Rocky Mountain Health Plans 015 Premier Medicare Formulary (List of Covered Drugs) PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN This formulary was updated on November 1, 015. For more recent information or other questions, please contact Rocky Mountain Health Plans (RMHP) Customer Service at 888-8-140. (TTY users should call 711 for Relay Colorado). Hours are 8:00 a.m. to 8:00 p.m., Mountain Time, October 1 - February 14, 7 days/week; February 15-September 30, Monday-Friday, or visit rmhpmedicare.org. Note to existing members: This formulary has changed since last year. Please review this document to make sure that it still contains the drugs you take. When this drug list (formulary) refers to we, us, or our, it means RMHP. When it refers to plan or our plan, it means RMHP. This document includes a list of the drugs (formulary) for our plan which is current as of November 1, 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, and/or copayments/coinsurance may change on January 1, 016, and from time to time during the year. RMHP is a Medicare-approved Cost plan. Enrollment in RMHP depends on contract renewal. The benefit information provided is a brief summary, not a complete description of benefits. For more information, contact RMHP. Limitations, copayments, and restrictions may apply. This information is available for free in other languages. Please call our Customer Service at 888-8-140 (TTY dial 711). Hours are 8am - 8pm, 7 days/week, Oct.1 Feb.14, and 8am - 8pm, M-F, Feb.15 Sept.30. Esta información está disponible gratuitamente en otros idiomas. Por favor llame a la línea de Atención a Clientes, al 888-8-140 (TTY marque 711). Horario de 8am - 8pm, 7 días a la semana, del 1 de octubre al 14 de febrero; y 8am - 8pm, de lunes a viernes, del 15 de febrero al 30 de septiembre. H060_PH_PremierFormulary _0813014 Accepted 000160 11 Version 16 FORM-Premier 015
What is the Rocky Mountain Health Plans Formulary? A formulary is a list of covered drugs selected by RMHP 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. RMHP will generally cover the drugs listed in our formulary as long as the drug is medically necessary, the prescription is filled at an RMHP network pharmacy, and other plan rules are followed. For more information on how to fill your prescriptions, please review your Evidence of Coverage. Can the Formulary (drug list) change? Generally, if you are taking a drug on our 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, 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 November 1, 015. To get updated information about the drugs covered by RMHP, please contact us. Our contact information appears on the front and back cover pages. The only changes made to the formulary mid-year are maintenance drug changes. This means we may add new drugs to the formulary and we may move a brand name drug to a higher tier if a bioequivalent generic becomes available and is included in the formulary. RMHP does not make non-maintenance formulary changes mid-year. How do I use the Formulary? There are two ways to find your drug within the formulary: Medical Condition The formulary begins on page 7. The drugs in this formulary are grouped into categories depending on the type of medical conditions that they are used to treat. For example, drugs used to treat a heart condition are listed under the category, Cardiovascular Agents. If you know what your drug is used for, look for the category name in the list that begins on page number 7. Then look under the category name for your drug. Alphabetical Listing If you are not sure what category to look under, you should look for your drug in the Index that begins on page I-1. The Index provides an alphabetical list of all of the drugs included in this document. Both brand name drugs and generic drugs are listed in the Index. Look in the Index and find your drug. Next to your drug, you will see the page number where you can find coverage information. Turn to the page listed in the Index and find the name of your drug in the first column of the list.
What are generic drugs? RMHP covers both brand name drugs and generic drugs. A generic drug is approved by the FDA as having the same active ingredient as the brand name drug. Generally, generic drugs cost less than brand name drugs. Are there any restrictions on my coverage? Some covered drugs may have additional requirements or limits on coverage. These requirements and limits may include: Prior Authorization: RMHP requires you or your physician to get prior authorization for certain drugs. This means that you will need to get approval from us before you fill your prescriptions. If you don t get approval, we may not cover the drug. Quantity Limits: For certain drugs, RMHP limits the amount of the drug that we will cover. For example, RMHP provides 1 tablets per month for Imitrex tablets. This may be in addition to a standard one month or three month supply. Step Therapy: In some cases, RMHP requires you to first try certain drugs to treat your medical condition before we will cover another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, we may not cover Drug B unless you try Drug A first. If Drug A does not work for you, we will then cover Drug B. You can find out if your drug has any additional requirements or limits by looking in the formulary that begins on page 7. You can also get more information about the restrictions applied to specific covered drugs by visiting our Web site. We have posted on line documents that explain our prior authorization and step therapy restrictions. You may also ask us to send you a copy. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages. You can ask RMHP to make an exception to these restrictions or limits or for a list of other, similar drugs that may treat your health condition. See the section, How do I request an exception to the RMHP formulary? below for information about how to request an exception. What if my drug is not on the Formulary? If your drug is not included in this formulary (list of covered drugs), you should first contact Customer Service and ask if your drug is covered. If you learn that RMHP does not cover your drug, you have two options: You can ask Customer Service for a list of similar drugs that are covered by RMHP. When you receive the list, show it to your doctor and ask him or her to prescribe a similar drug that is covered by RMHP. You can ask RMHP to make an exception and cover your drug. See below for information about how to request an exception. 3
