Transcription

1 CENTERS PLAN FOR HEALTHY LIVING 中央計劃管理式長期護理護士服務 CENTERS PLAN ADVANTAGE CARE (HMO) CENTERS PLAN CARE COMPLETE (MMP) Centers Plan for FIDA Care Complete Medicare-Medicaid計劃 2016年承保藥物清單 處方一覽表 本處方一覽表更新於7/1/2016 如果您有任何疑問 請致電Centers Plan for FIDA Care Complete 電話是 每週七天 每天早8點至晚8點 TTY使用者請致電 此電話 免費 We CARE... about your CARE H3018_16702_CY2016_Drug_List_CH

2

3 Centers Plan for FIDA Care Complete (Medicare-Medicaid 計劃 ) 2016 年承保藥物清單 本處方一覽表更新於 1/7/2016 如果您有任何疑問, 請致電 Centers Plan for FIDA Care Complete, 電話是 , 每週七天, 每天早 8 點至晚 8 點 TTY 使用者請致電 此電話免費 更多資訊, 請瀏覽 生效日期 年 1 月 1 日最後更新 :1/7/2016 處方一覽表 ID:16507, 第 16 版本 如果您有任何疑問, 請致電 Centers Plan for FIDA Care Complete, 電話是 , (TTY/TDD iii

4 如果您有任何疑問, 請致電 Centers Plan for FIDA Care Complete, 電話是 , (TTY/TDD iv

5 Centers Plan for FIDA Care Complete 2016 年承保藥物清單 ( 處方一覽表 ) 這是會員透過 Centers Plan for FIDA Care Complete 可獲得的一份藥物清單 Centers Plan for FIDA Care Complete (Medicare-Medicaid 計劃 ) 是由 Medicare 與紐約州衛生部 (Medicaid) 共同簽署的一份統籌保健計劃, 旨在透過 Fully Integrated Duals Advantage (FIDA) 計劃展示為會員同時提供 Medicare 和 Medicaid 的福利 承保藥物清單及 / 或藥店和醫療提供者網絡在全年內可能發生變化 在我們做出影響到您的修改之前, 我們將 向您傳送通知 福利可能在每年的 1 月 1 日發生變化 您可隨時線上檢視 Centers Plan for FIDA Care Complete 的最新承保藥物清單, 網址為 或者致電 Centers Plan for FIDA Care Complete 會員服務部, 電話是 限制和約束可能適用 有關詳細諮詢, 請致電 Centers Plan for FIDA Care Complete 會員服務部, 或閱讀 Centers Plan for FIDA Care Complete 會員手冊 任何承保藥物無自付費用 您可以其他格式 ( 大字型印刷 布拉耶點字法或音訊 ) 免費獲得此資訊 請在我們的工作時間內致電 ,TTY/TDD 使用者可致電 , 我們的工作時間是 : 每週 7 天 每天早 8 點至晚 8 點 此電話免費 You can get this information for free in other languages. Call , and TTY/TDD users call , during our hours of operation: 8 am to 8pm, seven days a week. The call is free. 您可以免費獲得我們用其他語言提供的該資訊 請在我們的工作時間內致電 ,TTY/TDD 使用者可致電 , 我們的工作時間是 : 每週 7 天 每天早 8 點至晚 8 點 致電是免費的 Ou ka jwenn enfòmasyon sa a gratis nan lòt lang yo. Rele , e itilizatè TTY/TDD yo ka rele , pandan lè fonksyonman: 8 am a 8pm, sèt jou pa semèn. Apèl la gratis. Queste informazioni sono disponibili gratuitamente in altre lingue. Chiamare x il numero e per gli utenti TTY/TDD negli orari di lavoro: dalle 08:00 alle 20:00, 7 giorni su 7. La chiamata è gratuita. 이정보를다른언어로무료로받아보실수있습니다 번으로전화주시고, TTY/TDD 사용자들은 번으로영업시간동안전화주십시오 : 오전 8시 ~ 오후 8시, 매주 7일간본전화료는무료입니다 如果您有任何疑問, 請致電 Centers Plan for FIDA Care Complete, 電話是 , (TTY/TDD v

6 Вы можете получить эту информацию бесплатно на других языках. Звоните по номеру , пользователи телетайпа/текстового телефона по номеру , во время наших часов работы: 08:00 20:00, семь дней в неделю. Звонок является бесплатным. Puede obtener esta información en otros idiomas de manera gratuita. Llame al , y los usuarios de TTY/TDD pueden llamar al , durante nuestras horas de operación: 8 a.m. a 8 p.m., los siete días de la semana. La llamada es gratuita. The State of New York has created a participant ombudsman program called the Independent Consumer Advocacy Network (ICAN) to provide Participants free, confidential assistance on any services offered by Centers Plan for FIDA Care Complete. ICAN may be reached toll-free at or online at icannys.org. 如果您有任何疑問, 請致電 Centers Plan for FIDA Care Complete, 電話是 , (TTY/TDD vi

7 常見問題 (FAQ) 如果您對於承保藥物清單有任何疑問, 請在此尋找答案 您可以閱讀所有常見問題 (FAQ) 以瞭解更多資訊, 或 尋找一個問題和答案 1. 承保藥物清單上包含哪些處方藥? ( 我們將承保藥物清單簡稱為藥物清單 ) 承保藥物清單 3 頁開始所列的各藥物為 Centers Plan for FIDA Care Complete 承保藥物 這些藥物均可在我們網 絡藥房內獲得 如果藥房與我們簽訂合作協定並向您提供服務, 則藥房在我們網絡內 我們把這些藥房稱為 網絡藥房 Centers Plan for FIDA Care Complete 將承保藥物清單上的所有藥物, 如果 : 您的醫生或其他開藥醫生表示您需要這些藥物以康復或維持健康, 藥物對治療您的病症具有醫療必要性, 以及 您在 Centers Plan for FIDA Care Complete 網絡藥房內配藥 Centers Plan for FIDA Care Complete 可能在獲得某些藥物上需要採取其他步驟 ( 請檢視以下第 5 個問題 ) 在一些情況下, 您在獲得藥物之前可能需要做其他事, 例如先嘗試其他藥物 查看最新承保藥物清單, 您可瀏覽我們網站 或致電會員服務部, 電話是 如果您有任何疑問, 請致電 Centers Plan for FIDA Care Complete, 電話是 , (TTY/TDD vii

8 2. 藥物清單是否會變更? 是 一年當中 Centers Plan for FIDA Care Complete 可能會新增或移除藥物清單中的某些藥物 通常, 只有在以下情況下藥物清單會有所變更 : 現在出現了一種新藥物, 其藥效與藥物清單上的藥物效果相同, 或者 我們瞭解到一種藥物並不安全 我們可能也會變更我們的藥物規則 例如, 我們可以 : 決定一種藥物是否需要事先核准 ( 事先核准是指在您可獲得藥物之前, 您需獲得 Centers Plan for FIDA Care Complete 或您的跨學科小組 (IDT) 的許可 ) 新增或變更您可獲得的藥量 ( 稱為 數量限制 ) 增加或變更藥物逐步治療限制 ( 逐步治療指在我們會承保其他藥物之前, 您必須先試用其他藥物 ) ( 有關這些藥物規則的更多資訊, 請參閱第 ix 頁 ) 一旦您正在服用的藥物從藥物清單上除名, 我們將告知您 一旦我們變更藥物的承保規則, 我們將告知您 以下第 3 4 以及 7 個問題就藥物清單變更會發生什麼的問題有更多闡述 您可總是線上查看 Centers Plan for FIDA Care Complete 的最新藥物清單, 網址是 您可致電會員服務部, 瞭解現行版本的藥物清單, 電話是 如果現在出現了一種與藥物清單上藥物效果相同且價格更低的新藥, 會發生什麼? 如果現出現了一種與藥物清單上藥物效果相同的新藥 : 您的藥劑師可能在您下次配藥時向您提供較便宜的藥物 如果您和您的提供者認定便宜的藥物對您並不適用, 您的提供者可讓藥劑師繼續向您提供您正在服用的藥物 Centers Plan for FIDA Care Complete 可能決定將較貴的藥物從藥物清單上移除 如果我們因為新藥具有相同藥效而將您在服用的一種藥物從藥物清單上移除, 我們將在藥物從藥物清單上移除前至少 60 天前或在您要求續配藥時通知您 隨後您可在藥物清單變更前購買 60 天的藥 如果我們決定將一種藥物從藥物清單上移除, 我們將在藥物從藥物清單上移除前至少 60 天以書面形式以及 / 或者電話方式通知您 如果您有任何疑問, 請致電 Centers Plan for FIDA Care Complete, 電話是 , (TTY/TDD viii

