2015 ( ) Health Net Cal MediConnect Plan (Medicare-Medicaid Plan) Health Net Cal MediConnect

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12 List of s by medical condition ADHD/AI-NARCOLEPSY/AI- OBESITY/ANOREXIAS - Drugs to Treat ADHD, Sleep and Eating Disorders Amphetamines ADDERALL XR (Use Amphetamine- Dextroamphetamine) DESOXYN (Use Methamphetamine HCl) DEXEDRINE 10 MG,15 MG,5 MG (Use Dextroamphetamine Sulfate) dextroamphetamine sulfate cp24 10 mg, 15 mg, 5 mg dextroamphetamine sulfate tabs 10 mg, 5 mg methamphetamine hcl amphetaminedextroamphetamine Anorexiants Non-Amphetamine ADIPEX-P (Use Phentermine HCl) diethylpropion hcl tabs 25 mg DIETHYLPROPION HCL TABS 25 MG (Use Diethylpropion HCl) diethylpropion hcl tb24 75 mg PA; ; PA; ; PA; ; PA; ; phentermine hcl QSYMIA REGIMEX SUPRENZA Anti-Obesity Agents ALLI BELVIQ CORAVE SAXENDA PA; ; PA; PA; ; PA; ; PA; PA; ; PA; ; PA; ; Attention-Deficit/Hyperactivity Disorder (ADHD) clonidine hcl (adhd) AL; guanfacine hcl (adhd) AL; IUNIV (Use Guanfacine HCl (ADHD)) KAPVAY (Use Clonidine HCl (ADHD)) You can find information on what symbols and abbreviations on this table mean by going to 1

13 STRATTERA Stimulants - Misc. CONCERTA 27 MG, 36 MG (Use Methylphenidate HCl) dexmethylphenidate hcl cp24 15 mg dexmethylphenidate hcl tabs 10 mg, 2.5 mg, 5 mg FOCALIN (Use Dexmethylphenidate HCl) FOCALIN XR 15 MG (Use Dexmethylphenidate HCl) METADATE CD (Use Methylphenidate HCl) methylphenidate hcl cp24 or 20 mg, 30 mg, 40 mg methylphenidate hcl cpcr or 10 mg, 20 mg, 30 mg, 40 mg, 50 mg, 60 mg methylphenidate hcl tabs or 10 mg, 20 mg, 5 mg methylphenidate hcl tb24 or 27 mg, 36 mg methylphenidate hcl tbcr or 20 mg, 27 mg, 36 mg modafinil PROVIGIL (Use Modafinil) RITALIN (Use Methylphenidate HCl) RITALIN LA 20 MG, 30 MG, 40 MG (Use Methylphenidate HCl) RITALIN LA 60 MG RITALIN SR (Use Methylphenidate HCl) ALTERNATIVE MEDICINES Alternative Medicine - A's ALPHA LIPOIC ACID CAPS OR 50 MG ALPHA-LIPOIC ACID alpha-lipoic acid (thioctic acid) caps 100 mg Alternative Medicine - C's CHEW Q 100 MG coenzyme q10 (ubidecarenone) caps 10 mg, 60 mg coenzyme q10 (ubidecarenone) caps 150 mg, 30 mg COENZYME Q10 CHEW OR 60 MG PA; PA; ; ; You can find information on what symbols and abbreviations on this table mean by going to 2

14 COENZYME Q10 TABS OR 25 MG Alternative Medicine - G's glucosamine sulfate caps or 500 mg glucosamine sulfate tabs or 500 mg Alternative Medicine - L's lutein caps or 6 mg ; ; Alternative Medicine Combinations glucosamine-chondroitin caps 200mg-250mg glucosamine-chondroitin tabs 200mg-250mg LIQ-10 50MG/5ML- 15UNIT/5ML VITALINE COQ10/VITAMIN E 100MG-300UNIT ; AMINOGLYCOSIDES - Drugs to Treat Bacterial Infections Aminoglycosides amikacin sulfate soln ij 1 gm/4ml, 500 mg/2ml BETHKIS B/D gentamicin in saline 0.9%- 0.8mg/ml gentamicin in saline 0.9%- 1.2mg/ml, 0.9%-1.6mg/ml, 0.9%-1mg/ml gentamicin sulfate soln ij 40 mg/ml gentamicin sulfate soln iv 10 mg/ml neomycin sulfate tabs or paromomycin sulfate TOBI (Use Tobramycin) B/D TOBI PODHALER tobramycin nebu in tobramycin sulfate soln ij 1.2 gm/30ml, 40 mg/ml, 80 mg/2ml tobramycin sulfate soln ij 10 mg/ml B/D You can find information on what symbols and abbreviations on this table mean by going to 3

15 tobramycin sulfate solr ij 1.2 gm ANALGESICS - AI-ILAMMATORY - Drugs to Treat Pain, Swelling, Muscle and Joint Conditions Anti-T-alpha - Monoclonal Antibodies PA HUMIRA HUMIRA PEDIATRIC PA CROHNS DISEASE STARTER PACK PA HUMIRA PEN HUMIRA PEN-CROHNS DISEASESTARTER HUMIRA PEN-PSORIASIS STARTER SIMPONI SIMPONI ARIA PA PA PA PA Antirheumatic - Enzyme Inhibitors PA XELJANZ Antirheumatic Antimetabolites OTREXUP RASUVO Gold Compounds RIDAURA Interleukin-1 Blockers ARCALYST PA PA LA Interleukin-1 Receptor Antagonist (IL-1Ra) PA KINERET Interleukin-1beta Blockers ILARIS LA Interleukin-6 Receptor Inhibitors PA ACTEMRA Nonsteroidal Anti-inflammatory Agents (NSAIDs) ADVIL (Use Ibuprofen) ; ADVIL MIGRAINE (Use Ibuprofen) ALEVE CAPS (Use Naproxen Sodium) ; You can find information on what symbols and abbreviations on this table mean by going to 4

16 ANAPROX (Use Naproxen Sodium) ANAPROX DS (Use Naproxen Sodium) ARTHROTEC 50 (Use Diclofenac w/ Misoprostol) ARTHROTEC 75 (Use Diclofenac w/ Misoprostol) CATAFLAM (Use Diclofenac Potassium) CELEBREX (Use Celecoxib) celecoxib CHILDRENS TRIN CHEW 50 MG CHILDRENS TRIN JUNIOR STRENGTH (Use Ibuprofen) CHILDRENS TRIN SUSP 40 MG/ML (Use Ibuprofen) DAYPRO (Use Oxaprozin) diclofenac potassium diclofenac sodium tb24 or 100 mg diclofenac sodium tbec or 25 mg, 50 mg, 75 mg ; diclofenac w/ misoprostol EC-NAPROSYN (Use Naproxen) etodolac caps or 200 mg, 300 mg etodolac tabs or 400 mg, 500 mg etodolac tb24 or 400 mg, 500 mg, 600 mg FELDENE (Use Piroxicam) flurbiprofen tabs or 100 mg, 50 mg ibuprofen caps or 200 mg ibuprofen chew or 100 mg ibuprofen susp or 100 mg/5ml ibuprofen susp or 40 mg/ml, 50 mg/1.25ml ibuprofen tabs or 100 mg ibuprofen tabs or 200 mg ; ; RX/OTC; ; You can find information on what symbols and abbreviations on this table mean by going to 5

17 ibuprofen tabs or 400 mg ibuprofen tabs or 600 mg ibuprofen tabs or 800 mg indomethacin caps or 25 mg, 50 mg indomethacin cpcr or 75 mg IAS ADVIL (Use Ibuprofen) ketoprofen caps or 50 mg, 75 mg ketorolac tromethamine soln ij 15 mg/ml, 30 mg/ml ketorolac tromethamine soln im 30 mg/ml, 60 mg/2ml mefenamic acid caps or meloxicam tabs or 15 mg, 7.5 mg QL(8 ea daily); QL(5 ea daily); QL(4 ea daily); AL; AL; AL; AL; BIC TABS 15 MG, 7.5 MG (Use Meloxicam) TRIN IAS (Use Ibuprofen) TRIN IAS DROPS (Use Ibuprofen) TRIN JUNIOR STRENGTH CHEW (Use Ibuprofen) TRIN JUNIOR STRENGTH TABS (Use Ibuprofen) nabumetone NAPROSYN (Use Naproxen) naproxen sodium caps or 220 mg naproxen sodium tabs or 275 mg, 550 mg naproxen tabs or 250 mg, 375 mg, 500 mg naproxen tbec or 375 mg, 500 mg oxaprozin piroxicam caps or 10 mg, 20 mg ; You can find information on what symbols and abbreviations on this table mean by going to 6