How do I request an exception to the RMHP Formulary? You can ask RMHP to make an exception to our coverage rules. There are several types of exceptions that you can ask us to make. You can ask us to cover your drug even if it is not on our formulary. If approved, this drug will be covered at a pre-determined cost-sharing level, and you would not be able to ask us to provide the drug at a lower cost-sharing level. You can ask us to cover a formulary drug at a lower cost-sharing level, if this drug is not on the specialty tier. If approved, this would lower the amount you must pay for your drug. You can ask us to waive coverage restrictions or limits on your drug. For example, for certain drugs, RMHP limits the amount of the drug that we will cover. If your drug has a quantity limit, you can ask us to waive the limit and cover a greater amount. Generally, RMHP will only approve your request for an exception if the alternative drugs included on the plan s formulary, the lower cost-sharing drug or additional utilization restrictions would not be as effective in treating your condition and/or would cause you to have adverse medical effects. You should contact us to ask us for an initial coverage decision for a formulary, tiering or utilization restriction exception. When you are requesting a formulary, tiering or utilization restriction exception you should submit a statement from your prescriber or physician supporting your request. Generally, we must make our decision within 7 hours of getting your prescriber s supporting statement. You can request an expedited (fast) exception if you or your doctor believe that your health could be seriously harmed by waiting up to 7 hours for a decision. If your request to expedite is granted, we must give you a decision no later than 4 hours after we get a supporting statement from your doctor or other prescriber. What do I do before I can talk to my doctor about changing my drugs or requesting an exception? As a new or continuing member in our plan you may be taking drugs that are not on our formulary. Or, you may be taking a drug that is on our formulary but your ability to get it is limited. For example, you may need a prior authorization from us before you can fill your prescription. You should talk to your doctor to decide if you should switch to an appropriate drug that we cover or request a formulary exception so that we will cover the drug you take. While you talk to your doctor to determine the right course of action for you, we may cover your drug in certain cases during the first 90 days you are a member of our plan. For each of your drugs that is not on our formulary or if your ability to get your drugs is limited, we will cover a temporary 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 91-day transition supply, consistent with the 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 4
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. When you have a level of care change (e.g. you are admitted to a Long Term Care facility), you may need additional supplies of your medications. When this occurs, the pharmacy can call the RMHP Pharmacy Help Desk to receive a transition supply of each affected drug. RMHP will not limit appropriate and necessary access to Part D benefits when you are being admitted to, or discharged from a Long Term Care facility. For more information For more detailed information about your RMHP prescription drug coverage, please review your Evidence of Coverage and other plan materials. If you have questions about RMHP, please contact us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages. If you have general questions about Medicare prescription drug coverage, please call Medicare at 1-800-MEDICARE (1-800-633-47) 4 hours a day/7 days a week. TTY users should call 1-877-486-048. Or, visit http://www.medicare.gov/. RMHP Formulary The formulary that begins on page 7 provides coverage information about the drugs covered by RMHP. If you have trouble finding your drug in the list, turn to the Index that begins on page I-1. The first column of the chart lists the drug name. Brand name drugs are capitalized (e.g., ALLEGRA) and generic drugs are listed in lower-case italics (e.g., amoxicillin). The information in the Requirements/Limits column tells you if RMHP has any special requirements for coverage of your drug. The RMHP formulary key for the Requirements/Limits column is as follows: Drug Tier 1 Drug Tier Drug Tier 3 Drug Tier 4 Drug Tier 5 Preferred Generic Drugs (lowest cost generic drugs) Nonpreferred Generic Drugs (may contain certain preferred brand name drugs) Preferred Brand Drugs Nonpreferred Brand Drugs Specialty Drugs See your Summary of Benefits or Evidence of Coverage to determine how much you will pay for prescription drugs in each tier. The Evidence of Coverage will help you determine when drugs listed in the Part D Formulary may be covered under Part B. All formulary drugs are available from mail order pharmacies. 5