9 4. 如果我們發現一種藥物並不安全, 會發生什麼? 如果食品和藥品管理局 (FDA) 表示您服用的藥物並不安全, 我們會立即將此藥從藥物清單上移除 我們亦將發函通知您這種不安全的藥物已從藥物清單上移除 在接收此信函以及 / 或者電話後, 請致電您的醫生並且請他或她開立一種替代藥 5. 藥物承保是否有約束或限制? 或者為取得某些藥品是否要求採取一些措施? 是, 一些藥物有承保規則或限制您所能取得的藥量 一些情況下, 您 您的醫生或其他開藥醫生在取得藥物之前必須先做某件事情 例如 : 事先核准 ( 或事先核准 ): 對於一些藥品, 您或您的醫生或其他開藥醫生必須在您配藥之前獲得 Centers Plan for FIDA Care Complete 或您的跨學科小組 (IDT) 的核准 若您未獲得核准,Centers Plan for FIDA Care Complete 可能不承保此藥品 數量限制 : 有時,Centers Plan for FIDA Care Complete 限制您能獲得的藥量 階段治療 : 有時 Centers Plan for FIDA Care Complete 要求您採取逐步治療 這意味著在應對您的醫療病症時, 您將必須按一定順序試用藥物 在我們會承保其他藥物之前, 您可能需要先試用其他藥物 如果您的醫生認為第一種藥物對您並不適用, 之後我們將承保第二種藥物 瞭解您的藥物是否有其他額外要求或限制, 您可從 xvi 頁開始查看各表格 您亦可透過瀏覽我們網站瞭解更多資訊, 網址為 我們發佈線上文件, 解釋我們的事先核准和逐步治療限制 您也可以要求我們向您傳送一份副本 您可對這些限制要求進行 例外處理 瞭解例外處理的更多資訊, 請查看第 11 個問題 如果您在護理設施或其他長期護理設施內, 並且需要藥物清單外的一種藥物, 或者如果您取得所需藥物並不方便, 我們可提供協助 我們將承保一次 31 天急救藥物用量 ( 除非您處方箋上註明的天數較少 ), 不論您是否為 Centers Plan for FIDA Care Complete 新會員 這將給您與您的醫生或其他開藥醫生商討留出時間 他或她可説明您決定是否採用藥物清單上的相似藥或是否需要要求例外處理 瞭解例外處理的更多資訊, 請查看第 11 個問題 6. 您將如何得知您想要的藥物是否有限制或取得藥物是否需要採取行動? 第 18 頁的承保藥物清單有一張柱狀圖, 標題是 必要行動 約束或使用限制 如果您有任何疑問, 請致電 Centers Plan for FIDA Care Complete, 電話是 , (TTY/TDD ix

10 7. 如果我們變更了藥物承保方式的規則, 會發生什麼? 例如, 如果我們增加了一種藥物的事先核准 ( 核准 ) 數量限制 以及 / 或者逐步治療 我將向您告知如果我們增加藥物的事先核准 數量限制, 以及 / 或者逐步治療限制 我們將在增加限制或在您要 求下次續配藥之前至少提前 60 天通知您 隨後您可在藥物清單變更前購買 60 天的藥 這將給您與您的醫生或其 他開藥醫生商討下一步操作的時間 8. 您如何在藥品清單上尋找一種藥物? 尋找藥物有兩個方法 : 您可按字母尋找 ( 如果您知道藥物名稱如何拼字 ), 或者 您可按醫療病症查詢 按字母查詢, 請翻至 I-1 頁檢視字母清單部分 然後在清單上尋找您的藥物的名稱 按醫療病症查詢, 請翻至第 18 頁查看 按醫療病症排列藥物清單 這一小節中的藥品根據它們用於治療的醫療狀況類型劃分為不同種類 例如, 如果您心臟有問題, 您應該尋找心血管藥物類別 您可在那裏找到應對心臟問題的藥物 9. 如果您想服用的藥品未在藥物清單上, 該怎麼辦? 如果您在藥物清單上並未看到您的藥物, 請致電 , 連絡會員服務部詢問情況 如果您瞭解到 Centers Plan for FIDA Care Complete 將不會對藥物進行承保, 您可採取以下一項操作 : 向會員服務部索取一份您想要服用的藥物清單 然後將清單給您的醫生或其他開藥醫生看 他或她可向您開立類似您想要服用且在藥物清單上的藥物 或 您可要求計劃或您的跨學科小組 (IDT) 作例外處理, 承保您的藥物 瞭解例外處理的更多資訊, 請查看第 11 個問題 如果您有任何疑問, 請致電 Centers Plan for FIDA Care Complete, 電話是 , (TTY/TDD x

11 10. 如果您新加入 Centers Plan for FIDA Care Complete, 並且在藥物清單上找不到或很難找到您的藥物, 您該怎麼辦? 我們竭誠相助 我們必須按需要承保在您成為 Centers Plan for FIDA Care Complete 會員最初 90 天的藥物暫時用 量 這將給您與您的醫生或其他開藥醫生商討留出時間 他或她可説明您決定是否採用藥物清單上的相似藥或是否需要要求例外處理 我們將向您承保最多 90 天的暫時藥物用量, 如果 : 您在服用的藥物並不在我們的藥物清單上, 或者 健康計劃規則並不能讓您獲得您的開藥醫生開立的藥量, 或者 藥物需要 Centers Plan for FIDA Care Complete 或您的跨學科小組 (IDT) 事先核准, 或者 您所服用的藥物為逐步治療限制的一部分 如果您在護理設施或其他長期護理設施內, 您可獲得的再次配藥藥量為至多 98 天 在您的計劃的最初 90 天期間, 您可以多次續配藥 這給予您的開藥醫生留出時間將您的藥物改為藥物清單上的藥物或者要求例外處理 如果下列一個護理等級變更情況適用於您, 您可能有資格獲得您目前正在服用的藥物的過渡用量 : 如果您從醫院或其他機構轉到長期護理機構 如果您離開長期護理機構回家 如果您出院回家 如果您從專業護理機構出院 如果您的狀態從安寧照護變為非安寧照護 如果您從精神病院出院並且具有個性化藥物計劃 以上所列的護理等級變更只是您可能有資格獲得過渡用量的一些原因, 有關更多資訊, 請連絡會員服務 部, 電話為 TTY 使用者請致電 代表工作時間為每週七天, 早 8 點至晚 8 點 如果您有任何疑問, 請致電 Centers Plan for FIDA Care Complete, 電話是 , (TTY/TDD xi

12 11. 您是否能夠要求例外處理以承保您的藥物? 是 您可要求 Centers Plan for FIDA Care Complete 或您的跨學科小組 (IDT) 作例外處理, 承保未在藥物清單上的藥物 您亦可要求 Centers Plan for FIDA Care Complete 或您的跨學科小組 (IDT) 變更藥物規則 例如,Centers Plan for FIDA Care Complete 可能限制了我們將承保的藥物劑量 如果您的藥物有限制, 您可要求我們或您的 IDT 變更限制或承保更多劑量 其他範例 : 您可要求我們或您的跨學科小組 (IDT) 擯棄逐步治療限制或事先核准要求 12. 獲得例外處理需要多少時間? 首先,Centers Plan for FIDA Care Complete 或您的跨學科小組 (IDT) 必須收到來自您的開藥醫生支援您例外處理要求的聲明 您將在我們收到聲明後 72 小時內獲得我們對於您的例外處理要求的決定 如果您或您的開藥醫生認為如果 72 小時的必須等待可能有損您的健康, 您可要求加快例外處理 這就是快速決定 如果您的開藥醫生支援您的要求, 您將在我們收到您的開藥醫生的支援性聲明後 24 小時內獲得決定 13. 您如何要求進行例外處理? 要求例外處理, 您可致電您的保健管理員 您的保健管理員將協助您和您的提供者協助您要求例外處理 14. 什麼是普通藥物? 普通藥物成分與品牌藥物相同 它們通常比品牌藥價格更低且藥名並不被熟知 普通藥獲食品與藥品管理局 (FDA) 核准 Centers Plan for FIDA Care Complete 承保品牌藥品和普通藥品 15. 什麼是非處方 (OTC) 藥物? OTC 表示 非處方藥 當非處方藥是由您的提供者開立時,Centers Plan for FIDA Care Complete 將承保這些非處方藥 您可閱讀 Centers Plan for FIDA Care Complete 藥物清單, 瞭解哪些非處方藥在承保之列 如果您有任何疑問, 請致電 Centers Plan for FIDA Care Complete, 電話是 , (TTY/TDD xii

13 16. Centers Plan for FIDA Care Complete 是否承保非處方藥非藥劑產品? 當非處方非藥劑產品是由您的提供者開立時,Centers Plan for FIDA Care Complete 將承保這些產品 非處方非 藥劑產品包括諸如酒精棉簽和紗布墊等物品 您可閱讀 Centers Plan for FIDA Care Complete 藥物清單, 瞭解哪些非處方非藥劑產品在承保之列 Centers Plan for FIDA Care Complete 同樣為會員提供每個月 $25 的補充非處方藥 (OTC) 福利, 以用於 Medicare 和 Medicaid 不承保的非處方藥清單上的項目 當月未用完的餘額不可轉入下個月 請參閱 會員手冊 第 4 章瞭解更多資訊, 或者致電會員服務部 : (TTY 使用者請致電 ), 工作時間是每週 7 天, 每天早 8 點至晚 8 點 17. 什麼是您的自付費用? 藥物清單上的藥物您無需支付自付費用 18. 什麼是藥物層級? 層級就是藥物組 所有計劃藥物清單上的藥物均為四 (4) 層級之一 您無需支付任一一層的藥物費用 第 1 層級為 Medicare 承保的普通藥物 這是最低一級 第 2 層級為 Medicare 承保的品牌藥物和專用藥物 第 3 層級為 Medicaid 承保的非 D 部分藥物 第 4 層級為 Medicaid 承保的非處方 (OTC) 藥 這是最高一級 如果您有任何疑問, 請致電 Centers Plan for FIDA Care Complete, 電話是 , (TTY/TDD xiii

