Apollo Constellation Health (HMO) Home Constellation Health (HMO) Olympus Constellation Health (PPO) Olympus Prime Constellation Health (PPO)

Transcription

1 Apollo Constellation Health (HMO) Home Constellation Health (HMO) Olympus Constellation Health (PPO) Olympus Prime Constellation Health (PPO) 208 Formulary List of Covered Drugs PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN HPMS Approved Formulary File Submission ID 8462, Version Number 4. This formulary was updated on 09/0/208. For more recent information or other questions, please contact us Constellation Health at (Metro Area), (Toll Free) or, for TTY users, , Monday through Sunday, from 8:00 a.m. to 8:00 p.m., or visit 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 Constellation Health. When it refers to plan or our plan, it means Apollo Constellation Health (HMO)/ Home- Constellation Health (HMO) / Olympus Constellation Health (PPO) / Olympus Prime Constellation Health (PPO). This document includes list of the drugs (formulary) for our plan which is current as of 09/0/8. For an updated formulary, please contact us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages. You must generally use network pharmacies to use your prescription drug benefit. Benefits, formulary, pharmacy network, and/or copayments/coinsurance may change on January, 209 and from time to time during the year. Page of 7

2 What is the Apollo Constellation Health (HMO)/ Home- Constellation Health (HMO)/ Olympus Constellation Health (PPO)/ Olympus Prime Constellation Health (PPO) Formulary? A formulary is a list of covered drugs selected by Constellation Health in consultation with a team of health care providers, which represents the prescription therapies believed to be a necessary part of a quality treatment program. Constellation Health will generally cover the drugs listed in our formulary as long as the drug is medically necessary, the prescription is filled at a Constellation Health network pharmacy, and other plan rules are followed. For more information on how to fill your prescriptions, please review your Evidence of Coverage. Can the Formulary (drug list) change? Generally, if you are taking a drug on our 208 formulary that was covered at the beginning of the year, we will not discontinue or reduce coverage of the drug during the 208 coverage year except when a new, less expensive generic drug becomes available or when new adverse information about the safety or effectiveness of a drug is released. Other types of formulary changes, such as removing a drug from our formulary, will not affect members who are currently taking the drug. It will remain available at the same cost-sharing for those members taking it for the remainder of the coverage year. We feel it is important that you have continued access for the remainder of the coverage year to the formulary drugs that were available when you chose our plan, except for cases in which you can save additional money or we can ensure your safety. If we remove drugs from our formulary, or add prior authorization, quantity limits and/or step therapy restrictions on a drug or move a drug to a higher cost-sharing tier, we must notify affected members of the change at least 60 days before the change becomes effective, or at the time the member requests a refill of the drug, at which time the member will receive a 60-day supply of the drug. If the Food and Drug Administration deems a drug on our formulary to be unsafe or the drug s manufacturer removes the drug from the market, we will immediately remove the drug from our formulary and provide notice to members who take the drug. The enclosed formulary is current as of 09/0/208. To get updated information about the drugs covered by Constellation Health please contact us. Our contact information appears on the front and back cover pages. How do I use the Formulary? There are two ways to find your drug within the formulary: Medical Condition The formulary begins on page 7. The drugs in this formulary are grouped into categories depending on the type of medical conditions that they are used to treat. For example, drugs used to treat a heart condition are listed under the category, Cardiovascular Agents. If you know what your drug is used for, look for the category name in the list that begins on page number 48. Then look under the category name for your drug. Page 2 of 7

3 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 56. 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? Constellation Health covers both brand name drugs and generic drugs. A generic drug is approved by the FDA as having the same active ingredient as the brand name drug. Generally, generic drugs cost less than brand name drugs. Are there any restrictions on my coverage? Some covered drugs may have additional requirements or limits on coverage. These requirements and limits may include: Prior Authorization: Constellation Health requires you or your physician to get prior authorization for certain drugs. This means that you will need to get approval from Constellation Health before you fill your prescriptions. If you don t get approval, Constellation Health may not cover the drug. Quantity Limits: For certain drugs, Constellation Health limits the amount of the drug that Constellation Health will cover. For example, Constellation Health provides 60 capsules per 0 days for celecoxib oral capsule. This may be in addition to a standard one-month or three-month supply. You can find out if your drug has any additional requirements or limits by looking in the formulary that begins on page 7. You can also get more information about the restrictions applied to specific covered drugs by visiting our Web site. We have posted on line a document that explain our prior authorization restriction. 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 Constellation Health to make an exception to these restrictions or limits or for a list of other, similar drugs that may treat your health condition. See the section, How do I request an exception to the Constellation Health formulary? on page 4 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 Member Services and ask if your drug is covered. For more information, please contact us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages. Page of 7

4 If you learn that Constellation Health does not cover your drug, you have two options: You can ask Member Services for a list of similar drugs that are covered by Constellation Health. When you receive the list, show it to your doctor and ask him or her to prescribe a similar drug that is covered by Constellation Health. You can ask Constellation Health to make an exception and cover your drug. See below for information about how to request an exception. How do I request an exception to the Apollo Constellation Health (HMO), Home- Constellation Health (HMO), Olympus Constellation Health (PPO), Olympus Prime Constellation Health (PPO)? You can ask Constellation Health to make an exception to our coverage rules. There are several types of exceptions that you can ask us to make. ou can ask us to cover a drug even if it is not on our formulary. If approved, this drug will be covered at a pre-determined cost-sharing level, and you would not be able to ask us to provide the drug at a lower cost-sharing level. You can ask us to cover a formulary drug at a lower cost-sharing level if this drug is not on the specialty tier. If approved this would lower the amount you must pay for your drug. You can ask us to waive coverage restrictions or limits on your drug. For example, for certain drugs, Constellation Health limits the amount of the drug that we will cover. If your drug has a quantity limit, you can ask us to waive the limit and cover a greater amount. Generally, Constellation Health will only approve your request for an exception if the alternative drugs included on the plan s formulary, the lower cost-sharing drug or additional utilization restrictions would not be as effective in treating your condition and/or would cause you to have adverse medical effects. You should contact us to ask us for an initial coverage decision for a formulary, or utilization restriction exception. When you request a formulary or utilization restriction exception you should submit a statement from your prescriber or physician supporting your request. Generally, we must make our decision within 72 hours of getting your prescriber s supporting statement. You can request an expedited (fast) exception if you or your doctor believe that your health could be seriously harmed by waiting up to 72 hours for a decision. If your request to expedite is granted, we must give you a decision no later than 24 hours after we get a supporting statement from your doctor or other prescriber. What do I do before I can talk to my doctor about changing my drugs or requesting an exception? As a new or continuing member in our plan you may be taking drugs that are not on our formulary. Or, you may be taking a drug that is on our formulary but your ability to get it is limited. For example, you may need Page 4 of 7

5 a prior authorization from us before you can fill your prescription. You should talk to your doctor to decide if you should switch to an appropriate drug that we cover or request a formulary exception so that we will cover the drug you take. While you talk to your doctor to determine the right course of action for you, we may cover your drug in certain cases during the first must be at least 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 0 day supply (unless you have a prescription written for fewer days) when you go to a network pharmacy. After your first the temporary 0-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 9 and may be up to a 98 day transition supply, consistent with dispensing increment, (unless you have a prescription written for fewer days). We will cover more than one refill of these drugs for the first 90 days you are a member of our plan. If you need a drug that is not on our formulary or if your ability to get your drugs is limited, but you are past the first 90 days of membership in our plan, we will cover a day emergency supply of that drug (unless you have a prescription for fewer days) while you pursue a formulary exception. Constellation Health has a transition policy for new and existing members. The transition process is applicable to members that recently qualified for a Medicare Part D plan, members that transitioned from one plan to another after the beginning of the year (that is, after January st ), members that moved from or to long term care facilities, and members currently enrolled in a Constellation Health plan that were affected by changes in the formulary from one year to the other. The copay for claims during the transition process are established by the complete benefit design in which the member is enrolled. Constellation extends its transition process from one year to another if a member enrolls in a plan with effective enrollment date of November st or December st and they need access to a transition supply. A written notification is sent to the member after they receive a temporary fill during the transition period. The notification follows Medicare guidelines and includes the following information: an explanation of the temporary transition supply received during the transition period, instructions on how to work with Constellation Health and the prescriber to identify an adequate therapeutic alternative that is in the Constellation Health formulary, an explanation of the member s right to request an exception, and a description of the process to request an exception. For more information For more detailed information about your Constellation Health prescription drug coverage, please review your Evidence of Coverage and other plan materials. If you have questions about Constellation Health please contact us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages. If you have general questions about Medicare prescription drug coverage, please call Medicare at MEDICARE ( ) 24 hours a day/7 days a week. TTY users should call Or, visit Page 5 of 7

