List of Covered Drugs: Formulary 2015

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1 Touchstone Health s List of Covered Drugs: Formulary 2015 PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT SOME OF THE DRUGS WE COVER IN THIS PLAN This formulary was updated in August 27, For more recent information or other questions, please contact Touchstone Health Member Concierge at or, for TTY/TDD users, 711, 8AM 8PM, 7 Days a week (Note: Member Concierge hours are 8:00AM to 8:00PM, 7 days a week from October 15, 2014 to February 14, Hours are 8:00AM to 8:00PM, Monday through Friday from February 15, 2015 to October 14, 2015) or visit Y0064_H3327_THPSMK_2444 Accepted

2 Touchstone Health HMO, Inc One North Lexington Ave 12th Floor White Plains, NY Prospective members should call or TTY/TDD hours a day, 7 days a week Current members should call or TTY/TDD 711 Hours are 8:00AM to 8:00PM, 7 days a week from October 15, 2014 to February 14, We are available for phone calls 8:00AM to 8:00PM, Monday through Friday from February 15, 2015 to October 14, This formulary was updated in August 27, For more recent information or other questions, please contact Touchstone Health Member Concierge at or, for TTY/TDD users, 711, 8AM 8PM, 7 Days a week (Note: Member Concierge hours are 8:00AM to 8:00PM, 7 days a week from October 15, 2014 to February 14, Hours are 8:00AM to 8:00PM, Monday through Friday from February 15, 2015 to October 14, 2015) or visit facebook.com/touchstoneh twitter.com/touchstoneh youtube.com/touchstonehealth Y0064_H3327_THPSMK_2444 Accepted Touchstone Health HMO, Inc. is a Medicare approved HMO with a Medicare Advantage Prescription Drug contract with the federal government and a contract with the New York Medicaid Program. Enrollment in Touchstone Health depends on contract renewal.

3 Touchstone Health HMO, Inc Formulary (List of Covered Drugs) PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT SOME OF THE DRUGS WE COVER IN THIS PLAN HPMS Approved Formulary File Submission ID , Version 19, Approved 8/25/2015 This formulary was updated on Augsut 27, For more recent information or other questions, please contact Touchstone Health Member Concierge at or, for TTY/TDD users, 711, 8AM 8PM, 7 Days a week (Note: Member Concierge hours are 8:00AM to 8:00PM, 7 days a week from October 15, 2014 to February 14, Hours are 8:00AM to 8:00PM, Monday through Friday from February 15, 2015 to October 14, 2015) or visit This information is available in a different format, including CD and Spanish, and can be obtained via e- mail. Please call Member Services at the number listed above if you need plan information in another format or language. Esta información está disponible en un formato diferente, incluyendo CD e español, y también puede obtenerse a través de correo electrónico. Si necesita información del plan en otro formato o lenguaje, por favor llame a la línea de Servicio al Miembro al número mencionado arriba. Touchstone Health HMO, Inc. is a Medicare approved HMO with a Medicare Advantage Prescription Drug contract with the federal government and a contract with the New York Medicaid Program. Enrollment in Touchstone Health depends on contract renewal. Y0064_H3327_THPSMK_2444 Accepted I

4 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 Touchstone Health. When it refers to plan or our plan, it means 2015 Touchstone Health plans. This document includes a list of the drugs (formulary) for our plan which is current as of August 27, 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, 2016, and from time to time during the year. What is the Touchstone Health Formulary? A formulary is a list of covered drugs selected by Touchstone Health 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. Touchstone Health will generally cover the drugs listed in our formulary as long as the drug is medically necessary, the prescription is filled at a Touchstone Health 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 2015 formulary that was covered at the beginning of the year, we will not discontinue or reduce coverage of the drug during the 2015 coverage year except when a new, less expensive generic drug becomes available or when new adverse information about the safety or effectiveness of a drug is released. Other types of formulary changes, such as removing a drug from our formulary, will not affect members who are currently taking the drug. It will remain available at the same cost-sharing for those members taking it for the remainder of the coverage year. We feel it is important that you have continued access for the remainder of the coverage year to the formulary drugs that were available when you chose our plan, except for cases in which you can save additional money or we can ensure your safety. If we remove drugs from our formulary, or add prior authorization, quantity limits and/or step therapy restrictions on a drug or move a drug to a higher cost-sharing tier, we must notify affected members of the change at least 60 days before the change becomes effective, or at the time the member requests a refill of the drug, at which time the member will receive a 60-day supply of the drug. If the Food and Drug Administration deems a drug on our formulary to be unsafe or the drug s manufacturer removes the drug from the market, we will immediately remove the drug from our formulary and provide notice to members who take the drug. The enclosed formulary is current as of August 27, To get updated information about the drugs covered by Touchstone Health please contact us. Our contact information appears on the front and back cover pages. Touchstone Health will mail you addendum sheets in the event of mid-year non-maintenance formulary changes. How do I use the Formulary? There are two ways to find your drug within the formulary: II

