2017 Comprehensive Formulary (List of Covered Drugs) Medicare Advantage Plans

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1 We re in this together: Quality Health Care 017 Comprehensive Formulary (List of Covered s) Medicare Advantage Plans Easy Choice Health Plan Plans in the following state: CA Easy Choice Best Plan(HMO) H HPMS Approved Formulary File Submission ID: 1796 Version Number: 17 Please Read: This document contains information about the drugs we cover in this plan. This formulary was updated on 11/01/017. For more recent information or other questions, please contact Easy Choice at the telephone number listed on the inside front and back covers of this formulary or visit Y0070_NA036_WCM_FOR_ENG_FINAL_07 CMS Approved WellCare 017 CA7RMRFOR08159E_CV07

2 We re always just a phone call away! If you re ready to enroll or have enrollment questions, call , 8 a.m. to 8 p.m., 7 days a week. If you re already a member, call the number listed below. California: All Plans Hours of operation are Monday Friday, 8 a.m. to 8 p.m. Between October 1 and February 1, representatives are available Monday Sunday, 8 a.m. to 8 p.m., or visit us anytime at Nurse Advice Line ( hours, 7 days a week) TTY for all of the above

3 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 Easy Choice. When it refers to plan or our plan, it means 017 Easy Choice. This document includes a list of the drugs (formulary) for our plan which is current as of 11/01/017. For an updated formulary, please contact us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages. You must generally use network pharmacies to use your prescription drug benefit. Benefits, formulary, pharmacy network, premium and/or co-payments/coinsurance may change on January 1, 018, and from time to time during the year. WHAT IS THE EASY CHOICE BEST PLAN (HMO) COMPREHENSIVE FORMULARY? A formulary is a list of covered drugs. Easy Choice selects the drugs by working with a team of health care providers. The list contains the prescription medications we believe are a necessary part of a quality treatment program. Easy Choice will generally cover the drugs listed in our formulary as long as: 1. the drug is medically necessary,. the prescription is filled at an Easy Choice network pharmacy, and 3. other plan rules are followed. For more information on how to fill your prescriptions, please see your Evidence of Coverage. CAN THE FORMULARY (DRUG LIST) CHANGE? In general, if you are taking a drug on our 017 formulary that was covered at the beginning of the year, we will not stop or reduce coverage of the drug during the 017 coverage year. However, there are some cases when we may stop or reduce coverage. These are: when a new, less expensive generic drug becomes available or when new negative 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. For those members, it will remain available at the same cost share for the remainder of the coverage year. We think it s important that you can continue to get the formulary drugs that were available when you chose our plan for the remainder of the coverage year. The only exceptions are for cases in which you can save additional money or we can ensure your safety. When we make certain changes to our formulary, we must notify the members who will be affected by the changes. This includes if we: remove drugs from our formulary; add restrictions on a drug such as prior authorization, quantity limits and/or step therapy; 017 Comprehensive Formulary I CA7RMRFOR08159E_CV07

4 move a drug to a higher cost-sharing tier. If we make any of these changes, we must notify affected members at least 60 days before the change goes into effect. We will also notify the member at the time he or she asks for a refill of the drug. In that case, the member will receive a 60-day supply of the drug. If the Food and Administration announces that a drug on our formulary is unsafe, or a drug manufacturer removes a drug from the market, we will immediately remove the drug from our formulary and notify members who take the drug. The enclosed formulary is current as of 11/01/017. To get updated information about the drugs covered by Easy Choice, please visit our website at or call Customer Service at the telephone number listed for your state/plan on the inside front and back cover pages of this formulary. Every month, our printed comprehensive formulary will be updated. Please contact Customer Service or visit our website at for more information. HOW DO I USE THE FORMULARY? There are two ways to find your drug within the formulary: Medical Condition The formulary begins on page 1. The drugs in this formulary are grouped into categories depending on the type of medical conditions that they are used to treat. For example, drugs used to treat a heart 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 17. 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? Easy Choice 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: 017 Comprehensive Formulary II

5 Prior Authorization: Easy Choice requires you or your physician to get prior authorization for certain drugs. This means that you will need to get approval from us before you fill your prescriptions. If you don t get approval, we may not cover the drug. Quantity Limits: For certain drugs, we limit the amount of the drug that we will cover. For example, Easy Choice provides 18 tablets for 30 days per prescription for rizatriptan 5mg. This may be in addition to a standard one-month or three-month supply. Step Therapy: In some cases, Easy Choice requires you to first try certain drugs to treat your medical condition before we will cover another drug for that condition. For example, if A and B both treat your medical condition, we may not cover B unless you try A first. If A does not work for you, we will then cover 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 website at We have posted online documents that explain our prior authorization restriction 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 Easy Choice 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 Easy Choice formulary? on page IV for information about how to request an exception. WHAT IF MY DRUG IS NOT ON THE FORMULARY? If your drug is not included in this formulary (list of covered drugs), you should first contact Customer Service and ask if your drug is covered. You can contact Customer Service at the telephone number listed for your state/plan on the inside front and back covers of this formulary. If you learn that Easy Choice does not cover your drug, you have two options: You can ask Customer Service for a list of similar drugs that are covered by Easy Choice. When you receive the list, show it to your doctor and ask him or her to prescribe a similar drug that is covered by Easy Choice. You can ask Easy Choice to make an exception and cover your drug. See below for information about how to request an exception. WHICH VACCINES DO WE COVER? Your prescription benefit may cover many vaccines. For details, see the Immunological Agents section. The cost for vaccines varies, depending on the facility where you receive them. For best coverage, use a network pharmacy. All commercially available vaccines are covered under Part D, except for those that are covered under Medicare Part B, such as influenza or pneumococcal vaccines. 017 Comprehensive Formulary III

6 HOW DO I REQUEST AN EXCEPTION TO THE EASY CHOICE BEST PLAN (HMO) FORMULARY? You can ask Easy Choice to make an exception to our coverage rules. There are several types of formulary exceptions that you can ask us to make. Initial Coverage Decision Exception You can ask us to cover your drug even if it is not on our formulary. If your request is approved, the drug will be covered at a pre-determined cost-sharing level. You would not be able to ask us to provide the drug at a lower cost-sharing level. Utilization Restriction Exception You can ask us to waive coverage restrictions or limits on your drug. For example, for certain drugs, the amount of the drug that we cover is limited. If your drug has a quantity limit, you can ask us to waive the limit and cover a greater amount. ing Exception You can ask us to cover a formulary drug at a lower cost-sharing level if the drug is not on the preferred generic, preferred brand or specialty tier. If approved, this would lower the amount you must pay for your drug. Generally, Easy Choice will only approve your request for an exception if: the alternative drugs included on the plan s formulary would not be as effective in treating your condition; the lower cost-sharing drug would not be as effective in treating your condition; the additional utilization restrictions would not be as effective in treating your condition and/or; the alternative drugs would cause you to have adverse medical effects. You should contact us to ask us for a formulary exception for an initial coverage decision, a tiering exception or a utilization restriction exception. When you request any of these exceptions, you should submit a statement from your prescriber or physician supporting your request. Generally, we must make our decision within 7 hours of getting your prescribing physician s supporting statement. You can request an expedited (fast) exception if you or your doctor believe that your health could be seriously harmed by waiting up to 7 hours for a decision. If your request for a fast review is granted, we must give you a decision no later than hours after we get your prescriber s or prescribing physician s supporting statement. WHAT DO I DO BEFORE I CAN TALK TO MY DOCTOR ABOUT CHANGING MY DRUGS OR REQUESTING AN EXCEPTION? As a new or continuing member in our plan, you may be taking drugs that are not on our formulary. Or you may be taking a drug that is on our formulary but your ability to get it is limited. For example, you may need a prior authorization from us before you can fill your prescription. You should talk to your doctor to decide if you should switch to an appropriate drug that we cover, or request a formulary exception so that we will cover the drug you take. While you talk to your doctor to determine the right course of action for you, we may cover 017 Comprehensive Formulary IV