Drugs that appear with: italics = Generic drugs CAPITALIZATION = Brand name drugs PA = Prior Authorization required PA BvD (Part B vs. Part D only) = Prior Authorization required. This drug may be covered under Medicare Part B or D depending upon the circumstances. Information may need to be submitted describing the use and setting of the drug to make the determination. PA NSO (PA for New Starts Only) = Prior Authorization required for new members or members who have not taken this drug previously QL = Quantity Limit applies ST = Step Therapy Refer to Medicare Prescription Drugs Requiring Step Therapy on the RMHP website at http://www.rmhp.org/members/prior-authorization/pharmacy. LA = Limited Access Drug. This prescription may be available only at certain pharmacies. For more information, consult your Provider Directory or call Customer Service at 970-44-791 or 888-8- 140. (TTY users call 711.) We are available for phone calls 8:00 a.m. to 8:00 p.m., Mountain Time, (from October 1-February 14, 7 days/week and from February 15 - September 30, Monday - Friday). 6
Analgesics Analgesics, Miscellaneous acetaminophen-codeine oral solution (Acetaminophen with Codeine) acetaminophen-codeine oral tablet (Tylenol-Codeine No.3) AVINZA ORAL CAPSULE, ER 4 QL (30 per 30 days) MULTIPHASE 4 HR 10 MG AVINZA ORAL CAPSULE, ER 4 QL (10 per 30 days) MULTIPHASE 4 HR 30 MG AVINZA ORAL CAPSULE, ER 4 QL (80 per 30 days) MULTIPHASE 4 HR 45 MG AVINZA ORAL CAPSULE, ER 4 QL (60 per 30 days) MULTIPHASE 4 HR 60 MG AVINZA ORAL CAPSULE, ER 4 QL (48 per 30 days) MULTIPHASE 4 HR 75 MG AVINZA ORAL CAPSULE, ER 4 QL (40 per 30 days) MULTIPHASE 4 HR 90 MG BUPRENEX 4 buprenorphine hcl injection (Buprenorphine HCl) butalbital-acetaminop-caf-cod (Fioricet with Codeine) butalbital-acetaminophen (Tencon) butalbital-acetaminophen-caff oral (Esgic) capsule butalbital-acetaminophen-caff oral tablet (Esgic) 50-35-40 mg butalbital-aspirin-caffeine oral capsule (Fiorinal) butorphanol tartrate (Butorphanol Tartrate) CAPITAL WITH CODEINE 3 codeine sulfate oral tablet (Codeine Sulfate) codeine-butalbital-asa-caffein oral (Fiorinal with Codeine capsule 30-50-35-40 mg #3) DEMEROL (PF) INJECTION 4 SOLUTION DEMEROL (PF) INJECTION SYRINGE 4 DEMEROL INJECTION SOLUTION 4 DEMEROL ORAL 4 DILAUDID 4 7
DILAUDID (PF) 4 DILAUDID-HP (PF) INJECTION 4 DOLOPHINE ORAL 4 DURAGESIC 4 QL (15 per 30 days) DURAMORPH (PF) 3 fentanyl citrate (Actiq) PA; QL (10 per 30 days); AGE (Min 16 Years) fentanyl transdermal patch 7 hour 100 (Duragesic) QL (15 per 30 days) mcg/hr, 1 mcg/hr, 5 mcg/hr, 50 mcg/hr, 75 mcg/hr FENTORA 4 PA; QL (10 per 30 days); AGE (Min 18 Years) FIORINAL-CODEINE #3 4 HYCET 4 hydrocodone-acetaminophen oral solution (Hycet) hydrocodone-acetaminophen oral tablet (Norco) 10-300 mg, 10-35 mg,.5-35 mg, 5-300 mg, 5-35 mg, 7.5-300 mg, 7.5-35 mg hydrocodone-ibuprofen oral tablet 7.5-00 (Vicoprofen) mg hydromorphone (pf) injection solution 10 (Hydromorphone mg/ml HCl/PF) hydromorphone oral liquid (Dilaudid) hydromorphone oral tablet (Dilaudid) hydromorphone oral tablet extended (Exalgo) 3 release 4 hr ibuprofen-oxycodone KADIAN ORAL CAPSULE,EXTEND.RELEASE PELLETS 10 MG KADIAN ORAL CAPSULE,EXTEND.RELEASE PELLETS 100 MG (Ibuprofen/Oxycodone HCl) 4 QL (360 per 30 days) 4 QL (36 per 30 days) 8
KADIAN ORAL 4 QL (30 per 30 days) CAPSULE,EXTEND.RELEASE PELLETS 130 MG, 150 MG, 00 MG KADIAN ORAL 4 QL (180 per 30 days) CAPSULE,EXTEND.RELEASE PELLETS 0 MG KADIAN ORAL 4 QL (10 per 30 days) CAPSULE,EXTEND.RELEASE PELLETS 30 MG KADIAN ORAL 4 QL (90 per 30 days) CAPSULE,EXTEND.RELEASE PELLETS 40 MG KADIAN ORAL 4 QL (7 per 30 days) CAPSULE,EXTEND.RELEASE PELLETS 50 MG KADIAN ORAL 4 QL (60 per 30 days) CAPSULE,EXTEND.RELEASE PELLETS 60 MG KADIAN ORAL 4 QL (51 per 30 days) CAPSULE,EXTEND.RELEASE PELLETS 70 MG KADIAN ORAL 4 QL (45 per 30 days) CAPSULE,EXTEND.RELEASE PELLETS 80 MG LAZANDA 5 PA; QL (10 per 30 days); AGE (Min 18 Years) levorphanol tartrate (Levorphanol Tartrate) LORTAB 10-35 LORTAB 5-35 LORTAB 7.5-35 meperidine (Demerol) meperidine (pf) (Meperidine HCl/PF) meperidine oral solution (Meperidine HCl) 3 meperidine oral tablet (Demerol) methadone hcl oral concentrate 10 mg/ml (Methadose) methadone injection (Methadone HCl) 3 methadone oral (Methadone HCl) 9
methadone oral (Dolophine HCl) morphine concentrate oral solution (Msir) morphine intravenous cartridge 10 mg/ml, (Morphine Sulfate) 8 mg/ml morphine intravenous cartridge mg/ml, (Morphine Sulfate) 3 4 mg/ml morphine intravenous syringe 10 mg/ml, 8 (Morphine Sulfate) mg/ml morphine intravenous syringe mg/ml, 4 (Morphine Sulfate) 3 mg/ml morphine oral capsule, er multiphase 4 (Avinza) QL (30 per 30 days) hr 10 mg morphine oral capsule, er multiphase 4 (Avinza) QL (10 per 30 days) hr 30 mg morphine oral capsule, er multiphase 4 (Avinza) QL (80 per 30 days) hr 45 mg morphine oral capsule, er multiphase 4 (Avinza) QL (60 per 30 days) hr 60 mg morphine oral capsule, er multiphase 4 (Avinza) QL (48 per 30 days) hr 75 mg morphine oral capsule, er multiphase 4 (Avinza) QL (40 per 30 days) hr 90 mg morphine oral capsule,extend.release (Kadian) QL (360 per 30 days) pellets 10 mg morphine oral capsule,extend.release (Kadian) QL (36 per 30 days) pellets 100 mg morphine oral capsule,extend.release (Kadian) QL (180 per 30 days) pellets 0 mg morphine oral capsule,extend.release (Kadian) QL (10 per 30 days) pellets 30 mg morphine oral capsule,extend.release (Kadian) QL (7 per 30 days) pellets 50 mg morphine oral capsule,extend.release (Kadian) QL (60 per 30 days) pellets 60 mg morphine oral capsule,extend.release (Kadian) QL (45 per 30 days) pellets 80 mg morphine oral solution (Msir) MORPHINE ORAL TABLET 3 10
morphine oral tablet extended release 100 (MS Contin) QL (36 per 30 days) mg morphine oral tablet extended release 15 (MS Contin) QL (40 per 30 days) mg morphine oral tablet extended release 00 (MS Contin) QL (18 per 30 days) mg morphine oral tablet extended release 30 (MS Contin) QL (10 per 30 days) mg morphine oral tablet extended release 60 (MS Contin) QL (60 per 30 days) mg MS CONTIN ORAL TABLET 4 QL (36 per 30 days) EXTENDED RELEASE 100 MG MS CONTIN ORAL TABLET 4 QL (40 per 30 days) EXTENDED RELEASE 15 MG MS CONTIN ORAL TABLET 4 QL (18 per 30 days) EXTENDED RELEASE 00 MG MS CONTIN ORAL TABLET 4 QL (10 per 30 days) EXTENDED RELEASE 30 MG MS CONTIN ORAL TABLET 4 QL (60 per 30 days) EXTENDED RELEASE 60 MG nalbuphine injection (Nalbuphine HCl) NORCO 4 NUCYNTA 3 NUCYNTA ER 4 QL (60 per 30 days) OPANA ER ORAL TABLET,ORAL 3 QL (10 per 30 days) ONLY,EXT.REL.1 HR 10 MG OPANA ER ORAL TABLET,ORAL 3 QL (90 per 30 days) ONLY,EXT.REL.1 HR 15 MG OPANA ER ORAL TABLET,ORAL 3 QL (60 per 30 days) ONLY,EXT.REL.1 HR 0 MG OPANA ER ORAL TABLET,ORAL 3 QL (40 per 30 days) ONLY,EXT.REL.1 HR 30 MG OPANA ER ORAL TABLET,ORAL 3 QL (30 per 30 days) ONLY,EXT.REL.1 HR 40 MG OPANA ER ORAL TABLET,ORAL 3 QL (40 per 30 days) ONLY,EXT.REL.1 HR 5 MG OPANA ER ORAL TABLET,ORAL ONLY,EXT.REL.1 HR 7.5 MG 3 QL (180 per 30 days) 11