14 承保藥物清單 18 頁開始的承保藥物清單向您提供 Centers Plan for FIDA Care Complete 承保的藥物資訊 如果您在藥物清單上找藥物有困難, 請翻至 I-1 頁, 開始閱讀索引部分 圖示第一柱列出了藥物名稱 品牌藥名稱大寫 ( 如 :NORTHERA), 普通藥為斜體小寫 ( 如 :clonidine) 必要行動 約束或使用限制柱狀圖向您說明您藥物的 Centers Plan for FIDA Care Complete 承保規則 文件文字部分可能會有以下使用管理縮寫承保註釋縮寫 縮寫說明解釋 使用管理約束 PA PA-HRM PA NSO 事前核准約束事前核准約束用於 B 部分及 D 部分判定 B 部分及 D 部分判定的高危藥品 B 部分及 D 部分判定的僅限於紐約州 在您獲得此藥配藥之前, 您 ( 或者您的醫生 ) 必須首先獲得 Centers Plan for FIDA Care Complete 的事前核准 若您未獲得核准,Centers Plan for FIDA Care Complete 可能不承保此藥品 在 Medicare B 部分或者 D 部分承保下, 該藥物可能符合支付資格 您 ( 或您的醫生 ) 必須在您獲得此藥配藥之前取得 Centers Plan for FIDA Care Complete 關於此藥在 Medicare D 部分承保下的事先核准 若您未獲得核准,Centers Plan for FIDA Care Complete 可能不承保此藥品 本藥品已經被 CMS 視為潛在有害藥品, 因此針對 Medicare65 周歲及以上受益者是高危藥品 65 周歲或以上參與者必須在您獲得此藥配藥之前首先獲得 Centers Plan for FIDA Care Complete 的事前核准 若您未獲得核准,Centers Plan for FIDA Care Complete 可能不承保此藥品 如果您是名新參與者或者如果您之前未曾服用過此藥, 您 ( 或您的醫生 ) 必須在您為此藥配藥之前獲得 Centers Plan for FIDA Care Complete 的事先核准 若您未獲得核准,Centers Plan for FIDA Care Complete 可能不承保此藥品 如果您有任何疑問, 請致電 Centers Plan for FIDA Care Complete, 電話是 , (TTY/TDD xiv

15 縮寫說明解釋 QL ST 數量限制約束 逐步治療約束 Centers Plan for FIDA Care Complete 限制每份處方或某指定期間所承保的藥量 在 Centers Plan for FIDA Care Complete 將為此藥提供承保之前, 您必須首先使用其他藥物以應對您的醫療病症 只有當其他藥物對您並不起作用的情況下, 此藥才可能獲得承保 如果您有任何疑問, 請致電 Centers Plan for FIDA Care Complete, 電話是 , (TTY/TDD xv

16 文件文字部分可能會有以下承保註釋縮寫 其他特殊承保要求 縮寫說明解釋 LA NM 獲得管道有限的藥物 非來信訂購藥品 該處方可能只能在一些藥房配藥 欲瞭解更多訊息, 請參閱您的 藥房名錄 或致電會員服務部 : , 工作時間為每週七天, 早 8 點至晚 8 點 TTY/TDD 使用者應致電 您可能在您的處方表中按折扣藥品分擔費用郵購多數藥品的 1 個月以上供給量 透過郵購福利無法獲得的藥品在您處方一覽表中的要求 / 限制一欄中以 NM 標註 * 不是 D 部分藥物 這種藥是一份非 D 部分藥物或一份非處方藥物或產品 注意 : 藥品邊上的 (*) 表示此藥並非 D 部分藥品 這些藥品有不同的上訴規則 上訴即要求我們審核並且在您認為存在錯誤的情況下變更承保決定的正式方式 例如,Centers Plan for FIDA Care Complete 或您的跨學科小組 (IDT) 可能決定您想要的藥物並未或不再受到 Medicare or Medicaid 承保 如果您或您的醫生或其他開藥醫生對該決定有異議, 您可提起上訴 瞭解如何上訴的指令, 請致電會員服務部, 電話是 或者致電獨立消費者宣導組織 (ICAN), 電話是 您亦可閱讀會員手冊, 瞭解如何對決定提起上訴 如果您有任何疑問, 請致電 Centers Plan for FIDA Care Complete, 電話是 , (TTY/TDD xvi

17 Table of Contents Analgesics... 3 Anesthetics Anti-Addiction/Substance Abuse Treatment Agents Antianxiety Agents Antibacterials Anticancer Agents Anticholinergic Agents Anticonvulsants Antidementia Agents Antidepressants Antidiabetic Agents Antifungals Antihistamines Anti-Infectives (Skin And Mucous Membrane) Antimigraine Agents Antimycobacterials Antinausea Agents Antiparasite Agents Antiparkinsonian Agents Antipsychotic Agents Antivirals (Systemic) Blood Products/Modifiers/Volume Expanders Caloric Agents

18 Cardiovascular Agents Central Nervous System Agents Contraceptives Cough And Cold Products Dental And Oral Agents Dermatological Agents Devices Disinfectants (For Non-Dermatologic Use) Enzyme Replacement/Modifiers Eye, Ear, Nose, Throat Agents Gastrointestinal Agents Genitourinary Agents Heavy Metal Antagonists Hormonal Agents, Stimulant/Replacement/Modifying Immunological Agents Inflammatory Bowel Disease Agents Irrigating Solutions Metabolic Bone Disease Agents Miscellaneous Therapeutic Agents Ophthalmic Agents Replacement Preparations Respiratory Tract Agents Skeletal Muscle Relaxants Sleep Disorder Agents Vasodilating Agents Vitamins And Minerals

19 Analgesics Analgesics, Miscellaneous acephen 120 mg suppository outer 120 mg * acephen 325 mg suppository outer 325 mg * acephen 650 mg suppository outer 650 mg * acetaminophen 120 mg suppos outer 120 mg * acetaminophen 160 mg/5 ml elx 160 mg/5 ml * acetaminophen 650 mg suppos 650 mg * acetaminophen 80 mg rapid tab children's 80 mg * acetaminophen 80 mg/0.8 ml drp infants 80 mg/0.8 ml * acetaminophen-codeine 120 mg-12 mg/5 ml solution mg/5 ml acetaminophen-codeine oral solution 300 mg-30 mg /12.5 ml acetaminophen-codeine oral tablet mg, mg acetaminophen-codeine oral tablet mg ALLZITAL ORAL TABLET MG ascomp with codeine oral capsule mg BELBUCA BUCCAL FILM 150 MCG, 300 MCG, 450 MCG, 600 MCG, 75 MCG, 750 MCG, 900 MCG buprenorphine hcl injection syringe 0.3 mg/ml butalbital compound w/codeine oral capsule mg (Acetaminophen) (Acetaminophen) (Acetaminophen) (Acetaminophen) (Acetaminophen) (Acetaminophen) (Acetaminophen) (Acetaminophen) (Acetaminophen with Codeine) (Acetaminophen with Codeine) (Tylenol-Codeine No.3) (Tylenol-Codeine No.3) (Fiorinal with Codeine #3) (Buprenorphine HCl) (Fiorinal with Codeine #3) QL (360 per 30 days) QL (30 per 30 days) QL (30 per 30 days) QL (30 per 30 days) QL (240 per 30 days) QL (30 per 30 days) QL (30 per 30 days) QL (30 per 30 days) QL (2700 per 30 days) QL (2700 per 30 days) QL (360 per 30 days) QL (180 per 30 days) PA-HRM; QL (180 per 30 days) ST; QL (60 per 30 days) PA-HRM; QL (180 per 30 days) 3

20 butalbital-acetaminop-caf-cod oral capsule mg, mg butalbital-acetaminophen oral tablet mg butalbital-acetaminophen-caff oral capsule mg butalbital-acetaminophen-caff oral tablet mg butalbital-aspirin-caffeine oral capsule mg BUTRANS TRANSDERMAL PATCH WEEKLY 10 MCG/HOUR, 15 MCG/HOUR, 20 MCG/HOUR, 5 MCG/HOUR, 7.5 MCG/HOUR (Fioricet with Codeine) (Tencon) (Esgic) (Esgic) (Fiorinal) capacet oral capsule mg (Esgic) child non-aspirin 160 mg/5 ml children's 160 mg/5 ml * child pain & fever 160 mg/5 ml a/f,gluten/f,cherry 160 mg/5 ml * child tactinal 80 mg tab chw 80 mg * children's mapap 80 mg rapid 80 mg * children's silapap elixir 160 mg/5 ml * codeine sulfate oral tablet 15 mg, 30 mg, 60 mg cvs child non-asa 80 mg tb chw 80 mg * cvs non-aspirin jr tab chew 160 mg * cvs pain relief adult liquid 500 mg/15 ml * endocet oral tablet mg, mg, mg, mg (Acetaminophen) (Infants' Tylenol) (Acetaminophen) (Acetaminophen) (Tylenol Sore Throat) (Codeine Sulfate) (Acetaminophen) (Acetaminophen) (Tylenol Sore Throat) (Xolox) PA-HRM; QL (180 per 30 days) PA-HRM; QL (180 per 30 days) PA-HRM; QL (180 per 30 days) PA-HRM; QL (180 per 30 days) PA-HRM; QL (180 per 30 days) QL (4 per 28 days) PA-HRM; QL (180 per 30 days) QL (240 per 30 days) QL (240 per 30 days) QL (30 per 30 days) QL (30 per 30 days) QL (240 per 30 days) QL (180 per 30 days) QL (30 per 30 days) QL (30 per 30 days) QL (120 per 30 days) QL (360 per 30 days) 4