7 your drug in certain cases during the first 90 days you are a member of our plan. For each of your drugs that is not on our formulary, or if your ability to get your drugs is limited, we will cover a temporary 30-day supply (unless you have a prescription written for fewer days) when you go to a network pharmacy. After your first 30-day supply, we will not pay for these drugs, even if you have been a member of the plan less than 90 days. If you are a resident of a long-term care facility, we will allow you to refill your prescription until we have provided you with a 93-day transition supply that meets the dispensing instructions (unless you have a prescription written for fewer days). We will cover more than one refill of these drugs for the first 93 days you are a member of our plan. If you need a drug that is not on our formulary, or if your ability to get your drugs is limited, but you are past the first 93 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 seek a formulary exception. If you experience a level of care change (such as being discharged or admitted to a long-term care facility), your physician or pharmacy can call our Provider Service Center and request a one-time override. This one-time override will be up to a 31-day supply (unless you have a prescription written for fewer days). FOR MORE INFORMATION For more details about your Easy Choice prescription drug coverage, please review your Evidence of Coverage and other plan materials. If you have questions about Easy Choice, please contact us. Our contact information, along with the date we last updated the formulary, is on the inside front and back covers of this document. Or visit If you have general questions about Medicare prescription drug coverage, please call Medicare at MEDICARE ( ) hours a day, 7 days a week. TTY users should call Or visit EASY CHOICE FORMULARY The comprehensive formulary that begins on page 1 provides coverage information about the drugs covered by Easy Choice. If you have trouble finding your drug in the list, turn to the Index that begins on page 17. The first column of the chart lists the drug name. Brand-name drugs are UPPERCASE (e.g., COUMADIN) and generic drugs are listed in lowercase italics (e.g., simvastatin). The information in the Requirements/Limits column tells you if Easy Choice has any special requirements for coverage of your drug. GC stands for Gap Coverage: We provide additional coverage of this prescription drug in the coverage gap. Please refer to your Evidence of Coverage for more information about this coverage. 017 Comprehensive Formulary V

8 ED stands for Excluded Part D : This prescription drug is not normally covered in a Medicare Prescription Plan. The amount you pay when you fill a prescription for this drug does not count toward your total drug costs (that is, the amount you pay does not help you qualify for catastrophic coverage). In addition, if you are receiving Extra Help to pay for your prescriptions, you will not get any Extra Help to pay for this drug. NM means the drug is not available via your monthly mail service benefit. This is noted in the Requirements/Limits column of your formulary. You may be able to receive more than one month s supply of most of the drugs on your formulary via mail service at a reduced cost share. Please see Chapter 5 of your Evidence of Coverage for more information.** PA stands for Prior Authorization: Please see page III for details. B/D stands for Covered under Medicare B or D: This drug may be eligible for payment under Medicare Part B or Part D. You (or your physician) are required to get prior authorization from Easy Choice to determine that this drug is covered under Medicare Part D before you fill your prescription for this drug. Without prior approval, Easy Choice may not cover this drug. QL stands for Quantity Limits: Please see page III for details. LA stands for Limited Access medication. This medication may be available from certain other pharmacies. For more information, please refer to the Specialty Pharmacy section of your Pharmacy Directory or contact Customer Service at the telephone number listed for your state/plan on the inside front and back cover pages of this formulary. ST stands for Step Therapy: Please see page III for details. ^ = may be available for up to a 30-day supply only. ** You have the choice to sign up for automated mail service delivery. You can get prescription drugs shipped to your home through our network mail service delivery program. You should expect to receive your prescription drugs within 7 10 business days from the time that the mail service pharmacy receives the order. If you do not receive your prescription drugs within this time, please contact us at the telephone number listed on the inside front and back covers of this formulary or visit DRUG TIER CO-PAYMENT/COINSURANCE AMOUNTS The Easy Choice formulary is divided into five tiers. 1: Preferred Generic s that are available at the lowest cost share for this plan. : Generic s that Easy Choice offers at a higher cost to you than preferred generics. 3: Preferred Brand s that Easy Choice may be able to offer at a lower cost to you than non-preferred brand drugs. : Non-Preferred s that Easy Choice offers at a higher cost to you than preferred brands. 017 Comprehensive Formulary VI

9 5: Specialty Some injectables and other high-cost drugs. ^ Indicates specialty drugs are available for up to a 30-day supply only. Brand drugs may be available in s 3, and 5. Generic drugs are available in all s. Consult your Evidence of Coverage or Summary of Benefits for your applicable co-pays/ coinsurance and deductible amounts. 017 Comprehensive Formulary VII

10 HOW TO READ FORMULARY LISTINGS: Name Requirements/Limits CENTRAL NERVOUS SYSTEM ANTICONVULSANTS BANZEL TAB 00MG BANZEL TAB 00MG carbamazepine cap sr 1hr 100 mg carbamazepine cap sr 1hr 00 mg Therapeutic Class PA PA Therapeutic Category of ^ = may be available for up to a 30-day supply only Name of UPPERCASE = Brand s lowercase italics = Generic s Find your drug quickly in the Index at the back of the book. Requirements/Limits Codes: GC = Gap Coverage ED = Excluded Part D LA = Limited Access NM = Not Available by Mail Service PA = Prior Authorization B/D = Covered under Medicare B or D QL = Quantity Limits ST = Step Therapy 017 Comprehensive Formulary VIII

11 ANALGESICS GOUT allopurinol oral tablet 100 mg, 300 mg 1 GC allopurinol sodium intravenous solution reconstituted 500 mg ALOPRIM INTRAVENOUS SOLUTION RECONSTITUTED 500 MG colchicine-probenecid oral tablet mg COLCRYS ORAL TABLET 0.6 MG 3 QL (10 EA per 30 days) probenecid oral tablet 500 mg ULORIC ORAL TABLET 0 MG, 80 MG 3 ST ZURAMPIC ORAL TABLET 00 MG PA MISCELLANEOUS diclofenac-misoprostol oral tablet delayed release mg, mg DUEXIS ORAL TABLET MG VIMOVO ORAL TABLET DELAYED RELEASE MG, MG NSAIDS celecoxib oral capsule 100 mg QL (10 EA per 30 days) celecoxib oral capsule 00 mg QL (60 EA per 30 days) celecoxib oral capsule 00 mg QL (30 EA per 30 days) celecoxib oral capsule 50 mg QL (0 EA per 30 days) diclofenac potassium oral tablet 50 mg QL (10 EA per 30 days) diclofenac sodium er oral tablet extended release hour 100 mg diclofenac sodium oral tablet delayed release 5 mg, 50 mg, 75 mg diflunisal oral tablet 500 mg etodolac er oral tablet extended release hour 00 mg, 500 mg, 600 mg etodolac oral capsule 00 mg, 300 mg etodolac oral tablet 00 mg, 500 mg 1