5 Medical Condition The formulary begins on page 1. The drugs in this formulary are grouped into categories depending on the type of medical conditions that they are used to treat. For example, drugs used to treat a heart condition are listed under the category, CARDIOVASCULAR AGENTS. If you know what your drug is used for, look for the category name in the list that begins on page 1. Then look under the category name for your drug. Alphabetical Listing If you are not sure what category to look under, you should look for your drug in the Index that begins on page 82. 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? Touchstone Health 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: Touchstone Health requires you or your physician to get prior authorization for certain drugs. This means that you will need to get approval from Touchstone Health before you fill your prescriptions. If you don t get approval, Touchstone Health may not cover the drug. Quantity Limits: For certain drugs, Touchstone Health limits the amount of the drug that Touchstone Health will cover. For example, Touchstone Health provides 30 capsules per prescription for NEXIUM. This may be in addition to a standard one-month or three-month supply. Step Therapy: In some cases, Touchstone Health 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, Touchstone Health may not cover Drug B unless you try Drug A first. If Drug A does not work for you, Touchstone Health will then cover Drug B. You can find out if your drug has any additional requirements or limits by looking in the formulary that begins on page 1. You can also get more information about the restrictions applied to specific covered drugs by visiting our Web site. We have posted on line documents that explain our prior authorization and step therapy restrictions. You may also ask us to send you a copy. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages. You can ask Touchstone Health 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 Touchstone Health s formulary? on page IV for information about how to request an exception. III

6 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 Member Services and ask if your drug is covered. For more information, 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 learn that Touchstone Health does not cover your drug, you have two options: You can ask Member Services for a list of similar drugs that are covered by Touchstone Health. When you receive the list, show it to your doctor and ask him or her to prescribe a similar drug that is covered by Touchstone Health. You can ask Touchstone Health to make an exception and cover your drug. See below for information about how to request an exception. How do I request an exception to the Touchstone Health s Formulary? You can ask Touchstone Health 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 a drug even if it is not on our formulary. If approved, this drug will be covered at a pre-determined cost-sharing level, and you would not be able to ask us to provide the drug at a lower cost-sharing level. 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, Touchstone Health 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, Touchstone Health will only approve your request for an exception if the alternative drugs included on the plan s formulary, the lower cost-sharing drug or additional utilization restrictions would not be as effective in treating your condition and/or would cause you to have adverse medical effects. You should contact us to ask us for an initial coverage decision for a formulary, tiering or utilization restriction exception. When you request a formulary, tiering or utilization restriction exception you should submit a statement from your prescriber or physician supporting your request. Generally, we must make our decision within 72 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 72 hours for a decision. If your request to expedite is granted, we must give you a decision no later than 24 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 IV