21 endodan oral tablet mg (Percodan) QL (360 per 30 days) fentanyl citrate buccal lozenge on a handle 1,200 mcg, 1,600 mcg, 200 (Actiq) PA; QL (120 per 30 days) mcg, 400 mcg, 600 mcg, 800 mcg fentanyl transdermal patch 72 hour 100 mcg/hr, 12 mcg/hr, 25 mcg/hr, 37.5 mcg/hour, 50 mcg/hr, 62.5 mcg/hour, 75 mcg/hr, 87.5 mcg/hour (Duragesic) QL (10 per 30 days) feverall 120 mg suppository QL (30 per 30 days) (Acetaminophen) children's, outer 120 mg * feverall 325 mg suppository junior QL (30 per 30 days) (Acetaminophen) str, outer 325 mg * feverall 650 mg suppository adult, QL (30 per 30 days) (Acetaminophen) outer 650 mg * hydrocodone-acetaminophen oral solution mg/15 ml(15 ml), mg/5 ml, mg/15 ml hydrocodone-acetaminophen oral tablet mg, mg, mg hydrocodone-acetaminophen oral tablet mg, mg, mg, mg hydrocodone-ibuprofen oral tablet mg, mg, mg, mg hydromorphone (pf) injection solution 10 mg/ml hydromorphone (pf) injection solution 4 mg/ml hydromorphone injection solution 2 mg/ml hydromorphone injection syringe 2 mg/ml (Hycet) (Norco) (Norco) (Ibudone) (Dilaudid-HP) (Dilaudid) QL (2700 per 30 days) (includes Vicodin, Vicodin ES and Vicodin HP); QL (390 per 30 days) QL (360 per 30 days) QL (150 per 30 days) (Hydromorphone HCl) (Hydromorphone HCl) hydromorphone oral liquid 1 mg/ml (Dilaudid) QL (1200 per 30 days) hydromorphone oral tablet 2 mg, 4 QL (180 per 30 days) (Dilaudid) mg 5

22 hydromorphone oral tablet 8 mg (Dilaudid) QL (240 per 30 days) HYSINGLA ER ORAL TABLET,ORAL ONLY,EXT.REL.24 HR 100 MG, 120 MG, 20 MG, 30 MG, 40 MG, 60 MG, 80 MG QL (30 per 30 days) junior mapap 160 mg rapid tab 160 QL (30 per 30 days) (Acetaminophen) mg * LAZANDA NASAL SPRAY,NON- AEROSOL 100 MCG/SPRAY, 400 MCG/SPRAY PA; QL (30 per 30 days) lorcet (hydrocodone) oral tablet 5- QL (360 per 30 days) (Norco) 325 mg lorcet hd oral tablet mg (Norco) QL (360 per 30 days) lorcet plus oral tablet mg (Norco) QL (360 per 30 days) mapap 160 mg/5 ml liquid 160 mg/5 QL (240 per 30 days) ml * mapap 160 mg/5 ml suspension 160 QL (240 per 30 days) (Infants' Tylenol) mg/5 ml * mapap 325 mg tablet 325 mg * (Tylenol) QL (360 per 30 days) mapap 500 mg capsule 500 mg * (Acetaminophen) QL (240 per 30 days) mapap 500 mg tablet 500 mg * (Tylenol) QL (240 per 30 days) mapap 500 mg/15 ml liquid 500 (Tylenol Sore QL (120 per 30 days) mg/15 ml * Throat) mapap 80 mg tablet chew 80 mg * (Acetaminophen) QL (30 per 30 days) mapap arthritis er 650 mg cplt 650 QL (180 per 30 days) (Acetaminophen) mg * margesic oral capsule PA-HRM; QL (180 per (Esgic) mg 30 days) methadone injection solution 10 mg/ml (Methadone HCl) methadone oral solution 10 mg/5 QL (1800 per 30 days) (Methadone HCl) ml, 5 mg/5 ml methadone oral tablet 10 mg, 5 mg (Diskets) QL (360 per 30 days) methadose oral tablet,soluble 40 mg (Diskets) QL (90 per 30 days) morphine (pf) in 0.9 % nacl intravenous pt controlled analgesia syring 50 mg/25 ml (2 mg/ml) (Morphine Sulfate/0.9% Nacl/PF) 6

23 morphine 10 mg/ml carpuject 10 mg/ml (Morphine Sulfate) morphine 2 mg/ml carpuject 2 mg/ml (Morphine Sulfate) morphine 4 mg/ml carpuject 4 mg/ml (Morphine Sulfate) morphine 8 mg/ml syringe 8 mg/ml (Morphine Sulfate) morphine concentrate oral solution QL (200 per 30 days) (Morphine Sulfate) 100 mg/5 ml (20 mg/ml) morphine concentrate oral syringe 20 mg/ml (Morphine Sulfate) morphine in dextrose 5 % injection pt controlled analgesia syring 100 (Morphine mg/50 ml (2 mg/ml), 50 mg/25 ml (2 Sulfate/D5W) mg/ml) morphine injection solution 15 mg/ml, 8 mg/ml (Morphine Sulfate) morphine injection syringe 10 mg/ml (Morphine Sulfate) morphine intramuscular pen injector 10 mg/0.7 ml (Morphine Sulfate) morphine intravenous cartridge 15 mg/ml (Morphine Sulfate) morphine intravenous solution 25 mg/ml, 50 mg/ml (Morphine Sulfate) morphine intravenous syringe 10 mg/ml, 2 mg/ml, 4 mg/ml, 8 mg/ml (Morphine Sulfate) morphine oral solution 10 mg/5 ml (Morphine Sulfate) QL (700 per 30 days) morphine oral solution 20 mg/5 ml QL (300 per 30 days) (Morphine Sulfate) (4 mg/ml) MORPHINE ORAL TABLET 15 QL (180 per 30 days) MG, 30 MG morphine oral tablet extended QL (120 per 30 days) (MS Contin) release 100 mg, 30 mg, 60 mg morphine oral tablet extended QL (180 per 30 days) (MS Contin) release 15 mg, 200 mg morphine rectal suppository 10 mg, 20 mg, 30 mg, 5 mg (Morphine Sulfate) 7

24 non-aspirin x-str 167 mg/5 ml 500 (Tylenol Sore QL (120 per 30 days) mg/15 ml * Throat) nortemp 80 mg/0.8 ml drop 80 QL (30 per 30 days) (Acetaminophen) mg/0.8 ml * NUCYNTA ER ORAL TABLET QL (60 per 30 days) EXTENDED RELEASE 12 HR 100 MG, 150 MG, 200 MG, 250 MG, 50 MG NUCYNTA ORAL TABLET 100 QL (181 per 30 days) MG, 50 MG, 75 MG oxycodone oral concentrate 20 QL (180 per 30 days) (Oxycodone HCl) mg/ml oxycodone oral solution 5 mg/5 ml (Oxycodone HCl) QL (1300 per 30 days) oxycodone oral tablet 10 mg, 15 mg, QL (180 per 30 days) (Roxicodone) 20 mg, 30 mg, 5 mg oxycodone oral tablet,oral QL (60 per 30 days) only,ext.rel.12 hr 10 mg, 15 mg, 20 mg, 30 mg, 40 mg, 60 mg (Oxycontin) oxycodone oral tablet,oral QL (120 per 30 days) (Oxycontin) only,ext.rel.12 hr 80 mg oxycodone-acetaminophen oral QL (360 per 30 days) tablet mg, mg, (Xolox) mg, mg oxycodone-acetaminophen oral QL (180 per 30 days) (Xolox) tablet mg oxycodone-acetaminophen oral QL (240 per 30 days) (Xolox) tablet mg oxycodone-aspirin oral tablet QL (360 per 30 days) (Percodan) mg OXYCONTIN ORAL QL (60 per 30 days) TABLET,ORAL ONLY,EXT.REL.12 HR 10 MG, 15 MG, 20 MG, 30 MG, 40 MG, 60 MG OXYCONTIN ORAL QL (120 per 30 days) TABLET,ORAL ONLY,EXT.REL.12 HR 80 MG 8