6 Constellation Health Formulary The formulary provides coverage information about some of the drugs covered by Constellation Health. If you have trouble finding your drug in the list, turn to the Index that begins on page 56. The first column of the chart lists the drug name. Brand name drugs are capitalized (e.g., LYRICA ORAL CAPSULE) and generic drugs are listed in lower-case italics (e.g., gabapentin oral capsule). The information in the Requirements/Limits column tells you if Constellation Health has any special requirements for coverage of your drug. Page 6 of 7

7 Apollo Constellation Health (HMO) Home- Constellation Health (HMO) Olympus Constellation Health (PPO) Olympus Prime Constellation Health (PPO) 208 Formulary Definition of symbols and abbreviations (Definición de símbolos y abreviaturas) CO = Cumulative Opioid (Acumulativo de Opiodes) EX-BFF = Extended But First Fill (Suplido Extendido Excepto Primer Despacho) LA = Limited Access (Acceso Limitado) MO/90 = Mail Order/90 Days Supply (Servicio de Correo/Suplido de 90 Días) PA = Prior-authorization (Precertificación) PA^ = Prior-authorization Part B vs Part D ONLY (Precertificación Parte B vs Parte D SOLAMENTE) PA# = Prior-authorization Clinical Criteria and Part B vs Part D (Precertificación Criterio Clínico y Parte B vs Parte D) PA> 65 = Prior-authorization applies to patients 65 years of age and older (Precertificación aplica a pacientes de 65 años de edad y mayores) QL = Quantity Limit (Límite de Cantidad) Drug (Medicamento) Level (Nivel) Instruction (Instrucción) Analgesics (Analgésicos) Analgesics (Analgésicos) acetaminophen-codeine #2 oral tablet 00-5 mg QL (60 EA per 0 days); CO acetaminophen-codeine # oral tablet 00-0 mg QL (60 EA per 0 days); CO acetaminophen-codeine #4 oral tablet mg QL (80 EA per 0 days); CO acetaminophen-codeine oral solution 20-2 mg/5ml HYCET ORAL SOLUTION MG/5ML CO hydrocodone-acetaminophen oral solution mg/5ml hydrocodone-acetaminophen oral tablet 0-00 mg, 0-25 mg, 5-25 mg, mg, mg CO CO QL (80 EA per 0 days); CO Page 7 of 7

8 hydrocodone-acetaminophen oral tablet 5-00 mg CO hydrocodone-ibuprofen oral tablet mg, mg NORCO ORAL TABLET 0-25 MG, 5-25 MG, MG oxycodone-acetaminophen oral tablet 0-25 mg, mg, 5-25 mg, mg PERCOCET ORAL TABLET 0-25 MG, MG, 5-25 MG, MG QL (50 EA per 0 days); CO QL (80 EA per 0 days); CO QL (20 EA per 0 days); CO QL (20 EA per 0 days); CO tramadol-acetaminophen oral tablet mg QL (240 EA per 0 days); CO TYLENOL WITH CODEINE # ORAL TABLET 00-0 MG TYLENOL WITH CODEINE #4 ORAL TABLET MG QL (60 EA per 0 days); CO QL (80 EA per 0 days); CO ULTRACET ORAL TABLET MG QL (240 EA per 0 days); CO Nonsteroidal Anti-Inflammatory Agents (Agentes Anti-inflamatorios No Esteroidales) CELEBREX ORAL CAPSULE 00 MG, 200 MG, 400 MG, 50 MG celecoxib oral capsule 00 mg, 200 mg, 400 mg, 50 mg diclofenac potassium oral tablet 50 mg diclofenac sodium er oral tablet extended release 24 hour 00 mg diclofenac sodium oral tablet delayed release 25 mg, 50 mg, 75 mg diclofenac sodium transdermal gel % EC-NAPROSYN ORAL TABLET DELAYED RELEASE 75 MG etodolac er oral tablet extended release 24 hour 400 mg, 500 mg, 600 mg etodolac oral capsule 200 mg, 00 mg etodolac oral tablet 400 mg, 500 mg QL (60 EA per 0 days) QL (60 EA per 0 days) Page 8 of 7

9 FELDENE ORAL CAPSULE 0 MG, 20 MG flurbiprofen oral tablet 00 mg, 50 mg ibuprofen oral tablet 400 mg, 600 mg, 800 mg indomethacin er oral capsule extended release 75 mg QL (60 EA per 0 days) indomethacin oral capsule 25 mg, 50 mg QL (20 EA per 0 days) ketorolac tromethamine injection solution 5 mg/ml, 0 mg/ml ketorolac tromethamine intramuscular solution 60 mg/2ml LODINE ORAL TABLET 400 MG meloxicam oral tablet 5 mg, 7.5 mg QL (0 EA per 0 days) MOBIC ORAL TABLET 5 MG, 7.5 MG QL (0 EA per 0 days) nabumetone oral tablet 500 mg, 750 mg NAPROSYN ORAL TABLET DELAYED RELEASE 75 MG, 500 MG naproxen dr oral tablet delayed release 75 mg, 500 mg naproxen oral suspension 25 mg/5ml naproxen oral tablet 250 mg, 75 mg, 500 mg naproxen sodium oral tablet 275 mg, 550 mg piroxicam oral capsule 0 mg, 20 mg sulindac oral tablet 50 mg, 200 mg VOLTAREN TRANSDERMAL GEL % Opioid Analgesics, Long-Acting (Analgésicos Opiodes, Larga Duración) ACTIQ BUCCAL LOZENGE ON A HANDLE 200 MCG, 600 MCG, 200 MCG, 400 MCG, 600 MCG, 800 MCG DURAGESIC-00 TRANSDERMAL PATCH 72 HOUR 00 MCG/HR PA; QL (20 EA per 0 days); CO QL (5 EA per 0 days); CO Page 9 of 7

10 DURAGESIC-2 TRANSDERMAL PATCH 72 HOUR 2 MCG/HR DURAGESIC-25 TRANSDERMAL PATCH 72 HOUR 25 MCG/HR DURAGESIC-50 TRANSDERMAL PATCH 72 HOUR 50 MCG/HR DURAGESIC-75 TRANSDERMAL PATCH 72 HOUR 75 MCG/HR duramorph injection solution 0.5 mg/ml, mg/ml fentanyl citrate buccal lozenge on a handle 200 mcg, 600 mcg, 200 mcg, 400 mcg, 600 mcg, 800 mcg fentanyl transdermal patch 72 hour 00 mcg/hr, 2 mcg/hr, 25 mcg/hr, 50 mcg/hr, 75 mcg/hr morphine sulfate (concentrate) oral solution 00 mg/5ml morphine sulfate er oral tablet extended release 00 mg, 5 mg, 0 mg, 60 mg morphine sulfate er oral tablet extended release 200 mg morphine sulfate oral solution 0 mg/5ml, 20 mg/5ml QL (5 EA per 0 days); CO QL (5 EA per 0 days); CO QL (5 EA per 0 days); CO QL (5 EA per 0 days); CO PA; QL (20 EA per 0 days); CO QL (5 EA per 0 days); CO CO QL (90 EA per 0 days); CO QL (60 EA per 0 days); CO CO morphine sulfate oral tablet 5 mg, 0 mg QL (20 EA per 0 days); CO MS CONTIN ORAL TABLET EXTENDED RELEASE 00 MG, 5 MG, 0 MG, 60 MG MS CONTIN ORAL TABLET EXTENDED RELEASE 200 MG oxycodone hcl er oral tablet er 2 hour abusedeterrent 0 mg, 5 mg, 20 mg, 0 mg, 40 mg, 60 mg oxycodone hcl er oral tablet er 2 hour abusedeterrent 80 mg QL (90 EA per 0 days); CO QL (60 EA per 0 days); CO QL (90 EA per 0 days); CO QL (60 EA per 0 days); CO Page 0 of 7

