrigine orally disintegrating tab 100 mg lamotrigine orally disintegrating tab 00 mg lamotrigine tab chewable dispersible 5 mg lamotrigine tab chewable dispersible 5 mg lamotrigine tab 5 mg lamotrigine tab 100 mg 1 lamotrigine tab 150 mg lamotrigine tab 00 mg levetiracetam inj 500 mg/5ml (100 mg/ml) levetiracetam oral soln 100 mg/ml levetiracetam tab 50 mg levetiracetam tab 500 mg levetiracetam tab 750 mg levetiracetam tab 1000 mg LYRICA - pregabalin soln 0 mg/ 3 ml LYRICA - pregabalin cap 5 mg 3 LYRICA - pregabalin cap 50 mg 3 LYRICA - pregabalin cap 75 mg 3 LYRICA - pregabalin cap 100 mg 3 LYRICA - pregabalin cap 150 mg 3 LYRICA - pregabalin cap 00 mg 3 LYRICA - pregabalin cap 5 mg 3 LYRICA - pregabalin cap 300 mg 3 1 = Preferred Generic Drugs = Non-Preferred Generic Drugs 3 = Preferred Brand Drugs = Non-Preferred Brand Drugs 5 = Specialty Drugs = Utilization Management (UM) * = Limited Distribution Drug # = High Risk Medication (HRM) 10

19 ONFI - clobazam suspension.5 mg/ml ONFI - clobazam tab 5 mg ONFI - clobazam tab 10 mg ONFI - clobazam tab 0 mg oxcarbazepine susp 300 mg/5ml (60 mg/ml) oxcarbazepine tab 150 mg oxcarbazepine tab 300 mg oxcarbazepine tab 600 mg PEGANONE - ethotoin tab 50 mg PHENOBARBITAL - phenobarbital tab 15 mg# PHENOBARBITAL - phenobarbital tab 30 mg# PHENOBARBITAL - phenobarbital tab 60 mg# PHENOBARBITAL - phenobarbital tab 100 mg# phenobarbital elixir 0 mg/5ml# PHENOBARBITAL SODIUM - phenobarbital sodium inj 65 mg/ ml# phenobarbital sodium inj 130 mg/ ml# phenobarbital tab 16. mg# phenobarbital tab 3. mg# phenobarbital tab 6.8 mg# phenobarbital tab 97. mg# phenytoin chew tab 50 mg phenytoin sodium extended cap 100 mg phenytoin sodium extended cap 00 mg phenytoin sodium extended cap 300 mg phenytoin susp 15 mg/5ml POTIGA - ezogabine tab 50 mg POTIGA - ezogabine tab 00 mg POTIGA - ezogabine tab 300 mg POTIGA - ezogabine tab 00 mg primidone tab 50 mg primidone tab 50 mg SABRIL - vigabatrin tab 500 mg SABRIL - vigabatrin powd pack 500 mg TEGRETOL-XR - carbamazepine tab sr 1hr 100 mg tiagabine hcl tab mg tiagabine hcl tab mg topiramate sprinkle cap 15 mg topiramate sprinkle cap 5 mg topiramate tab 5 mg 1 topiramate tab 50 mg 1 topiramate tab 100 mg topiramate tab 00 mg valproate sodium inj 100 mg/ml valproate sodium syrup 50 mg/5ml valproic acid cap 50 mg 1 = Preferred Generic Drugs = Non-Preferred Generic Drugs 3 = Preferred Brand Drugs = Non-Preferred Brand Drugs 5 = Specialty Drugs = Utilization Management (UM) * = Limited Distribution Drug # = High Risk Medication (HRM) 11