7 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 93-day transition supply, consistent with dispensing increment, (unless you have a prescription written for fewer days). We will cover more than one refill of these drugs for the first 90days you are a member of our plan. If you need a drug that is not on our formulary or if your ability to get your drugs is limited, but you are past the first 90 days of membership in our plan, we will cover a 31-day emergency supply of that drug (unless you have a prescription for fewer days) while you pursue a formulary exception. Other times when we will cover a temporary 30-day transition supply (unless you have a prescription for fewer days) include: If you enter or leave a long-term care facility If you are discharged from a hospital If you leave a skilled nursing facility If you cancel hospice care If you are discharged from a psychiatric hospital on a special medication regimen For more information For more detailed information about your Touchstone Health prescription drug coverage, please review your Evidence of Coverage and other plan materials. If you have questions about Touchstone Health, please contact us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages. If you have general questions about Medicare prescription drug coverage, please call Medicare at MEDICARE ( ) 24 hours a day/7 days a week. TTY users should call Or, visit Touchstone Health s Formulary The formulary that begins on the next page provides coverage information about the drugs covered by Touchstone Health. If you have trouble finding your drug in the list, turn to the Index that begins on page 82. The first column of the chart lists the drug name. Brand name drugs are capitalized (e.g., CELEBREX) and generic drugs are listed in lower-case italics (e.g., atorvastatin). The information in the Requirements/Limits column tells you if Touchstone Health has any special requirements for coverage of your drug. V

8 Below is a list of abbreviations that may appear on the following pages in the Requirement/Limits column that tells you if there are any special requirements for coverage of your drug. ABBREVIATION DEFINITION DESCRIPTION LA LIMITED AVAILABILITY This prescription may be available only at certain pharmacies. For more information consult your Pharmacy Directory or call Member Concierge at , TTY/TDD call 711, Monday-Friday, 8AM to 8PM. PA PRIOR AUTHORIZATION The Plan requires you or your physician to get prior authorization for certain drugs. This means that you will need to get approval before you fill your prescriptions. If you don t get approval, we may not cover the drug. PA* PRIOR AUTHORIZATION NEW STARTS The Plan requires you or your physician to get prior authorization for this drug if this drug is new for you. ST STEP THERAPY In some cases, the Plan 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. QL QUANTITY LIMIT For certain drugs, the Plan limits the amount of the drug that we will cover. For example, the Plan provides 30 capsules per prescription for NEXIUM. VI

9 MO MAIL ORDER This prescription drug is available through our mail-order service, as well as through our retail network pharmacies. Consider using mail order for your long-term (maintenance) medications (such as high blood pressure medications). Retail network pharmacies may be more appropriate for short-term prescriptions (such as antibiotics). B/D MEDICARE B vs. D 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. The co-pay or coinsurance may vary depending on the benefit. Please refer to our Evidence of Coverage for more information. 1 TIER 1 Preferred Generic drugs on the Touchstone Health Formulary. 2 TIER 2 Non-Preferred Generic drugs on the Touchstone Health Formulary. 3 TIER 3 Preferred Brand drugs on the Touchstone Health Formulary. 4 TIER 4 Non-Preferred Brand drugs on the Touchstone Health Formulary. 5 TIER 5 High cost oral and injectable specialty drugs. These medications are available to you at a coinsurance level and are not eligible for exceptions for payment at a lower tier. VII

10 ANALGESICS Analgesics alagesic lq sol 2 apap/codeinesol120-12/5 1 QL per 30 days apap/codeinetab300-15mg 2 QL per 30 days apap/codeinetab300-30mg 2 QL per 30 days apap/codeinetab300-60mg 2 QL per 30 days ascomp/cod cap30mg 2 QL per 30 days but/apap/cafcap 2 but/apap/cafcapcodeine 2 QL per 30 days but/apap/caftab 2 but/asa/caffcap 2 butal/apap tab50-325mg 2 diclo/misoprtab50-0.2mg 2 diclo/misoprtab75-0.2mg 2 hycet sol QL per 30 days hydroco/apapsol QL per 30 days hydroco/apaptab10-300mg 2 QL per 30 days hydroco/apaptab10-325mg 2 QL per 30 days hydroco/apaptab5-300mg 2 QL per 30 days hydroco/apaptab5-325mg 2 QL per 30 days hydroco/apaptab QL per 30 days hydroco/apaptab QL per 30 days hydrocod/ibutab QL per 30 days oxycod/apap tab10-325mg 2 QL per 30 days oxycod/apap tab QL per 30 days oxycod/apap tab5-325mg 2 QL per 30 days oxycod/apap tab QL per 30 days oxycod/asa tab 2 QL per 30 days oxycod/ibu tab5-400mg 2 QL per 30 days reprexain tab10-200mg 1 QL per 30 days reprexain tab QL per 30 days reprexain tab5-200mg 1 QL per 30 days tramadl/apaptab QL per 30 days vicodin tab5-300mg 2 QL per 30 days vicodin es tab QL per 30 days vicodin hp tab10-300mg 2 QL per 30 days xodol tab10-300mg 2 QL per 30 days xodol tab5-300mg 2 QL per 30 days xodol tab QL per 30 days zamicet sol10-325mg 1 QL per 30 days Nonsteroidal Anti-Inflammatory Drugs