18 PONSTEL (Use Mefenamic Acid) sulindac tabs or 150 mg, 200 mg tolmetin sodium caps 400 mg tolmetin sodium tabs 200 mg VOLTAREN-XR (Use Diclofenac Sodium) Phosphodiesterase 4 (PDE4) Inhibitors PA OTEZLA Pyrimidine Synsis Inhibitors ARAVA (Use Leflunomide) leflunomide tabs or 10 mg, 20 mg Selective Costimulation Modulators PA ORENCIA Soluble Tumor Necrosis Factor Receptor Agents PA ENBREL ENBREL SURECLICK PA ANALGESICS - NonNarcotic - Drugs to Treat Pain, Muscle and Joint Conditions Analgesic Combinations acetaminophen-caffeinepyrilamine BIPHENOX MIDOL COMPLETE 500MG-15MG-60MG (Use Acetaminophen-Caffeine- Pyrilamine) MIDOL MAXIMUM STRENGTH MENSTRUAL (Use Acetaminophen- Caffeine-Pyrilamine) MIDOL MAXIMUM STRENGTH MENSTRUAL FORMULA (Use Acetaminophen-Caffeine- Pyrilamine) Analgesics Or acetaminophen chew or 160 mg acetaminophen chew or 80 mg acetaminophen elix or 160 mg/5ml, 80 mg/2.5ml acetaminophen liqd or 160 mg/5ml acetaminophen soln or 100 mg/ml, 160 mg/5ml, 80 mg/0.8ml ; ; ; You can find information on what symbols and abbreviations on this table mean by going to 7

19 acetaminophen supp re 120 mg acetaminophen susp or 160 mg/5ml, 80 mg/2.5ml acetaminophen susp or 80 mg/0.8ml acetaminophen tbdp or 160 mg acetaminophen tbdp or 80 mg ELIXSURE FEVER/PAIN FEVERALL IAS TYLENOL CHILDRENS (Use Acetaminophen) TYLENOL CHILDRENS/FLAVORCRE ATOR (Use Acetaminophen) TYLENOL IAS 160 MG/5ML (Use Acetaminophen) TYLENOL IAS 80 MG/0.8ML (Use Acetaminophen) TYLENOL JR MELTAWAYS (Use Acetaminophen) Salicylates ASCRIPTIN ; ; ; ; ; ; ; aspirin buffered (cal carbmag carb-mag oxide) ASPIRIN SUPP RE 120 MG, 200 MG aspirin supp re 300 mg, 600 mg aspirin tabs or 325 mg aspirin tabs or 81 mg aspirin tbec or 324 mg, 325 mg, 500 mg, 81 mg BUFFERIN (Use Aspirin Buffered (Cal Carb-Mag Carb-Mag Oxide)) diflunisal ECOTRIN MAXIMUM STRENGTH (Use Aspirin) ECOTRIN REGULAR STRENGTH (Use Aspirin) ; ; ; ; ; ; ANALGESICS - OPIOID - Drugs to Treat Pain, Muscle and Joint Conditions Opioid Agonists ACTIQ 1200 MCG, 1600 MCG, 400 MCG, 600 MCG, 800 MCG (Use Fentanyl Citrate) ACTIQ 200 MCG (Use Fentanyl Citrate) DEMEROL SOLN IJ 100 MG/ML, 50 MG/ML (Use Meperidine HCl) PA; QL(4 ea daily); PA; QL(6 ea daily); You can find information on what symbols and abbreviations on this table mean by going to 8

20 DEMEROL SOLN IJ 25 MG/ML (Use Meperidine HCl) DILAUDID LIQD OR 1 MG/ML (Use Hydromorphone HCl) DILAUDID SOLN IJ 2 MG/ML DILAUDID TABS OR 2 MG (Use Hydromorphone HCl) DILAUDID TABS OR 4 MG (Use Hydromorphone HCl) DILAUDID TABS OR 8 MG (Use Hydromorphone HCl) DILAUDID-HP SOLN 10 MG/ML (Use Hydromorphone HCl) DOLOPHINE 10 MG (Use Methadone HCl) DOLOPHINE 5 MG (Use Methadone HCl) DURAGESIC 100 MCG/HR (Use Fentanyl) DURAGESIC 12 MCG/HR (Use Fentanyl) DURAGESIC 25 MCG/HR (Use Fentanyl) DURAGESIC 50 MCG/HR (Use Fentanyl) DURAGESIC 75 MCG/HR (Use Fentanyl) fentanyl 100 mcg/hr fentanyl 12 mcg/hr QL(30 ml daily); QL(29 ea daily); QL(14 ea daily); QL(7 ea daily); QL(19 ea daily); QL(38 ea daily); QL(1 ea daily); QL(1.44 ea daily); QL(0.7 ea daily); QL(0.74 ea daily); QL(0.61 ea daily); QL(1 ea daily); QL(1.44 ea daily); fentanyl 25 mcg/hr fentanyl 50 mcg/hr fentanyl 75 mcg/hr fentanyl citrate lpop bu 1200 mcg, 1600 mcg, 400 mcg, 600 mcg, 800 mcg fentanyl citrate lpop bu 200 mcg hydromorphone hcl liqd or 1 mg/ml hydromorphone hcl soln ij 10 mg/ml, 2 mg/ml, 50 mg/5ml, 500 mg/50ml hydromorphone hcl tabs or 2 mg hydromorphone hcl tabs or 4 mg hydromorphone hcl tabs or 8 mg QL(0.7 ea daily); QL(0.74 ea daily); QL(0.61 ea daily); PA; QL(4 ea daily); PA; QL(6 ea daily); QL(30 ml daily); QL(29 ea daily); QL(14 ea daily); QL(7 ea daily); You can find information on what symbols and abbreviations on this table mean by going to 9

21 HYSINGLA ER 100 MG, 120 MG HYSINGLA ER 20 MG, 30 MG, 40 MG, 60 MG, 80 MG KADIAN 100 MG (Use Morphine Sulfate) KADIAN 20 MG, 30 MG, 50 MG, 60 MG, 80 MG (Use Morphine Sulfate) LAZANDA 100 MCG/ACT LAZANDA 400 MCG/ACT meperidine hcl soln ij 100 mg/ml, 50 mg/ml meperidine hcl soln ij 25 mg/ml meperidine hcl soln or 50 mg/5ml methadone hcl conc or 10 mg/ml methadone hcl soln or 10 mg/5ml PA; QL(2 ea daily) PA; QL(2 ea daily); QL(6 ea daily); QL(5 ea daily); PA; QL(6 ea daily); PA; QL(4 ea daily) AL; QL(4 ml daily); QL(20 ml daily); methadone hcl soln or 5 mg/5ml methadone hcl tabs or 10 mg methadone hcl tabs or 5 mg METHADOSE 10 MG/ML (Use Methadone HCl) METHADOSE SUGAR- FREE (Use Methadone HCl) morphine sulfate cp24 or 100 mg morphine sulfate cp24 or 20 mg, 30 mg, 50 mg, 60 mg, 80 mg morphine sulfate soln ij 0.5 mg/ml morphine sulfate soln ij 1 mg/ml morphine sulfate soln or 10 mg/5ml morphine sulfate soln or 100 mg/5ml, 20 mg/ml QL(40 ml daily); QL(19 ea daily); QL(38 ea daily); QL(4 ml daily); QL(4 ml daily); QL(6 ea daily); QL(5 ea daily); QL(60 ml daily); QL(6 ml daily); You can find information on what symbols and abbreviations on this table mean by going to 10

22 morphine sulfate soln or 20 mg/5ml RPHINE SULFATE TABS OR 15 MG RPHINE SULFATE TABS OR 30 MG morphine sulfate tbcr or 100 mg, 200 mg, 30 mg, 60 mg morphine sulfate tbcr or 15 mg MS COIN 100 MG, 200 MG, 30 MG, 60 MG (Use Morphine Sulfate) MS COIN 15 MG (Use Morphine Sulfate) OPANA TABS OR 10 MG (Use Oxymorphone HCl) OPANA TABS OR 5 MG (Use Oxymorphone HCl) oxycodone hcl caps or 5 mg oxycodone hcl conc or 100 mg/5ml, 20 mg/ml oxycodone hcl tabs or 15 mg QL(30 ml daily); QL(8 ea daily); QL(14 ea daily); QL(8 ea daily); QL(8 ea daily); QL(4 ea daily); QL(8 ea daily); QL(17 ea daily); QL(4 ml daily); QL(11 ea daily); oxycodone hcl tabs or 30 mg oxycodone hcl tabs or 5 mg oxymorphone hcl tabs 10 mg oxymorphone hcl tabs 5 mg oxymorphone hcl tb12 15 mg oxymorphone hcl tb mg ROXICODONE 15 MG (Use Oxycodone HCl) ROXICODONE 30 MG (Use Oxycodone HCl) ROXICODONE 5 MG (Use Oxycodone HCl) SUBSYS 100 MCG, 200 MCG SUBSYS 1200 MCG, 1600 MCG SUBSYS 400 MCG, 600 MCG, 800 MCG QL(15 ea daily); QL(17 ea daily); QL(4 ea daily); QL(8 ea daily); QL(2.67 ea daily); QL(5 ea daily); QL(11 ea daily); QL(15 ea daily); QL(17 ea daily); PA; QL(6 ea daily); PA; QL(4 ea daily) PA; QL(4 ea daily); You can find information on what symbols and abbreviations on this table mean by going to 11