12 FENOPROFEN CALCIUM ORAL CAPSULE 00 MG fenoprofen calcium oral tablet 600 mg flurbiprofen oral tablet 100 mg, 50 mg ibuprofen oral suspension 100 mg/5ml ibuprofen oral tablet 00 mg, 600 mg, 800 mg 1 GC ketoprofen er oral capsule extended release hour 00 mg ketoprofen oral capsule 50 mg, 75 mg mefenamic acid oral capsule 50 mg MELOXICAM ORAL SUSPENSION 7.5 MG/5ML meloxicam oral tablet 15 mg, 7.5 mg 1 GC nabumetone oral tablet 500 mg, 750 mg NAPRELAN ORAL TABLET EXTENDED RELEASE HOUR 750 MG naproxen dr oral tablet delayed release 375 mg, 500 mg 1 GC naproxen oral suspension 15 mg/5ml naproxen oral tablet 50 mg, 375 mg, 500 mg 1 GC NAPROXEN SODIUM ER ORAL TABLET EXTENDED RELEASE HOUR 375 MG, 500 MG naproxen sodium oral tablet 75 mg, 550 mg oxaprozin oral tablet 600 mg piroxicam oral capsule 10 mg, 0 mg sulindac oral tablet 150 mg, 00 mg 1 GC tolmetin sodium oral capsule 00 mg tolmetin sodium oral tablet 00 mg, 600 mg VIVLODEX ORAL CAPSULE 10 MG, 5 MG OPIOID ANALGESICS, CII ABSTRAL SUBLINGUAL TABLET SUBLINGUAL 100 MCG, 00 MCG, 300 MCG, 00 MCG, 600 MCG, 800 MCG PA; QL (10 EA per 30 days) CODEINE SULFATE ORAL TABLET 15 MG QL (70 EA per 30 days) CODEINE SULFATE ORAL TABLET 30 MG QL (360 EA per 30 days) CODEINE SULFATE ORAL TABLET 60 MG QL (180 EA per 30 days)

13 DURAMORPH INJECTION SOLUTION 0.5 MG/ML, 1 MG/ML EMBEDA ORAL CAPSULE EXTENDED RELEASE 100- MG, MG, MG, 50- MG, 60-. MG, MG endocet oral tablet mg,.5-35 mg, 5-35 mg, mg fentanyl citrate buccal lozenge on a handle 100 mcg, 1600 mcg, 00 mcg, 00 mcg, 600 mcg, 800 mcg fentanyl transdermal patch 7 hour 100 mcg/hr, 1 mcg/hr, 5 mcg/hr, 50 mcg/hr, 75 mcg/hr FENTORA BUCCAL TABLET 100 MCG, 00 MCG, 00 MCG, 600 MCG, 800 MCG hydrocodone-acetaminophen oral solution mg/15ml hydrocodone-acetaminophen oral tablet mg, mg, mg hydrocodone-acetaminophen oral tablet mg,.5-35 mg, 5-35 mg, mg hydrocodone-ibuprofen oral tablet mg, 5-00 mg, mg hydromorphone hcl er oral tablet er hour abusedeterrent 1 mg, 8 mg hydromorphone hcl er oral tablet er hour abusedeterrent 16 mg HYDROMORPHONE HCL ER ORAL TABLET ER HOUR ABUSE-DETERRENT 3 MG HYDROMORPHONE HCL INJECTION SOLUTION 1 MG/ML, MG/ML, MG/ML hydromorphone hcl oral liquid 1 mg/ml B/D QL (60 EA per 30 days) QL (360 EA per 30 days) PA; QL (10 EA per 30 days) QL (10 EA per 30 days) PA; QL (10 EA per 30 days) QL (500 ML per 30 days) QL (00 EA per 30 days) QL (360 EA per 30 days) QL (150 EA per 30 days) QL (60 EA per 30 days) B/D QL (60 EA per 30 days) QL (60 EA per 30 days) hydromorphone hcl oral tablet mg, mg, 8 mg QL (70 EA per 30 days) hydromorphone hcl pf injection solution 10 mg/ml, 50 mg/5ml, 500 mg/50ml HYSINGLA ER ORAL TABLET ER HOUR ABUSE- DETERRENT 100 MG, 10 MG, 80 MG B/D 3 QL (30 EA per 30 days) 3

14 HYSINGLA ER ORAL TABLET ER HOUR ABUSE- DETERRENT 0 MG, 30 MG, 0 MG, 60 MG 3 QL (60 EA per 30 days) ibudone oral tablet mg, 5-00 mg QL (150 EA per 30 days) INFUMORPH 00 INJECTION SOLUTION 00 MG/0ML (10 MG/ML) INFUMORPH 500 INJECTION SOLUTION 500 MG/0ML (5 MG/ML) KADIAN ORAL CAPSULE EXTENDED RELEASE HOUR 00 MG KADIAN ORAL CAPSULE EXTENDED RELEASE HOUR 0 MG LAZANDA NASAL SOLUTION 100 MCG/ACT, 300 MCG/ACT, 00 MCG/ACT B/D B/D QL (60 EA per 30 days) QL (60 EA per 30 days) PA; QL (30 EA per 30 days) levorphanol tartrate oral tablet mg QL (180 EA per 30 days) lorcet hd oral tablet mg QL (360 EA per 30 days) lorcet oral tablet 5-35 mg QL (360 EA per 30 days) lorcet plus oral tablet mg QL (360 EA per 30 days) METHADONE HCL INJECTION SOLUTION 10 MG/ML methadone hcl intensol oral concentrate 10 mg/ml QL (10 ML per 30 days) methadone hcl oral solution 10 mg/5ml, 5 mg/5ml QL (600 ML per 30 days) methadone hcl oral tablet 10 mg, 5 mg QL (0 EA per 30 days) MORPHABOND ER ORAL TABLET ER 1 HOUR ABUSE- DETERRENT 100 MG, 60 MG MORPHABOND ER ORAL TABLET ER 1 HOUR ABUSE- DETERRENT 15 MG, 30 MG MORPHINE SULFATE (CONCENTRATE) ORAL SOLUTION 100 MG/5ML morphine sulfate (pf) injection solution 0.5 mg/ml, 1 mg/ml MORPHINE SULFATE (PF) INTRAVENOUS SOLUTION 10 MG/ML, 15 MG/ML, MG/ML, MG/ML, 8 MG/ML morphine sulfate er beads oral capsule extended release hour 10 mg, 30 mg, 5 mg, 60 mg, 75 mg, 90 mg QL (60 EA per 30 days) QL (60 EA per 30 days) B/D B/D QL (60 EA per 30 days)