11 celecoxib cap100mg 2 QL - 60 per 30 days celecoxib cap200mg 2 QL - 60 per 30 days celecoxib cap400mg 2 QL - 60 per 30 days celecoxib cap50mg 2 QL - 60 per 30 days diclofen pottab50mg 2 diclofenac tab100mg er 2 diclofenac tab25mg dr 2 diclofenac tab50mg dr 2 diclofenac tab75mg dr 2 diflunisal tab500mg 2 etodolac cap200mg 2 etodolac cap300mg 2 etodolac tab400mg 2 etodolac tab500mg 2 etodolac er tab400mg 2 etodolac er tab500mg 2 etodolac er tab600mg 2 fenoprofen tab600mg 2 FLECTOR DIS1.3% 4 PA flurbiprofentab100mg 2 flurbiprofentab50mg 2 ibuprofen sus100/5ml 1 ibuprofen tab400mg 1 ibuprofen tab600mg 1 ibuprofen tab800mg 1 indomethacincap25mg 1 indomethacincap50mg 1 indomethacincap75mg er 1 ketoprofen cap200mg er 2 ketoprofen cap50mg 2 ketoprofen cap75mg 2 ketorolac tab10mg 1 meclofen sodcap100mg 2 meclofen sodcap50mg 2 mefenam acidcap250mg 2 meloxicam tab15mg 2 QL - 30 per 30 days meloxicam tab7.5mg 2 QL - 30 per 30 days nabumetone tab500mg 2 nabumetone tab750mg 2 naproxen sus125/5ml 1 naproxen tab250mg 1 naproxen tab375mg 1 naproxen tab500mg 1 naproxen dr tab375mg 1 2

12 naproxen dr tab500mg 1 naproxen sodtab275mg 1 naproxen sodtab550mg 1 oxaprozin tab600mg 2 piroxicam cap10mg 2 piroxicam cap20mg 2 sulindac tab150mg 2 sulindac tab200mg 2 tolmetin sodcap400mg 2 tolmetin sodtab200mg 2 tolmetin sodtab600mg 2 Opioid Analgesics, Long-Acting fentanyl dis100mcg/h 2 QL - 30 per 30 days fentanyl dis12mcg/hr 2 QL - 30 per 30 days fentanyl dis25mcg/hr 2 QL - 30 per 30 days fentanyl dis50mcg/hr 2 QL - 30 per 30 days fentanyl dis75mcg/hr 2 QL - 30 per 30 days fentanyl dis37.5mcg/hr 2 QL - 30 per 30 days fentanyl dis62.5mcg/hr 2 QL - 30 per 30 days fentanyl dis87.5mcg/hr 2 QL - 30 per 30 days hydromorphontab12mg er 2 hydromorphontab16mg er 2 hydromorphontab8mg er 2 hydromorphontab32mg er 2 levorphanol tab2mg 2 QL per 30 days METHADONE INJ10MG/ML 4 QL per 30 days; B/D methadone sol10mg/5ml 2 QL per 30 days methadone sol5mg/5ml 2 QL per 30 days methadone tab10mg 2 QL per 30 days methadone tab5mg 2 QL per 30 days morphine sulcap100mg er 2 QL - 60 per 30 days morphine sulcap10mg er 2 QL - 60 per 30 days morphine sulcap120mg er 2 QL - 60 per 30 days morphine sulcap20mg er 2 QL - 60 per 30 days morphine sulcap30mg er 2 QL - 60 per 30 days morphine sulcap30mg er 2 QL - 60 per 30 days morphine sulcap45mg er 2 QL - 60 per 30 days morphine sulcap50mg er 2 QL - 60 per 30 days morphine sulcap60mg er 2 QL - 60 per 30 days morphine sulcap60mg er 2 QL - 60 per 30 days morphine sulcap75mg er 2 QL - 60 per 30 days morphine sulcap80mg er 2 QL - 60 per 30 days morphine sulcap90mg er 2 QL - 60 per 30 days morphine sultab100mg er 2 QL per 30 days 3