20 VIMPAT - lacosamide tab 50 mg 3 VIMPAT - lacosamide tab 100 mg 3 VIMPAT - lacosamide tab 150 mg 3 VIMPAT - lacosamide tab 00 mg 3 VIMPAT - lacosamide iv inj 3 00 mg/0ml (10 mg/ml) VIMPAT - lacosamide oral 3 solution 10 mg/ml zonisamide cap 5 mg zonisamide cap 50 mg zonisamide cap 100 mg Antidementia Agents donepezil hydrochloride orally disintegrating tab 5 mg donepezil hydrochloride orally disintegrating tab 10 mg donepezil hydrochloride tab 5 mg donepezil hydrochloride tab 1 10 mg donepezil hydrochloride tab 3 mg ergoloid mesylates tab 1 mg# EXELON - rivastigmine td patch 3 hr.6 mg/hr EXELON - rivastigmine td patch 3 hr 9.5 mg/hr EXELON - rivastigmine td patch 3 hr 13.3 mg/hr galantamine hydrobromide cap sr hr 8 mg galantamine hydrobromide cap sr hr 16 mg galantamine hydrobromide cap sr hr mg galantamine hydrobromide oral soln mg/ml galantamine hydrobromide tab mg galantamine hydrobromide tab 8 mg galantamine hydrobromide tab 1 mg memantine hcl oral solution mg/ ml memantine hcl tab 5 mg memantine hcl tab 10 mg memantine hcl tab 5 mg (8) & 10 mg (1) titration pak NAMENDA - memantine hcl oral solution mg/ml NAMENDA - memantine hcl tab 5 mg NAMENDA - memantine hcl tab 10 mg NAMENDA TITRATION PAK - memantine hcl tab 5 mg (8) & 10 mg (1) titration pak NAMENDA XR - memantine hcl cap sr hr 7 mg NAMENDA XR - memantine hcl cap sr hr 1 mg NAMENDA XR - memantine hcl cap sr hr 1 mg = Preferred Generic Drugs = Non-Preferred Generic Drugs 3 = Preferred Brand Drugs = Non-Preferred Brand Drugs 5 = Specialty Drugs = Utilization Management (UM) * = Limited Distribution Drug # = High Risk Medication (HRM) 1

21 NAMENDA XR - memantine hcl 3 cap sr hr 8 mg NAMENDA XR TITRATION PACK 3 - memantine hcl cap sr hr 7 mg & 1 mg & 1 mg & 8 mg pack rivastigmine tartrate cap 1.5 mg rivastigmine tartrate cap 3 mg rivastigmine tartrate cap.5 mg rivastigmine tartrate cap 6 mg rivastigmine td patch hr.6 mg/hr rivastigmine td patch hr 9.5 mg/hr rivastigmine td patch hr 13.3 mg/hr Antidepressants ABILIFY - aripiprazole tab mg ABILIFY - aripiprazole tab 5 mg ABILIFY - aripiprazole tab 10 mg ABILIFY - aripiprazole tab 15 mg ABILIFY - aripiprazole tab 0 mg ABILIFY - aripiprazole tab 30 mg ABILIFY MAINTENA - aripiprazole im for extended release susp 300 mg ABILIFY MAINTENA - aripiprazole im for extended release susp 00 mg amitriptyline hcl tab 10 mg# amitriptyline hcl tab 5 mg# amitriptyline hcl tab 50 mg# amitriptyline hcl tab 75 mg# amitriptyline hcl tab 100 mg# amitriptyline hcl tab 150 mg# AMOXAPINE - amoxapine tab 5 mg AMOXAPINE - amoxapine tab 50 mg AMOXAPINE - amoxapine tab 100 mg AMOXAPINE - amoxapine tab 150 mg ARIPIPRAZOLE ODT - aripiprazole orally disintegrating tab 10 mg ARIPIPRAZOLE ODT - aripiprazole orally disintegrating tab 15 mg aripiprazole oral solution 1 mg/ml aripiprazole tab mg aripiprazole tab 5 mg aripiprazole tab 10 mg aripiprazole tab 15 mg aripiprazole tab 0 mg aripiprazole tab 30 mg BRINTELLIX - vortioxetine hbr tab 5 mg BRINTELLIX - vortioxetine hbr tab 10 mg BRINTELLIX - vortioxetine hbr tab 0 mg 1 = Preferred Generic Drugs = Non-Preferred Generic Drugs 3 = Preferred Brand Drugs = Non-Preferred Brand Drugs 5 = Specialty Drugs = Utilization Management (UM) * = Limited Distribution Drug # = High Risk Medication (HRM) 13