25 oxymorphone oral tablet 10 mg, 5 QL (180 per 30 days) (Opana) mg oxymorphone oral tablet extended QL (60 per 30 days) release 12 hr 10 mg, 15 mg, 20 mg, 5 mg, 7.5 mg (Opana ER) oxymorphone oral tablet extended QL (120 per 30 days) (Opana ER) release 12 hr 30 mg, 40 mg pain relief 500 mg capsule 500 mg * (Acetaminophen) QL (240 per 30 days) pain reliever er 650 mg caplet 8 QL (180 per 30 days) (Acetaminophen) hour, caplet 650 mg * pharbetol 325 mg tablet regular QL (360 per 30 days) (Tylenol) strength 325 mg * pharbetol 500 mg caplet extra-str, QL (240 per 30 days) (Tylenol) caplet 500 mg * pv non-aspirin 500 mg softgel exstr,liq filled 500 mg * QL (240 per 30 days) (Acetaminophen) q-pap 160 mg/5 ml solution a/f, (Tylenol Sore QL (240 per 30 days) cherry 160 mg/5 ml * Throat) q-pap 325 mg tablet 325 mg * (Tylenol) QL (360 per 30 days) q-pap 80 mg/0.8 ml drops 80 mg/0.8 QL (30 per 30 days) (Acetaminophen) ml * q-pap ex-str 500 mg tablet aspirin QL (240 per 30 days) (Tylenol) free 500 mg * ra jr acetaminophen 160 mg tab QL (30 per 30 days) (Acetaminophen) rapid melts 160 mg * reprexain oral tablet mg, QL (150 per 30 days) (Ibudone) mg, mg (Oxycodone QL (1800 per 30 days) roxicet oral solution mg/5 ml HCl/Acetaminophe n) silapap infant's drops infant's 80 QL (30 per 30 days) (Acetaminophen) mg/0.8 ml * sm arthritis pain er 650 mg caplet QL (180 per 30 days) (Acetaminophen) 650 mg * sm pain rel jr str tab chew 160 mg * (Acetaminophen) QL (30 per 30 days) sm pain reliever 80 mg tab QL (30 per 30 days) (Acetaminophen) children's 80 mg * tactinal 325 mg tablet 325 mg * (Tylenol) QL (360 per 30 days) 9

26 tactinal 500 mg tablet extra-strength 500 mg * (Tylenol) QL (240 per 30 days) tencon oral tablet mg (Tencon) PA-HRM; QL (180 per 30 days) tramadol oral tablet 50 mg (Ultram) QL (240 per 30 days) tramadol-acetaminophen oral tablet mg (Ultracet) QL (240 per 30 days) vicodin es oral tablet mg (Norco) (includes Vicodin, Vicodin ES and Vicodin HP); QL (390 per 30 days) vicodin hp oral tablet mg (Norco) (includes Vicodin, Vicodin ES and Vicodin HP); QL (390 per 30 days) vicodin oral tablet mg (Norco) (includes Vicodin, Vicodin ES and Vicodin HP); QL (390 per 30 days) xylon 10 oral tablet mg (Ibudone) QL (150 per 30 days) zebutal oral capsule mg (Esgic) Nonsteroidal Anti- Inflammatory Agents ADVIL 100 MG TABLET JR STRENGTH,COATED 100 MG * ADVIL 200 MG TABLET 200 MG * ADVIL JR STR 100 MG TAB CHEW TB CHEW,8 HOUR,GRAPE 100 MG * aspirin 300 mg suppository 300 mg * (Aspirin) aspirin 325 mg tablet 325 mg * (Ecotrin) aspirin 600 mg suppository 600 mg (Aspirin) * aspirin 81 mg chewable tablet 81 mg * (Bayer Chewable Aspirin) PA-HRM; QL (180 per 30 days) 10

27 aspirin buffered 325 mg tab 325 mg (Aspirin/Calcium * Carbonate/Mag) aspirin ec 325 mg tablet 325 mg * (Ecotrin) aspirin ec 500 mg tablet 500 mg * (Ecotrin) aspirin ec 81 mg tablet low dose 81 (Ecotrin) mg * aspir-low ec 81 mg tablet 81 mg * (Ecotrin) CALDOLOR INTRAVENOUS RECON SOLN 400 MG/4 ML (100 MG/ML) celecoxib oral capsule 100 mg, 200 (Celebrex) mg, 400 mg, 50 mg CHILDREN'S ADVIL 100 MG/5 ML A/F (OTC) 100 MG/5 ML * cvs ibuprofen 200 mg softgel liquid (Advil) filled,softge 200 mg * diclofenac sodium oral tablet (Voltaren-XR) extended release 24 hr 100 mg diclofenac sodium oral (Diclofenac tablet,delayed release (dr/ec) 25 mg, Sodium) 50 mg, 75 mg diclofenac sodium topical gel 3 % (Voltaren) diclofenac-misoprostol oral tablet,ir,delayed rel,biphasic (Arthrotec 50) mg-mcg, mg-mcg diflunisal oral tablet 500 mg (Diflunisal) ecpirin ec 325 mg tablet 325 mg * (Ecotrin) etodolac oral capsule 200 mg, 300 (Etodolac) mg etodolac oral tablet 400 mg, 500 mg (Etodolac) bufferin 325 mg tablet coated 325 choline,magnesium salicylate oral diclofenac potassium oral tablet 50 (Aspirin/Calcium (Choline Sal/Mag (Diclofenac mg * liquid 500 mg/5 ml mg Carbonate/Mag) Salicylate) Potassium) QL (60 per 30 days) 11

28 etodolac oral tablet extended release 24 hr 400 mg, 500 mg, 600 mg fenoprofen oral tablet 600 mg (Etodolac) (Fenoprofen Calcium) FLECTOR TRANSDERMAL PATCH 12 HOUR 1.3 % flurbiprofen oral tablet 100 mg, 50 mg (Flurbiprofen) gnp ibuprofen jr str 100 mg tb 100 mg * (Advil) ibuprofen 100 mg/5 ml susp children's (otc) 100 mg/5 ml * (Children'S Advil) ibuprofen 200 mg tablet 200 mg * (Advil) ibuprofen oral suspension 100 mg/5 ml (Ibuprofen) ibuprofen oral tablet 400 mg, 600 mg, 800 mg (Ibuprofen) indomethacin oral capsule 25 mg (Indomethacin) indomethacin oral capsule 50 mg (Indomethacin) indomethacin oral capsule, extended (Indomethacin) release 75 mg indomethacin sodium intravenous (Indomethacin recon soln 1 mg Sodium) infant ibuprofen 50 mg/1.25 ml d/f,a/f,non-staining 50 mg/1.25 ml * (Infants' Motrin) INFANTS' MOTRIN 50 MG/1.25 ML D/F, BERRY FLAVOR 50 3 $0 MG/1.25 ML * ketoprofen oral capsule 50 mg, 75 mg (Ketoprofen) ketoprofen oral capsule,ext rel. pellets 24 hr 200 mg (Ketoprofen) ketorolac oral tablet 10 mg (Ketorolac Tromethamine) mefenamic acid oral capsule 250 mg (Ponstel) PA PA-HRM; QL (240 per 30 days) PA-HRM; QL (120 per 30 days) PA-HRM; QL (60 per 30 days) PA-HRM QL (20 per 30 days) 12

29 meloxicam oral suspension 7.5 mg/5 ml (Mobic) meloxicam oral tablet 15 mg, 7.5 mg (Mobic) nabumetone oral tablet 500 mg, 750 mg (Nabumetone) naproxen oral suspension 125 mg/5 ml (Naprosyn) naproxen oral tablet 250 mg, 375 mg, 500 mg (Naprosyn) naproxen oral tablet,delayed release (Ec-Naprosyn) (dr/ec) 375 mg, 500 mg naproxen sodium oral tablet 275 mg, 550 mg (Anaprox) piroxicam oral capsule 10 mg, 20 mg (Feldene) ra aspirin tri-buffered tb 325 mg * (Aspirin/Calcium Carbonate/Mag) sm ibuprofen ib 100 mg tablet junior (Advil) strength 100 mg * st. joseph aspirin 81 mg chew (Bayer Chewable orange 81 mg * Aspirin) st. joseph aspirin ec 81 mg tb enteric coated 81 mg * (Ecotrin) sulindac oral tablet 150 mg, 200 mg (Sulindac) tolmetin oral capsule 400 mg (Tolmetin Sodium) tolmetin oral tablet 200 mg, 600 mg (Tolmetin Sodium) VOLTAREN TOPICAL GEL 1 % wal-profen 200 mg softgel softgel 200 mg * (Advil) Anesthetics Local Anesthetics glydo mucous membrane jelly in applicator 2 % (Lidocaine HCl) lidocaine (pf) injection solution 15 mg/ml (1.5 %), 40 mg/ml (4 %), 5 (Xylocaine-MPF) mg/ml (0.5 %) lidocaine 2% viscous soln 2 % (Xylocaine) 13

30 lidocaine hcl injection solution 10 mg/ml (1 %), 20 mg/ml (2 %) (Xylocaine) lidocaine hcl laryngotracheal solution 4 % (Xylocaine) lidocaine hcl mucous membrane gel 2 % (Lidocaine HCl) lidocaine hcl mucous membrane jelly in applicator 2 % (Lidocaine HCl) lidocaine hcl mucous membrane solution 2 %, 4 % (40 mg/ml) (Xylocaine) lidocaine hcl urethral gel 2 % (Lidocaine HCl) lidocaine topical adhesive patch,medicated 5 % (Lidoderm) lidocaine topical ointment 5 % (Lidocaine) lidocaine-prilocaine topical cream % (EMLA) Anti-Addiction/Substance Abuse Treatment Agents Anti-Addiction/Substance Abuse Treatment Agents acamprosate oral tablet,delayed release (dr/ec) 333 mg buprenorphine hcl sublingual tablet 2 mg, 8 mg buprenorphine-naloxone sublingual tablet mg, 8-2 mg bupropion hcl sr 150 mg tablet f/c 150 mg CHANTIX CONTINUING MONTH BOX ORAL TABLET 1 MG CHANTIX ORAL TABLET 0.5 MG, 1 MG CHANTIX STARTING MONTH BOX ORAL TABLETS,DOSE PACK 0.5 MG (11)- 1 MG (42) (Acamprosate Calcium) (Buprenorphine HCl) (Buprenorphine HCl/Naloxone HCl) (Zyban) PA PA; QL (90 per 30 days) PA; QL (90 per 30 days) QL (168 per 84 days) QL (168 per 84 days) QL (53 per 28 days) 14