15 morphine sulfate er oral capsule extended release hour 10 mg, 0 mg, 30 mg, 50 mg, 60 mg, 80 mg morphine sulfate er oral capsule extended release hour 100 mg morphine sulfate er oral tablet extended release 100 mg, 15 mg, 30 mg, 60 mg QL (60 EA per 30 days) QL (60 EA per 30 days) QL (90 EA per 30 days) morphine sulfate er oral tablet extended release 00 mg QL (60 EA per 30 days) MORPHINE SULFATE INTRAVENOUS SOLUTION 1 MG/ML, 150 MG/30ML MORPHINE SULFATE ORAL SOLUTION 10 MG/5ML, 0 MG/5ML B/D MORPHINE SULFATE ORAL TABLET 15 MG, 30 MG QL (180 EA per 30 days) NUCYNTA ER ORAL TABLET EXTENDED RELEASE 1 HOUR 100 MG, 50 MG NUCYNTA ER ORAL TABLET EXTENDED RELEASE 1 HOUR 150 MG NUCYNTA ER ORAL TABLET EXTENDED RELEASE 1 HOUR 00 MG, 50 MG QL (10 EA per 30 days) QL (60 EA per 30 days) QL (60 EA per 30 days) NUCYNTA ORAL TABLET 100 MG QL (180 EA per 30 days) NUCYNTA ORAL TABLET 50 MG QL (360 EA per 30 days) NUCYNTA ORAL TABLET 75 MG QL (0 EA per 30 days) OPANA ER ORAL TABLET ER 1 HOUR ABUSE- DETERRENT 10 MG, 15 MG, 0 MG, 30 MG, 0 MG, 5 MG, 7.5 MG 3 QL (10 EA per 30 days) oxycodone hcl oral capsule 5 mg QL (180 EA per 30 days) oxycodone hcl oral concentrate 100 mg/5ml OXYCODONE HCL ORAL SOLUTION 5 MG/5ML oxycodone hcl oral tablet 10 mg, 15 mg, 0 mg, 30 mg, 5 mg QL (180 EA per 30 days) oxycodone-acetaminophen oral solution 5-35 mg/5ml QL (1800 ML per 30 days) oxycodone-acetaminophen oral tablet mg,.5-35 mg, 5-35 mg, mg QL (360 EA per 30 days) oxycodone-aspirin oral tablet mg QL (360 EA per 30 days) oxycodone-ibuprofen oral tablet 5-00 mg QL (8 EA per 30 days) 5

16 oxymorphone hcl oral tablet 10 mg, 5 mg QL (180 EA per 30 days) SUBSYS SUBLINGUAL LIQUID 100 MCG, 100 (600 X ) MCG, 1600 (800 X ) MCG, 00 MCG, 00 MCG, 600 MCG, 800 MCG PA; QL (10 EA per 30 days) vicodin es oral tablet mg QL (00 EA per 30 days) vicodin hp oral tablet mg QL (00 EA per 30 days) vicodin oral tablet mg QL (00 EA per 30 days) XARTEMIS XR ORAL TABLET EXTENDED RELEASE MG XTAMPZA ER ORAL CAPSULE ER 1 HOUR ABUSE- DETERRENT 13.5 MG, 18 MG, 7 MG, 9 MG XTAMPZA ER ORAL CAPSULE ER 1 HOUR ABUSE- DETERRENT 36 MG QL (10 EA per 30 days) QL (10 EA per 30 days) QL (0 EA per 30 days) xylon oral tablet mg QL (150 EA per 30 days) zamicet oral solution mg/15ml QL (500 ML per 30 days) ZOHYDRO ER ORAL CAPSULE ER 1 HOUR ABUSE- DETERRENT 10 MG, 15 MG, 0 MG ZOHYDRO ER ORAL CAPSULE ER 1 HOUR ABUSE- DETERRENT 30 MG, 0 MG, 50 MG OPIOID ANALGESICS QL (10 EA per 30 days) QL (60 EA per 30 days) acetaminophen-codeine # oral tablet mg QL (00 EA per 30 days) acetaminophen-codeine #3 oral tablet mg QL (00 EA per 30 days) acetaminophen-codeine # oral tablet mg QL (00 EA per 30 days) acetaminophen-codeine oral solution 10-1 mg/5ml QL (5000 ML per 30 days) apap-caff-dihydrocodeine oral capsule mg QL (360 EA per 30 days) ASPIRIN-CAFF-DIHYDROCODEINE ORAL CAPSULE MG BELBUCA BUCCAL FILM 150 MCG, 300 MCG, 50 MCG, 75 MCG QL (360 EA per 30 days) PA; QL (10 EA per 30 days) BELBUCA BUCCAL FILM 600 MCG, 750 MCG, 900 MCG PA; QL (60 EA per 30 days) butorphanol tartrate injection solution 1 mg/ml, mg/ml butorphanol tartrate nasal solution 10 mg/ml QL (10 ML per 30 days) 6

17 BUTRANS TRANSDERMAL PATCH WEEKLY 10 MCG/HR, 7.5 MCG/HR BUTRANS TRANSDERMAL PATCH WEEKLY 15 MCG/HR, 0 MCG/HR 3 QL (8 EA per 8 days) 3 QL ( EA per 8 days) BUTRANS TRANSDERMAL PATCH WEEKLY 5 MCG/HR 3 QL (16 EA per 8 days) nalbuphine hcl injection solution 10 mg/ml, 0 mg/ml tramadol hcl er (biphasic) oral tablet extended release hour 100 mg tramadol hcl er (biphasic) oral tablet extended release hour 00 mg, 300 mg TRAMADOL HCL ER ORAL CAPSULE EXTENDED RELEASE HOUR 100 MG TRAMADOL HCL ER ORAL CAPSULE EXTENDED RELEASE HOUR 00 MG TRAMADOL HCL ER ORAL CAPSULE EXTENDED RELEASE HOUR 300 MG tramadol hcl er oral tablet extended release hour 100 mg tramadol hcl er oral tablet extended release hour 00 mg TRAMADOL HCL ER ORAL TABLET EXTENDED RELEASE HOUR 300 MG QL (90 EA per 30 days) QL (30 EA per 30 days) QL (90 EA per 30 days) QL (60 EA per 30 days) QL (30 EA per 30 days) QL (90 EA per 30 days) QL (30 EA per 30 days) QL (30 EA per 30 days) tramadol hcl oral tablet 50 mg QL (0 EA per 30 days) tramadol-acetaminophen oral tablet mg QL (0 EA per 30 days) trezix oral capsule mg QL (360 EA per 30 days) ANESTHETICS LOCAL ANESTHETICS lidocaine hcl (pf) injection solution 0.5 %, 1 %, % B/D lidocaine hcl (pf) injection solution % lidocaine hcl injection solution 0.5 %, 1 %, 1.5 %, % B/D ANTI-INFECTIVES ANTI-BACTERIALS - MISCELLANEOUS amikacin sulfate injection solution 1 gm/ml, 500 mg/ml 7

18 BETHKIS INHALATION NEBULIZATION SOLUTION 300 MG/ML gentamicin in saline intravenous solution mg/ml-%, mg/ml-%, mg/ml-%, mg/ml-%, -0.9 mg/ml-% gentamicin sulfate injection solution 10 mg/ml, 0 mg/ml PA gentamicin sulfate intravenous solution 10 mg/ml neomycin sulfate oral tablet 500 mg paromomycin sulfate oral capsule 50 mg streptomycin sulfate intramuscular solution reconstituted 1 gm sulfadiazine oral tablet 500 mg TOBI PODHALER INHALATION CAPSULE 8 MG PA; LA tobramycin inhalation nebulization solution 300 mg/5ml PA tobramycin sulfate injection solution 1. gm/30ml, 10 mg/ml, gm/50ml, 80 mg/ml tobramycin sulfate injection solution reconstituted 1. gm ANTIFUNGALS ABELCET INTRAVENOUS SUSPENSION 5 MG/ML B/D AMBISOME INTRAVENOUS SUSPENSION RECONSTITUTED 50 MG B/D amphotericin b injection solution reconstituted 50 mg B/D CANCIDAS INTRAVENOUS SOLUTION RECONSTITUTED 50 MG, 70 MG CASPOFUNGIN ACETATE INTRAVENOUS SOLUTION RECONSTITUTED 50 MG, 70 MG CRESEMBA INTRAVENOUS SOLUTION RECONSTITUTED 37 MG CRESEMBA ORAL CAPSULE 186 MG ERAXIS INTRAVENOUS SOLUTION RECONSTITUTED 100 MG, 50 MG 8