22 bupropion hcl tab sr 1hr 100 mg bupropion hcl tab sr 1hr 150 mg bupropion hcl tab sr 1hr 00 mg bupropion hcl tab sr hr 150 mg bupropion hcl tab sr hr 300 mg bupropion hcl tab 75 mg bupropion hcl tab 100 mg citalopram hydrobromide oral soln 10 mg/5ml citalopram hydrobromide tab 1 10 mg citalopram hydrobromide tab 1 0 mg citalopram hydrobromide tab 0 mg 1 clomipramine hcl cap 5 mg# clomipramine hcl cap 50 mg# clomipramine hcl cap 75 mg# desipramine hcl tab 10 mg desipramine hcl tab 5 mg desipramine hcl tab 50 mg desipramine hcl tab 75 mg desipramine hcl tab 100 mg desipramine hcl tab 150 mg doxepin hcl cap 10 mg# doxepin hcl cap 5 mg# doxepin hcl cap 50 mg# doxepin hcl cap 100 mg# doxepin hcl cap 150 mg# doxepin hcl conc 10 mg/ml# duloxetine hcl enteric coated pellets cap 0 mg duloxetine hcl enteric coated pellets cap 30 mg duloxetine hcl enteric coated pellets cap 60 mg EMSAM - selegiline td patch hr 5 6 mg/hr EMSAM - selegiline td patch hr 5 9 mg/hr EMSAM - selegiline td patch hr 5 1 mg/hr escitalopram oxalate soln 5 mg/5ml escitalopram oxalate tab 5 mg 1 escitalopram oxalate tab 10 mg 1 escitalopram oxalate tab 0 mg 1 FETZIMA - levomilnacipran hcl cap sr hr 0 mg FETZIMA - levomilnacipran hcl cap sr hr 0 mg FETZIMA - levomilnacipran hcl cap sr hr 80 mg FETZIMA - levomilnacipran hcl cap sr hr 10 mg FETZIMA TITRATION PACK - levomilnacipran hcl cap sr hr 0 & 0 mg therapy pack fluoxetine hcl cap 10 mg 1 fluoxetine hcl cap 0 mg 1 fluoxetine hcl cap 0 mg 1 = Preferred Generic Drugs = Non-Preferred Generic Drugs 3 = Preferred Brand Drugs = Non-Preferred Brand Drugs 5 = Specialty Drugs = Utilization Management (UM) * = Limited Distribution Drug # = High Risk Medication (HRM) 1

23 fluoxetine hcl solution 0 mg/5ml fluoxetine hcl tab 10 mg fluoxetine hcl tab 0 mg fluvoxamine maleate tab 5 mg fluvoxamine maleate tab 50 mg fluvoxamine maleate tab 100 mg imipramine hcl tab 10 mg# imipramine hcl tab 5 mg# imipramine hcl tab 50 mg# MAPROTILINE HCL - maprotiline hcl tab 5 mg MAPROTILINE HCL - maprotiline hcl tab 50 mg MAPROTILINE HCL - maprotiline hcl tab 75 mg MARPLAN - isocarboxazid tab 10 mg mirtazapine orally disintegrating tab 15 mg mirtazapine orally disintegrating tab 30 mg mirtazapine orally disintegrating tab 5 mg mirtazapine tab 7.5 mg mirtazapine tab 15 mg 1 mirtazapine tab 30 mg 1 mirtazapine tab 5 mg NEFAZODONE HCL - nefazodone hcl tab 100 mg NEFAZODONE HCL - nefazodone hcl tab 150 mg NEFAZODONE HCL - nefazodone hcl tab 00 mg nefazodone hcl tab 50 mg nefazodone hcl tab 50 mg NORTRIPTYLINE HCL - nortriptyline hcl soln 10 mg/5ml nortriptyline hcl cap 10 mg 1 nortriptyline hcl cap 5 mg 1 nortriptyline hcl cap 50 mg 1 nortriptyline hcl cap 75 mg paroxetine hcl tab sr hr 1.5 mg paroxetine hcl tab sr hr 5 mg paroxetine hcl tab sr hr 37.5 mg paroxetine hcl tab 10 mg 1 paroxetine hcl tab 0 mg 1 