OPANA ORAL 4 oxycodone hcl-acetaminophen oral (Oxycodone solution 5-35 mg/5 ml HCl/Acetaminophen) oxycodone hcl-acetaminophen oral tablet (Percocet) 10-35 mg, 5-35 mg, 7.5-35 mg oxycodone hcl-aspirin (Percodan) oxycodone oral capsule (Oxycodone HCl) oxycodone oral concentrate (Oxycodone HCl) oxycodone oral solution (Oxycodone HCl) oxycodone oral tablet (Roxicodone) oxycodone oral tablet,oral only,ext.rel.1 (Oxycodone HCl) 3 QL (40 per 30 days) hr 10 mg oxycodone oral tablet,oral only,ext.rel.1 (Oxycodone HCl) 3 QL (10 per 30 days) hr 0 mg, 80 mg oxycodone oral tablet,oral only,ext.rel.1 (Oxycodone HCl) 3 QL (60 per 30 days) hr 40 mg oxycodone-acetaminophen oral tablet (Percocet) 10-35 mg,.5-35 mg, 5-35 mg, 7.5-35 mg oxycodone-aspirin (Percodan) OXYCONTIN ORAL TABLET,ORAL 3 QL (40 per 30 days) ONLY,EXT.REL.1 HR 10 MG OXYCONTIN ORAL TABLET,ORAL 3 QL (160 per 30 days) ONLY,EXT.REL.1 HR 15 MG OXYCONTIN ORAL TABLET,ORAL 3 QL (10 per 30 days) ONLY,EXT.REL.1 HR 0 MG, 80 MG OXYCONTIN ORAL TABLET,ORAL 3 QL (80 per 30 days) ONLY,EXT.REL.1 HR 30 MG OXYCONTIN ORAL TABLET,ORAL 3 QL (60 per 30 days) ONLY,EXT.REL.1 HR 40 MG, 60 MG oxymorphone oral tablet (Opana) oxymorphone oral tablet extended release (Opana ER) 3 QL (10 per 30 days) 1 hr 10 mg oxymorphone oral tablet extended release (Opana ER) 3 QL (90 per 30 days) 1 hr 15 mg oxymorphone oral tablet extended release 1 hr 0 mg (Opana ER) 3 QL (60 per 30 days) 1
oxymorphone oral tablet extended release 1 hr 30 mg oxymorphone oral tablet extended release 1 hr 40 mg oxymorphone oral tablet extended release 1 hr 5 mg oxymorphone oral tablet extended release 1 hr 7.5 mg pentazocine-naloxone (Opana ER) 3 QL (40 per 30 days) (Opana ER) 3 QL (30 per 30 days) (Opana ER) 3 QL (40 per 30 days) (Opana ER) 3 QL (180 per 30 days) (Pentazocine HCl/Naloxone HCl) PERCOCET ORAL TABLET 10-35 4 MG,.5-35 MG, 5-35 MG, 7.5-35 MG PERCODAN 4 ROXICODONE 4 SYNALGOS-DC 4 TALWIN 3 tramadol oral tablet (Ultram) tramadol oral tablet extended release 4 (Ultram ER) hr 100 mg, 00 mg tramadol-acetaminophen (Ultracet) TYLENOL-CODEINE #3 4 TYLENOL-CODEINE #4 4 ULTRACET 4 ULTRAM 4 ULTRAM ER 4 VICOPROFEN 4 ZOHYDRO ER ORAL CAPSULE, 4 QL (60 per 30 days) ORAL ONLY, ER 1HR Nonsteroidal Anti-Inflammatory Agents ANAPROX 4 ANAPROX DS 4 ARTHROTEC 50 4 ARTHROTEC 75 4 CAMBIA 4 QL (9 per 30 days) CATAFLAM 4 CELEBREX 4 celecoxib (Celebrex) 13
COMFORT PAC-IBUPROFEN COMFORT PAC-MELOXICAM COMFORT PAC-NAPROXEN DAYPRO 4 diclofenac potassium (Cataflam) diclofenac sodium oral tablet extended (Voltaren-XR) release 4 hr diclofenac sodium oral tablet,delayed (Diclofenac Sodium) release (dr/ec) diclofenac sodium topical gel (Solaraze) diclofenac-misoprostol (Arthrotec 75) diflunisal (Diflunisal) EC-NAPROSYN 4 etodolac (Etodolac) FELDENE 4 FENOPROFEN ORAL CAPSULE 3 fenoprofen oral tablet (Fenoprofen Calcium) flurbiprofen (Ansaid) ibuprofen oral (Ibuprofen) ibuprofen oral tablet 400 mg, 600 mg, 800 (Ibuprofen) mg INDOCIN ORAL 3 indomethacin oral (Indomethacin) ketoprofen oral capsule (Ketoprofen) ketoprofen oral capsule,ext rel. pellets 4 (Ketoprofen) 3 hr 00 mg ketorolac injection solution 15 mg/ml, 30 (Ketorolac mg/ml (1 ml) Tromethamine) ketorolac intramuscular solution (Ketorolac Tromethamine) ketorolac oral (Ketorolac Tromethamine) meclofenamate oral (Meclofenamate 3 Sodium) mefenamic acid (Ponstel) meloxicam oral suspension (Mobic) 3 meloxicam oral tablet (Mobic) 14
MOBIC 4 nabumetone (Nabumetone) NAPROSYN 4 naproxen oral suspension (Naprosyn) naproxen oral tablet (Naprosyn) naproxen oral tablet,delayed release (Ec-Naprosyn) (dr/ec) naproxen sodium oral tablet 75 mg, 550 (Anaprox Ds) mg naproxen sodium oral tablet, er (Naprelan) multiphase 4 hr oxaprozin (Daypro) piroxicam (Feldene) PONSTEL 4 SOLARAZE 4 sulindac oral (Sulindac) tolmetin oral capsule (Tolmetin Sodium) tolmetin oral tablet 00 mg (Tolmetin Sodium) tolmetin oral tablet 600 mg (Tolmetin Sodium) 3 VOLTAREN TOPICAL 4 VOLTAREN-XR 4 Anesthetics Local Anesthetics EMLA 4 PA BvD lidocaine (pf) injection solution 5 mg/ml (Xylocaine-MPF) PA BvD (0.5 %) lidocaine hcl injection solution 10 mg/ml (Xylocaine) PA BvD (1 %) lidocaine hcl injection solution 0 mg/ml (Xylocaine) ( %) lidocaine hcl mucous membrane gel (Lidocaine HCl) lidocaine hcl mucous membrane jelly in (Lidocaine HCl) applicator lidocaine hcl mucous membrane solution (Xylocaine) lidocaine hcl urethral (Lidocaine HCl) lidocaine topical adhesive patch,medicated (Lidoderm) PA 15
lidocaine topical ointment (Lidocaine) PA BvD lidocaine-prilocaine topical (EMLA) PA BvD lidocaine-prilocaine topical kit (Relador Pak) PA BvD lidocaine-tetracaine (Pliaglis) PA BvD LIDODERM 4 PA SYNERA 3 PA BvD XYLOCAINE MUCOUS MEMBRANE SOLUTION Anti-Addiction/Substance Abuse Treatment Agents Anti-Addiction/Substance Abuse Treatment Agents acamprosate (Campral) ANTABUSE 4 buprenorphine hcl sublingual (Subutex) buprenorphine-naloxone (Buprenorphine HCl/Naloxone HCl) bupropion hcl sr 150 mg tablet f/c (Zyban) CAMPRAL 4 CHANTIX 3 QL (336 per 365 days) CHANTIX STARTING MONTH BOX 3 QL (106 per 365 days) disulfiram (Antabuse) EVZIO 4 QL (0.8 per 365 days) naloxone injection syringe 1 mg/ml (Naloxone HCl) naltrexone (Revia) NICOTROL 3 NICOTROL NS 3 REVIA 4 SUBOXONE SUBLINGUAL FILM 3 ZYBAN 4 Antianxiety Agents Benzodiazepines clonazepam oral tablet (Klonopin) clonazepam oral tablet,disintegrating (Clonazepam) clorazepate dipotassium (Tranxene T-Tab) DIASTAT 4 DIASTAT ACUDIAL 4 diazepam intensol (Diazepam) 3 4 16