13 morphine sultab15mg er 2 QL per 30 days morphine sultab200mg er 2 QL per 30 days morphine sultab30mg er 2 QL per 30 days morphine sultab60mg er 2 QL per 30 days OXYCONTIN TAB10MG CR 3 ST; QL - 90 per 30 days OXYCONTIN TAB15MG CR 3 ST; QL - 90 per 30 days OXYCONTIN TAB20MG CR 3 ST; QL - 90 per 30 days OXYCONTIN TAB30MG CR 3 ST; QL - 90 per 30 days OXYCONTIN TAB40MG CR 3 ST; QL - 90 per 30 days OXYCONTIN TAB60MG CR 3 ST; QL - 90 per 30 days OXYCONTIN TAB80MG CR 3 ST; QL - 90 per 30 days oxymorphone tab10mg er 1 QL - 90 per 30 days oxymorphone tab15mg er 1 QL - 90 per 30 days oxymorphone tab20mg er 1 QL - 90 per 30 days oxymorphone tab30mg er 1 QL - 90 per 30 days oxymorphone tab40mg er 1 QL - 90 per 30 days oxymorphone tab5mg er 1 QL - 90 per 30 days oxymorphone tab7.5mg er 1 QL - 90 per 30 days tramadol hcltab100mg er 2 QL - 30 per 30 days tramadol hcltab200mg er 2 QL - 30 per 30 days tramadol hcltab300mg er 2 QL per 30 days Opioid Analgesics, Short-Acting butorphanol inj1mg/ml 1 QL per 30 days butorphanol inj2mg/ml 1 QL per 30 days butorphanol sol10mg/ml 2 QL - 10 per 30 days CODEINE SULFTAB15MG 1 QL per 30 days CODEINE SULFTAB30MG 1 QL - 90 per 30 days CODEINE SULFTAB60MG 1 QL per 30 days duramorph inj0.5mg/ml 2 QL per 30 days; B/D duramorph inj1mg/ml 2 QL per 30 days; B/D fentanyl ot loz1200mcg 5 QL per 30 days; PA fentanyl ot loz1600mcg 5 QL per 30 days; PA fentanyl ot loz200mcg 2 QL per 30 days; PA fentanyl ot loz400mcg 5 QL per 30 days; PA fentanyl ot loz600mcg 5 QL per 30 days; PA fentanyl ot loz800mcg 5 QL per 30 days; PA hydromorphoninj500/50ml 1 QL per 30 days hydromorphontab2mg 2 QL per 30 days hydromorphontab4mg 2 QL per 30 days hydromorphontab8mg 2 QL per 30 days morphine sulsol10mg/5ml 2 QL per 30 days MORPHINE SULSOL20MG/5ML 2 QL per 30 days morphine sulsol20mg/ml 2 QL per 30 days 4