19 fluconazole in dextrose intravenous solution 00 mg/100ml, 00 mg/00ml fluconazole in sodium chloride intravenous solution mg/50ml-%, mg/100ml-%, mg/00ml-% fluconazole oral suspension reconstituted 10 mg/ml, 0 mg/ml fluconazole oral tablet 100 mg, 150 mg, 00 mg, 50 mg 1 GC flucytosine oral capsule 50 mg, 500 mg griseofulvin microsize oral suspension 15 mg/5ml griseofulvin microsize oral tablet 500 mg griseofulvin ultramicrosize oral tablet 15 mg, 50 mg itraconazole oral capsule 100 mg PA ketoconazole oral tablet 00 mg PA LAMISIL ORAL PACKET 15 MG, MG MYCAMINE INTRAVENOUS SOLUTION RECONSTITUTED 100 MG, 50 MG NOXAFIL INTRAVENOUS SOLUTION 300 MG/16.7ML NOXAFIL ORAL SUSPENSION 0 MG/ML NOXAFIL ORAL TABLET DELAYED RELEASE 100 MG nystatin oral tablet unit ONMEL ORAL TABLET 00 MG PA SPORANOX ORAL SOLUTION 10 MG/ML terbinafine hcl oral tablet 50 mg 1 GC; QL (90 EA per 365 days) voriconazole intravenous solution reconstituted 00 mg voriconazole oral suspension reconstituted 0 mg/ml voriconazole oral tablet 00 mg, 50 mg ANTI-INFECTIVES - MISCELLANEOUS ALBENZA ORAL TABLET 00 MG ALINIA ORAL SUSPENSION RECONSTITUTED 100 MG/5ML ALINIA ORAL TABLET 500 MG atovaquone oral suspension 750 mg/5ml 9

20 AZACTAM IN DEXTROSE INTRAVENOUS SOLUTION 1 GM, GM aztreonam injection solution reconstituted 1 gm, gm BILTRICIDE ORAL TABLET 600 MG 3 CAYSTON INHALATION SOLUTION RECONSTITUTED 75 MG clindamycin hcl oral capsule 150 mg, 300 mg, 75 mg 1 GC clindamycin palmitate hcl oral solution reconstituted 75 mg/5ml clindamycin phosphate in d5w intravenous solution 300 mg/50ml, 600 mg/50ml, 900 mg/50ml CLINDAMYCIN PHOSPHATE IN NACL INTRAVENOUS SOLUTION MG/50ML-%, MG/50ML-%, MG/50ML-% clindamycin phosphate injection solution 300 mg/ml, 600 mg/ml, 9 gm/60ml, 900 mg/6ml, 9000 mg/60ml clindamycin phosphate intravenous solution 150 mg/ml, 900 mg/6ml colistimethate sodium injection solution reconstituted 150 mg CUBICIN INTRAVENOUS SOLUTION RECONSTITUTED 500 MG DALVANCE INTRAVENOUS SOLUTION RECONSTITUTED 500 MG dapsone oral tablet 100 mg, 5 mg daptomycin intravenous solution reconstituted 500 mg DORIBAX INTRAVENOUS SOLUTION RECONSTITUTED 50 MG, 500 MG DORIPENEM INTRAVENOUS SOLUTION RECONSTITUTED 50 MG, 500 MG emverm oral tablet chewable 100 mg imipenem-cilastatin intravenous solution reconstituted 50 mg, 500 mg INVANZ INJECTION SOLUTION RECONSTITUTED 1 GM PA; LA 10

21 INVANZ INTRAVENOUS SOLUTION RECONSTITUTED 1 GM ivermectin oral tablet 3 mg LINEZOLID IN SODIUM CHLORIDE INTRAVENOUS SOLUTION MG/300ML-% linezolid intravenous solution 600 mg/300ml LINEZOLID ORAL SUSPENSION RECONSTITUTED 100 MG/5ML LINEZOLID ORAL TABLET 600 MG meropenem intravenous solution reconstituted 1 gm, 500 mg MEROPENEM-SODIUM CHLORIDE INTRAVENOUS SOLUTION RECONSTITUTED 1 GM/50ML, 500 MG/50ML methenamine hippurate oral tablet 1 gm METRO INTRAVENOUS SOLUTION MG/100ML- % metronidazole in nacl intravenous solution mg/100ml-% metronidazole oral capsule 375 mg metronidazole oral tablet 50 mg, 500 mg 1 GC NEBUPENT INHALATION SOLUTION RECONSTITUTED 300 MG nitrofurantoin macrocrystal oral capsule 100 mg, 5 mg, 50 mg 3 B/D PA nitrofurantoin monohyd macro oral capsule 100 mg PA nitrofurantoin oral suspension 5 mg/5ml PA ORBACTIV INTRAVENOUS SOLUTION RECONSTITUTED 00 MG PENTAM INJECTION SOLUTION RECONSTITUTED 300 MG polymyxin b sulfate injection solution reconstituted unit PRIMSOL ORAL SOLUTION 50 MG/5ML 11

22 SIVEXTRO INTRAVENOUS SOLUTION RECONSTITUTED 00 MG SIVEXTRO ORAL TABLET 00 MG sulfamethoxazole-trimethoprim intravenous solution mg/5ml sulfamethoxazole-trimethoprim oral suspension 00-0 mg/5ml sulfamethoxazole-trimethoprim oral tablet mg, mg SYNERCID INTRAVENOUS SOLUTION RECONSTITUTED MG TIGECYCLINE INTRAVENOUS SOLUTION RECONSTITUTED 50 MG 1 GC trimethoprim oral tablet 100 mg 1 GC TYGACIL INTRAVENOUS SOLUTION RECONSTITUTED 50 MG VANCOMYCIN HCL IN NACL INTRAVENOUS SOLUTION GM/00ML-%, MG/100ML-%, MG/150ML-% vancomycin hcl intravenous solution reconstituted 10 gm, 1000 mg, 500 mg, 5000 mg, 750 mg vancomycin hcl oral capsule 15 mg, 50 mg VIBATIV INTRAVENOUS SOLUTION RECONSTITUTED 750 MG XIFAXAN ORAL TABLET 00 MG ANTIMALARIALS atovaquone-proguanil hcl oral tablet mg, mg chloroquine phosphate oral tablet 50 mg, 500 mg COARTEM ORAL TABLET 0-10 MG mefloquine hcl oral tablet 50 mg PRIMAQUINE PHOSPHATE ORAL TABLET 6.3 MG 3 quinine sulfate oral capsule 3 mg PA 1

23 ANTIRETROVIRAL AGENTS abacavir sulfate oral tablet 300 mg APTIVUS ORAL CAPSULE 50 MG APTIVUS ORAL SOLUTION 100 MG/ML CRIXIVAN ORAL CAPSULE 00 MG, 00 MG didanosine oral capsule delayed release 15 mg, 00 mg, 50 mg, 00 mg EDURANT ORAL TABLET 5 MG EMTRIVA ORAL CAPSULE 00 MG 3 EMTRIVA ORAL SOLUTION 10 MG/ML 3 FUZEON SUBCUTANEOUS SOLUTION RECONSTITUTED 90 MG INTELENCE ORAL TABLET 100 MG, 00 MG INTELENCE ORAL TABLET 5 MG INVIRASE ORAL CAPSULE 00 MG INVIRASE ORAL TABLET 500 MG ISENTRESS HD ORAL TABLET 600 MG ISENTRESS ORAL PACKET 100 MG ISENTRESS ORAL TABLET 00 MG ISENTRESS ORAL TABLET CHEWABLE 100 MG ISENTRESS ORAL TABLET CHEWABLE 5 MG 3 lamivudine oral solution 10 mg/ml lamivudine oral tablet 150 mg, 300 mg LEXIVA ORAL SUSPENSION 50 MG/ML LEXIVA ORAL TABLET 700 MG nevirapine er oral tablet extended release hour 100 mg, 00 mg NEVIRAPINE ORAL SUSPENSION 50 MG/5ML nevirapine oral tablet 00 mg NORVIR ORAL CAPSULE 100 MG 3 NORVIR ORAL SOLUTION 80 MG/ML 3 NORVIR ORAL TABLET 100 MG 3 13