23 tramadol hcl tabs or 50 mg tramadol hcl tb24 or 100 mg tramadol hcl tb24 or 200 mg, 300 mg ULTRAM (Use Tramadol HCl) ULTRAM ER 100 MG (Use Tramadol HCl) ULTRAM ER 200 MG, 300 MG (Use Tramadol HCl) ZOHYDRO ER C12A 10 MG, 15 MG, 20 MG, 30 MG, 40 MG, 50 MG ZOHYDRO ER CP12 10 MG, 15 MG, 20 MG, 30 MG, 40 MG, 50 MG Opioid Combinations acetaminophen w/ codeine soln 120mg/5ml-12mg/5ml acetaminophen w/ codeine tabs 300mg-15mg, 300mg- 30mg, 300mg-60mg butalbital-aspirin-caffeine w/cod FIORINAL/CODEINE #3 (Use Butalbital-Aspirin- Caffeine w/cod) QL(8 ea daily); QL(3 ea daily); QL(1 ea daily); QL(8 ea daily); QL(3 ea daily); QL(1 ea daily); PA; QL(2 ea daily); PA; QL(2 ea daily) QL(166 ml daily); QL(13 ea daily); AL; AL; hydrocodoneacetaminophen soln 2.5mg/5ml-108mg/5ml, 5mg/10ml-217mg/10ml, 7.5mg/15ml-325mg/15ml hydrocodoneacetaminophen tabs 10mg- 300mg, 5mg-300mg, 7.5mg-300mg hydrocodoneacetaminophen tabs 10mg- 325mg, 5mg-325mg, 7.5mg-325mg hydrocodone-ibuprofen oxycodone w/ acetaminophen soln 5mg/5ml-325mg/5ml oxycodone w/ acetaminophen tabs 10mg- 325mg, 2.5mg-325mg, 5mg-325mg, 7.5mg-325mg oxycodone-aspirin PERCODAN (Use Oxycodone-Aspirin) tramadol-acetaminophen ULTRACET (Use Tramadol-Acetaminophen) VICOPROFEN (Use Hydrocodone-Ibuprofen) Opioid Partial Agonists BUPRENEX (Use Buprenorphine HCl) QL(184 ml daily); QL(13 ea daily); QL(12 ea daily); QL(61 ml daily) QL(12 ea daily); QL(12 ea daily); QL(12 ea daily); You can find information on what symbols and abbreviations on this table mean by going to 12

24 buprenorphine hcl soln ij 0.3 mg/ml buprenorphine hcl subl sl 2 mg buprenorphine hcl subl sl 8 mg buprenorphine hclnaloxone hcl dihydrate 2mg-0.5mg buprenorphine hclnaloxone hcl dihydrate 8mg-2mg butorphanol tartrate soln ij 2 mg/ml butorphanol tartrate soln na 10 mg/ml nalbuphine hcl soln ij 10 mg/ml, 20 mg/ml PA; QL(16 ea daily); PA; QL(4 ea daily); PA; QL(16 ea daily); PA; QL(4 ea daily); QL(4.2 ml daily); ANDROGENS-ANABOLIC - Drugs to Regulate Hormones Anabolic Steroids ANADROL-50 OXANDRIN (Use Oxandrolone) oxandrolone tabs or 10 mg, 2.5 mg Androgens ANDRODERM ANDROGEL MG/1.25GM,40.5 MG/2.5GM ANDROGEL 25 MG/2.5GM,50 MG/5GM (Use Testosterone) ANDROGEL PUMP AVEED danazol caps or 100 mg, 200 mg, 50 mg fluoxymesterone tabs or TESTIM testosterone cypionate GL; GL; GL; GL; LA GL; You can find information on what symbols and abbreviations on this table mean by going to 13

25 testosterone enanthate soln im TESTOSTERONE GEL TD 1 %, 25 MG/2.5GM, 50 MG/5GM testosterone gel td 25 mg/2.5gm, 50 mg/5gm TESTOSTERONE PUMP VOGELXO VOGELXO PUMP GL; GL; GL; GL; GL; ANORECTAL AGES - Rectal Drugs to Treat Pain, Swelling and Itching Intrarectal Steroids CORTENEMA (Use Hydrocortisone (Intrarectal)) hydrocortisone (intrarectal) UCERIS FOAM RE 2 MG/ACT Rectal Combinations phenylephrine-shark liver oil-glycerin-petrolatum Rectal Products - Misc. starch (topical) TUCKS (Use Starch (topical)) Rectal Steroids hydrocortisone (rectal) PROCTOCORT CREA 1 % (Use Hydrocortisone (Rectal)) Vasodilating Agents RECTIV ; ; AACIDS - Ulcer and Stomach Acid Drugs Antacid Combinations ALMACONE alum & mag hydroxsimethicone chew 200mg- 25mg-200mg alum & mag hydroxsimethicone liqd 200mg/5ml-20mg/5ml- 200mg/5ml, 400mg/5ml- 40mg/5ml-400mg/5ml ; You can find information on what symbols and abbreviations on this table mean by going to 14

26 alum & mag hydroxsimethicone susp 200mg/5ml-200mg/5ml- 20mg/5ml-20mg/5ml- 200mg/5ml-200mg/5ml, 200mg/5ml-20mg/5ml- 200mg/5ml, 400mg/5ml- 400mg/5ml-40mg/5ml- 40mg/5ml-400mg/5ml- 400mg/5ml, 400mg/5ml- 40mg/5ml-400mg/5ml aluminum hydroxide-mag trisil GELUSIL 200MG-25MG- 200MG (Use Alum & Mag Hydrox-Simethicone) HYVEE ADVANCED AACID MAXIMUM STRENGTH (Use Alum & Mag Hydrox-Simethicone) MYLAA DOUBLE- STRENGTH (Use Alum & Mag Hydrox-Simethicone) MYLAA SUSP 200MG/5ML-20MG/5ML- 200MG/5ML (Use Alum & Mag Hydrox-Simethicone) Antacids - Aluminum Salts ALUMINUM HYDROXIDE Antacids - Calcium Salts calcium carbonate (antacid) 500 mg, 750 mg calcium carbonate (antacid) 600 mg CALCIUM CARBONATE TABS OR 648 MG ; ; ; ; ; ; MAALOX (Use Calcium Carbonate (Antacid)) TUMS (Use Calcium Carbonate (Antacid)) TUMS E-X 750 (Use Calcium Carbonate (Antacid)) TUMS KIDS (Use Calcium Carbonate (Antacid)) TUMS LASTING EFFECTS (Use Calcium Carbonate (Antacid)) TUMS SOTHIES 750 MG (Use Calcium Carbonate (Antacid)) ; ; ; ; ; AHELMIICS - Drugs to Treat Worm Infections Anlmintics ALBENZA ivermectin tabs or STROMECTOL (Use Ivermectin) AI-IECTIVE AGES - MISC. - Drugs to Treat Bacterial Infections Anti-infective Agents - Misc. AZACTAM (Use Aztreonam) aztreonam You can find information on what symbols and abbreviations on this table mean by going to 15

27 CAYSTON colistimethate sodium solr ij COLY-MYCIN M (Use Colistimethate Sodium) FLAGYL (Use Metronidazole) metronidazole caps or 375 mg metronidazole in nacl metronidazole tabs or 250 mg, 500 mg NEBUPE PEAM 300 TINDAMAX (Use Tinidazole) tinidazole tabs or 250 mg, 500 mg trimethoprim tabs or ; B/D VANCOCIN HCL (Use Vancomycin HCl) vancomycin hcl caps or 125 mg, 250 mg VANCOMYCIN HCL IN DEXTROSE vancomycin hcl solr iv 10 gm, 1000 mg, 5000 mg vancomycin hcl solr iv 500 mg XIFAXAN PA; PA; Anti-infective Misc. - Combinations BACTRIM (Use Sulfamethoxazole- Trimethoprim) BACTRIM DS (Use Sulfamethoxazole- Trimethoprim) Antiprotozoal Agents ALINIA TABS 500 MG atovaquone sulfamethoxazoletrimethoprim You can find information on what symbols and abbreviations on this table mean by going to 16