14 morphine sultab15mg 2 QL per 30 days morphine sultab30mg 2 QL per 30 days nalbuphine inj10mg/ml 4 QL per 30 days; B/D nalbuphine inj20mg/ml 4 QL per 30 days; B/D oxycodone cap5mg 2 QL per 30 days oxycodone con100/5ml 2 QL per 30 days oxycodone tab10mg 2 QL per 30 days oxycodone tab15mg 2 QL per 30 days oxycodone tab20mg 2 QL per 30 days oxycodone tab30mg 2 QL per 30 days oxycodone tab5mg 2 QL per 30 days tramadol hcltab50mg 2 QL per 30 days ANESTHETICS Local Anesthetics lido/prilocncre % 2 lidocaine gel2% jelly 2 lidocaine gel2% jelly 2 lidocaine gel2% jelly 2 lidocaine inj0.5% 4 B/D lidocaine inj1% 4 lidocaine oin5% 2 lidocaine pad5% 2 QL - 90 per 30 days; PA lidocaine sol2% visc 1 lidocaine sol4% 1 ANTI-ADDICTION/SUBSTANCE ABUSE TREATMENT AGENTS Alcohol Deterrents/Anti-craving acampro cal tab333mg 2 disulfiram tab250mg 2 MO disulfiram tab500mg 2 MO VIVITROL INJ380MG 5 PA Opioid Dependence Treatments bupren/naloxsub2-0.5mg 2 QL per 30 days; MO bupren/naloxsub8-2mg 2 QL per 30 days; MO buprenorphininj0.3mg/ml 3 MO buprenorphinsub2mg 2 QL per 30 days; MO buprenorphinsub8mg 2 QL per 30 days; MO BUTRANS DIS10MCG/HR 4 QL - 4 per 28 days BUTRANS DIS15MCG/HR 4 QL - 4 per 28 days BUTRANS DIS20MCG/HR 4 QL - 4 per 28 days BUTRANS DIS5MCG/HR 4 QL - 4 per 28 days SUBOXONE MIS12-3MG 4 QL per 30 days; MO 5

15 SUBOXONE MIS2-0.5MG 4 QL - 90 per 30 days; MO SUBOXONE MIS4-1MG 4 QL per 30 days; MO SUBOXONE MIS8-2MG 4 QL - 90 per 30 days; MO Opioid Reversal Agents naloxone inj1mg/ml 3 MO naltrexone tab50mg 2 MO Smoking Cessation Agents buproban tab150mg 2 QL - 90 per 30 days; MO bupropion tab100mg 2 QL per 30 days; MO bupropion tab100mg sr 2 QL - 60 per 30 days; MO bupropion tab150mg sr 2 QL - 90 per 30 days; MO bupropion tab200mg sr 2 QL - 30 per 30 days; MO bupropion tab75mg 2 QL per 30 days; MO bupropn hcl tab150mg xl 2 MO bupropn hcl tab300mg xl 2 MO CHANTIX PAK0.5& 1MG 3 QL - 60 per 30 days; PA; MO CHANTIX TAB0.5MG 3 QL - 60 per 30 days; PA; MO CHANTIX TAB1MG 3 QL - 60 per 30 days; PA; MO FORFIVO XL TAB450MG 4 QL - 30 per 30 days NICOTROL NS SPR10MG/ML 4 QL - 40 per 30 days; MO ANTIBACTERIALS Aminoglycosides gentak oin0.3% op 2 gentam/nacl inj0.9mg/ml 1 gentam/nacl inj1.4mg/ml 1 gentam/nacl inj100mg 1 gentam/nacl inj60mg 1 gentam/nacl inj80mg 4 gentam/nacl inj80mg 1 gentamicin cre0.1% 2 gentamicin inj10mg/ml 2 gentamicin inj40mg/ml 2 B/D GENTAMICIN OIN0.1% 1 gentamicin sol0.3% op 2 neomycin tab500mg 2 paromomycin cap250mg 2 streptomycininj1gm 3 tobra/nacl inj80/0.9 1 B/D TOBRADEX OIN % 4 tobramycin inj10mg/ml 4 B/D tobramycin inj80mg/2ml 4 B/D tobramycin neb300/5ml 5 PA tobramycin sol0.3% op 2 6