paroxetine hcl tab 30 mg 1 paroxetine hcl tab 0 mg 1 PAXIL - paroxetine hcl oral susp 10 mg/5ml phenelzine sulfate tab 15 mg PRISTIQ - desvenlafaxine succinate tab sr hr 5 mg PRISTIQ - desvenlafaxine succinate tab sr hr 50 mg PRISTIQ - desvenlafaxine succinate tab sr hr 100 mg protriptyline hcl tab 5 mg protriptyline hcl tab 10 mg 1 = Preferred Generic Drugs = Non-Preferred Generic Drugs 3 = Preferred Brand Drugs = Non-Preferred Brand Drugs 5 = Specialty Drugs = Utilization Management (UM) * = Limited Distribution Drug # = High Risk Medication (HRM) 15

24 quetiapine fumarate tab 5 mg quetiapine fumarate tab 50 mg quetiapine fumarate tab 100 mg quetiapine fumarate tab 00 mg quetiapine fumarate tab 300 mg quetiapine fumarate tab 00 mg REXULTI - brexpiprazole tab 0.5 mg REXULTI - brexpiprazole tab 0.5 mg REXULTI - brexpiprazole tab 1 mg REXULTI - brexpiprazole tab mg REXULTI - brexpiprazole tab 3 mg REXULTI - brexpiprazole tab mg SEROQUEL XR - quetiapine fumarate tab sr hr 50 mg SEROQUEL XR - quetiapine fumarate tab sr hr 150 mg SEROQUEL XR - quetiapine fumarate tab sr hr 00 mg SEROQUEL XR - quetiapine fumarate tab sr hr 300 mg SEROQUEL XR - quetiapine fumarate tab sr hr 00 mg sertraline hcl oral conc 0 mg/ml sertraline hcl tab 5 mg 1 sertraline hcl tab 50 mg 1 sertraline hcl tab 100 mg 1 SURMONTIL - trimipramine maleate cap 5 mg# SURMONTIL - trimipramine maleate cap 50 mg# SURMONTIL - trimipramine maleate cap 100 mg# tranylcypromine sulfate tab 10 mg trazodone hcl tab 50 mg 1 trazodone hcl tab 100 mg 1 trazodone hcl tab 150 mg 1 trazodone hcl tab 300 mg trimipramine maleate cap 5 mg# trimipramine maleate cap 50 mg# trimipramine maleate cap 100 mg# venlafaxine hcl cap sr hr 37.5 mg venlafaxine hcl cap sr hr 75 mg venlafaxine hcl cap sr hr 150 mg venlafaxine hcl tab 5 mg venlafaxine hcl tab 37.5 mg venlafaxine hcl tab 50 mg venlafaxine hcl tab 75 mg venlafaxine hcl tab 100 mg VIIBRYD - vilazodone hcl tab 10 mg VIIBRYD - vilazodone hcl tab 0 mg 1 = Preferred Generic Drugs = Non-Preferred Generic Drugs 3 = Preferred Brand Drugs = Non-Preferred Brand Drugs 5 = Specialty Drugs = Utilization Management (UM) * = Limited Distribution Drug # = High Risk Medication (HRM) 16

25 VIIBRYD - vilazodone hcl tab 0 mg VIIBRYD - vilazodone hcl tab starter kit 10 (7) & 0 (7) & 0 (16) mg VIIBRYD STARTER PACK - vilazodone hcl tab starter kit 10 (7) & 0 (3) mg Antiemetics ALOXI - palonosetron hcl iv soln 0.5 mg/5ml CHLORPROMAZINE HCL - chlorpromazine hcl inj 5 mg/ml CHLORPROMAZINE HCL - chlorpromazine hcl inj 50 mg/ml chlorpromazine hcl tab 10 mg chlorpromazine hcl tab 5 mg chlorpromazine hcl tab 50 mg chlorpromazine hcl tab 100 mg chlorpromazine hcl tab 00 mg diphenhydramine hcl inj 50 mg/ml dronabinol cap.5 mg X dronabinol cap 5 mg X dronabinol cap 10 mg X EMEND - aprepitant capsule therapy pack 80 & 15 mg EMEND - fosaprepitant dimeglumine for iv infusion 150 