28 MEPRON (Use Atovaquone) Carbapenems imipenem-cilastatin INVANZ IJ meropenem MERREM (Use Meropenem) PRIMAXIN IV (Use Imipenem-Cilastatin) Chloramphenicols chloramphenicol sodium succinate Cyclic Lipopeptides CUBICIN Glycylcyclines TYGACIL Leprostatics dapsone tabs or 100 mg, 25 mg Lincosamides CLEOCIN CAPS OR 150 MG, 300 MG, 75 MG (Use Clindamycin HCl) CLEOCIN IN D5W (Use Clindamycin Phosphate in D5W) CLEOCIN PHOSPHATE IJ 600 MG/4ML, 900 MG/6ML (Use Clindamycin Phosphate) CLEOCIN PHOSPHATE IV 300MG/50ML-5%, 600MG/50ML-5%, 900MG/50ML-5% (Use Clindamycin Phosphate in D5W) clindamycin hcl caps or 150 mg, 300 mg, 75 mg clindamycin palmitate hydrochloride clindamycin phosphate in d5w clindamycin phosphate soln ij 150 mg/ml, 9000 mg/60ml clindamycin phosphate soln ij 600 mg/4ml, 900 mg/6ml clindamycin phosphate soln iv 150 mg/ml, 600 mg/4ml You can find information on what symbols and abbreviations on this table mean by going to 17

29 LINCOCIN Oxazolidinones linezolid soln iv 2 mg/ml linezolid tabs or 600 mg SIVEXTRO SOLR IV SIVEXTRO TABS OR ZYVOX SOLN IV 2 MG/ML (Use Linezolid) ZYVOX SUSR OR 100 MG/5ML ZYVOX TABS OR 600 MG (Use Linezolid) Polymyxins polymyxin b sulfate solr ij Streptogramins SYNERCID AIANGINAL AGES - Drugs to Treat Chest Pain Antianginals-Or RANEXA Nitrates ISORDIL TITRADOSE 5 MG (Use Isosorbide Dinitrate) isosorbide dinitrate tabs or 10 mg, 20 mg, 30 mg, 5 mg isosorbide dinitrate tbcr or 40 mg isosorbide mononitrate tabs 10 mg, 20 mg isosorbide mononitrate tb mg, 30 mg, 60 mg NITRO-DUR 0.1 MG/HR, 0.2 MG/HR, 0.4 MG/HR, 0.6 MG/HR (Use Nitroglycerin) NITROGLYCERIN LINGUAL PA; You can find information on what symbols and abbreviations on this table mean by going to 18

30 nitroglycerin pt24 td 0.1 mg/hr, 0.2 mg/hr, 0.4 mg/hr, 0.6 mg/hr nitroglycerin soln tl 0.4 mg/spray NITROLINGUAL PUMPSPRAY (Use Nitroglycerin) NITROMIST NITROSTAT AIANXIETY AGES - Drugs to Treat Anxiety Antianxiety Agents - Misc. buspirone hcl tabs or 10 mg, 15 mg, 30 mg, 5 mg, 7.5 mg hydroxyzine hcl soln im 25 mg/ml, 50 mg/ml hydroxyzine hcl soln or 10 mg/5ml hydroxyzine hcl syrp or 10 mg/5ml hydroxyzine hcl tabs or 10 mg, 25 mg, 50 mg AL; AL; AL; AL; hydroxyzine pamoate caps or 25 mg, 50 mg VISTARIL (Use Hydroxyzine Pamoate) Benzodiazepines alprazolam tabs or 0.25 mg, 0.5 mg, 1 mg, 2 mg alprazolam tb24 or 0.5 mg, 1 mg, 2 mg, 3 mg alprazolam tbdp or 0.25 mg, 0.5 mg, 1 mg, 2 mg ATIVAN SOLN IJ 2 MG/ML (Use Lorazepam) ATIVAN SOLN IJ 4 MG/ML (Use Lorazepam) ATIVAN TABS OR 0.5 MG, 1 MG, 2 MG (Use Lorazepam) clorazepate dipotassium diazepam conc or 5 mg/ml diazepam soln or 1 mg/ml diazepam tabs or 10 mg, 2 mg, 5 mg AL; AL; You can find information on what symbols and abbreviations on this table mean by going to 19

31 lorazepam conc or 2 mg/ml lorazepam soln ij 2 mg/ml, 20 mg/10ml lorazepam soln ij 4 mg/ml lorazepam tabs or 0.5 mg, 1 mg, 2 mg NIRAVAM (Use Alprazolam) oxazepam TRANXENE T (Use Clorazepate Dipotassium) VALIUM (Use Diazepam) XANAX (Use Alprazolam) XANAX XR (Use Alprazolam) AIARRHYTHMICS - Drugs to treat abnormal heart rhythms Antiarrhythmics Type I-A disopyramide phosphate NORPACE (Use Disopyramide Phosphate) AL; AL; quinidine gluconate tbcr or 324 mg quinidine sulfate Antiarrhythmics Type I-B mexiletine hcl Antiarrhythmics Type I-C flecainide acetate 100 mg flecainide acetate 150 mg flecainide acetate 50 mg propafenone hcl RYTHL (Use Propafenone HCl) RYTHL SR (Use Propafenone HCl) Antiarrhythmics Type III amiodarone hcl tabs or 100 mg, 200 mg, 400 mg CORDARONE (Use Amiodarone HCl) QL(4 ea daily); QL(2 ea daily); QL(8 ea daily); You can find information on what symbols and abbreviations on this table mean by going to 20

32 MULTAQ TIKOSYN AIASTHMATIC AND BRONCHODILATOR AGES - Drugs to Treat Lung Conditions Anti-Inflammatory Agents cromolyn sodium nebu in ; B/D Antiasthmatic - Monoclonal Antibodies PA; LA XOLAIR Asthma and Bronchodilator Agent Combinations dyphylline-guaifenesin Bronchodilators - Anticholinergics ATROVE HFA INCRUSE ELLIPTA ipratropium bromide soln in SPIRIVA HANDIHALER QL(0.86 gm daily); QL(1 ea daily); ; B/D QL(1 ea daily); SPIRIVA RESPIMAT 1.25 MCG/ACT SPIRIVA RESPIMAT 2.5 MCG/ACT SPIRIVA RESPIMAT 2.5 MCG/ACT TUDORZA PRESSAIR Leukotriene Modulators ACCOLATE (Use Zafirlukast) montelukast sodium chew 4 mg, 5 mg montelukast sodium tabs 10 mg SINGULAIR CHEW 4 MG, 5 MG (Use Montelukast Sodium) SINGULAIR TABS 10 MG (Use Montelukast Sodium) zafirlukast 60 actuations;ql( 0.14 gm daily) 60 actuations;ql( 0.14 gm daily); 28 actuations;ql( 0.28 gm daily); QL(0.04 ea daily); Selective Phosphodiesterase 4 (PDE4) Inhibitors QL(1 ea daily); DALIRESP Steroid Inhalants You can find information on what symbols and abbreviations on this table mean by going to 21

33 AEROSPAN ARNUITY ELLIPTA budesonide (inhalation) 0.25 mg/2ml, 0.5 mg/2ml FLOVE DISKUS 100 MCG/BLIST FLOVE DISKUS 250 MCG/BLIST FLOVE DISKUS 50 MCG/BLIST FLOVE HFA 110 MCG/ACT, 220 MCG/ACT FLOVE HFA 44 MCG/ACT PULMICORT 0.25 MG/2ML, 0.5 MG/2ML (Use Budesonide (Inhalation)) QVAR Sympathomimetics QL(0.6 gm daily); QL(1 ea daily); ; B/D QL(20 ea daily); QL(8 ea daily); QL(40 ea daily); QL(0.8 gm daily); QL(0.36 gm daily); ; B/D QL(0.87 gm daily); ADVAIR DISKUS ADVAIR HFA albuterol sulfate nebu in %, 0.5 %, 0.63 mg/3ml, 1.25 mg/3ml albuterol sulfate syrp or 2 mg/5ml albuterol sulfate tabs or 2 mg, 4 mg albuterol sulfate tb12 or 4 mg, 8 mg ANORO ELLIPTA BREO ELLIPTA 25MCG/INH-100MCG/INH, 25MCG/INH-200MCG/INH BREO ELLIPTA 25MCG/INH-100MCG/INH, 25MCG/INH-200MCG/INH COMBIVE RESPIMAT QL(4 gm daily); ; B/D QL(2 ea daily); Limited to 2 inhalers per month (Institutional Pack);QL(2 ea daily); Limit 1 inhaler per month;ql(2 ea daily); You can find information on what symbols and abbreviations on this table mean by going to 22

34 DULERA DUONEB (Use Ipratropium-Albuterol) EPHEDRINE HCL TABS OR EPHEDRINE SULFATE CAPS OR epinephrine hcl sosy 0.1 mg/ml FORADIL AEROLIZER ipratropium-albuterol levalbuterol hcl nebu in 0.31 mg/3ml, 0.63 mg/3ml, 1.25 mg/0.5ml, 1.25 mg/3ml PROAIR HFA PROAIR RESPICLICK PROVEIL HFA QL(4 gm daily); ; B/D ; QL(2 ea daily); ; B/D ; B/D SEREVE DISKUS STIOLTO RESPIMAT STRIVERDI RESPIMAT STRIVERDI RESPIMAT terbutaline sulfate tabs or 2.5 mg, 5 mg XOPENEX (Use Levalbuterol HCl) XOPENEX CONCERATE (Use Levalbuterol HCl) Xanthines aminophylline ophylline tb mg, 200 mg, 300 mg, 450 mg ophylline tb mg, 600 mg QL(2 ea daily); Limited to 1 inhaler per month;ql(0.14 gm daily); QL(0.14 gm daily); Institutional Pack;QL(0.28 gm daily); AICOAGULAS - Blood Thinners Coumarin Anticoagulants ; B/D ; B/D You can find information on what symbols and abbreviations on this table mean by going to 23