11 OXYCONTIN ORAL TABLET ER 2 HOUR ABUSE-DETERRENT 0 MG, 5 MG, 20 MG, 0 MG, 40 MG, 60 MG OXYCONTIN ORAL TABLET ER 2 HOUR ABUSE-DETERRENT 80 MG QL (90 EA per 0 days); CO QL (60 EA per 0 days); CO Opioid Analgesics, Short-acting (Analgésicos Opiodes, Corta Duración) ACTIQ BUCCAL LOZENGE ON A HANDLE 200 MCG, 600 MCG, 200 MCG, 400 MCG, 600 MCG, 800 MCG butorphanol tartrate injection solution mg/ml, 2 mg/ml butorphanol tartrate nasal solution 0 mg/ml CO DEMEROL INJECTION SOLUTION 25 MG/ML, 50 MG/ML DURAGESIC-00 TRANSDERMAL PATCH 72 HOUR 00 MCG/HR DURAGESIC-2 TRANSDERMAL PATCH 72 HOUR 2 MCG/HR DURAGESIC-25 TRANSDERMAL PATCH 72 HOUR 25 MCG/HR DURAGESIC-50 TRANSDERMAL PATCH 72 HOUR 50 MCG/HR DURAGESIC-75 TRANSDERMAL PATCH 72 HOUR 75 MCG/HR fentanyl citrate buccal lozenge on a handle 200 mcg, 600 mcg, 200 mcg, 400 mcg, 600 mcg, 800 mcg fentanyl transdermal patch 72 hour 00 mcg/hr, 2 mcg/hr, 25 mcg/hr, 50 mcg/hr, 75 mcg/hr LAZANDA NASAL SOLUTION 00 MCG/ACT, 00 MCG/ACT, 400 MCG/ACT meperidine hcl injection solution 00 mg/ml, 25 mg/ml, 50 mg/ml PA; QL (20 EA per 0 days); CO PA^ QL (5 EA per 0 days); CO QL (5 EA per 0 days); CO QL (5 EA per 0 days); CO QL (5 EA per 0 days); CO QL (5 EA per 0 days); CO PA; QL (20 EA per 0 days); CO QL (5 EA per 0 days); CO PA; CO PA^ Page of 7

12 morphine sulfate (concentrate) oral solution 00 mg/5ml morphine sulfate oral solution 0 mg/5ml, 20 mg/5ml CO CO morphine sulfate oral tablet 5 mg, 0 mg QL (20 EA per 0 days); CO oxycodone hcl oral capsule 5 mg QL (80 EA per 0 days); CO oxycodone hcl oral tablet 5 mg, 0 mg, 5 mg QL (80 EA per 0 days); CO ROXICODONE ORAL TABLET 5 MG, 0 MG, 5 MG QL (80 EA per 0 days); CO tramadol hcl oral tablet 50 mg QL (240 EA per 0 days); CO ULTRAM ORAL TABLET 50 MG QL (240 EA per 0 days); CO Anesthetics (Anestésicos) Local Anesthetics (Anestésicos Locales) lidocaine external ointment 5 % lidocaine external patch 5 % PA; QL (90 EA per 0 days) lidocaine hcl (pf) injection solution 0.5 %, % PA^ lidocaine hcl external gel 2 % lidocaine viscous mouth/throat solution 2 % lidocaine-prilocaine external cream % LIDODERM EXTERNAL PATCH 5 % PA; QL (90 EA per 0 days) Anti-Addiction / Substance Abuse Treatment Agents (Agentes Contra la Adicción / Agentes para el Tratamiento de Abuso de Sustancias) Alcohol Deterrents / Anti-Craving (Disuasivos de Alcohol / Anti-ansiedad) acamprosate calcium oral tablet delayed release mg ANTABUSE ORAL TABLET 250 MG, 500 MG disulfiram oral tablet 250 mg, 500 mg naltrexone hcl oral tablet 50 mg VIVITROL INTRAMUSCULAR SUSPENSION RECONSTITUTED 80 MG Page 2 of 7

13 Opioid Dependence Treatments (Tratamiento para la Dependencia a Opioides) buprenorphine hcl sublingual tablet sublingual 2 mg, 8 mg buprenorphine hcl-naloxone hcl sublingual tablet sublingual mg, 8-2 mg naltrexone hcl oral tablet 50 mg SUBOXONE SUBLINGUAL FILM 2- MG, MG, 4- MG, 8-2 MG VIVITROL INTRAMUSCULAR SUSPENSION RECONSTITUTED 80 MG ZUBSOLV SUBLINGUAL TABLET SUBLINGUAL MG, MG, MG, MG, MG PA PA PA PA Opioid Reversal Agents (Agentes para la Reversión de Efectos de Opioides) naloxone hcl injection solution 0.4 mg/ml naloxone hcl injection solution cartridge 0.4 mg/ml naloxone hcl injection solution prefilled syringe 2 mg/2ml Smoking Cessation Agents (Agentes para Cesación de Fumar) bupropion hcl er (smoking det) oral tablet extended release 2 hour 50 mg CHANTIX CONTINUING MONTH PAK ORAL TABLET MG CHANTIX ORAL TABLET 0.5 MG, MG CHANTIX STARTING MONTH PAK ORAL TABLET 0.5 MG X & MG X 42 EX-BFF; MO/90 NICOTROL INHALATION INHALER 0 MG NICOTROL NS NASAL SOLUTION 0 MG/ML ZYBAN ORAL TABLET EXTENDED RELEASE 2 HOUR 50 MG Antibacterials (Antibacterianos) Page of 7

14 Aminoglycosides (Aminoglicósidos) gentak ophthalmic ointment 0. % gentamicin sulfate external cream 0. % gentamicin sulfate external ointment 0. % gentamicin sulfate injection solution 40 mg/ml PA^ gentamicin sulfate ophthalmic solution 0. % neomycin sulfate oral tablet 500 mg paromomycin sulfate oral capsule 250 mg streptomycin sulfate intramuscular solution reconstituted gm TOBI INHALATION NEBULIZATION SOLUTION 00 MG/5ML TOBI PODHALER INHALATION CAPSULE 28 MG TOBRADEX OPHTHALMIC OINTMENT % tobramycin inhalation nebulization solution 00 mg/5ml PA^ 4 PA^; LA 4 PA 4 PA^ tobramycin ophthalmic solution 0. % tobramycin sulfate injection solution 0 mg/ml, 80 mg/2ml PA^ TOBREX OPHTHALMIC OINTMENT 0. % TOBREX OPHTHALMIC SOLUTION 0. % Antibacterials (Antibacterianos) colistimethate sodium injection solution reconstituted 50 mg SYNERCID INTRAVENOUS SOLUTION RECONSTITUTED MG Antibacterials, Other (Antibacterianos, Otros) PA^ PA^ acetic acid otic solution 2 % ALCOHOL SWABS Page 4 of 7