mg EMEND - aprepitant capsule 0 mg 3 X 3 X EMEND - aprepitant capsule 3 X 80 mg EMEND - aprepitant capsule 3 X 15 mg meclizine hcl tab 1.5 mg metoclopramide hcl soln 5 mg/5ml (10 mg/10ml) metoclopramide hcl tab 5 mg 1 metoclopramide hcl tab 10 mg 1 ondansetron hcl inj mg/ml ( mg/ml) ondansetron hcl inj 0 mg/0ml ( mg/ml) ondansetron orally disintegrating X tab mg ondansetron orally disintegrating X tab 8 mg perphenazine tab mg perphenazine tab mg perphenazine tab 8 mg perphenazine tab 16 mg prochlorperazine edisylate inj 5 mg/ml prochlorperazine maleate tab 5 mg prochlorperazine maleate tab 10 mg prochlorperazine suppos 5 mg promethazine hcl syrup 6.5 mg/5ml# 1 = Preferred Generic Drugs = Non-Preferred Generic Drugs 3 = Preferred Brand Drugs = Non-Preferred Brand Drugs 5 = Specialty Drugs = Utilization Management (UM) * = Limited Distribution Drug # = High Risk Medication (HRM) 17

26 Antifungals AMBISOME - amphotericin b 5 X liposome iv for susp 50 mg AMPHOTERICIN B - X amphotericin b for inj 50 mg CANCIDAS - caspofungin acetate 5 for iv soln 50 mg CANCIDAS - caspofungin acetate 5 for iv soln 70 mg clotrimazole troche 10 mg CRESEMBA - isavuconazonium sulfate cap 186 mg CRESEMBA - isavuconazonium sulfate for iv soln 37 mg fluconazole for susp 10 mg/ml fluconazole for susp 0 mg/ml fluconazole in dextrose inj 00 mg/100ml fluconazole in dextrose inj 00 mg/00ml fluconazole in nacl 0.9% inj 00 mg/100ml fluconazole in nacl 0.9% inj 00 mg/00ml fluconazole tab 50 mg fluconazole tab 100 mg fluconazole tab 150 mg fluconazole tab 00 mg flucytosine cap 50 mg 5 flucytosine cap 500 mg 5 griseofulvin microsize susp 15 mg/5ml itraconazole cap 100 mg ketoconazole tab 00 mg MYCAMINE - micafungin sodium for iv soln 50 mg MYCAMINE - micafungin sodium 5 for iv soln 100 mg NOXAFIL - posaconazole susp 0 mg/ml NOXAFIL - posaconazole iv soln 300 mg/16.7ml (18 mg/ml) nystatin susp unit/ml terbinafine hcl tab 50 mg 1 terconazole vaginal cream 0.% terconazole vaginal cream 0.8% voriconazole for inj 00 mg voriconazole for susp 0 mg/ml voriconazole tab 50 mg voriconazole tab 00 mg Antigout Agents allopurinol tab 100 mg 1 allopurinol tab 300 mg 1 colchicine w/ probenecid tab mg COLCRYS - colchicine tab 0.6 mg 3 probenecid tab 500 mg ULORIC - febuxostat tab 0 mg 3 ULORIC - febuxostat tab 80 mg 3 1 = Preferred Generic Drugs = Non-Preferred Generic Drugs 3 = Preferred Brand Drugs = Non-Preferred Brand Drugs 5 = Specialty Drugs = Utilization Management (UM) * = Limited Distribution Drug # = High Risk Medication (HRM) 18