31 disulfiram oral tablet 250 mg, 500 mg (Antabuse) naloxone injection solution 0.4 mg/ml (Naloxone HCl) naloxone injection syringe 0.4 mg/ml, 1 mg/ml (Naloxone HCl) naltrexone oral tablet 50 mg (Revia) NARCAN NASAL SPRAY,NON- AEROSOL 4 MG/ACTUATION NICODERM CQ 14 MG/24HR PATCH 14 MG/24 HR * NICODERM CQ 21 MG/24HR PATCH 21 MG/24 HR * NICODERM CQ 7 MG/24HR PATCH 7 MG/24 HR * nicorelief 2 mg gum 2 mg * (Nicorette) nicorelief 4 mg gum 4 mg * (Nicorette) nicorette 2 mg chewing gum white ice mint 2 mg * (Nicorette) nicotine 14 mg/24hr patch outer (otc) 14 mg/24 hr * (Nicoderm Cq) nicotine 2 mg chewing gum sugar free 2 mg * (Nicorette) nicotine 2 mg lozenge mint, 3 quittube 2 mg * (Nicorette) nicotine 21 mg/24hr patch step 1 (otc) 21 mg/24 hr * (Nicoderm Cq) nicotine 22 mg/24hr patch 1 week starter kit 22 mg/24 hr * (Nicoderm Cq) nicotine 4 mg chewing gum 4 mg * (Nicorette) nicotine 4 mg lozenge mint, 3 quittube 4 mg * (Nicorette) nicotine 7 mg/24hr patch (otc) 7 mg/24 hr * (Nicoderm Cq) NICOTROL INHALATION CARTRIDGE 10 MG QL (4 per 30 days) QL (168 per 365 days) QL (168 per 365 days) QL (180 per 365 days) QL (168 per 365 days) QL (168 per 365 days) QL (180 per 365 days) QL (1008 per 90 days) 15

32 ZUBSOLV SUBLINGUAL TABLET MG, MG, MG, MG, MG Antianxiety Agents Benzodiazepines alprazolam oral tablet 0.25 mg, 0.5 PA; QL (90 per 30 days) QL (120 per 30 days) (Xanax) mg, 1 mg, 2 mg chlordiazepoxide hcl oral capsule (Chlordiazepoxide QL (120 per 30 days) 10 mg, 25 mg, 5 mg HCl) clonazepam oral tablet 0.5 mg, 1 mg (Klonopin) QL (90 per 30 days) clonazepam oral tablet 2 mg (Klonopin) QL (300 per 30 days) clonazepam oral tablet,disintegrating mg, 0.25 mg, 0.5 mg, 1 mg (Clonazepam) QL (90 per 30 days) clonazepam oral QL (300 per 30 days) (Clonazepam) tablet,disintegrating 2 mg clorazepate dipotassium oral tablet QL (120 per 30 days) (Tranxene T-Tab) 15 mg clorazepate dipotassium oral tablet QL (60 per 30 days) (Tranxene T-Tab) 3.75 mg, 7.5 mg diazepam injection syringe 5 mg/ml (Diazepam) QL (10 per 28 days) diazepam intensol oral concentrate QL (1200 per 30 days) (Diazepam) 5 mg/ml diazepam oral solution 5 mg/5 ml (1 QL (1200 per 30 days) (Diazepam) mg/ml) diazepam oral tablet 10 mg, 2 mg, 5 QL (120 per 30 days) (Valium) mg diazepam rectal kit mg, 2.5 mg, mg (Diastat) lorazepam oral tablet 0.5 mg, 1 mg, QL (90 per 30 days) (Ativan) 2 mg ONFI ORAL SUSPENSION 2.5 PA NSO; QL (480 per MG/ML 30 days) Antibacterials Aminoglycosides 16

33 BETHKIS INHALATION SOLUTION FOR NEBULIZATION 300 MG/4 ML gentamicin in nacl (iso-osm) intravenous piggyback 100 mg/100 ml, 100 mg/50 ml, 60 mg/50 ml, 70 mg/50 ml, 80 mg/100 ml, 80 mg/50 ml, 90 mg/100 ml gentamicin injection solution 40 mg/ml gentamicin ped 20 mg/2 ml vial 25's,pedi,latex-free 20 mg/2 ml gentamicin sulfate (pf) intravenous solution 80 mg/8 ml (Gentamicin In Nacl, Iso-Osm) (Gentamicin Sulfate) (Gentamicin Sulfate/PF) (Gentamicin Sulfate/PF) neomycin oral tablet 500 mg (Neomycin Sulfate) streptomycin intramuscular recon (Streptomycin soln 1 gram Sulfate) TOBI PODHALER INHALATION CAPSULE, W/INHALATION DEVICE 28 MG tobramycin in % nacl inhalation solution for nebulization 300 mg/5 ml tobramycin in 0.9 % nacl intravenous piggyback 60 mg/50 ml, 80 mg/100 ml tobramycin sulfate injection solution 10 mg/ml, 40 mg/ml Antibacterials, Miscellaneous bacitracin intramuscular recon soln 50,000 unit chloramphenicol sod succinate intravenous recon soln 1 gram clindamycin 75 mg/5 ml soln 75 mg/5 ml clindamycin hcl oral capsule 150 mg, 300 mg, 75 mg (Tobi) (Tobramycin/Sodiu m Chloride) (Tobramycin Sulfate) (Bacitracin) (Chloramphenicol Sod Succ) (Cleocin Palmitate) (Cleocin HCl) QL (224 per 28 days) 17

34 clindamycin in 5 % dextrose intravenous piggyback 300 mg/50 ml, 600 mg/50 ml, 900 mg/50 ml clindamycin pediatric oral recon soln 75 mg/5 ml clindamycin phosphate injection solution 150 mg/ml clindamycin phosphate intravenous solution 600 mg/4 ml colistin (colistimethate na) injection recon soln 150 mg CUBICIN INTRAVENOUS RECON SOLN 500 MG linezolid intravenous parenteral solution 600 mg/300 ml linezolid oral suspension for reconstitution 100 mg/5 ml (Cleocin Phosphate In D5w) (Cleocin Palmitate) (Cleocin Phosphate) (Cleocin Phosphate) (Coly-Mycin M Parenteral) (Zyvox) (Zyvox) linezolid oral tablet 600 mg (Zyvox) methenamine hippurate oral tablet 1 gram (Hiprex) metronidazole in nacl (iso-os) (Metronidazole/So intravenous piggyback 500 mg/100 dium Chloride) ml metronidazole oral capsule 375 mg (Flagyl) metronidazole oral tablet 250 mg, 500 mg (Flagyl) nitrofurantoin macrocrystal oral capsule 100 mg, 25 mg (Macrodantin) nitrofurantoin macrocrystal oral capsule 50 mg (Macrodantin) PA-HRM; QL (120 per 30 days) PA-HRM; (High Risk Med. QL applies to all participants; PA required for 65 years and older with over 90 days cumulative use of nitrofurantoin drugs); QL (120 per 30 days) 18

35 nitrofurantoin monohyd/m-cryst oral capsule 100 mg nitrofurantoin monohyd/m-cryst oral capsule 100 mg (75/25) (Macrobid) (Macrobid) polymyxin b sulfate injection recon (Polymyxin B soln 500,000 unit Sulfate) SYNERCID INTRAVENOUS RECON SOLN 500 MG trimethoprim oral tablet 100 mg (Trimethoprim) vancomycin hcl 1g/200 ml bag 1 (Vancomycin gram/200 ml HCl/D5W) vancomycin intravenous recon soln 1,000 mg, 10 gram, 750 mg (Vancomycin HCl) vancomycin intravenous recon soln (Vancomycin 500 mg HCl/D5W) vancomycin oral capsule 125 mg, 250 mg (Vancocin HCl) XIFAXAN ORAL TABLET 200 MG XIFAXAN ORAL TABLET 550 MG ZYVOX ORAL SUSPENSION FOR RECONSTITUTION 100 MG/5 ML Cephalosporins cefaclor oral capsule 250 mg, 500 mg (Cefaclor) PA-HRM; (High Risk Med. QL applies to all participants; PA required for 65 years and older with over 90 days cumulative use of nitrofurantoin drugs); QL (120 per 30 days) PA-HRM; (High Risk Med. QL applies to all participants; PA required for 65 years and older with over 90 days cumulative use of nitrofurantoin drugs); QL (120 per 30 days) PA; QL (9 per 30 days) PA 19