24 PREZISTA ORAL SUSPENSION 100 MG/ML PREZISTA ORAL TABLET 150 MG, 75 MG 3 PREZISTA ORAL TABLET 600 MG, 800 MG RESCRIPTOR ORAL TABLET 100 MG, 00 MG RETROVIR INTRAVENOUS SOLUTION 10 MG/ML 3 REYATAZ ORAL CAPSULE 150 MG, 00 MG, 300 MG REYATAZ ORAL PACKET 50 MG SELZENTRY ORAL SOLUTION 0 MG/ML SELZENTRY ORAL TABLET 150 MG, 300 MG, 75 MG SELZENTRY ORAL TABLET 5 MG stavudine oral capsule 15 mg, 0 mg, 30 mg, 0 mg SUSTIVA ORAL CAPSULE 00 MG SUSTIVA ORAL CAPSULE 50 MG 3 SUSTIVA ORAL TABLET 600 MG TIVICAY ORAL TABLET 10 MG 3 TIVICAY ORAL TABLET 5 MG, 50 MG TYBOST ORAL TABLET 150 MG 3 VIDEX ORAL SOLUTION RECONSTITUTED GM, GM VIRACEPT ORAL TABLET 50 MG, 65 MG VIRAMUNE ORAL SUSPENSION 50 MG/5ML VIREAD ORAL POWDER 0 MG/GM VIREAD ORAL TABLET 150 MG, 00 MG, 50 MG, 300 MG ZERIT ORAL SOLUTION RECONSTITUTED 1 MG/ML ZIAGEN ORAL SOLUTION 0 MG/ML 3 zidovudine oral capsule 100 mg zidovudine oral syrup 50 mg/5ml zidovudine oral tablet 300 mg ANTIRETROVIRAL COMBINATION AGENTS ABACAVIR SULFATE-LAMIVUDINE ORAL TABLET MG 1

25 abacavir-lamivudine-zidovudine oral tablet mg ATRIPLA ORAL TABLET MG COMPLERA ORAL TABLET MG DESCOVY ORAL TABLET 00-5 MG EVOTAZ ORAL TABLET MG GENVOYA ORAL TABLET MG KALETRA ORAL SOLUTION MG/5ML KALETRA ORAL TABLET MG 3 KALETRA ORAL TABLET MG lamivudine-zidovudine oral tablet mg lopinavir-ritonavir oral solution mg/5ml ODEFSEY ORAL TABLET MG PREZCOBIX ORAL TABLET MG STRIBILD ORAL TABLET MG TRIUMEQ ORAL TABLET MG TRUVADA ORAL TABLET MG QL (60 EA per 30 days) TRUVADA ORAL TABLET MG, MG, MG ANTITUBERCULAR AGENTS QL (30 EA per 30 days) CAPASTAT SULFATE INJECTION SOLUTION RECONSTITUTED 1 GM cycloserine oral capsule 50 mg ethambutol hcl oral tablet 100 mg, 00 mg isoniazid injection solution 100 mg/ml isoniazid oral syrup 50 mg/5ml isoniazid oral tablet 100 mg, 300 mg 1 GC paser oral packet gm 3 PRIFTIN ORAL TABLET 150 MG pyrazinamide oral tablet 500 mg rifabutin oral capsule 150 mg rifamate oral capsule mg 15

26 rifampin intravenous solution reconstituted 600 mg rifampin oral capsule 150 mg, 300 mg RIFATER ORAL TABLET MG SIRTURO ORAL TABLET 100 MG PA; LA TRECATOR ORAL TABLET 50 MG ANTIVIRALS acyclovir oral capsule 00 mg 1 GC acyclovir oral suspension 00 mg/5ml acyclovir oral tablet 00 mg, 800 mg 1 GC acyclovir sodium intravenous solution 50 mg/ml B/D acyclovir sodium intravenous solution reconstituted 500 mg adefovir dipivoxil oral tablet 10 mg BARACLUDE ORAL SOLUTION 0.05 MG/ML cidofovir intravenous solution 75 mg/ml B/D DAKLINZA ORAL TABLET 30 MG, 60 MG, 90 MG PA entecavir oral tablet 0.5 mg, 1 mg EPCLUSA ORAL TABLET MG PA EPIVIR HBV ORAL SOLUTION 5 MG/ML famciclovir oral tablet 15 mg, 50 mg, 500 mg ganciclovir sodium intravenous solution reconstituted 500 mg B/D HARVONI ORAL TABLET MG PA lamivudine oral tablet 100 mg MAVYRET ORAL TABLET MG PA moderiba 100 dose pack oral tablet 600 mg moderiba 800 dose pack oral tablet 00 mg moderiba oral tablet 00 & 00 mg, 00 & 600 mg moderiba oral tablet 00 mg oseltamivir phosphate oral capsule 30 mg, 5 mg, 75 mg 16

27 PEGASYS PROCLICK SUBCUTANEOUS SOLUTION 135 MCG/0.5ML, 180 MCG/0.5ML PEGASYS SUBCUTANEOUS SOLUTION 180 MCG/0.5ML, 180 MCG/ML REBETOL ORAL SOLUTION 0 MG/ML RELENZA DISKHALER INHALATION AEROSOL POWDER BREATH ACTIVATED 5 MG/BLISTER ribasphere oral capsule 00 mg ribasphere oral tablet 00 mg ribasphere oral tablet 00 mg, 600 mg ribasphere ribapak oral tablet 00 & 00 mg, 00 & 600 mg, 00 mg, 600 mg ribavirin oral capsule 00 mg ribavirin oral tablet 00 mg rimantadine hcl oral tablet 100 mg SOVALDI ORAL TABLET 00 MG PA TAMIFLU ORAL SUSPENSION RECONSTITUTED 6 MG/ML 3 TYZEKA ORAL TABLET 600 MG valacyclovir hcl oral tablet 1 gm, 500 mg VALCYTE ORAL SOLUTION RECONSTITUTED 50 MG/ML valganciclovir hcl oral solution reconstituted 50 mg/ml valganciclovir hcl oral tablet 50 mg VEMLIDY ORAL TABLET 5 MG VOSEVI ORAL TABLET MG PA ZEPATIER ORAL TABLET MG PA CEPHALOSPORINS AVYCAZ INTRAVENOUS SOLUTION RECONSTITUTED.5 (-0.5) GM cefaclor er oral tablet extended release 1 hour 500 mg 3 cefaclor oral capsule 50 mg, 500 mg cefaclor oral suspension reconstituted 15 mg/5ml, 50 mg/5ml, 375 mg/5ml 3 cefadroxil oral capsule 500 mg 1 GC 17 PA PA