35 COUMADIN TABS OR 1 MG, 10 MG, 2 MG, 2.5 MG, 3 MG, 4 MG, 5 MG, 6 MG, 7.5 MG (Use Warfarin Sodium) warfarin sodium Direct Factor Xa Inhibitors ELIQUIS XARELTO XARELTO STARTER PACK Heparins And Heparinoid-Like Agents ARIXTRA (Use Fondaparinux Sodium) enoxaparin sodium fondaparinux sodium FRAGMIN UNIT/ML, UNIT/0.5ML, UNIT/0.6ML, U/0.72ML, 2500 UNIT/0.2ML, UNIT/ML, 5000 UNIT/0.2ML, 7500 UNIT/0.3ML FRAGMIN UNIT/3.8ML heparin sodium (porcine) LOVENOX (Use Enoxaparin Sodium) Thrombin Inhibitors argatroban 250 mg/2.5ml PRADAXA AICONVULSAS - Drugs to Treat Seizures AMPA Glutamate Receptor Antagonists FYCOMPA 10 MG FYCOMPA 12 MG FYCOMPA 2 MG FYCOMPA 4 MG FYCOMPA 6 MG QL(1.2 ea daily); QL(1 ea daily); QL(6 ea daily); QL(3 ea daily); QL(2 ea daily); You can find information on what symbols and abbreviations on this table mean by going to 24

36 FYCOMPA 8 MG Anticonvulsants - Benzodiazepines clonazepam tabs or 0.5 mg clonazepam tabs or 1 mg clonazepam tabs or 2 mg clonazepam tbdp or mg, 0.25 mg, 0.5 mg, 1 mg, 2 mg DIASTAT ACUDIAL DIASTAT PEDIATRIC DIAZEPAM GEL RE 10 MG, 2.5 MG, 20 MG KLONOPIN 0.5 MG (Use Clonazepam) KLONOPIN 1 MG (Use Clonazepam) KLONOPIN 2 MG (Use Clonazepam) QL(1.5 ea daily); QL(40 ea daily); QL(20 ea daily); QL(10 ea daily); QL(40 ea daily); QL(20 ea daily); QL(10 ea daily); OI Anticonvulsants - Misc. APTIOM 200 MG APTIOM 400 MG APTIOM 600 MG APTIOM 800 MG BANZEL carbamazepine chew or 100 mg carbamazepine cp12 or 100 mg, 200 mg, 300 mg carbamazepine susp or 100 mg/5ml carbamazepine tabs or 200 mg QL(6 ea daily); QL(3 ea daily); QL(2 ea daily); QL(1 ea daily); You can find information on what symbols and abbreviations on this table mean by going to 25

37 carbamazepine tb12 or 200 mg, 400 mg CARBATROL (Use Carbamazepine) gabapentin caps or 100 mg, 300 mg, 400 mg gabapentin soln or 250 mg/5ml gabapentin tabs or 600 mg, 800 mg KEPPRA (Use Levetiracetam) KEPPRA XR (Use Levetiracetam) LAMICTAL CHEWABLE DISPERSIBLE (Use Lamotrigine) LAMICTAL TABS 100 MG, 150 MG, 200 MG, 25 MG (Use Lamotrigine) LAMICTAL XR KIT LAMICTAL XR TB MG, 200 MG, 25 MG, 250 MG, 300 MG, 50 MG (Use Lamotrigine) lamotrigine chew 25 mg, 5 mg lamotrigine tabs 100 mg, 150 mg, 200 mg, 25 mg lamotrigine tb mg, 200 mg, 25 mg, 250 mg, 300 mg, 50 mg LEVETIRACETAM SOLN IV 1000MG/100ML- 750MG/100ML, 1500MG/100ML- 540MG/100ML, 500MG/100ML- 820MG/100ML levetiracetam soln iv 500 mg/5ml levetiracetam soln or 100 mg/ml, 500 mg/5ml levetiracetam tabs or 1000 mg, 250 mg, 500 mg, 750 mg levetiracetam tb24 or 500 mg, 750 mg LYRICA CAPS 100 MG LYRICA CAPS 150 MG LYRICA CAPS 200 MG QL(6 ea daily); QL(4 ea daily); QL(3 ea daily); You can find information on what symbols and abbreviations on this table mean by going to 26

38 LYRICA CAPS 225 MG, 300 MG LYRICA CAPS 25 MG LYRICA CAPS 50 MG LYRICA CAPS 75 MG LYRICA SOLN 20 MG/ML MYSOLINE (Use Primidone) NEUROIN (Use Gabapentin) oxcarbazepine POTIGA 200 MG POTIGA 300 MG POTIGA 400 MG QL(2 ea daily); QL(24 ea daily); QL(12 ea daily); QL(8 ea daily); QL(30 ml daily); QL(6 ea daily); QL(4 ea daily); QL(3 ea daily); POTIGA 50 MG primidone tabs or 250 mg, 50 mg TEGRETOL (Use Carbamazepine) TEGRETOL-XR 100 MG TEGRETOL-XR 200 MG, 400 MG (Use Carbamazepine) TOPAMAX (Use Topiramate) TOPAMAX SPRINKLE (Use Topiramate) topiramate cpsp or 15 mg, 25 mg topiramate tabs or 100 mg, 200 mg, 25 mg, 50 mg TRILEPTAL (Use Oxcarbazepine) VIMPAT SOLN IV 200 MG/20ML VIMPAT SOLN OR 10 MG/ML VIMPAT TABS OR 100 MG, 150 MG, 200 MG, 50 MG QL(24 ea daily); You can find information on what symbols and abbreviations on this table mean by going to 27

39 ZONEGRAN (Use Zonisamide) zonisamide Carbamates felbamate FELBATOL (Use Felbamate) GABA Modulators GABITRIL 12 MG, 16 MG GABITRIL 2 MG, 4 MG (Use Tiagabine HCl) SABRIL tiagabine hcl Hydantoins CEREBYX 100 MG PE/2ML (Use Fosphenytoin Sodium) CEREBYX 500 MG PE/10ML (Use Fosphenytoin Sodium) DILAIN-125 (Use Phenytoin) fosphenytoin sodium 100 mg pe/2ml LA fosphenytoin sodium 500 mg pe/10ml PEGANONE phenytoin chew or 50 mg phenytoin sodium extended phenytoin sodium soln ij phenytoin susp or 125 mg/5ml Succinimides CELOIN ethosuximide caps or 250 mg ethosuximide soln or 250 mg/5ml ZAROIN 250 MG (Use Ethosuximide) Valproic Acid DEPACON (Use Valproate Sodium) You can find information on what symbols and abbreviations on this table mean by going to 28

40 DEPAKENE (Use Valproate Sodium) DEPAKENE (Use Valproic Acid) DEPAKOTE (Use Divalproex Sodium) DEPAKOTE ER (Use Divalproex Sodium) DEPAKOTE SPRINKLES (Use Divalproex Sodium) divalproex sodium STAVZOR valproate sodium soln iv 100 mg/ml, 500 mg/5ml valproate sodium soln or 250 mg/5ml valproate sodium syrp or 250 mg/5ml valproic acid caps or AIDEPRESSAS - Drugs to Treat Depression Alpha-2 Receptor Antagonists (Tetracyclics) mirtazapine REMERON (Use Mirtazapine) REMERON SOLTAB (Use Mirtazapine) Antidepressants - Misc. bupropion hcl tabs or 100 mg bupropion hcl tabs or 75 mg bupropion hcl tb12 or 100 mg bupropion hcl tb12 or 150 mg, 200 mg bupropion hcl tb24 or 150 mg bupropion hcl tb24 or 300 mg FORFIVO XL maprotiline hcl WELLBUTRIN 100 MG (Use Bupropion HCl) WELLBUTRIN 75 MG (Use Bupropion HCl) QL(4.5 ea daily); QL(6 ea daily); QL(4 ea daily); QL(2 ea daily); QL(3 ea daily); QL(1 ea daily); QL(4.5 ea daily); QL(6 ea daily); You can find information on what symbols and abbreviations on this table mean by going to 29