diazepam oral solution (Diazepam) 3 diazepam oral tablet (Valium) diazepam rectal (Diastat Acudial) lorazepam injection solution (Ativan) lorazepam injection syringe 4 mg/ml (Ativan) lorazepam oral tablet (Ativan) ONFI ORAL SUSPENSION 3 ONFI ORAL TABLET 10 MG, 0 MG 3 QL (60 per 30 days) oxazepam (Oxazepam) temazepam oral capsule 15 mg, 30 mg, 7.5 mg (Restoril) Antibacterials Aminoglycosides amikacin (Amikacin Sulfate) gentamicin in nacl (iso-osm) intravenous piggyback 100 mg/100 ml, 60 mg/50 ml, 80 mg/100 ml, 80 mg/50 ml gentamicin in nacl (iso-osm) intravenous piggyback 70 mg/50 ml, 90 mg/100 ml (Gentamicin In Nacl, Iso-Osm) (Gentamicin In Nacl, 3 Iso-Osm) gentamicin injection solution (Garamycin) gentamicin sulfate (ped) (pf) (Gentamicin Sulfate/PF) gentamicin sulfate (pf) intravenous (Gentamicin Sulfate/PF) solution neomycin (Neomycin Sulfate) streptomycin intramuscular (Streptomycin Sulfate) 3 TOBI 5 TOBI PODHALER INHALATION 5 tobramycin in 0.5 % nacl (Tobi) 4 tobramycin in 0.9 % nacl intravenous (Tobramycin/Sodium 3 piggyback 80 mg/100 ml Chloride) tobramycin sulfate injection solution (Nebcin) Antibacterials, Miscellaneous bacitracin (Bacitracin) bacitracin intramuscular (Bacitracin) 4 chloramphenicol sod succinate (Chloramphenicol Sod 3 Succ) CLEOCIN IN 5 % DEXTROSE 4 17
clindamycin hcl (Cleocin HCl) clindamycin in 5 % dextrose (Cleocin Phosphate In D5w) clindamycin palmitate hcl (Cleocin Palmitate) clindamycin phosphate injection (Cleocin Phosphate) CLINDAMYCIN PHOSPHATE 4 INJECTION SOLUTION 150 MG/ML clindamycin phosphate intravenous (Cleocin Phosphate) solution CLINDAMYCIN PHOSPHATE ORAL 4 CAPSULE 150 MG, 300 MG, 75 MG CLINDAMYCIN PHOSPHATE ORAL 4 RECON SOLN 75 MG/5 ML colistin (colistimethate na) (Coly-Mycin M Parenteral) COLY-MYCIN M PARENTERAL 4 CUBICIN 3 FURADANTIN 4 HIPREX 4 LINCOCIN 4 linezolid intravenous (Zyvox) 3 linezolid oral (Zyvox) 4 MACROBID 4 MACRODANTIN 4 methenamine hippurate (Hiprex) methenamine mandelate oral tablet 1 (Methenamine gram Mandelate) MONUROL 3 nitrofurantoin macrocrystal oral capsule (Macrodantin) 100 mg, 50 mg nitrofurantoin monohyd/m-cryst (Macrobid) nitrofurantoin oral (Furadantin) polymyxin b sulfate (Polymyxin B Sulfate) PRIMSOL 3 SYNERCID 3 trimethoprim (Trimethoprim) VANCOCIN 4 18
vancomycin in d5w intravenous piggyback (Vancomycin HCl/D5W) vancomycin intravenous recon soln 1,000 (Vancomycin HCl) mg, 10 gram vancomycin intravenous recon soln 500 (Vancomycin mg HCl/D5W) vancomycin oral capsule (Vancocin HCl) XIFAXAN ORAL TABLET 00 MG 3 XIFAXAN ORAL TABLET 550 MG 5 ZYVOX INTRAVENOUS 3 PARENTERAL SOLUTION ZYVOX ORAL 5 Cephalosporins CEDAX 4 cefaclor oral capsule (Cefaclor) cefaclor oral suspension for reconstitution (Cefaclor) 3 15 mg/5 ml, 50 mg/5 ml, 375 mg/5 ml cefaclor oral tablet extended release 1 hr (Cefaclor) 3 cefadroxil oral capsule (Cefadroxil) cefadroxil oral suspension for (Cefadroxil) reconstitution 50 mg/5 ml, 500 mg/5 ml cefadroxil oral tablet (Cefadroxil) cefazolin in dextrose (iso-os) intravenous (Cefazolin Sodium) 3 piggyback 1 gram/50 ml cefazolin in dextrose (iso-os) intravenous (Cefazolin piggyback gram/50 ml Sodium/Dextrose, Iso) cefazolin injection recon soln (Ancef) cefazolin injection recon soln 100 gram, (Cefazolin Sodium) 300 g cefazolin intravenous (Cefazolin Sodium) 3 cefdinir (Cefdinir) cefditoren pivoxil (Spectracef) cefepime (Maxipime) CEFEPIME IN DEXTROSE 5 % CEFEPIME IN DEXTROSE,ISO-OSM INTRAVENOUS PIGGYBACK cefixime (Suprax) 3 19
cefotaxime (Claforan) cefotetan (Cefotetan Disodium) 3 cefoxitin (Mefoxin) cefoxitin in dextrose, iso-osm intravenous (Cefoxitin 3 piggyback gram/50 ml Sodium/Dextrose, Iso) cefpodoxime (Cefpodoxime Proxetil) cefprozil (Cefprozil) ceftazidime (Fortaz) CEFTAZIDIME IN D5W 3 ceftazidime injection recon soln gram, 6 (Fortaz) gram ceftibuten (Cedax) CEFTIN ORAL SUSPENSION FOR 4 RECONSTITUTION CEFTIN ORAL TABLET 50 MG, 500 4 MG ceftriaxone in dextrose,iso-os intravenous (Ceftriaxone piggyback 1 gram/50 ml Na/Dextrose, Iso) CEFTRIAXONE IN DEXTROSE,ISO-OS INTRAVENOUS PIGGYBACK GRAM/50 ML ceftriaxone injection recon soln (Rocephin) ceftriaxone intravenous recon soln 1 gram (Ceftriaxone Na/Dextrose, Iso) CEFTRIAXONE INTRAVENOUS RECON SOLN GRAM cefuroxime axetil oral tablet (Ceftin) cefuroxime sodium injection recon soln (Zinacef) 1.5 gram, 750 mg cefuroxime sodium intravenous (Zinacef) cephalexin oral capsule 50 mg, 500 mg (Keflex) cephalexin oral suspension for (Cephalexin) reconstitution cephalexin oral tablet (Cephalexin) 3 CLAFORAN INJECTION 4 CLAFORAN INTRAVENOUS RECON 4 SOLN GRAM FORTAZ INJECTION RECON SOLN 4 0
FORTAZ INTRAVENOUS 4 KEFLEX ORAL CAPSULE 50 MG, 500 4 MG MAXIPIME INJECTION 4 ROCEPHIN INJECTION RECON SOLN 4 500 MG SPECTRACEF ORAL TABLET 400 MG 4 SUPRAX 3 TEFLARO 3 ZINACEF INJECTION 4 ZINACEF INTRAVENOUS RECON 4 SOLN Macrolides azithromycin (Zithromax) BIAXIN ORAL SUSPENSION FOR 4 RECONSTITUTION 50 MG/5 ML BIAXIN ORAL TABLET 4 BIAXIN XL 4 clarithromycin oral suspension for (Biaxin) reconstitution clarithromycin oral tablet (Biaxin) clarithromycin oral tablet extended (Biaxin XL) release 4 hr DIFICID 4 PA ERYPED 00 4 ERYPED 400 3 ERYTHROCIN INTRAVENOUS 3 RECON SOLN 500 MG erythromycin base oral tablet,delayed (Erythromycin Base) 3 release (dr/ec) 50 mg, 500 mg ERYTHROMYCIN BASE ORAL 3 TABLET,DELAYED RELEASE (DR/EC) 333 MG erythromycin ethylsuccinate oral (Eryped 00) 4 suspension for reconstitution 00 mg/5 ml erythromycin ethylsuccinate oral tablet (Erythromycin Ethylsuccinate) 1