15 bacitracin ophthalmic ointment 500 unit/gm BACTROBAN EXTERNAL CREAM 2 % chloramphenicol sod succinate intravenous solution reconstituted gm CLEOCIN ORAL CAPSULE 50 MG, 00 MG, 75 MG CLEOCIN PHOSPHATE INJECTION SOLUTION 900 MG/6ML CLEOCIN VAGINAL CREAM 2 % CLEOCIN VAGINAL SUPPOSITORY 00 MG PA^ PA^; MO/90 CLEOCIN-T EXTERNAL GEL % CLEOCIN-T EXTERNAL SOLUTION % clindamycin hcl oral capsule 50 mg, 00 mg, 75 mg clindamycin phosphate external gel % clindamycin phosphate external solution % clindamycin phosphate injection solution 00 mg/2ml, 600 mg/4ml, 900 mg/6ml clindamycin phosphate vaginal cream 2 % colistimethate sodium injection solution reconstituted 50 mg CUBICIN INTRAVENOUS SOLUTION RECONSTITUTED 500 MG daptomycin intravenous solution reconstituted 500 mg FLAGYL ORAL CAPSULE 75 MG FLAGYL ORAL TABLET 250 MG, 500 MG PA^; MO/90 PA^ PA^ PA^ global alcohol prep ease pad 70 % HIPREX ORAL TABLET GM linezolid intravenous solution 600 mg/00ml 4 PA# linezolid oral suspension reconstituted 00 mg/5ml 4 PA# Page 5 of 7

16 linezolid oral tablet 600 mg 4 PA# MACROBID ORAL CAPSULE 00 MG MACRODANTIN ORAL CAPSULE 00 MG, 25 MG, 50 MG methenamine hippurate oral tablet gm METROCREAM EXTERNAL CREAM 0.75 % METROGEL-VAGINAL VAGINAL GEL 0.75 % METROLOTION EXTERNAL LOTION 0.75 % metronidazole external cream 0.75 % metronidazole external gel 0.75 % metronidazole external lotion 0.75 % metronidazole in nacl intravenous solution mg/00ml-% metronidazole oral capsule 75 mg metronidazole oral tablet 250 mg, 500 mg PA^ metronidazole vaginal gel 0.75 % mupirocin calcium external cream 2 % mupirocin external ointment 2 % nitrofurantoin macrocrystal oral capsule 00 mg, 25 mg, 50 mg nitrofurantoin monohyd macro oral capsule 00 mg SIVEXTRO INTRAVENOUS SOLUTION RECONSTITUTED 200 MG PA# SIVEXTRO ORAL TABLET 200 MG PA# trimethoprim oral tablet 00 mg TYGACIL INTRAVENOUS SOLUTION RECONSTITUTED 50 MG tigecycline intravenous solution reconstituted 50 mg PA^ PA^ Page 6 of 7

17 VANCOCIN HCL ORAL CAPSULE 25 MG, 250 MG vancomycin hcl intravenous solution reconstituted 000 mg, 500 mg vancomycin hcl oral capsule 25 mg, 250 mg XIFAXAN ORAL TABLET 200 MG, 550 MG ZYVOX INTRAVENOUS SOLUTION 600 MG/00ML ZYVOX ORAL SUSPENSION RECONSTITUTED 00 MG/5ML 4 PA^ 4 PA# 4 PA# ZYVOX ORAL TABLET 600 MG 4 PA# Beta-Lactam, Cephalosporins (Cefalosporinas, Beta-lactámicas) cefaclor er oral tablet extended release 2 hour 500 mg PA# cefaclor oral capsule 250 mg, 500 mg PA# cefadroxil oral capsule 500 mg PA# cefadroxil oral suspension reconstituted 250 mg/5ml, 500 mg/5ml PA# cefadroxil oral tablet gm PA# cefazolin sodium injection solution reconstituted gm, 500 mg cefdinir oral capsule 00 mg cefdinir oral suspension reconstituted 25 mg/5ml, 250 mg/5ml cefepime hcl injection solution reconstituted gm, 2 gm cefixime oral suspension reconstituted 00 mg/5ml, 200 mg/5ml cefoxitin sodium injection solution reconstituted 0 gm cefoxitin sodium intravenous solution reconstituted gm, 2 gm PA^ PA^ PA^ Page 7 of 7

18 cefpodoxime proxetil oral suspension reconstituted 00 mg/5ml, 50 mg/5ml cefpodoxime proxetil oral tablet 00 mg, 200 mg cefprozil oral suspension reconstituted 25 mg/5ml, 250 mg/5ml cefprozil oral tablet 250 mg, 500 mg ceftazidime injection solution reconstituted gm, 2 gm ceftriaxone sodium injection solution reconstituted 250 mg, 500 mg ceftriaxone sodium intravenous solution reconstituted gm ceftriaxone sodium intravenous solution reconstituted 2 gm cefuroxime axetil oral tablet 250 mg, 500 mg cefuroxime sodium injection solution reconstituted.5 gm, 750 mg cephalexin oral capsule 250 mg, 500 mg cephalexin oral suspension reconstituted 25 mg/5ml, 250 mg/5ml MAXIPIME INJECTION SOLUTION RECONSTITUTED GM, 2 GM PA^ PA^ PA^ PA^ SUPRAX ORAL CAPSULE 400 MG SUPRAX ORAL SUSPENSION RECONSTITUTED 00 MG/5ML, 200 MG/5ML, 500 MG/5ML TEFLARO INTRAVENOUS SOLUTION RECONSTITUTED 400 MG, 600 MG Beta-Lactam, Other (Beta-lactámicos, Otros) AZACTAM IN DEXTROSE INTRAVENOUS SOLUTION GM, 2 GM aztreonam injection solution reconstituted gm PA^ PA^ Page 8 of 7

19 imipenem-cilastatin intravenous solution reconstituted 250 mg, 500 mg INVANZ INJECTION SOLUTION RECONSTITUTED GM meropenem intravenous solution reconstituted 500 mg, gm MERREM INTRAVENOUS SOLUTION RECONSTITUTED 500 MG PRIMAXIN IV INTRAVENOUS SOLUTION RECONSTITUTED MG Beta-Lactam, Penicillins (Penicilinas, Beta-lactámicas) amoxicillin oral capsule 250 mg, 500 mg amoxicillin oral suspension reconstituted 25 mg/5ml, 200 mg/5ml, 250 mg/5ml, 400 mg/5ml amoxicillin oral tablet 500 mg, 875 mg amoxicillin oral tablet chewable 25 mg, 250 mg amoxicillin-pot clavulanate er oral tablet extended release 2 hour mg amoxicillin-pot clavulanate oral suspension reconstituted mg/5ml, mg/5ml, mg/5ml, mg/5ml amoxicillin-pot clavulanate oral tablet mg, mg, mg amoxicillin-pot clavulanate oral tablet chewable mg, mg ampicillin oral capsule 500 mg ampicillin sodium injection solution reconstituted gm, 25 mg ampicillin-sulbactam sodium injection solution reconstituted.5 (-0.5) gm, (2-) gm ampicillin-sulbactam sodium intravenous solution reconstituted 5 (0-5) gm PA^ PA^ PA^ PA^ PA^ PA^ Page 9 of 7

20 AUGMENTIN ORAL SUSPENSION RECONSTITUTED MG/5ML BICILLIN C-R 900/00 INTRAMUSCULAR SUSPENSION UNIT/2ML BICILLIN C-R INTRAMUSCULAR SUSPENSION UNIT/2ML BICILLIN L-A INTRAMUSCULAR SUSPENSION UNIT/2ML, UNIT/4ML, UNIT/ML dicloxacillin sodium oral capsule 250 mg, 500 mg nafcillin sodium injection solution reconstituted gm penicillin g procaine intramuscular suspension unit/ml penicillin g sodium injection solution reconstituted unit penicillin v potassium oral solution reconstituted 25 mg/5ml, 250 mg/5ml penicillin v potassium oral tablet 250 mg, 500 mg piperacillin sod-tazobactam so intravenous solution reconstituted 2.25 ( gm),.75 (- 0.75) gm, 4.5 (4-0.5) gm UNASYN INJECTION SOLUTION RECONSTITUTED 5 (0-5) GM, (2-) GM Macrolides (Macrólidos) PA^ PA^ PA^ PA^ AZASITE OPHTHALMIC SOLUTION % azithromycin intravenous solution reconstituted 500 mg azithromycin oral suspension reconstituted 00 mg/5ml, 200 mg/5ml azithromycin oral tablet 250 mg, 250 mg (6 pack), 500 mg, 500 mg ( pack), 600 mg clarithromycin oral suspension reconstituted 25 mg/5ml, 250 mg/5ml Page 20 of 7