41 WELLBUTRIN SR 100 MG (Use Bupropion HCl) WELLBUTRIN SR 150 MG, 200 MG (Use Bupropion HCl) WELLBUTRIN XL 150 MG (Use Bupropion HCl) WELLBUTRIN XL 300 MG (Use Bupropion HCl) Monoamine Oxidase Inhibitors (MAOIs) EMSAM MARPLAN NARDIL (Use Phenelzine Sulfate) PARNATE (Use Tranylcypromine Sulfate) phenelzine sulfate tabs or tranylcypromine sulfate QL(4 ea daily); QL(2 ea daily); QL(3 ea daily); QL(1 ea daily); Selective Serotonin Reuptake Inhibitors (SSRIs) CELEXA 10 MG (Use QL(4 ea daily); Citalopram Hydrobromide) CELEXA 20 MG (Use QL(2 ea daily); Citalopram Hydrobromide) CELEXA 40 MG (Use QL(1 ea daily); Citalopram Hydrobromide) QL(20 ml citalopram hydrobromide daily); soln 10 mg/5ml citalopram hydrobromide tabs 10 mg citalopram hydrobromide tabs 20 mg citalopram hydrobromide tabs 40 mg escitalopram oxalate fluoxetine hcl caps or 10 mg, 20 mg, 40 mg fluoxetine hcl cpdr or 90 mg fluoxetine hcl soln or 20 mg/5ml fluoxetine hcl tabs or 10 mg, 20 mg fluvoxamine maleate LEXAPRO (Use Escitalopram Oxalate) LUVOX CR (Use Fluvoxamine Maleate) QL(4 ea daily); QL(2 ea daily); QL(1 ea daily); You can find information on what symbols and abbreviations on this table mean by going to 30

42 paroxetine hcl PAXIL CR (Use Paroxetine HCl) PAXIL SUSP 10 MG/5ML PAXIL TABS 10 MG, 20 MG, 30 MG, 40 MG (Use Paroxetine HCl) PROZAC (Use Fluoxetine HCl) PROZAC WEEKLY (Use Fluoxetine HCl) sertraline hcl conc or 20 mg/ml sertraline hcl tabs or 100 mg, 25 mg, 50 mg ZOLOFT (Use Sertraline HCl) Serotonin Modulators BRIELLIX 10 MG BRIELLIX 20 MG BRIELLIX 5 MG ST; QL(2 ea daily); ST; QL(1 ea daily); ST; QL(4 ea daily); nefazodone hcl trazodone hcl tabs or 100 mg, 150 mg, 300 mg, 50 mg VIIBRYD VIIBRYD STARTER PACK ST; ST Serotonin-Norepinephrine Reuptake Inhibitors CYMBALTA (Use Duloxetine HCl) DESVENLAFAXINE ER 100 MG, 50 MG DESVENLAFAXINE ER 100 MG, 50 MG duloxetine hcl 20 mg, 30 mg, 60 mg EFFEXOR XR 150 MG (Use Venlafaxine HCl) EFFEXOR XR 37.5 MG (Use Venlafaxine HCl) EFFEXOR XR 75 MG (Use Venlafaxine HCl) FETZIMA 120 MG, 40 MG, 80 MG ST; ST; Fumarate QL(1 ea daily); QL(6 ea daily); QL(3 ea daily); ST; QL(1 ea daily); You can find information on what symbols and abbreviations on this table mean by going to 31

43 FETZIMA 20 MG FETZIMA TITRATION PACK KHEDEZLA PRISTIQ venlafaxine hcl cp mg venlafaxine hcl cp mg venlafaxine hcl cp24 75 mg VENLAFAXINE HCL ER venlafaxine hcl tabs 100 mg venlafaxine hcl tabs 25 mg ST; QL(2 ea daily); ST; ST; ST; QL(1 ea daily); QL(6 ea daily); QL(3 ea daily); ST; QL(1 ea daily); QL(3.5 ea daily); QL(15 ea daily); venlafaxine hcl tabs 37.5 mg venlafaxine hcl tabs 50 mg venlafaxine hcl tabs 75 mg venlafaxine hcl tb mg venlafaxine hcl tb mg venlafaxine hcl tb24 75 mg Tricyclic Agents amitriptyline hcl amoxapine ANAFRANIL (Use Clomipramine HCl) clomipramine hcl caps or 25 mg, 50 mg, 75 mg desipramine hcl tabs or 10 mg, 100 mg, 150 mg, 25 mg, 50 mg, 75 mg QL(10 ea daily); QL(7.5 ea daily); QL(5 ea daily); QL(1 ea daily); QL(6 ea daily); QL(3 ea daily); AL; AL; AL; You can find information on what symbols and abbreviations on this table mean by going to 32

44 doxepin hcl caps or 10 mg, 100 mg, 150 mg, 25 mg, 50 mg, 75 mg doxepin hcl conc or 10 mg/ml imipramine hcl tabs or 10 mg, 25 mg, 50 mg imipramine pamoate NORPRAMIN (Use Desipramine HCl) nortriptyline hcl caps or 10 mg, 25 mg, 50 mg, 75 mg nortriptyline hcl soln or 10 mg/5ml PAMELOR (Use Nortriptyline HCl) protriptyline hcl SURIL TOFRANIL-PM (Use Imipramine Pamoate) trimipramine maleate caps or 100 mg, 25 mg, 50 mg AL; AL; AL; AL; AL; AL; AL; AIDIABETICS - Drugs to Regulate Blood Sugar Alpha-Glucosidase Inhibitors acarbose GLYSET PRECOSE (Use Acarbose) Antidiabetic - Amylin Analogs SYMLINPEN 120 SYMLINPEN 60 Antidiabetic Combinations ACTOPLUS MET (Use Pioglitazone HCl-Metformin HCl) DUETACT (Use Pioglitazone HCl- Glimepiride) glipizide-metformin hcl 2.5mg-250mg glipizide-metformin hcl 2.5mg-500mg, 5mg-500mg GLUCOVANCE 1.25MG- 250MG (Use Glyburide- Metformin) QL(3 ea daily); QL(3 ea daily); QL(3 ea daily); QL(0.4 ml daily); QL(0.4 ml daily); QL(3 ea daily); QL(1.5 ea daily); QL(8 ea daily); QL(4 ea daily); AL; QL(8 ea daily); You can find information on what symbols and abbreviations on this table mean by going to 33

45 GLUCOVANCE 2.5MG- 500MG, 5MG-500MG (Use Glyburide-Metformin) glyburide-metformin 1.25mg-250mg glyburide-metformin 2.5mg- 500mg, 5mg-500mg INVOKAMET 150MG- 1000MG, 150MG-500MG, 50MG-1000MG INVOKAMET 50MG- 500MG JANUMET JANUMET XR 100MG- 1000MG JANUMET XR 50MG- 1000MG, 50MG-500MG JEADUETO KAZANO KOMBIGLYZE XR 2.5MG- 1000MG AL; QL(4 ea daily); AL; QL(8 ea daily); AL; QL(4 ea daily); QL(2 ea daily); QL(4 ea daily); QL(2 ea daily); QL(1 ea daily); QL(2 ea daily); QL(2 ea daily); QL(2 ea daily); QL(2 ea daily); KOMBIGLYZE XR 5MG- 1000MG, 5MG-500MG OSENI 12.5MG-15MG OSENI 12.5MG-30MG, 12.5MG-45MG, 25MG- 15MG, 25MG-30MG, 25MG-45MG pioglitazone hcl-glimepiride pioglitazone hcl-metformin hcl PRANDIMET Biguanides FORTAMET 1000 MG (Use Metformin HCl) FORTAMET 500 MG (Use Metformin HCl) GLUCOPHAGE 1000 MG (Use Metformin HCl) GLUCOPHAGE 500 MG (Use Metformin HCl) GLUCOPHAGE 850 MG (Use Metformin HCl) GLUCOPHAGE XR 500 MG (Use Metformin HCl) GLUCOPHAGE XR 750 MG (Use Metformin HCl) QL(1 ea daily); QL(2 ea daily); QL(1 ea daily); QL(1.5 ea daily); QL(3 ea daily); QL(5 ea daily); QL(2 ea daily); Osmotic;QL(5 ea daily); QL(2.5 ea daily); QL(5 ea daily); QL(3 ea daily); QL(4 ea daily); QL(2 ea daily); You can find information on what symbols and abbreviations on this table mean by going to 34