erythromycin ethylsuccinate oral tablet (Erythromycin 4 400 mg Ethylsuccinate) erythromycin oral tablet (Erythromycin Base) 3 erythromycin stearate oral tablet 50 mg (Erythromycin Stearate) KETEK 4 PCE 3 ZITHROMAX INTRAVENOUS 4 ZITHROMAX ORAL SUSPENSION 4 FOR RECONSTITUTION ZITHROMAX ORAL TABLET 4 ZITHROMAX TRI-PAK 4 ZITHROMAX Z-PAK 4 ZMAX 3 Miscellaneous B-Lactam Antibiotics AZACTAM IN DEXTROSE (ISO-OSM) 3 AZACTAM INJECTION RECON SOLN 4 aztreonam (Azactam) CAYSTON 5 LA DORIBAX INTRAVENOUS RECON 3 SOLN 500 MG imipenem-cilastatin (Primaxin) INVANZ INJECTION 3 meropenem (Merrem) MERREM 4 PRIMAXIN IV 4 Penicillins amoxicillin oral capsule (Amoxicillin) amoxicillin oral suspension for (Amoxil) reconstitution amoxicillin oral tablet (Amoxicillin) amoxicillin oral tablet, er multiphase 4 (Moxatag) 3 hr amoxicillin oral tablet,chewable 15 mg, (Amoxicillin) 50 mg amoxicillin-pot clavulanate oral (Augmentin) suspension for reconstitution amoxicillin-pot clavulanate oral tablet (Augmentin)
amoxicillin-pot clavulanate oral tablet (Augmentin XR) extended release 1 hr amoxicillin-pot clavulanate oral (Amoxicillin/Potassium tablet,chewable Clav) ampicillin oral capsule (Ampicillin Trihydrate) ampicillin oral suspension for (Ampicillin Trihydrate) 3 reconstitution ampicillin sodium injection recon soln (Totacillin-N) ampicillin sodium intravenous recon soln (Totacillin-N) ampicillin-sulbactam injection (Unasyn) ampicillin-sulbactam intravenous recon (Unasyn) soln AUGMENTIN ES-600 4 AUGMENTIN ORAL SUSPENSION 4 FOR RECONSTITUTION 15-31.5 MG/5 ML, 50-6.5 MG/5 ML AUGMENTIN ORAL TABLET 500-15 4 MG, 875-15 MG AUGMENTIN XR 4 BICILLIN C-R 3 BICILLIN L-A 3 dicloxacillin (Dicloxacillin Sodium) nafcillin in dextrose iso-osm (Nafcillin In 3 Dextrose,Iso-Osm) nafcillin injection (Unipen) oxacillin in dextrose(iso-osm) (Oxacillin 3 Sodium/Dextrose, Iso) oxacillin injection recon soln (Oxacillin Sodium) oxacillin intravenous recon soln (Oxacillin Sodium) penicillin g pot in dextrose intravenous (Pen G 3 piggyback million unit/50 ml, 3 million unit/50 ml Pot/Dextrose-Water) penicillin g potassium injection recon soln (Penicillin G Potassium) penicillin g procaine intramuscular (Penicillin G Procaine) 3 syringe 1. million unit/ ml penicillin g sodium (Penicillin G Sodium) 3 penicillin v potassium (Penicillin V Potassium) piperacillin-tazobactam (Zosyn) 3
TIMENTIN INTRAVENOUS RECON 3 SOLN 31 GRAM UNASYN INJECTION 4 ZOSYN IN DEXTROSE (ISO-OSM) 3 ZOSYN INTRAVENOUS RECON SOLN 4 3.375 GRAM, 40.5 GRAM Quinolones AVELOX 4 AVELOX ABC PACK 4 AVELOX IN NACL (ISO-OSMOTIC) 4 CIPRO IN D5W INTRAVENOUS 4 PIGGYBACK CIPRO ORAL 3 SUSPENSION,MICROCAPSULE RECON CIPRO ORAL TABLET 50 MG, 500 4 MG ciprofloxacin (Cipro) ciprofloxacin (mixture) (Cipro XR) ciprofloxacin hcl oral (Cipro) ciprofloxacin in 5 % dextrose (Cipro I.V.) ciprofloxacin lactate intravenous solution (Cipro I.V.) 400 mg/40 ml FACTIVE 4 LEVAQUIN IN 5 % DEXTROSE 4 INTRAVENOUS PIGGYBACK LEVAQUIN ORAL 4 levofloxacin in d5w intravenous piggyback (Levaquin) levofloxacin intravenous (Levofloxacin) levofloxacin oral (Levaquin) moxifloxacin (Avelox) moxifloxacin-sod.ace,sul-water (Moxifloxacin/Sod.Ace, Sul/Water) NOROXIN 4 ofloxacin oral (Ofloxacin) Sulfonamides AZULFIDINE 4 4
AZULFIDINE EN-TABS 4 BACTRIM 4 BACTRIM DS 4 sulfadiazine oral (Sulfadiazine) 3 sulfamethoxazole-trimethoprim (Sulfamethoxazole/Trim 3 intravenous ethoprim) sulfamethoxazole-trimethoprim oral (Sulfamethoxazole/Trim suspension ethoprim) sulfamethoxazole-trimethoprim oral tablet (Bactrim DS) sulfasalazine (Azulfidine) sulfazine (Azulfidine) sulfazine ec (Azulfidine) Tetracyclines demeclocycline oral (Demeclocycline HCl) doxycycline hyclate oral capsule 100 mg (Vibramycin) doxycycline hyclate 100 mg tab f/c (Doryx) doxycycline hyclate intravenous (Doxycycline Hyclate) doxycycline hyclate oral capsule 100 mg (Adoxa) doxycycline hyclate oral capsule 50 mg (Vibramycin) doxycycline hyclate oral tablet 100 mg, 50 (Adoxa) mg doxycycline hyclate oral tablet 0 mg (Doryx) doxycycline hyclate oral tablet,delayed (Doryx) release (dr/ec) 100 mg doxycycline hyclate oral tablet,delayed (Doryx) 3 release (dr/ec) 75 mg doxycycline mono 100 mg cap (Adoxa) doxycycline mono 100 mg tablet (Adoxa) doxycycline monohydrate oral capsule 50 (Adoxa) mg, 75 mg doxycycline monohydrate oral capsule,ir (Oracea) 3 & delay rel,biphase doxycycline monohydrate oral suspension (Vibramycin) for reconstitution doxycycline monohydrate oral tablet 50 (Adoxa) mg, 75 mg minocycline oral capsule (Minocin) 5
minocycline oral tablet (Minocycline HCl) ORACEA 3 SOLODYN ORAL TABLET 5 EXTENDED RELEASE 4 HR 105 MG, 115 MG, 55 MG, 65 MG, 80 MG tetracycline (Ala-Tet) 3 TYGACIL 3 VIBRAMYCIN ORAL CAPSULE 100 4 MG VIBRAMYCIN ORAL SUSPENSION 4 FOR RECONSTITUTION VIBRAMYCIN ORAL SYRUP 3 Anticancer Agents Anticancer Agents ABRAXANE 3 ADCETRIS 5 PA NSO AFINITOR 5 PA NSO AFINITOR DISPERZ 5 PA NSO ALIMTA INTRAVENOUS RECON 3 SOLN ALKERAN INTRAVENOUS 4 PA BvD anastrozole (Arimidex) ARIMIDEX 4 AROMASIN 4 ARRANON 3 ARZERRA 5 PA NSO AVASTIN 5 PA NSO azacitidine (Vidaza) 3 BELEODAQ 5 PA NSO bexarotene (Targretin) 5 bicalutamide (Casodex) BICNU 3 bleomycin (Bleomycin Sulfate) PA BvD BOSULIF 5 PA NSO BUSULFEX INTRAVENOUS 4 CAMPTOSAR INTRAVENOUS SOLUTION 4 6
CAPRELSA 5 PA NSO carboplatin intravenous solution (Carboplatin) CASODEX 4 cisplatin (Cisplatin) cladribine (Cladribine) PA BvD CLOLAR 5 AGE (Max 1 Years) COMETRIQ 5 PA NSO COSMEGEN 3 CYCLOPHOSPHAMIDE ORAL PA BvD CAPSULE cyclophosphamide oral tablet (Cyclophosphamide) PA BvD CYRAMZA 5 PA NSO cytarabine (Cytarabine) 3 PA BvD cytarabine (pf) injection recon soln (Cytarabine/PF) PA BvD cytarabine (pf) injection solution (Cytarabine/PF) 3 PA BvD dacarbazine intravenous recon soln (Dtic-Dome IV) DACOGEN 5 dactinomycin (Dactinomycin) 3 DAUNORUBICIN HCL 4 daunorubicin intravenous (Cerubidine) DAUNOXOME 4 decitabine (Dacogen) 5 DOCEFREZ 3 docetaxel intravenous solution (Taxotere) 3 DOXIL 4 PA BvD doxorubicin hcl intravenous recon soln 10 (Doxorubicin HCl) PA BvD mg doxorubicin hcl peg-liposomal intravenous (Doxil) suspension mg/ml doxorubicin intravenous solution mg/ml, (Doxorubicin HCl) PA BvD 50 mg/5 ml doxorubicin, peg-liposomal (Doxil) DROXIA 3 ELIGARD 3 ELLENCE 4 ELOXATIN INTRAVENOUS SOLUTION 4 7