16 Antibacterials cefotetan inj10g 1 cefotetan inj1gm/10ml 1 cefotetan inj2gm/20ml 1 colistimeth inj150mg 4 B/D neo/poly gu sol40/ml ir 2 SYNERCID INJ500MG 5 B/D Antibacterials, Other acetic acid sol2% otic 2 baciim inj50000unt 4 B/D bacitracin oinop 2 chloramphen inj1gm 2 B/D clindamycin cap150mg 2 clindamycin cap300mg 2 clindamycin cre2% vag 2 clindamycin gel1% 2 clindamycin inj150mg/ml 4 clindamycin lot1% 2 clindamycin pad1% 2 clindamycin sol1% 2 CUBICIN SOL500MG 4 B/D linezolid inj2mg/ml 5 PA mafenide acepak5% 2 methenam hiptab1gm 2 metron/nacl inj500mg 1 metronidazolcre0.75% 2 metronidazolgel0.75% 2 metronidazolgel0.75%vag 2 metronidazollot0.75% 2 metronidazoltab250mg 2 metronidazoltab500mg 2 mupirocin cre2% 2 mupirocin oin2% 2 nitrofur maccap50mg 2 nitrofurantncap100mg 2 nitrofurantnsus25mg/5ml 2 polymyxin b inj primsol sol50mg/5ml 3 SULFAMYLON CRE85MG/GM 4 tinidazole tab250mg 1 tinidazole tab500mg 1 trimethoprimtab100mg 2 TYGACIL INJ50MG 4 PA vancomycin cap125mg 5 7

17 vancomycin cap250mg 5 vancomycin inj1000mg 4 PA vancomycin inj10gm 4 PA vancomycin inj500mg 4 PA XIFAXAN TAB550MG 5 ZYVOX SOL2MG/ML 5 PA ZYVOX SUS100MG/5M 5 PA ZYVOX TAB600MG 5 QL - 28 per 14 days; PA Beta-lactam, Cephalosporins cefaclor cap250mg 1 cefaclor cap500mg 1 cefaclor er tab500mg 1 cefadroxil cap500mg 1 cefadroxil sus250/5ml 1 cefadroxil sus500/5ml 1 cefadroxil tab1gm 1 cefazolin inj10gm 4 B/D cefazolin inj1gm 4 B/D cefazolin inj1gm/50ml 4 B/D cefazolin inj500mg 4 B/D cefdinir cap300mg 2 cefdinir sus125/5ml 2 cefdinir sus250/5ml 2 cefepime inj1gm 1 B/D cefepime inj2gm 1 B/D cefotaxime inj10gm 1 cefoxitin inj10gm 4 B/D cefoxitin inj1gm 4 cefoxitin inj1gm 4 B/D cefoxitin inj2gm 4 B/D cefoxitin inj2gm 4 cefpodo proxsus100/5ml 2 cefpodo proxsus50mg/5ml 2 cefpodoxime tab100mg 2 cefpodoxime tab200mg 2 cefprozil sus125/5ml 2 cefprozil sus250/5ml 2 cefprozil tab250mg 2 cefprozil tab500mg 2 ceftazidime inj1gm 1 ceftazidime inj2gm 1 ceftazidime inj6gm 1 ceftriaxone inj10gm 4 B/D ceftriaxone inj1gm 4 8

18 ceftriaxone inj250mg 4 B/D ceftriaxone inj2gm 4 ceftriaxone inj500mg 4 B/D cefuroxime inj1.5gm 4 B/D cefuroxime inj7.5gm 4 B/D cefuroxime inj750mg 4 B/D cefuroxime tab250mg 2 cefuroxime tab500mg 2 cephalexin cap250mg 1 cephalexin cap500mg 1 cephalexin sus125/5ml 1 cephalexin sus250/5ml 1 cephalexin tab250mg 1 cephalexin tab500mg 1 SUPRAX CAP400MG 4 suprax chw100mg 2 suprax chw200mg 2 SUPRAX SUS100/5ML 4 SUPRAX SUS200/5ML 4 SUPRAX SUS500/5ML 4 SUPRAX TAB400MG 4 TEFLARO INJ400MG 4 B/D TEFLARO INJ600MG 4 B/D Beta-lactam, Other AZACTAM/DEX INJ1GM 4 AZACTAM/DEX INJ2GM 5 aztreonam inj1gm 2 imipenem/cilinj250mg 2 imipenem/cilinj500mg 2 INVANZ INJ1GM 4 meropenem inj500mg 2 B/D Beta-lactam, Penicillins amox/k clav chw200mg 1 amox/k clav chw400mg 1 amox/k clav sus200/5ml 1 amox/k clav sus250/5ml 1 amox/k clav sus400/5ml 1 amox/k clav sus600/5ml 1 amox/k clav tab250mg 1 amox/k clav tab500mg 1 amox/k clav tab875mg 1 amoxicillin cap250mg 1 amoxicillin cap500mg 1 amoxicillin chw125mg 1 9