46 GLUMETZA 1000 MG GLUMETZA 500 MG metformin hcl tabs or 1000 mg metformin hcl tabs or 500 mg metformin hcl tabs or 850 mg metformin hcl tb24 or 1000 mg, 750 mg metformin hcl tb24 or 500 mg metformin hcl tb24 or 500 mg Diabetic Or BD GLUCOSE CVS GLUCOSE 4 GM DEX4 QUICK DISSOLVE GLUCOSE QL(2 ea daily); QL(4 ea daily); QL(2.5 ea daily); QL(5 ea daily); QL(3 ea daily); QL(2 ea daily); Osmotic;QL(5 ea daily); QL(4 ea daily); ; ; dextrose (diabetic use) gel 15 gm/38gm, 40 % GLUCAGEN HYPOKIT glucagon (rdna) GLUCOSE CHEW 4 GM GNP GLUCOSE 4 GM GNP QUICK DISSOLVE GLUCOSE LEADER QUICK DISSOLVE GLUCOSE MS QUICK DISSOLVE GLUCOSE PROGLYCEM SM GLUCOSE 4 GM ULTILET GLUCOSE WALGREENS GLUCOSE 4 GM ; ; ; ; ; ; ; ; ; Dipeptidyl Peptidase-4 (DPP-4) Inhibitors You can find information on what symbols and abbreviations on this table mean by going to 35

47 JANUVIA NESINA ONGLYZA TRADJEA Dopamine Receptor Agonists - Antidiabetic QL(6 ea daily); CYCLOSET Incretin Mimetic Agents (GLP-1 Receptor ST; BYDUREON ST; BYETTA ST; QL(0.3 ml VICTOZA daily); Insulin Sensitizing Agents ACTOS 15 MG (Use Pioglitazone HCl) ACTOS 30 MG, 45 MG (Use Pioglitazone HCl) QL(3 ea daily); QL(1 ea daily); AVANDIA 2 MG AVANDIA 4 MG AVANDIA 8 MG pioglitazone hcl 15 mg pioglitazone hcl 30 mg, 45 mg Insulin HUMALOG HUMALOG KWIKPEN HUMALOG MIX 50/50 HUMALOG MIX 50/50 KWIKPEN HUMALOG MIX 75/25 QL(4 ea daily); LA; QL(2 ea daily); LA; QL(1 ea daily); LA; QL(3 ea daily); QL(1 ea daily); QL(1.5 ml daily); QL(1.5 ml daily); QL(1.5 ml daily); QL(1.5 ml daily); QL(1.5 ml daily); You can find information on what symbols and abbreviations on this table mean by going to 36

48 HUMALOG MIX 75/25 KWIKPEN HUMULIN 70/30 HUMULIN 70/30 KWIKPEN HUMULIN 70/30 PEN HUMULIN N HUMULIN N KWIKPEN HUMULIN N U-100 PEN HUMULIN R HUMULIN R U-500 (CONCERATED) LAUS QL(1.5 ml daily); QL(1.5 ml daily); QL(1.5 ml daily); QL(1.5 ml daily); QL(1.5 ml daily); QL(1.5 ml daily); QL(1.5 ml daily); QL(1.5 ml daily); QL(1.5 ml daily); QL(1.5 ml daily); LAUS SOLOSTAR LEVEMIR LEVEMIR FLEXPEN LEVEMIR FLEXTOUCH TOUJEO SOLOSTAR Meglitinide Analogues nateglinide PRANDIN 0.5 MG (Use Repaglinide) PRANDIN 1 MG (Use Repaglinide) PRANDIN 2 MG (Use Repaglinide) repaglinide 0.5 mg repaglinide 1 mg QL(1.5 ml daily); QL(1.5 ml daily); QL(1.5 ml daily); QL(1.5 ml daily); Limited to 15mls per month;ql(0.5 ml daily); QL(3 ea daily); QL(32 ea daily); QL(16 ea daily); QL(8 ea daily); QL(32 ea daily); QL(16 ea daily); You can find information on what symbols and abbreviations on this table mean by going to 37

49 repaglinide 2 mg STARLIX (Use Nateglinide) QL(8 ea daily); QL(3 ea daily); Sodium-Glucose Co-Transporter 2 (SGLT FARXIGA INVOKANA JARDIANCE 10 MG JARDIANCE 25 MG Sulfonylureas AMARYL 1 MG (Use Glimepiride) AMARYL 2 MG (Use Glimepiride) AMARYL 4 MG (Use Glimepiride) DIABETA 1.25 MG (Use Glyburide) DIABETA 2.5 MG (Use Glyburide) DIABETA 5 MG (Use Glyburide) QL(2 ea daily); QL(1 ea daily); QL(8 ea daily); QL(4 ea daily); QL(2 ea daily); AL; QL(16 ea daily); AL; QL(8 ea daily); AL; QL(4 ea daily); glimepiride 1 mg glimepiride 2 mg glimepiride 4 mg glipizide tabs or 10 mg glipizide tabs or 5 mg glipizide tb24 or 10 mg glipizide tb24 or 2.5 mg glipizide tb24 or 5 mg GLUCOTROL 10 MG (Use Glipizide) GLUCOTROL 5 MG (Use Glipizide) GLUCOTROL XL 10 MG (Use Glipizide) GLUCOTROL XL 2.5 MG (Use Glipizide) GLUCOTROL XL 5 MG (Use Glipizide) QL(8 ea daily); QL(4 ea daily); QL(2 ea daily); QL(4 ea daily); QL(8 ea daily); QL(2 ea daily); QL(8 ea daily); QL(4 ea daily); QL(4 ea daily); QL(8 ea daily); QL(2 ea daily); QL(8 ea daily); QL(4 ea daily); You can find information on what symbols and abbreviations on this table mean by going to 38

50 glyburide 1.25 mg glyburide 2.5 mg glyburide 5 mg glyburide micronized 1.5 mg glyburide micronized 3 mg glyburide micronized 6 mg GLYNASE 1.5 MG (Use Glyburide Micronized) GLYNASE 3 MG (Use Glyburide Micronized) GLYNASE 6 MG (Use Glyburide Micronized) tolazamide 250 mg tolazamide 500 mg tolbutamide AL; QL(16 ea daily); AL; QL(8 ea daily); AL; QL(4 ea daily); AL; QL(8 ea daily); AL; QL(4 ea daily); AL; QL(2 ea daily); AL; QL(8 ea daily); AL; QL(4 ea daily); AL; QL(2 ea daily); QL(4 ea daily); QL(2 ea daily); QL(6 ea daily); AIDIARRHEALS - Drugs to Treat Diarrhea Antidiarrheal Agents - Misc. bismuth subsalicylate chew or 262 mg bismuth subsalicylate susp or 262 mg/15ml, 525 mg/15ml, 527 mg/30ml bismuth subsalicylate tabs or 262 mg PEPTO BISL (Use Bismuth Subsalicylate) PEPTO-BISL (Use Bismuth Subsalicylate) PEPTO-BISL INSTACOOL (Use Bismuth Subsalicylate) PEPTO-BISL MAX STRENGTH (Use Bismuth Subsalicylate) PEPTO-BISL TO-GO (Use Bismuth Subsalicylate) Antiperistaltic Agents diphenoxylate w/ atropine LOTIL (Use Diphenoxylate w/ Atropine) loperamide hcl caps or 2 mg ; ; ; ; ; ; RX/OTC; AIDOTES - Drugs to Treat Overdose or Toxicity Antidotes - Chelating Agents You can find information on what symbols and abbreviations on this table mean by going to 39

51 EXJADE FERRIPROX JADENU Antidotes IPECAC SM IPECAC SYRUP Opioid Antagonists naloxone hcl soln ij 1 mg/ml naltrexone hcl tabs or LA PA; LA AIEMETICS - Drugs to Treat Nausea and Vomiting 5-HT3 Receptor Antagonists granisetron hcl tabs or 1 mg ondansetron ; B/D ; B/D ondansetron hcl soln ij 4 mg/2ml, 40 mg/20ml ondansetron hcl soln or 4 mg/5ml ondansetron hcl tabs or 24 mg, 4 mg, 8 mg ZOFRAN ODT (Use Ondansetron) ZOFRAN SOLN IJ 40 MG/20ML (Use Ondansetron HCl) ZOFRAN SOLN OR 4 MG/5ML (Use Ondansetron HCl) ZOFRAN TABS OR 4 MG, 8 MG (Use Ondansetron HCl) ; B/D ; B/D ; B/D ; B/D ; B/D Antiemetics - Anticholinergic ; meclizine hcl chew 25 mg RX/OTC; meclizine hcl tabs 12.5 mg, 25 mg TIGAN SOLN IM 100 MG/ML TRANSDERM-SCOP AL; You can find information on what symbols and abbreviations on this table mean by going to 40

52 trimethobenzamide hcl soln im 100 mg/ml AL; Antiemetics - Miscellaneous ; B/D CESAMET ; B/D dronabinol MARINOL (Use Dronabinol) ; B/D Substance P/Neurokinin 1 (NK Receptor ; B/D EMEND CAPS OR 125 MG, 80 MG PA; EMEND CAPS OR 40 MG AIFUNGALS - Drugs to Treat Fungal Infections Antifungal - Glucan Synsis Inhibitors CANCIDAS 50 MG CANCIDAS 70 MG ERAXIS 100 MG MYCAMINE Antifungals ABELCET AMBISOME amphotericin b solr ij 50 mg ANCOBON (Use Flucytosine) flucytosine GRIS-PEG (Use Griseofulvin Ultramicrosize) griseofulvin microsize griseofulvin ultramicrosize LAMISIL TABS 250 MG (Use Terbinafine HCl) nystatin tabs or You can find information on what symbols and abbreviations on this table mean by going to 41