EMCYT 3 epirubicin intravenous solution 50 mg/5 (Ellence) ml ERBITUX 3 PA NSO ERIVEDGE 5 PA NSO ERWINAZE 5 ETOPOPHOS 3 etoposide intravenous (Etoposide) exemestane (Aromasin) FARESTON 3 FARYDAK 5 PA NSO FASLODEX 3 PA NSO FEMARA 4 FIRMAGON KIT W DILUENT 4 SYRINGE floxuridine (FUDR) fludarabine (Fludara) PA BvD fluorouracil intravenous solution.5 (Fluorouracil) PA BvD gram/50 ml, 5 gram/100 ml, 500 mg/10 ml flutamide (Flutamide) FOLOTYN 3 GAZYVA 5 PA NSO gemcitabine intravenous recon soln 1 (Gemzar) gram GEMZAR 5 GILOTRIF 5 PA NSO GLEEVEC 5 PA NSO HALAVEN 5 PA NSO HERCEPTIN 5 PA BvD HEXALEN 3 HYCAMTIN INTRAVENOUS 4 HYDREA 4 hydroxyurea (Hydrea) IBRANCE 5 PA NSO ICLUSIG 5 PA NSO IDAMYCIN PFS 4 idarubicin (Idamycin Pfs) 8
IFEX INTRAVENOUS RECON SOLN 4 PA BvD ifosfamide intravenous recon soln (Ifex) PA BvD ifosfamide intravenous solution (Ifex) PA BvD IMBRUVICA 5 PA NSO INLYTA 5 PA NSO irinotecan intravenous solution (Camptosar) ISTODAX 5 PA NSO IXEMPRA 5 PA NSO JAKAFI 5 PA NSO JEVTANA 5 KADCYLA 5 PA NSO KEYTRUDA 5 PA NSO LENVIMA 5 PA NSO letrozole (Femara) LEUKERAN 3 leuprolide (Leuprolide Acetate) lomustine (Gleostine) 3 LUPRON DEPOT 3 LUPRON DEPOT (3 MONTH) 3 LUPRON DEPOT (4 MONTH) 3 LUPRON DEPOT (6 MONTH) 3 LUPRON DEPOT-PED 3 LUPRON DEPOT-PED (3 MONTH) 3 INTRAMUSCULAR SYRINGE KIT LYNPARZA 5 PA NSO LYSODREN 3 MATULANE 5 MEGACE 4 MEGACE ES 3 megestrol oral suspension 400 mg/10 ml (Megace Es) (40 mg/ml), 65 mg/5 ml megestrol oral tablet (Megestrol Acetate) MEKINIST 5 PA NSO melphalan hcl intravenous (Alkeran) 5 PA BvD mercaptopurine (Purinethol) methotrexate sodium (pf) injection recon soln (Methotrexate Sodium/PF) PA BvD 9
methotrexate sodium (pf) injection (Methotrexate Sodium) PA BvD solution methotrexate sodium injection (Methotrexate Sodium) PA BvD methotrexate sodium oral (Methotrexate Sodium) mitomycin intravenous recon soln (Mitomycin) PA BvD mitoxantrone (Mitoxantrone HCl) MUSTARGEN 3 NAVELBINE INTRAVENOUS 4 SOLUTION NEXAVAR 5 PA NSO NILANDRON 3 NIPENT 4 ONCASPAR 5 OPDIVO INTRAVENOUS SOLUTION 5 PA NSO 40 MG/4 ML oxaliplatin intravenous solution 100 (Eloxatin) mg/0 ml paclitaxel (Paclitaxel) pentostatin (Pentostatin) PERJETA 5 PA NSO PHOTOFRIN 5 POMALYST 5 PA NSO PROLEUKIN 5 PURINETHOL 4 PURIXAN 3 REVLIMID 5 LA RHEUMATREX 4 PA BvD RITUXAN 5 SOLTAMOX 4 SPRYCEL 5 PA NSO STIVARGA 5 PA NSO SUTENT 5 PA NSO SYLVANT 5 PA NSO SYNRIBO 5 PA NSO TABLOID 3 TAFINLAR 5 PA NSO tamoxifen (Tamoxifen Citrate) 30
TARCEVA 5 PA NSO TARGRETIN 5 TASIGNA 5 PA NSO TAXOTERE INTRAVENOUS 4 SOLUTION 0 MG/ML (1 ML), 80 MG/4 ML (0 MG/ML) teniposide (Teniposide) 5 thiotepa (Thiotepa) toposar intravenous (Etoposide) topotecan intravenous (Hycamtin) 3 TORISEL 5 PA NSO TREANDA INTRAVENOUS RECON 5 PA NSO SOLN TREANDA INTRAVENOUS 5 PA NSO SOLUTION TRELSTAR 3 tretinoin (chemotherapy) (Tretinoin) TREXALL 3 PA BvD TRISENOX 3 TYKERB 5 PA NSO VALSTAR 5 VECTIBIX 3 PA NSO VELCADE 5 VIDAZA 4 vinblastine intravenous (Vinblastine Sulfate) 3 PA BvD vincristine (Vincristine Sulfate) PA BvD vincristine sulfate intravenous solution 1 (Vincristine Sulfate) PA BvD mg/ml vinorelbine intravenous solution (Navelbine) VOTRIENT 5 PA NSO XALKORI 5 PA NSO XTANDI 5 PA NSO YERVOY 5 ZANOSAR 3 ZELBORAF 5 PA NSO ZOLADEX SUBCUTANEOUS IMPLANT 10.8 MG 5 31
ZOLADEX SUBCUTANEOUS 4 IMPLANT 3.6 MG ZOLINZA 5 PA NSO ZYDELIG 5 PA NSO ZYKADIA 5 PA NSO ZYTIGA 5 PA NSO Anticholinergic Agents Antimuscarinics/Antispasmodics atropine injection syringe 0.05 mg/ml (Atropine Sulfate) 3 atropine injection syringe 0.1 mg/ml (Atropine Sulfate) propantheline (Propantheline Bromide) 3 Anticonvulsants Anticonvulsants APTIOM 3 BANZEL 3 carbamazepine (Tegretol) carbamazepine oral capsule, er (Carbatrol) multiphase 1 hr carbamazepine oral suspension (Tegretol) carbamazepine oral tablet extended (Tegretol XR) release 1 hr carbamazepine oral tablet,chewable (Carbamazepine) CARBATROL 4 CELONTIN ORAL CAPSULE 300 MG 3 CEREBYX 4 DEPACON 4 DEPAKENE 4 DEPAKOTE 4 DEPAKOTE ER 4 DEPAKOTE SPRINKLES 4 DILANTIN CAPSULE 30 MG 4 DILANTIN EXTENDED 4 DILANTIN INFATABS 4 DILANTIN-15 4 divalproex oral capsule, sprinkle (Depakote Sprinkle) 3
divalproex oral tablet extended release 4 (Depakote ER) hr divalproex oral tablet,delayed release (Depakote) (dr/ec) EQUETRO 3 ethosuximide (Zarontin) felbamate (Felbatol) FELBATOL 4 fosphenytoin (Cerebyx) FYCOMPA ORAL TABLET 3 AGE (Min 1 Years) gabapentin oral capsule (Neurontin) gabapentin oral solution (Neurontin) gabapentin oral tablet 600 mg, 800 mg (Neurontin) GABITRIL 4 HORIZANT 4 KEPPRA ORAL 4 KEPPRA XR 4 LAMICTAL 4 LAMICTAL ODT 3 LAMICTAL ODT STARTER (BLUE) 4 LAMICTAL ODT STARTER (GREEN) 4 LAMICTAL ODT STARTER (ORANGE) 4 LAMICTAL STARTER (BLUE) KIT 4 LAMICTAL STARTER (GREEN) KIT 4 LAMICTAL STARTER (ORANGE) KIT 4 LAMICTAL XR 4 LAMICTAL XR STARTER (BLUE) 4 LAMICTAL XR STARTER (GREEN) 4 LAMICTAL XR STARTER (ORANGE) 4 lamotrigine oral tablet (Lamictal) lamotrigine oral tablet extended release (Lamictal XR) 4hr lamotrigine oral tablet, chewable (Lamictal) dispersible lamotrigine oral tablet,disintegrating (Lamictal Odt) lamotrigine oral tablets,dose pack 5 mg (35) (Lamictal (Blue)) 33
levetiracetam in nacl (iso-os) (Levetiracetam In Nacl (Iso-Os)) levetiracetam intravenous (Keppra) levetiracetam oral solution (Keppra) levetiracetam oral tablet (Keppra) levetiracetam oral tablet extended release (Keppra XR) 4 hr LYRICA 4 MYSOLINE 4 NEURONTIN 4 oxcarbazepine (Trileptal) OXTELLAR XR 4 PEGANONE 3 phenobarbital (Phenobarbital) PHENYTEK 4 phenytoin oral suspension 15 mg/5 ml (Dilantin-15) phenytoin oral (Dilantin) phenytoin sodium (Phenytoin Sodium) phenytoin sodium extended (Dilantin) POTIGA 3 QL (90 per 30 days); AGE (Min 18 Years) primidone (Mysoline) QUDEXY XR 4 SABRIL 4 TEGRETOL ORAL SUSPENSION 4 TEGRETOL ORAL TABLET 4 TEGRETOL XR 4 tiagabine (Gabitril) TOPAMAX 4 topiramate oral capsule, sprinkle (Topamax) topiramate oral capsule,sprinkle,er 4hr (Qudexy XR) 3 topiramate oral tablet (Topamax) TRILEPTAL 4 valproate sodium (Depacon) valproic acid (Depakene) valproic acid (as sodium salt) oral solution 50 mg/5 ml (Depakene) 34