36 cefaclor oral suspension for reconstitution 125 mg/5 ml, 250 (Cefaclor) mg/5 ml, 375 mg/5 ml cefadroxil oral capsule 500 mg (Cefadroxil) cefadroxil oral suspension for reconstitution 250 mg/5 ml, 500 (Cefadroxil) mg/5 ml cefadroxil oral tablet 1 gram (Cefadroxil) CEFAZOLIN IN DEXTROSE (ISO-OS) INTRAVENOUS PIGGYBACK 1 GRAM/50 ML cefazolin in dextrose (iso-os) intravenous piggyback 2 gram/50 ml (Cefazolin Sodium/Dextrose, Iso) cefazolin injection recon soln 1 gram, 10 gram, 500 mg (Cefazolin Sodium) cefdinir oral capsule 300 mg (Cefdinir) cefdinir oral suspension for reconstitution 125 mg/5 ml, 250 (Cefdinir) mg/5 ml cefditoren pivoxil oral tablet 200 mg, 400 mg (Spectracef) CEFEPIME 2 GM INJECTION 2 GRAM/100 ML CEFEPIME IN DEXTROSE 5 % INTRAVENOUS PIGGYBACK 1 GRAM/50 ML, 2 GRAM/50 ML cefepime injection recon soln 1 gram, 2 gram (Maxipime) cefotaxime injection recon soln 1 gram, 10 gram, 2 gram, 500 mg (Claforan) (Cefoxitin cefoxitin in dextrose, iso-osm Sodium/Dextrose, intravenous piggyback 2 gram/50 ml Iso) cefoxitin intravenous recon soln 1 gram, 10 gram, 2 gram (Cefoxitin Sodium) 20

37 cefpodoxime oral suspension for reconstitution 100 mg/5 ml, 50 mg/5 ml cefpodoxime oral tablet 100 mg, 200 mg cefprozil oral suspension for reconstitution 125 mg/5 ml, 250 mg/5 ml (Cefpodoxime Proxetil) (Cefpodoxime Proxetil) (Cefprozil) cefprozil oral tablet 250 mg, 500 mg (Cefprozil) ceftazidime injection recon soln 2 gram, 6 gram (Fortaz) ceftibuten oral capsule 400 mg (Cedax) ceftibuten oral suspension for reconstitution 180 mg/5 ml (Cedax) ceftriaxone 1 gm piggyback 50ml (Ceftriaxone galaxycontainer 1 gram/50 ml Na/Dextrose, Iso) ceftriaxone 1 gm vial 10's, fliptop,l/f 1 gram (Rocephin) ceftriaxone 2 gm piggyback 50ml (Ceftriaxone galaxycontainer 2 gram/50 ml Na/Dextrose, Iso) ceftriaxone injection recon soln 10 gram, 250 mg, 500 mg (Rocephin) ceftriaxone intravenous recon soln 1 (Ceftriaxone gram, 2 gram Na/Dextrose, Iso) cefuroxime axetil oral tablet 250 mg, 500 mg (Ceftin) cefuroxime sodium injection recon soln 1.5 gram, 750 mg (Zinacef) cefuroxime sodium intravenous recon soln 7.5 gram (Zinacef) cephalexin oral capsule 250 mg, 500 mg, 750 mg (Keflex) cephalexin oral suspension for reconstitution 125 mg/5 ml, 250 mg/5 ml (Cephalexin) cephalexin oral tablet 250 mg, 500 mg (Cephalexin) 21

38 MEFOXIN IN DEXTROSE (ISO- OSM) INTRAVENOUS PIGGYBACK 1 GRAM/50 ML, 2 GRAM/50 ML SUPRAX ORAL TABLET,CHEWABLE 100 MG, 200 MG tazicef injection recon soln 2 gram, 6 gram (Fortaz) TEFLARO INTRAVENOUS RECON SOLN 400 MG, 600 MG Macrolides azithromycin intravenous recon soln 500 mg (Zithromax) azithromycin oral packet 1 gram (Zithromax) azithromycin oral suspension for reconstitution 100 mg/5 ml, 200 (Zithromax) mg/5 ml azithromycin oral tablet 250 mg, 250 mg (6 pack), 600 mg (Zithromax) azithromycin oral tablet 500 mg (Zithromax) clarithromycin oral suspension for reconstitution 125 mg/5 ml, 250 (Biaxin) mg/5 ml clarithromycin oral tablet 250 mg, 500 mg (Biaxin) clarithromycin oral tablet extended release 24 hr 500 mg (Clarithromycin) DIFICID ORAL TABLET 200 MG QL (20 per 10 days) e.e.s. 400 oral tablet 400 mg (Erythromycin Ethylsuccinate) e.e.s. granules oral suspension for reconstitution 200 mg/5 ml (Eryped 200) ery-tab oral tablet,delayed release (Erythromycin (dr/ec) 250 mg, 500 mg Base) ERY-TAB ORAL TABLET,DELAYED RELEASE (DR/EC) 333 MG 22

39 erythrocin (as stearate) oral tablet 250 mg ERYTHROCIN INTRAVENOUS RECON SOLN 1,000 MG, 500 MG erythromycin ethylsuccinate oral tablet 400 mg erythromycin oral capsule,delayed release(dr/ec) 250 mg erythromycin oral tablet 250 mg, 500 mg Miscellaneous B-Lactam Antibiotics aztreonam injection recon soln 1 gram CAYSTON INHALATION SOLUTION FOR NEBULIZATION 75 MG/ML imipenem-cilastatin intravenous recon soln 250 mg, 500 mg INVANZ INJECTION RECON SOLN 1 GRAM meropenem intravenous recon soln 500 mg meropenem iv 1 gm vial outer, latexfree 1 gram Penicillins amoxicillin oral capsule 250 mg, 500 mg amoxicillin oral suspension for reconstitution 125 mg/5 ml, 200 mg/5 ml, 250 mg/5 ml, 400 mg/5 ml amoxicillin oral tablet 500 mg, 875 mg amoxicillin oral tablet,chewable 125 mg, 250 mg (Erythromycin Stearate) (Erythromycin Ethylsuccinate) (Erythromycin Base) (Erythromycin Base) (Azactam) (Primaxin) (Merrem) (Merrem) (Amoxicillin) (Amoxicillin) (Amoxicillin) (Amoxicillin) LA 23

40 amoxicillin-pot clavulanate oral suspension for reconstitution mg/5 ml, mg/5 ml, mg/5 ml, mg/5 ml amoxicillin-pot clavulanate oral tablet mg, mg, mg amoxicillin-pot clavulanate oral tablet extended release 12 hr 1, mg amoxicillin-pot clavulanate oral tablet,chewable mg, mg ampicillin 2 gm vial 10's, latex-free 2 gram ampicillin oral capsule 250 mg, 500 mg ampicillin oral suspension for reconstitution 125 mg/5 ml, 250 mg/5 ml ampicillin sodium injection recon soln 1 gram, 10 gram, 125 mg ampicillin sodium intravenous recon soln 2 gram ampicillin-sulbactam 1.5 gm vl p/f, latex-free 1.5 gram ampicillin-sulbactam injection recon soln 15 gram, 3 gram ampicillin-sulbactam intravenous recon soln 1.5 gram BICILLIN C-R INTRAMUSCULAR SYRINGE 1,200,000 UNIT/ 2 ML(600K/600K), 1,200,000 UNIT/ 2 ML(900K/300K) BICILLIN L-A INTRAMUSCULAR SYRINGE 1,200,000 UNIT/2 ML, 2,400,000 UNIT/4 ML, 600,000 UNIT/ML (Augmentin) (Augmentin) (Augmentin XR) (Amoxicillin/Potas sium Clav) (Ampicillin Sodium) (Ampicillin Trihydrate) (Ampicillin Trihydrate) (Ampicillin Sodium) (Ampicillin Sodium) (Unasyn) (Unasyn) (Unasyn) 24

41 dicloxacillin oral capsule 250 mg, 500 mg nafcillin 2 gm vial sterile, latex-free 2 gram nafcillin injection recon soln 1 gram, 10 gram nafcillin intravenous recon soln 2 gram oxacillin 1 gm add-vantage vl addvantage, inner 1 gram oxacillin in dextrose(iso-osm) intravenous piggyback 1 gram/50 ml, 2 gram/50 ml oxacillin injection recon soln 10 gram oxacillin intravenous recon soln 2 gram penicillin g pot in dextrose intravenous piggyback 1 million unit/50 ml, 2 million unit/50 ml, 3 million unit/50 ml penicillin g potassium injection recon soln 5 million unit penicillin g procaine intramuscular syringe 1.2 million unit/2 ml, 600,000 unit/ml penicillin gk 20 million unit 20 million unit penicillin v potassium oral recon soln 125 mg/5 ml, 250 mg/5 ml penicillin v potassium oral tablet 250 mg, 500 mg pfizerpen-g injection recon soln 20 million unit piperacillin-tazobactam intravenous recon soln 2.25 gram, gram, 4.5 gram (Dicloxacillin Sodium) (Nafcillin Sodium) (Nafcillin Sodium) (Nafcillin Sodium) (Oxacillin Sodium) (Oxacillin Sodium/Dextrose, Iso) (Oxacillin Sodium) (Oxacillin Sodium) (Pen G Pot/Dextrose- Water) (Penicillin G Potassium) (Penicillin G Procaine) (Penicillin G Potassium) (Penicillin V Potassium) (Penicillin V Potassium) (Penicillin G Potassium) (Zosyn) 25