28 cefadroxil oral suspension reconstituted 50 mg/5ml, 500 mg/5ml cefadroxil oral tablet 1 gm cefazolin sodium injection solution reconstituted 1 gm, 10 gm, 0 gm, 500 mg cefazolin sodium intravenous solution 1-5 gm-% 3 cefazolin sodium intravenous solution reconstituted 1 gm CEFAZOLIN SODIUM-DEXTROSE INTRAVENOUS SOLUTION - GM/100ML-% cefdinir oral capsule 300 mg cefdinir oral suspension reconstituted 15 mg/5ml, 50 mg/5ml cefepime hcl injection solution reconstituted 1 gm, gm CEFEPIME HCL INTRAVENOUS SOLUTION 1 GM/50ML, GM/100ML CEFEPIME-DEXTROSE INTRAVENOUS SOLUTION RECONSTITUTED 1 GM/50ML, GM/50ML cefixime oral suspension reconstituted 100 mg/5ml, 00 mg/5ml cefotaxime sodium injection solution reconstituted 1 gm, gm, 500 mg cefotetan disodium injection solution reconstituted 1 gm, 10 gm, gm cefoxitin sodium injection solution reconstituted 10 gm cefoxitin sodium intravenous solution reconstituted 1 gm, gm CEFOXITIN SODIUM-DEXTROSE INTRAVENOUS SOLUTION RECONSTITUTED 1- GM-%, -. GM-% cefpodoxime proxetil oral suspension reconstituted 100 mg/5ml, 50 mg/5ml cefpodoxime proxetil oral tablet 100 mg, 00 mg cefprozil oral suspension reconstituted 15 mg/5ml, 50 mg/5ml 3 18

29 cefprozil oral tablet 50 mg, 500 mg CEFTAZIDIME AND DEXTROSE INTRAVENOUS SOLUTION RECONSTITUTED 1 GM/50ML, GM/50ML ceftazidime injection solution reconstituted 1 gm, gm, 6 gm CEFTIBUTEN ORAL CAPSULE 00 MG CEFTIBUTEN ORAL SUSPENSION RECONSTITUTED 180 MG/5ML CEFTIN ORAL SUSPENSION RECONSTITUTED 15 MG/5ML, 50 MG/5ML ceftriaxone sodium injection solution reconstituted 1 gm, gm, 50 mg, 500 mg ceftriaxone sodium intravenous solution reconstituted 1 gm, 10 gm, gm cefuroxime axetil oral tablet 50 mg, 500 mg cefuroxime sodium injection solution reconstituted 1.5 gm, 7.5 gm, 750 mg cefuroxime sodium intravenous solution reconstituted 1.5 gm cephalexin oral capsule 50 mg, 500 mg 1 GC cephalexin oral capsule 750 mg cephalexin oral suspension reconstituted 15 mg/5ml, 50 mg/5ml cephalexin oral tablet 50 mg, 500 mg MAXIPIME INTRAVENOUS SOLUTION RECONSTITUTED 1 GM, GM SUPRAX ORAL CAPSULE 00 MG 3 SUPRAX ORAL SUSPENSION RECONSTITUTED 500 MG/5ML suprax oral tablet chewable 100 mg, 00 mg tazicef injection solution reconstituted 1 gm, gm, 6 gm tazicef intravenous solution reconstituted 1 gm, gm TEFLARO INTRAVENOUS SOLUTION RECONSTITUTED 00 MG, 600 MG 3 19

30 ZERBAXA INTRAVENOUS SOLUTION RECONSTITUTED 1.5 (1-0.5) GM ERYTHROMYCINS/MACROLIDES azithromycin intravenous solution reconstituted 500 mg AZITHROMYCIN ORAL PACKET 1 GM azithromycin oral suspension reconstituted 100 mg/5ml, 00 mg/5ml azithromycin oral tablet 50 mg, 50 mg (6 pack), 500 mg, 500 mg (3 pack), 600 mg clarithromycin er oral tablet extended release hour 500 mg clarithromycin oral suspension reconstituted 15 mg/5ml, 50 mg/5ml 1 GC clarithromycin oral tablet 50 mg, 500 mg DIFICID ORAL TABLET 00 MG e.e.s. 00 oral tablet 00 mg E.E.S. GRANULES ORAL SUSPENSION RECONSTITUTED 00 MG/5ML ERYPED 00 ORAL SUSPENSION RECONSTITUTED 00 MG/5ML ERYPED 00 ORAL SUSPENSION RECONSTITUTED 00 MG/5ML ery-tab oral tablet delayed release 50 mg, 333 mg, 500 mg erythrocin lactobionate intravenous solution reconstituted 500 mg erythrocin stearate oral tablet 50 mg erythromycin base oral capsule delayed release particles 50 mg erythromycin base oral tablet 50 mg, 500 mg erythromycin ethylsuccinate oral suspension reconstituted 00 mg/5ml erythromycin ethylsuccinate oral tablet 00 mg PCE ORAL TABLET DELAYED RELEASE 333 MG, 500 MG 0

31 ZMAX ORAL SUSPENSION RECONSTITUTED GM FLUOROQUINOLONES AVELOX INTRAVENOUS SOLUTION 00 MG/50ML ciprofloxacin hcl oral tablet 100 mg, 50 mg, 500 mg, 750 mg ciprofloxacin in d5w intravenous solution 00 mg/100ml, 00 mg/00ml ciprofloxacin intravenous solution 00 mg/0ml, 00 mg/0ml ciprofloxacin oral suspension reconstituted 50 mg/5ml (5%), 500 mg/5ml (10%) ciprofloxacin-ciproflox hcl er oral tablet extended release hour 1000 mg, 500 mg levofloxacin in d5w intravenous solution 50 mg/50ml, 500 mg/100ml, 750 mg/150ml levofloxacin intravenous solution 5 mg/ml levofloxacin oral solution 5 mg/ml 1 GC levofloxacin oral tablet 50 mg, 500 mg, 750 mg 1 GC MOXIFLOXACIN HCL INTRAVENOUS SOLUTION 00 MG/50ML moxifloxacin hcl oral tablet 00 mg PENICILLINS amoxicillin oral capsule 50 mg, 500 mg 1 GC amoxicillin oral suspension reconstituted 15 mg/5ml, 00 mg/5ml, 50 mg/5ml, 00 mg/5ml 1 GC amoxicillin oral tablet 500 mg, 875 mg 1 GC amoxicillin oral tablet chewable 15 mg, 50 mg 1 GC amoxicillin-pot clavulanate er oral tablet extended release 1 hour mg amoxicillin-pot clavulanate oral suspension reconstituted mg/5ml, mg/5ml, mg/5ml, mg/5ml amoxicillin-pot clavulanate oral tablet mg, mg, mg 1

32 amoxicillin-pot clavulanate oral tablet chewable mg, mg ampicillin oral capsule 50 mg, 500 mg 1 GC ampicillin oral suspension reconstituted 15 mg/5ml, 50 mg/5ml ampicillin sodium injection solution reconstituted 1 gm, 10 gm, 15 mg, gm, 50 mg, 500 mg ampicillin sodium intravenous solution reconstituted 1 gm, 10 gm, gm ampicillin-sulbactam sodium injection solution reconstituted 1.5 (1-0.5) gm, 15 (10-5) gm, 3 (-1) gm ampicillin-sulbactam sodium intravenous solution reconstituted 15 (10-5) gm AUGMENTIN ORAL SUSPENSION RECONSTITUTED MG/5ML BACTOCILL IN DEXTROSE INTRAVENOUS SOLUTION 1 GM/50ML BACTOCILL IN DEXTROSE INTRAVENOUS SOLUTION GM/50ML BICILLIN C-R 900/300 INTRAMUSCULAR SUSPENSION UNIT/ML BICILLIN C-R INTRAMUSCULAR SUSPENSION UNIT/ML BICILLIN L-A INTRAMUSCULAR SUSPENSION UNIT/ML, UNIT/ML, UNIT/ML dicloxacillin sodium oral capsule 50 mg, 500 mg NAFCILLIN SODIUM IN DEXTROSE INTRAVENOUS SOLUTION 1 GM/50ML, GM/100ML nafcillin sodium injection solution reconstituted 1 gm, 10 gm, gm nafcillin sodium intravenous solution reconstituted 1 gm, gm oxacillin sodium injection solution reconstituted 1 gm, gm oxacillin sodium injection solution reconstituted 10 gm