53 terbinafine hcl tabs or Imidazole-Related Antifungals CRESEMBA CAPS OR 186 MG CRESEMBA SOLR IV 372 MG DIFLUCAN (Use Fluconazole) fluconazole in dextrose fluconazole in nacl 200mg/100ml-0.9%, 400mg/200ml-0.9% fluconazole susr or 10 mg/ml, 40 mg/ml fluconazole tabs or 100 mg, 150 mg, 200 mg, 50 mg itraconazole caps or ketoconazole tabs or NOXAFIL SOLN IV 300 MG/16.7ML NOXAFIL SUSP OR 40 MG/ML NOXAFIL TBEC OR 100 MG SPORANOX CAPS 100 MG (Use Itraconazole) SPORANOX PULSEPAK (Use Itraconazole) VFEND IV (Use Voriconazole) VFEND TABS 200 MG, 50 MG (Use Voriconazole) voriconazole solr iv 200 mg voriconazole tabs or 200 mg, 50 mg AIHISTAMINES - Drugs to Treat Allergies Antihistamines - Alkylamines CHLOR-TRIMETON (Use Chlorpheniramine Maleate) chlorpheniramine maleate syrp or 2 mg/5ml chlorpheniramine maleate tabs or 4 mg ED CHLORPED Antihistamines - Ethanolamines AL; ; AL; ; AL; ; AL; You can find information on what symbols and abbreviations on this table mean by going to 42

54 ALER-DRYL BENADRYL (Use Diphenhydramine HCl) BENADRYL ALLERGY (Use Diphenhydramine HCl) BENADRYL ALLERGY CHILDRENS CHEW 12.5 MG (Use Diphenhydramine HCl) BENADRYL ALLERGY CHILDRENS LIQD 12.5 MG/5ML (Use Diphenhydramine HCl) BENADRYL DYE-FREE ALLERGYLIQUID-GELS (Use Diphenhydramine HCl) carbinoxamine maleate clemastine fumarate tabs or 2.68 mg diphenhydramine hcl caps or 25 mg diphenhydramine hcl chew or 12.5 mg diphenhydramine hcl elix or 12.5 mg/5ml diphenhydramine hcl liqd or 12.5 mg/5ml, 25 mg/10ml, 50 mg/20ml AL; AL; ; AL; ; AL; AL; ; AL; ; AL; AL; AL; ; AL; RX/OTC AL; ; diphenhydramine hcl soln ij 50 mg/ml diphenhydramine hcl syrp or 12.5 mg/5ml diphenhydramine hcl tabs or 25 mg TRIAMINIC COUGH & RUNNY NOSE AL; AL; RX/OTC; AL; ; AL; Antihistamines - Non-Sedating RX/OTC; cetirizine hcl soln 1 mg/ml RX/OTC; cetirizine hcl syrp 1 mg/ml, 5 mg/5ml CLARINEX REDITABS 5 MG (Use Desloratadine) CLARINEX TABS 5 MG (Use Desloratadine) desloratadine tabs 5 mg desloratadine tbdp 5 mg levocetirizine dihydrochloride XYZAL (Use Levocetirizine Dihydrochloride) Antihistamines - Phenothiazines You can find information on what symbols and abbreviations on this table mean by going to 43

55 promethazine hcl soln ij 25 mg/ml, 50 mg/ml promethazine hcl soln or 6.25 mg/5ml promethazine hcl supp re 12.5 mg, 25 mg promethazine hcl syrp or 6.25 mg/5ml promethazine hcl tabs or 12.5 mg, 25 mg, 50 mg Antihistamines - Piperidines cyproheptadine hcl syrp or 2 mg/5ml cyproheptadine hcl tabs or 4 mg AL; AL; AL; AL; AL; AL; AL; AIHYPERLIPIDEMICS - Drugs to Treat High Cholesterol Antihyperlipidemics - Combinations LIPTRUZET Antihyperlipidemics - Misc. KYNAMRO PA; LA LOVAZA (Use Omega-3- acid Ethyl Esters) omega-3-acid ethyl esters VASCEPA Bile Acid Sequestrants cholestyramine light cholestyramine pack or 4 gm cholestyramine powd or 4 gm/dose COLESTID (Use Colestipol HCl) COLESTID FLAVORED GRAN 5 GM (Use Colestipol HCl) colestipol hcl WELCHOL Fibric Acid Derivatives AARA 130 MG, 43 MG (Use Fenofibrate Micronized) You can find information on what symbols and abbreviations on this table mean by going to 44

56 AARA 30 MG AARA 90 MG choline fenofibrate fenofibrate micronized fenofibrate tabs 145 mg, 160 mg, 48 mg, 54 mg gemfibrozil tabs or QL(3 ea daily); QL(1 ea daily); LOPID (Use Gemfibrozil) TRICOR (Use Fenofibrate) TRIGLIDE TRILIPIX (Use Choline Fenofibrate) HMG CoA Reductase Inhibitors atorvastatin calcium ST; CRESTOR fluvastatin sodium caps 20 mg, 40 mg LESCOL (Use Fluvastatin Sodium) LIPITOR (Use Atorvastatin Calcium) lovastatin MEVACOR (Use Lovastatin) PRAVACHOL (Use Pravastatin Sodium) pravastatin sodium simvastatin tabs or 10 mg simvastatin tabs or 20 mg simvastatin tabs or 40 mg simvastatin tabs or 5 mg simvastatin tabs or 80 mg ZOCOR 10 MG (Use Simvastatin) QL(8 ea daily); QL(4 ea daily); QL(2 ea daily); QL(16 ea daily); You can find information on what symbols and abbreviations on this table mean by going to QL(1 ea daily); QL(8 ea daily); 45

57 ZOCOR 20 MG (Use Simvastatin) ZOCOR 40 MG (Use Simvastatin) ZOCOR 5 MG (Use Simvastatin) ZOCOR 80 MG (Use Simvastatin) QL(4 ea daily); QL(2 ea daily); QL(16 ea daily); QL(1 ea daily); Intestinal Cholesterol Absorption Inhibitors ZETIA Microsomal Triglyceride Transfer Protein (MTP) PA; QL(6 ea JUXTAPID 10 MG daily); LA JUXTAPID 20 MG JUXTAPID 30 MG JUXTAPID 40 MG, 60 MG JUXTAPID 5 MG Nicotinic Acid Derivatives niacin (antihyperlipidemic) NIASPAN (Use Niacin (Antihyperlipidemic)) PA; QL(3 ea daily); LA PA; QL(2 ea daily); LA PA; QL(1 ea daily); LA PA; QL(12 ea daily); LA Proprotein Convertase Subtilisin/Kexin Type 9 PRALUE SOPN 150 MG/ML PRALUE SOPN 75 MG/ML PRALUE SOSY 150 MG/ML PRALUE SOSY 75 MG/ML PA; QL(0.08 ml daily); PA; QL(0.15 ml daily); PA; QL(0.08 ml daily); PA; QL(0.15 ml daily); AIHYPERTENSIVES - Drugs to Treat High Blood Pressure ACE Inhibitors ACCUPRIL (Use Quinapril HCl) ACEON 4 MG (Use Perindopril Erbumine) ACEON 8 MG (Use Perindopril Erbumine) ALTACE (Use Ramipril) benazepril hcl tabs or 10 mg, 20 mg, 40 mg, 5 mg captopril tabs or 100 mg, 12.5 mg, 25 mg, 50 mg enalapril maleate tabs or 10 mg, 2.5 mg, 20 mg, 5 mg QL(4 ea daily); QL(2 ea daily); You can find information on what symbols and abbreviations on this table mean by going to 46

58 fosinopril sodium lisinopril tabs or 10 mg, 2.5 mg, 20 mg, 30 mg, 40 mg, 5 mg LOTENSIN (Use Benazepril HCl) MAVIK (Use Trandolapril) moexipril hcl perindopril erbumine 2 mg perindopril erbumine 4 mg perindopril erbumine 8 mg PRINIVIL (Use Lisinopril) quinapril hcl ramipril trandolapril QL(4 ea daily); QL(2 ea daily); UNIVASC (Use Moexipril HCl) VASOTEC (Use Enalapril Maleate) ZESTRIL (Use Lisinopril) Agents for Pheochromocytoma DEMSER DIBENZYLINE (Use Phenoxybenzamine HCl) phenoxybenzamine hcl caps or Angiotensin II Receptor Antagonists ATACAND (Use Candesartan Cilexetil) AVAPRO (Use Irbesartan) candesartan cilexetil COZAAR (Use Losartan Potassium) DIOVAN (Use Valsartan) eprosartan mesylate irbesartan You can find information on what symbols and abbreviations on this table mean by going to 47