VIMPAT INTRAVENOUS 3 VIMPAT ORAL SOLUTION 3 VIMPAT ORAL TABLET 3 ZARONTIN 4 ZONEGRAN ORAL CAPSULE 100 MG, 4 5 MG zonisamide (Zonegran) Antidementia Agents Antidementia Agents ARICEPT ODT 4 ARICEPT ORAL TABLET 10 MG, 5 MG 4 donepezil oral tablet 10 mg, 5 mg (Aricept) donepezil oral tablet,disintegrating (Aricept Odt) EXELON ORAL CAPSULE 4 EXELON ORAL SOLUTION 3 EXELON TRANSDERMAL 3 QL (30 per 30 days) galantamine oral capsule,ext rel. pellets (Razadyne ER) 4 hr galantamine oral solution (Razadyne) galantamine oral tablet (Razadyne) memantine (Namenda) PA; AGE (Min 7 Years) NAMENDA 3 PA; AGE (Min 7 Years) NAMENDA TITRATION PAK 3 PA; AGE (Min 7 Years) NAMENDA XR 4 PA; AGE (Min 7 Years) RAZADYNE 4 RAZADYNE ER 4 rivastigmine (Exelon) 3 rivastigmine tartrate (Exelon) Antidepressants Antidepressants amitriptyline (Amitriptyline HCl) 35
amitriptyline-chlordiazepoxide (Amitrip HCl/Chlordiazepoxide) amoxapine (Amoxapine) 3 ANAFRANIL 4 BRINTELLIX 4 ST bupropion hcl oral tablet (Wellbutrin SR) bupropion hcl oral tablet extended release (Wellbutrin SR), 150 mg bupropion hcl oral tablet extended release (Wellbutrin XL) 4 hr CELEXA ORAL TABLET 4 citalopram oral solution (Citalopram 1 Hydrobromide) citalopram oral tablet (Celexa) 1 clomipramine (Anafranil) CYMBALTA 4 desipramine oral (Norpramin) doxepin oral (Doxepin HCl) duloxetine (Cymbalta) EFFEXOR XR 4 EMSAM 3 escitalopram oxalate (Lexapro) FETZIMA 4 ST fluoxetine oral capsule (Prozac) 1 fluoxetine oral solution (Fluoxetine HCl) 1 fluoxetine oral tablet 10 mg, 0 mg (Fluoxetine HCl) 1 fluvoxamine oral tablet (Fluvoxamine Maleate) imipramine hcl (Tofranil) imipramine pamoate (Tofranil-Pm) LEXAPRO 4 maprotiline (Maprotiline HCl) 3 MARPLAN 3 mirtazapine (Remeron) NARDIL 4 nefazodone (Nefazodone HCl) NORPRAMIN 4 nortriptyline oral capsule (Pamelor) 36
nortriptyline oral solution (Nortriptyline HCl) 4 olanzapine-fluoxetine (Symbyax) PAMELOR 4 PARNATE 4 paroxetine hcl oral tablet (Paxil) 1 paroxetine hcl oral tablet extended release (Paxil CR) 4 hr PAXIL 4 perphenazine-amitriptyline (Perphenazine/Amitripty 3 line HCl) phenelzine (Nardil) PRISTIQ 4 protriptyline (Vivactil) PROZAC ORAL CAPSULE 4 REMERON 4 REMERON SOLTAB 4 sertraline oral concentrate (Zoloft) sertraline oral tablet (Zoloft) 1 SURMONTIL 4 SYMBYAX 4 TOFRANIL 4 TOFRANIL-PM 4 tranylcypromine (Parnate) trazodone (Trazodone HCl) venlafaxine oral capsule,extended release (Effexor XR) 4hr venlafaxine oral tablet (Venlafaxine HCl) VIIBRYD 4 VIVACTIL 4 WELLBUTRIN 4 WELLBUTRIN SR 4 WELLBUTRIN XL 4 ZOLOFT 4 Antidiabetic Agents Antidiabetic Agents, Miscellaneous acarbose (Precose) 37
ACTOPLUS MET 4 ACTOPLUS MET XR 4 ACTOS 4 AVANDAMET 4 AVANDARYL 4 AVANDIA 4 BYDUREON 4 QL (4 per 8 days) BYETTA 4 CYCLOSET 3 DUETACT 4 FARXIGA 4 ST GLUCOPHAGE 4 GLUCOPHAGE XR 4 GLUMETZA 4 GLYSET 4 GLYXAMBI 3 INVOKAMET 3 QL (60 per 30 days) INVOKANA 3 ST JANUMET 3 JANUMET XR 3 JANUVIA 3 JARDIANCE 3 ST JENTADUETO 3 metformin oral tablet (Glucophage) 1 metformin oral tablet extended release 4 (Glucophage XR) 1 hr nateglinide (Starlix) pioglitazone (Actos) pioglitazone-glimepiride (Duetact) pioglitazone-metformin (Actoplus Met) PRANDIMET 4 PRANDIN 4 PRECOSE 4 repaglinide (Prandin) RIOMET 3 STARLIX 4 38
SYMLINPEN 10 3 SYMLINPEN 60 3 SYNJARDY 3 QL (60 per 30 days) TANZEUM 4 TRADJENTA 3 TRULICITY 3 VICTOZA 3 XIGDUO XR ORAL TABLET, IR & ER, 4 QL (30 per 30 days) BIPHASIC 4HR 10-1,000 MG, 10-500 MG, 5-500 MG XIGDUO XR ORAL TABLET, IR & ER, 4 QL (60 per 30 days) BIPHASIC 4HR 5-1,000 MG Insulins AFREZZA INHALATION CARTRIDGE, 4 W/INHALATION DEVICE 4 UNIT, 4 UNIT (30)/ 8 UNIT (60), 4 UNIT (60)/ 8 UNIT (30) APIDRA 4 APIDRA SOLOSTAR 4 HUMALOG 3 HUMALOG KWIKPEN 3 HUMALOG MIX 50-50 3 HUMALOG MIX 50-50 KWIKPEN 3 HUMALOG MIX 75-5 3 HUMALOG MIX 75-5 KWIKPEN 3 HUMULIN 70/30 3 HUMULIN 70/30 KWIKPEN 3 HUMULIN N 3 HUMULIN N KWIKPEN 3 HUMULIN R 3 HUMULIN R U-500 3 (CONCENTRATED) LANTUS 3 LANTUS SOLOSTAR 3 LEVEMIR 3 LEVEMIR FLEXTOUCH 3 NOVOLIN 70/30 3 39
NOVOLIN N 3 NOVOLIN R 3 NOVOLOG 3 NOVOLOG FLEXPEN 3 NOVOLOG MIX 70-30 3 NOVOLOG MIX 70-30 FLEXPEN 3 NOVOLOG PENFILL 3 TOUJEO SOLOSTAR 4 Sulfonylureas AMARYL 4 DIABETA 4 glimepiride (Amaryl) 1 glipizide oral tablet (Glucotrol) glipizide oral tablet extended release 4hr (Glucotrol XL) glipizide-metformin (Glipizide/Metformin HCl) GLUCOTROL 4 GLUCOTROL XL 4 GLUCOVANCE 4 glyburide (Glyburide) glyburide micronized (Glynase) glyburide-metformin (Glucovance) GLYNASE 4 tolazamide (Tolazamide) tolbutamide (Tolbutamide) 3 Antifungals Antifungals ABELCET 3 PA BvD AMBISOME 3 PA BvD amphotericin b (Amphotericin B) PA BvD ANCOBON 5 CANCIDAS 5 ciclopirox topical cream (Ciclodan) ciclopirox topical gel (Loprox) ciclopirox topical shampoo (Loprox) ciclopirox topical solution (Penlac) 40
ciclopirox topical suspension (Ciclopirox Olamine) ciclopirox-ure-camph-menth-euc (Ciclodan) clotrimazole 1% cream (otc) (Clotrimazole) clotrimazole mucous membrane (Clotrimazole) clotrimazole topical cream 1 % (Mycelex) clotrimazole topical solution (Lotrimin) clotrimazole-betamethasone topical cream (Lotrisone) clotrimazole-betamethasone topical lotion (Clotrimazole/Betameth asone Dip) DIFLUCAN 4 econazole topical (Econazole Nitrate) ERAXIS(WATER DILUENT) 3 INTRAVENOUS RECON SOLN ERTACZO 4 EXELDERM 3 fluconazole (Diflucan) fluconazole in dextrose(iso-o) intravenous (Fluconazole In piggyback Nacl,Iso-Osm) fluconazole in nacl (iso-osm) intravenous (Fluconazole In piggyback Nacl,Iso-Osm) flucytosine (Ancobon) griseofulvin microsize oral suspension (Griseofulvin, Microsize) griseofulvin microsize oral tablet (Grifulvin V) griseofulvin ultramicrosize (Gris-Peg) GRIS-PEG (ULTRAMICROSIZE) 4 itraconazole (Sporanox) ketoconazole oral (Ketoconazole) ketoconazole topical cream (Ketoconazole) ketoconazole topical shampoo (Nizoral) LAMISIL 4 LOPROX TOPICAL SHAMPOO 4 LOTRISONE TOPICAL CREAM 4 MENTAX 3 miconazole nitrate vaginal suppository 00 mg (Monistat 3) 3 41