21 clarithromycin oral tablet 250 mg, 500 mg e.e.e. 400 oral tablet 400 mg E.E.S. GRANULES ORAL SUSPENSION RECONSTITUTED 200 MG/5ML ERYPED 200 ORAL SUSPENSION RECONSTITUTED 200 MG/5ML ERYPED 400 ORAL SUSPENSION RECONSTITUTED 400 MG/5ML ERYTHROCIN LACTOBIONATE INTRAVENOUS SOLUTION RECONSTITUTED 500 MG erythromycin stearate oral tablet 250 mg erythromycin base oral tablet 250 mg, 500 mg erythromycin ethylsuccinate oral suspension reconstituted 200 mg/5ml erythromycin ethylsuccinate oral tablet 400 mg PA^ erythromycin external gel 2 % erythromycin external solution 2 % erythromycin ophthalmic ointment 5 mg/gm ZITHROMAX INTRAVENOUS SOLUTION RECONSTITUTED 500 MG ZITHROMAX ORAL SUSPENSION RECONSTITUTED 00 MG/5ML, 200 MG/5ML ZITHROMAX ORAL TABLET 250 MG, 500 MG, 600 MG Quinolones (Quinolonas) AVELOX ORAL TABLET 400 MG CILOXAN OPHTHALMIC SOLUTION 0. % CIPRO ORAL SUSPENSION RECONSTITUTED 250 MG/5ML (5%), 500 MG/5ML (0%) CIPRO ORAL TABLET 250 MG, 500 MG Page 2 of 7

22 ciprofloxacin hcl ophthalmic solution 0. % ciprofloxacin hcl oral tablet 250 mg, 500 mg, 750 mg ciprofloxacin oral suspension reconstituted 250 mg/5ml (5%), 500 mg/5ml (0%) ciprofloxacin-ciproflox hcl er oral tablet extended release 24 hour 000 mg, 500 mg LEVAQUIN ORAL TABLET 500 MG, 750 MG levofloxacin intravenous solution 25 mg/ml PA^ levofloxacin oral tablet 250 mg, 500 mg, 750 mg MOXEZA OPHTHALMIC SOLUTION 0.5 % moxifloxacin hcl ophth soln 0.5% moxifloxacin hcl oral tablet 400 mg OCUFLOX OPHTHALMIC SOLUTION 0. % ofloxacin ophthalmic solution 0. % ofloxacin otic solution 0. % VIGAMOX OPHTHALMIC SOLUTION 0.5 % Sulfonamides (Sulfonamidas) BACTRIM DS ORAL TABLET MG BACTRIM ORAL TABLET MG BLEPH-0 OPHTHALMIC SOLUTION 0 % SILVADENE EXTERNAL CREAM % silver sulfadiazine external cream % sulfacetamide sodium ophthalmic solution 0 % sulfadiazine oral tablet 500 mg sulfamethoxazole-trimethoprim intravenous solution mg/5ml sulfamethoxazole-trimethoprim oral suspension mg/5ml sulfamethoxazole-trimethoprim oral tablet mg, mg PA^ Page 22 of 7

23 Tetracyclines (Tetraciclinas) demeclocycline hcl oral tablet 50 mg, 00 mg doxy 00 intravenous solution reconstituted 00 mg doxycycline hyclate oral capsule 00 mg, 50 mg doxycycline hyclate oral tablet 00 mg, 20 mg MINOCIN ORAL CAPSULE 00 MG, 50 MG minocycline hcl oral capsule 00 mg, 50 mg, 75 mg tetracycline hcl oral capsule 250 mg, 500 mg VIBRAMYCIN ORAL CAPSULE 00 MG Anticonvulsants (Anticonvulsivantes) Anticonvulsants, Other (Anticonvulsivantes, Otros) BRIVIACT INTRAVENOUS SOLUTION 50 MG/5ML PA^ PA^ BRIVIACT ORAL SOLUTION 0 MG/ML BRIVIACT ORAL TABLET 0 MG, 00 MG, 25 MG, 50 MG, 75 MG DIASTAT ACUDIAL RECTAL GEL 0 MG, 20 MG DIASTAT PEDIATRIC RECTAL GEL 2.5 MG diazepam intensol oral concentrate 5 mg/ml diazepam oral solution mg/ml diazepam oral tablet 0 mg, 2 mg, 5 mg QL (20 EA per 0 days) KEPPRA ORAL SOLUTION 00 MG/ML KEPPRA ORAL TABLET 000 MG, 250 MG, 500 MG, 750 MG KEPPRA XR ORAL TABLET EXTENDED RELEASE 24 HOUR 500 MG, 750 MG levetiracetam er oral tablet extended release 24 hour 500 mg, 750 mg Page 2 of 7

24 levetiracetam intravenous solution 500 mg/5ml PA^ levetiracetam oral solution 00 mg/ml levetiracetam oral tablet 000 mg, 250 mg, 500 mg, 750 mg SPRITAM ORAL TABLET DISINTEGRATING SOLUBLE 000 MG, 250 MG, 500 MG, 750 MG Calcium Channel Modifying Agents (Agentes Modificadores de Canales de Calcio) CELONTIN ORAL CAPSULE 00 MG ethosuximide oral capsule 250 mg ethosuximide oral solution 250 mg/5ml LYRICA ORAL CAPSULE 00 MG, 50 MG, 200 MG, 25 MG, 50 MG, 75 MG 2 QL (90 EA per 0 days); MO/90 LYRICA ORAL CAPSULE 225 MG, 00 MG 2 QL (60 EA per 0 days); MO/90 LYRICA ORAL SOLUTION 20 MG/ML 2 MO/90 ZARONTIN ORAL CAPSULE 250 MG ZARONTIN ORAL SOLUTION 250 MG/5ML ZONEGRAN ORAL CAPSULE 00 MG, 25 MG zonisamide oral capsule 00 mg, 25 mg, 50 mg Gamma-Aminobutyric Acid (GABA) Augmenting Agents (Agentes Aumentadores del Ácido Gamma-Aminobutírico) ATIVAN ORAL TABLET 0.5 MG, MG, 2 MG clonazepam oral tablet 0.5 mg, mg, 2 mg clonazepam oral tablet dispersible 0.25 mg, 0.25 mg, 0.5 mg, mg, 2 mg clorazepate dipotassium oral tablet 5 mg,.75 mg, 7.5 mg DEPACON INTRAVENOUS SOLUTION 00 MG/ML PA^ DEPAKENE ORAL CAPSULE 250 MG DEPAKENE ORAL SOLUTION 250 MG/5ML Page 24 of 7

25 DEPAKOTE ER ORAL TABLET EXTENDED RELEASE 24 HOUR 250 MG, 500 MG DEPAKOTE ORAL TABLET DELAYED RELEASE 25 MG, 250 MG, 500 MG DEPAKOTE SPRINKLES ORAL CAPSULE DELAYED RELEASE SPRINKLE 25 MG DIASTAT ACUDIAL RECTAL GEL 0 MG, 20 MG DIASTAT PEDIATRIC RECTAL GEL 2.5 MG diazepam intensol oral concentrate 5 mg/ml diazepam oral solution mg/ml diazepam oral tablet 0 mg, 2 mg, 5 mg QL (20 EA per 0 days) divalproex sodium er oral tablet extended release 24 hour 250 mg, 500 mg divalproex sodium oral capsule delayed release sprinkle 25 mg divalproex sodium oral tablet delayed release 25 mg, 250 mg, 500 mg gabapentin oral capsule 00 mg, 00 mg, 400 mg gabapentin oral solution 250 mg/5ml gabapentin oral tablet 600 mg, 800 mg GABITRIL ORAL TABLET 2 MG, 6 MG, 2 MG, 4 MG KLONOPIN ORAL TABLET 0.5 MG, MG, 2 MG lorazepam oral tablet 0.5 mg, mg, 2 mg MYSOLINE ORAL TABLET 250 MG, 50 MG NEURONTIN ORAL CAPSULE 00 MG, 00 MG, 400 MG NEURONTIN ORAL SOLUTION 250 MG/5ML NEURONTIN ORAL TABLET 600 MG, 800 MG ONFI ORAL SUSPENSION 2.5 MG/ML Page 25 of 7