42 piperacil-tazobact 40.5 gram p/f, pharmacy bulk 40.5 gram (Zosyn) Quinolones ciprofloxacin 200 mg/20 ml vl (Ciprofloxacin sdv,latex-free 200 mg/20 ml Lactate) ciprofloxacin hcl oral tablet 100 mg, (Cipro) 250 mg, 500 mg, 750 mg ciprofloxacin in 5 % dextrose intravenous piggyback 200 mg/100 ml (Cipro I.V.) ciprofloxacin lactate intravenous (Ciprofloxacin solution 400 mg/40 ml Lactate) ciprofloxacin oral suspension,microcapsule recon 250 (Cipro) mg/5 ml, 500 mg/5 ml ciprofloxacn-d5w 400 mg/200 ml p/f,latex/f, in d5w 400 mg/200 ml (Cipro I.V.) levofloxacin in d5w intravenous piggyback 500 mg/100 ml, 750 (Levaquin) mg/150 ml levofloxacin intravenous solution 25 mg/ml (Levofloxacin) levofloxacin oral solution 250 mg/10 ml (Levaquin) levofloxacin oral tablet 250 mg, 500 mg, 750 mg (Levaquin) moxifloxacin oral tablet 400 mg (Avelox) ofloxacin oral tablet 400 mg (Ofloxacin) Sulfonamides sulfadiazine oral tablet 500 mg (Sulfadiazine) sulfamethoxazole-trimethoprim intravenous solution mg/5 ml sulfamethoxazole-trimethoprim oral suspension mg/5 ml sulfamethoxazole-trimethoprim oral tablet mg, mg (Sulfamethoxazole/ Trimethoprim) (Sulfamethoxazole/ Trimethoprim) (Bactrim) sulfasalazine oral tablet 500 mg (Azulfidine) 26

43 sulfasalazine oral tablet,delayed release (dr/ec) 500 mg sulfatrim oral suspension mg/5 ml Tetracyclines doxy 100 vial 10's, p/f 100 mg doxycycline hyclate 100 mg cap 100 mg doxycycline hyclate 100 mg tab f/c 100 mg doxycycline hyclate intravenous recon soln 100 mg doxycycline hyclate oral capsule 100 mg doxycycline hyclate oral capsule 50 mg doxycycline hyclate oral tablet 100 mg, 50 mg doxycycline hyclate oral tablet 20 mg doxycycline mono 100 mg cap 100 mg doxycycline mono 100 mg tablet f/c 100 mg doxycycline mono 50 mg tablet 50 mg doxycycline monohydrate oral capsule 150 mg, 50 mg, 75 mg doxycycline monohydrate oral suspension for reconstitution 25 mg/5 ml doxycycline monohydrate oral tablet 150 mg, 75 mg minocycline oral capsule 100 mg, 50 mg, 75 mg minocycline oral tablet 100 mg, 50 mg, 75 mg (Azulfidine) (Sulfamethoxazole/ Trimethoprim) (Doxycycline Hyclate) (Morgidox) (Doryx) (Doxycycline Hyclate) (Adoxa) (Morgidox) (Avidoxy) (Doryx) (Adoxa) (Avidoxy) (Avidoxy) (Adoxa) (Vibramycin) (Avidoxy) (Minocin) (Minocycline HCl) 27

44 tetracycline oral capsule 250 mg, 500 mg TYGACIL INTRAVENOUS RECON SOLN 50 MG Anticancer Agents Anticancer Agents ABRAXANE INTRAVENOUS SUSPENSION FOR RECONSTITUTION 100 MG ADCETRIS INTRAVENOUS RECON SOLN 50 MG adriamycin intravenous recon soln 10 mg, 20 mg, 50 mg adriamycin intravenous solution 10 mg/5 ml adrucil 2,500 mg/50 ml vial outer, latex-free 2.5 gram/50 ml adrucil intravenous solution 500 mg/10 ml AFINITOR DISPERZ ORAL TABLET FOR SUSPENSION 2 MG, 3 MG, 5 MG (Tetracycline HCl) (Doxorubicin HCl) (Doxorubicin HCl) (Fluorouracil) (Fluorouracil) AFINITOR ORAL TABLET 10 MG AFINITOR ORAL TABLET 2.5 MG, 5 MG, 7.5 MG ALECENSA ORAL CAPSULE 150 MG ALIMTA INTRAVENOUS RECON SOLN 500 MG anastrozole oral tablet 1 mg (Arimidex) AVASTIN INTRAVENOUS SOLUTION 25 MG/ML, 25 MG/ML (16 ML) azacitidine injection recon soln 100 mg BELEODAQ INTRAVENOUS RECON SOLN 500 MG (Vidaza) PA NSO; QL (4 per 21 days) PA NSO; QL (112 per 28 days) PA NSO; QL (56 per 28 days) PA NSO; QL (28 per 28 days) PA NSO; QL (240 per 30 days) PA NSO PA NSO 28

45 BENDEKA INTRAVENOUS SOLUTION 25 MG/ML bexarotene oral capsule 75 mg (Targretin) bicalutamide oral tablet 50 mg (Casodex) bleomycin injection recon soln 30 (Bleomycin unit Sulfate) bleomycin sulfate 15 unit vial latexfree 15 unit Sulfate) (Bleomycin BLINCYTO INTRAVENOUS KIT 35 MCG BOSULIF ORAL TABLET 100 MG BOSULIF ORAL TABLET 500 MG CABOMETYX ORAL TABLET 20 MG, 60 MG CABOMETYX ORAL TABLET 40 MG CAPRELSA ORAL TABLET 100 MG CAPRELSA ORAL TABLET 300 MG COMETRIQ ORAL CAPSULE 100 MG/DAY(80 MG[1]-20 MG[1]), 140 MG/DAY(80 MG[1]-20 MG[3]), 60 MG/DAY (20 MG [3]/DAY) COTELLIC ORAL TABLET 20 MG cyclophosphamide intravenous (Cyclophosphamid recon soln 1 gram, 2 gram, 500 mg e) CYCLOPHOSPHAMIDE ORAL CAPSULE 25 MG, 50 MG cyclophosphamide oral tablet 25 (Cyclophosphamid mg, 50 mg e) PA NSO PA NSO; QL (420 per 30 days) PA NSO; QL (140 per 365 days) PA NSO; QL (120 per 30 days) PA NSO; QL (30 per 30 days) PA NSO; QL (30 per 30 days) PA NSO; QL (60 per 30 days) PA NSO; QL (60 per 30 days) PA NSO; QL (30 per 30 days) PA NSO; QL (112 per 28 days) PA NSO; LA; QL (63 per 28 days) ; ST ; ST 29

46 CYRAMZA INTRAVENOUS SOLUTION 10 MG/ML, 10 MG/ML (50 ML) dactinomycin intravenous recon soln 0.5 mg (Dactinomycin) DARZALEX INTRAVENOUS SOLUTION 20 MG/ML decitabine intravenous recon soln 50 mg (Dacogen) doxorubicin, peg-liposomal intravenous suspension 2 mg/ml (Doxil) DROXIA ORAL CAPSULE 200 MG, 300 MG, 400 MG ELIGARD SUBCUTANEOUS SYRINGE 22.5 MG (3 MONTH) ELIGARD SUBCUTANEOUS SYRINGE 30 MG (4 MONTH) ELIGARD SUBCUTANEOUS SYRINGE 45 MG (6 MONTH) ELIGARD SUBCUTANEOUS SYRINGE 7.5 MG (1 MONTH) EMCYT ORAL CAPSULE 140 MG EMPLICITI INTRAVENOUS RECON SOLN 300 MG, 400 MG ERIVEDGE ORAL CAPSULE 150 MG ETOPOPHOS INTRAVENOUS RECON SOLN 100 MG etoposide intravenous solution 20 mg/ml (Etoposide) exemestane oral tablet 25 mg (Aromasin) FARESTON ORAL TABLET 60 MG FARYDAK ORAL CAPSULE 10 MG, 15 MG, 20 MG FASLODEX INTRAMUSCULAR SYRINGE 250 MG/5 ML PA NSO PA NSO; LA QL (1 per 84 days) QL (1 per 112 days) QL (1 per 168 days) PA NSO PA NSO; QL (30 per 30 days) PA NSO 30

47 floxuridine injection recon soln 0.5 gram (Floxuridine) fluorouracil 5,000 mg/100 ml latexfree 5 gram/100 ml (Fluorouracil) fluorouracil intravenous solution 2.5 gram/50 ml (Fluorouracil) flutamide oral capsule 125 mg (Flutamide) GAZYVA INTRAVENOUS SOLUTION 1,000 MG/40 ML GILOTRIF ORAL TABLET 20 MG, 30 MG, 40 MG GLEEVEC ORAL TABLET 100 MG GLEEVEC ORAL TABLET 400 MG GLEOSTINE ORAL CAPSULE 10 MG, 100 MG, 40 MG HERCEPTIN INTRAVENOUS RECON SOLN 440 MG HEXALEN ORAL CAPSULE 50 MG hydroxyurea oral capsule 500 mg (Hydrea) IBRANCE ORAL CAPSULE 100 MG, 125 MG, 75 MG ICLUSIG ORAL TABLET 15 MG ICLUSIG ORAL TABLET 45 MG ifosfamide 1 gm/20 ml vial sd polymer vial 1 gram/20 ml ifosfamide intravenous recon soln 1 gram ifosfamide-mesna intravenous kit 1-1 gram, 3,000-1,000 mg IMBRUVICA ORAL CAPSULE 140 MG (Ifex) (Ifex) (Ifosfamide/Mesna ) PA NSO PA NSO; QL (30 per 30 days) PA NSO; QL (90 per 30 days) PA NSO; QL (60 per 30 days) PA NSO PA NSO; QL (21 per 28 days) PA NSO; QL (60 per 30 days) PA NSO; QL (30 per 30 days) PA NSO 31