33 PENICILLIN G POT IN DEXTROSE INTRAVENOUS SOLUTION 0000 UNIT/ML, 0000 UNIT/ML, UNIT/ML penicillin g potassium injection solution reconstituted unit, unit penicillin g procaine intramuscular suspension unit/ml penicillin g sodium injection solution reconstituted unit 3 penicillin v potassium oral solution reconstituted 15 mg/5ml, 50 mg/5ml 1 GC penicillin v potassium oral tablet 50 mg, 500 mg 1 GC pfizerpen-g injection solution reconstituted unit, unit piperacillin sod-tazobactam so intravenous solution reconstituted 13.5 (1-1.5) gm,.5 (-0.5) gm, ( ) gm,.5 (-0.5) gm, 0.5 (36-.5) gm ZOSYN INTRAVENOUS SOLUTION -0.5 GM/50ML, GM/50ML, -0.5 GM/100ML TETRACYCLINES demeclocycline hcl oral tablet 150 mg, 300 mg doxy 100 intravenous solution reconstituted 100 mg doxycycline hyclate intravenous solution reconstituted 100 mg doxycycline hyclate oral capsule 100 mg, 50 mg doxycycline hyclate oral tablet 100 mg, 0 mg doxycycline hyclate oral tablet delayed release 100 mg, 150 mg, 00 mg, 50 mg, 75 mg doxycycline monohydrate oral capsule 100 mg, 150 mg, 50 mg, 75 mg doxycycline monohydrate oral suspension reconstituted 5 mg/5ml doxycycline monohydrate oral tablet 100 mg, 150 mg, 50 mg, 75 mg 3

34 minocycline hcl er oral tablet extended release hour 135 mg, 5 mg, 90 mg minocycline hcl oral capsule 100 mg, 50 mg, 75 mg minocycline hcl oral tablet 100 mg, 50 mg, 75 mg morgidox oral capsule 50 mg TETRACYCLINE HCL ORAL CAPSULE 50 MG, 500 MG VIBRAMYCIN ORAL SYRUP 50 MG/5ML ANTINEOPLASTIC AGENTS ALKYLATING AGENTS BENDEKA INTRAVENOUS SOLUTION 100 MG/ML B/D BICNU INTRAVENOUS SOLUTION RECONSTITUTED 100 MG B/D busulfan intravenous solution 6 mg/ml B/D BUSULFEX INTRAVENOUS SOLUTION 6 MG/ML B/D cyclophosphamide injection solution reconstituted 1 gm, gm, 500 mg B/D CYCLOPHOSPHAMIDE ORAL CAPSULE 5 MG, 50 MG B/D dacarbazine intravenous solution reconstituted 100 mg, 00 mg EMCYT ORAL CAPSULE 10 MG GLEOSTINE ORAL CAPSULE 10 MG, 100 MG, 0 MG, 5 MG HEXALEN ORAL CAPSULE 50 MG B/D IFEX INTRAVENOUS SOLUTION RECONSTITUTED 3 GM B/D ifosfamide intravenous solution 1 gm/0ml, 3 gm/60ml B/D ifosfamide intravenous solution reconstituted 1 gm B/D IFOSFAMIDE INTRAVENOUS SOLUTION RECONSTITUTED 3 GM LEUKERAN ORAL TABLET MG B/D melphalan hcl intravenous solution reconstituted 50 mg B/D MUSTARGEN INJECTION SOLUTION RECONSTITUTED 10 MG B/D thiotepa injection solution reconstituted 15 mg B/D

35 TREANDA INTRAVENOUS SOLUTION RECONSTITUTED 100 MG, 5 MG B/D ZANOSAR INTRAVENOUS SOLUTION RECONSTITUTED 1 GM ANTHRACYCLINES B/D adriamycin intravenous solution mg/ml B/D daunorubicin hcl intravenous injectable 5 mg/ml B/D doxorubicin hcl intravenous solution mg/ml B/D doxorubicin hcl intravenous solution reconstituted 10 mg, 50 mg B/D doxorubicin hcl liposomal intravenous injectable mg/ml B/D epirubicin hcl intravenous solution 00 mg/100ml, 50 mg/5ml B/D idarubicin hcl intravenous solution 10 mg/10ml, 0 mg/0ml, 5 mg/5ml ANTIBIOTICS B/D bleomycin sulfate injection solution reconstituted 15 unit, 30 unit B/D COSMEGEN INTRAVENOUS SOLUTION RECONSTITUTED 0.5 MG mitomycin intravenous solution reconstituted 0 mg, 0 mg, 5 mg ANTIMETABOLITES B/D B/D adrucil intravenous solution.5 gm/50ml, 5 gm/100ml, 500 mg/10ml B/D ALIMTA INTRAVENOUS SOLUTION RECONSTITUTED 100 MG, 500 MG B/D ARRANON INTRAVENOUS SOLUTION 5 MG/ML B/D azacitidine injection suspension reconstituted 100 mg B/D cladribine intravenous solution 10 mg/10ml B/D clofarabine intravenous solution 1 mg/ml B/D CLOLAR INTRAVENOUS SOLUTION 1 MG/ML B/D cytarabine (pf) injection solution 100 mg/ml B/D 5

36 cytarabine injection solution 0 mg/ml B/D decitabine intravenous solution reconstituted 50 mg B/D fludarabine phosphate intravenous solution 50 mg/ml B/D fludarabine phosphate intravenous solution reconstituted 50 mg fluorouracil intravenous solution 1 gm/0ml,.5 gm/50ml, 5 gm/100ml, 500 mg/10ml GEMCITABINE HCL INTRAVENOUS SOLUTION 1 GM/6.3ML, GM/5.6ML, 00 MG/5.6ML gemcitabine hcl intravenous solution reconstituted 1 gm, gm, 00 mg mercaptopurine oral tablet 50 mg methotrexate sodium (pf) injection solution 1 gm/0ml, 100 mg/ml, 00 mg/8ml, 50 mg/10ml, 50 mg/ml B/D B/D B/D B/D B/D methotrexate sodium injection solution 50 mg/10ml B/D METHOTREXATE SODIUM INJECTION SOLUTION 50 MG/ML methotrexate sodium injection solution reconstituted 1 gm NIPENT INTRAVENOUS SOLUTION RECONSTITUTED 10 MG PURIXAN ORAL SUSPENSION 000 MG/100ML TABLOID ORAL TABLET 0 MG ANTIMITOTIC, TAXOIDS ABRAXANE INTRAVENOUS SUSPENSION RECONSTITUTED 100 MG DOCEFREZ INTRAVENOUS SOLUTION RECONSTITUTED 0 MG DOCETAXEL INTRAVENOUS CONCENTRATE 160 MG/8ML, 0 MG/ML, 80 MG/ML B/D B/D B/D B/D B/D B/D docetaxel intravenous concentrate 00 mg/10ml B/D DOCETAXEL INTRAVENOUS SOLUTION 160 MG/16ML, 0 MG/ML, 80 MG/8ML B/D 6

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