26 ONFI ORAL TABLET 0 MG QL (60 EA per 0 days); MO/90 ONFI ORAL TABLET 20 MG QL (20 EA per 0 days); MO/90 phenobarbital oral elixir 20 mg/5ml phenobarbital oral tablet 00 mg, 5 mg, 6.2 mg, 0 mg, 2.4 mg, 60 mg, 64.8 mg, 97.2 mg primidone oral tablet 250 mg, 50 mg QL (90 EA per 0 days); MO/90 SABRIL ORAL PACKET 500 MG LA; MO/90 SABRIL ORAL TABLET 500 MG LA; MO/90 tiagabine hcl oral tablet 2 mg, 4 mg, 2 mg, 6 mg TRANXENE-T ORAL TABLET 7.5 MG VALIUM ORAL TABLET 0 MG, 2 MG, 5 MG QL (20 EA per 0 days) valproate sodium intravenous solution 00 mg/ml PA^ valproate sodium oral solution 250 mg/5ml valproic acid oral capsule 250 mg vigabatrin oral packet 500 mg Glutamate Reducing Agents (Agentes Reductores de Glutamato) felbamate oral suspension 600 mg/5ml felbamate oral tablet 400 mg, 600 mg FELBATOL ORAL SUSPENSION 600 MG/5ML FELBATOL ORAL TABLET 400 MG, 600 MG FYCOMPA ORAL SUSPENSION 0.5 MG/ML FYCOMPA ORAL TABLET 0 MG, 2 MG, 2 MG, 4 MG, 6 MG, 8 MG LAMICTAL ORAL TABLET 00 MG, 50 MG, 200 MG, 25 MG LAMICTAL ORAL TABLET CHEWABLE 25 MG, 5 MG LAMICTAL XR ORAL TABLET EXTENDED RELEASE 24 HOUR 00 MG, 200 MG, 25 MG, 250 MG, 00 MG, 50 MG QL (0 EA per 0 days); MO/90 Page 26 of 7

27 lamotrigine er oral tablet extended release 24 hour 00 mg, 200 mg, 25 mg, 250 mg, 00 mg, 50 mg lamotrigine oral tablet 00 mg, 50 mg, 200 mg, 25 mg lamotrigine oral tablet chewable 25 mg, 5 mg TOPAMAX ORAL TABLET 00 MG, 200 MG, 25 MG, 50 MG TOPAMAX SPRINKLE ORAL CAPSULE SPRINKLE 5 MG, 25 MG topiramate oral capsule sprinkle 5 mg, 25 mg topiramate oral tablet 00 mg, 200 mg, 25 mg, 50 mg TROKENDI XR ORAL CAPSULE EXTENDED RELEASE 24 HOUR 00 MG, 200 MG, 25 MG, 50 MG Sodium Channel Agents (Agentes Canales de Sodio) APTIOM ORAL TABLET 200 MG, 400 MG, 800 MG QL (0 EA per 0 days); MO/90 APTIOM ORAL TABLET 600 MG QL (60 EA per 0 days) BANZEL ORAL SUSPENSION 40 MG/ML BANZEL ORAL TABLET 200 MG, 400 MG carbamazepine er oral tablet extended release 2 hour 00 mg, 200 mg, 400 mg carbamazepine oral suspension 00 mg/5ml carbamazepine oral tablet 200 mg carbamazepine oral tablet chewable 00 mg CEREBYX INJECTION SOLUTION 500 MG PE/0ML DILANTIN INFATABS ORAL TABLET CHEWABLE 50 MG PA^ 2 MO/90 DILANTIN ORAL CAPSULE 00 MG, 0 MG 2 MO/90 Page 27 of 7

28 DILANTIN ORAL SUSPENSION 25 MG/5ML 2 fosphenytoin sodium injection solution 00 mg pe/2ml PA^ oxcarbazepine oral suspension 00 mg/5ml oxcarbazepine oral tablet 50 mg, 00 mg, 600 mg OXTELLAR XR ORAL TABLET EXTENDED RELEASE 24 HOUR 50 MG, 00 MG, 600 MG PEGANONE ORAL TABLET 250 MG phenytoin oral suspension 25 mg/5ml phenytoin oral tablet chewable 50 mg phenytoin sodium extended oral capsule 00 mg phenytoin sodium injection solution 50 mg/ml PA^ TEGRETOL ORAL SUSPENSION 00 MG/5ML TEGRETOL ORAL TABLET 200 MG TEGRETOL-XR ORAL TABLET EXTENDED RELEASE 2 HOUR 00 MG, 200 MG, 400 MG TRILEPTAL ORAL SUSPENSION 00 MG/5ML TRILEPTAL ORAL TABLET 50 MG, 00 MG, 600 MG VIMPAT INTRAVENOUS SOLUTION 200 MG/20ML PA^ VIMPAT ORAL SOLUTION 0 MG/ML VIMPAT ORAL TABLET 00 MG, 50 MG, 200 MG, 50 MG Antidementia Agents (Antidemencia) Antidementia Agents, Other (Agentes Antidemencia, Otros) ergoloid mesylates oral tablet mg Cholinesterase Inhibitors (Inhibidores de la Colinesterasa) ARICEPT ORAL TABLET 0 MG, 2 MG, 5 MG QL (0 EA per 0 days); MO/90 donepezil hcl oral tablet 0 mg, 2 mg, 5 mg QL (0 EA per 0 days); MO/90 Page 28 of 7

29 donepezil hcl oral tablet dispersible 0 mg, 5 mg QL (0 EA per 0 days); MO/90 EXELON TRANSDERMAL PATCH 24 HOUR. MG/24HR, 4.6 MG/24HR, 9.5 MG/24HR galantamine hydrobromide er oral capsule extended release 24 hour 6 mg, 24 mg, 8 mg galantamine hydrobromide oral solution 4 mg/ml galantamine hydrobromide oral tablet 2 mg, 4 mg, 8 mg RAZADYNE ER ORAL CAPSULE EXTENDED RELEASE 24 HOUR 6 MG, 24 MG, 8 MG RAZADYNE ORAL TABLET 2 MG, 4 MG, 8 MG rivastigmine tartrate oral capsule.5 mg, mg, 4.5 mg, 6 mg rivastigmine transdermal patch 24 hour. mg/24hr, 4.6 mg/24hr, 9.5 mg/24hr QL (0 EA per 0 days); EX-BFF; MO/90 QL (0 EA per 0 days); MO/90 QL (60 EA per 0 days); MO/90 QL (0 EA per 0 days); MO/90 QL (60 EA per 0 days); MO/90 QL (60 EA per 0 days); MO/90 QL (0 EA per 0 days); EX-BFF; MO/90 N-Methyl-D-Aspartate (NMDA) Receptor Antagonists (Antagonistas del Receptor de N-metil-Daspartato (NMDA)) memantine hcl oral solution 2 mg/ml memantine hcl oral tablet 0 mg, 5 mg memantine hcl oral tablet 5 (28)-0 (2) mg NAMENDA ORAL TABLET 0 MG, 5 MG NAMENDA TITRATION PAK ORAL TABLET 5 (28)-0 (2) MG NAMENDA XR ORAL CAPSULE EXTENDED RELEASE 24 HOUR 4 MG, 2 MG, 28 MG, 7 MG NAMENDA XR TITRATION PACK ORAL CAPSULE EXTENDED RELEASE 24 HOUR 7 & 4 & 2 & 28 MG Antidepressants (Antidepresivos) Antidepressants (Antidepresivos) 2 QL (0 EA per 0 days); MO/90 2 Page 29 of 7