19 amoxicillin chw250mg 1 amoxicillin sus125/5ml 1 amoxicillin sus200/5ml 1 amoxicillin sus250/5ml 1 amoxicillin sus400/5ml 1 amoxicillin tab500mg 1 amoxicillin tab875mg 1 amox-pot clataber 1 ampicillin cap250mg 1 ampicillin cap500mg 1 ampicillin inj10gm 4 B/D ampicillin inj125mg 4 B/D ampicillin inj1gm 4 B/D ampicillin sus125/5ml 1 ampicillin sus250/5ml 1 amp-sulbactainj1.5gm 4 B/D amp-sulbactainj15gm 4 B/D amp-sulbactainj3gm 4 B/D BICILLIN C-RINJ BICILLIN C-RINJ900/300 3 BICILLIN L-AINJ BICILLIN L-AINJ BICILLIN L-AINJ dicloxacill cap250mg 1 dicloxacill cap500mg 1 nafcillin inj10gm 5 B/D nafcillin inj1gm 4 B/D oxacillin inj10gm 5 oxacillin inj2gm 1 pen g proc inj B/D pen g sod inj B/D PENICILL GK/INJDEX 2MU 4 B/D PENICILL GK/INJDEX 3MU 4 B/D penicilln gkinj5mu 4 B/D penicilln vksol125/5ml 1 penicilln vksol250/5ml 1 penicilln vktab250mg 1 penicilln vktab500mg 1 piper/tazobainj g 1 ZOSYN SOL2-0.25GM 4 PA ZOSYN SOL G 4 PA Macrolides azithromycininj500mg 4 B/D azithromycinsus100/5ml 2 QL - 30 per 5 days 10

20 azithromycinsus200/5ml 2 QL - 90 per 5 days azithromycintab250mg 2 QL - 6 per 5 days azithromycintab500mg 2 QL - 6 per 5 days azithromycintab600mg 2 QL - 6 per 5 days clarithromycsus125/5ml 2 clarithromycsus250/5ml 2 clarithromyctab250mg 2 QL - 28 per 14 days clarithromyctab500mg 2 QL - 28 per 14 days clarithromyctab500mg er 2 QL - 28 per 14 days DIFICID TAB200MG 5 PA ery pad2% 2 ery-tab tab250mg ec 2 ery-tab tab333mg ec 2 ery-tab tab500mg ec 2 ERYTHROCIN INJ500MG 4 B/D erythrocin tab250mg 2 ERYTHROM ETHTAB400MG 4 erythromycingel2% 2 erythromycinoinop 2 erythromycinsol2% 2 erythromycintab250mg bs 2 erythromycintab500mg bs 2 ZMAX SUS2GM 4 QL - 60 per 30 days Quinolones AVELOX INJ 4 B/D CILOXAN OIN0.3% OP 4 ciprofloxacninj400mg 4 ciprofloxacnsol0.3% op 2 ciprofloxacnsus250mg/5 2 ciprofloxacnsus500mg/5 2 ciprofloxacntab1000mg 2 ciprofloxacntab100mg 2 ciprofloxacntab250mg 1 ciprofloxacntab500mg 1 ciprofloxacntab500mg er 2 ciprofloxacntab750mg 2 gatifloxacinsol0.5% 1 levofloxacinsol0.5% 2 levofloxacinsol25mg/ml 2 levofloxacintab250mg 2 QL - 14 per 14 days levofloxacintab500mg 2 QL - 14 per 14 days levofloxacintab750mg 2 QL - 14 per 14 days moxifloxacintab400mg 2 QL - 10 per 10 days ofloxacin dro0.3% op 2 11

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