27 Anti-Inflammatory Agents diclofenac potassium tab 50 mg diclofenac sodium tab delayed release 5 mg diclofenac sodium tab delayed release 50 mg diclofenac sodium tab delayed release 75 mg diclofenac sodium tab sr hr 100 mg etodolac cap 00 mg etodolac cap 300 mg etodolac tab 00 mg etodolac tab 500 mg ibuprofen tab 00 mg 1 ibuprofen tab 600 mg 1 ibuprofen tab 800 mg 1 meloxicam tab 7.5 mg 1 meloxicam tab 15 mg 1 nabumetone tab 500 mg nabumetone tab 750 mg naproxen tab 50 mg 1 naproxen tab 375 mg 1 naproxen tab 500 mg 1 sulindac tab 150 mg sulindac tab 00 mg VOLTAREN - diclofenac sodium gel 1% Antimigraine Agents butalbital-acetaminophen-caff w/ cod cap mg# butalbital-acetaminophen-caff w/ cod cap mg# butalbital-aspirin-caff w/ codeine cap mg# divalproex sodium cap sprinkle 15 mg divalproex sodium tab delayed release 15 mg divalproex sodium tab delayed release 50 mg divalproex sodium tab delayed release 500 mg divalproex sodium tab sr hr 50 mg divalproex sodium tab sr hr 500 mg MIGERGOT - ergotamine w/ caffeine suppos -100 mg MIGRANAL - dihydroergotamine mesylate nasal spray mg/ml naratriptan hcl tab 1 mg naratriptan hcl tab.5 mg propranolol hcl inj 1 mg/ml propranolol hcl tab 10 mg 1 propranolol hcl tab 0 mg 1 propranolol hcl tab 0 mg 1 propranolol hcl tab 80 mg 1 rizatriptan benzoate orally disintegrating tab 5 mg 3 1 = Preferred Generic Drugs = Non-Preferred Generic Drugs 3 = Preferred Brand Drugs = Non-Preferred Brand Drugs 5 = Specialty Drugs = Utilization Management (UM) * = Limited Distribution Drug # = High Risk Medication (HRM) 19

28 rizatriptan benzoate orally disintegrating tab 10 mg rizatriptan benzoate tab 5 mg rizatriptan benzoate tab 10 mg SUMATRIPTAN - sumatriptan nasal spray 5 mg/act SUMATRIPTAN - sumatriptan nasal spray 0 mg/act SUMATRIPTAN SUCCINATE - sumatriptan succinate solution prefilled syringe 6 mg/0.5ml sumatriptan succinate inj 6 mg/0.5ml sumatriptan succinate solution auto-injector mg/0.5ml sumatriptan succinate solution auto-injector 6 mg/0.5ml sumatriptan succinate solution cartridge mg/0.5ml sumatriptan succinate solution cartridge 6 mg/0.5ml sumatriptan succinate tab 5 mg sumatriptan succinate tab 50 mg sumatriptan succinate tab 100 mg topiramate sprinkle cap 15 mg topiramate sprinkle cap 5 mg topiramate tab 5 mg 1 topiramate tab 50 mg 1 topiramate tab 100 mg topiramate tab 00 mg Antimyasthenic Agents GUANIDINE HCL - guanidine hcl tab 15 mg MESTINON - pyridostigmine bromide syrup 60 mg/5ml pyridostigmine bromide tab 60 mg Antimycobacterials CAPASTAT SULFATE - capreomycin sulfate for inj 1 gm DAPSONE - dapsone tab 5 mg DAPSONE - dapsone tab 100 mg ethambutol hcl tab 100 mg ethambutol hcl tab 00 mg ISONIAZID - isoniazid inj 100 mg/ ml isoniazid tab 100 mg 1 isoniazid tab 300 mg 1 PASER - aminosalicylic acid cr granules packet gm PRIFTIN - rifapentine tab 150 mg pyrazinamide tab 500 mg rifabutin cap 150 mg rifampin cap 150 mg rifampin cap 300 mg rifampin for inj 600 mg SEROMYCIN - cycloserine cap 50 mg TRECATOR - ethionamide tab 50 mg 1 = Preferred Generic Drugs = Non-Preferred Generic Drugs 3 = Preferred Brand Drugs = Non-Preferred Brand Drugs 5 = Specialty Drugs = Utilization Management (UM) * = Limited Distribution Drug # = High Risk Medication (HRM) 0