30 perphenazine-amitriptyline oral tablet 2-0 mg, 2-25 mg, 4-0 mg, 4-25 mg, 4-50 mg Antidepressants, Other (Antidepresivos, Otros) ABILIFY MAINTENA INTRAMUSCULAR SUSPENSION RECONSTITUTED 00 MG, 00 MG (.5ML SYRINGE), 400 MG ABILIFY ORAL TABLET 0 MG, 5 MG, 2 MG, 20 MG, 0 MG, 5 MG aripiprazole oral tablet 0 mg, 5 mg, 2 mg, 20 mg, 0 mg, 5 mg 4 PA^ QL (0 EA per 0 days); MO/90 QL (0 EA per 0 days); MO/90 aripiprazole oral tablet dispersible 0 mg QL (90 EA per 0 days); MO/90 aripiprazole oral tablet dispersible 5 mg QL (60 EA per 0 days); MO/90 aripiprazole oral solution mg/ml bupropion hcl er (sr) oral tablet extended release 2 hour 00 mg, 50 mg, 200 mg bupropion hcl er (xl) oral tablet extended release 24 hour 50 mg, 00 mg bupropion hcl oral tablet 00 mg, 75 mg maprotiline hcl oral tablet 25 mg, 50 mg, 75 mg mirtazapine oral tablet 5 mg, 0 mg, 45 mg, 7.5 mg mirtazapine oral tablet dispersible 5 mg, 0 mg, 45 mg QL (60 EA per 0 days); MO/90 QL (0 EA per 0 days); MO/90 QL (0 EA per 0 days); MO/90 QL (0 EA per 0 days); MO/90 nefazodone hcl oral tablet 00 mg, 250 mg, 50 mg QL (60 EA per 0 days); MO/90 nefazodone hcl oral tablet 50 mg QL (20 EA per 0 days); MO/90 nefazodone hcl oral tablet 200 mg QL (90 EA per 0 days); MO/90 quetiapine fumarate er oral tablet extended release 24 hour 50 mg, 200 mg, 50 mg quetiapine fumarate er oral tablet extended release 24 hour 00 mg, 400 mg quetiapine fumarate oral tablet 00 mg, 200 mg, 25 mg, 50 mg QL (0 EA per 0 days); MO/90 QL (60 EA per 0 days); MO/90 QL (90 EA per 0 days); MO/90 Page 0 of 7

31 quetiapine fumarate oral tablet 00 mg, 400 mg QL (60 EA per 0 days); MO/90 REMERON ORAL TABLET 5 MG, 0 MG QL (0 EA per 0 days); MO/90 REMERON SOLTAB ORAL TABLET DISPERSIBLE 5 MG, 0 MG, 45 MG SEROQUEL ORAL TABLET 00 MG, 200 MG, 25 MG, 50 MG QL (0 EA per 0 days); MO/90 QL (90 EA per 0 days); MO/90 SEROQUEL ORAL TABLET 00 MG, 400 MG QL (60 EA per 0 days); MO/90 SEROQUEL XR ORAL TABLET EXTENDED RELEASE 24 HOUR 50 MG, 200 MG, 50 MG SEROQUEL XR ORAL TABLET EXTENDED RELEASE 24 HOUR 00 MG, 400 MG trazodone hcl oral tablet 00 mg, 50 mg, 00 mg, 50 mg WELLBUTRIN SR ORAL TABLET EXTENDED RELEASE 2 HOUR 00 MG, 50 MG, 200 MG WELLBUTRIN XL ORAL TABLET EXTENDED RELEASE 24 HOUR 50 MG, 00 MG QL (0 EA per 0 days); MO/90 QL (60 EA per 0 days); MO/90 Monoamine Oxidase Inhibitors (Inhibidores de Monoamina Oxidasa) EMSAM TRANSDERMAL PATCH 24 HOUR 2 MG/24HR, 6 MG/24HR, 9 MG/24HR MARPLAN ORAL TABLET 0 MG NARDIL ORAL TABLET 5 MG PARNATE ORAL TABLET 0 MG phenelzine sulfate oral tablet 5 mg tranylcypromine sulfate oral tablet 0 mg QL (60 EA per 0 days); MO/90 QL (0 EA per 0 days); MO/90 QL (0 EA per 0 days); MO/90 SSRIs/ SNRIs (Selective Serotonin Reuptake Inhibitors / Serotonin and Norepinephrine Reuptake Inhibitors) (SSRIs/SNRIs (Inhibidores de la Recaptación Selectiva de Serotonina / Inhibidores de la Recaptación de Serotonina y Norepinefrina)) CELEXA ORAL TABLET 0 MG, 20 MG, 40 MG QL (0 EA per 0 days); MO/90 Page of 7

32 citalopram hydrobromide oral solution 0 mg/5ml citalopram hydrobromide oral tablet 0 mg, 20 mg, 40 mg CYMBALTA ORAL CAPSULE DELAYED RELEASE PARTICLES 20 MG CYMBALTA ORAL CAPSULE DELAYED RELEASE PARTICLES 0 MG, 60 MG desvenlafaxine succinate er oral tablet extended release 24 hour 00 mg, 25 mg, 50 mg duloxetine hcl oral capsule delayed release particles 20 mg duloxetine hcl oral capsule delayed release particles 0 mg, 60 mg EFFEXOR XR ORAL CAPSULE EXTENDED RELEASE 24 HOUR 50 MG, 7.5 MG EFFEXOR XR ORAL CAPSULE EXTENDED RELEASE 24 HOUR 75 MG escitalopram oxalate oral solution 5 mg/5ml escitalopram oxalate oral tablet 0 mg, 20 mg, 5 mg FETZIMA ORAL CAPSULE EXTENDED RELEASE 24 HOUR 20 MG, 20 MG, 40 MG, 80 MG FETZIMA TITRATION ORAL CAPSULE ER 24 HOUR THERAPY PACK 20 & 40 MG QL (0 EA per 0 days); MO/90 QL (90 EA per 0 days); MO/90 QL (60 EA per 0 days); MO/90 QL (0 EA per 0 days); MO/90 QL (90 EA per 0 days); MO/90 QL (60 EA per 0 days); MO/90 QL (0 EA per 0 days); MO/90 QL (90 EA per 0 days); MO/90 QL (0 EA per 0 days); MO/90 QL (0 EA per 0 days); MO/90 fluoxetine hcl oral capsule 0 mg, 20 mg, 40 mg QL (60 EA per 0 days); MO/90 fluoxetine hcl oral solution 20 mg/5ml fluvoxamine maleate oral tablet 00 mg, 25 mg, 50 mg LEXAPRO ORAL TABLET 0 MG, 20 MG, 5 MG maprotiline hcl oral tablet 25 mg, 50 mg, 75 mg QL (90 EA per 0 days); MO/90 QL (0 EA per 0 days); MO/90 nefazodone hcl oral tablet 00 mg, 250 mg, 50 mg QL (60 EA per 0 days); MO/90 Page 2 of 7

33 nefazodone hcl oral tablet 50 mg QL (20 EA per 0 days); MO/90 nefazodone hcl oral tablet 200 mg QL (90 EA per 0 days); MO/90 paroxetine hcl er oral tablet extended release 24 hour 2.5 mg, 25 mg paroxetine hcl er oral tablet extended release 24 hour 7.5 mg QL (0 EA per 0 days); MO/90 QL (60 EA per 0 days); MO/90 paroxetine hcl oral tablet 0 mg, 20 mg, 40 mg QL (0 EA per 0 days); MO/90 paroxetine hcl oral tablet 0 mg QL (60 EA per 0 days); MO/90 PAXIL CR ORAL TABLET EXTENDED RELEASE 24 HOUR 2.5 MG, 25 MG PAXIL CR ORAL TABLET EXTENDED RELEASE 24 HOUR 7.5 MG PAXIL ORAL SUSPENSION 0 MG/5ML QL (0 EA per 0 days); MO/90 QL (60 EA per 0 days); MO/90 PAXIL ORAL TABLET 0 MG, 20 MG, 40 MG QL (0 EA per 0 days); MO/90 PAXIL ORAL TABLET 0 MG QL (60 EA per 0 days); MO/90 PRISTIQ ORAL TABLET EXTENDED RELEASE 24 HOUR 00 MG, 25 MG, 50 MG PROZAC ORAL CAPSULE 0 MG, 20 MG, 40 MG sertraline hcl oral concentrate 20 mg/ml QL (0 EA per 0 days); MO/90 QL (60 EA per 0 days); MO/90 sertraline hcl oral tablet 00 mg QL (60 EA per 0 days); MO/90 sertraline hcl oral tablet 25 mg sertraline hcl oral tablet 50 mg QL (0 EA per 0 days); MO/90 TRINTELLIX ORAL TABLET 0 MG, 20 MG, 5 MG venlafaxine hcl er oral capsule extended release 24 hour 50 mg, 7.5 mg venlafaxine hcl er oral capsule extended release 24 hour 75 mg venlafaxine hcl oral tablet 00 mg, 25 mg, 7.5 mg, 50 mg, 75 mg QL (0 EA per 0 days); MO/90 QL (0 EA per 0 days); MO/90 QL (90 EA per 0 days); MO/90 Page of 7

34 VIIBRYD ORAL TABLET 0 MG, 20 MG, 40 MG QL (0 EA per 0 days); MO/90 ZOLOFT ORAL TABLET 00 MG QL (60 EA per 0 days); MO/90 ZOLOFT ORAL TABLET 25 MG ZOLOFT ORAL TABLET 50 MG QL (0 EA per 0 days); MO/90 Tricyclics (Tricíclicos) amitriptyline hcl oral tablet 0 mg, 00 mg, 50 mg, 25 mg, 50 mg, 75 mg amoxapine oral tablet 00 mg, 50 mg, 25 mg, 50 mg ANAFRANIL ORAL CAPSULE 25 MG, 50 MG, 75 MG clomipramine hcl oral capsule 25 mg, 50 mg, 75 mg desipramine hcl oral tablet 0 mg, 00 mg, 50 mg, 25 mg, 50 mg, 75 mg doxepin hcl oral capsule 0 mg, 00 mg, 50 mg, 25 mg, 50 mg, 75 mg doxepin hcl oral concentrate 0 mg/ml imipramine hcl oral tablet 0 mg, 25 mg, 50 mg NORPRAMIN ORAL TABLET 0 MG, 25 MG nortriptyline hcl oral capsule 0 mg, 25 mg, 50 mg, 75 mg nortriptyline hcl oral solution 0 mg/5ml PAMELOR ORAL CAPSULE 0 MG, 25 MG, 50 MG, 75 MG protriptyline hcl oral tablet 0 mg, 5 mg SURMONTIL ORAL CAPSULE 00 MG, 25 MG, 50 MG TOFRANIL ORAL TABLET 0 MG, 25 MG, 50 MG Page 4 of 7

35 trimipramine maleate oral capsule 00 mg, 25 mg, 50 mg Antiemetics (Antieméticos) Antiemetics, Other (Antieméticos, Otros) chlorpromazine hcl injection solution 50 mg/2ml chlorpromazine hcl oral tablet 0 mg, 00 mg, 200 mg, 25 mg, 50 mg diphenhydramine hcl injection solution 50 mg/ml hydroxyzine hcl oral syrup 0 mg/5ml hydroxyzine hcl oral tablet 0 mg, 25 mg, 50 mg meclizine hcl oral tablet 2.5 mg, 25 mg metoclopramide hcl injection solution 5 mg/ml metoclopramide hcl oral solution 5 mg/5ml metoclopramide hcl oral tablet 0 mg, 5 mg perphenazine oral tablet 6 mg, 2 mg, 4 mg, 8 mg PHENERGAN INJECTION SOLUTION 25 MG/ML, 50 MG/ML prochlorperazine edisylate injection solution 5 mg/ml prochlorperazine maleate oral tablet 0 mg, 5 mg prochlorperazine rectal suppository 25 mg promethazine hcl injection solution 25 mg/ml, 50 mg/ml promethazine hcl oral syrup 6.25 mg/5ml EX-BFF; MO/90 promethazine hcl oral tablet 2.5 mg, 25 mg, 50 mg promethazine hcl rectal suppository 2.5 mg, 25 mg, 50 mg promethegan rectal suppository 50 mg EX-BFF; MO/90 REGLAN ORAL TABLET 0 MG, 5 MG Page 5 of 7

36 TRANSDERM-SCOP (.5 MG) TRANSDERMAL PATCH 72 HOUR MG/DAYS scopolamine transdermal patch 72 hr mg/days Emetogenic Therapy Adjuncts (Adjuvantes para Terapia Emetogénica) aprepitant oral capsule 25 mg, 40 mg, 80 & 25 mg, 80 mg PA^ dronabinol oral capsule 0 mg, 2.5 mg, 5 mg PA^ EMEND ORAL CAPSULE 25 MG, 40 MG, 80 MG EMEND TRI-PACK ORAL CAPSULE 80 & 25 MG MARINOL ORAL CAPSULE 0 MG, 2.5 MG, 5 MG PA^ PA^ PA^ ondansetron hcl injection solution 4 mg/2ml PA^ ondansetron hcl oral tablet 4 mg, 8 mg PA^ ondansetron oral tablet dispersible 4 mg, 8 mg PA^ VARUBI ORAL TABLET 90 MG PA^ ZOFRAN ODT ORAL TABLET DISPERSIBLE 4 MG, 8 MG PA^ ZOFRAN ORAL TABLET 4 MG, 8 MG PA^ Antifungals (Antifungales) Antifungals (Antifungales) ABELCET INTRAVENOUS SUSPENSION 5 MG/ML AMBISOME INTRAVENOUS SUSPENSION RECONSTITUTED 50 MG amphotericin b injection solution reconstituted 50 mg ANCOBON ORAL CAPSULE 250 MG, 500 MG CANCIDAS INTRAVENOUS SOLUTION RECONSTITUTED 50 MG, 70 MG PA^ PA^ PA^ 4 PA^ Page 6 of 7

37 caspofungin acetate intravenous solution reconstituted 50 mg, 70 mg 4 PA^ ciclopirox external gel 0.77 % ciclopirox external shampoo % ciclopirox external solution 8 % ciclopirox olamine external cream 0.77 % ciclopirox olamine external suspension 0.77 % clotrimazole external cream % clotrimazole external solution % clotrimazole mouth/throat lozenge 0 mg CRESEMBA INTRAVENOUS SOLUTION RECONSTITUTED 72 MG CRESEMBA ORAL CAPSULE 86 MG 4 DIFLUCAN ORAL SUSPENSION RECONSTITUTED 0 MG/ML, 40 MG/ML DIFLUCAN ORAL TABLET 00 MG, 50 MG, 200 MG, 50 MG 4 PA^ econazole nitrate external cream % ERAXIS INTRAVENOUS SOLUTION RECONSTITUTED 00 MG, 50 MG fluconazole in sodium chloride intravenous solution mg/00ml-%, mg/200ml- % fluconazole oral suspension reconstituted 0 mg/ml, 40 mg/ml fluconazole oral tablet 00 mg, 50 mg, 200 mg, 50 mg flucytosine oral capsule 250 mg, 500 mg griseofulvin microsize oral tablet 500 mg griseofulvin ultramicrosize oral tablet 25 mg, 250 mg itraconazole oral capsule 00 mg PA^ PA^ Page 7 of 7